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HOW CHILDREN STARVE

In Gaza, hunger is taking a toll on the bodies of children. The impact can last
a lifetime.

By Mahmoud Issa, Adolfo Arranz, Mariano Zafra, Jitesh Chowdhury and Tom Perry
Published June 24, 2024  09:00 MESZ

Nearly 166 million people worldwide are estimated to need urgent action against
hunger, according to the Integrated Food Security Phase Classification (IPC), a
global partnership which measures food insecurity.

That includes nearly everyone in the Gaza Strip, where the Israeli military
launched an offensive in October following an attack on Israel by Hamas
militants. More than one million of Gaza’s inhabitants face the most extreme
form of malnutrition – classified by the IPC as ‘Catastrophe or Famine.’

Seven-month-old Majd Salem is one of them.

Born on Nov. 1, three weeks after Israel launched the offensive, the child was
being treated for a chest infection in the neonatal ICU at Kamal Adwan hospital
in northern Gaza on May 9. The nurse caring for him said he was suffering from
severe malnutrition.

Majd was born at a healthy weight of 3.5 kg (7.7 pounds), said his mother,
Nisreen al-Khateeb.

By May, when he was six months old, his weight had barely changed to 3.8 kg, she
said – around 3 kg less than would be expected for a baby his age.

Majd, whose eyes keenly followed visiting reporters in the ward, had to be given
antibiotics for the infection and fortified milk to boost his weight, his mother
said. Reuters was unable to trace them after May 21, when the hospital was
evacuated following an Israeli raid.

One in three children in northern Gaza are acutely malnourished or suffering
from wasting, according to the U.N. children’s agency UNICEF, citing data from
its partners on the ground. Ismail Al-Thawabta, director of the Hamas-run
government media office, said their records showed 33 people had died of
malnutrition in Gaza including 29 children, but added that the number could be
higher.

COGAT, an Israeli defence ministry agency tasked with coordinating aid
deliveries into Palestinian territories, did not respond to a request for
comment for this story. Israel’s foreign ministry in late May issued a detailed
statement questioning the IPC’s methods of analysis, which it said omitted
measures Israel had taken to improve access to food in Gaza. The IPC declined to
comment.

The plight of Gaza’s children is part of a bigger trend. Globally last year more
than 36 million children under 5 were acutely malnourished, nearly 10 million of
them severely, according to the Global Report on Food Crises, a collaborative
analysis of food insecurity by 16 international organizations.

The food shortage in Gaza, while particularly widespread, comes amid a broader
spike in extreme hunger as conflicts around the world intensify.

Two other countries – South Sudan and Mali – each have thousands of people
living in zones listed on the IPC website as facing famine. Another 35 –
including Sudan, Nigeria and the Democratic Republic of Congo – have many people
in the IPC’s next-most acute category of food deprivation.

The IPC, a grouping of United Nations agencies, national governments and
non-governmental organizations, is expected to update its assessment of the
picture in war-torn Sudan in coming weeks. A preliminary projection reported by
Reuters earlier this month said as many as 756,000 people in Sudan could face
catastrophic food shortages by September.

Gaza’s hunger crisis is also a product of war. The Israeli military invaded the
Strip in response to the Oct. 7 cross-border assault by Hamas on Israel. More
than 37,000 Palestinians and nearly 1,500 Israelis have been killed since then,
Gazan and Israeli tallies show.

The Israeli assault has destroyed swathes of Gazan farmland. In the early days
of the war, Israel imposed a total blockade on Gaza. It later allowed some
humanitarian supplies to enter but is still facing international calls to let in
more.

The International Criminal Court’s prosecutor, in seeking arrest warrants for
Israeli and Hamas leaders, last month accused Israeli Prime Minister Benjamin
Netanyahu and Defence Minister Yoav Gallant of using starvation of civilians as
a method of warfare, among other alleged crimes. Netanyahu, calling that move “a
moral outrage of historic proportions,” said Israel is fighting in full
compliance with international law and taking unprecedented measures to ensure
aid reaches those in need.

Israel has accused Hamas of stealing aid, which Hamas strongly denies. Israel
has also said any distribution problems within Gaza are the fault of the
international agencies.

Even when children survive, nutrition experts say food deprivation in the early
years can do lasting damage.

A child’s brain develops at its fastest rate in the first two years of life. So
even if they don't starve to death or die from illness due to their weakened
immune system, children may face delays in growth and development, said Aashima
Garg, adviser on nutrition at UNICEF for the Middle East and North Africa.

“While they may be alive, they may not thrive that well in childhood and
beyond,” she said.

Three families in Gaza told Reuters about their day-to-day diets, and four
global health experts explained how such deprivation affects the growing body.
Damage done in weeks manifests over years, they said.

