Foreign Affairs: The Looming Famine in Gaza and How to Stop It

This piece was originally published by Foreign Affairs.

According to assessments by the Famine Review Committee, the gold-standard international body that analyzes famine risk, the Gaza Strip now stands on the brink of famine. On February 27, senior UN officials warned the UN Security Council that famine is now imminent in Gaza. If famine takes hold, the number of Gazans who die of hunger or disease could outstrip the Israel-Hamas war’s already breathtaking number of civilian deaths. It is still possible to prevent a famine. But the window for action is rapidly narrowing. Unless the fighting stops and Israel halts the siege tactics that are preventing a large-scale relief operation, aid agencies will be unable to avert a full-blown famine and the death toll that comes with it.

In the modern era, famine is both predictable and preventable. Sophisticated early-warning analyses can project the risk of famine with a reliability that rivals hurricane early-warning systems. When these forecasts indicate an impending famine, humanitarian organizations have well-tested strategies at their disposal to avert the worst outcomes, including delivering enriched food products, rolling out innovative ready-to-use malnutrition therapies, and launching proven public health interventions, all deployed through world-class logistics networks.

These interventions, however, succeed only if humanitarians have the space and safety to do their jobs. And that, in turn, depends on politics. At present, the wartime conduct of the Israeli government is both accelerating Gaza’s descent toward mass hunger and obstructing the deployment of the resources necessary to prevent it. In an incident emblematic of the larger problem, a clearly marked UN relief convoy waiting at an Israeli military checkpoint was bombarded on February 5 by Israeli naval forces despite having cleared the movement with the Israeli military in advance. The UN was forced to halt food deliveries to northern Gaza for weeks as a result.

Aid agencies are being denied the resources, access, and security they need to scale up a viable famine-prevention effort. UN and nongovernmental organization facilities have been repeatedly struck in Israeli bombardments. Israeli inspections routinely and arbitrarily prevent critical relief supplies from reaching Gaza. Once aid gets inside, movements within Gaza rely on Israeli government authorizations that are frequently denied, and Israel has yet to establish a reliable process to ensure humanitarian operators are not targeted by their forces.

The United States is likely the only outside power that can ensure a famine is avoided, given the leverage it has with its ally Israel. As negotiations about a second cease-fire and hostages-for-prisoners swap gain steam, the United States has a crucial opportunity to press Israel to change course and allow a major famine-prevention effort. U.S. President Joe Biden must act now to make famine prevention a top priority and be prepared to deploy meaningful U.S. leverage—including pausing arms sales—if the Israeli government does not comply. Famine would not only constitute a humanitarian cataclysm; it would also represent a geopolitical failure that would damage U.S. credibility in the Middle East for years to come.

A Preventable Tragedy

As a champion of the international humanitarian system and the most prominent backer of Israel’s war in Gaza, the United States has a clear moral and geostrategic obligation to take on a stronger leadership role. Even beyond the Middle East, a full-blown famine in Gaza would undermine U.S. efforts to uphold international norms in Ukraine and elsewhere. But Israel’s military conduct and the bureaucratic impediments it has imposed on aid groups remain the principal obstacles to a meaningful humanitarian relief effort for Gaza. It is time for the United States to fully exercise its leverage with Israel in service of rolling out a large and comprehensive aid operation.

The first component of this operation must be a large-scale push to restore access to food through aid delivery and a resumption of the commercial imports that have traditionally supplied most of Gaza’s food. This effort will also depend heavily on expanding fuel imports to restart bakeries and provide cooking fuel for households. A monitoring system should be established to assess food availability in each area of Gaza and avoid supply gaps.

The next line of effort should address rapidly rising cases of malnutrition. Acute malnutrition, which was negligible before the war, now affects over 15 percent of children in northern Gaza, halfway to the famine threshold of 30 percent. According to the UN World Food Program, such a decline in nutritional status in three months is unprecedented. It is critical to establish a screening system for malnutrition, set up inpatient treatment centers for highly severe cases, and import substantial volumes of ready-to-use therapeutic food, a high-calorie paste proven to help children quickly recover from malnutrition.

Another top priority must be to repair and resupply health facilities to get the public health system back online. Most deaths in famine result from infections spreading among populations weakened by prolonged hunger. Preventing and treating disease is a critical defense against famine risk, but Gaza’s health system has been devastated almost beyond description. The few remaining facilities are overwhelmed with war-related injuries, leaving little capacity to manage infectious diseases. Reestablishing basic health surveillance will be crucial to detecting infectious disease outbreaks. Cholera treatment and vaccination capacity should be prepared now in case cholera is confirmed.

Many of these diseases spread via contaminated drinking water, and clean water is scarce in Gaza. After October 7, the Israeli government closed pipes supplying the territory with water; these pipes remain turned off in some areas, and Israeli bombardment has destroyed much of the infrastructure that distributes water. Repairs are being prevented by both a lack of humanitarian access and the rejection of replacement pipes and other repair supplies by Israeli inspectors. Other standard interventions, such as the distribution of chlorine tablets to enable households to purify drinking water, have also been blocked by Israeli inspectors. All this must change immediately.

