“Our monitoring suggests that the numbers provided by the Ministry of Health may be under-reporting as they do not include fatalities who did not reach hospitals or may be lost under the rubble.” — UN human rights office

RAMALLAH/BEIRUT (Dec 7): Israeli forces unleashed an aerial and ground blitz against Hamas in Gaza after a cross-border rampage by the enclave's ruling Islamist group on Oct 7. At least 16,015 Palestinians have been killed since then, according to Gaza Health Ministry figures, while 1,200 people were killed in Hamas' incursion into Israel, according to Israeli tallies.

Aid agencies warn that a humanitarian disaster in Gaza is worsening by the hour with most of its 2.3 million people homeless and trapped in a tiny, embattled coastal enclave, with little food, water, medical care, fuel or secure shelter.

With basic infrastructure devastated, phone and internet services frequently disrupted, and a number of health statisticians having been killed or gone missing, there is increasing concern that Gaza health authorities will be unable to continue keeping an accurate count of the casualty toll.

How have casualty tolls been compiled so far?

In the first six weeks of the war, hospital morgues across Gaza sent figures to the health ministry's main collection centre at Al Shifa Hospital. Officials used Excel sheets to keep track of names, ages and ID card numbers of the dead and transmitted these to the Palestinian Health Ministry in Ramallah, part of the Palestinian Authority (PA) that exercises limited self-rule in the Israeli-occupied West Bank.

But Omar Hussein Ali, director of the Ramallah ministry's emergency operations centre, said that of the four officials who ran the Shifa data centre, one died in an air strike that hit the hospital while the other three went missing when Israeli forces seized the premises as an alleged Hamas hideout.

"The kind of casualty recording required to understand what's going on is getting harder. Information infrastructure, the health systems that existed, are being systematically destroyed," said Hamit Dardagan of Iraq Body Count, set up during the US-led invasion and occupation of Iraq.

The organisation has also been trying to keep track of Gaza casualties, using the health ministry data and monitoring social media and other media reports of deaths.

Since a one-week truce collapsed on Dec 1, casualty updates that had generally been issued daily have become irregular. The last update from Gaza's health ministry came on Monday from spokesperson Ashraf Al-Qidra, raising the death toll to 15,899.

He did not hold his regular news conference on Tuesday. He did not issue a statement for about 48 hours, until late on Wednesday, when he sent a WhatsApp message to journalists that did not include a daily casualty report but said Al-Ahli al-Arabi Hospital in Gaza City was overwhelmed with casualties and "the wounded are bleeding to death".

Reuters was unable to immediately verify the report.

Only two ministry piecemeal reports adding to the death toll have been issued, based on the number of bodies brought to two hospitals — 43 on Tuesday, 73 on Wednesday.

Palestinian Health Minister Mai al-Kaila said on Tuesday Gaza's health services were in a "disastrous" state, with over 250 staff killed and at least 30 arrested by Israeli forces.

Are the published casualty numbers comprehensive?

No, experts told Reuters.

"Our monitoring suggests that the numbers provided by the Ministry of Health may be under-reporting as they do not include fatalities who did not reach hospitals or may be lost under the rubble," the UN human rights office spokesperson said.

"It is a logical assumption that the numbers being reported are underestimated, are low," said Nathaniel Raymond, executive director of the Humanitarian Research Lab at the Yale School of Public Health, who has worked on death counts in armed conflict and natural disasters for more than 20 years.

The PA's Oct 26 report said at least 1,000 bodies could not be recovered or brought to morgues, citing families interviewed by its Gaza staff — a clear and plausible example of the impact of war "on data capture and reporting", the Lancet article read.

The number of bodies feared buried under the rubble now reaches into the thousands and much of the Gaza civil defence force's digging equipment has been destroyed in air strikes, the PA's health minister al-Kaila said on Tuesday.

How credible are the casualty figures to date?

Pre-war Gaza had robust population statistics — from a 2017 census and more recent UN surveys — and well-functioning health information systems better than in most Middle East countries, public health experts told Reuters.

Oona Campbell, professor at the London School of Hygiene and Tropical Medicine, said Palestinian health authorities have longstanding credibility with their methods of maintaining baseline statistics and tracking deaths in general, not just during times of war. UN agencies rely on them.

"Palestinian data collection capabilities are professional and many ministry staff have been trained in the United States. They work hard to ensure statistical fidelity," said Yale University's Raymond.

On Oct 26 the PA Health Ministry published a 212-page report with the names, ages and ID numbers of 7,028 Palestinians it recorded as dead from air strikes — after US President Joe Biden cast doubt on the casualty figures.

Campbell and two other academics analysed the data for a Lancet medical journal report on Nov 26 and concluded there was no obvious reason to doubt their validity. "We consider it implausible that these patterns (of mortality rates) would arise from data fabrication," the researchers wrote.

The PA Health Ministry has not issued a similar detailed report since, a reflection of fading communications with Gaza.