Ninety-nine American health care workers who volunteered in Gaza over the past year published an open letter to US President Joe Biden and Vice President Kamla Harris on Thursday detailing the horrors they witnessed and calling for an end to US military support for Israel.

Health workers said they believed the real death toll in Gaza was much higher than the Gaza Health Ministry reported, which put it at more than 118,908.

“This letter and annex show compelling evidence that the human toll in Gaza since October is much higher than is commonly understood in the United States,” the letter says. “The death toll from this conflict is likely to be greater than 118,908, which represents 5.4% of Gaza’s population.”

The latest figures from the Gaza Health Ministry put the number of Palestinians killed by Israel in Gaza since October 7, 2023 at 41,788. The ministry’s figures only count bodies taken to hospitals and morgues and do not take into account people who are missing and presumed dead under the rubble.

Everyone in Gaza, the American health workers said, is either sick, injured, or both. “With only marginal exceptions, everyone in Gaza is sick, injured, or both,” the letter says. “That includes every national aid worker, every international volunteer, and perhaps every Israeli hostage: every man, woman, and child.”

They said that almost every child under the age of five they encountered “suffered from coughing and watery diarrhea.” All who signed the letter saw wounds on the children that showed they had been deliberately targeted by the Israeli military.

“In particular, every one of us who worked in the emergency room, intensive care unit or surgical department treated pre-teens who were shot in the head or chest on a regular or even daily basis,” the letter read. “It is impossible that the widespread shooting of young children throughout Gaza, which has continued for an entire year, could have been accidental or unknown to the highest Israeli civilian and military authorities.”

“Gaza was the first time I held a child’s brain in my hands. The first of many,” Dr. Mark Perlmutter, an orthopedic and hand surgeon, was quoted in the letter as saying.

Newborns are dying from conditions caused by the Israeli blockade and attacks on hospitals, health workers said. “Every day, I saw babies dying,” said Asmaa Taha, a pediatric nurse. “They were born healthy. Their mothers were so malnourished that they couldn’t breastfeed, and we had no formula or clean water to feed them, so they starved to death.”

The health workers said their Palestinian colleagues were targeted by Israeli forces and captured during Israeli raids on hospitals. “Many of these colleagues were taken by Israel during attacks. They all told us a slightly different version of the same story: in captivity, they were barely fed, subjected to constant physical and psychological abuse, and finally dumped naked on the side of the road. Many told us they were subjected to mock executions and other forms of ill-treatment and torture,” the letter said.

Israel claims that Hamas has used hospitals as “command centers,” but the letter said none of the signatories saw any signs of militant activity. “The 99 signatories to this letter spent a total of 254 weeks inside Gaza’s largest hospitals and clinics. We want to be absolutely clear: not once did any of us see any kind of Palestinian militant activity in any of Gaza’s hospitals or other healthcare facilities,” the letter said.

The letter concludes with an appeal to Biden and Harris to end American support for the genocidal war: “Every day we continue to supply weapons and ammunition to Israel is another day women are torn apart by our bombs and children are killed by our bullets. President Biden and Vice President Harris, we urge you to end this madness now!”