Starvation is spreading in Gaza — and treating it won’t be easy

Victoria Bisset

In late July, the world’s leading hunger monitor declared what many had already feared: Famine is unfolding across Gaza, it said, with “a rise in hunger-related deaths” driven by “widespread starvation, malnutrition, and disease.”

Nearly 200 people have died of starvation in the enclave, according to the Gaza Health Ministry - a number experts believe is an undercount, both because malnutrition leaves patients more vulnerable to other infections and conditions that are listed as the cause of death, as well as the difficulty of recording deaths that take place outside hospitals.

The wave of starvation sweeping across Gaza is making an already desperate situation worse. Even if Israel allows a surge in aid deliveries - as rights groups and its allies have urged - a boost in food supplies alone may not be enough to save severely malnourished patients, particularly children, who are more vulnerable to the worst effects and may need specialized treatment and intensive care.

Severe acute malnutrition requires careful treatment plans and monitoring - as patients may struggle to keep food down or may suffer from other health conditions.

“Just sending food into a crisis situation doesn’t really solve the problem of severe acute malnutrition,” Robert Akparibo, an associate professor in global health and nutrition at the University of Sheffield, said. “It may contribute to address food insecurity, but the availability of food alone is not enough,” he added, stressing the need to ensure that malnourished patients receive the right nutrients and are assessed by professionals.

In the first week or two of treatment, malnourished patients are at a greater risk of refeeding syndrome, in which electrolyte and fluid shifts can lead to serious complications such as seizures, respiratory failure and cardiac arrest, Pooja Yerramilli, an assistant professor and hospitalist at Johns Hopkins University, wrote last year.

Ideally, high-risk patients should be observed carefully in medical facilities, with “methodical titration of electrolyte repletion and nutritional intake to prevent complications,” Yerramilli wrote, adding that “these insights and practices suggest that the impacts of malnutrition in Gaza will not be easily or quickly undone with a focus on food aid alone.”

Rather than giving patients regular food right away, experts recommend starting with ready-to-use therapeutic food (RUTF) - an energy-dense paste with balanced micronutrients and macronutrients that helps patients gain weight quickly and, crucially for emergency situations like in Gaza, has a long shelf life and does not need to be refrigerated.

The sickest patients, including children with health complications and those who cannot keep down food, may be given specialized high-energy milks or intravenous rehydration, according to Francesco Checchi, a professor of epidemiology and international health at the London School of Hygiene and Tropical Medicine. Severely malnourished children who have a severe infection or other conditions will normally need inpatient treatment, in which they may be given antibiotics, deworming treatment or other treatments to stabilize their condition, he added.

Naziha El Moussaoui, a food security, nutrition and livelihoods adviser at the British Red Cross, highlighted the need for specialized care, adding that the high-energy milks are specially formulated to restore the balance of electrolytes and are low in carbohydrates to avoid the risk of refeeding syndrome. The calorie content of the milks is gradually increased until the patient is stabilized and any infections have been ruled out.

Even then, patients will still require weekly monitoring “because even after finishing the milk treatment, you can’t immediately go back to normal food,” she said.

While children with health complications will usually be a minority - perhaps one-fifth of all children with severe acute malnutrition - those without immediate complications will also need to be given RUTF on an outpatient basis, Checchi said. Treatment for adults “will almost invariably” involve RUTF or the use of the specialized milks where needed, he said.

Although the approved treatment methods for severe acute malnutrition are considered highly effective, ensuring those in need can access such treatment is particularly challenging in Gaza, where Israel’s 22-month war has caused mass displacement and destruction and has damaged or destroyed at least 94 percent of all hospitals, according to the World Health Organization.

All four of Gaza’s specialized centers to treat malnutrition are overstretched and running low on fuel, “with supplies expected to run out by mid-August,” the WHO said in an email.

“We’re seeing the shortages on the medical side; we’re seeing it on the nutritional side,” Mohammed Fadlalla, a doctor and the medical activity manager of Gaza’s al-Zawaida Surgical Field Hospital with Doctors Without Borders (MSF), said in an interview this week.

With food supplies running low across Gaza, there is insufficient nutritious food that children recovering from malnutrition can use to supplement their diet with. “In these kinds of situations where there is basically chronic unresolved food insecurity at the household level, what we tend to see is that these nutritional programs have high cure rates,” according to Checchi - “but the rates of relapse are really high as well.”

“So it’s likely that the child will recover weight and will at least temporarily recover from severe or moderate malnutrition, but then you’re left with the same situation that led the child down that track in the first instance,” he added.

Access to clean water - another major challenge in Gaza - is also important for basic survival and because of the risk that waterborne diseases and diarrhea can pose to the patient’s weakened immune system, said El Moussaoui.

Israeli Prime Minister Benjamin Netanyahu, in recent weeks, has dismissed reports of starvation in Gaza as a “bold-faced lie” - a stance contradicted by his ally President Donald Trump, who has acknowledged that “real starvation” is occurring there.

For months, Israel has imposed a near-total blockade on Gaza, allowing only small amounts of food to enter the Strip. In late May, Israel replaced U.N. aid distribution with the controversial U.S.- and Israeli-backed Gaza Humanitarian Foundation (GHF), which the United Nations and established aid groups have criticized.

As of July 31, more than 1,300 people had been killed while seeking aid in and around GHF sites, according to the U.N. human rights office, which said that “most of these killings were committed by the Israeli military.” The Israeli military says it has only fired warning shots and disputes the toll.

“Food aid shipments have been highly inadequate, and our analysis of the food packages supplied by the GHF shows that their distribution plan would lead to mass starvation, even if it was able to function without the appalling levels of violence that have been reported,” the Famine Review Committee - an independent body that reviews the findings of the U.N.-linked hunger monitor - said in late July.

Other Palestinians have been killed in airdrops of aid, which experts say are ineffective and dangerous.

Meanwhile, with doctors reporting dizzy spells on their rounds and nongovernmental organizations warning that their own staff are “wasting away” from lack of food, the medical teams needed to treat those with malnutrition may also suffer.

The spread of severe malnutrition has wider impacts, too: Children who survive can be left with long-term health problems, while people injured in bombings, explosions or shootings, or infected by diseases, can take much longer to recover - overwhelming the health system further.

“Every one of our patients that we’re operating on has some level of malnourishment, just based on how their body is healing,” Fadlalla said, with wounds taking “much, much longer to heal than they normally should or would” and increased infections.

“I can tell you firsthand that everybody in Gaza is hungry, everybody,” he added.

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