Northern Gaza (Figure 1; includes Gaza and North Gaza governorates: 1.06 million people)
After 22 months of war, repeated mass displacements, the destruction of nearly all essential infrastructure, and extreme restrictions on the entry of food, northern Gazans have long exhausted their coping capacity. Since May, recorded violent fatalities have surged by 120 percent, while airstrikes and evacuation orders have displaced hundreds of thousands into increasingly small areas of Gaza and along North Gaza’s southern border. The confinement of the population, density of overcrowding amid scarce shelter, and increasing strain on extremely limited humanitarian and healthcare services are all expected to worsen in the lead-up to Israel’s plan to forcibly displace the entire population of Gaza City by October.
The share of surveyed households with extreme hunger (≥50 percent caloric deficit) based on the Household Hunger Scale (HHS) more than tripled in Gaza and more than doubled in North Gaza from May to July. Results from Computer Assisted Telephone Interviews (CATI) conducted in July suggested that 36 percent of respondents in Gaza (n=504) and 28 percent in North Gaza (n=94) faced Catastrophic (IPC Phase 5) hunger, which surpasses the starvation threshold (≥20 percent) for Famine (IPC Phase 5). These CATI survey results, while not statistically representative, are expected to be biased downward since the households most affected by conflict and displacement are less likely to respond, meaning the results are more likely to underestimate the share of the population experiencing extreme hunger. Israel’s Coordination of Government Activities in the Territories (COGAT) reported that no food entered the north from March to May, and only 1,124 trucks (21,650 MT)2 of food and non-food aid were approved for entry through Zikim/Erez West from June 1 to August 17. The majority of U.N.-coordinated aid is intercepted by desperate civilians or looted by armed actors. All bakeries remain closed, and community kitchens run by 16 humanitarian organizations report reaching less than 10 percent of the northern population daily from June to mid-August (99,000 meals per day). Gaza Humanitarian Foundation (GHF) food distribution points are largely inaccessible from the north, with the closest site at least 5-15 kilometers away across the heavily militarized Netzarim Corridor in northern Deir al-Balah.
Prolonged starvation and the interaction of hunger and disease have led to a rapid increase in levels of acute malnutrition in Gaza, crossing the threshold for Famine (IPC Phase 5) in July; a similar trend can be inferred in North Gaza. Screenings of over 15,000 children under five identified global acute malnutrition (GAM) levels of 12.7-19.9 percent based on mid-upper arm circumference (MUAC), surpassing the IPC’s long-established GAM-MUAC threshold for Famine (≥15 percent). Reports from Médecins Sans Frontières (MSF) indicate that patient enrollment for malnutrition in treatment centers in Gaza City nearly quadrupled from the beginning of May to mid-July. Data submitted by 28 organizations, including Action Against Hunger, MedGlobal, and Médecins du Monde, also show that admissions of children under five to treatment programs more than doubled from June to July (from 2,027 to 5,236 children), and cases of severe acute malnutrition more than tripled month-on-month in Gaza (341 to 1,095 children). Shortages of lipid-based nutrient supplements are reported across the Gaza Strip. While screenings have not been possible in North Gaza, it is highly likely that acute malnutrition levels are similar to or worse than those in Gaza – the population is heavily concentrated along the Gaza-North Gaza border just hundreds of meters away from Gaza City – and health and humanitarian service providers report that North Gaza residents cross into Gaza City to access available resources, such that children from North Gaza are among those screened for acute malnutrition in Gaza.
While gold standard estimates of mortality in northern Gaza are unavailable, the body of evidence strongly suggests mortality attributed to hunger and disease has likely reached the Famine (IPC Phase 5) threshold of 2 people per 10,000 per day. Empirical evidence from past famines indicates that as starvation and disease push acute malnutrition above the second Famine threshold, levels of mortality rapidly accelerate and surpass the third threshold within 4-12 weeks. Furthermore, once Famine (IPC Phase 5) is underway, mortality typically remains elevated even in the weeks after a scale up of assistance due to lagged physiological recovery from starvation. Malnutrition-related deaths have been reported by health facilities across the Gaza Strip since July 1, which is likely an underestimate as it excludes non-trauma deaths outside of health facilities. Contextual information indicates a high and rising likelihood of deaths: more than one in three households in Gaza and one in four households in North Gaza are experiencing extreme hunger; acute watery diarrhea had affected 9,000 children in Gaza Governorate by July; there are growing reports of multidrug-resistant bacterial infections that increase the risk of mortality for otherwise treatable conditions; and there are mounting barriers to life-saving care for neonatal and maternal health complications. Gaps in mortality data do not imply a low level of mortality on the ground.
