Hostilities in the Gaza Strip and Israel | Flash Update #45

KEY POINTS

• On 20 November, the Indonesian Hospital in Beit Lahiya (North Gaza) came under attack, reportedly resulting in at least 12 fatalities, including patients and their companions, alongside many injuries. This is the fifth time the hospital has been hit since the start of hostilities. It is reportedly besieged, and patients and staff are unable to leave. This health facility is under an electrical power backout due to lack of fuel and it also faces severe shortages of water, essential medicines and supplies. In this context, the World Health Organization (WHO) stated on 20 November that “health workers and civilians should never have to be exposed to such horror, and especially while inside a hospital.”  
• Hospitals and medical personnel are specifically protected under international humanitarian law (IHL) and all parties to the conflict must ensure their protection. Hospitals must not be used to shield military objectives from attack. Any military operation around or within hospitals must take steps to spare andprotect the patients, medical staff, and other civilians. All feasible precautions must be taken, including effective warnings, which consider the ability of patients, medical staff, and other civilians to evacuate safely. 
• Attacks and shortages of fuel, medicines, safe water, and other essential resources, have resulted in hospital bed capacity across Gaza declining from 3,500 beds before 7 October to 1,400 beds presently, and is  compounded by the exponential increase in those seeking treatment since the war started, leaving critical gaps for patients with injuries and other illness that require hospitalization, according to WHO.  
• On 20 November, about 40 trucks carrying the medical equipment, alongside 180 doctors and nurses, have entered Gaza from Egypt. This equipment and medical personnel are intended for the establishment of a second Jordanian field hospital in Khan Younis, southern Gaza, with a capacity of 150 beds. 
• On the occasion of the World’s Children Day, the Humanitarian Coordinator Lynn Hastings reiterated her appeal “to all parties to the conflict to protect Palestinian and Israeli children and their rights." As of 10 November, 4,506 Palestinian children were killed and about 1,500 have been reported missing and may be trapped or dead under the rubble, awaiting rescue or recovery, according to the Ministry of Health (MoH) in Gaza. The number of children killed so far has exceeded annual figures in all war zones since 2019, according to Save the Children. At least 33 Israeli children were killed on 7 October, and, according to the Israeli military spokesperson, 40 children are held hostage in Gaza. 
• On 20 November, an estimated 25,000 additional people fled the north through the Salah Ad Deen “corridor.” Due to the lack of space in existing shelters in the south, thousands of internally displaced persons (IDPs) are sleeping out in the open, against the walls of shelters, seeking food and water, as well as protection. Their situation has significantly worsened in the past 24 hours, as they became exposed to the heavy rains. 
• On 19 November, at about 11:30, Israeli forces reportedly hit a residential building in Gaza city. The attack occurred while people crowded to fill water from an adjacent desalination station. As a result, six Palestinians were killed and ten were injured. 
• This report includes an updated section on humanitarian needs and responses, covering 13-19 November. 

Hostilities and casualties (Gaza Strip)

• Intense ground clashes between Israeli forces and Palestinian armed groups continued in and around Gaza city, as well as in several areas in the North Gaza governorate, as well as in Khan Younis and east of Rafah (in the south). Airstrikes and shelling by Israeli forces also continued in multiple areas across Gaza. Israeli ground troops have maintained the effective severance of the north from the south along Wadi Gaza, except for the “corridor” to the south.  
• In two separate attacks reported on 19 November, in Jabalia and Gaza city, residential buildings were hit, reportedly killing 18 and 40 Palestinians, respectively. On another attack, on 20 November, at about 04:20, Israeli forces reportedly hit two residential buildings, near An Najjar hospital, eastern Rafah, southern Gaza, killing 17 Palestinians and injuring 15 others.  
• Since 11 November, following the collapse of services and communications at hospitals in the north, MoH in Gaza has not updated cumulative casualty figures. Their reported fatality toll as of 10 November at 14:00 (latest update provided) stood at 11,078, of whom 4,506 were children and 3,027 women. About 2,700 others, including some 1,500 children, have been reported missing and may be trapped or dead under the rubble, awaiting rescue or recovery. Another 27,490 Palestinians have reportedly been injured. 
• As of 11 November, at least 3,117 school students and 183 educational staff have been killed in Gaza and more than 4,613 students and 403 teachers have been injured, according to the Ministry of Health in Ramallah. Additionally, as of 13 November, about 300 school buildings (61 per cent of all such buildings in Gaza) are said to have sustained damage. 
• Since 7 October, the Committee to Protect Journalists (CPJ) has preliminarily documented the death of 50 journalists and media workers, including 45 Palestinians, 4 Israelis and 1 Lebanese, making it the deadliest period for journalists since CPJ began gathering data in 1992. 
• In the 24 hours preceding 18:00 on 20 November, two Israeli soldiers were reportedly killed in Gaza, bringing the total number of soldiers killed since the start of ground operations to 71, according to official Israeli sources. 
• See the latest snapshot for more breakdowns.

