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00:00Starvation in Gaza. The entire population food-deprived after months of Israel blocking vital supplies and waging relentless attacks.
00:10Experts say the strategy means long-term damage for the health of Gaza's people.
00:15What are the consequences of Israel's actions? This is Inside Story.
00:30Hello again, I'm James Bayes. Israel has destroyed most of Gaza and has also been starving its people since breaking the last ceasefire in March.
00:45Medieval tactics of siege deliberately deny Palestinians many of the essentials needed for human health and survival.
00:53All this in full glare of the world, the story of Gaza's horror being told by its journalists, themselves starving too.
01:01How this could happen in today's world will shame those responsible when the pages of history are read by future generations.
01:07But for the people of Gaza, that's too late for them.
01:10The health consequences of such planned, organised starvation will blight the lives of an entire generation.
01:17Exploring this in detail is central to finding out what's behind Israel's policy of starvation,
01:22what it's doing to the health and lives of Palestinians in Gaza.
01:26We'll talk to our guests in a moment.
01:28First, this report from Joel Evans with a warning.
01:30Some viewers may find the images distressing.
01:36Hunger is haunting the people of Gaza.
01:41The starvation crisis, unleashed by Israel, is deepening.
01:46Palestinians have been dying of malnutrition.
01:49Doctors at this hospital in Gaza hand over the body of a child to her father, another victim of starvation.
01:59Her name was Zainab Abu Halib.
02:02When she was born, she weighed just over three kilograms.
02:06When she died, she weighed less than two kilos.
02:10I've been in the hospital for three months to no avail.
02:13This is how she looked before being sick.
02:16Her picture before the illness.
02:18And this is the referral.
02:19Ready, but no one listens.
02:21We had a lot of appeals.
02:22And the girl suffered a lot while sick.
02:24Malnutrition, lack of formula milk, and the closure of the border crossings.
02:28All against the people.
02:30There are a lot of children like her case.
02:32Pediatric doctors at Nasser Hospital say Zainab's condition grew worse,
02:37with vomiting and diarrhea that led to dehydration.
02:42She was also infected with sepsis.
02:44Unfortunately, the malnutrition cases increased in numbers.
02:49We have the statistics of the Minister of Health that nearly 124 patients died due to severe malnutrition
03:04or severe acute malnutrition.
03:07And nearly 84 from them, they were pediatric or children.
03:12The health ministry says hundreds of thousands are facing the same fate as Zainab.
03:18In March, Israeli Prime Minister Benjamin Netanyahu ordered a blockade of all aid into Gaza.
03:27And his government says there is no hunger,
03:30denying what international aid agencies and governments are saying,
03:34that this is a man-made disaster.
03:37But aid agencies and the UN have been sounding the alarm for months.
03:43The World Food Programme reports at least one in three Palestinians is not eating for days at a time.
03:49More than 1,000 Palestinians have been killed trying to get food from the notorious
03:54Gaza Humanitarian Aid Foundation distribution sites.
04:01Sites the UN and others have described as death traps.
04:04And the situation is growing more desperate for more than 2 million Palestinians across the Gaza Strip.
04:13Joel Evans, Al Jazeera, for Inside Story.
04:19Let's discuss this further with our guests today.
04:23And in Oxford in the UK, we have Dr. Nick Maynard, a surgeon who's just returned from volunteering in Gaza with medical aid for Palestinians.
04:33In Amman, Dr. Tanya Haj Hassan, a pediatric intensive care doctor who's worked in Gaza many times treating acute malnutrition.
04:42And in Boston, Alex Duval, executive director of the World Peace Foundation and author of the book,
04:49mass starvation, the history and future of famine.
04:53We are dealing with a very grim subject.
04:56I warn viewers, we're going to ask you to be very, very frank about the situation and how bad it is.
05:02And let me start on that with you, Dr. Nick.
05:06You have been to Gaza, I believe, three times during the war since October 2023.
05:13But you've just come back in the last week compared to your previous visits.
05:20How much worse has it got?
05:23Hello.
05:24And thank you for asking me on.
05:26It's much worse.
05:27I've seen malnutrition on all three trips since October 2023.
05:34And each time I go, I feel I'm going to be prepared for what I'm going to see because I know Gaza so well.