Southern Gaza (Figure 1; includes Deir al-Balah, Khan Younis, and Rafah governorates: 1.04 million people)
In southern Gaza, large-scale displacement, the expansion of ground incursions into Deir al-Balah in July, the widespread destruction of basic infrastructure, and extreme difficulties in accessing the minimal quantities of available food have pushed the population to the brink of Famine (IPC Phase 5). The majority of the population is already experiencing large to extreme food consumption gaps indicative of Emergency (IPC Phase 4) and Catastrophe (IPC Phase 5) outcomes, and acute malnutrition levels are rising rapidly. Over 1 million people have been forcibly and repeatedly displaced into increasingly small areas of land in the south, while livelihoods and coping capacity have largely collapsed. The advancement of ground operations into Deir al-Balah, combined with escalating attacks on Gaza City, are expected to intensify human suffering and displacement in the coming weeks as populations in northern Gaza seek shelter to the south.
From May to July, the share of surveyed households with extreme hunger (≥50 percent caloric deficit) based on HHS tripled in Deir al-Balah and rose by nearly 50 percent in Khan Younis. CATI surveys conducted in these two governorates in July found that 22 percent of respondents in Khan Younis (n=225) and 33 percent of respondents in Deir al-Balah (n=173) faced Catastrophic (IPC Phase 5) hunger, surpassing the first threshold for Famine (IPC Phase 5). Similar to the CATI surveys conducted in northern Gaza, this survey method is associated with downward bias. Eighty-four and 95 percent of surveyed households in Khan Younis and Deir al-Balah, respectively, also reported resorting to extreme coping strategies to access food, including searching through rubble for food or undertaking extreme safety risks to access food. Over 700 deaths linked to the distribution of aid were reported across the Gaza Strip in July alone, including 390 in or near GHF distribution sites in the south.
While Israel has taken some steps since late July to increase the entry and distribution of food – including the easing of humanitarian and commercial restrictions and daily 10-hour pauses in military operations in select areas – quantities of food have remained below the minimum requirements since March; current methods of food distribution in the south leave segments of the population at a systematic disadvantage in accessing available supplies; and barriers to humanitarian access to the south remain high. According to COGAT’s data, no food entered the south in March and April, and only 140,196 MT of humanitarian food and non-food aid have been approved for entry via Kerem Shalom from May 1 to August 17. Supplies continue to be intercepted by desperate civilians or looted by armed groups, raising the risk that the worst-off households are unable to access food. As of August 10, the 16 humanitarian organizations running community kitchens report they are reaching just 22 percent of the southern population (around 225,000 meals per day). Meanwhile, access to food at GHF’s four distribution sites has been severely compromised by life-threatening violence and theft and – until mid-August – very short operation windows and a first-come, first-served system. Staple food prices trended 500-5,000 percent above pre-war prices in Deir al-Balah in late July, with the price of wheat flour soaring to 200-300 shekels (58-88 USD) per kilogram prior to July 20. While wheat flour prices have fallen sharply since then, household access to cash to purchase food remains very low amid economic collapse, the severe cash liquidity crisis, and e-wallet cashout fees of around 40 percent.
Levels of acute malnutrition currently remain below the threshold for Famine (IPC Phase 5) in southern Gaza but have increased at an alarming rate since late May. Under current conditions, statistical analysis of the rate of increase in acute malnutrition levels indicates a rapid acceleration to Extremely Critical (IPC Phase 5) levels will occur between mid-August and September. In comparison to northern Gaza, southern Gaza has had marginally higher access to food and health services over the course of the conflict, which has likely slowed the pace of increase in acute malnutrition from hunger and disease until now. Nevertheless, screenings of over 20,500 children under five show GAM-MUAC levels have more than doubled since May, reaching 4.9-9.1 percent in Khan Younis and 1.3-12.0 percent in Deir al-Balah. Access to water, sanitation, and hygiene services has nearly collapsed. Only six hospitals are operational in southern Gaza, and medical supplies are widely out of stock or projected to run out as hospitals warn they may be forced to turn patients away. Acute respiratory infections, acute watery diarrhea cases, and acute bloody diarrhea cases are rising, with 5,400 cases among children reported in Deir al-Balah by July.
The increase in acute malnutrition is expected to accelerate levels of mortality attributed to hunger and disease, and this third threshold for Famine (IPC Phase 5) is projected to be crossed by late September. Similar to northern Gaza, direct quantitative evidence of mortality is unavailable, but current levels of starvation and malnutrition within the south, increases in malnutrition-related deaths in health facilities, and the high likelihood that non-trauma mortality is underreported are all indicative of rising levels of hunger-related mortality. In the absence of immediate intervention, the interaction between hunger and disease will leave malnourished children and adults increasingly vulnerable to mortality, and only consistent energy intake and treatment of micronutrient deficiencies can slow or reverse the weakening of immune systems and depletion of the muscle, tissues, and organs that sustain life. Only concerted and sustained efforts to ensure food, nutrition, and medical assistance reach the individuals most at risk of malnutrition and mortality will mitigate ongoing loss of life and avert the current trajectory toward Famine (IPC Phase 5) in southern Gaza.
