As Gaza suffers, experts call on hunger monitor to redefine famine

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 paediatric 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 organisation 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 Israeli 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.

The seeming disconnect between what’s happening on the ground and how the IPC characterises conditions in Gaza has given rise to many questions: Does the hunger monitor need a more flexible definition of famine? How would a famine finding make a practical or legal difference? And how might the IPC be able to overcome limitations in gathering and evaluating data?

“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 programme 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.

'Historical judgment'

The debate over whether and how to update the IPC’s approach to famine comes as hunger continues to spread around the world, especially in war-torn areas such as Myanmar and Sudan, where people have resorted to eating leaves. In 2023, almost 282 million people faced what the IPC considers high levels of acute food insecurity. More than 36 million children under the age of 5 were acutely malnourished.

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.

Those injured in war zones also may succumb to infections they would otherwise survive if the lack of proper nutrients hadn’t weakened their immune systems, doctors say. In such cases, malnutrition may not be recorded as the cause of death even if it played a role.

A famine finding by the IPC, some experts say, would have significantly ratcheted up the pressure on the Israeli government to allow more humanitarian aid into Gaza because of the international opprobrium Israel would have faced.

The war began in October 2023, when Hamas staged a surprise attack on Israel. The attack killed some 1,200 people, Israel says. In Israel’s ongoing military campaign, at least 1.9 million people — about 90 per cent of Gaza’s population — have been displaced, and some 45,000 Palestinians have been killed, according to local health authorities.

Governing authorities in countries being assessed usually head the team carrying out the IPC analysis. In some countries suffering severe hunger crises, Reuters found that governments or rebels have tried to impede IPC deliberations. In Gaza, the IPC set up an ad hoc group, headed by its own staff rather than local government representatives. Two IPC sources told Reuters that the move reflected in part an effort to maintain neutrality.

Since December 2023, the IPC has repeatedly found that the territory’s proportion of people experiencing an extreme lack of food is the highest it has seen anywhere in the world.

Israeli authorities continue to maintain a tight hold on what goes into Gaza. A Reuters analysis of past relief shipments suggests that outside pressure may have made some difference. At several key moments when the US or other powerful actors raised urgent concerns about food access in Gaza, Israel allowed more goods to enter the territory, Reuters found. But those increases have always been short-lived and never enough to ease hunger for sustained periods, according to interviews with aid workers and residents of Gaza.

One example: In March, the IPC’s Famine Review Committee, which vets and verifies a famine finding, published an analysis projecting that famine was “imminent” in northern Gaza. The International Court of Justice also ordered Israel to ensure the delivery of aid to Palestinians throughout Gaza. That month, Israeli government figures show, aid into Gaza began to increase.

Then in early April, after Israel killed seven people working for American aid charity World Central Kitchen, US President Joe Biden threatened to condition support for Israel’s offensive in Gaza on Israel taking concrete steps to protect aid workers and civilians. That month, aid to Gaza rose to the highest levels since the war began. It hasn’t reached those levels in any month since.

In a statement, Israeli authorities told Reuters that efforts are made “almost daily” to coordinate time windows where Israeli soldiers “cease fire in certain areas” to allow movements for aid organisations, medical teams, and humanitarian supplies. “Residents are informed in advance of such pauses,” the statement reads.

Even when supplies make it into Gaza, however, looting by armed gangs has thwarted efforts to feed the hungry. Israeli restrictions on movement and the ongoing fighting also mean other aid fails to reach those in need.

On November 7, for instance, Israeli authorities approved a request to send 10 trucks of food and one truck of water from Gaza City to areas in northern Gaza that had received no food aid for more than a month, according to the World Food Programme, or WFP, the UN’s primary food-aid distributor. While the convoy was held at an Israeli checkpoint for two hours, desperate civilians took some of the aid, a WFP spokesperson told Reuters.

The convoy was then allowed to move. But after a few kilometers, Israeli soldiers ordered the drivers to unload the trucks, leaving the aid on the ground near the checkpoint in north Gaza. A WFP spokesperson said staff members were told it wasn’t safe to proceed and to abandon the aid.

According to the WFP, the aid never reached its destination: schools where displaced people were sheltering and a hospital. The WFP spokesperson said it would have been impossible for civilians to approach the area where the aid was unloaded because of the presence of the Israeli military.

Around that time, Israel’s military released a statement about the incident. It said that 11 trucks carrying food, water and medicine reached northern Gaza. It also published a video and photos, showing aid workers leaving the aid on the side of the road. The statement did not mention that the aid failed to reach its intended destination. COGAT, the Israeli government body that is responsible for aid to Gaza, did not respond to Reuters questions about the incident. A spokesperson for the Israel Defense Forces had no comment.

As for the debates over the exact toll hunger has taken in Gaza, de Waal said they miss a larger point. “We need to dethrone the concept that if it’s not famine, it’s OK,” he said. “Even if it’s not a famine, it can be truly terrible.”