Displacement (Gaza Strip)

• On 20 November, the Israeli military continued calling and exerting pressure on residents of the north to leave southwards through a “corridor” along the main traffic artery, Salah Ad Deen Road, between 9:00 and 16:00. OCHA’s monitoring team estimates that about 25,000 people moved during the day, most of whom arrived at Wadi Gaza by donkey carts or buses, and some on foot.  
• Israeli forces have been arresting some people moving through the “corridor.” IDPs interviewed by OCHA reported that Israeli forces had established an unstaffed checkpoint where people are directed from a distance to pass through two structures, where a surveillance system is thought to be installed. IDPs are ordered to show their IDs and undergo what appears to be a facial recognition scan.  
• The movement of unaccompanied children and separated families, including women who were ordered to leave their children, while people are on the move has been increasingly observed. Intensive bombing was heard multiple times in the vicinity of the corridor.  
• The OCHA monitoring team noted an increased number of wounded people crossing on 20 November through the “corridor.” One woman interviewed reported that she had come from Tal Az Za'tar in Jabalia, where her home had been bombed and she sustained shrapnel injuries in her abdomen. She had been walking while pressing a towel against her wounds. Previously, she attempted to receive treatment at the Indonesian hospital, but was not admitted due to collapse of the services there.  
• Over 1.7 million people in Gaza are estimated to be internally displaced, including almost 900,000 IDPs who are staying in at least 154 UNRWA shelters. UNRWA shelters are accommodating far more people than their intended capacity and are unable to accommodate new arrivals.  
• Overcrowding is contributing to the spread of diseases, including acute respiratory illness and diarrhea, prompting environmental and health concerns. On average, there is one shower unit for every 700 people and a single toilet for every 150 people. The congestion is affecting UNRWA's ability to provide effective and timely services. 
• Over 15 per cent of the IDPs are estimated to have disabilities as of 1 November, yet most shelters are not adequately equipped for their needs. Shelters lack the required medical mattresses and beds, causing ulcers for people unable to move and other medical issues that cannot be treated in unsterilized conditions. The UN Special Rapporteur on the rights of persons with disabilities demands unconditional and unrestricted humanitarian aid access and relief for people with disabilities in the Gaza Strip. 
• In recent days, UNRWA, in cooperation with the ‘Humanity and Inclusion’ NGO, has provided 3,830 persons with disabilities, injured people, children and the elderly with hygiene kits, assistive devices, eyeglasses, first aid kits and baby kits.   
• See the live IDP dashboard for the latest figures and more breakdowns.

Humanitarian Access (Gaza Strip)

• On 20 November, two trucks carrying about 67,000 litres of fuel entered Gaza from Egypt, as part of an Israeli decision on 18 November to allow the daily entry of small amounts of fuel for essential humanitarian operations. Fuel is set to be distributed by UNRWA to support food distribution, and the operation of generators at hospitals, water and sanitation facilities, shelters, and other critical services. 
• Additionally, 51 trucks carrying humanitarian supplies entered on 20 November as of 18:00, and another 70* entered on 19 November. Overall, between 21 October and 20 November at 18:00, at least 1,320 trucks of humanitarian supplies have entered Gaza via Egypt (excluding fuel).   
• On 19 November, the Egyptian border opened for the evacuation of 723 dual and foreign nationals and 67 wounded and sick people. Between 2 and 19 November, nearly 7,877 dual and foreign nationals exited Gaza to Egypt. 
• The Kerem Shalom crossing with Israel, which prior to the hostilities was the main entry point for goods, remains closed. According to media reports, the Israeli authorities have rejected requests by Member States to operate this crossing to increase the entry of humanitarian aid. 

