DUBAI, United Arab Emirates, and RAMALLAH, West Bank — Eman Abusaeid struggled to keep her children safe in Gaza, as Israeli bombs targeted her neighborhood in the days after Oct. 7, when Hamas militants stormed into Israel.
The Palestinian architect and mother of two could hear Israeli fighter jets rumbling overhead as air strikes took out the building next to hers. Bodies were being pulled from the rubble. She was trying to shield her children from scenes of death all around.
"We woke up with the dust bombing on our faces and bodies, and smelling of gunpowder and dirt. My kids crying and shouting all the day because of the bombing from the F-16 war airplanes," she said in a call with NPR on Oct. 9. "We're trying to escape, but we don't [know] where to go."
Gaza's health ministry said Thursday that the number of Palestinians killed in the war has surpassed 30,000. The official number now stands at 30,035 deaths. The figure is widely viewed as the most reliable one available.
The health ministry provided NPR with one of its latest reports on the death toll, 38 pages long, to analyze. A close look at how Gaza's health ministry counts those killed in the war reveals a system that is buckling under the weight of war and unable to keep an accurate toll of the dead.
Thousands remain unaccounted for — either missing under the rubble, buried hastily in side streets or decomposing in areas that can't be safely reached.
The health ministry's official database was made public in October
The Gaza health ministry says its daily tally now relies on a combination of accurate death counts from hospitals that are still partially operating, and on estimates from media reports to assess deaths in the north of Gaza, where Israeli forces control access. Its detailed daily report shows that its electronic system for counting the dead was disrupted on Nov. 12, when communication was lost with three major hospitals in the north, soon followed by more in other parts of Gaza.
In the early days of the war, as the wounded and dead streamed into hospitals, Gaza's health ministry kept a detailed daily count of the number of people killed. Public and private hospitals were recording into an electronic database the names, ages, genders and ID numbers of the dead.
In late October, after President Biden said he had "no confidence" in the figures reported by Gaza's health ministry, which falls under Hamas' administration, the ministry published the database with thousands of victims' names.
Israel blames Hamas for the high death toll, saying its fighters use civilian infrastructure as cover and operates in tunnels that run under schools, homes and hospitals.
The numbers are calculated using a combination of hospital data and public sources
The health ministry's figures rely mostly on hospital emergency rooms, which record information about patients who come in. Hospitals tally the number of people dying in their overflowing hallways and operating rooms each day.
According to the ministry, more than 17,000 Palestinian deaths have been recorded this way, with the victim's name and other information recorded in the electronic database unless the body cannot be identified, in which case it is indicated as such.
The health ministry spokesman in Gaza, Ashraf al-Qudra, says the system for counting the dead is computerized, with clear input instructions. People working in hospital emergency departments can be easily trained on how to update the electronic database, he says.
The other 13,000 or so deaths in its overall total of 30,000 are based on accounts from "reliable media sources," though the ministry doesn't cite or say which sources those are. Al-Qudra tells NPR this reliance on public sources of information is the result of multiple communication blackouts, in which phone lines and internet service were cut in Gaza, sometimes for more than a week. This made it difficult to communicate with hospitals and upload the number of casualties to the ministry's database. During some of these blackouts, the ministry in Gaza couldn't provide daily death toll figures.
The scale of devastation has overwhelmed Gaza's health system
Other breaks in the system have occurred. In November, Israeli forces struck and raided Al-Shifa, Gaza's largest hospital, which Israel's military said was being used by Hamas. People at the hospital were burying bodies in shallow graves on its premises, with no staff able to record the deaths as the Israeli raid was closing in and the hospital was besieged.
More recently, this month, Israeli troops besieged and attacked two hospitals in Khan Younis in the south. In the Nasser Medical Complex, the military said it was searching for hostages. That hospital has not reported death tolls since Feb. 13, according to the health ministry.
Israel says around 1,200 people were killed in the Hamas attack of Oct. 7 and that 240 people were taken hostage. Israel says around 100 people are still being held hostage in Gaza.
Health workers have also been hit — injured, displaced and killed. The health ministry says nearly 350 medical staff have been killed across the Gaza Strip since the start of the war. Others have been wounded, including the director-general for Gaza's health ministry, Dr. Munir al-Bursh, who was hurt and lost a young daughter in an Israeli air strike in December, according to Al Jazeera footage showing him speaking as he was being transported in an ambulance and cradling his daughter's body.
