In June, Nour el-Hourani watched with tears in her eyes as doctors tried to revive her baby. Her son, five-month-old Abdel Aziz, had been starving since the day he was born, and now his heart had stopped beating. The lights in the neonatal unit flickered from a lack of fuel in the hospital’s generator, occasionally leaving doctors to work in the dark. They administered adrenaline and oxygen and used their fingers to pump his chest. For several minutes, the heart rate monitor showed a flat line.

The doctors kept trying long after what was usual for resuscitation and eventually got a pulse. Abdel Aziz was still unconscious but breathing again with the help of machines. His belly was bloated and his limbs were too thin for an infant, telltale signs of malnourishment. By this age, he should have been about double his birth weight. But he weighed less than he had when he was born.

Starvation spreads

Within days of a Hamas-led attack on Israel during which 1,139 people were killed and about 250 taken captive, Israel cut off fuel, food and water to Gaza. Within weeks, starvation had spread in the north of the Gaza Strip. Nour, who is 28 years old, was six months pregnant with her first child when the first bombs began to fall on Gaza.

In December, she was displaced to Kamal Adwan Hospital. Nour is a nurse and volunteered in the emergency department. But later that month, Israeli forces laid siege to the hospital and detained at least 70 medical workers. Nour wanted to stay close to the hospital as her due date was nearing. But she was forcibly evacuated along with more than 2,500 others.

She went to the Jabalia refugee camp, where she slept on a duvet on the floor of a school-turned-shelter alongside thousands of other people. Fresh food was scarce. There was no bread or meat. She ate canned beans or peas for breakfast, lunch and dinner. It wasn’t enough to keep her nourished.

“Getting food supplies was very difficult,” she says. “No vegetables, no fruits are available in the market. Whatever is available is inedible like rotten potatoes, which animals wouldn’t eat.”

Like many Palestinians in Gaza, Nour ate animal feed and foraged for a wild herb known as khubaiza to survive. Occasionally, her husband would chase down boxes of humanitarian aid that were airdropped by the United States and Jordan. She says the food in them was sometimes expired and the cans were rusted.

Jabalia was cramped and filthy. Sewage was overflowing into the street and there was little access to clean water. Nour says she drank rainwater. “We were swimming in sewage,” she says. “We could smell corpses and carcasses.”

Amid bombardment, a birth

Late one night in January, Nour went into labour. It was during a bombardment, and, worried that Israeli forces would kill anyone in a vehicle, she decided to walk back to Kamal Adwan Hospital, which has Gaza’s only neonatal unit and was the last functioning medical centre in the north for many months.

“It was scary. No one was in the street,” she recalls.

Nour gave birth to Abdel Aziz on January 27 with no anaesthesia, then walked 2km (about 1 mile) to her home that same day with her husband and newborn son.

By the time Abdel Aziz was born, nine in 10 people in northern Gaza ate only one meal a day. Mothers need to be well-nourished to nurse their babies, and Nour wasn’t producing enough breast milk. She searched all over the north for infant formula but there was none to be found.

“There was no formula available for 10 days,” she says. “So my son suffered from severe dehydration.”

At 20 days old, Abdel Aziz became sick with a fever and constant diarrhoea, and he started to lose weight. Nour tried grinding rice and mixing it with water to feed him, but it didn’t help. When he was two months old, she brought Abdel Aziz to the children’s malnutrition clinic at Kamal Adwan Hospital and he was admitted to the intensive care unit (ICU).

“Ninety-nine percent of the cases I saw at the hospital were diagnosed with malnutrition,” Nour explains. “I mean, children’s bodies were almost skeletal due to dehydration. There was no food. One woman told me once that she was dizzy with hunger.”

Abdel Aziz was diagnosed with severe dehydration and malnutrition. Doctors put him on an IV and attempted infant formula, but little seemed to help. Doctors thought he might have a milk allergy. He needed antibiotics and a vitamin-fortified plant-based milk that the hospital didn’t have.

“His fever measured 40 degrees (Celsius or 104 degrees Fahrenheit) and his blood tests showed low mineral levels,” Nour says. “He suffered nonstop diarrhoea.”

His health started to improve slowly. But in May, Israeli forces again laid siege to the hospital. Nour was determined to stay, but when Israeli soldiers fired a rocket into one of the rooms next to where she was staying, she knew she had to leave. She took Abdel Aziz with her even though he was in the middle of his treatment.

“We are not safe, even in hospitals,” she says.

By the time Israeli forces withdrew from Kamal Adwan Hospital and the Jabalia refugee camp at the end of May, Abdel Aziz’s condition had worsened and he’d had a high fever for 20 days. Nour returned with him to the hospital.

