Israelis in southern and northern Israel huddled in shelters under missile and rocket fire from Gaza’s Hamas and Lebanon’s Hezbollah militia. Palestinians in northern Gaza were being forced to relocate away from yet another incursion of Israeli tanks into densely populated urban areas, including Jabalia refugee camp. Lebanese in southern Lebanon fled at a thickening pace of Israeli air attacks on Hezbollah targets Monday – all in the grinding cycle of violence that marked the one year anniversary of the start of the Israel-Hamas war on October 7 2023. 

One year after the bloody Hamas rampage into Israeli villages and towns near Gaza in the early morning hours that killed almost 1,200 people, mostly Israeli civilians in one day, the war has exacted the largest death toll on Gaza Palestinians. Gaza’s Hamas-controlled Health Ministry has reported over 41,000 deaths to date – while the apocalyptic destruction of the tiny enclave’s infrastructure, including roughly half of Gaza’s hospital network, are plainly evident.

But the powerful advances of Israel’s military into Gaza have so far failed to achieve what was supposed to be the main goal of the invasion – the release of some 101 remaining Israeli hostages held by Hamas, whose chances of physical survival in harsh underground conditions are waning, against the unrelenting circle of displacement, death, disease and mental health distress.  And Monday’s memorial events, punctuated by Lebanese, Hamas and Yemenite Houthi missile and rocket fire aimed at Israeli cities and towns from north to south, highlighted the fact that Israelis are no longer immune either to the fallout of an escalating conflict – despite a much-vaunted missile defense system.

Locked in an expanding circle of fire 

In the diplomatic domain, Palestinians have chalked up clear gains. In early June, the Ramallah-based Palestinian Authority has obtained quasi-state recognition by the World Health Organization and the UN General Asssembly, while Israel has found itself increasingly marginalized.  That, despite the fact that on the ground, realities are harsher than ever.

The skyline of Gaza City, which only a year ago had seen a decade-long building boom of new high rise apartments, sports arenas, restaurants, malls, and even luxury hotels, is now buried in sand and rubble – under which thousands more missing Gazans may still be buried as well.  Some 1.9 million Palestinians, or 90% of Gaza’s population, have been displaced at least once over the past year, with hundreds of thousands sheltered from sweltering summer heat and bitter winter cold only by flimsy tents.  Hunger, poverty and disease have all tightened their grip, even if Hamas still wields enough control to launch missiles into Israel – 14 in total on Monday.  

Now, as the focus of Israeli wrath shifts northward, an estimated 1 million Lebanese have been displaced, mostly in just the past week, including hundreds of thousands who have fled the country, by air when they could afford it, and if not, overland into Syria. Pressure on Lebanese health and emergency services is meanwhile mounting, as Israel widened its arc of aerial bombardment from the air, complemented by a recent ground invasion. 

But despite the recent Israeli advances into Lebanon, the 68,000 Israelis who fled their homes along Israel’s northern border last October and November, still see no date of return in sight. Another 75,200 Israelis along Gaza’s southern border also remain displaced, according to data cited by the Norwegian Refugee Council, and WHO.

In both southern Lebanon and northern Israel, towns are increasingly pockmarked with craters.  Burnt out forests and fields charred from fires are visible in areas that were popular tourist areas in calmer times. And even before the recent escalation, the year-long tit for tat cycle of attacks along the Israel-Lebanese border, which began with the Gaza war, had exacted human casualties on both sides, including a dozen Druse children, struck by a Hezbollah missile on a playground in late July. 

Meanwhile, everyone in the region was waiting to see what would come of Israel’s promised retaliation on Iran – following the Islamic state’s attack last Tuesday evening, 1 October, with 180 high-speed missiles.

‘Dangerous escalation – the best medicine is peace’

“The Islamic republic of Iran’s attack on Israel is a dangerous escalation, with serious consequences for the region,” said WHO Director General Dr Tedros Adhanom Ghebreyesus, speaking at a WHO press conference Thursday, 3 October, just after the Iranian barrage and ahead of the October war anniversary date. 

 “WHO calls for a de-escalation of the conflict, for health care to be protected and not attacked, for access routes to be secured and supplies delivered, and for a ceasefire a political solution and peace, the best medicine is peace,”  Tedros added. 

But on the morning of 7 October, 2024, that vision seemed further than ever from reality. 

As bereaved Israeli families gathered at 6:30 a.m. Monday in a memorial ceremony at the site of the Nova music festival, where about 400 young revelers were gunned down a year ago, and others were taken hostage, Hamas fired off the first four of the day’s 14 missiles from nearby Gaza, setting off sirens as far north as Tel Aviv, where two people were wounded from falling debris. Later in the morning, six more Israelis in the country’s third largest city, Haifa, as well as Tiberias were wounded from Hezbollah missile, rocket and drone fire from southern Lebanon.  Throughout the memorial day, hundreds of thousands of Israelis in northern Israeli communities, Jews, Palestinian Arab and Druse, were forced to stay in shelters as a total of 135 Hezbollah missiles and rockets came their way.

