A year of war: For Gaza’s children, their home is little more than a graveyard 

One year in, and little has changed since UNICEF declared Gaza “a graveyard for children.”

Since Oct. 7, 2023, at least 11,000 children have died during the ongoing war in Gaza. This conservative estimate is higher than in any other conflict in recent history. 

The death of children is only part of the larger loss of life in Gaza over the past 12 months. 

“It is not implausible to estimate that up to 186,000 or even more deaths could be attributable to the current conflict in Gaza,” wrote The Lancet in July, or between 7-9 per cent of Gaza’s population.

Future of Good spoke to Dalia Al Awqati, Head of Humanitarian Affairs at Save the Children Canada, to understand the war’s consequences on children beyond the statistics.

Q: What were your initial reactions after Oct. 7, as Save the Children, and also personally? What were your fears about what might unfold?

It’s a good question but also a difficult one. For me, it’s hard to separate the organizational response from my personal reaction. My mother is Palestinian, so this isn’t a new experience for me—the experience of war and conflict. I would sum it up by saying I could immediately see how horrific this could become. 

From an organizational perspective, our first concern was for the children. We were focused on the violations of international humanitarian law. Children should never be subject to these kinds of violations, no matter where they come from. Simply put, we were all intensely worried about how things would unfold.

It was clear there would be a response, and based on history—not to use the word “proportionality” because that’s not the language we use in the humanitarian space—Israeli actions have had a significant impact on Palestinians, especially children. 

So, from the moment the attacks happened, we knew the repercussions on Gaza’s population, especially the children, would be immense.

Even knowing that from the beginning, I don’t think there was a global understanding or sufficient communication about how bad it would get. 

Honestly, that feeling hasn’t left me or anyone working on this crisis. That sense of dread, that overwhelming worry, is with us every day because the situation has only gotten worse.

Q: How soon did it become clear what the Israeli response would be? Were you expecting it to be this extreme?

In terms of the scale of the response, I knew it would be large and intense. However, I didn’t expect the sheer number of violations we’ve continued to see. It’s hard to put the emotions into words, but the denial of humanitarian aid—denying food and resources to an entire population—is beyond what I expected.

I thought there would be more calls for restraint. If you look back, even the word “ceasefire” wasn’t used by the international community, particularly Israel’s allies, until months later. 

We were doing advocacy work as Save the Children, along with other Canadian NGOs, and it wasn’t until December that our government finally used the word “ceasefire.” 

By then, nearly 5,000 children had already been killed. This has real repercussions on people, on children, on families.

Did we expect the magnitude of the response? Maybe in our hearts, we knew it was a possibility, but as humanitarian organizations, we work in a world governed by international norms. This level of violence shouldn’t have been an option. That’s been the hardest part to reconcile. 

Even today, we’re still pushing for an arms embargo, for stronger diplomatic measures. It’s happening not just in Gaza but also in the West Bank, where there’s been massive escalations of violence. 

People have been displaced, and children are being detained in horrific conditions. And now we’re facing the looming threat of a regional escalation. 

Did we see all of this coming? We hoped it wouldn’t happen, but we knew it was a possibility.

Q: Can you tell me more about Save the Children’s response after Oct. 7?

Absolutely. We’ve had a presence in the Occupied Palestinian Territories (OPT) since the 1950s and a permanent presence since the 1970s, which speaks to how long these issues have existed and the need for international humanitarian actors there.

Right now, we’re heavily involved in emergency response efforts in Gaza, where we’ve reached 683,000 people since last October. We’ve also reached over 24,000 people in the West Bank who have also been affected by violence during that time.

We’re providing drinking water, shelter support, hygiene products, cash assistance, learning materials, and toys. We also support child-friendly spaces so children have a safe space to engage with each other. Although we deliver structured activities, we’re acutely aware of the gaps in assistance and the reasons for those gaps.

We’ve also had to provide health and nutrition services for the first time, including maternal and child health services, which we weren’t doing before October 2023. The absence of primary health services in Gaza has been a significant issue.

Through all of this, we continue to see the catastrophic impacts this war is having on children and their families. 

Gaza is being starved at a rate the world has never seen before, and that speaks to the intentional denial of humanitarian assistance.

As humanitarian actors, our work is being made purposefully complicated by design, to make it difficult for us to meet the needs of those we serve. It’s everything from getting supplies to navigating evacuation orders. 

Quite frankly, this is the worst situation we’ve ever seen in our lifetimes.

Q: Regarding the worst situation, could you tell us more about the challenges you’ve faced over the past 12 months operating in Gaza?