05:42I've been going there for 15 years.
05:44I have been in regular contact with friends and colleagues out there.
05:49But of course, each time I go is much, much worse than I expected.
05:52On this most recent occasion, I have spent a month out there.
05:56I returned four days ago.
05:58The malnutrition in particular, I mean, many things were worse, but the malnutrition in particular was really quite appalling.
06:06Patients of mine died as a result of their malnutrition because of their inability to heal following the major injuries and the major surgery they were acquiring.
06:19I had children on the paediatric intensive care unit.
06:22Children up there were dying.
06:24So the malnutrition was really unimaginably bad and much worse than I'd expected.
06:30Dr. Tanya, you have also been to Gaza during the war.
06:34You've also been to Gaza many times.
06:36Every day we look at the figures of the number of people, in particular children, who are starving to death.
06:44Those numbers continue to rise.
06:46Are we reaching a tipping point?
06:48I'm not even sure what a tipping point means anymore.
06:55I think if there was a tipping point, we reached it a very long time ago.
07:01Dr. Nick referred to the cases that he saw on his previous trips that would die or succumb to their injuries partially as a consequence of their underlying malnutrition.
07:12And so we've been seeing this for months.
07:14I've been on Al Jazeera talking about malnutrition in the past before, you know, over a year ago now.
07:19So it's a frighteningly worsening problem as we speak to the extent that even our colleagues are starving.
07:30I mean, just 20 minutes ago, I received a message from one of my colleagues saying, a colleague who never complains actually, saying that he hasn't eaten bread in six days and that he's very hungry.
07:41And he made light of it and joked about it as he always does.
07:45But everybody is hungry at the moment, which is a change from the past where maybe the North colleagues in the North were hungry, but the South were able to get not necessarily quality, but at least quantities of calories that were sufficient.
08:00And he proceeded to joke, but then confirmed that he was very serious, that he now weighs less than I do.
08:06I was lost with him in March. He's significantly taller than me.
08:09He's also male. And generally, he should be weighing a lot more than I do.
08:13I'm quite a small person. And that tells you something about the conditions when even health care workers who continue to work, who are often some of the more well off in society are starving themselves.
08:27So, yes, it's significantly, significantly worse.
08:30And the head of pediatrics in one of the hospitals contacted me yesterday morning, actually asking me to get on the media and speak internationally, not only about the starvation, but also the other complications of the conditions that have been architectured by this regime that are clearly make it very difficult to stay alive.
08:52I mean, people are not only being killed intentionally, frankly, and I'm sure you'll hear more about that from the other speakers on the panel through starvation, but they're also being killed through complications of poor hygiene, you know, leading to bouts of diarrhea after diarrhea.
09:13And more recently, this outbreak of something called Guillain-Barré syndrome, or at least that's what we assume it might be.
09:20But it's a condition where your immunity attacks itself, usually after an infection, often a diarrheal infection, and it attacks your nerve cells, essentially.
09:33And in the severe cases, you end up with paralysis of most of your muscles, including the muscles needed to breathe.
09:40So it's a life-threatening condition that's treated with one specific medication and one machine that kind of rinses the blood, something called plasmapheresis, and the medication is intravenous immunoglobulin.
09:52And they're unable to provide these medications anymore because they don't have any more intravenous immunoglobulin, and they don't have the filters for the IV, for the plasmapheresis.
10:03And so he's begging me, after telling me, yes, I'm doing okay, thank you so much for asking, yeah, the food situation's difficult, it's really hard, I don't know what to feed my children, but I have something important I want to talk to you about.
10:15And he proceeds to tell me about how they've been receiving at least two cases per day, and he can't actually treat them.
10:21These are all complications of these conditions.
10:24We have these brief outcries about starvation or polio, and then it kind of winds down and everybody forgets and focuses on the next international scandal.
10:36But the reality is these conditions that have been killing people at a frightening rate have been ongoing from day one and exponentially worsening every day.
10:46Alex, you wrote the book, Mass Starvation, the History and Future of Famine.
10:52And given what you know about famines in the past, famines around the world, if you were to plot the deaths in Gaza from starvation on a graph, what do you think is likely to happen to that curve?
