The hunger crisis in Gaza is at a tipping point, with critically low supplies of fortified milk and special nutritious pastes exacerbating food shortages and pushing greater numbers of children into starvation, according to aid agencies, malnutrition experts and the United Nations.
A report by the Integrated Food Security Phase Classification (IPC), the main global hunger monitor working with the UN and other aid agencies, is due on Friday.
An interim statement it released in late July said famine was "playing out" in Gaza. Reuters has previously reported the IPC's struggle to get access to data required to assess the crisis.
After a global outcry at Israel severely restricting aid from March, its military began allowing more food into Gaza in late July.
But volumes are too small and distribution too chaotic to stop more people becoming malnourished, while those who are already starving or vulnerable are not getting life-saving supplements, three hunger experts and aid workers from six agencies told Reuters.
According to figures from Gaza's Health Ministry, verified by the World Health Organization, deaths from malnutrition and starvation are spiking.
In the 22 months following the October 7, 2023 attacks by Hamas, 89 fatalities were attributed to malnutrition or starvation, mostly children under 18. In just the first 20 days of August, there were 133 deaths, including 25 under 18s, the ministry said on Wednesday.
"We are seeing the worst possible humanitarian catastrophe that we can even measure," said Jeanette Bailey, a child nutrition lead at the International Rescue Committee, a New York-based aid organization.
There are "going to be a lot more children dying, a lot more pregnant and lactating women suffering from malnutrition."
Israel does not accept there is widespread malnutrition among Palestinians in Gaza and disputes the hunger fatality figures given by the health ministry of Gaza's Hamas-run government, arguing that the deaths were due to other medical causes.
Reuters could not independently confirm the figures in this story, including those relating to malnutrition or famine-related mortality and supplies of different food products. Some of the most malnourished children are in the few hospitals still operating in Gaza, where doctors are scrambling for supplies of special therapeutic milks.
At Rantisi Hospital in Gaza City, doctor Ahmed Basal held up an infant, arms stick thin and wizened from wasting. He said normal formula, even when available, cost up to $58 per carton, while mothers were themselves too malnourished to breastfeed.
Gaunt-looking Aisha Wahdan gave her eight-month-old son Hatem fortified milk from a bottle, saying that before coming to hospital she tried to wean him on wild plants such as carob, chamomile and thyme because she could not breastfeed.
"There was no milk. I used natural herbs and tried everything because there was no milk substitute," she said.
Some ordinary baby formula, needed for those whose mothers are dead or unable to breastfeed, or when the child is unwell, has entered Gaza since the aid blockade was loosened, UNICEF said on Tuesday. However, the agency said it only has stocks for 2,500 babies for a month and estimates that at least 10,000 babies need formula.
"Without consistent entry and distribution of items like specialized supplementary feeding items - high energy biscuits and fortified foods - we are watching a preventable crisis turn into a widespread nutrition emergency," said Antoine Renard, Palestine country director of the World Food Program.
"At first it affects the most vulnerable groups but of course that will broaden," he said.
COGAT, the Israeli military agency responsible for aid, said in an August 12 media statement that most deaths attributed to malnutrition by Palestinian health authorities were caused by other medical conditions.
Malnutrition experts say deaths among people with existing health problems are typical in the early stages of a hunger crisis.
Israel has recognized shortages of food, but blames the United Nations for failing to effectively distribute supplies and Hamas for stealing it, which the groups denies. An official Israeli review found "no signs of a widespread malnutrition phenomenon among the population in Gaza", COGAT said.
In response to a request for comment about Israel's response to the shortage of supplements, COGAT said Israel's military was acting to "allow and facilitate the continued entry of humanitarian aid into the Gaza Strip in accordance with international law."
Ismail Al-Thawabta, the director of the Hamas-run Gaza media office said the government believed famine conditions were "more grave" than reported. "Hamas is keen more than anyone else for aid to flow into Gaza and to reach our people," he said. The United Nations human rights office in June accused Israel of "weaponizing" food for civilians, calling it a war crime, after documenting hundreds of people killed by the Israeli military as they tried to reach aid distribution sites by run Israel- and US-backed organization the Gaza Humanitarian Foundation (GHF).
The Israeli military has acknowledged that its forces have killed some Palestinians seeking aid and says it has given its troops new orders to improve their response.
TWO KILO BABY
Kholoud al-Aqra is three months old and weighs only two kilograms, her mother Heba al-Aqra said, far below the nearly six-kilograms average for girls of that age listed by the World Health Organization.
