Human Rights Watch – (Beirut, April 9, 2024) – Children in Gaza have been dying from starvation-related complications since the Israeli government began using starvation as a weapon of war, Human Rights Watch said today. Doctors and families in Gaza described children, as well as pregnant and breastfeeding mothers, suffering from severe malnutrition and dehydration, and hospitals ill-equipped to treat them.
Concerned governments should impose targeted sanctions and suspend arms transfers to press the Israeli government to ensure access to humanitarian aid and basic services in Gaza, in accordance with Israel’s obligations under international law and the recent International Court of Justice order in South Africa’s genocide case.
“The Israeli government’s use of starvation as a weapon of war has proven deadly for children in Gaza,” said Omar Shakir, Israel and Palestine director at Human Rights Watch. “Israel needs to end this war crime, stop this suffering, and allow humanitarian aid to reach all of Gaza unhindered.”
A United Nations-coordinated partnership of 15 international organizations and UN agencies investigating the hunger crisis in Gaza reported on March 18, 2024, that “all evidence points towards a major acceleration of death and malnutrition.” The partnership said that in northern Gaza, where 70 percent of the population is estimated to be experiencing catastrophic hunger, famine could occur anytime between mid-March and May.
Gaza’s Health Ministry reported as of April 1, that 32 people, including 28 children, had died of malnutrition and dehydration at hospitals in northern Gaza. Save the Children confirmed on April 2 the deaths from starvation and disease of 27 children. Earlier in March, World Health Organisation (WHO) officials found “children dying of starvation” in northern Gaza’s Kamal Adwan and al-Awda hospitals. In southern Gaza, where aid is more accessible but still grossly inadequate, UN agencies in mid-February said that 5 percent of children under age 2 were found to be acutely malnourished.
Human Rights Watch in March interviewed a doctor in northern Gaza, a volunteer doctor who has since left Gaza, the parents of two infants who doctors said died of starvation-related complications in both mother and child, and the parents of four other children suffering from malnutrition and dehydration.
Human Rights Watch reviewed the death certificate for one of the children, and photos of two of the children in critical condition that showed signs of emaciation. All had been treated at Kamal Adwan hospital in Beit Lahia, northern Gaza.
Human Rights Watch health advisers also reviewed verified pictures and videos online of three other evidently emaciated children who died and four others in critical condition who also showed signs of emaciation.
Dr. Hussam Abu Safiya, who heads Kamal Adwan hospital’s pediatrics unit, told Human Rights Watch on April 4 that 26 children had died after experiencing starvation-related complications in his hospital alone. He said that at least 16 of the children who died were under 5 months old, at least 10 were between 1 and 8 years old, and that a 73-year-old man suffering from malnutrition had also died.
Dr. Safiya said one of the infants died at just two days old after being born severely dehydrated, apparently exacerbated by his mother’s poor health: “[She] had no milk to give him.”
Nour al-Huda, an 11-year-old girl with cystic fibrosis, was admitted to Kamal Adwan hospital on March 15. Doctors there told her mother that Nour was suffering from malnutrition, dehydration, and an infection in her lungs, and administered her oxygen and a saline solution. “Nour al-Huda now weighs 18 kilograms [about 40 pounds],” her mother told Human Rights Watch. “I can see her chest bones sticking out.”
International humanitarian law prohibits the starvation of civilians as a method of warfare. The Rome Statute of the International Criminal Court provides that intentionally starving civilians by “depriving them of objects indispensable to their survival, including willfully impeding relief supplies,” is a war crime.
Since the Hamas-led October 7, 2023, attacks in Israel, the Israeli government has deliberately blocked the delivery of aid, food, and fuel into Gaza, while impeding humanitarian assistance and depriving civilians of the means to survive. Israeli officials ordering or carrying out these actions are committing collective punishment against the civilian population and the starvation of civilians as a method of warfare, both of which are war crimes.
Israeli government actions that undermine the ability of the UN Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) to carry out its recognized role in distributing aid in Gaza have exacerbated the effects of the restrictions.
A doctor who volunteered at the European hospital in Khan Younis in southern Gaza for two weeks in late January said that medical staff were forced to treat patients with limited medical supplies. He described the difficulty of treating malnutrition and dehydration, lacking essential items such as glucose, electrolytes, and feeding tubes. He said that one patient’s mother, desperate for solutions, resorted to crushing potatoes to create a makeshift liquid for tube feeding. Despite its nutritional inadequacy, the doctor said, “I ended up telling my other patients to find potatoes and do the same.”
On January 26, the International Court of Justice, in a case brought by South Africa, ordered provisional measures, including requiring Israel to “take immediate and effective measures to enable the provision of urgently needed basic services and humanitarian aid” and other actions to comply with the 1948 Genocide Convention. On March 28, the court indicated that Israel had not complied with this order and imposed a more detailed provisional measure requiring the government to ensure the unimpeded provision of basic services and aid in full cooperation with the UN, while noting that “famine is setting in.”
