Some of the bodies are badly mutilated. Only those that have been identified or claimed by relatives can go for burial and be included in the Gaza Health Ministry's death toll for the war. The rest are stored in the morgue's refrigerator, often for weeks.

The toll stood at around 20,000 people on Thursday, amid renewed international calls for a fresh ceasefire in Gaza. The ministry says thousands more dead remain buried beneath the rubble. About 70 percent of those killed are women and children, it says.

The ministry's figures have drawn international attention to the high number of civilians being killed in the Israeli military's offensive, which it launched after Hamas' Oct. 7 attack on Israel, the bloodiest in the country's 75 year history.

But with most hospitals across Gaza now closed, hundreds of doctors and other health workers killed, and communications hampered by lack of fuel and electricity, it's becoming increasingly difficult to compile the casualty figures.

The morgue workers at the Nasser Hospital are part of an international effort – including doctors and health officials in Gaza as well as academics, activists and volunteers around the world – to ensure the toll doesn't become a casualty of the increasingly dire conditions of the war.

The workers, some of them volunteers, do not have enough food or water for their families, but they keep going because recording the number of Palestinians dying matters to them, said Hamad Hassan Al Najjar.

He said the psychological toll of the work was immense. Holding a piece of white paper with handwritten information about one of the dead, the 42-year-old said he was often shocked to find the badly damaged corpse of a friend or relative brought in.

The body of the morgue's director, Saeed Al-Shorbaji, and those of several of his family members, arrived in early December, after they were killed in an Israeli airstrike, Al Najjar said.

"He was one of the pillars of this morgue," said Al Najjar, his face worn with sadness and fatigue. Preparing the bodies of dead children, some of them missing heads or limbs, was the most painful task: "It takes you hours to recover your psychological balance, to recover from the effects of this shock."

The Israel Defense Forces (IDF) has expressed regret for civilian deaths but blamed Hamas – the Palestinian militant group that ran the Gaza Strip - for sheltering in densely populated areas. Hamas gunmen killed 1,200 people in the Oct. 7 attack, most of them civilians, and seized some 240 hostages.

Israel says it will continue its offensive until Hamas is eliminated, the hostages returned and the threat of future attacks on Israel removed.

An Israeli military spokesperson said in response to a comment request for this article that the IDF "follows international law and takes feasible precautions to mitigate civilian harm".

UN Vouches For The Data

The data recorded by Al Najjar and his colleagues is collated by workers at an information centre set up by the health ministry at the Nasser Hospital, in the city of Khan Younis. Ministry staff fled their offices at Al-Shifa Hospital in northern Gaza after Israeli forces entered it in mid-November. 

Ministry spokesperson Ashraf Al-Qidra, a 50-year-old doctor, reads the numbers at press conferences, or posts the figures on social media if communications are hampered by the hostilities. The head of the ministry's information centre did not respond to requests for comment.

Since early December, the ministry has said it was unable to collect regular reports from morgues at hospitals in northern Gaza, amid the collapse of communications services and other infrastructure in Gaza due to the Israeli offensive.

According to the World Health Organization (WHO), only six of Gaza's 36 hospitals were receiving casualties as of Wednesday, all of them in the south.

The WHO cited this as one reason it believes the ministry's tally may be an undercount; the toll also excludes dead who were never taken to hospitals or whose bodies were never recovered. The WHO and other experts said it was not possible for now to determine the extent of any undercounting. 

US President Joe Biden said on Oct. 25 he had "no confidence" in the Palestinian data. The ministry's figures say nothing about cause of death, and they don't distinguish between civilians and combatants.

Following Biden's remark, the ministry released a 212-page report listing 7,028 people killed in the conflict until Oct. 26, including identity cards, names, age and sex. Since then, the ministry has not released such detailed data, making it hard for researchers to corroborate the latest figures.

However, the United Nations – which has long-standing cooperation with Palestinian health authorities - continues to vouch for the quality of the data. The WHO noted that – compared to previous conflicts in Gaza – the figures show more civilians have been killed, including a greater proportion of women and children. 

Israeli officials this month said they believe the data released to date is broadly accurate; they have estimated that one third of those killed in Gaza are enemy combatants, without providing detailed figures.

The Palestinian Health Ministry, which is located in the occupied West Bank and pays the salaries of Gazan ministry workers, said it has lost almost all contact recently with hospitals in the enclave. It also has no information on the fate of several hundred health workers arrested by Israeli forces, it added.

Asked about the arrests, the IDF said it had detained some hospital staff based on intelligence that Hamas was using medical facilities for its operations. Those not involved in these activities were released after questioning, it said, without providing the number of detainees.