Electricity

• Since 11 October, the Gaza Strip has been under an electricity blackout, after the Israeli authorities cut off the electricity supply, and fuel reserves for Gaza’s sole power plant depleted.  

Health care, including attacks (Gaza Strip)

• On 20 November, 28 out of the 31 premature babies, who had been evacuated from the Shifa Hospital the day before, were safely transferred to Egypt to receive medical treatment. The remaining three babies continue to receive treatment at the Emarati Hospital in southern Gaza. Five newborns had died in Shifa before the evacuation, following the collapse of the medical services. All babies are fighting serious infections and others conditions, and need specialised medical care. 
• Israeli operations at Shifa Hospital continued on 20 November for the fifth consecutive day. Nineteen health workers and 259 patients remain in Shifa, according to MoH in Gaza, as of 19 November, facing critical shortages of power, water, and medical supplies. This includes two people in intensive care, 22 dialysis patients, 32 stretcher patients, and 27 patients with spinal injuries, who will be prioritized for the next evacuation. The hospital is no longer operational and is not admitting new patients. 
• On 20 November, a clinic operated by Médecins Sans Frontières (MSF) in Gaza city was hit, resulting in damage to the building and five MSF cars burned and crushed by tank shelling. A total of 21 people are in the clinic, and might be in extreme danger and their status is unknown, the organization has warned. 
• In the past six weeks, there have been multiple and ongoing attacks on health facilities accross the Gaza Strip. As a result, many were killed and injured among patients, companions, and IDPs staying in health facilities and mass displacement as been noted. WHO has recorded 164 attacks on health care in the Gaza Strip since 7 October. 

Water and sanitation (Gaza Strip)

• On 19 November, UNRWA and UNICEF distributed 19,500 litres of fuel to water and sanitation facilities across the south, enabling them to operate generators and resume operations, more than a week after they had been forced to shut down. The fuel supplied during the day is expected to last for about 24 hours. The facilities supplied included two seawater desalination plants, 79 waterwells, 15 water pumping stations, 18 sewage pumping stations, and one wastewater treatment plant. The latter two facilities are critical in mitigating the risk of flooding. Supply of potable water in the south via two pipelines coming from Israel has continued.  
• In the north, grave concerns of dehydration and waterborne diseases due to water consumption from unsafe sources continue. The water desalination plant and the Israeli pipeline supplying water to the north of Wadi Gaza are not functioning. There has been no distribution of bottled water among IDPs accommodated in shelters for over a week, raising grave concerns about dehydration and waterborne diseases due to water consumption from unsafe sources.  

Food security

• Since 7 November, members of the Food Security Sector have been unable to deliver assistance in the north, as access has been largely cut off. Due to the lack of cooking facilities and fuel, people are resorting to consuming the few raw vegetables or unripe fruits that remain. No bakeries are active due to the lack of fuel, water, and wheat flour, and structural damage. Wheat flour is reportedly no longer available in the market. Food Security Cluster members have raised serious concerns about the nutritional status of people, especially lactating women, and children. 
• Also in the north, livestock is facing starvation and the risk of death due to the shortage of fodder and water. Crops are being increasingly abandoned and damaged because of the lack of fuel which is required to pump irrigation water. 
• Across Gaza, farmers have begun slaughtering their animals due to the immediate need for food and the lack of fodder. This practice poses an additional threat to food security as it leads to the depletion of productive assets. 

Hostilities and casualties (Israel)

• The indiscriminate firing of rockets by Palestinian armed groups towards Israeli population centres has continued over the past 24 hours, with no reported fatalities. In total, over 1,200 Israelis and foreign nationals have been killed in Israel, according to the Israeli authorities as cited by the media, the vast majority on 7 October. As of 20 November, the names of over 1,200 fatalities in Israel have been released, including 859 civilians and police officers. Of those whose ages have been provided, 33 are children. 
• According to the Israeli authorities, 237 people are held captive in Gaza, including Israelis and foreign nationals. The Israeli military spokesperson said on 20 November that 40 of the hostages are children. So far, four civilian hostages have been released by Hamas, one Israeli soldier was rescued by Israeli forces, and three bodies of hostages have reportedly been retrieved by Israeli forces. On 17 November, the Emergency Relief Coordinator, Martin Griffiths, reiterated his call for the immediate and unconditional release of all hostages. 

