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Three researchers wrote in an article in the Lancet Journal that the estimate includes both direct deaths from the conflict and indirect deaths from causes such as reproductive diseases and communicable and non-communicable diseases.

The researchers – including Martin McKee, a member of the editorial board of the Israel Journal of Health Policy Research – arrived at this estimate by extrapolating the death toll, which the Gaza Health Ministry reported on June 19 as 37,396.

“Armed conflict has indirect health impacts that go beyond the direct harm of violence,” the researchers said in the letter published in The Lancet.

“Given the intensity of this conflict, the destroyed health infrastructure, the severe shortages of food, water and shelter, the inability of the population to flee to safe places and the loss of funding for the humanitarian agency UNRWA, the overall death toll is expected to be high,” they wrote.

“In recent conflicts, such indirect deaths are three to 15 times higher than direct deaths. If one conservatively estimates four indirect deaths for every one direct death out of the 37,396 reported deaths, it is not implausible to assume that up to 186,000 or even more deaths can be attributed to the current conflict in Gaza,” they added.

The estimate was published in the Lancet’s correspondence section, which contains letters to the editor that are not normally subject to external peer review.