International Efforts

Academics, advocates and volunteers across Europe, the United States and India are working to analyse the data provided by the Gaza Health Ministry, to corroborate the details of those killed and determine the numbers of civilian casualties.

Much of this is based on the Oct. 26 list that includes names, identity card numbers, and other details. Some other researchers, meanwhile, are "scraping" social media to preserve accounts posted there for future analysis. 

"There are far more eyes and players involved in recording Gaza deaths than is normal and than exist in the world's other worst crises", said Leslie Roberts, Professor Emeritus of Population and Family Health at Columbia University's Mailman School of Public Health at Columbia University. Roberts has been involved in more than 50 mortality surveys during wars since the early 1990s.

London-based Airwars – a non-profit affiliated with the department of media and communications at Goldsmiths, University of London, that investigates civilian deaths in conflicts - is using social media and the ministry's Oct. 26 document to compile a detailed record of casualties.

Airwars director Emily Tripp said some 20 volunteers were working on the project alongside regular staff, and so far it had positively identified some 900 civilians killed in the fighting. Even if the fighting stopped today, it could take another year to finish the survey, she said.

"What we're also seeing now is civilians who've been killed who are displaced from other areas, so they're not easily identified by their neighbors," Tripp told Reuters. "That makes the process of counting and identification really challenging."

Zeina Jamaluddine, a doctoral student at the London School of Hygiene and Tropical Medicine, co-authored an analysis last month in the Lancet medical journal based on the health ministry's Oct. 26 list. The study concluded that the identification numbers of those listed as killed were highly correlated with age, a pattern unlikely to arise from data fabrication.

She said the Palestinian health authorities' systems for collecting data had been tested over multiple wars and revised through United Nations-backed efforts: "While no data is 100 percent perfect, Palestine has high quality data."

While excess mortality experts have tools for calculating total deaths after conflicts end, there are challenges to doing so and the final post-war toll could end up being incomplete unless deaths are recorded to the greatest extent possible in real time, she said.

"Every name on the list represents a person, a life, a story. Each one deserves to be remembered."

Entire Families Killed

Researchers use methods such as surveys of households after a conflict is over to estimate the overall toll.

Household surveys could be difficult following this conflict because in some cases entire families have been killed by bombardments – sometimes dozens of members, according to the Oct. 26 list. More than four-fifth of Gaza's pre-war population has fled their homes - 1.9 million people, according to UN figures - and may be difficult to locate, experts say.

But given how close-knit Gazan society is, there is hope that such studies could eventually be conducted in a meaningful way, said Hamit Dardagan of the Iraq Body Count (IBC), an organisation that records violent deaths resulting from the 2003 U.S.-led invasion of Iraq. The IBC has already published an analysis on age and other characteristics of those killed in Gaza, based on the ministry's Oct. 26 data.

"The pace of civilian deaths - at least 200 each day since October 7, except for the week-long truce - is unprecedented this century, and was not seen at height of the Iraq invasion," Dardagan said.

It will take years to recover the remains of people from beneath the rubble, and the costly, technical process will not result in the identification of each body, said Dr Gilbert Burnham, a doctor and professor at Johns Hopkins University who has worked since the 1970s on humanitarian health problems in wars.

In addition to the dead, the ministry says there have been more than 52,500 people wounded in the conflict. The WHO points to the growing risk of disease due to a lack of clean water, food and medical attention. 

Dr Ghassan Abu Sitta, a British-Palestinian surgeon who volunteered in two hospitals in northern Gaza for the first six weeks of the war, said some people were dying because of lack of treatment of open wounds.

"The death toll is a poor proxy of human suffering", said Dr Annie Sparrow, a pediatrician who has worked with medics treating the wounded in the Syrian civil war for more than a decade and is an Associate Professor of Global Health at the Icahn School of Medicine at Mount Sinai in New York City.

But the use of records to fight the fear of erasure runs deep in Palestinian culture, said Abdel Razzaq Takriti, associate professor of Modern Arab History at Rice University in Texas. He quoted from a poem by prominent Palestinian poet Mahmoud Darwish: "You will be forgotten as if you never were".

Takriti said many Palestinians see the Gaza war as part of a history of conflict and displacement by Israeli forces dating back to the Nakba – or catastrophe in Arabic – when more than 700,000 Palestinians fled or were expelled from their homes in what is now Israel during the war over the formation of the country in 1948.

"For the sake of the present, future, and the past, we need to have an accurate rendition of numbers," Takriti said.