A dentist stood at the bed of a doctor, his good friend Ehab Madhoun, 32, who had just died, his shrapnel-pitted body wrapped in a white shroud.
The day before, Dr. Madhoun, a general practitioner, was in an ambulance responding to an Israeli strike at the Jabalya refugee camp in northern Gaza. Another missile hit the ambulance. The driver, Muhammad Abu Hasira, died instantly. Dr. Madhoun lingered for a day, dying of his wounds on Wednesday in the intensive care unit of Shifa Hospital, where hundreds of people have been brought since Israel began its heaviest assault on Gaza in three decades.
The dentist cried.
“He was just doing his work,” said the dentist, who would not give his name. “He’s a doctor, and I can’t understand why Israel would hit an ambulance. They can tell from the cameras it’s an ambulance.”
It has always been this way, over years of conflict here, that civilians are killed in the densely populated Gaza Strip when Israel stages military operations it says are essential for its security. But five days of Israeli airstrikes have surpassed past operations in scale and intensity; the long-distance bombardment of the Hamas-controlled territory has, however well aimed at those suspected of being militants, splintered families and shattered homes in one of the most densely populated places on Earth.
Among the total dead — between 320 and 390, according to the United Nations — Palestinian medical officials say that 38 were children and 25 were women. The United Nations agency that helps Palestinian refugees said 25 percent of those killed had been civilians. Israel said it knew of 40 civilian deaths but that it was still checking.
Israeli officials are coming under increasing pressure to ease conditions for civilians, with tight supplies of electricity, water, food and medicine worsening shortages in an area already largely sealed off from the outside world. While Israel on Wednesday refused a 48-hour cease-fire suggested by the French to allow critical supplies into Gaza, it has been sensitive enough to the ever-louder complaints to say it will do all it can to allow in supplies.
On the issue of civilian casualties, Israeli officials maintain that they do not take aim at civilians and do everything possible — like using precision-guidance systems, up-to-the minute intelligence, leaflets and phone calls to targeted areas — to avoid hitting them.
They say killing and wounding civilians only undermines their primary mission: to stop Hamas from firing rockets into civilian areas of Israel.
“I haven’t seen too many tears shed in Paris, London or Berlin over the fact that we have hit Hamas targets,” said Mark Regev, a spokesman for Israel’s prime minister, Ehud Olmert. “So we have many reasons, both moral and political, for doing the utmost to make sure that our strikes are as surgical as possible.”
Further complicating matters is that fact that Gaza is the size of Detroit, with one and a half times as many people. The military and government facilities of Hamas are intertwined with buildings where Gaza’s civilian population lives and works. Israelis say Hamas fires rockets at Israel from civilian neighborhoods.
The United States military has also faced much criticism for killing civilians in Iraq and Afghanistan, despite what officials say is the utmost precaution against doing so.
In Gaza, human rights groups say that the new scale of Israel’s operation puts the area’s civilians, even those accustomed to conflict, under particular stress. Some of the wounded are afraid to seek treatment at the already overwhelmed hospitals, fearful of heading into a rocket attack while driving through streets of pummeled buildings and concrete shards.
Large, multigenerational families huddle in their houses, hoarding the shrinking supplies of water, food and gasoline. Despite the cold, many have kept their windows open to prevent them from shattering when bombs explode nearby. Shops are closed except for grocery stores, bakeries and pharmacies.
“Conditions for parents and children in Gaza are dangerous and frightening,” Maxwell Gaylard, United Nations humanitarian coordinator for the Palestinian territories, said in a statement.
“It is absolutely crucial that there is an end to the fighting,” he said. “Without it, more civilians will continue to be killed. Without the violence stopping, it is extremely difficult to get food to people who need it, we cannot assess where the most urgent needs are.”
In the debate over civilian casualties, there is no clear understanding of what constitutes a military target. Palestinians argue that because Hamas is also the government in Gaza, many of the police officers who have been killed were civil servants, not hard-core militants. Israel disagrees, asserting also that a university chemistry laboratory, which it claims was used for making rockets, was a fair target in an attack this week, even if it could not show conclusively that those inside the laboratory at the time where engaged in making weapons.
The ambiguity was evident at the intensive care ward in Shifa Hospital, where Dr. Madhoun’s body lay. There were 11 patients. One was a pharmacist, Rawya Awad, 32, who had a shrapnel wound to the head. Several were police officers. It was impossible to know the identities of many of the others.
But there were several children in another intensive care unit on Tuesday. Among them was Ismael Hamdan, 8, who had severe brain damage as well as two broken legs, according to a doctor there. Earlier that day, two of his sisters, Lama, 5, and Hayya, 12, were killed.
“I prepared them breakfast that day in the garden,” said their mother, Ayda, 36. “They had the tea, bread and thyme. Lama wanted a second pita, but we all teased her saying, ‘Keep it for lunch.’ She told us, ‘Don’t worry, God will provide us with bread.’
“She made all of us laugh,” the mother said. “I cleaned after them and collected the garbage. Ismael volunteered to dump the garbage, but Hayya and Lama joined him. The garbage can is in front of the house, a five-minute walk away. All of a sudden I heard the news from a neighbor, and I ran barefoot to the hospital. A relative collected the bodies of Lama and Hayya on a donkey cart.
“The neighbors ran trying to save Ismael, who was the only one breathing,” she said. “They say my kids flew 40 meters before hitting the ground.”
Ismael died Wednesday night.
At Kamal Edwan Hospital in Beit Lahiya, in northern Gaza, Mahmoud al-Sheik, 11, was recovering from wounds he received two days before — he thinks from a rocket fired by an Israeli warplane. Even at his age, he is aware of how fighters and civilians are mixed together in Gaza, saying that the bomb was aimed at the house of his neighbor, Salim Zaqout, whom he identified as a member of Hamas.
“But Zaqout and his family evacuated the house a few days ago,” Mahmoud said. “Can’t Israel see all these houses that are adjacent to Zaqout’s? Now Zaqout’s house is completely destroyed, but so are other houses that have nothing to do with Hamas.
“I have a big hole in my left hand. The doctor told me I’m fine. He filled the hole,” Mahmoud said, “but it’s hurting. It feels like fire inside it.”