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KHAN YOUNIS, Gaza Strip: The dead body of 2 1/2-year-old Ro’a Mashi lay on the table in Gaza’s Nasser Hospital, her arms and rib cage skeletal, her eyes sunken in her skull. Doctors say she had no preexisting conditions and wasted away over months as her family struggled to find food and treatment.
Her family showed The Associated Press a photo of Ro’a’s body at the hospital, and it was confirmed by the doctor who received her remains. Several days after she died, Israeli Prime Minister Benjamin Netanyahu on Sunday told local media, “There is no hunger. There was no hunger. There was a shortage, and there was certainly no policy of starvation.”
In the face of international outcry, Netanyahu has pushed back, saying reports of starvation are “lies” promoted by Hamas.
However, UN spokesman Stephane Dujarric this week warned that starvation and malnutrition in Gaza are at the highest levels since the war began.
The UN says nearly 12,000 children under 5 were found to have acute malnutrition in July — including more than 2,500 with severe malnutrition, the most dangerous level. The World Health Organization says the numbers are likely an undercount.

The past two weeks, Israel has allowed around triple the amount of food into Gaza than had been entering since late May. That followed 2 1/2 months when Israel barred all food, medicine and other supplies, saying it was to pressure Hamas to release hostages taken during its 2023 attack that launched the war. The new influx has brought more food within reach for some of the population and lowered some prices in marketplaces, though it remains far more expensive than prewar levels and unaffordable for many.
While better food access might help much of Gaza’s population, “it won’t help the children who are severely malnourished,” said Alex DeWaal, executive director of the World Peace Foundation at Tufts University, who has worked on famine and humanitarian issues for more than 40 years.
When a person is severely malnourished, vital micronutrients are depleted and bodily functions deteriorate. Simply feeding the person can cause harm, known as “refeeding syndrome,” potentially leading to seizures, coma or death. Instead, micronutrients must first be replenished with supplements and therapeutic milk in a hospital.
“We’re talking about thousands of kids who need to be in hospital if they’re going to have a chance of survival,” DeWaal said. “If this approach of increasing the food supply had been undertaken two months ago, probably many of those kids would not have gotten into this situation.”
Any improvement is also threatened by a planned new Israeli offensive that Netanyahu says will capture Gaza City and the tent camps where most of the territory’s population is located. That will prompt a huge new wave of displacement and disrupt food delivery, UN and aid officials warn.

Preexisting conditions

The Gaza Health Ministry says 42 children died of malnutrition-related causes since July 1, along with 129 adults. It says 106 children have died of malnutrition during the entire war. The ministry, part of the Hamas-run government, is staffed by medical professionals and its figures on casualties are seen by the UN and other experts as the most reliable.
The Israeli military Tuesday pointed to the fact that some children who died had preexisting conditions, arguing their deaths were “unrelated to their nutritional status.” It said a review by its experts had concluded there are “no signs of a widespread malnutrition phenomenon” in Gaza.
At his press briefing Sunday, Netanyahu spoke in front of a screen reading “Fake Starving Children” over photos of skeletal children with preexisting conditions. He accused Hamas of starving the remaining Israeli hostages and repeated claims the militant group is diverting large amounts of aid, a claim the UN denies.
Doctors in Gaza acknowledge that some of those dying or starving have chronic conditions, including cerebral palsy, rickets or genetic disorders, some of which make children more vulnerable to malnutrition. However, those conditions are manageable when food and proper medical treatments are available, they say.
“The worsening shortages of food led to these cases’ swift deterioration,” said Dr. Yasser Abu Ghali, head of Nasser’s pediatrics unit. “Malnutrition was the main factor in their deaths.”
Of 13 emaciated children whose cases the AP has seen since late July, five had no preexisting conditions — including three who died — according to doctors.
Abu Ghali spoke next to the body of Jamal Al-Najjar, a 5-year-old who died Tuesday of malnutrition and was born with rickets, which hinders the ability to metabolize vitamins, weakening bones.
In the past months, the boy’s weight fell from 16 kilograms to 7 (35 pounds to 15), said his father, Fadi Al-Najjar, whose lean face showed his own hunger.
Asked about Netanyahu’s claim there was no hunger in Gaza, he pointed at Jamal’s protruding rib cage. “Of course there’s famine,” he said. “Does a 5-year-old child’s chest normally come to look like this?”
 

Skin and bones

Dr. Ahmed Al-Farra, Nasser’s general director of pediatrics, said the facility receives 10-20 children with severe malnutrition a day, and the numbers are rising.
On Sunday, a severely malnourished 2-year-old, Shamm Qudeih, cried in pain in her hospital bed. Her arms, legs and ribs were skeletal, her belly inflated.
“She has lost all fat and muscle,” Al-Farra said. She weighed 4 kilograms (9 pounds), a third of a 2-year-old’s normal weight.
Doctors suspect Shamm suffers from a rare genetic condition called glycogen storage disease, which changes how the body uses and stores glycogen, a form of sugar, and can impact muscle and bone development. But they can’t test for it in Gaza, Al-Farra said.
Normally, the condition can be managed through a high-carbohydrate diet.
Her family applied a year ago for medical evacuation, joining a list of thousands the WHO says need urgent treatment abroad. For months, Israel slowed evacuations to a near standstill or halted them for long stretches. But it appears to be stepping up permissions, with more than 60 allowed to leave in the first week of August, according to the UN
Permission for Shamm to leave Gaza finally came this week, and on Wednesday, she was heading to a hospital in Italy.
 

A child died in her family’s tent

Ro’a was one of four dead children who suffered from malnutrition brought to Nasser over the course of just over two weeks, doctors say.
Her mother, Fatma Mashi, said she first noticed Ro’a losing weight last year, but she thought it was because she was teething. When she took Ro’a to Nasser Hospital in October, the child was severely malnourished, according to Al-Farra, who said Ro’a had no preexisting conditions.
At the time, in the last months of 2024, Israel had reduced aid entry to some of the lowest levels of the war.
The family was also displaced multiple times by Israeli military operations. Each move interrupted Ro’a’s treatment as it took time to find a clinic to get nutritional supplements, Mashi said. The family was reduced to one meal a day — often boiled macaroni — but “whatever she ate, it didn’t change anything in her,” Mashi said.
Two weeks ago, they moved into the tent camps of Muwasi on Gaza’s southern coast. Ro’a’s decline accelerated.
“I could tell it was only a matter of two or three more days,” Mashi said in the family’s tent Friday, the day after she had died.
Mashi and her husband Amin both looked gaunt, their cheeks and eyes hollow. Their five surviving children – including a baby born this year — are thin, but not nearly as emaciated as Ro’a.
DeWaal said it’s not unusual in famines for one family member to be far worse than others. “Most often it will be a kid who is 18 months or 2 years” who is most vulnerable, he said, while older siblings are “more robust.”
But any number of things can set one child into a spiral of malnutrition, such as an infection or troubles after weaning.
“A very small thing can push them over.”