When dawn broke last Monday morning, signalling the beginning of Ramadan, it brought a cruel irony for the people of Gaza.

The holy month when Muslims fast during daylight had arrived amid a looming famine.

Gazans had already endured five months of war. Virtually the entire population was already dependent on food aid to survive.

"The people here have already been fasting for months," said Dr Amjad Eleiwa, the deputy director of the emergency department at al-Shifa hospital, Gaza City.

"They scour the city looking for food to survive, but they cannot find any." Israel's bombardment of Gaza, in response to the Hamas attacks of 7 October, has destroyed food infrastructure and farmland across the territory. Aid agencies say enhanced Israeli security checks on delivery trucks have created bottlenecks around aid reaching the population.

The global body responsible for declaring famine, the Integrated Food Security Phase Classification (IPC), reported this Monday that 1.1 million people - virtually half the population of Gaza - was already starving and the rest of the people there could be in a famine by July.

The food crisis is most acute in northern Gaza. Unlike previous Ramadans, residents there cannot rely this year on lining their stomachs with suhoor, the pre-dawn breakfast, nor look forward to assuaging their hunger with iftar, the post-sunset meal.

Street decorations, drummers and stalls loaded with treats have been replaced by destruction, death and a daily fight to find food. Prices for what little flour or wheat is available have risen five-fold.

"I remember the last Ramadan, there was good food - juices, dates, milk, everything you could want," said Nadia Abu Nahel, a 57-year-old mother caring for an extended family of 10 children in Gaza City.

"Compared to this year, it is like heaven and hell," she said. "The children now are craving a loaf of bread, it is a meal they dream of. Their bones are becoming softer. They are dizzy, they struggle to walk. They are becoming very thin."

According to the poverty charity Care, at least 27 people - 23 of them children - have died from malnutrition or dehydration in northern Gaza in recent weeks. The real number, according to doctors from several northern hospitals, is likely to be higher.

Among those treated for malnutrition by Dr Eleiwa at al-Shifa hospital recently was a boy aged between 10 and 12 who died last week during Ramadan; a boy aged around four months whose mother was killed, leaving him short of milk when none was available to buy; and an 18-year-old girl who was already suffering from epilepsy.

"She was already sick and none of her medicine was available any longer and her family had no food," Dr Eleiwa said.

"In the end her body was very meagre, just bones and skin and no fat."

Under his care at al-Shifa on Friday, 16-year-old Rafeeq Dughmoush was lying on his side, bedbound. Rafeeq's bones were showing and one of his legs had been amputated from the knee down. A colostomy bag was attached to his torso.

"I am emaciated," he said, speaking slowly in order to draw breath between words. "I am so weak I cannot move my body from one side to another. My uncle has to move me."

Rafeeq and his sister Rafeef, 15, were severely injured when an Israeli air strike hit their home, killing 11 members of the family, their uncle Mahmoud said. Among the dead were their mother, four other siblings and their nieces and nephews.

Rafeeq was already suffering from malnutrition, he said, before the strike that wounded him. "We could not find any kind of fruit to eat, no apple, no guava, there was no meat and any food at the markets was all too expensive," he said.

Rafeef, whose leg was shattered by the strike and pinned together, said she had asked the hospital staff for any kind of fruit or vegetable for him to eat, "but they cannot provide any".

Ramadan used to be a time of pure joy, Rafeef said, "heaven compared to now".

"It really was beautiful," she said. "But these times will not come back. The best people in our lives have disappeared."

The doctors at al-Shifa have transferred many child malnutrition patients further north to Kamal Adwan hospital, because it has better paediatric facilities, but children have died there in high numbers too.

Dr Hussam Abu Safiya, the head of paediatrics at Kamal Adwan, said that 21 children had died at the hospital from malnutrition or dehydration in the past four weeks, and there were currently 10 children in an acute condition.

"I feel helpless to save these children and it is a hard and shameful feeling," Dr Safiya said. "I have the same feeling for my staff, who cannot find enough food for themselves and some days do not eat."

Israel was waging a "war by starvation," he said.

"Intentionally depriving children of food, killing them with hunger - there is no law in the world that allows occupiers to do this."

The EU's foreign policy chief Josep Borrell has also accused Israel of intentionally starving Gazans. "In Gaza we are no longer on the brink of famine, we are in a state of famine," he said on Monday. "This is unacceptable. Starvation is used as a weapon of war. Israel is provoking famine."

Israel denies it is intentionally starving Gazans. It has blamed the UN, which it says has created logistical challenges around aid deliveries, as well as Hamas, which Israel says has commandeered aid. The Israeli Prime Minister, Benjamin Netanyahu, denied last week that Gazans were starving. "That's not the information we have, and we monitor it closely," he told the media outlet Politico.

But Gazans are starving. "The facts speak for themselves," said Abeer Etefa, the World Food Programme's senior spokesperson for the Middle East. "1.1 million under the IPC phase 5 - that's catastrophic hunger. And more than a third of children under two are acutely malnourished. That means they are at risk of death."

On Friday, 200 tonnes of food aid provided by the charity World Central Kitchen arrived by barge at a newly built jetty off the coast of Gaza, constructed by the charity from the rubble of destroyed buildings. It is hoped that it will alleviate the severe shortages in north and central Gaza, and bring some relief during the remainder of Ramadan.

But the charitable aid operation has led to accusations against Israel that it has abandoned its humanitarian responsibilities to the civilian population, leaving it up to charities and other nations to step in to fill the void.

"As an occupying power, the state of Israel is obliged to cater to the needs of the population, or to facilitate the delivery of humanitarian aid," said Juliette Touma, director of communications for the UN refugee agency, UNRWA. "And they are not doing that. Not sufficiently."

On Friday, as the World Central Kitchen barge neared the Gaza shoreline, Khaled Naji, a father of six, was helping his wife prepare dinner in the ruins of their home in Deir al-Balah, central Gaza.

"We need this aid," Mr Naji said. "They talk about humanitarian aid but we get nothing."

Like many in Gaza, Mr Naji and his family were attempting to observe Ramadan. "We are fasting for God but this year we cannot enjoy it," he said.

"Not the suhoor, not the moment we break our fast, not the rituals we usually follow. We are not dressing our children and taking them to prayers. We are not teaching them about our faith. You just feed your child something small and you are afraid all the time a shell will fall on your head."

When sunset arrived, Mr Naji laid a blanket on a concrete slab and sat with his family amid the rubble. They had scrounged a small amount of fresh food for the evening meal. On some previous days, there had been none.

(Source: BBC)