Causing the deaths of civilian populations
Last updated: June 18, 2024
Israel has placed a stranglehold on the Palestinian population of Gaza since the beginning of the war.1 The absence of supplies in Gaza – a siege – has been the stated policy of top Israeli officials since the beginning of the war.2 Israel’s military operation have destroyed much of the local infrastructure for food production in Gaza (agricultural lands, greenhouses, fishing boats and food production facilities such as bakeries and manufacturing)3 as well as severely degrading, destroying or putting out of use much of the water infrastructure (wells, reservoirs and desalination plants).4 Throughout the war, only some 100-150 full truckloads have been allowed in daily,5 out of about 300 that are necessary for humanitarian needs (supply of food and water).6
Israel has weaponized humanitarian aid to Gaza, limiting its entrance to Gaza based on political reasoning which is often opaque.7 Trucks that attempt to enter the Strip encounter multiple problems as they try to do so, including attacks by the IDF.8 The list of items that are forbidden in the Gaza strip remains unclear six months into the war, but has included chocolate croissants, animal feed, nail clippers, toys in wooden boxes, and crutches.9 In one case, it took a UN organization three months to get approval to deliver 500 tons of animal feed.10 The UN’s humanitarian coordinator explained in April some of the ways in which Israel was impeding aid. For example, Israel required then that all aid trucks enter Gaza half full, and demanded a complete separation between Egyptian truck drivers (who crossed into Gaza, then unloaded and left) and Palestinian truck drivers (who would wait for the Egyptians to leave, come with trucks, load them, and deliver aid to UN warehouses). Food convoys to the North of the Strip – where the population is undergoing famine – are three times as likely to be denied than other humanitarian convoys with other types of material.11
In late March about 7,000 trucks were waiting on the Egyptian side of the border to bring supplies into the Strip because of Israel’s inefficient process of inspections (the average wait time is 20 days).12 In the first two weeks of March, for example, only half of the planned humanitarian missions to northern Gaza took place. The other half were denied by the IDF or postponed.13 The numbers were similar in May.14 Some of the food on these trucks rots during the long times they wait to enter Gaza.15
Beginning in February, Israel began to weaponize also the distribution of aid. In the first months of the war, Gaza’s civilian police was responsible for the internal distribution of aid, including through tasks such as guarding warehouses, accompanying convoys, and overseeing the actual distribution of aid. Israel’s underlying policy is to not differentiate between Hamas’ armed military wing and Hamas as the non-state actor governing Gaza – both are seen by Israel as the same terrorist organization. As a IDF officer stated “Hamas police is Hamas… and we won’t allow Hamas to control the humanitarian assistance”.16 In February, Israeli attacked several police cars, then dropped flyers that showed a destroyed police car with a message stating that Israel will not allow Hamas’ security apparatus to continue working.17 In response, police withdrew from this role. Ten days later, the UN aid delivery The World Food Program stopped aid delivery because of the collapse of civil order, followed by UNRWA.18 Both the US and the UN asked Israel to stop targeting the police to avoid “a total breakdown of law and order”.19 Israel refused, and tested its own approach – to rule Gaza through prominent local families that could oversee aid.