Gaza also needs a mass injection of temporary shelter materials. The absence of shelter contributes greatly to human physical deterioration, especially in winter. Most of Gaza’s population is now displaced. Much of the residential infrastructure has also been destroyed, and people in Gaza are being forced to scrounge framing materials from the rubble. Yet Israeli inspectors continue to block much of the importation of humanitarian shelter materials.

A Way Out

An operation on this scale will remain impossible as long as fighting continues. A permanent cease-fire is vital to preventing famine, but an extended truce in the immediate term, tied to a second hostage-prisoner swap, would buy critical time for humanitarian aid groups to begin scaling up efforts. That hostage deal must include modalities to facilitate humanitarian relief and be closely synchronized with a famine-prevention plan to maximize aid delivery. A deal must also stop an Israeli ground offensive into Rafah, where more than 1.4 million Gazans are sheltering in squalid conditions. Such an offensive would be devastating for the civilian population and would disrupt relief efforts across Gaza’s south. A Rafah offensive could become the act that tips the territory officially into famine.

Israeli authorities must allow the free flow of aid into Gaza and stop hindering humanitarian operations in the territory. This would include scaling back dual-use restrictions on critical humanitarian supplies (aid groups have reported that relief truckloads were rejected because they included nail clippers, insulin pens, and green sleeping bags) and establishing clear screening procedures. Limits on fuel imports should also be lifted.

Before October 7, commercial vendors and aid groups were able to send up to 500 trucks into Gaza daily. This pre-conflict capacity would need to be fully restored by expanding scanning facilities, reestablishing dedicated trucking routes, and removing arbitrary requirements put in place after October 7. Aid delivery to the north could be expanded by reopening the Karni and Eres border crossings in the northeast and by facilitating seaborne transport from Cyprus, as the UN did during Israel’s 2006 war in Lebanon.

The plan would also need to empower the UN. It should be developed and implemented jointly with Sigrid Kaag, the UN’s senior humanitarian and reconstruction coordinator for Gaza. Her office is mandated to lead relief and recovery efforts, and the UN Secretariat and UN member states should provide the resources her team needs to succeed. Kaag can use her briefings to the UN Security Council to update the world on the implementation of the famine-prevention plan and hold different stakeholders accountable for meeting their benchmarks.

The entire effort would have to lean heavily on the emergency capacities of UN agencies and on international nongovernmental organizations with a presence in Gaza. But the UN Relief and Works Agency would be its logistical backbone. Last month, the United States and other key donors paused funding for UNRWA in response to grave allegations that 12 UNRWA employees participated in the heinous attack on October 7. UNRWA swiftly fired the accused individuals. An independent investigation is now underway, complicated by the fact that Israel has not shared the underlying intelligence with UNRWA, according to UN officials, or even the United States, as reported by the Wall Street Journal.

The funding freeze has thrown the agency’s operations into doubt. The United States and other donors need to reverse course. Eighty percent of aid to Gaza is delivered via UNRWA, and the agency employs more than 13,000 staff in Gaza, of whom 3,000 work in emergency relief. If UNRWA shuts down, no other agency can step into the breach in the time frame required to avert famine, and senior U.S. officials have acknowledged as much. UNRWA’s mandate is controversial with many Israelis and with some members of the U.S. Congress. But now is not the time to debate the future of the agency.

Finally, a system must be established to protect humanitarian action from military strikes. Humanitarian workers, convoys, and offices in Gaza have repeatedly come under fire, and more than 160 UN staff have been killed since Israel began its operations in the area. A hostage deal could silence the guns for weeks or months, but if the deal breaks down, aid agencies will need an insurance policy for what comes next. There is a precedent for effectively limiting conflict for humanitarian relief in the region: during the 2006 Israel-Lebanon war, UN staff were embedded with the Israel Defense Forces and successfully coordinated the delivery of aid. A similar arrangement is needed for Gaza, but this time with official U.S. government representation to help guarantee results.

Hamas—the group responsible for the abhorrent October 7 attack—must not interfere with the relief effort, either. The group appears indifferent to the humanitarian suffering of Gaza’s civilians, although aid organizations inside Gaza have reported few instances of its obstruction or diversion of aid deliveries since the fighting started. But Hamas must stop using civilians as human shields, just as Israel must stop reflexively justifying devastating civilian harm in a given area based on reports of Hamas’s presence there.

Famine is close but not yet inevitable. Although famine-level hunger now exists throughout much of Gaza, and malnutrition is rising rapidly, this crisis has not yet translated into widespread excess mortality. The area’s death rates are shocking, but they remain mostly related to war injuries rather than hunger. This means there is a window to reverse the descent toward famine—if there is the political will to do so. But time is of the essence. Once famine-related mortality gains momentum, it is even harder to slow down. The first step will be for the U.S. government to give this challenge the priority it deserves.