Violence and casualties (West Bank)

• On 20 November, one Palestinian man died of wounds sustained after being shot by Israeli forces during a search-and-arrest operation in Jenin Refugee Camp on 9 November, bringing the death toll during that operation to 15, including four children.  
• Since 7 October, 201 Palestinians, including 52 children, have been killed by Israeli forces; and an additional eight, including one child, have been killed by Israeli settlers in the West Bank, including East Jerusalem. Four Israelis have been killed in attacks by Palestinians. 
• The number of Palestinians killed in the West Bank since 7 October accounts for 47 per cent of all Palestinian fatalities in the West Bank in 2023 (442). About 66 per cent of the fatalities since 7 October have occurred during confrontations that followed Israeli search-and-arrest operations, primarily in Jenin and Tulkarm governorates; 24 per cent have been in the context of demonstrations concerning  Gaza; seven per cent have been killed while attacking or allegedly attacking Israeli forces or settlers; two per cent have been killed in settler attacks against Palestinians; and one per cent during punitive demolitions. 
• Since 7 October, Israeli forces have injured 2,811 Palestinians, including at least 355 children, over half of them in the context of demonstrations. An additional 74 Palestinians have been injured by settlers. Some 33 per cent of those injuries have been caused by live ammunition. 
• On 19 November, Israeli settlers vandalized two solar panel systems and stole other agricultural equipment belonging to a Palestinian family from Kisan village (Bethlehem). In another incident, according to Palestinian eyewitnesses, a group of Israeli settlers vandalized 650 olive trees in the outskirt of Khashem ad Daraj herding community (Hebron).  
• Since 7 October, OCHA has recorded 256 settler attacks against Palestinians, resulting in Palestinian casualties (31 incidents), damage to Palestinian-owned property (189 incidents), or both casualties and damage to property (36 incidents). This reflects a daily average of almost six incidents, compared with three since the beginning of the year. Over one-third of these incidents included threats with firearms, including shootings. In nearly half of all incidents, Israeli forces were either accompanying or actively supporting the attackers. 

Displacement (West Bank)

• No new displacements have been recorded during the past 24 hours. Since 7 October, at least 143 Palestinian households comprising 1,014 people, including 388 children, have been displaced amid settler violence and access restrictions. The displaced households are from 15 herding/Bedouin communities.  
• Additionally, 143 Palestinians, including 72 children, have been displaced since 7 October following demolitions in Area C and East Jerusalem, due to lack of permits; and 48 Palestinians, including 24 children, have been displaced following punitive demolitions. 

Funding

• As of 20 November, Member States have disbursed US$147.1 million against the updated Flash Appeal launched by the UN and its partners to implement its response plan in support of 2.2 million people in the Gaza Strip and 500,000 in the West Bank. This constitutes about 12 per cent of the $1.2 billion requested. An additional $250 million has been pledged, which if materialized, would bring the Flash Appeal funding level to 32 per cent. Private donations are collected through the Humanitarian Fund.

HUMANITARIAN NEEDS AND RESPONSES: 13-19 November

Health 

On 18 November, the World Health Organization led a joint UN team that visited Shifa Hospital, in Gaza city to conduct a rapid situational analysis, assess medical priorities, and establish logistics options for the evacuation of patients. 

• Since 1 November, Cluster partners have delivered the following items across Gaza:  
• arious medical supplies to ten hospitals and the ambulances; 
• assistive and mobility devices, wound dressing kits and first aid kits to 805 people;  
• 87 reproductive health kits to hospitals to enable safe deliveries;  
• cash transfers to 724 vulnerable women in Gaza, including pregnant and lactating women, breast cancer patients, and survivors of gender-based violence (GBV);  
• 600 postpartum kits;  
• 900 family hygiene kits distributed in one IDP shelter in An-Nusseirat and 120 host community shelters;  
• 1,070 dignity kits to women staying in IDP shelters. 

