Extract from ABC News
Helmi Hirez's (left) mother Ibtisam was killed in an Israeli air strike while sheltering in Rafah. (Supplied)
To register his mother's death, Helmi Hirez spent hours carrying bodies and getting covered in blood.
Warning: This story contains details and images some readers may find disturbing
After Ibtisam Hirez was killed by an Israeli strike on the house she and her family were staying next to in Rafah on February 12, Helmi and his brother had to take her body between hospitals and morgues.
It's the main way to have a loved one's death be counted in Gaza — for their body to be verified at an official medical centre and recorded by the Ministry of Health.
Helmi Hirez and his brother had to take their mother's body to hospital to try and register her death. (Supplied)
"Me and my twin brother went with the ambulance … (and) we helped him carry more than 15 bodies," the 19-year-old computer science student said.
"Many of the bodies were shattered into pieces of meat, so they filled the entire ambulance with blood and our clothes with blood.
"All the bodies just mixed with each other. And my mother's shroud was wet from someone else's blood.
"We just moved them, and when we reached the hospital, there was like an old chief, a policeman or something like this, who just asked us and anyone who was around the bodies to identify them," he said.
Ibtisam is now recorded on the official death toll from Israel's invasion and bombardment of Gaza, which has reached at least 42,400.
The ABC analysed the latest available data and broke down the numbers; see how we did that.
But the ordeal shows one difficulty in assessing the true toll of Israel's assault on Gaza that began in retaliation for the October 7 Hamas attacks that killed around 1,200 Israelis.
The other is when bodies never make it to hospital because they're trapped under rubble, left unidentifiable, or were buried in back gardens, vacant blocks or even on the side of the road.
One man told the ABC that paramedics divide up remains found in specific locations and distribute them to family members of people believed to be killed there. But there is never confirmation that the remains families are burying are their loved one.
Israel has attempted to discredit the death toll, saying it is produced by Hamas, full of deliberate errors and exaggerated.
But despite enormous challenges in collecting data, experts say the death toll is not only recorded honestly, it is likely an under-count.
Families killed, many not registered
Dalloul Alneder's mother Halima was killed in an Israeli air strike. (Supplied)
Dalloul al-Neder lost four of his immediate family members in an air strike on his family home in the northern Gaza area of Jabalia in December.
The bodies of his mother, brother, and niece were found and their deaths have been recorded.
But his brother's pregnant wife was believed to have been trapped under the rubble and was not counted, neither was his other sister-in-law who was killed months later.
"It is impossible to register the whole family," he said.
"For example, my mum, we thought she had survived (the air strike). So, we managed to move her to the hospital and she got registered [after she died]."
Dalloul al-Neder's 11-year-old niece Remas was killed in an Israeli air strike on the family home. (Supplied)
Dalloul's sisters-in-law Rajha (left) and Haneen were likely trapped under rubble and not counted. His mother Halima, and brother Mohamad were found and buried. (Supplied)
Like Dalloul's relatives, many were trapped under bombed buildings and died.
The Palestinian Civil Defence organisation, which responds to building collapses and recovers bodies, said more than 10,000 people have suffered that fate and their bodies are yet to be recovered.
Gazan health ministry officials reject Israel's claims their figures are dictated by Hamas, a militant group listed as a terrorist organisation by the Australian government, which was also the government of Gaza.
Israel's invasion has destroyed much of the administrative capacity in Gaza, but some agencies, like the Ministry of Health (MoH) are still functioning.
The ministry coordinates with its counterpart in the West Bank, which is controlled by the internationally recognised Palestinian Authority, although there is significant duplication of functions, according to the World Health Organisation and other medical groups.
"Control of the MoH was given back to the PA as part of the 2017 reconciliation agreement between Fatah and Hamas," Physicians for Human Rights Israel, a charity which helps with multiple aspects of healthcare in Gaza, told the ABC.
"One of key components of the agreement was the transfer of administrative control of Gaza, including the Ministry of Health, back to the Palestinian Authority. However, the full implementation of the agreement was not entirely realised."
Two Palestine Red Crescent Society paramedics were killed when an ambulance on a mission to rescue people was hit in an Israeli strike in May, according to medics. (Reuters: Hatem Khaled)
The ministry has a digital system, its Health Information Centre (HIC), which collates deaths from Gaza's hospitals.
