Medical Journal Entry on Israel-Hamas War's Death Toll Went Viral — But Was Missing Context

In July 2024, The Lancet — a well-known medical journal — published an article that went viral across multiple social media sites. People claimed the article estimated the death toll in Gaza from the Israel-Hamas war to be at least 186,000, or approximately 8% of the Palestinian region's population.

While there was some truth to the framing of the article — the article truly estimated Gaza's death toll could be 186,000 — many social media posts left out important context about that number and/or erroneously implied the report was a peer-reviewed, empirical study.

The article, authored by three researchers in the medical field, estimated the death toll as of early July 2024 could be 186,000, or 8% of Gaza's population, if people considered "indirect deaths" in addition to "direct deaths."

The authors defined "indirect deaths" as those caused by, for example, "destroyed health-care infrastructure; severe shortages of food, water, and shelter; the population's inability to flee to safe places; and the loss of funding to UNRWA [United Nations Relief and Works Agency for Palestine]" and defined "direct deaths" as killings as a direct result of war violence. The authors used official death toll data that the Gaza Health Ministry collected, as reported by the UN Office for the Coordination of Humanitarian Affairs. Overall, the report was an attempt to call awareness to what it described as underestimations of deaths in Gaza.

Furthermore, The Lancet published the entry as a "correspondence" — that is, a letter submission by readers. It was not one of the medical journal's many peer-reviewed studies.

Here's a PDF of the letter:

https://media.snopes.com/2024/07/counting_the_dead_in_gaza_difficult_but_essential.pdf

Essentially, the article touched on:

• The official death toll as of June 19, 2024, according to the Gaza Health Ministry (37,396).

• The difficulty in collecting accurate data due to broken infrastructure.

• Arguments for why official death tolls by the Gaza Health Ministry are likely underestimations.

The article claimed:

• When considering the Israel-Hamas war's toll on human life, more people should consider indirect deaths due to "reproductive, communicable, and non-communicable diseases" and "destroyed health-care infrastructure; severe shortages of food, water, and shelter; the population's inability to flee to safe places; and the loss of funding to UNRWA."

• The estimated number of total deaths including indirect deaths: "It is not implausible to estimate that up to 186,000 [almost 8% of the 2022 population] or even more deaths could be attributable to the current conflict in Gaza."

• Calls for a ceasefire "accompanied by measures to enable the distribution of medical supplies, food, clean water, and other resources for basic human needs."

• Calls for "documenting the true scale" and "nature of suffering in this conflict" for "ensuring historical accountability and acknowledging the full cost of the war."

Three authors contributed to the story, including:

• Rasha Khatib, a researcher from the Advocate Aurora Research Institute whose speciality lies in prevention of cardiovascular disease.

• Martin McKee, medical director of the London School of Hygiene & Tropical Medicine, whose main focus of research is on health in societies undergoing major social, political, and economic change.

• Salim Yusuf, executive director of the Population Health Research Institute, whose work as a cardiologist and epidemiologist has focused on prevention and treatment of cardiovascular disease.

We reached out to Khatib via email, seeking clarification on the scope of the letter. She confirmed that this story is "not a peer-reviewed study but rather a call for improved analyses that can tell us what has happened while reviewing the information that is available."

The authors primarily emphasized the inaccuracy of only counting direct deaths without also taking into account indirect deaths. According to the U.K.-based non-profit Every Casualty Counts, "direct deaths result directly from the violent actions of participants to the conflict, during conflict activities" while "indirect deaths might happen as a consequence of conflict (e.g. a person dies because of a life-threatening illness but could not reach a hospital because of hostilities)." As Khatib pointed out, other outlets – such as The Nation – made similar assertions regarding indirect deaths.

In the case of Israel's declared war on Gaza following Hamas' attack on Israel on Oct. 7, 2023, indirect deaths make up a significant fraction of total deaths due to the collapse of Gaza's medical services, the disintegration of public services (such as functioning roads), the destruction of homes and apartment complexes, widespread malnourishment and risk of famine, to name a few. All in all, the extent of indirect deaths as a result of Israel's war on Gaza are catastrophic – and largely under-reported – due to difficulties collecting data.