During the same period, there have been an average of 10,000 consultations a day at mobile primary healthcare providers in shelters; 2,925 children were vaccinated after this service resumed in November; 132 wound dressing and 60 physiotherapy sessions were provided. Limited mental health and psychosocial services are being provided by partners, mainly in shelters. Cluster partners are also working to strengthen disease surveillance and early warning systems. 

Main factors that have been impeding operations include limited access to the north; shortage of fuel, medical supplies, water, food, and other essential supplies; displacement of partners, their staff and families; and overcrowding in IDP shelters. NGO partners have experienced difficulties with their logistics capacity in Egypt. So far, only 19 per cent of funding required to respond has been committed. 

Protection

Mine contamination is already widespread and poses devastating risks for people in Gaza. Despite challenges, during the reporting period, 18 Explosive Ordnance Risk Education (EORE) focal points were deployed in UNRWA shelters in the south and will begin awareness raising. The UN Mine Action Service is developing a training for 20 UNRWA staff in Khan Younis and Rafah. Planning for the expansion of risk education outreach in non-UNRWA shelters is underway. One NGO also reached 4,900 people with risk education about unexploded ordnances, and sent 500,000 SMS related messages.  

A mapping of GBV-related service providers and responders has been completed. The main priority in this context is to reduce overcrowding in shelters, which increase stressors, reduce privacy and exacerbate risks of violence towards women and girls. Of concern is the significant gap in dignity kits supplies and access for women of the reproductive age. There are 3,000 kits in Egypt ready to move into Gaza once approved, and a further 6,000 in the pipeline. Funding is urgently needed to meet the soaring needs of women and girls in Gaza. 

Cluster partners are assessing needs and available supply of assistive devices and kits in UNRWA southern governorate shelters. While demand for assistive devices continues to increase, the remaining stockpiles in northern Gaza are unaccesible. Further supplies are being procured and in the pipeline via Egypt. Significant damage to rehabilitation facilities has cut critical services.  

Mental health care needs are skyrocketing, especially for persons with disabilities, children and those with pre-existing complex conditions. However, many services have been destroyed and many staff are unable to work. Only limited psychosocial support (PSS) services and psychological first aid is being provided in some shelters across Gaza where protection actors are sheltering and have capacity to respond. 

Despite extreme overcrowding at shelters, UNRWA has been able to provide some recreational activities, PSS support, and mine risk awareness sessions. They have also conducted child protection assessments and been assessing how to implement activities with children and young adults and scale up these activities across all their shelters.  

Food Security

Since 7 October, the World Food Programme (WFP) has reached an estimate of 550,300 IDPs in UN shelters with daily fresh bread, canned food, or date bars. Additionally, food parcels were distributed to 38,659 displaced people in host communities to support their food needs over a 15-day period. In addition, WFP has provided cash-based transfers. In November, redemption rates decreased compared with October, due to the closure of the majority of WFP-contracted shops, stock depletion, or connectivity disturbances preventing assistance activities across Gaza. WFP is piloting a programme relying on existing electronic voucher platform to distribute food parcels at shops and partner distribution points. Overall, 73.5 WPF truckloads entered Gaza carrying 1,296 metric tons of food assistance. This falls short from meeting the necessary needs of food in the Strip.  

In addition to in-kind food distribution, UNRWA has been distributing flour to bakeries for producing bread for distribution. To date, 88 UNRWA trucks containing food entered Gaza, carrying 1,760 metric tons of food assistance.  

Twenty international and local NGOs have jointly reached 1,9 million people since the beginning of the war (cumulative). Partners have used different modalities, including food parcels, hot meals and e-vouchers.

Water, Sanitation and Hygiene (WASH) 

During the reporting period, WASH Cluster partners delivered the following items. In the absense of safe access to the north, distribution has been made possible in areas south of Wadi Gaza only. 

Some 165 cubic metres of bottled water at IDP centres, addresing drinkable water needs of about 100,000 people. 

Some 1,733 cubic metres of water through water trucking for hosting communities and IDP centres from the municipal and private desalination plants in the south, addressing the drinking and domestic water needs of 300,000 people (less than 5 litres a day per person).  

Four cleaning kits for four IDP centres in Rafah, hosting about 10,000 people. 

Some 6,500 family hygiene kits for IDPs (3,800 in the north and 2,700 in the south), serving about 40,000 people. 

Additional sanitary units for UNRWA IDPs. 