The clinic

The cries of hungry children fill the halls of the malnutrition clinic at Kamal Adwan Hospital every day. As anxious parents and grandparents wait for their turn at the reception desk, doctors calmly take intake notes by hand while nurses measure the circumference of listless children’s upper arms.

“We did not record a single case of malnutrition before the war,” explains Dr Ahmed Hashem Abu Nasser, a paediatrician at the hospital.

As he makes his rounds, parents and guardians stop him, hoping for answers about their children. He speaks to them slowly and carefully, explaining the tests and treatments needed. But there is only so much he can do. His hospital is short of supplies, medicine and specialists.

The 28-year-old doctor graduated from medical school only two years ago and is now part of a small team with hundreds of children under their care. He says dozens are admitted to his clinic daily.

“In most cases, there is chronic diarrhoea, there is respiratory illness because malnutrition essentially causes weak immunity,” he explains. “These symptoms appeared after five months of war and exacerbated over time.”

Abu Nasser took care of Abdel Aziz when Nour brought him in, and says he was one of the first malnutrition cases at the clinic.

“The situation is very serious,” he says. “The child cannot absorb anything in his body. Anything that enters the body is excreted.”

It takes the youngest first

In July, United Nations experts warned that famine was occurring in the Gaza Strip. Ninety-six percent of Palestinians in Gaza are acutely food insecure. So far, at least 38 people have died of malnutrition since October 2023. All but one were children. Another 50,000 malnourished children require immediate medical intervention.

When famine starts, it takes the youngest first. In February, Hanan Assaf and her husband Muhammad buried their two-year-old son, Khaled. The child began to wither away as food ran out. Like Nour, they survived off khubaiza because the markets were empty and whatever food there was was unaffordable.

“The boy looked like a skeleton,” Hanan says. “I would hold him like a newborn. He stopped being able to sit up, move or walk. His body became very weak.”

They took Khaled to Kamal Adwan, but the doctors didn’t have the medicines they needed to treat him. He died two days after being admitted into the ICU.

“Before the war, we thought about how our children would get married and go to college,” Hanan reflects. “Now, we only think about how to get food and water for our children.”

‘They turn on, they turn off’

Fears of a famine in Gaza started after Israeli leaders announced a crippling blockade in the days following Hamas’s attack. “We are imposing a complete siege on Gaza. There will be no electricity, no food, no water, no fuel. Everything will be closed,” Israeli Defence Minister Yoav Gallant announced on October 9, 2023. “We are fighting human animals and we are acting accordingly.”

Israel has maintained a partial siege on Gaza since 2007 after Hamas was elected. Before the war, an average of 500 trucks of humanitarian aid and commercial goods entered Gaza each day. Now it’s less than half that, despite the desperate need. For months, the trucks that did try to get through were attacked by far-right Israeli groups as police and soldiers did little to stop them. In September, food aid fell to its lowest levels in seven months, according to UN and Israeli data.

Israel and its most powerful ally, the US, deny that aid to Gaza is being blocked, which is a war crime. But Fault Lines’ reporting has found that Israel has restricted the flow of humanitarian assistance since the start of the war, creating one of the worst man-made famines of the 21st century. We conducted more than 20 interviews with UN staff, rights groups, aid workers and former US officials. They described how Israel restricts aid, denies deliveries and creates supply bottlenecks.

“It is widely known and documented in the humanitarian community and the US government that Israel has been blocking humanitarian assistance since the start of the Gaza conflict,” former senior US State Department official Stacy Gilbert says.

Gilbert worked at the State Department for 20 years in the Bureau of Population, Refugees, and Migration (PRM), which is responsible for providing US humanitarian aid in crisis zones. She resigned in May in protest after the Biden administration released a report that concluded Israel was not blocking aid.

“So it’s like a spigot: they turn on, they turn off,” Gilbert says. “So Israel and the United States government will say, ‘Look, some assistance is going in’ but it’s never been enough and they know that.”

‘How do you explain that to a mum?’

The UN has accused Israel of arbitrarily restricting 83 percent of humanitarian aid into Gaza since October 2023, from unnecessarily long security checks of supply trucks to outright closing the crossings best equipped for a large volume of shipments. Every truck bound for Gaza must be screened at the border crossing and then offloaded and reloaded onto a truck that will make deliveries inside the Strip. However, according to the UN, Israel put in place a requirement to send across only half-full trucks as part of its screening process. With fuel in short supply and movements around the Strip dangerous, the UN makes deliveries with only full trucks, so aid will often pile up at staging areas while humanitarian workers wait for more to fill an entire truck.