Aqra is still breastfeeding, but with very little food herself she is not producing enough milk and there is none to buy, she said. Aqra said she sometimes goes one or two days with nothing to eat but a single bowl of soup.
"I am exhausted myself. I feel dizzy when I breastfeed her because there is no good food for me also," Aqra said by phone from their shelter in Deir al-Balah in central Gaza.
Reuters could not independently confirm the details of Aqra's account. It is consistent with reports by aid agencies and the United Nations of the hunger crisis and how it affects breastfeeding mothers and their infants.
A typical treatment for an acutely malnourished nursing child like Kholoud would involve several weeks of feeding with therapeutic milk, as well as an abundance of food for her breastfeeding mother, including supplements, three nutrition experts said.
Despite the increase in aid and commercial food supplies entering Gaza, there is still very little available in the market or in the charitable community kitchen where the family seeks food daily, Aqra said.
They have also not managed to find supplements for either the baby, her mother, or the family's two older children.
When malnourished people do not get supplements that they can take at home alongside an adequate amount of normal nutritious food, their condition starts to deteriorate, said Mariana Adrianopoli, a nutrition lead for the WHO.
"Those children are vulnerable. Their immune system is compromised. They are susceptible to infections that can increase rapidly," she said.
"The deterioration of health conditions in a malnourished population can be very fast," she said.
In an environment like that of Gaza today, where most people live in tents or shelters with very little clean water, and with much of the sewage system destroyed, illness is rife and people with weakened immunity are at even greater risk, all the aid agencies said.
TIPPING POINT
All six agencies pointed to alarming indicators showing a rapid deterioration last month that they say would require greatly increased food imports to reverse alongside weeks of sustained extra supplements such as peanut butter paste and enriched milk formula for those most at risk. The number of children under five recorded as suffering wasting from food shortages nearly doubled from June to over 12,000, the WHO said, while more than 2,500 had the most severe form of extreme weight loss that can lead to death from starvation.
Those figures only represent children who showed up at clinics or hospitals, so the true number is likely much higher, all the agencies and hunger experts Reuters spoke to said.
At the same time, of 290,000 children under five who need supplements to prevent them sliding into severe malnourishment, only 3% were reached in July, a report by UN aid agency OCHA said, a major drop from an average of 26% between April and June.
In response to questions from Reuters, OCHA attributed the drop to limits on the quantities allowed in, active conflict and desperation that results in looting.
UNICEF said its stocks of the small packs of the nutritious pastes have either run out or nearly run out, with only enough for 5,000 children for the next month, the agency told Reuters on Tuesday.
Last month, Reuters reported Gaza would also run out of another specialized therapeutic food needed to save children already suffering the severe malnutrition that causes wasting by mid-August if nothing changed.
UNICEF has since been able to bring in some of those supplements, known as RUTF, but only enough for just below 5,800 children for one month. UNICEF calculates a current caseload of 70,000 children requiring RUTF.
WHAT'S GETTING IN?
Agriculture and fishing, traditionally the main sources of food inside Gaza, have been decimated by the war and the enclave's more than 2 million people rely almost entirely on imports.
Israel ended a ceasefire in March and imposed a near total blockade on aid entering Gaza until late May, when the Gaza Humanitarian Foundation began distributing food boxes at four places in the enclave.
GHF, in partnership with Samaritan's Purse, an evangelical Christian aid organization, began bringing in supplementary pastes last week, according to GHF's daily reports, totaling more than 150,000 packs so far, enough for around 5,000 children for a month.
GHF and Samaritan's Purse did not immediately respond to requests for comment for this story.
Israel began facilitating more aid deliveries through the main checkpoint into Gaza from late July but about 90% of food trucked into Gaza is taken before reaching a distribution point, either by hungry crowds or by armed gangs, a recent report by the UN aid agency OCHA said, meaning it may not reach the most vulnerable.
In response to a request for comment, GHF said its trucks had not been looted, adding that in recent days it had launched or piloted ways of distributing food directly to vulnerable populations.
Commercial supplies have also started entering Gaza - a step seen as crucial to increasing overall food amounts and preventing a sharper slip towards widespread malnutrition by providing fresh produce and richer foods like eggs, dairy and meat. But few people can afford to buy.
"The overall volume of nutrition supplies remains completely insufficient to prevent further deterioration. The market needs to be flooded. There needs to be dietary diversity," said Rik Peeperkorn, World Health Organization representative for Palestine.