The “flour massacre” in late February (discussed above) was apparently the result of this approach of Israel to coordinate aid delivery with a Gaza City family.1 Hamas reacted by attempting to set up local emergency committees for security and aid distribution, apparently using al-Shifa Hospital for this coordination in the North.20 Israel reduced the number of trucks it let into the Strip to less than a third than what it had committed to facilitating,21 while also attacking Gazan police officers responsible for coordinating aid.22 This was the context for Israel’s second raid on al-Shifa in mid-March (discussed in Zoom-in #1 below), during which it killed several figures closely associated with aid efforts.23 By late March, Israeli strikes on the emergency committees killed more than 70 people waiting for aid, so the committees stopped working. Israel further limited the distribution of aid by informing the UN that it would not allow further UNRWA convoys to North Gaza.24 Additional police officers associated with the distribution of aid were killed in April.25
An analysis of reported data found at least 80 separate attacks by Israel on aid in Gaza between January and mid May. There were at least 37 attacks on civilians seeking aid.26
Famine and starvation
December to April
The siege reality has resulted in severe shortages of basic necessities (food, water and energy) as well as a sharply deteriorating humanitarian situation.27 A report by the NGO International Crisis Group noted people in Rafah who queued for flour for ten hours at a time on four consecutive days in December. Some left empty-handed.28 In January, a survey among shop owners revealed a significant shortage of basic food items, with 81% indicating depletion and 19% having only limited supplies.29 The situation has been extreme in North Gaza. In the northern parts of the Gaza Strip in early February, the price of a bag of flour, 30 shekels (~$8) before the war, reached 500-1000 shekels (~$125-250), 15-30 times higher.30 In late February, the price of a plate with some raw meat and rice reached $95 (US) according to social media,31 while a nurse in Al-Shifa hospital claimed he had not eaten bread for 2 months during which he consumed animal feed.32 At the same time, the UN’s leading expert on the right to food described the circumstances as ‘a situation of genocide’, while the World Food Programme stated that “people are already dying from hunger-related causes”.33 In early March, the head of Israel’s Committee for Food Security called for a ceasefire because of the humanitarian conditions in the Gaza Strip.34 In April, the price of a kilogram of sugar reached between $19 and $30.35
As of mid-April, at least 31 people (of which 28 were children) in Gaza died of malnutrition or dehydration.36 In this context, the High Representative of the EU for Foreign Affairs and Security Policy stated in front of the UN Security Council that “starvation is being used [by Israel] as a war arm”.37 Leading NGOs such as Human Rights Watch and Oxfam concluded that “the Israeli government is using starvation of civilians as a weapon of war in Gaza”.38 Israeli accounts have de facto admitted this,39 and within a broader historical context, Israel has long used food in such a manner in Gaza.40 A report by a global authority on food security and nutrition from mid March stated that famine (their definition here41) was imminent in the northern governorates of the Strip over the next two months.42 Anecdotal evidence confirms this. In late March, the UNICEF spokesperson wrote that he saw a dozen “skeletal” children in a single hospital in Beit Lahia.43 The price of a bag of flour in northern Gaza increased to $275 (normally $8) by mid March, alongside rampant banditry.21 By late March, apparently in the same area, the price of a few dozen kilograms (estimated from video) of vegetables reached some $3,000.44 For context, the average income in Gaza before the war was $13-20/day.45 Humanitarian conditions were somewhat less dire in the south of the Gaza Strip, where a late March poll of Gazans found that only 44% have enough food for a day or two, and only 19% can access a place for assistance of food and water without great risk.46 Individual accounts confirm these details.47
As a result, the vast majority of Gaza’s population is at risk of famine.48 Already by January virtually all households were skipping meals every day, with 50-80% of households going entire days and nights without eating.49 Some 90% of civilians in Gaza experienced “high levels of acute food insecurity”.50 In late January the World Health Organization’s Director-General noted the food shortages that result in medical staffs and patients receiving only one meal per day.51 Some 40% experience “emergency levels” and over 15% (378,000) experience catastrophic levels, namely “extreme lack of food, starvation and exhaustion of coping capacities”.52 in January, the Chief Economist of the World Food Program has stressed that “In my life, I’ve never seen anything like this in terms of severity, in terms of scale, and then in terms of speed.”53 Despite this situation, IDF officers demanded a further lowering of the humanitarian aid to Gaza.54 A prominent scholar of famine and Executive Director of the World Peace Foundation stated that he had never seen the war crime of starvation perpetrated in such scale over the 40 years of his career55 and that “The rigor, scale and speed of the destruction of the structures necessary for survival, and enforcement of the siege, surpasses any other case of man-made famine in the last 75 years”.56