Israel’s Coordination of Government Activities in the Territories (COGAT), a military unit responsible for facilitating humanitarian aid to Gaza, maintains a list of so-called “dual use” items that it strictly prohibits from entering the territory. These are items that it says Hamas may find useful, such as tent poles, solar panels and batteries. But these are essential items for displaced people and for aid workers who need to carry out lifesaving missions.

“The middle management (of COGAT) seems to butcher us on the details. I’ll say I need 100 sets of radios and then the questions are endless. And then they’ll start all over again if a new colonel comes in,” said one UN official in Gaza who asked not to be named.

And even when aid crosses the border, Israel creates obstacles for humanitarian workers to deliver supplies. Checkpoints, damage to roads and lack of coordination have delayed aid distribution and worsened the hunger crisis.

“We were hampered almost every single step of the way in the missions that I went on,” explains Tess Ingram, communications coordinator at UNICEF. “There’s a lot of restrictions on our access to places, which results in delays or even danger to staff.”

Ingram was delivering aid to Kamal Adwan Hospital with a UN convoy in April when it came under fire near an Israeli checkpoint. Bullets hit the door and the window of the armoured vehicle that she was riding in. She says the shooting came from the direction of the checkpoint and may have been from Israeli soldiers and directed at a group of civilians in the area.

After the incident, soldiers continued to hold the convoy for several more hours without explanation. Ingram says they were held so long that the mission was no longer feasible for that day and they had to return to Rafah for the night. They tried again the next day and were met with more delays at Israeli checkpoints. The convoy eventually made it to the north but after being held up by the Israeli military, they only had 45 minutes to deliver the aid to Kamal Adwan Hospital when they had planned to spend several hours offloading supplies.

Aid deliveries have to be carefully coordinated with the military to avoid active combat areas so they are not targeted. But Ingram and other sources at the UN told us that active fighting and lack of consistent communication from COGAT greatly slowed their efforts.

“It’s these sorts of delays that really prevent us from doing our job,” Ingram says. “And at the end of the day, it’s the kids that pay the price for that. And that is heartbreaking. And how do you explain that to a mum who is asking you what you can do for my child?”

Ingram says her team raised the shooting incident with the highest levels of the Israeli military and were told that soldiers weren’t involved and that no investigation would be conducted.

This has been the deadliest conflict for humanitarian workers ever recorded. Nearly 300 of them have been killed so far – the majority being Palestinians working for the UN.

UNRWA, the UN organisation for Palestinian refugees, says many of its facilities and convoys have come under attack despite coordination with Israeli forces. Israel has tried to dismantle the UNRWA for decades. It supports more than 1.5 million refugees in Gaza and is considered the backbone of aid delivery.

“To put it very simply and bluntly: our humanitarian response for the occupied Palestinian territory is dependent, completely dependent, on UNRWA being adequately funded and operational,” UN aid chief Martin Griffiths told the UN Security Council in January.

‘Not seen as fully human’

But it’s not just delivering aid that can be deadly. Many civilians have been killed while collecting it. In February, more than 100 Palestinians seeking food from aid trucks in north Gaza were killed and hundreds more injured after Israeli forces opened fire on them. It became known as the “flour massacre”. And Fault Lines found many more similar incidents.

Fault Lines partnered with open-source investigators at Forensic Architecture, a research group based at Goldsmiths, University of London, to examine the data behind attacks on people seeking aid. Using social media videos, news reports, health ministry data and satellite imagery, researchers were able to document more than 40 attacks on civilians seeking aid.

“So when we hear of the flour massacre, it’s not one isolated incident that was an accident,” Peter Polack, a researcher with Forensic Architecture, explains. “As we looked into more of these attacks, we started to see that they were systematic in nature and not arbitrary.”

The investigation also revealed that Israeli attacks didn’t just kill civilians seeking aid. They also destroyed key infrastructure that received humanitarian assistance. Forensic Architecture documented 16 attacks on bakeries between October and November 2023, sometimes while people queued for bread. And 107 shelters that received aid had been destroyed up until January.

“When aid is initially distributed, flour is distributed to bakeries. Bakeries are targeted. When it starts to be distributed to schools, then schools become the target,” Forensic Architecture’s Julia Ngo says.

Then, at the start of the new year, there were attacks on police and civilians who escorted humanitarian convoys. Police suspended their operations. Local kinship networks of influential families took over the escorts, but then they were attacked.

“They’re creating essentially a chilling effect so that it sends a clear message, that if you’re receiving aid, if you’re planning aid, if you’re working with it in any capacity, you are at risk,” Polack says.

We asked Israeli authorities about the findings of this investigation. They did not respond.

But we know that the decision to withhold humanitarian aid from Gaza is popular in Israeli politics. Our team analysed hundreds of posts in Hebrew on X from members of the Israeli government. We found that a majority of Israeli Knesset members oppose humanitarian aid to Gaza.