With most of Gaza's hospitals forced to close, the few that are still partially functioning do not have enough medical supplies, doctors or staff to cope with the number of dead and wounded, particularly in the north, where Israel ordered evacuations. The United Nations says the war has displaced around 2 million people in Gaza.
Thousands missing beneath rubble are not included in the official count
Abusaeid, the mother trying to protect her son and daughter in October, fled her home in Gaza City several days into the war. She sought refuge in her parents' apartment in the central area of Nuseirat, where she sheltered with her husband and kids, siblings and young nieces and nephews.
"It's a horrible, horrible, horrible things to see here in Gaza," she told NPR before evacuating her home. "I try to make my kids safe."
On Oct. 31, Israeli warplanes targeted the five-story building the family was in. Abusaeid, 40, was killed. So were her husband and children. In all, 23 members of the family lost their lives in the attack.
Only one person in the apartment survived, a younger sister whose six children were among those killed, according to relatives who confirmed the details.
Gaza's health ministry says more than 2,685 families have been killed in the war.
NPR visited the site of the airstrike and saw large gray mounds of mangled steel and crushed cement, the remains of 20 apartments turned to rubble.
NPR reached out to the Israeli military multiple times, including with coordinates of the building, with questions about why it was bombed, but did not receive a response.
Relatives say Abusaeid's husband, Iyad, her brother, Mahmoud, her son, Ziyad, and three other children in the family are still missing under the rubble. Their bodies were never recovered.
Deaths like theirs are mostly excluded from the health ministry's casualty figures. Around seven weeks into the war, the Gaza health ministry said at least 6,800 people were missing under the rubble. That figure has not been officially updated since. The latest reports only say that "a large number of victims are still under the rubble and on the roads."
"We have made it clear that there are people whose names and information cannot be recorded, whether those who are still under the rubble or those who are recovered from under the rubble and buried immediately," al-Qudra says.
The health ministry's director of international cooperation in the West Bank, Dr. Yaser Bozya, says he works closely with ministry colleagues in Gaza. Speaking with NPR in late January from his office in Ramallah, he said an estimated 10,000 people are missing and presumed dead under the rubble in Gaza — but even that number is low.
"It is like a snowball," he says. "It's only an estimation. The actual number is much, much higher."
Gaza's official toll largely leaves out deaths from indirect war impacts — and some important details
Bozya and doctors in Gaza say the death count published by the health ministry also largely excludes people who have died from a lack of adequate treatment, disease and other impacts from the war, like hunger.
The death toll only includes people killed by the "occupation bombardment," Boyza says. The health ministry describes its casualty figures as those resulting from "Israeli aggression."
Bozya says a colleague in Gaza told him the only way to really know how many people have died is to count the number of people still alive compared with the population of Gaza before Oct. 7.
"Because of the continued, brutal war going on there, we could not have the real number. It will be after the war has been finished," Bozya says.
The death toll also does not make clear how many militants are among the dead. Israel says its forces have killed more than 10,000 fighters in Gaza, but has not provided evidence or detailed information to back up its estimate.
Gaza's health ministry says 70% of those killed in the territory are women and children. Its most recent breakdown of casualties recorded in hospitals shows women and children make up 58% of those deaths. Al-Qudra could not explain the discrepancy. Recently, Al Jazeera obtained and published a list of thousands of names of Palestinian children in Gaza killed in the war.
In past wars with Israel, the Gaza health ministry's death tolls were mostly in line with counts by the United Nations and Israel, though there have been discrepancies in the past with Israel on the numbers of civilians vs. militants killed.
An analysis published in the Lancet medical journal in December found that Gaza's health ministry has "historically reported accurate mortality data," with discrepancies between 1% and roughly 3% when compared with U.N. analysis of deaths in previous conflicts. The study found "no evidence of inflated rates" in the current war and noted that difficulties in obtaining accurate death counts "should not be interpreted as intentionally misreported data."
For those who've lost loved ones in the war, these casualty figures aren't just numbers. Each one represents a life, someone who worked hard, had aspirations and was loved.
Abusaied's brother, Mohammed, who lives in the U.K., says his sister Taqwa, who survived the airstrike but lost her six children, is hardly able to speak when he calls her now in southern Gaza.
He misses being able to call his parents in Gaza and share photos of his children in the U.K. over WhatsApp with them. He finds it hard to look at the pictures of his parents, six siblings, 12 nieces and nephews and other relatives who were killed in the Oct. 31 attack.
"When I look at pictures, it's very painful," he says. "Ten years, I was praying to Allah, you know, to reunite with my family. But this will never happen."
Anas Baba contributed to this report from Rafah, the Gaza Strip.
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