In February, an aid organization stated on CNN that Gaza was the fastest decline in nutritional status ever recorded in a human population.57 In late February and early March about half of the missions aimed at delivering aid to areas in the north part of the Gaza Strip were denied access by Israeli authorities.58 On more than one occasion, the IDF attacked a food convoy.59 In mid-March, The UK foreign secretary described a series of obstacles Israel was placing in the delivery of aid, de facto blaming Israel for the humanitarian crisis and Israel’s spokesperson for providing false information.60 In late March, the International Court of Justice ordered Israel to allow unimpeded food aid into Gaza.61 In early April, a group of US government humanitarian experts privately warned other officials that the spread of hunger in Gaza is “unprecedented in modern history”.62 At the same time, Oxfam stated that people in northern Gaza have been forced to survive on an average of 245 calories a day since January, less than 12% of average daily calorie needs.63 Despite reports about increased aid deliveries to Gaza in early April, In mid-April a UN official said that Israel turned down more than 40% of the UN’s requests to deliver aid for Palestinians to northern Gaza the previous week, stating “We’re dealing with this dance where we do one step forward, two steps backward, or two steps forward, one step backward, which leaves us basically always at the same point”.64 In late April a leaked US administration paper written by US experts on food security in the Department of State and USAID stated that famine in Gaza was inevitable, and that the deterioration of food security in Gaza “exponentially” outpaced the long term declines that led to the other 21st century famines in Somalia (2011) and South Sudan (2017).65 A group of aid organizations that include UNICEF stated in late February that over 90% of children under the age of 5 in Gaza were facing “severe food poverty”. A similar percentage was suffering from infectious diseases, with 70% of them having diarrhoea over two weeks in February.66 Images and videos from the strip appear to confirm these findings.67
May and June
Although April saw an uptick of aid entering Gaza, partially the result of international pressure after Israel’s bombing of the World Central Kitchen’s convoy, the amount of aid entering Gaza dropped again in May, this time as a result of fighting in the North and in the South, in which Israel took control of the Rafah crossing into Egypt.68 In the rest of May, the amount of food entering Gaza dropped by 70%69 (discrepancies with Israeli-supplied numbers derive from the different ways of counting trucks,70 as well as the entry of commercial food sales).71 Due to the food shortages, known famine-related mortality resumed after a hiatus of several weeks. The World Food Program suspended food distribution in Rafah because of lack of supplies and insecurity.72 The much-heralded US pier,73 that was supposed to provide additional aid (and cost $320 million), encountered problems from its beginning – including a hiatus in its operation – and was ineffective into early June, before being moved away again in mid June.74 Israel re-opened commercial food sales in Gaza in late May, but the amount of commercial trucks that entered was far smaller than the amount of humanitarian aid (which, as aforementioned, was far from enough for the needs of the population).75 In late May, a poll of Gazans in the south of the Gaza Strip found that 64% had enough food for a day or two (44% in March) and 26% could access a place to get assistance with food and water without great risk (19% in March).76
Subsequent reports in May and June continued to indicate a serious crisis. The Famine Early Warning Systems Network (FEWS NET) said that “it is possible, if not likely” that famine was underway in northern Gaza since April, and that it is possible the famine will persist in the area through July. This was the first time an organization stated the possibility that famine was already happening.77 The uncertainty derived from major difficulties since only limited information was available, a situation nonetheless similar to that in other famines. Regardless of whether the reality in northern Gaza fit the technical definition of famine, “acute malnutrition among children is extremely high and this will result in irreversible physiological impacts”.77 The World Food Program and the Food and Agriculture Organization said that hunger is worsening, especially