In clinics across Gaza, starving children are getting treatment, but they probably can't be saved.
They lie on hospital beds, skeletal, wasted, many barely making a sound.
Medical workers say that's what scares them most.
CONTENT WARNING: This story contains images of sick children that may be distressing.
"They're so exhausted, they're so sick, they're no longer able to cry," said Rachel Cummings, the humanitarian director for Save the Children in Gaza, describing a visit to one of the organisation's clinics last week.
"It was nearly silent."
Many of those children who can still speak are saying they want to die.
"We have many children now in our child protection services saying that they wish to die [because] in heaven, in paradise, there is food, there is water," Ms Cummings said.
Malnutrition deaths likely under-reported: doctor
The horrifying truth, according to doctors in Gaza, is that many will soon get their wish.
"All of the children who are currently malnourished will die," said Canadian doctor Tarek Loubani, the medical director of the healthcare organisation Glia, who is working in Gaza at the moment.
"That is, unless there is an absolutely rapid and consistent reversal of what is happening.
"However, let's be very realistic. Anybody who is malnourished right now will die."
The number of malnutrition deaths in Gaza could be vastly under-reported, said Dr Loubani, who spoke at a recent press conference alongside multiple aid workers, including Ms Cummings.
They don't include children with pre-existing medical conditions, even if those conditions are also exacerbated by the war, he said.
"The figures are very, very conservative," he said.
"The directive that we receive in the emergency [ward] is that we do not report any death that has a substantial — even primary — malnutrition component if there is any other comorbidity.
"That is to say, the only deaths that are marked as malnutrition deaths are the ones where there is really well and truly nothing else going on but the malnutrition."
He believes the official malnutrition death numbers could be just 10 per cent of the reality.
'It's not enough to save them'
The medical term "malnutrition" masks the harshness of the situation.
What's occurring in Gaza now — say doctors, aid workers and the people themselves — is starvation.
In the Patient Friends Hospital, which hosts the main specialised malnutrition treatment centre in Gaza City, doctors can't do much to help.
"Although a nutritional plan is attempted, there are no adequate supplies — there's simply nothing available to nourish the children," said Dr Fawaz Al Husseini, a paediatrician specialising in malnutrition.
"In normal circumstances, infants might consume butter and milk at home. But here, even hospitalised children with severe malnutrition gain little weight due to the limited food available.
"What little aid enters Gaza is grossly insufficient; it doesn't even begin to meet the children's needs."
Even for moderately malnourished Gazan children, the prospects are grim.
The use of a simple, yet specialised, measuring device called a MUAC (Mid-Upper Arm Circumference) tape determines whether a child is healthy (green), moderately malnourished (orange) or suffering from acute malnutrition (red).
The orange and red cases are given a paste from peanut, sugar and milk powder called "Plumpy'Nut" — a Nutella-inspired health supplement designed to treat malnutrition.
But it's not enough to save them.
"The treatment for moderate, the orange, is inadequate because there are no complementary foods. You can't survive on Plumpy'Nut alone," Ms Cummings said.
"Children are just getting sicker and sicker, even though they're in a treatment program for malnutrition.
"This is why we see this downward trajectory of child outcomes and that's why my team were so upset … because they know they're sending the children home [and] they will bounce back to the clinic in a worse state."
More than two months of no food
Israel blocked all food from entering Gaza from March 2 to May 21, saying it was trying to pressure the militant group Hamas to accept its ceasefire terms.
It also tried to replace the comprehensive and extensive UN-led aid distribution system with a newly formed American contractor, the Gaza Humanitarian Foundation (GHF), which had never before delivered humanitarian relief.
Israel argued these changes were to stop Hamas diverting aid, something the UN and international relief agencies denied was occurring and for which a US government analysis found no evidence.
The result of Israel's policy was widespread deprivation and desperation, culminating in an urgent declaration by the UN's Integrated Food Security Phase Classification group that most of Gaza had crossed famine thresholds.
Hundreds of people were killed — likely by Israeli tank and gunfire — trying to get food from the limited aid points set up by the private contractor, which, by its own numbers, has never distributed enough food to come close to feeding Gaza's population.
The few aid trucks that came through have been swarmed by desperate people, as seen in recent satellite vision.
It was only when faced with global condemnation and pressure from its closest ally, the United States, that Israel allowed more trucks into Gaza.
Over the past week, the UN said Israel also granted an increased number of requests from its agencies to pick up aid already sitting under Israeli military guard inside the strip.
Israel also announced "tactical pauses" — basically agreeing not to bomb or attack certain areas with ground troops — so drivers can take goods to stricken populations.
It allowed several countries to parachute food into Gaza by plane, a practice condemned by many aid agencies as ineffective, dangerous and expensive.
The United Nations said those measures have made little difference to the overall situation, with most of the trucks that did bring aid into the strip this week being looted.
'Cruel phase of war'
Palestinians seeking aid allege Israeli soldiers continue to shoot at and kill them and vulnerable people continue to miss out.
Aid workers say the situation has devolved into a "survival of the fittest" and is failing to deliver food to people like Mohassen Shaaban, who is nursing her one-month-old daughter Rahaf in a tent in a camp in Gaza.
"They keep promising aid but we haven't seen anything," she told the ABC.
Because most of the increased aid over the past week has been looted before making it to the agencies' warehouses, there has been no distribution to people like her.
"We adults have nothing to eat — no food at all. So how can I feed her [baby Rahaf]? I can't find anything for her or for us," she said.
"The situation is terrible for us — imagine what it's like for the children."
Ms Shaaban said she often boiled mint leaves in water to give to her daughter, in an attempt to stop her crying.
"She needs milk. She needs a clean place to live. We all need milk and a clean, safe space," she said.
"We need food — not just for the children, but for ourselves too, so we can breastfeed them. There are no nutrients.
"This situation is driving me crazy. It's unbearable not being able to find anything to feed her."
Damage from malnutrition 'not reversible'
Even if Gaza's malnourished children survive this cruel phase in the war, they will be forever marked by it.
"Child malnutrition causes cognitive impairment, memory loss, and inflammation; impacting the child's developmental potential," said Fawaz Al Husseini, the paediatric malnutrition specialist.
"It affects walking, memory, and vision — it impacts the entire body. In some cases, it even affects the kidneys; some children suffer kidney failure due to malnutrition."
Many adults in Gaza are malnourished too, but the impact on children is worse. The developmental damage is irreversible, said Rob Williams, the CEO of the War Child Alliance.
"The process of development stops, the process of building a brain, of creating neurons that will establish cognitive ability, will stop," he said.
"If you're a child at a vulnerable age for brain development … if that development stops, that is not reversible.
"The trucks coming in now will do nothing to restore the injury that's been done to the brains and the physical development of children who have been acutely malnourished.
"It's also true to say that hundreds of thousands of children have permanent damage — permanent physical and cognitive damage — from a deliberate policy of restricting the supply of food in Gaza."
The UN and other agencies say only a ceasefire and the unrestricted opening of Gaza's crossings to aid and commercial goods will solve the hunger crisis.
"It's not just about how many trucks get to the barrier, it's how effectively they get to the population, and especially the vulnerable ones who can't fight for food as the trucks enter and who can't risk their lives going to the GHF," Mr Williams said.
"The question that policymakers seem to be asking themselves is not 'How do you stop mass starvation in Gaza?' — the question they seem to be asking is 'How do we do something that will make it look like we're doing something?'
"We are at the point in Gaza where anything that doesn't include a complete ceasefire, a complete opening of those walls, a complete opening of the perfectly competent aid system that was there before … anything less than is policymakers condemning tens of thousands of people to death."