Hospitals in Israel’s north moved critical operations underground long ago – and unlike counterparts in Gaza and Lebanon, Israel’s health system is thus “handling the pressure in the face of rocket attacks,” a WHO spokesperson told Health Policy Watch, adding, “there is immense human suffering on all sides of the conflict.  As humanitarians, our job is to help alleviate that suffering to the degree possible while urging warring parties to exercise restraint.”      

Disproportionate death toll 

Restraint has been a highly contentious concept, however, from the very beginning of the conflict. 

Israel’s bombardment of Gaza, described as amongst the most intense of modern warfare in the first months of the invasion, prompted South Africa to bring charges against Israel of genocide and other war crimes in the International Court of Justice in December 2023. Israelis denounced the accusations, arguing that the huge casualties sustained in Gaza were largely due to the fact that Hamas had embedded its forces within and underneath civilian areas; it invested heavily in tunnel networks to protect its armed forces, while leaving civilians helplessly exposed.

Since 7 October 2023, more than 1000 Gaza health workers have died, according to the most recent tally by Gaza’s Hamas-controlled Health Ministry. As of 30 August, only 17 of Gaza’s 36 hospitals remain partially operable, according to WHO. And Gaza’s largest and most sophisticated health facility, Al Shifa, was virtually destroyed after being surrounded by Israelis and caught in the crosshairs of fierce gunbattles with Hamas forces over two weeks in late March. Some 21 patients died in the hospital while more than 100 patients were trapped with insufficient food and water or hygiene during Israel’s seige, according to WHO – which it denounced as illegal under international law.

Israelis, on their side, have long contended that along with schools and refugee centers, Hamas systematically embedded armed units in Gaza’s health facilities, sometimes holding or ferrying Israeli hostages there too. Around three dozen hostages were held at  Al Nassar Hospital in October and early November 2023, former Israeli hostage Sharon Aloni Cunio told CNN in January. Cunio described how she and her twin three-year-old daughters were held one of three hospital rooms, each containing about a dozen hostages, for most of their captivity and prior to their release in late November.  Her husband David still remains hostage in Gaza. 

Rising Lebanese death of emergency responders 

In Lebanon, as well, where Hezbollah militias also are deeply embedded in civilian areas that also lack shelters or significant air defenses, the death toll is now rising too. Some 1,974 people, including 127 children and 261 women, have been killed by Israel since 7 October, said said Lebanon’s Minister of Public Health, Dr. Firas Al-Abyad, in a 3rd October press conference. More than 140 Lebanese ambulance workers, firefighters and paramedics also have died.

The death toll has mounted sharply during the most recent series of Israeli attacks on Hezbollah’s top leadership, including Hassan Nasrallah, killed in an Israeli aerial raid on Beirut on 27 September. That has been followed by an Israeli ground incursion into southern Lebanon – which has the stated aim of pushing Hezbollah back from the border area, so that displaced Israelis can safely return to their homes in the north.

“In southern Lebanon, 37 health facilities have been closed, while in Beirut, three hospitals have been forced to fully evacuate staff and patients, and another two were partially evacuated,” said Tedros in his remarks to the media last Thursday. [On Friday, a sudden Israeli air strike outside the gates of a hospital in Marjyoun, killed seven paramedics and forced that facility to close as well[. 

“Health and humanitarian workers, including WHO staff, have done incredible work under very difficult and dangerous conditions with limited supplies, and yet healthcare continues to come under attack in Lebanon,” Tedros added. As a result, he noted, “many health workers are not reporting to duty as they fled the areas where they work due to bombardments. 

“This is severely limiting the provision of mass trauma management and continuity of health services…. We had planned to deliver a large shipment of trauma and medical supplies tomorrow to Lebanon. Unfortunately, this has not been possible due to the almost complete closure of Beirut’s airport.  WHO calls on all partners to facilitate flights to deliver much needed life-saving supplies to Lebanon.”

Dramatically different perceptions of the war affect responses to its worst atrocities

On both sides, dramatically different perceptions of the reasons behind the war, and its conduct, have fueled disbelief, or indifference, to reports of attacks on civilians, on hospitals and health workers, as well as reports of abuse and atrocities on either side of the Palestinian-Israeli divide.