in northern Gaza, because of the heavy restrictions on humanitarian access and the collapse of the local food system.78 The UN’s aid chief said that “delivering aid was become almost impossible” in Gaza.79 In late May, head of USAID said that conditions in Gaza are “worse… than ever before”.69 A WHO spokesperson said in May that 85% of children “did not eat for a whole day at least once in the [past] three days” and that “children are starving”.80 A UNICEF spokesperson tried to bring medical and nutritional supplies to North Gaza in mid June. Despite receiving the necessary approvals in advance, on the ground the trucks were refused entry and sent back after a long delay.81 On the other hand, a group of Israeli scholars attempted to argue in a white paper in June that the amount of available food entering Gaza had increased between January and April, but their contribution suffers from fundamental methodological issues.82
Additional findings
Evidence from the Strip reveals some of the actions that desperate Gazans are forced into because of the lack of food.83 Media coverage refers to people eating horse meat,84 grass and drinking contaminated water or sea water.85 One video shows a group of people swimming in an area flooded with sewage to procure airdropped aid that landed in that area.86 As of late March, about 18 Gazans died from circumstances associated with attempting to get aid (aid falling on Gazans, trampling, and drowning while trying to get to aid that fell in the sea).87 Others fell as a building on which an airdrop of aid landed had collapsed.88
About 60 percent of Israeli Jews oppose humanitarian aid to Gaza, a stable figure over time.89 Jewish activists have completely blocked the entrance of aid to Gaza on several occasions in recent months.90 IDF soldiers recorded themselves destroying and burning food warehouses in Gaza.91 In May, Israeli settlers/protestors blocked92 and sometimes attacked Jordanian convoys of aid to Gaza.93 Such attacks included causing massive damage to the trucks themselves, as well as throwing away the humanitarian aid onto the road.94 Some of these attacks took place near IDF blockades and local eyewitnesses noted that the Israeli soldiers and the police allowed the destruction and looting of aid to take place.95 Other road blocks took place in major cities – including Jerusalem – with little to no police interference.96 In at least two occasions trucks were burned,97 and at least in two cases settlers attacked and injured the Palestinian truck drivers who were hospitalized (including once in which the truck was not involved in bringing aid to Gaza).98 Action against allowing humanitarian aid to Gaza extends beyond fringe groups. According to a Guardian investigation, Israeli soldiers and police tip off the groups that attack the trucks.99 The deputy speaker of the Israeli Knesset claimed he blocked aid trucks with his private car.100 In mid June, the Israeli Chief of Police claimed in a letter that the Minister of National Security – a figure closely associated with settler groups – attempted to cancel the police escorts meant to accompany the trucks.101
Non-food shortages (electricity, medicine, water)
As of writing, since the beginning of the war there is no electricity supply in Gaza (i.e. full electricity blackout; for comparison, in the years before the war, electricity was available on average for 12-13 hours a day).102 As of December, fuel prices had increased by over 500 percent.103 In April, the price of a liter of gasoline reached 150 shekels (~$40).104 I have not come across subsequent prices for fuel, suggesting that any sales of it are extremely limited. A study revealed that by January nighttime light across Gaza has been reduced by 84% (91% in Gaza City) compared to the pre-war reality.105 This data includes light coming from IDF troops within the Strip, and presumably light from the still functioning Palestinian hospitals that receive petrol for operating their generators. Testimonies from the Strip reveal that university library books were burned as kindling for cooking fires.106
In November, the average water supply per person in Gaza was between 1.5-1.8 liters daily (the minimum average volume of water for drinking and domestic hygiene should be 15 liters),103 but this number decreased to less than one liter on average in February.107 Even basic medical supplies are in short supply. Gauze, for example, is sterilized and reused for the next patient.1 Some have begun to die from treatable diseases such as hepatitis.108
