E. Mark Windle 30 May 2025.
A range of amino acids, vitamins and minerals are essential for the manufacture and functioning of immune cells. Optimum immune function is dependent not only an adequate intake of these nutrients but also on the ability of the body to utilise them. Chronic gastrointestinal disease and related malabsorption, vomiting or reduced intake due to nausea perpetuates the malnutrition-infection cycle.
SOURCES OF INFECTION
Cases of watery diarrhoea in Gaza reported by the Health Cluster and WHO in August 2024 were in excess of 577,000. Data collated by Medecins San Frontieres, other healthcare organisations and emergency clinics suggested another 100,000 cases had occurred by the end of the first year of the conflict. While gastrointestinal disease in Gaza has had bacterial, viral and parasitic origins, a particular culprit has been the viral pathogen Hepatitis A, causing fatigue, nausea and abdominal pain.
The polio virus produces debilitating and often irreversible neurological and neuromuscular damage (rather than gastrointestinal symptoms) but had been completely eradicated from Gaza for 25 years with the rolling-out of vaccination. The rediscovery of the virus during wastewater sampling in July 2024 was deeply concerning, though not entirely surprising given the extreme living and sanitary conditions. Mass vaccination programmes followed the confirmation of the first case of a child paralyzed by polio in Deir al-Balah. Some attempts were thwarted due to bombing in northern Gaza. Meanwhile, the IDF offered immunisation sessions for its soldiers.
Having taken the main force of airstrikes in the early phases of the war, north and central regions were exposed to extremely poor sanitary conditions. Increases in gastrointestinal, respiratory and skin infections reflected this. Outbreaks of parasitic disease such as scabies and lice were also on the rise. To assess the situation, Solutions Consultancy Research and Monitoring performed a survey at household level to assess the situation. To “adjust” for a lack of available water, 78% of families had reduced oral intake and 42% reduced personal hygiene practices. More than three-quarters reported being unable to access soap, sanitary pads, disposable diapers or detergent (for washing dishes) for at least a month. Open sewage was an issue — only one third had access to a functioning toilet. With unhygienic conditions so prevalent, implementation of sanitation-related facilities was essential to break the malnutrition-infection cycle. However, full integration of these at a local level was almost impossible — aid agencies continually fought an uphill battle given extent of the destruction of sanitary facilities, the exponential rise in the incidence of disease, and logistical difficulties of executing vaccination programmes in a war zone.
FOOD POISONING
Other hazards included food poisoning due to transport delays of perishable goods, and a lack of electricity for cooking and refrigeration purposes. Fifteen women and children were hospitalised due to eating spoiled canned products in the Shujaiya region. Accusations from Palestinian Civil Defence that the IDF had deliberately left these goods to cause harm on consumption went unchallenged. In a separate incident, Israeli soldiers suffered food poisoning outbreak caused by Shigella bacterial infection — reportedly as a result of donated food that had been inadequately stored. Foraging and consumption of products intended for animal consumption has also been common practice among Gazan civilians. In the north, children were admitted to Kamal Adwan Hospital with food poisoning after consuming animal feed consisting of straw, barley and corn.
EFFECTS OF MALNUTRITION AND INFECTION ON WOUND HEALING
A number of processes are involved in wound healing, including haemostasis (clotting processes), inflammation (immune cell infiltration at the wound site), proliferation (synthesis of new skin cells, vasculature and collagen) and a final remodelling phase that can take several months before wound resolution or scar formation is complete.
Old age, the presence of diabetes and other non-communicable diseases, and lifestyle factors such as smoking can all negatively influence wound healing. Adequate nutrition is a key part of management — many nutrients are required for optimising immune function and structural repair. Amino acids from dietary protein sources provide the materials for rebuilding muscle and growth, scar formation and for tissues that connect muscle to bone. A range of B vitamins are crucial for red blood cell formation, and in the maintenance of skin and nerve cell integrity. Red blood cell replication is dependent on folic acid and cobalamin (vitamin B12). Vitamin C is found in high amounts in lymphocyte cells. As an antioxidant it also protects against free radicals, harmful by-products produced in biochemical reactions that would otherwise damage vessels and organs. Vitamin E and K are also indirectly involved in wound healing due to their roles in immune function and regulation of blood clotting. It is logical then — and has been repeatedly confirmed through research in elective hospitalised surgical patients — that malnourished subjects have an increased risk of wound infection, delayed wound repair, sepsis, and longer-term complications.
INJURIES SUSTAINED IN THE ISRAEL-HAMAS CONFLICT
Where both nutrition and sanitary conditions are severely compromised in combat zones, the effect is heightened. Medical staff in Gaza frequently reported finding open wounds infested with maggots or remaining unhealed due to chronic bacterial infection, including the emergence of Methicillin-resistant Staphylococcus aureus (MRSA) and other antibiotic-resistant strains. In one Khan Younis clinic operated by the NGO Anera, infected conflict-related wounds were the most common type encountered. Approximately 750 cases were managed per month.
Prior to the Israel-Hamas war, a study of adult burned patients in the Gaza Strip highlighted that a high number of injuries were the result of cooking accidents. In the Anera clinic, burns were the second most common injury seen and reflected a mix of combat and domestic-related incidents. Burn severity is determined by burn size and depth, and age of the patient. These are important predictors of long-term complications and mortality. Regarding size, a major burn injury is usually considered to one affected at least 20% total body surface area (the equivalent surface area of one whole arm or greater, although the actual wound distribution is often not confined to one area). Clinical management requires early rescue and intravenous fluid resuscitation to correct the life-threatening drop in blood volume that occurs as part of the physiological response. Due to the difficulties of accessing emergency services in Gaza, most individuals with major burns are likely to have died at or near where the injury was acquired, whether by airstrike, rigged ground explosions, property fires or white phosphorous airdrops. Aggressive nutritional support to counter the catabolic effects of major burn injury. Dietary protein requirements in the acute phase can be 1.5–2g/kg body weight per day — up to twice that of a non-burned patient. Daily energy needs are also often raised well above baseline.
PREDICTED CONTRIBUTION TO THE DEATH TOLL
Attributing death toll figures “directly” to malnutrition and food insecurity is complex and difficult to assess on a mass scale and in a war zone. Given those caveats, Gaza remains at risk of famine according to the UN and other supporters of the IPC food security monitoring scales. In straightforward terms, it is predicted that 50,000 cases of acute malnutrition in Gazan children will require management in 2025. Latest figures suggest that the ultimate death toll could be as much as 200,000 due to the effect of malnutrition and infected wounds on a sustained background of unresolved sanitation systems, blockades on drinking water and food, and an inability to access appropriate healthcare.
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