Despite oft-fierce criticism of Prime Minister Benjamin Netanyahu for ducking a hostage deal, Israel’s mainstream TV channels have only portrayed only a fraction of the scenes from Gaza’s humanitarian crisis, regularly played out in European and American media – not to mention Asia and the Middle East.   

Conversely, the narrative of Israeli commuities in southern Israel that were brutalized and displaced on October 7, and subsequently in the north, has continued to dominate the Israeli media, long after it was forgotten elsewhere.  Accounts of Hamas sexual violence and sexual torture of Israeli women were questioned or ignored altogether by the humanitarian community, until a visit to Israel by a UN special representative, Pramila Patten, in late January. She later told the UN Security Council that there were ‘reasonable grounds’ to believe the Israeli reports. 

“What I witnessed in Israel were scenes of unspeakable violence perpetrated with shocking brutality,” Patten told the Security Council at a session in March, following her interviews with nearly 3 dozen survivors and witnesses of the 7 October attacks, including released hostages, and review of extensive film footage of the attacks. “It was a catalogue of the most extreme and inhumane forms of killing, torture and other horrors.”   

Inside Israel, meanwhile, allegations of sexual abuse and torture of Gazan Palestinians captured and held as prisoners at the Sde Teiman detention camp in the Negev desert, which surfaced over the summer as a result of a series of media leaks by Israeli medical doctors disturbed with what they had witnessed, were also met with widespread disbelief or denial in Israel.  

“The testimonies reveal that Palestinians currently in Israeli prisons are being subjected to harsh arbitrary violence on a frequent basis, sexual assault, humiliation and degradation, deliberate starvation, forced lack of hygiene, sleep deprivation,” and more, stated an August report by the Israeli human rights group B”Tselem. 

The late August arrest of 10 soldiers suspected of aggravated sodomy prompted a mob of right-wing Israeli protestors to attempt to overrun the army detention facility where the soldiers were being held. Five reservists whose investigation continued were later released to house arrest. In a September ruling, the country’s High Court of Justice ordered the military to abide by Israeli law and international conventions – but declined to close the facility altogether, saying conditions had improved.    

Children the ultimate victims 

On both sides, as well, displaced, injured and traumatized children have been the biggest victims of the war.

A recent study on the health status of some 19 Israeli children and 7 women who were among the 80 Israelis and foreign residents released from Hamas captivity in late November and early December 2023, during a brief cease-fire, found that while the group had all suffered from weight loss, hygiene-related infections and shrapnel injuries, the biggest impact was on mental health.  

“The most concerning aspects we experienced as a medical team among the returnees are psychological. Long-term follow-up is necessary to understand the medical and psychological implications of captivity,” said Dr. Noa Ziv, lead investigator for the study, published in August in the international journal Acta Paediatrica.

But here, as well, in terms of absolute numbers, it is Gaza’s children who have suffered more – with as many as 14,000 child casualties of war, according to Gaza’s Health Ministry.

Some 9 out of 10 children suffer under-nutrition risks according to a UNICEF report in early June. Sewage, unhealthy water supplies and piles of rubbish have increased the risks of infectious diseases of all kinds – particularly for children who are generally more vulnerable. That risk came to a head with the discovery of poliovirus in waste water in July, followed by the confirmation of an active case of the virus in a 10-month-old child. 

An initial mass vaccination campaign concluded successfully with some 560,000 children receiving the oral vaccine during a series of agreed- humanitarian pauses.  Now a second round of the WHO polio campaign is planned to commence on 14 October. 

“We have asked the Israeli authorities to consider a similar scheme that we had for the first round, something they call ‘tactical pauses’ (in fighting) during the working hours of the campaign,” said Ayadil Saparbekov, WHO lead for emergencies in the occupied Palestinian territory, in a UN press briefing in Geneva on Friday.

But with Israel stepping up its military action again in Gaza, while also preparing for a retaliatory attack on Iran, it remains to be seen if September’s successful campaign can be repeated.  

And polio is not the only threat, said UNICEF Executive Director Ted Chaiban, following a late September visit to Israel, Gaza and the West Bank.

“Since my last visit, tons of untreated solid waste have accumulated,” he reported. “I spoke to children digging in huge piles of garbage. They told me they were looking for bits of paper or cartons to light fires to cook their meals with their families. I visited Geraar Al Qudua school, which was turned into a shelter. There, in the middle of the school court, the people dug a makeshift open sewage to evacuate wastewater. With the current temperatures, these are terrible recipes for the emergence and spreading of diseases.”

Disabilities and acute rehabilitation needs

Along with the infectious disease risks, some 22,500 Gazans have have sustained life-changing injuries, including  shattered and amputated limbs, or various forms of spinal and brain trauma. And these are largely going untreated according to a WHO analysis released on 12 September. 