11:07What I fear is we are already in a stage where those preventable deaths will increase at an exponential rate.
11:19The people of Gaza have, over the last 20 months, been subjected to such stress across the board, not just nutritional stress, but as the physicians have been describing, a whole breadth of stress on health, on living conditions, on everything that is necessary to sustain life.
11:45And starvation is also a societal phenomenon.
11:49It's the degradation of those very basic ties that bind communities together.
11:55It is deeply humiliating, shaming, degrading, dehumanizing.
12:00And when a society is destroyed so systematically over such a sustained period, it gets to a place where the harms are so deep, so complex and so intertwined that the death rate escalates.
12:20And bringing it back is not simply a question of distributing rations.
12:26It needs something much, much more all-encompassing and across the board, caring for every aspect of human life, starting with those most vulnerable children.
12:43Dr. Nick, from your experience there in the last week in Gaza, how difficult is it in the hospitals?
12:50We heard from Tanya, who spoke to one of her colleagues who himself is now starving.
12:56What sort of facilities, if any, do you have to help, particularly these starving children?
13:03I'm told there's no baby formula anymore.
13:07No, I mean, there's no feed in the hospital.
13:09The adult patients, there is no food at all for the adult patients.
13:14They're completely reliant upon food that their relatives bring in, which, of course, is incredibly difficult for them to get to.
13:22All the relatives of the patients are going to these food distribution points and risking their lives at these food distribution points because so many are being shot there to get food for their patients.
13:33On the paediatric unit, I was there every day because I had a patient on the paediatric intensive care unit.
13:40There were many days when there was no formula feed there.
13:43No formula feed has been allowed in to Gaza for many months now.
13:48There were several doctors I know who took in formula feed in their luggage and every single carton of it was confiscated, was taken away by the Israeli border guards, very specifically the formula feed.
14:04So none of it was allowed in.
14:07We had some children who were being fed with 10 percent dextrose, which is effectively water with sugar added to it, which has got no nutritional value at all.
14:19We had there were newborn babies that being given the wrong type of feed because that's all that was available and they were losing weight.
14:28And in my time there, there were four premature babies who died as a direct result of malnutrition.
14:37You're showing a picture there of a girl I remember from the unit there, Huda, who I saw most days there.
14:43So the horrors that I witnessed both on the adult wards and the paediatric wards were due to a lack of nutrition, which has been there's been no nutrition being allowed in there for many months.
15:00And it was very distressing to see that this girl.
15:04I spent all night operating on her once to repair her esophagus, which had been damaged, and she was totally reliant upon nutritional support because she couldn't eat or drink.
15:17We were trying to we managed to saw some feed to put down a feeding tube into her intestines, but she wasn't tolerating that because she had a lot of biochemical abnormalities.
15:28Because she'd been deprived of food for so long, she needed intravenous feeding and we had no intravenous feeding to give her at all.
15:37And tragically, she died yesterday morning.
15:39I got phoned by the hospital to say that she tragically died.
15:44And that was very clearly related to the inability to give her proper nutritional support.
15:50So and there'll be many, many more deaths.
15:53I mean, no doubt about that and less food and specific nutritional support like formula feed is allowed in.
16:01Dr. Tanya, I know this is a very distressing subject, but I think we need to know exactly what we're talking about and the medical details.
16:09So explain to us what happens inside the human body when it is faced with starvation.
16:16I'll speak specifically about children because those are the cases I treat.
16:23You know, with my work with doctors about borders, we often set up these feeding centers or inpatient therapeutic feeding centers to treat children with severe acute malnutrition.
16:36And the reason they need to be treated as an inpatient, I know I received this question before in the past week.
16:43You know, once the food is able to enter, if it is able to enter, you know, what is that going to look like and does the problem end there?
16:51The reality is it doesn't. And for me, as a clinician, that's usually the very frightening time is starting to feed somebody who has been malnourished for a long time.
17:02As Dr. Maynard mentioned with his previous patients, having these sort of shifts in salts and other things inside their body, these shifts can be life threatening.
17:10And so they need to be fed in a very intensive way. The reason that's the case is because malnutrition impacts all aspects of the body's function.