Absolutely. As I mentioned, the denial of humanitarian aid makes it really difficult for us to get assistance in Gaza. That challenge has impacted healthcare facilities, which are running but on very limited supplies. Our healthcare teams are often forced to make do with next to nothing.

One example is that we deal with pediatric amputees in one of our primary healthcare clinics. Our colleagues and nurses use breathing techniques and various distraction methods to help children manage their pain because the only pain relief available is the equivalent of Tylenol. We haven’t been able to stock stronger pain relief. These are pediatric amputees, and it’s the same for burn victims. 

For anyone who’s ever experienced even minor burns, surgery, or childbirth, pain management and the availability of drugs is integral to recovery. Now, imagine managing amputations with something like Tylenol. That alone is traumatic, not to mention the shelling or bombardment that caused the amputation or the loss of life likely associated with it. So, we’re dealing with a severely traumatized population. 

They’ve been crammed into one space lacking basic needs, creating a breeding ground for infectious diseases. They are self-reporting their need for psychosocial support and mental health assistance. They’re telling us they don’t know how to cope anymore. 

We rely heavily on our Palestinian staff. A majority of our operations are run by them, and they’re experiencing the same conditions as everyone else. It’s their homes, their families, their communities. The fact that they continue delivering humanitarian aid in such times is beyond brave and honorable. It’s a testament to the imperative they feel to support their people, at a time when it’s literally a matter of life and death.

Movement is a challenge. Finding accommodation is difficult. Getting humanitarian supplies across the border is hard enough, but even when we do, it’s difficult to get those supplies to the areas where they’re needed because of military presence and the need for approvals. Over the past year, we’ve also seen humanitarian workers and aid workers being targeted. These are just a few of the many challenges that agencies, including Save the Children, face in Gaza.

Q: You mentioned this is the first time you’re providing primary healthcare support. Is that correct?

Yes, this is our first time providing it in Gaza. We have a really robust healthcare portfolio globally, but in Gaza, this is new for us.

Q: Could you tell me more about how this came about, particularly with targeting healthcare facilities? How did these concerns come to your attention, and how did you respond to them by adding this to your Gaza portfolio?

Absolutely. Our health services are provided through the Emergency Health Unit, whose deployment was requested by the World Health Organization (WHO). When wars happen, a lot of non-emergency healthcare gets put on hold because resources are redirected to deal with more acute needs like war wounds, trauma, and blast injuries. That means the average person can’t access basic primary or secondary healthcare, and that includes children needing vaccinations and women needing prenatal and postnatal care.

These gaps started emerging very quickly in Gaza. The WHO requested that Save the Children’s Emergency Health Unit assist with maternal healthcare. Our first intervention was supporting a maternity unit attached to a partner hospital, where we were able to deliver babies. Now, we’re also providing primary healthcare, which includes maternal and child healthcare.

The nutrition crisis is growing rapidly, too. The population is being starved at an alarming rate. Children under five and pregnant and lactating women are specifically vulnerable to malnutrition. So, we provide critical prenatal and postnatal support to women, to ensure children are vaccinated and to support lactating women with feeding. All of this is incredibly important, but we’re still lacking the ability to bring in the supplies we need at the scale required to address critical healthcare needs. 

Q: You mentioned the example of child amputees whose only pain relief is Tylenol. Can you help readers understand how that impacts a child, their parents, families, and even siblings who witness something like this? I’m trying to convey the deep psychological toll this can have.

Let me approach this from a different angle. Every year, Save the Children releases research on our work with children in the OPT. Two years ago, we did a report on how children in Gaza were already at a mental breaking point. 

This was before the current escalation, and we found that almost 80 per cent of the children we surveyed were experiencing mental distress. That manifested in different ways—anxiety, insomnia, bedwetting, and, in some cases, aggression.

When you think about 80 per cent of children already suffering mental distress before this war, and then add everything that’s happened in the last 12 months, you can only imagine the strain on them and their caregivers. 

Children need routine, safe spaces, and networks to cope with trauma. Safe spaces might be something like our child-friendly areas, but also schools, which have now been closed for a second consecutive year. Their networks include parents, siblings, extended family—grandparents, aunts, uncles, cousins—all of which have been stripped away.

The trauma is layered: there’s the trauma of bombardment, losing friends and family, and experiencing injuries. That trauma reverberates through families, and there’s no real way to deal with it. 

We, as humanitarian actors, can only offer small spaces for coping. But as long as the war continues, as long as the bombardments happen and they’re denied basic needs like food, we can’t even begin to put in place the mechanisms to help them start healing.

The road to recovery is incredibly long, and we’re nowhere near stabilizing the situation enough for people even to begin to process their trauma.