The lack of medical supplies has resulted in the conduction of medical operations, including C-sections and amputations, without anesthesia or blood supplies.109 An online video shows a Gazan doctor who had to amputate his daughter’s foot on the dining table in their home without anesthesia.110 A medical student at Al-Shifa hospital recounts how he had to stitch the face of a boy who was wounded in an Israeli bombardment for 3 hours in darkness and without anesthesia.111 A British surgeon who visited al-Aqsa hospital recounted in the UN the story of a girl burned so badly that he could see her facial bones. She had no chance of surviving it, so she died in agony because there was no morphine to give her, and because there was no place for her to die in she was simply left on the floor to die. The surgeon stated there were many such cases and recounted several.112 There are many similar stories. These stories have long-term implications. For example, by January there were already over 1,000 Gazan children amputees, each of which will require 8-12 more surgical interventions as they grow up.113
As a result of the lack of supplies, women who face postpartum bleeding as they give birth have undergone hysterotomies for lack of medicine and blood supply, preventing them from giving birth in the future.114 Oxfam’s Middle East Regional Director stated that “Amongst the horror and carnage in Gaza, we are now at the abhorrent stage of babies dying because of diarrhoea and hypothermia. It is shattering that newborns are coming into the world and due to the apocalyptic conditions, stand little chance of survival.” In some cases, mothers had to give birth in classrooms full with 70 other people, which the director described as “simply inhumane”.115 Miscarriages in Gaza have increased by 300% compared to the pre-war situation.116 A doctor from Doctors Without Borders who spent a few weeks in Gaza stated the special vulnerability of breastfeeding women as well, who cannot produce enough milk because of malnutrition, and their infants, who often have neither the milk nor formula because of the lack of clean water in Gaza.117 Women in Gaza also have difficulties finding menstrual pads, with some using alternatives such as the corners of their tents to manage their periods.118
Gaza’s health system
Gaza’s health system has all but collapsed. 84% of all health facilities have been damaged or destroyed.119 At times, less than a third of Gaza’s hospitals and a quarter of its primary health centers were even partially operational.120 As of writing, about half of the hospitals in the Strip are partially operational.14 Doctors who visited the Gaza Strip during the war recount horror tales of the conditions within the overcrowded hospitals, the types and quantities of patient cases, and the recurring attacks on hospitals throughout the war.121 There are over a million reported cases of diseases in Gaza so far.14 As of mid June, there have been over 865,000 cases of acute respiratory infections.14 Over 485,000 cases of diarrhea have been reported, over 113,000 of which are among children aged 5 or less.14 In a single week in mid-December, 3,200 cases of diarrhea were reported every day (compared to some 500 per week before the war).122 On average, there is one shower in Gaza for every 4,500 people, and a toilet for every 220.123 Important public voices in Israel – such as a former general and head of Israel’s National Security Council and official wartime advisor to Israel’s Defense Minister124 – have spoken in favor of allowing diseases to decimate the civilian population in Gaza.125 A mid March report found that ~75% of Gaza’s solid waste is dumped into random sites, contaminating water sources, so that 97% of ground water was unfit for human consumption.126 Exposure to high temperatures within refugee tents has also killed Palestinians sheltering inside them.127
Israel has systematically dismantled the health system in Gaza, making it inoperable.128 In late February, the head of MSF stated that “there is no health system to speak of left in Gaza”.129 Israel justified much of this by stating that the medical facilities were used for military purposes, but the head of MSF stated in late February that his organization has “seen zero independently verified evidence of this”.129 In mid March, an Oxfam report stated that Israel continues to block aid response in seven different ways and warned that Gaza “will suffer mass death from disease and starvation far beyond the current 31,000 Palestinian war casualties”.130 A global authority on food security and nutrition released its own report in mid March, highlighting catastrophic levels (the highest level of malnutrition) of food insecurity across the Gaza Strip (55% in the north to 25% in the south).131 An MSF report from April about conditions in Rafah revealed upward trends in the number of cases of acute malnutrition and concluded that the level of exposure of the population to traumatic events “has left the mental health of Gaza’s population in tatters”. The health system in Gaza “stands shattered”, and its long and uncertain road to recovery would take years if not decades.132
As a result of the above, the chair of global public health at the University of Edinburgh has stated in December that “the world faces the prospect of almost a quarter of Gaza’s 2 million population – close to half a million human beings – dying within a year. These would be largely deaths from preventable health causes and the collapse of the medical system”.133 Other academics reached similar and more detailed conclusions.134