The Grave Long-Term Effects of the Gaza Malnutrition Crisis

The moment Merry Fitzpatrick realized that Gaza’s malnutrition crisis had progressed to a newer and deadlier phase was when surgeons at the few hospitals still operational on the Strip reported that wounds were no longer closing.

“There’s so much traumatic injury, like blast wounds and broken bones,” says Fitzpatrick, an assistant professor at the Friedman School of Nutrition at Tufts University. “But they’re not healing, because people don’t have the nutrients to build the collagen necessary to close them. So wounds that are a month, even two months old, still look as fresh as if they had occurred in the last week.”

According to the Hamas-run health ministry in Gaza, malnutrition deaths in the territory since October 2023 have now reached 154, with 89 of the fatalities coming in children. The World Health Organization reported this week that July witnessed a particular spike in deaths, with 63 malnutrition-related fatalities reported at health facilities, including 38 adults, one child over 5, and 24 children under 5. Most of these patients were declared dead on arrival.

The extent of this crisis has been conveyed to the watching world through photos of emaciated babies and infants with thinning hair. Fitzpatrick, who studies starvation and its biological effects, explains that in conditions of extreme scarcity, the body has an inbuilt prioritization system, designed to preserve the most vital organs, the heart and the brain, until the very end. After using up its primary fuel supplies—glycogen stored in the liver and muscles—she says the body uses fat for energy, before degrading bone, muscle, and then if necessary, the more resilient organs like the liver in order to extract protein. “The skin and hair are the first to be neglected,” says Fitzpatrick. “Hair will just fall out. A lot of times it’ll change color. The skin becomes very thin.”

In some cases, severe protein deficiency can cause a condition known as kwashiorkor, or famine edema, characterized by swelling due to fluid moving into the body’s tissues, particularly in the abdomen. “There’s different types of acute malnutrition,” says Fitzpatrick. “There’s the getting thin type and there’s the kwashiorkor, and we see both in Gaza. In babies, you might see it in their face. Their cheeks get puffy and you’re like, ‘Oh, they’re doing OK.’ But no, that’s fluid.”

Much of our understanding of acute malnutrition comes from studies carried out on survivors of the Holocaust, major famines of the 20th century such as the Great Chinese Famine and the Ethiopian famine of the 1980s, and anorexia. Marko Kerac, associate professor of global child health and nutrition at the London School of Hygiene & Tropical Medicine, describes the body as going into a progressive winding down process where for a period, people are malnourished but still medically stable, before entering a far more serious phase characterized by loss of appetite, lethargy, and either apathy or anxiety.

Based on the latest reports from Gaza, with the WHO describing nearly one in five children under the age of 5 being acutely malnourished, Kerac says that more and more people are entering this latter phase. Statistics collected by the NGO the Global Nutrition Cluster show a surge of cases since early June, with more than 5,000 under-5s being admitted to Gaza’s four malnutrition treatment centers this month and 6,500 in June. “Youngest children are more vulnerable because their organs are still developing,” says Kerac.

The reason why children under 5 are most at risk is because they can lose weight very fast, while their small stomachs and permeable intestines, designed to absorb food very quickly, make them more vulnerable to diseases of poor sanitation, which are currently rife in Gaza. At the same time, Fitzpatrick says that adults will often go hungry to protect the youngest, meaning that if infants are visibly suffering, many adults are also likely in a critical condition. Based on Global Nutrition Cluster data, more than 40 percent of pregnant and breastfeeding women are severely malnourished, with rates in Gaza’s Middle Area having tripled since June.

For all, infection is one of the biggest short-term threats. Kerac says that in cases of acute malnutrition, the body begins to shut down the immune system, because fighting a pathogen requires energy the body does not have. A consequence of protein deficiency is that the body lacks the amino acids it needs for the continuous regeneration of the gut wall, Fitzpatrick explains, meaning that the intestines become more permeable, and making it more likely for bacteria to leach out into the bloodstream and drive blood poisoning known as sepsis.

If the situation in Gaza does not improve swiftly, Fitzpatrick predicts that malnutrition-induced hypothermia will also be a major killer going into the fall. “When you’re severely malnourished, the body has a real hard time with temperature regulation,” she says. “Speaking to doctors in Gaza, patients are already shivering, and so if the situation doesn’t improve over the next few months, there will be hypothermia deaths.”

