With its health infrastructure devastated and Israel's offensive widening, Gaza is losing track of its dead

WARNING: This story contains disturbing images of death and violence.

Gaza's Health Ministry says more than 18,600 Palestinians have been killed and nearly 50,600 injuredsinceIsrael responded with a punishing bombing campaign and ground incursion to a deadly attack on Oct. 7 by Hamas militants that killed 1,200 people and saw another 240 taken hostage.

The mounting death toll and deteriorating conditions for civilians inside Gaza are in part what prompted 153 members of the United Nations including Canada to vote this week in favour of demanding an immediate humanitarian ceasefire in Gaza.

With much of the territory's infrastructure destroyed or damaged,communications networks disruptedand many of the health workerscharged with maintaining death statistics killed, missing or displaced along withthe majority of Gaza's2.3 million people, it's getting increasingly more difficult to keep track of civilian deaths.

CBC News and wire agencies have been reporting on the challenges around death tollsthroughout the war. Here, we revisit how the situation on the ground has changed since we last reported on this issue.

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How have deathtolls been tallied so far?

In the first six weeks of Israel's military offensive, hospital morgues in Gaza sent figures to the Health Ministry's main collection centre at Al-Shifa Hospital in Gaza City.

There, officials used spreadsheets to track names, ages and ID card numbers of the deadbefore transmitting that information to the Palestinian Health Ministry in Ramallah, in the Israeli-occupied West Bank.

"Every person entering our hospital is recorded," Atef Al-Kahlout, director of Gaza's Indonesian Hospital, told The Associated Presslast month.

But of the four officials who ran the Al-Shifa data centre, one has since died in an airstrike that hit the hospital in November and the other three went missing when Israeli forces seized control of the premises,Omar Hussein Ali, director of the Ramallah ministry's emergency operations centre, told Reuters.

The once-daily casualty updates by the Gaza Health Ministry have become irregular, in part because of frequentdisruptions to thecommunications network.

Hamit Dardagan, who ran the Iraq Body Count project, which compiledcivilian death statistics in the 2003 U.S-led invasion of Iraq and isattempting to trackdeaths in Gaza, told Reuters that the kind of casualty recording required to understand what's going on in Gaza is getting harder to do.

"Information infrastructure, the health systems that existed, are being systematically destroyed," he said.

Palestinian Health Minister Mai Al-Kailasaidlast weekGaza's health services were in a "disastrous" state, with over 250 staff killed and at least 30 arrested by Israeli forces.

How comprehensive is the data?

In addition to the challenges around record keeping, there are alsopractical impediments to accounting for all the dead.

"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," Jeremy Laurence, spokesperson forthe Office of the United Nations High Commissioner for Human Rights,told CBC News.

An Oct. 26 report by the Palestinian Authority (PA), which governsparts of the West Bank, said at least 1,000 bodies could not be recovered or brought to morgues, citing families that were interviewed by its staff.

This can't be verified, because most of the Gaza civil defence force's digging equipment has been destroyed in Israeli airstrikes, Al-Kailasaid last week.

The PA report, which included names, ages and ID numbers of 7,028 Palestinians it recorded as dead from airstrikes, was released after U.S. President Joe Biden said he had "no confidence"in Gaza's casualty figures.

Are Gaza's statistics credible?

UN agencies, the International Committee of the Red Cross and the Palestinian Red Crescent Society have allused the Health Ministry numbers in the past.

"The five, six cycles of conflict in the Gaza Strip, these figures were considered as credible, and no one ever really challenged these figures," Philippe Lazzarini, head of the UN Relief and Works Agency for Palestinian Refugees in the Near East,told reporters on Oct. 27.

Furthermore, the UN's previouscounts have largely been consistent with the Gaza Health Ministry's counts, with minor discrepancies. For example, during the 2021 war, the ministry reported that 260 Palestinians were killedwhile the UN said256 were killed.

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.

Campbell and two other academicsanalysedthe data from the PA report for a Lancet medical journal paper and concluded there was no obvious reason to doubt itsvalidity.

Despite Biden's commentsin this conflict, the U.S. government's annual human rights assessments from the region havefrequently cited the Gaza ministry as recently as 2022.

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Israel's own accounts of Palestinian casualties have sometimes come close to the Gaza ministry's tally. For example, Israel's Foreign Affairs Ministry said 2,125 Palestinians were killed in the 2014 war slightly lower than the ministry's tally of 2,310 and the UN's totalof 2,251.

And last week, Reuters reported, Israeli authorities told journaliststhat death toll figures provided by Palestinian authorities at that time were "more or less right."

What's missing from the data?

That doesn't mean the Health Ministry's findings haven't been scrutinized. Following the Oct. 17 explosion at Al-Ahli Arab Hospital, the Health Ministry at one point reported that as many as 500 people had been killed by the blast, but Western intelligence agenciesconcludedthe toll was considerably lower.

The source of the blast was also disputed, with Israel and outside groups saying it was likelycaused by a misfiring of a rocket launched from inside Gaza and not, as the ministryinitially said, by an Israeli airstrike.

A UN spokesperson toldCBC News the international body has not been able to verify all the information published by the Health Ministry during current hostilities due to the "intensity of the Israeli offensive." Nevertheless, it considers the figures as "a reasonably accurate reflection of the situation to date."

"Information from the ministry is used in our casualty reporting process, in part because the ministry collects data directly from hospitals and morgues," they said. "We seek to corroborate it to the extent possible, and use it, along with other sources, for corroboration."

Figuring out how many ofthose killed are combatants or civilians, however, is more challenging. Palestinian authorities do not break down the count.

Without detailing how that estimate was reached, asenior Israeli official told journalists last Monday that around a third of those killed in Gaza so far were enemy combatants meaning the majority of Gazans killed have beencivilians.

The PA Ministry has reported that close to 70 per cent of those killed were women and childrenbut has not given a breakdown by age since its Oct. 26 report.

Rights groups and researchers say the high civilian tollarises from the heavy weapons used, including so-called bunker busterbombs that Israel claims are used to destroy Hamas'stunnelnetwork; and strikes on residential districts, where Israel allegesHamas has hidden bases, rocket launch pads and weaponry.

Doesn't Hamas run the Health Ministry?

Hamas does exert some control over the Health Ministry as Gaza's ruling authority, but it's different than the political and security agencies that Hamas runs.

For one, the PA, which controlled Gaza prior to it being taken over by Hamas in 2007, still retains power over health and education services in the territory. As well, the current ministry is a mix of recent Hamas hires and older civil servants affiliated with the Fatah party, officials told The Associated Press.

Hamas tightly controls access to information and runs the government media office that offers details on Israeli airstrikes, but Health Ministry employeesinsist Hamas doesn't dictate casualty figures.

"Hamas is one of the factions. Some of us are aligned with Fatah;some are independent," Ahmed Al-Kahlout, director of Kamal Adwan Hospital in northern Gaza, told The Associated Press. "More than anything, we are medical professionals."

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