The situation in the north is of exterme concern and the highest priority for the WASH Cluster: the water desalination plant and the Israeli pipeline are not functioning, while there has been no distribution of bottled water among IDPs accommodated in shelters, raising grave concerns about dehydration and waterborne diseases due to water consumption from unsafe sources. 

The average water production from all of the Gaza water sources currently does not exceed 12 per cnet of its usual capacity before the escalation.

https://drive.google.com/file/d/1CKXb57tu3AYViYC3PgRSpqI9w4qvU16E/view 

WASH partners have secured US$6 million, representing some 15.6 per cent of the need for immediate response to the current situation. 

Shelter and Non-Food Items (NFI)  

During the reporting period, Shelter Cluster partners delivered the following items. In the absense of safe access to the north, distribution has been made possible in areas south of Wadi Gaza only.  

• 7,600 bedding sets (blankets, mattresses, and mats),  
• 2,000 kitchen sets,  
• 2000 washing kits,  
• 370 tarps, 1000 dignity kits in public schools and buildings, including hospitals,  
• 350 tents donated to UNRWA to decongest overcrowded shelters. 

Due to limited supplies, cluster partners only covered less than 7 per cent of the estimated Shelter and NFIs needs.  

There is still a major gap in shelter winterization materials and essential NFIs, including sealing off kits for damaged houses and creating additional living spaces; a high shortage in bedding sets, including mattresses and blankets to cover the needs of the IDPs in different settings, including UNRWA shelters; and winterized tents to protect homeless IDPs from harsh weather conditions.  

Education 

Since 7 October, eight Education Cluster partners have reached a total of 45,867 students and teachers. The main deliverables included emergency learning and recreational supplies (42,533 people reached), psychosocial support (30,018 reached), and recreational activities (8,082 reached). The response has been focusing on Khan Younis, Rafah and Middle governorates, as North Gaza and Gaza governorates are inaccessible. 

Logistics

6 November marked one month since the activation of the Palestine Logistics Cluster. The Palestine – Gaza Response Operation Overview and One Month Infographic are available on the dedicated operation webpage. 

During the reporting period, the entry of limited amounts of fuel for UNRWA has been coordinated, for the first time since the start of hostilities, with regular daily deliveries expected from 19 November. fewer trucks entered Gaza for several days during the week due to a backlog of aid from previous days, shortage of fuel and a communication shutdown leading to an inability to effectively manage or coordinate humanitarian aid convoys under these circumstances. 

Three staff members based in Gaza joined the Logistics Cluster to support UNRWA, the Palestine Red Crescent Society (PRCS) and a partner NGO in receiving shipments crossing from Rafah.  

The Logistics Cluster has also conducted a Storage Needs and Capacity Survey in Gaza and Egypt. Results show that about 165,000 cubic metres of storage space is available inside Gaza, the majority of which is in Gaza city and Rafah. Sixteen organizations require storage inside Gaza, while 14 organizations require storage in Egypt. The Logistics Cluster will continue following up with the organizations to ensure needs are met. 

Emergency Telecommunications

The Emergency Telecommunications Cluster (ETC) coordination team continues to engage all parties ― the Egyptian Red Crescent, OCHA, the International Telecommunications Union (ITU), and the Egyptian authorities ― to fast-track the importation process of telecommunications equipment through either Egypt or Israel into Gaza. Liaison with OCHA continues on the importation of equipment into Gaza via Israel. To coordinate a collective approach among partners for the importation of equipment, a survey was launched on 16 November and is currently ongoing. A security communications services implementation plan is being developed. 

Reliable communications networks are needed to enable humanitarians to stay connected in high-risk situations, restore security communications networks for UN staff, and coordinate response activities. 

Protection against sexual abuse and exploitation (PSEA) remains a cross-cutting priority for all clusters. The SAWA helpline, reachable at 121 and through WhatsApp at +972 59-4040121 (East Jerusalem at 1-800-500-121), operates 24/7. This toll-free number is widely disseminated across all areas of intervention to report cases of SEA and to facilitate emergency counseling and referrals for affected communities to access life-saving services. The PSEA Network monitors calls daily and will increase the number of counselors if necessary.

* Asterisks indicate that a figure, sentence, or section has been rectified, added, or retracted after the initial publication of this update.