As malnutrition deaths are reported and hunger grows, will 'famine' be declared in Gaza?

After months of aid agencies' warnings that Palestinians in the Gaza Strip were at high risk of famine, many worry it is now taking hold in the northern part of the enclave where children have begun to die of malnutrition and dehydration.

The Gaza Health Ministry said Wednesday that at least 20 people have died of malnutrition at hospitals and warned that it believes "dozens are dying silently" unable to reach medical facilities. The World Health Organization visited northern Gaza over the weekend and confirmed at least 10 child starvation deaths at the time of the team's visit.

Israeli officials have repeatedly said they are committed to humanitarian assistance for civilians and have not placed any limits on aid entering the Palestinian enclave.

A famine has not yet been declared in Gaza, but the Integrated Food Security Phase Classification initiative, or IPC, has activated its famine review committee to assess the situation.

While hunger is a long-standing issue around the world, a declaration of famine is relatively rare.

What is famine?

The dictionary defines famine simply as an "extreme scarcity of food," but among world aid agencies addressing food insecurity, it has a much clearer definition and specific guidelines for when to classify a situation as such. According to the IPC, famine is a situation in which starvation and extremely critical levels of acute malnutrition are evident.

"It's a technical term that sort of encapsulates a series of conditions," said Tobias Stillman, Action Against Hunger's director of technical services and innovation. "So very significant food insecurity, meaning people don't have sufficient food to support their physiological need ... so they are both experiencing hunger and physiologically in many cases, compensating for the lack of food."

What pushes food insecurity into a famine declaration?

The IPC and the World Food Program offer a mathematical threshold for what constitutes a famine for the population of a specific area: 20% of households with an extreme lack of food, 30% of children suffering from acute malnutrition and 2 in 10,000 people dying per day "due to outright starvation or to the interaction of malnutrition and disease."

The IPC, which was created in 2004 by the United Nations’ Food and Agriculture Organization, partners with more than a dozen organizations worldwide, as well as governments, to examine food insecurity using evidence-based analysis.

Its five-phase index measures food insecurity, with Phase 5 being catastrophe or famine. Gaza is in the "emergency" phase, which is a step below famine.

"Even though the levels of acute malnutrition and non-trauma related mortality might not have yet crossed famine thresholds, these are typically the outcomes of prolonged and extreme food consumption gaps," the website says.

A representative noted of the IPC said its experts are working on a coming report on Gaza and were not available for interviews.

Who declares a famine?

Declaring a famine is a multistep process for the IPC, Stillman said, and it requires complete consensus from five people on the independent committee.

A group of 25 to 30 people is assessing data from Gaza to offer its recommendation for analysis to the famine review committee. If there is a specific point of contention on a particular data point, it would be noted in a manner similar to what someone might see in the U.S. Supreme Court, Stillman said.

"If the five of them can't achieve consensus — if there's one, for example, that digresses — they can draft a dissenting statement so that that committee will still come out with an overall recommendation or an overall classification, but there may be a dissenting voice,” he said.

After the review committee makes its designation, the analysis is sent to IPC's global steering committee, which Action Against Hunger chairs, to review the findings before they are released publicly.

An official declaration of famine is made by governments, Stillman said.

Those who work on hunger and food insecurity understand that it is a complex system, Stillman said. But the teams working on the declarations "will be justifying their conclusions every step of the way."

"It needs to be complicated because it is so incredibly important," Stillman said. "And, you know, famine carries such important political connotations that nobody wants to take that lightly. ... It is very, very process-oriented."

How is hunger being assessed in Gaza?

The situation in Gaza has posed unique challenges because limited access has complicated the ordinary process. But teams are collecting real-time data to provide to the IPC, Stillman said.

Usually, the larger country-level committee, which consists of government representatives, aid groups and other partners, would meet in person to go over the data. The Gaza team, however, has had to meet virtually and work anonymously, he said.

"It's never been done that way before," Stillman said. "And the reason it's been done that way is because of the highly sensitive nature of what's happening out there."

Decisions are based on a series of surveys that look at such factors as malnutrition diagnoses and mortality rates. In Gaza, adjustments have been made about how some of the data is collected because of the limited access.

"There are people in Gaza, as we speak, who are measuring malnutrition, and they are not using the traditional method of weight and height," Stillman said. "They are using mid-upper-arm circumference."

Though it is faster, he said, by IPC standards, the method is not the best standard for data collection. Information is also more readily available in some areas of Gaza than in others.

If the committees are not entirely confident in the data collection, or if all the information indicates catastrophe conditions but does not quite meet specific thresholds for famine, Stillman said, the IPC may declare a "likely famine."

"And that likely means, you know, there's a very strong case to be made that there is actually famine present but they don't have all the data they need to truly classify as famine," he said.

What is the current situation in Gaza?

Since shortly after the Hamas-led attacks on Oct. 7, Gaza has been essentially cut off from the outside world as Israel enforces its blockade on the strip, restricting access to food, fuel and running water. It was not until two weeks after the start of the war that aid convoys entered the Palestinian enclave through the shared border with Egypt.

From the beginning, the U.N. and aid groups warned that the convoys were incapable of meeting the requirements of more than 2 million people who had the most basic needs.

The U.S. urged Israel to open access to a commercial crossing, Kerem Shalom, to help streamline the process. Kerem Shalom has been used to help conduct security screenings, but Israeli citizens have protested at Kerem Shalom to try to stop aid from entering Gaza.

Starvation is most apparent in northern Gaza, where convoys have had inconsistent access and civil order has broken down. Last week, a number of deaths were reported after witnesses alleged the Israel Defense Forces opened fire on a crowd that surrounded an Israeli convoy of aid.

The IDF has denied the allegation, saying a crowd swarmed the trucks and soldiers fired "warning shots" in a failed attempt to disperse the group before they retreated. Israel attributed most of the deaths to a crush and stampeding during the chaos that surrounded the convoy.

The incident prompted the U.S. to drop thousands of ready-to-eat meals as convoys face repeated struggles traveling from the southern border to the north.

On Tuesday, the World Food Program announced that the IDF turned away its first convoy to the north since Feb. 20. Food supplies were able to be air-dropped with help from the Royal Jordanian Air Force, said Carl Skau, the group's deputy executive director.

"Airdrops are a last resort and will not avert famine," Skau said. "We need entry points to northern Gaza that will allow us to deliver enough food for half a million people in desperate need."

This article was originally published on NBCNews.com