GAZA CITY: Five times in the course of the past year, the world’s leading hunger monitor warned that Gaza could be teetering on the precipice of famine. Each time, the watchdog stopped short of concluding one was under way. Gregory Shay, a retired pediatric pulmonologist from California, spent October treating children in Gaza, and to him it looked like famine was gripping the territory. Shay worked at Nasser Hospital in the southern Gaza city of Khan Younis. Most of the children he treated subsisted on bread and rice, recalled Shay, a volunteer with the US-based non-profit organization MedGlobal. Without vegetables, fruit or meat, he said, the children lacked the vitamins or minerals needed to stave off disease.

Most days, Shay said he treated on average 40 new patients who were admitted to the hospital. Many had severe cases of pneumonia, and several others suffered from meningitis, an illness that can kill in hours. Newborns were often small for their age, he said. Some had birth defects or suffered from neonatal sepsis, a blood infection that’s a leading cause of infant mortality. “I’ve never seen the kind and number of infections that I saw in Gaza,” said Shay, who has made 35 medical aid trips during the past decade. “You just look at these kids and you know that it’s a famine.”

Many food-security experts, aid workers and doctors say famine took hold in Gaza many months ago. But amid relentless Zionist entity bombing and restrictions on movement, analysts with the world’s main hunger monitor, the Integrated Food Security Phase Classification system (IPC), have struggled to get access to key data on acute malnutrition levels and deaths unrelated to violence. These metrics are vital for the IPC to determine if starvation has technically risen to the level of a famine.

IPC reports use a one-to-five scale to rank areas for acute food insecurity. It slides from minimal to stressed, crisis, emergency and famine. Gaza has consistently approached, but never technically reached, famine level. Most recently, the IPC’s Famine Review Committee has warned that famine is imminent in areas of northern Gaza. Some experts want the IPC to lower its threshold for determining famine in conflict-ridden areas and expand the types of data it uses. In Ethiopia, Yemen and Sudan, Reuters found that governments or rebels have blocked or falsified the flow of data to the IPC or tried to quash its findings.

“If we can’t access critical information, confirming a famine becomes impossible – and so does saving lives,” said Dalmar Ainashe, a food-security analyst with relief group CARE. For 10 years, Ainashe served as a member of the IPC Technical Advisory Group, which provides expert advice to IPC’s leadership. He also has recounted how he survived a famine as a child in his native Somalia.

“In the chaos of conflict, clinging to unattainable quantitative thresholds isn’t just unrealistic,” Ainashe told Reuters. “It’s a fatal oversight that risks abandoning entire populations to suffer and die in silence.” Jose Lopez, the IPC’s global program manager, said the hunger monitor does rely on various types of evidence to “ensure that IPC analysis findings are robust and thus credible.” Regardless, a famine finding isn’t a silver bullet. As Reuters reported, limited aid has reached Zamzam, a camp in Sudan for displaced people that the IPC deemed to be in famine. Moreover, if aid only flows when a famine is found, it’s too late: Food and medical relief need to start arriving much earlier, long before people start dying.

To prevent deaths, governments and others who can help address hunger need “to act before a famine is confirmed or even projected,” the IPC’s Lopez said. “Simply changing the terminology is unlikely to address the issue.” Even so, internal IPC documents reviewed by Reuters show that the hunger watchdog is considering modifying its famine definition. Among options mentioned in the September documents: lowering the mortality threshold or examining mortality trends rather than simply using a hard-and-fast threshold.

Such changes will take time, Lopez cautioned. “This work requires considerable collaborative effort and studies,” he told Reuters. In Gaza, children were already dying of malnutrition-related causes in December last year, according to local medical staff. That’s what Mona Abdel Atti says she witnessed when she began caring for malnourished patients as a midwife at Nasser Hospital.

One day last December, two infants were admitted to the hospital – a 5-month-old girl, and an 8-month-old boy, she recalled. Both were breathing rapidly and showing clear signs of malnutrition and dehydration. Their weights were critically low for their ages, their stomachs bloated and their skin dry, she said. The medical staff quickly administered plasma and blood transfusions and placed them on ventilators, Abdel Atti said, but their bodies were too weak. They died an hour apart. 

For Michael Fakhri, the UN special rapporteur on the right to food, it became clear that famine had taken hold in Gaza months later, when more children began dying of malnutrition-related causes. Along with other UN experts, he declared in July that famine had spread throughout Gaza. “Parents and communities feed their children before they feed themselves,” Fakhri told Reuters, “so when a child dies it tells us that social structures are collapsing and an entire people is under attack.”

In addition to other thresholds, the IPC currently says famine occurs when two of every 10,000 people or four of every 10,000 children under 5 die each day “due to outright starvation or to the interaction of malnutrition and disease.”

But little is known about how many people in Gaza have died of causes unrelated to violence since the war began. In late October, a Gaza health ministry official shared with Reuters a list of 38 people whose deaths were attributed to malnutrition or dehydration. A majority were children, including infants under the age of 1. The official said he believes the tally substantially undercounts actual deaths. Many families bury their dead without reporting the death because of the cost, dangers and difficulties of moving around in Gaza, the official said. The official added that the ministry has little information about recent malnutrition cases and deaths in besieged areas in northern Gaza, where hunger levels are believed to be highest.

“A formal famine determination would signal a historically grave calamity brought about by the military tactics of the Zionist entity state,” said Konyndyk, the former director of the US Agency for International Development’s Office of US Foreign Disaster Assistance. “That word – famine – has a lot of power ... It takes it from a technical determination to a historical judgment. And that, of course, was not a historical judgment that the Zionist entity government wanted to be held responsible for.”

COGAT did not respond to questions about whether Zionist entity allowed more aid into Gaza to prevent a famine determination, or whether outside pressure influenced Zionist entity to temporarily loosen restrictions. An IPC famine finding could be used in legal cases against Zionist entity or its officials, some experts say.

In November, the International Criminal Court in The Hague issued arrest warrants for Zionist entity Prime Minister Benjamin Netanyahu and his former defense chief. One of the war crimes that’s alleged: starvation as a method of warfare. Starvation is also at the crux of South Africa’s case accusing Zionist entity of state-led genocide. That case is before the International Court of Justice, the UN’s highest legal body. – Reuters