There were 40 posts supporting the use of starvation as a weapon of war and 12 advocating for a complete siege of Gaza. An additional 234 posts expressed opposition to humanitarian aid altogether and 65 other posts advocated for aid to be conditioned on the return of the captives.

South African prosecutors have submitted comments like these to the International Court of Justice in The Hague as evidence of Israel’s intention to starve the people of Gaza.

“The distinctive feature of this case has not been the silence as such but the reiteration and repetition of genocidal speech throughout every sphere of state in Israel,” South African prosecutor Tembeka Ngcukaitobi told the court in January.

“It’s sort of like a murderer just holding a knife and saying, ‘I’m going to kill these people’ and doing it … and we’re still wondering if there’s intent in this particular crime,” Alex Smith, a specialist in child and maternal health and former USAID contractor, says. USAID is the agency responsible for deploying US humanitarian aid.

Smith was scheduled to give a presentation at a USAID conference in March on maternal health in Gaza, but was told the day before that his lecture had been cancelled. After that, he resigned.

“Decisions are made based on politics and who people are, and certain people, depending on their race and their ethnicity and their geography, where they happen to live, are not seen as fully human,” he says.

The US ‘deliberately denies the facts’

The US gives Israel about $4bn in security funding each year, but the Biden administration has refused calls to condition US security assistance to Israel on improving the humanitarian situation in Gaza. Instead, the US has relied on ineffective measures, such as airdrops and a now-defunct pier.

Humanitarian groups have long insisted that the most effective way to get aid into Gaza is through established ground routes.

The administration even faced unprecedented levels of dissent from within for its unyielding support of Israel despite mounting evidence of it committing war crimes in Gaza. At least a dozen officials resigned in protest and several dissent memos rejecting Biden’s policies had been circulated at the State Department from USAID.

In April, Gilbert, the former State Department official, was asked for her input on a Biden administration report to the US Congress on whether Israel was committing war crimes in Gaza. Based on the reporting from her partners on the ground, she advised that Israel was blocking aid. But when the report was released the following month, it determined that Israel was not obstructing the flow of humanitarian assistance. Gilbert resigned as a result of that report.

“The administration deliberately denies the facts on the ground because it would trigger consequences to cut off security funding,” Gilbert says. “The weapons are the engine that fuels this war, and we are not taking responsibility for our role.”

There is a US law called 620I that prohibits arms transfers to countries that are blocking humanitarian assistance. If the Biden administration acknowledged that Israel was denying aid to Palestinians in Gaza, it would trigger the law and arms would have to be cut off immediately.

When asked by Fault Lines at a press briefing about how the US continues to support Israel with arms despite the evidence that it is breaking its own laws, State Department spokesperson Matthew Miller said the US had pressured its ally to open border crossings to let more aid in. “So I would encourage you to read the report that we issued on this very question a few months ago that looked into Israel’s compliance with international humanitarian law and their work and whether they had done a good enough job to let humanitarian assistance in, where we said that there were some roadblocks that needed to be overcome,” Miller said. “And we had worked to overcome those. And we had seen Israel take steps to allow humanitarian assistance in.”

Killing ‘in the short and long term’

When famines happen, it means many people are likely too severely starved to save, especially children. Even if aid were to flood into Gaza, children are likely to feel the effects of starvation for the rest of their lives. Severe malnutrition can impair a child’s physical and mental development.

“When you bombard and starve pregnant women and children and people, that it’s going to have massive impacts on their health,” Smith, the specialist in maternal and child health, explains. “It’s going to kill people in the short term and in the long term through epigenetic changes.”

Starvation can lead to lasting changes in how the body processes food and stores energy like slower growth and slower weight gain and a higher risk for mental and physical disorders. These have been shown to be passed on to future generations, particularly to children who were malnourished in the womb.

On June 20, one week after doctors revived Abdel Aziz’s heart, the infant died from severe dehydration. The hospital didn’t have what it needed to take care of him sufficiently. And still, more starving children continue to arrive at the malnutrition clinic.

In August, another five-month-old baby named Muhammad, was admitted to the hospital in serious condition. He was born on February 11 during the famine. His mother Hala said she didn’t get enough nutrition while she was pregnant, so neither did he. Muhammad needs a special formula that is not available in Gaza. Like every baby at the hospital, the entirety of his life has been shaped by this war. “I’m terrified I’m going to lose him at any moment,” Hala says.

With additional reporting in Gaza by Bilal Salem, Mohammed Al-Yaqoubi, Omar Abu Nada, Wisam Al-Sakni, Doaa Khaled, Hussien Jaber, Hasan Mashharawi and Ashraf Mashharawi.