Hostilities in the Gaza Strip and Israel | Flash Update #46

KEY POINTS

• On 21 November, Al Awda Hospital in North Gaza, came under attack which killed three doctors and one patient companion, and injured many patients.* Médecins Sans Frontières (MSF), which operates in the hospital, called for the urgent and safe evacuation of more than 200 patients to a functioning medical facility. Since the start of the war, the World Health Organization (WHO) has documented 178 health attacks in Gaza Strip that resulted in 22 fatalities and 48 injuries among health care workers on duty.
• Some 500 patients and staff were evacuated on 21 November from the Indonesian Hospital in Beit Lahiya (North Gaza) to a hospital in Khan Younis (in the south), in coordination with humanitarian agencies. This follows an attack the previous day that directly hit the hospital and killed at least 12 people, according to the WHO. The hospital remains surrounded by Israeli troops and tanks, and fighting with armed groups has been reported in its vicinities, with additional patients and thousands of internally displaced persons (IDPs) trapped in the facility and awaiting evacuation.
• Only two small hospitals to the north of Wadi Gaza (hereafter: the north), one in Gaza city and another in Beit Lahiya, are estimated to be partially operational and admit patients, with the remaining 22 being out of service. Of the 11 medical facilities in the south, seven are currently functional. The bed capacity across Gaza has declined from 3,500 prior to the war to 1,400 presently, amid a surge in those seeking treatment. one of the currently functional hospitals has the capacity to treat critical trauma cases or perform complex surgery, according to the WHO.
• 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 and protect 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.
• On 20 November, at about midday, an UNRWA school in Al Bureij camp (Middle Area), sheltering IDPs, was reportedly hit by artillery fire, killing at least 12 people and injuring 35 others. As of 19 November, at least 176 IDPs sheltering in UNRWA premises had been killed and 778 injured.
• On 21 November, a WHO staff was killed alongside her 6-month-old baby, her husband and two brothers. As of 19 November, 108 UNRWA staff have been killed in Gaza since 7 October.
• Nearly 770,000 IDPs, out of 1.7 million, are sheltering in 99 UNRWA facilities south of Wadi Gaza (hereafter: the south), in extremely overcrowded conditions. In the past two weeks, the agency has recorded a 35 per cent increase in skin diseases and a 40 per cent increase in cases of diarrhea. The poor sanitary conditions, combined with cold rain recently, has exacerbated the risk of epidemics and may lead to a spike in child pneumonia, according to the WHO.

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 other areas in the north, Jabalia in particular. 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.
• Two airstrikes, one on 20 November, at around about 23:00, and one on 21 November, close to 6:00 a.m., hit residential buildings in the An Nuseirat Camp (Middle Area), reportedly killing 17 people in the former and 20 in the latter; dozens have been injured.
• 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, per the latest available figures from MoH Gaza.
• Two journalists were reportedly killed on 20 November in Gaza city and in North Gaza. According to the Committee to Protect Journalists, at least 53 journalists have been killed since the hostilities began on 7 October.
• In the 24 hours preceding 18:00 on 21 November, two Israeli soldiers were reportedly killed in Gaza, bringing the total number of soldiers killed since the start of ground operations to 73, according to official Israeli sources.

Displacement (Gaza Strip)

• On 21 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 observed a significant decline in the volume of people moving during the day, however, no estimate could be produced. Most people 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 has been increasingly observed. An interagency plan is being developed to respond to this situation including the registration of cases.
• Over 1.7 million people in Gaza are estimated to be internally displaced, including almost 930,000 IDPs who are staying in at least 154 UNRWA shelters across the strip. 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, 160 people sheltering in UNRWA schools share a single toilet. In the Rafah Logistics base where more than 8,000 people have sought shelter, 400 people are sharing one toilet. Due to the poor sanitary conditions, since 7 November there has been a 35 per cent increase in skin diseases and a 40 per cent increase in cases of diarrhea.
• 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.
• 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.

Humanitarian Access (Gaza Strip)

• On 21 November, 63,800 litres of fuel entered Gaza from Egypt, following an Israeli decision from 18 November to allow the daily entry of small amounts of fuel for essential humanitarian operations. Fuel is being distributed by UNRWA to support food distribution, and the operation of generators at hospitals, water and sanitation facilities, shelters, and other critical services.
• A total of 79 trucks carrying humanitarian supplies entered from Egypt on 21 November as of 20:00. Overall, between 21 October and 21 November at 18:00, at least 1,399 truckloads of humanitarian supplies (excluding fuel) have entered Gaza through the Egyptian border, compared to a monthly average of nearly 10,000 truckloads of commercial and humanitarian commodities (excluding fuel) entering Gaza before 7 October.
• On 20 November, the Egyptian border opened for the evacuation of 571 dual and foreign nationals and 67 wounded and sick people. Between 2 and 20 November, nearly 8,448 dual and foreign nationals and 392 wounded and sick people 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)

• Israeli operations at Shifa Hospital continued on 21 November. Nineteen health workers and 259 patients remain in Shifa, according to MoH in Gaza, 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, all of whom will be prioritized for an upcoming evacuation. The hospital is no longer operational and is not admitting new patients.
• For additional information on hospitals see Key Points section above.
• On 18 and 19 November, nine out of 22 UNRWA health centres were still operational in the Middle Area and the south, recording 19,162 patient visits.

Water and sanitation (Gaza Strip)

• On 19 November, UNRWA and UNICEF distributed 19,500 litres of fuel to two seawater desalination plants, 79 waterwells, 15 water pumping stations, 18 sewage pumping stations, and one wastewater treatment plant. This has enabled them to operate generators and resume operations, more than a week after they had been forced to shut down. An additional fuel distribution was expected on 21 November. 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 are not functioning. There has been no distribution of bottled water among IDPs accommodated in shelters for over a week.

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 available to them. 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 been 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 most 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, 236 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)

• No Palestinian fatalities have been reported in the West Bank in the past 24 hours.
• 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 2,814 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.
• In the past 24 hours, in three separate incidents, armed assailants known by Palestinian residents to be settlers, yet wearing Israeli military uniforms, raided Palestinian communities. In Kisan (Bethlehem), they broke into a home and physically assaulted a woman and a man and threatened to kill them if they do not leave the area. In the community of Tuba (southern Hebron), in an area declared by the Israeli authorities as “Firing Zone 918,” an animal shelter and fodder sacs were vandalized. In Mantiqat Shi'b al Butum (Hebron), water tanks and a solar panel system serving the community school were vandalized, along with a residential structure, and 20 trees were uprooted.
• Since 7 October, OCHA has recorded 271 settler attacks against Palestinians, resulting in Palestinian casualties (33 incidents), damage to Palestinian-owned property (202 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 due to settler-related violence 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.
• On 21 November, Israeli forces demolished two structures in two separate locations in East Jerusalem, Al Isawiya and Silwan, due to the lack of Israeli-issued building permits. As a result, six people, including four children, were displaced. 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 21 November, 23:59 local time, Member States have disbursed US$171.6 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 14 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:

• Various 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 unaccessible. 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 absence 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, addressing 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 extreme 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 cent of its usual capacity before the escalation. WASH Cluster issued a document outlines the Water Supply and Fuel Relationship.

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 absence 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

16 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.