Using data and further information from various factions of the United Nations, Vice, Airwars, Reuters, Action on Armed Violence UK, and the International Court of Justice, the authors estimate that if casualty reports take into account indirect deaths, "up to 186,000 or even more deaths could be attributable to the current conflict in Gaza." The authors explain:

Unlike the journal's typically lengthy, peer-reviewed studies, this piece fell under the journal's category of "correspondence," which it describes on its website as:

In claiming that the article conservatively estimated that the death toll in Gaza since Oct. 7, 2023, could be 186,000 or more — and framing this claim by saying that a prestigious medical journal published such findings, as many on the internet did — the actual scope of the article was misrepresented.

In Their Own Words – What Were Authors Looking to Accomplish?

"Our Correspondence in The Lancet does not posit that almost 8% of Gaza's population had been wiped out since Oct. 7," Khatib wrote via email. She made clear that the main assertion of the article was that "there is an imperative to collect data on deaths in Gaza, as in other settings, and this should include direct deaths." Crucially, "any analysis that ignores these deaths is incomplete."

Khatib also pointed out that if the ratio of indirect deaths to direct deaths is between three and 15 to one, according to "data from previous conflicts," using a ratio of four to one indirect to direct deaths – as they used to arrive at the 186,000 death toll calculation – is "extremely conservative."

She also pointed to the fact that they made clear in the article that "many of the indirect deaths can be expected in the weeks and months to come.

"Unfortunately, many people have chosen to take our figure as representing deaths that have already occurred, which is not what we say," Khatib wrote.

The Bottom Line

While a future empirical study may later find the estimated 186,000 number to be accurate, that is not what this letter established, or aimed to establish. Many on the internet incorrectly implied that because a medical journal published the letter, readers could interpret the estimated numbers as hard evidence. Rather, the authors' main assertion was that "any analysis that ignores these [indirect] deaths is incomplete."

Sources:

'Direct and Indirect Conflict Deaths'. Every Casualty Counts, https://everycasualty.org/knowledge-base/direct-and-indirect-conflict-deaths/. Accessed 17 July 2024.

Domaradzki-Kim, Siena. 'Strikes, Raids and Incursions: Seven Months of Relentless Attacks on Healthcare in Palestine'. Doctors Without Borders / Médecins Sans Frontières (MSF ..., 29 May 2024, https://www.doctorswithoutborders.ca/strikes-raids-and-incursions-seven-months-of-relentless-attacks-on-healthcare-in-palestine/.

Gaffney, Adam. Don't Believe the Conspiracies About the Gaza Death Toll. 30 May 2024. www.thenation.com, https://www.thenation.com/article/world/gaza-death-toll-evidence/." target="blank">https://www.thenation.com/article/world/gaza-death-toll-evidence/.">https://www.thenation.com/article/world/gaza-death-toll-evidence/.

GAZA STRIP: Famine Is Imminent as 1.1 Million People, Half of Gaza, Experience Catastrophic Food Insecurity | IPC - Integrated Food Security Phase Classification. https://www.ipcinfo.org/ipcinfo-website/alerts-archive/issue-97/en/. Accessed 17 July 2024.

Khatib, Rasha, et al. 'Counting the Dead in Gaza: Difficult but Essential'. The Lancet, July 2024. https://doi.org/https://doi.org/10.1016/S0140-6736(24)01169-3.

'The Unprecedented Destruction of Housing in Gaza Hasn't Been Seen since World War II, the UN Says'. AP News, 2 May 2024, https://apnews.com/article/un-report-gaza-destruction-housing-economy-recovery-4f61dcca7db3fd5eb3da5c6a25001e12.

'United Nations Office for the Coordination of Humanitarian Affairs - Occupied Palestinian Territory | Humanitarian Situation Update #191 | Gaza Strip'. United Nations Office for the Coordination of Humanitarian Affairs - Occupied Palestinian Territory, 15 July 2024, http://www.ochaopt.org/content/humanitarian-situation-update-191-gaza-strip.

UNOSAT. https://unosat.org/products/3804. Accessed 17 July 2024.