17:21You know, it's the fuel for your cells. And so when your cells are starved, it impacts essentially every organ in your body.
17:28We, I guess, colloquially think of it as, you know, low energy, not enough sugar to burn as energy.
17:36And then you lose fat and then you lose protein and you end up losing weight and looking quite thin.
17:41But in reality, all of the cells in your body are altered by this.
17:46In your intestines, the villi, so the cells lining your intestines, die.
17:51And that results in issues with absorption, bacterial overgrowth.
17:56Your pancreatic suffers, so you struggle as pancreas suffer.
18:00So you struggle absorbing fats.
18:02And that means that even when you're fed, you can't necessarily absorb the calories.
18:07You end up with diarrhea and losing a lot of fluids.
18:10The cells in your heart become very weak and thinned and they have poor contractility.
18:15Their connections are also impacted so that the heart rate slows quite a bit.
18:22And these children often die of heart failure or life-threatening changes in rhythm, even during the period where they're being,
18:30and sometimes especially during the periods that they're being fed, refed.
18:34They also have life-threatening shifts in salts.
18:39And these can also lead to life, fatal heart rhythms.
18:45They're more prone to, you know, everything life-threatening from sepsis, as someone just mentioned right now, to shock.
18:53I think it was Dr. Ahmed that mentioned that the baby, I think her name was Zainab, also had sepsis.
19:00So sepsis shock, other infections, including skin infections, particularly ulcerating skin lesions, low blood pressure, inability to maintain body temperature.
19:13So hypothermia, fluid overload, especially when you're refeeding, fungal infections, acute vitamin deficiencies that threaten even your vision, can cause alterations in your bone growth for children and so on.
19:31And then, of course, for your brain, which is the long-term impact that we talk about a lot for your brain, it can result in death of brain cells, alterations in,
19:44so a reduction in the number of brain cells, alterations in the way they branch, in the connections between them, all of which results in decreased brain size,
19:54slowed brain growth, and ultimately delays in motor function, in global function, in memory.
20:02And so that when they do studies of adults who were treated for severe acute malnutrition as children, and so they underwent rehabilitation,
20:12they often find that they have issues with education, vocabulary, learning difficulties.
20:20And recently there was a study actually in April in the British Medical Journal that followed adults that were treated as children.
20:28And they had issues with everything from mobility to their social networks, their social participation to household daily tasks and etc.
20:38Okay, if I could bring in Dr. Nick again now, Dr. Tanya.
20:44As I understand it, just reintroducing food will not fix some of these children.
20:52There is a point that they reach, I think Tanya mentioned it, this thing, refeeding syndrome.
20:59Are you worried about that in Gaza, even if food was to arrive?
21:04Absolutely, and we saw it all the time, and we saw it in a lot of the adults I was treating as well.
21:10It leads to very severe electrolyte or biochemical abnormalities in the blood, which, as Tanya said,
21:16can cause severe dysrhythmias of the heart, can cause the heart to go into a very fast rhythm,
21:22might even cause the heart to stop working.
21:26And I'm pretty sure that's what happened with the young girl, Habiba, who died yesterday morning, tragically.
21:37The other thing to add in is, and it's linked to what Tanya was saying, that the immune system is so suppressed in these patients
21:45that their ability for their tissues to heal following the major trauma they've had and following the major surgery we've carried out is greatly impaired.
21:55So if they're very malnourished to start with, we might do this very major surgery to repair their liver or their pancreas or their duodenum or their intestines or their stomach.
22:07And because they're so malnourished, the ability of those tissues to heal properly is often very, very diminished.
22:18So those repairs we've done will then break down, causing terrible infections, terrible leakages of bodily contents into the abdomen, into the chest.
22:29That causes more infections that stops, for example, the intestine working.
22:35So you cannot use the intestine for nutritional support, which means they need to have intravenous feeding.
22:41And that is impossible in Gaza. So you get these into a vicious cycle and often die.
22:48Alex, if I could bring you back in. Israel in recent hours has done an airdrop.
22:55There are some other countries apparently going to do airdrops.
22:59It's talking about humanitarian corridors and a tactical pause.
23:02I think we're all justified in being pretty cynical after what we've seen for the last 21 months that's taken place in Gaza.