It lists deaths using an identification number given to Palestinians born inside Gaza and sent to the Israeli military administration for approval. These numbers are later used for things like applying to Israeli authorities for permits to leave Gaza.
The destruction of Gaza's 36 hospitals by Israeli troops (of which only 16 remain partially functional) meant the digital system broke down and for months, health ministry staff were not receiving updated information about how many people had died.
In that time, the hospitals' communications staff wrote the details of the dead on paper to be put in the civil registry at a later date.
If the hospital was particularly busy, it would do a headcount of the new bodies to relay the numbers and photograph the bodies for later identification, Zaher Al Wahaidi the director of the HIC told Sky News UK.
Now, with some health services restored in Gaza, deaths are being collated again based on hospital records.
Mr Al Wahaidi told Sky News that paper records from the period without the digital system have since been digitised.
Document lists 14 pages of babies
The Ministry of Health has been periodically releasing lists of the deceased with their names, birthdates and ID numbers, so they can be publicly scrutinised.
The latest 649-page document was released in September and contained data up to August 31, officially identifying 34,344 people. After analysing the data and removing duplicates, the ABC found 34,328 unique entries.
That number is around 6,400 short of the ministry's death toll as reported at the end of August because it only includes people who have been formally identified.
The age break down shows thousands of those killed were children.
There were 169 babies born and killed during the war, 21 of them were too young to have been given a name.
In total, 707 babies under the age of 12 months have been killed in the conflict. Their names spanned 14 pages in the MoH document.
The total number of children, or people under the age of 18, who have been killed is 11,347.
The MoH figures don't differentiate between combatants and civilians, but children, women and elderly represent 60 per cent of the identified dead — people who were unquestionably civilians or unlikely to have been combatants.
Names, not just numbers
Four-day old twins Ayssel and Asser Abu al-Qumsan, who were killed with their mother while their father was picking up their birth certificates, were listed in the document.
Mohammed Abu Al-Qumsan, whose wife Jumann, and newborn twins Asser and Ayssel were killed in an Israeli strike. (Reuters: Abdullah Al-Attar )
So too was Hind Rajab, the almost six-year-old who was killed by Israeli forces while trapped in a car, begging to be rescued 12 days before her body was found surrounded by those of her family members and two ambulance workers who had come to rescue.
The oldest people listed were two men born in 1922 and 1924 who were killed at the ages of 101 and 100. The next group were five women and a man aged 97.
But Hala Khreis, a 57-year-old grandmother who was shot while fleeing holding her grandson's hand and a white flag, was not on the list.
She was never taken to a hospital to be counted; instead, she was buried "in a shallow grave, in a small alleyway next to the family home, her grave stone written in chalk", according to CNN.
Hind Rajab had been in a car with family members on January 29 as they attempted to flee from approaching Israeli forces in the Tel al-Hawa area of Gaza City. (AFP: Family Handout)
In an update on Friday the Ministry said 1,206 Palestinian families had been entirely wiped from the civil registry with no members surviving.
It added that 2,271 families only have one survivor while 3,110 families "were subjected to massacrers and have more than one survivor".
Minuscule mistakes
There is a robust system in place for verifying a death, identifying that person and adding them to the death toll even if a body cannot be found, or taken to a medical centre.
Relatives can register the name of someone they believe is missing, presumed dead with the MoH.
Then, the ministry will obtain various forms of evidence and testimony to verify the death and whether it was a direct result of an Israeli attack.
"Death is first proven through a judicial ruling from the judge, for those who are under the rubble or have not reached any hospital or have no proof of death," it said.
It uses its own records to verify identities and note correct information, and where that is not possible it checks against details submitted by relatives.
A number of the deaths will never be identified, it said, for various reasons including the high daily death tolls in the early days of the war where overwhelmed medical staff only counted the totals. Some days the toll reached 800 bodies a day, it said.
A cousin of a Palestinian child killed in an Israeli strike holds the body in Deir Al-Balah in the central Gaza Strip, August 20, 2024. (Reuters: Ramadan Abed)
"It's really an impressive level of transparency to be putting out these detailed spreadsheets," said Michael Spagat, an economics professor who chairs the board of Every Casualty Counts, a charity which aims to accurately record deaths in armed conflict.