Governments should impose targeted sanctions, including travel bans and asset freezes, against officials and individuals responsible for the continued commission of the war crimes of collective punishment, deliberate obstruction of humanitarian aid and using starvation of civilians as a weapon of war.
Several countries have responded to the Israeli government’s unlawful restrictions on assistance by airdropping aid. The United States also pledged to build a temporary seaport in Gaza. However, aid groups and UN officials have said such efforts are inadequate to prevent a famine. Another attempt to deliver aid by sea was halted after an Israeli attack on aid workers on April 1.
On April 4, the Israeli cabinet agreed to several measures to increase the amount of aid entering Gaza, apparently following pressure from the US government.
“Governments outraged by the Israeli government starving civilians in Gaza should not be looking for band-aid solutions to this humanitarian crisis,” Shakir said. “Israel’s announcement that it will increase aid shows that outside pressure works. Israel’s allies like the US, UK, France, and Germany need to press for full-throttle aid delivery by immediately suspending their arms transfers.”
Starvation in Gaza
Prior to the current hostilities, 1.2 million of Gaza’s then-2.2 million people were estimated to be facing acute food insecurity, and over 80 percent were reliant on humanitarian aid. Israel maintains overarching control over Gaza, including over the movement of people and goods, territorial waters, airspace, the infrastructure upon which Gaza relies, and the population registry. This leaves Gaza’s population, whom Israel has subjected to an unlawful closure for more than 16 years, almost entirely dependent on Israel for access to fuel, electricity, medicine, food, and other essential commodities.
Nonetheless, before October 7, large amounts of humanitarian assistance reached the population. “Before this crisis, there was enough food in Gaza to feed the population,” said WHO Director-General Dr. Tedros Adhanom Ghebreyesus. “Malnutrition was a rare occurrence. Now, people are dying, and many more are sick.”
The WHO reported that the number of children under age 5 who are acutely malnourished has jumped from 0.8 percent before the hostilities in Gaza to between 12.4 and 16.5 percent in northern Gaza. Oxfam said on April 3 that since January, people in northern Gaza have been forced to survive on an average of 245 calories a day, “less than a can of fava beans.”
According to a nutrition vulnerability analysis conducted in March by the Global Nutrition Cluster, a network of humanitarian organizations chaired by UNICEF, 90 percent of children ages 6-23 months and pregnant and breastfeeding women across Gaza faced “severe food poverty,” eating two or fewer food groups each day.
Children with preexisting health conditions are particularly vulnerable to the devastating effects of malnutrition, which significantly weakens immunity. And starvation, even for survivors, leads to lasting harm, especially in children, causing stunted growth, cognitive issues, and developmental delays.
Gaza’s Health Ministry announced on March 8 that about 60,000 pregnant women in Gaza suffered from malnutrition, dehydration and inadequate health care. Poor nutrition during pregnancy harms both the baby and the mother, increasing the risk of miscarriages, fetal deaths, compromised immune system development, growth impacts, and maternal mortality.
Older people are also at particular risk of malnutrition, which increases mortality among those with acute or chronic illnesses. HelpAge International reported that even before October, 45 percent of older people in Gaza were going to bed hungry at least once a week, with 6 percent hungry every night.
The impact on Gaza’s population of the Israeli government’s use of starvation as a weapon of war is compounded by the near-total collapse of the healthcare system. Out of Gaza’s 36 hospitals, according to the UN Office for the Coordination of Humanitarian Affairs (OCHA), only 10 are operational, none of them fully, both as a result of the Israeli military’s repeated, apparently unlawful attacks on medical facilities, personnel, and transport, as well as the severe restrictions on the entry of fuel and other supplies.
Accounts from Gaza
On March 19, Andrea De Domenico, head of OCHA in the occupied Palestinian territory, visited Kamal Adwan hospital, where he said about 15 malnourished children arrive daily due to shortages in food, water, and proper sanitation. He described dire conditions at the hospital, noting damage to certain areas and its reliance on a single generator.
Among the cases that Human Rights Watch investigated:
- A man from Beit Lahia said his infant son, Abdelaziz, died just hours after his severely malnourished mother gave birth to him in Kamal Adwan hospital on February 24. He shared Abdelaziz’s death certificate with Human Rights Watch, which said that Abdelaziz was born premature. His father said that the hospital staff hooked Abdelaziz up to a ventilator because he was having trouble breathing, but that the ventilator stopped working after the hospital ran out of the necessary fuel a few hours later. “Abdelaziz died immediately,” he said. He expressed concern for his wife, who had been surviving on legumes and canned food, emphasizing their ongoing struggle to access adequate nourishment.