Both infections and hypothermia can be prevented with broad-spectrum antibiotics and ready-to-use therapeutic foods specially formulated to treat severe malnutrition. According to Nina Sivertsen, an associate professor in the College of Nursing and Health Sciences at Flinders University, while the most natural reaction to treating people whose bodies have been in a state of starvation for months may seem to be to give them an excess of calories, this can actually induce a deadly condition known as “refeeding syndrome,” which was notoriously seen in Holocaust concentration camp survivors.

“When the body has been starved, its metabolism slows right down, organs weaken, and it loses the ability to digest and absorb food normally,” says Sivertsen. “Feeding too much, too quickly, can overwhelm the body and cause a dangerous shift in fluids and electrolytes [like sodium and potassium] that can cause heart failure, seizures, and even death.”

Instead, recovery is a long and delicate process, one which Kerac has observed while working in pediatric wards in Malawi. Therapeutic foods typically consist of milks or pastes that are given in small, frequent amounts to gently restart the digestive system and give the electrolytes time to rebalance themselves, before individuals are slowly transitioned back to balanced meals rich in protein, fats, vitamins, and minerals to rebuild muscle, organs, and the immune system. Given such treatment, Kerac says that many people can recover remarkably well from the acute effects of severe malnutrition, but stocks of therapeutic foods in Gaza’s malnutrition treatment centers are extremely low, and according to Fitzpatrick, some ran out completely back in May.

Even if significant foreign aid can reach Gaza in the coming months to reverse the tide, scientists say that the long-term health consequences will be felt for decades. Children and adolescents will likely be most affected, through stunted growth and impaired brain development. “The first thousand days of life, from conception to age 2, are a critical window for building the brain, bones, and organs,” says Sivertsen. “Without proper nutrition, children can experience lifelong stunting, weaker bones, underdeveloped organs, and structural changes in the brain that impair memory, attention, learning, and emotional regulation. Adults may recover their muscle mass and physical health once food is available again, but many children never catch up.”

This is not to mention the acute and long-term mental health consequences of malnutrition. Fitzpatrick gives the example of the infamous Minnesota Starvation Experiment, a psychological study in the 1940s where volunteers received less than 1,600 calories per day, half their customary intake, for six months, leading many to develop acute anxiety. “That’s way more than the people in Gaza are getting, and many of them still developed these psychological effects and paranoia,” says Fitzpatrick.

Research on the survivors of past famines has also shown that starvation can change how genes function through a process called DNA methylation, where molecules attach to DNA and change how the body reads it. (The process can be driven by various types of environmental stress, from trauma to smoking.) When driven by malnutrition, in many cases it appears to rewire metabolism, making survivors notably more at risk of chronic diseases such as heart disease, high blood pressure, type 2 diabetes, and disordered blood fats in subsequent decades.

In pregnant women, the effects are particularly impactful, as such DNA changes not only play out in the mother, but in the developing fetus and also the germ cells within the fetus, the precursors to sperm and eggs. “This means that malnutrition has the potential to influence three generations—the mother, her child, and her grandchild,” says Hasan Khatib, a professor of genetics and epigenetics at the University of Wisconsin-Madison. Such effects have been seen in the descendants of both the Great Chinese Famine and the Dutch Hunger Winter during World War II, where the children of babies starved in the womb carry genetic alterations that have placed them at higher risk of diabetes, as well as addiction and even schizophrenia in adulthood.

As the world watches, Fitzpatrick is communicating with doctors to document the crisis. She says that compared to many instances of population-level malnutrition in recent decades, typically induced by famine, the Gaza population is unusual, and scientists have less idea about whether this is conferring more or less resilience. “Compared with typical famine populations, they were kind of on the overweight side at the start of this, they’re highly educated, until now they’ve had relatively good health care, and they’re a rather urban population, so there’s a lot of demographics that are quite different about this,” she says.

But as the months have progressed, and the reports from hospitals have become ever more desperate, it has become imperative in her mind that the rest of the world needs to take immediate action.