More than 186,000 deaths in Gaza could result from the Israel-Hamas war, according to an analysis published by The Lancet medical journal.

The analysis, which was published in The Lancet’s correspondence section, was not peer-reviewed, but it underscores the difficulty of accurately documenting the conflict’s death toll. The official Gaza toll since Oct. 7 is at least 38,000, according to the Gaza Health Ministry.

The researchers pointed to the number of eventual indirect deaths in recent conflicts, which ranged from three to 15 times the number of direct deaths.

“Even if the conflict ends immediately, there will continue to be many indirect deaths in the coming months and years from causes such as reproductive, communicable, and non-communicable diseases,” they wrote.

For their estimate, the researchers added four indirect deaths for each direct death reported so far in Gaza, concluding that “it is not implausible to estimate that up to 186,000 or even more deaths could be attributable to the current conflict.”

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Counting the death toll in Gaza is a monumental effort that has become increasingly difficult, with international human rights groups and news reports saying the official count is likely incomplete. Authorities have struggled to identify the bodies buried in mass graves, or body parts pulled from the rubble, while suffering from starvation and dehydration themselves.

Israeli government agencies have previously accused the Gaza Health Ministry, which is run by Hamas, of inflating the death toll. President Joe Biden similarly suggested at one point that those numbers are not to be believed. However, human rights groups, news organizations and even Israeli intelligence services have previously considered the health ministry’s numbers to be largely accurate.

Israel’s assault on Gaza after Hamas’ attack has been catastrophic. United Nations experts say famine is spreading throughout Gaza, and they accuse Israel of carrying out a “targeted starvation campaign” against Palestinians. Much of Gaza’s infrastructure — schools, hospitals, housing, and water and electricity supplies — has been destroyed or damaged.

The human toll of the war has been especially devastating. Most of the people killed in the past nine months have been women and children, according to the official numbers. The Associated Press recently documented 60 Palestinian families in which at least 25 people have been killed, with some of the deaths spanning four generations in one family.