- The father of newborn twin girls said that one of his babies, Joud, died at Kamal Adwan hospital on March 2 after suffering from malnutrition, eight days after she was born. He said that he struggled to feed his family prior to the girls’ birth, but that they only had bread to eat, without meat or protein. He said that after the twins’ birth, his wife could not produce milk to breastfeed the girls and that store-bought milk was scarce. He described Joud’s deteriorating condition, saying that her “limbs became very cold, and she was breathing very slowly.” His mother-in-law accompanied Joud to the hospital, where she later passed away. The father expressed concern for the health of the surviving twin.
- Fadi, a 6-year-old boy from al-Nasser neighborhood in Gaza City, has cystic fibrosis, a genetic disorder that causes damage to the lungs. Fadi’s mother said that because of the Israeli blockade, she struggled to obtain the necessary medication and provide adequate nourishment. By mid-January, Fadi’s health had deteriorated to the point where he could no longer walk, prompting his hospitalization. “Fadi weighed 30 kilograms [about 66 pounds] before the war, now he is 12 [about 26 pounds],” she said. Fadi was evacuated from Kamal Adwan hospital on March 23 and was receiving treatment at a hospital in Cairo, a relative said on March 28.
- Wissam Hammad, the uncle of 5-year-old Muhammad, who has cerebral palsy and is lactose and gluten-intolerant and can only eat blended food, had great difficulties in securing food for him:
Most of his food should be fruit and vegetables, which is what I try to buy. But all I can find and afford are oranges. The problem is that he cannot chew, so we need to break down the food for him. Everything is very expensive.
- Dr. Ahmed Shahin, a pediatrician, said that before he could leave Gaza on November 16, Osman, his 14-year-old son with cerebral palsy, who uses a gastrostomy feeding tube, had lost seven kilograms (about 15 pounds) since the beginning of the hostilities because they lacked access to both the specific food he needed—such as vegetables—and electricity to blend his food.
Obstacles to Aid Delivery
Ongoing Israeli bombardment and ground operations, lack of security assurances from Israel, widespread infrastructure damage, and communications disruptions make it difficult to distribute the little aid that does get into Gaza. Humanitarian organizations have reported that Israeli forces have attacked their aid convoys and workers. Israeli forces have also shot at and shelled people congregating to collect aid, killing and injuring hundreds.
An Israeli government spokesperson stated on March 18 that aid entering Gaza faced no limits apart from security concerns. Other officials have blamed the UN for distribution delays and accused Hamas of aid diversion or the Gaza police of failing to secure convoys. On March 29, the Israeli Defense Ministry’s body governing civilian affairs in the Palestinian territories, COGAT, disputed the March 18 UN-supported humanitarian report warning of an imminent famine, and said that it “does not reflect the full situation.” COGAT denied that the Israeli government was purposely starving Gaza’s civilian population. Human Rights Watch wrote to COGAT on April 2 seeking comment on our findings, but did not receive a response as of the time of publication.
However, OCHA reported on April 8 that only one of four food aid missions that require coordination in Gaza were facilitated by Israeli authorities in March. Only nine World Food Programme aid shipments have made it to the north since January 1, the most recent of which was 18 truckloads on March 17. The World Food Programme said at least 300 trucks are needed every day for the north alone.
The United States has resorted to airdropping food into Gaza and plans to build a floating pier at sea to deliver aid, a proposal criticized by 26 nongovernmental organizations, including Human Rights Watch, as “risky, expensive, and ineffective.” UN Humanitarian Coordinator Jamie McGoldrick has stressed that road transport is the only viable solution for increasing aid flow.
The restrictions on aid delivery make accessing food for people requiring a specific diet particularly difficult. Several representatives of humanitarian organizations said that they have been unable to provide food for children on special diets or to reach them. A Palestine Children’s Relief Fund staff member said they could only provide baby formula and could not respond to the needs of children with specific diet requirements. Medical Aid for Palestine said the special food items they had in storage ran out quickly, and since then, they have been unable to find and provide those in need with specialized food items:
Assistance is barely coming in: a quarter of the population is at risk of famine. Under these circumstances, people with disabilities and [people in vulnerable situations] suffer the most. When you speak about food, it’s hard to support people who need a specific diet and medical assistance.
Following an Israeli airstrike in central Gaza on April 1, 2024, which hit three marked vehicles from the international food organization World Central Kitchen and killed seven aid workers from several countries, Cyprus announced that ships carrying around 240 tons of aid for Gaza would turn back. World Central Kitchen, Project Hope, and ANERA, all providers of food aid, suspended their Gaza operations in light of the attack, and the United Arab Emirates paused its involvement in a maritime aid corridor.
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