Q: When I mentioned wanting to understand the impact of the war beyond just numbers—beyond just the number of children dead or under the rubble—are there other ways your organization’s experience in Gaza can convey the depth of this?

I have an excerpt from one of our Palestinian doctors about a little boy, Amjad, not even a year old, suffering from severe acute malnutrition. When a child reaches that stage, their muscles waste away, their vision blurs, their immune system weakens, and their organs start to shut down. And this isn’t an isolated case—it’s something we’re seeing more and more.

This little boy weighed less than six kilograms when our doctor met him. His father was missing in the north of Gaza, and his mother was living alone in a tent in the south, with almost nothing—no food, no breast milk, because hunger, exhaustion, and constant fear had left her unable to produce any. On top of that, the child was battling skin infections, and there wasn’t a single pharmacy in Gaza with the cream needed to treat his condition.

Our doctor made countless phone calls and put in enormous effort just to secure the minimum treatment Amjad needed. It took weeks to find the cream and even longer to see any improvement. 

Amjad was eventually moved from severe acute malnutrition to moderate acute malnutrition, which, while a small step, was significant given the complexity of his condition. But it shouldn’t take that much effort, that level of complexity, just to make this one small step toward recovery.

And the thing is, malnutrition—especially severe acute malnutrition—doesn’t just have immediate impacts. It affects a child’s long-term growth and development as well. So, this is just one example of the heart and effort it takes to treat one child in a situation where, frankly, all of it is preventable.

Q: Could you talk about some of the generational effects this war will have? We’ve seen children who are permanently disabled, who’ve lost their limbs. I think this is the largest number of child amputees in history, right? So, what kind of long-term effects does this have on the children and, more broadly, on Gaza’s society?

I believe it was Dr. Ghassan Abu-Sittah who said that Gaza has the largest cohort of child amputees ever known. The impacts are huge. There are the physical aspects, of course—loss of movement, limitations—but as these children grow, they’ll also experience chronic pain. And that’s for the children who survive long enough to grow up.

On top of that, there’s the psychological trauma that comes with it. In the long term, this population will need significant assistance.

I really dread to think what the future will look like physically because the infrastructure will have to change to accommodate this growth of people with disabilities—many of whom are multiple-limb amputees. 

It’s hard to say exactly what will happen, aside from knowing that this will deeply impact both their physical and mental health. Right now, about ten children lose a limb or more each day in Gaza. That fact alone is horrifying, and I can’t think of any other context where this has happened.

Q: One of my last questions concerns the role of the international community over the past 12 months. What has your organization’s experience been coordinating with different international bodies—governments, the UN, etc.? How would you qualify your experience this past year within the larger global framework?

I can speak largely from a Canadian perspective but also from our collaborations with other offices internationally. It’s been really difficult. 

We’re supposed to exist in a world where rights and law matter, yet we’ve seen open violations throughout this war, and there’s been little to no accountability. In the best-case scenarios, there’s a reluctance to apply accountability, which is deeply concerning.

As Canadians, we believe in international law for all. But it’s taken time to get to that point, and I don’t think we’re fully there yet. 

We, along with other NGOs in Canada, have been doing a lot of advocacy with the government—working with Global Affairs Canada, members of parliament—trying to say, “We need to be true to our values for everyone. We can’t pick and choose who those values apply to.”

In some cases, we applaud the Government of Canada for holding violators of international law accountable, but this is one of the areas where we’ve struggled. We haven’t seen the kind of action we need to uphold the standards we claim to believe in. 

 It’s been a similar struggle internationally and in some places, even more so. Specifically, in the Western hemisphere, there has been a delay in calls for a ceasefire, whereas globally, countries have been calling for it long before Canada and its allies made that formal call. 

It’s time for us to catch up with our values. 

The international community must recognize that what’s happening in Gaza isn’t just about the current violations of international law. It will have serious repercussions for how conflicts are conducted in the future and for the protections humanitarian workers expect to have.

Q: One last question: How does centring children’s rights in a war help us understand the nature of that war and call for an end?

That’s a great question. Children have special protections in conflict because of their vulnerability. 

They’re often the most vulnerable population in war, and understanding the impact on children gives us a clearer picture of how that conflict is being conducted.

If protections for children are respected—schools aren’t targeted, and children can access food and assistance—that’s a key indicator of the warring parties’ conduct and intent. 

But if we see grave violations, some of which are happening in Gaza, it’s also an indicator of that intent. There are six grave violations against children during times of armed conflict identified by the UN Security Council in 1999. These include the killing and maiming of children, and the number of child amputees in Gaza is a clear indicator that grave violations are occurring.

In short, looking at the treatment of children is one of the clearest ways to understand whether the laws of war are being applied or not.

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