Photo of a young boy sitting on rubble by Hosny Salah via Pixabay

Report 2: 20 May to 17 August 2024

The ongoing Israel-Gaza war has heavily affected civilians in both the Gaza Strip and Israel. Over 85% of Gazans have been displaced, many multiple times. They live in overcrowded conditions with insufficient access to water, sanitation, and food, and health services have been severely disrupted.

Researchers from the London School of Hygiene & Tropical Medicine and the Center for Humanitarian Health at the Johns Hopkins University initiated a project to estimate the potential public health impact of the crisis under different future trajectories of its evolution to inform humanitarian and other decision-makers working on the Gaza crisis. In February 2024, the team released a report entitled Crisis in Gaza: Scenario-based Health Impact Projections. Since the first report was published, the war has continued throughout Gaza with an expansion southward towards Rafah. 

Since the majority of Gazans fled to Rafah by December 2023, there has been an intense focus on how the war will be executed there. Following the 6 May 2024 evacuation order for Gazans to leave eastern Rafah, bombardment and land incursions began, with hundreds of thousands of Gazans fleeing the area and an increase in deaths occurring due to traumatic injuries. The objective of the phase 2 of the Gaza Projections Project is to provide a projection of the number of deaths due to traumatic injuries in the Rafah governorate from 20 May to 17 August 2024 (90 days) to inform strategies and decisions by policymakers and humanitarians. Ultimately, it is hoped that these projections will make some contribution to saving lives.

About the Report | Key Findings

Who undertook this research?

This project is an independent collaboration between researchers from The London School of Hygiene & Tropical Medicine and the Center for Humanitarian Health at the Johns Hopkins University.

What is the goal of this projection?

The goal of this scenario-based model is to provide a plausible projection of the number of traumatic injury deaths that could occur in Rafah over the coming 3 months so that policymakers and humanitarians can make sound, evidence-based decisions. Ultimately, it is hoped that this projection will make some contribution to saving lives.

Scenario-based models are needed to support forward looking evidence-based decision-making in Rafah.  Since mortality and other data sources in Gaza are no longer able to provide a complete picture of deaths, multiple data sources are needed for this projection. 

Why focus on traumatic injury deaths in Rafah? 

We focused on projecting the number of traumatic injury deaths amongst Gazans in Rafah from 20 May 2024 and for the subsequent 90 days. 

While conflict continues throughout Gaza, Rafah was selected as the focus of this scenario-based model because, until recently, this was the area where most Gazans had fled to and there had not yet been a wide-scale military invasion in this Governorate since the conflict began on 7 October 2023. However, the Israeli government made its intention to invade Rafah clear, and this began on 6 May 2024 following an evacuation order. 

This scenario is focused solely on Gazans who are likely to die directly due to traumatic injuries and does not include:

Deaths that have already occurred in Rafah previously, including those since the 6 May evacuation order.

Deaths that will occur in Rafah after the projection period due to non-fatal traumatic injuries sustained during that period. 

Deaths indirectly caused by the war, including deaths due to infectious diseases, non-communicable diseases and maternal and child health issues.   

These other causes of death were considered in the project’s first scenario-based health impact projections report which projected excess mortality for the period of February to August 2024 across all of Gaza.

This report was developed as a supplement to the prior report because an escalation in the intensity of the conflict in Rafah is likely to significantly increase direct deaths due to traumatic injuries in this governorate compared to previous traumatic injury deaths in Rafah. 

What are the results?

The researchers project 3,509 traumatic injury deaths to occur between 20 May to 17 August 2024 solely in the Rafah governorate. That is the equivalent to nearly 40 deaths/day for 90 days. In comparison, from 6-19 May, there have been 16 deaths/day due to traumatic injuries in Rafah as reported by ACLED.

Many more traumatic injury deaths are continuing to occur throughout Gaza. Furthermore, we would expect to see increased deaths due to other causes, such as infectious diseases, non-communicable diseases and those due to maternal and child health occurring in the Rafah Governorate and beyond.

The uncertainty range of this projection is 3,143 to 3,946 traumatic injury deaths; for the higher estimate, the daily death rate increases to 44 deaths/day.

This projection is not a “worst-case scenario,” and deaths may increase significantly if Israeli military tactics differ substantially from what we have seen in Khan Younis during 16 December 2023 to 14 March 2024.

What data sources were used?

Four sources of available data were used for this projection: 1) Ministry of Health (MoH) data on conflict fatalities; 2) Armed Conflict Location & Events Data Project (ACLED) data on fatalities for the five governorates in Gaza since 7 October 2023; 3) United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) reports of traumatic injury fatalities among its employees; and 4) Estimates of population by governorate since 7 October, adjusted for displacement by the Oxford Population Health Unit. The first three sources are publicly available, and the latter is available upon request.

What is the methodology used?

The projection for Rafah is based on empirical observations from the Israeli military operation that began in Khan Younis in December 2023. The researchers hypothesize, based on available evidence, that the patterns and outcomes witnessed during this phase of the conflict could resemble potential developments in Rafah under comparable circumstances. They are based on the time series of traumatic injury fatalities from Khan Younis over the 90-day period starting from 16 December 2023 (14 days after the 2 December 2023 evacuation notice for Khan Younis) to 14 March 2024, adjusted for differences in population size.

The Gaza Ministry of Health’s reporting on fatalities does not include geographic locations. Consequently, researchers used the ACLED database, which was incomplete, but did include the locations of traumatic injury deaths. They then resolved this uncertainty through machine learning imputation and adjusted the ratio of traumatic injury deaths reported by the MoH and ACLED to remove some potential bias due to incomplete detection of deaths by ACLED. Finally, to obtain the projection of the number of counted Rafah fatalities, the number of counted fatalities in Khan Younis was scaled by the ratio of the Rafah and Khan Younis populations at day 14 following their respective evacuation orders. 

As in the first report, researchers used the UNRWA staff death reports as an independent source and compared it to the MoH mortality database to estimate the uncounted deaths from the latter; these include people who died under the rubble and other deaths that may not have been reported through the MoH system. 

What are the main conclusions of the report?

The researchers conclude: (1) the projection of possible traumatic injury deaths in Rafah highlights the urgent and lifesaving need for an immediate ceasefire to reduce the mortality amongst civilians; (2) International diplomacy and humanitarian efforts must prioritize the cessation of hostilities; and (3) advocacy for a ceasefire and the urgent need for civilian protection must be sustained.

How to contact the project for additional information. 

Please direct any questions to humanithealth@jhu.edu

For the complete report visit: https://gaza-projections.org/

Disclaimers:

The findings do not necessarily represent the views of the funder, the Johns Hopkins University, or the London School of Hygiene & Tropical Medicine. The funder had no role in shaping the analyses, this report or other scientific outputs of the project. The authors are solely responsible for the analysis and interpretation. This publication is partly based on third party-generated data herein analyzed and interpreted, and it is not intended to question or challenge such data.  Any geographical entities or references to armed conflict events are only for the purpose of the analysis/report, and do not imply acknowledgement or endorsement of facts relating to these geographical entities or events.