“It can have a long-term impact on their immune system, their ability to absorb
good nutrition, and on their cognitive and physical development,” said Hannah
Stephenson, global head of nutrition and health at Save The Children, a
non-profit.


FIRST DAYS

Gaza has the most households globally in the most extreme stage of food poverty,
according to the IPC, which classifies levels of hunger in five categories, the
worst of which is famine.

Households in North Gaza, where Majd lives, are already suffering a full-blown
famine, Cindy McCain, Executive Director of the World Food Programme, said on
May 5.

It can take months for the international measurement system to declare a famine.
But the first damage to a child’s body is counted in days.

NORMAL

When the body receives adequate nutrients,

its metabolism functions regularly. Food is

efficiently broken down to provide energy

and maintain body functions such as growth,

tissue repair, and the immune system.

After 24 hours

Brain

After a day without food, the body uses

stored glucose as its main energy source. A

hormone called glucagon is released,

instructing the liver to produce more glucose,

primarily used to fuel the brain.

Glucose

Liver

First few days

The body starts breaking

down fat tissue for energy in

the first few days. Muscles use

the fatty acids produced

during this process as their

main energy source.

Ketones

Fatty acids

These fatty acids form

ketones in the liver, which

are released into the

bloodstream and can be

used by the brain as

fuel. Over time, this

emergency measure for the

body can be lethal.

Fat tissue

Description to come here.

Nine out of 10 children aged 6 months to 2 years in Gaza live in severe child
food poverty, a UNICEF survey in late May found. This means they are eating from
two or fewer food groups a day, which UNICEF’s Garg said means grains or some
form of milk.

This has been the case since December 2023, with only a slight improvement in
April 2024, she said. As many as 85% of children of all ages did not eat for a
whole day at least once in the three days before the survey was conducted.

The main cause of acute malnutrition in North Gaza is a lack of diversity in the
diets of children and pregnant and breastfeeding women, according to a report in
February 2024 from the Global Nutrition Cluster, a group of humanitarian
agencies led by UNICEF.

This deficient intake, both prior to and during pregnancy and breastfeeding,
harms both mothers and infants.

Abed Abu Mustafa, 49, a father of six, was still living in Gaza City in early
April. He said people there already had eaten “almost every green plant we could
find” and he hadn’t had meat or chicken for at least five months.

In Rafah in the south, Mariam, 33, a mother of five, has been living in a school
along with two dozen of her relatives. She described a typical meal for her
family before the conflict and what they are currently eating, shown below.

BREAKFAST

Before

Now

Salad, cucumber and tomato

Bread

Glass of milk

Hummus

Falafel

Sandwich of thyme

Eggs, fried or boiled

Fool, stewed fava beans

Cheese

LUNCH

Salad or some cooked meal

Beef or chicken with rice

Canned beef or sardines

DINNER

Salad, cucumber and tomato

Cheese

Glass of milk

Hummus

Dinner skipped

Eggs, fried or boiled

Falafel

Bread

Fool, stewed fava beans

Before the war, Majd’s mother said an average family meal consisted of rice with
chicken or meat, along with vegetables such as okra, cauliflower or peas. During
the war, flour scarcity forced the family to make bread from animal feed.
Recently, bread and canned goods like tuna and beans started to reappear, but
these are not widely available.

Unable to find food to feed herself and forced to flee Israeli bombardment early
in the war, Khateeb said she had found great difficulty in breastfeeding Majd.

She said she could find neither good quality baby formula nor clean water to mix
it, so she fed him various types of powdered feed mixed with rainwater or
brackish water from Gaza's polluted wells, causing diarrhoea.

“There is no chance to get proper food to have breastmilk, there is no meat, no
proteins, no calcium, none of the elements that produce good milk for the
child,” she said.

Garg, the UNICEF adviser, said the nutrition of breastfeeding mothers in Gaza
was severely compromised, and with it their ability to produce milk.

“They are not eating fruits and vegetables. They are not eating meat. They are
not having much milk,” she said. This lack of nutrients translates into poor
quality breast milk. Diluted formula is not safe and risks diarrhoea, which
itself can be deadly.

Moderately malnourished mothers can still breastfeed, with their bodies
effectively sacrificing their own nutritional needs to save the child. But
severely malnourished women struggle.

Ahmed al-Kahlout, the nurse who heads the unit, said Majd’s infection was due to
malnutrition.

“There is no immunity, so any disease that the child catches in the shelters …
afflicts the child with these severe lung infections,” he said.

Susceptibility to infections typically increases after two weeks with
insufficient food.

The body’s consumption of its fat reserves eats away muscle tissue, which is why
aid workers in the field use basic tape measures to assess the gravity of
children’s conditions.