The ministry's releases of spreadsheets led to accusations there were mistakes and falsehoods in the data, but Professor Spagat said those had since been explained, including that the ministry was forced to use placeholder ID numbers for bodies that had been received but which could not be identified.
"Yes, you can find invalid IDs in there, you can find duplicates, (but) not huge numbers," he said.
"All of that stuff can be fixed ultimately over the long run.
"(But) they're putting that (information) out and something that I think doesn't get said enough is that the Israelis are not putting out anything like this."
Bodies of Palestinians killed by Israel and buried at Nasser hospital in Khan Younis in the southern Gaza Strip are moved to a cemetery, April 21, 2024. (Reuters: Ramadan Abed)
Professor Spagat said the ministry had since been going back through its records to correct mistakes and include more detail, like adding the names of people who had subsequently been identified.
"In the June 30th release (of spreadsheets) I think the number of invalid IDs decreased to below 500 — previously it had been over 2,000," he said.
"So they're kind of systematically improving the information."
Indirect deaths not counted
The Israeli military said on August 15 that it had killed 17,000 "terrorists", meaning members of Palestinian militant groups like Hamas and Palestinian Islamic Jihad.
The IDF later told Israeli media it had identified 10,000 of them, but its methods and evidence were given in a classified briefing and could not be verified.
Thousands of people remain missing in Gaza though and have not been included in official death figures. About 100,000 have also been injured.
People work to move into a cemetery bodies of Palestinians killed by Israel and buried at Nasser hospital in Khan Younis in the southern Gaza Strip, April 21, 2024. (Reuters: Ramadan Abed)
The World Health Organisation and human rights groups argue the real death toll of the invasion and bombardment of Gaza is likely much higher than reported by the Ministry of Health.
Israel's invasion and bombing has also displaced more than 90 per cent of Gaza's population, according to the United Nations, breaking contact between family members and communities.
The destruction of communications infrastructure and the detention of many Gazans by Israeli troops also makes it hard for families to know what has happened to their loved ones.
Palestinians preparing graves in a cemetery in Khan Younis in the southern Gaza Strip, August 15, 2024. (Reuters: Mohammed Salem)
Israeli Prison Service figures show 1,761 Gazans captured by Israeli forces remain detained and the Israeli human rights group B'Tselem said at least 48 have died in custody.
Even if the fighting stops, deaths will continue to rise, because Israel has destroyed water and sanitation infrastructure in Gaza and disease is rife.
The Ministry of Health casualty figures also only include people killed by the conflict, not those who have died from indirect causes like disease and malnutrition.
A letter published in July by the medical journal The Lancet, written by three public health researchers, said if a conservative estimate of four indirect deaths per one direct death was applied, the true death toll at that time would have been 186,000, or 7.9 per cent of Gaza's population.
Mourners transport the bodies of their relatives killed in by Israeli bombardment during their funeral in Deir al-Balah, Gaza, on September 23, 2024. (AP: Abdel Kareem Hana)
This was the case of Halima Abu Dayya, 97, and Fatima, 89, both of whom survived the Nakba in 1948 and who died after being displaced numerous times in the past year.
The number and rate of casualties from Israel's bombardment and invasion continue to horrify and provoke outrage around the world.
The current death toll is already higher than any other single event in the conflict's history, including the 1948 Palestine war, and experts say the early months of the war saw one of the highest death rates in any conflict in history.
The toll is high enough to fill the entire capacity of the Sydney Football Stadium or Brisbane's Gabba.
It also includes at least 130 journalists and media workers, and more than 280 humanitarian workers, the majority from UNRWA, according to the International Federation of Journalists and UN OCHA.
More women and children were killed by the Israeli military "over the past year than the equivalent period of any other conflict over the past two decades", Oxfam analysis found.
The World Health Organisation agrees that large numbers of Gazans are dying and will continue to die indirectly from the conflict.
"Given the large scale and impact of the conflict, indirect mortality is expected to increase, such as through a spread of infectious diseases, and discontinuation of care, compounded by malnutrition and overwhelmed health facilities," the WHO said.
Relatives of Palestinians buried at al-Amal Hospital in Khan Younis sit next to their graves as preparations are made to exhume them for reburial in a cemetery on July 18, 2024. (Reuters: Hatem Khaled)
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