23:10It's probably just a PR effort. But if, and this is a very big if, if Israel allowed aid in at scale now, could things be turned around or not?
23:21Is it too late?
23:23So Israel is obliged, actually legally obliged, to provide a full spectrum of unhindered humanitarian access and restoration of basic services, food, water, sanitation, hygiene, fuel, medical care, etc.
23:42It is a requirement for it to do that, to be in conformity with its obligation to prevent genocide.
23:49And as with every passing day, the actual steps that Israel needs to take to conform to that obligation are getting higher and higher and higher.
24:02It is not simply enough to airdrop a little bit of food to set up this so-called Gaza humanitarian foundation and distribute some rations at the southern edge of Gaza, which, as we know, are death traps.
24:17A fully comprehensive program of humanitarian specialist medical care is needed in order to stop this, what is already a catastrophe, from spiraling completely out of control.
24:35Everything that's on offer today is just like the smallest beginning in that step.
24:41Tanya, I mean, we've talked about the physical effects of the famine and the starvation and the effects on those who may even survive.
24:50There clearly are psychological effects as well.
24:53What would you say, given that you deal with children, will be the effect on this generation of people in Gaza, the lasting effect?
25:03I don't know, you know, I've described some of the patients I treated before, but this last time I was in Gaza, most of the children I treated in the ICU weren't interactive at all.
25:17You know, after they had recovered and we had taken the breathing tubes out, children often stared at the wall.
25:23The children that we had with burns that would come in, would not cry, they wouldn't ask for food, they often wouldn't even ask for their parents.
25:34All of this is not normal behavior for a child.
25:38I have a friend who's a specialist in child mental health, and we have conversations about this all the time because she's also going to Gaza frequently and nothing about the way children are reacting at the moment is normal.
25:56But at the same time, even though this is unprecedented, and at least in my career, I've never treated a child that's been through what the children in Gaza have been through in the last two years, it's kind of, I guess, expected.
26:12I mean, when you're in the emergency department, you can imagine what the children who are brought in, injured, and still conscious are seeing around them.
26:26And that's what I'm mostly exposed to, so it's hard for me to talk about children in the community.
26:30In the hospital, the children are seeing people around them, injured in ways that are so horrific that even as healthcare providers, we walk away changed.
26:40Okay, let me bring in Nick about that point, walking away changed.
26:46You were just days ago in Gaza.
26:49You're now in Oxford, known as one of the places of education, one of the most civilized places in the world.
26:57The contrast to the way people are being treated in Gaza, I know you're a medical professional, but are you angry?
27:03Most certainly, and I know I'm speaking to Tanya about this.
27:11When you leave Gaza, you have this very complex mix of many deep emotions coming out.
27:20You clearly feel a bit of relief, you're coming home to see your loved ones, but you feel intense anger because of what has been done to the Gazans and how profoundly unjust and evil it is.
27:35You feel guilt for leaving because you're leaving patients behind, you're leaving friends and colleagues who are being left to work.
27:44They don't have the luxury of getting out again, and that's all magnified when you get back to what is normal living for us, when you get back to your home and you see how everyone can live outside Gaza.
28:00So a very complex mix of emotions, but absolutely anger is paramount in that.
28:06And again, particularly in the UK, because our government has done nothing to help the Gazans, and they're all talking a lot at the moment.
28:22They're all coming out with very strong words, but not taking any actions at all.
28:27So that makes me very angry indeed.
28:29Thank you very much, and thank you to all of our guests today, Dr. Nick Maynard, Dr. Tanya Haj-Hassan, and Alex Daval.
28:37Around the clock, Al Jazeera brings you continuing coverage of developments in Gaza from our team on the ground, and you can find more analysis and insight on our website, aljazeera.com.
28:47We'd like to hear your comments and opinions too.
28:50All you need to do is go to our Facebook page.
28:52That's facebook.com forward slash AJ Inside Story.
28:55Another option is X there.
28:57Just look for at AJ Inside Story.
28:59I'll be back here very soon.
29:00Until next time, from me, James Bays, as well as the team behind the camera, stay safe and well.
29:05Bye-bye for now.
29:06Make sure to subscribe to our channel to get the latest news from Al Jazeera.