The WHO report refrained from providing any breakdown of casualties by gender or age.  But UNICEF says thousands of Gazan children are among those disabled since the 7 October war began, in addition to the estimated 98,000 children already living with a disability.  A recent report by Human Rights Watch drills down into the plight of disabled children living in substandard conditions and unable to access treatment. 

Another report, in The Lancet, addresses the escalating mental health crisis among Gaza’s children – in a society where 65% of the population are under the age of 25. “Constant bombardment and displacement and the loss of family members are predisposing many children to anxiety, depression, post-traumatic stress disorder (PTSD), and other adverse mental health conditions. In fact, a 2020 study showed that 53·5% of Gazan children had PTSD even before this conflict,” stated the paper published in April, and led by researchers from Egypt and Gaza, as well as Georgetown and Harvard. 

Israeli hostages – time running out 

On the Israeli side of the divide, meanwhile, an overwhelming concern remains the dwindling prospects for survival of the 101 hostages still held by Hamas or allied groups. Approximately one-third are thought to have already perished in captivity, while chances for survival of those still alive is diminishing by the day, experts warn. This includes the youngest child hostage, Kfir Bibas, who was just 9-months old when he was taken captive along with his 4-year-old brother Kfir and their mother, Shiri, on October 7 at Kibbutz Nir Oz. Hamas later said the family was  killed during an Israeli attack on the southern Gaza city of Khan Yunis, although the Bibas family still holds out hope for their survival.  

“All hostages are humanitarian cases in imminent danger. As time progresses, the number of survivors decreases sharply, potentially reaching a point where none remain alive,” stated an August report on hostage health, published by Israel’s Hostages and Missing Families Forum, marking ten months in captivity. Risks to survival range from pre-existing chronic conditions to the impacts of poor hygiene and infection exposure, lack of sunlight, exercise and adequate nutrition, leading to new diseases and chronic health conditions even in the healthiest hostages.

“It can be said with high certainty that everyone who was captured and remains alive is now suffering from various diseases and symptoms that will worsen to the point of endangering their lives, if they are not released from captivity soon,” the report stated.   

Many Israelis doubtful that a wider war will lead to hostages’ return

Against that grim picture, many or most Israelis who are connected to the hostages as family or close friends doubt that the government’s latest campaign in Lebanon will really achieve the desired effect of ramping up pressure on Hamas, Hezbollah and Iran sufficiently to bring their loved ones home alive. 

And even those Israelis who view Hezbollah as an existential threat, (and most do), see the strategic priorities of Prime Minister Netanyahu as driven largely by his political aims, which include keeping his hard-right governing coalition intact. And that aim is better further by perpetuation of the conflict, as compared to a cease-fire, including the hostages’ return – opposed by the  hardliners.  

“I don’t think that the military pressure in Lebanon will improve Israel’s negotiating position. The war in the North is a reaction which should have been taken in 2007, when Hezbollah started to break the UN Resolution 1701,” said Dita Kohl, a relative of Israeli hostage Carmel Gat, referring to the 2006 agreement in which Israel withdrew from Lebanon, in exchange for Lebanon removing Hezbollah militias from the border area, thus ending the Second Lebanon War. 

Kohl, spoke to Health Policy Watch from a bomb shelter in Tel Aviv late Monday afternoon as Israel’s central region caught another fresh volley of missile fire – including two missiles from Yemen, and a little later, from Hezbollah again. 

The family had waged a year long war for Gat’s release before the 40-year-old occupational therapist, was found dead along with five other hostages in a Hamas tunnel on 1 September – all with recent gunshot wounds to their heads.  

“The hostages are in the hands of a psychopath who does not play by any rules,” Kohl said, referring to Hamas leader Yahya Sinwar, who remains bunkered in Gaza, according to most reports,  possibly alongside other surviving captives.   

Only a few hours later, several thousand Israelis from across the country would defy the missile threats and gather for an October 7 commemoration in Tel Aviv’s  HaYarkon Park, convened by the Hostage Families Forum.  The Forum created the event as an alternative to the official state memorial ceremony, which was boycotted by most hostage families and allies – who have been blocking roads, protesting and calling for Netanyahu’s resignation over his handling of the war and management of the hostage crisis for most of the past year.    

Said Kohl, a member of the Forum, “The fundamental issue that the state of Israel and Israeli society is facing is where does the value of protecting the lives of civilians stand?”

Image Credits: HPW, UNRWA , UNICEF/Dar Al Mussawir, UNRWA , ITV/Channel 12, Doron Horowitz/FLASH90, UNICEF/UNI501989/Al-Qattaa, © 2024 Ahmad AL lulu for Human Rights Watch, Israeli Families of Hostages and Missing Persons Forum.