The tapes measuring Mid-Upper Arm Circumference (MUAC) have been used for
decades. If the upper arm’s circumference is 11.5 cm (4 1/2 inches) or smaller
for a child between 6 months and 5 years old, the child is assessed as having
severe acute malnutrition, according to standards drawn up by the United
Nations.

After a week

When fatty acid reserves are

depleted, the body uses protein as

an energy source. The speed of this

process depends on the individual's

body fat; if they have little fat,

protein use will begin sooner.

The breakdown of

muscle protein leads to

muscle mass loss.

Muscles

After two weeks

As muscle breakdown

accelerates, the body loses

functionality in the heart, liver,

and kidneys. This disrupts

normal functions and exposes

the body to infections and

multiple complications. As

weight loss increases, the body's

systems become more affected

and cell function deteriorates

due to lack of proteins.

Heart

Liver

Kidneys

Other issues

Appetite decreases,

irritability increases

Measuring mid-upper arm circumference (MUAC)

Red

Severe acute

malnutrition

Yellow

Moderate acute

malnutrition

Green

No acute

malnutrition

Description to come here.

MUAC screening data across Gaza since mid-January found more than 7,000 children
aged 6 months to about 5 years were already acutely malnourished as of May 26,
the United Nations humanitarian agency OCHA said.

This is how that looks.

Healthy arm

Arm with

severe acute

malnutrition

A reduction in the mid-upper arm circumference suggests a loss of muscle mass
and fat, which indicates severe malnutrition.

Comparative size

(6 cm diameter)

Gaza has the most people at risk of starvation, but according to the IPC
classifications, many millions are one step behind the enclave in food poverty.

The IPC categorises the severity and scale of food insecurity and malnutrition.
Readings of 3, 4 or 5 on the five-category scale require urgent action.

Households in Phase 3 are in “Crisis,” the IPC says. They have high or more than
usual acute malnutrition, or can meet their minimum food needs but only by
selling assets or through crisis measures.

Phase 4 is an “Emergency.” Households have either “very high” acute malnutrition
and death rates or are only able to make up for the lack of food by taking
emergency measures and selling assets.

Phase 5 is “Catastrophe” or “Famine.” Households have an extreme lack of food
and/or other basic needs and starvation, death, destitution and extremely
critical acute malnutrition levels are evident. An entire area is only
classified as in Famine if high food insecurity comes with certain levels of
acute malnutrition and mortality.

For the IPC, areas in Famine meet at least two of the following three criteria:

 * The area has at least 20% of households facing an extreme lack of food,
 * About one in three children there suffer from acute malnutrition,
 * Two adults or four children out of every 10,000 die each day due to outright
   starvation, or to the interaction of malnutrition and disease.

The IPC report issued in March projected that the entire population of the Gaza
Strip would fall into Phases 3 to 5 between March and July. U.N. officials told
Reuters they expect the next IPC analysis on Gaza to be released on June 25.

Catastrophe

or famine

Emergency

Crisis

Gaza

Countries where

IPC says people

fall into Phase 5

South Sudan

Mali

Central

African Republic

Stressed

Minimal or no food stress

Afghanistan

Pakistan

Myanmar

Democratic Republic

of the Congo

Bar depth is

proportional to

total population size

Population

109,594,986

Eswatini

1,188,391

Zambia

9,134,428

Nigeria

200,345,759

Ghana

32,155,878

Add a description of the graphic for screen readers. This is invisible on the
page.

South Sudan and Mali are the other two other countries with households projected
to fall into the same Phase 5 category as Gaza, based on the IPC’s latest
published analyses.

Overall, the three countries with the largest numbers of people at Phase 3 and
above are Nigeria (25 million), Democratic Republic of Congo (23.4 million) and
Sudan (17.7 million), according to the IPC website.

The IPC said its latest analysis of Sudan, conducted in December, was too
outdated to include in the tables Reuters used for this chart.

As a consequence of severe malnutrition, various complications arise.

MORE THAN THREE WEEKS

Hair loss and

thinning

Eye lesions can occur due

to a deficiency of vitamin A

Muscle atrophy

and weakness

Constant cold

sensation

Chronic

constipation

Dry and

flaky skin

Bone

mass loss

Swelling of

the limbs

Add a description of the graphic for screen readers. This is invisible on the
page.

This is the impact of starvation after just three weeks. Like many children in
Gaza, Majd’s lack of adequate food dates back months.

Photographs

Additional reporting by Nidal al-Mughrabi in Cairo, Saleh Salem in Doha,
Michelle Nichols in Washington, DC and Jennifer Rigby and Aidan Lewis in London

Sources

Integrated Food Security Phase Classification (IPC); Global Nutrition Cluster;
Reuters reporting

Edited by

Simon Scarr and Sara Ledwith


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