PONE-D-24-35303Catastrophic Hunger in Gaza: Unprecedented Levels of Hunger Post-October 7th. A Real Population-Based Study from the Gaza StripPLOS ONE

Dear Dr. Faris,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

We have evaluated your manuscript ID D-24-35303 entitled "Catastrophic Hunger in Gaza: Unprecedented Levels of Hunger Post-October 7th. A Real Population-Based Study from the Gaza Strip" which you submitted to PLOS ONE and require revisions before your article can be published. As you can see below, the reviewers provide comments. Please consider addressing these comments as an essential next step to take this manuscript forward.

Please submit your revised manuscript by Jan 02 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

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We look forward to receiving your revised manuscript.

Kind regards,

Marianne Clemence, Staff Editor, on behalf of,

Dr. Mohammed Alkhaldi

Academic Editor

PLOS ONE

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Additional Editor Comments:

Thank you for submitting your manuscript to PLOS ONE and I look forward to receiving your revision.

Dr. Mohammed Alkhaldi

Comments from the Journal Office

Please ensure that your Discussion is focused on the findings of your study rather than more general political discussion.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Partly

Reviewer #4: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: I Don't Know

Reviewer #2: Yes

Reviewer #3: I Don't Know

Reviewer #4: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

Reviewer #4: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: This paper is an important contribution in documenting Israel's genocide against Palestinians. While I appreciate the authors' attempts to use "neutral" language to describe and document the levels of food insecurity and hunger currently experienced by Palestinians, it is critical that the authors consider the connections between the hunger and famine being experienced in Gaza, and the concept of starvation as a weapon of a genocidal war being perpetrated by Israel.

I would therefore like to recommend that the authors consider the report produced by Human Rights Watch on this matter: https://www.hrw.org/news/2023/12/18/israel-starvation-used-weapon-war-gaza. The report asserts that: (1) The Israeli government is using starvation of civilians as a method of warfare in the Gaza Strip, which is a war crime; and (2) Israeli officials have made public statements expressing their aim to deprive civilians in Gaza of food, water, and fuel – statements reflected in Israeli forces’ military operations.

On a personal note, as an author who has struggled to publish papers in peer reviewed journals because reviewers tend to question the neutrality and objectivity in my analysis of Israel's genocidal tactics, I completely understand your decision and approach with this paper. Consequently, my comments above should be considered as a recommendation rather than as a prerequisite for publication.

Reviewer #2: The manuscript is well written, the research study is of good quality, the topic is of high importance covering a pressing issue and it is necessary to have publications in this area. The access of researchers to Gaza is limited making the study very valuable.

Some minor writing mistakes need to be corrected

Page 10 I suggest to add some information on the history of the blockade on Gaza

Page 12 the repetition of the word report is redundant in this sentence "the report of the Global Nutrition Cluster (GNC) Report"

Page 12 GNS should be GNC

Page 15 Middle GA should be clarified

Reviewer #3: 1) General Comments:

This paper covers a highly relevant and urgent issue by examining hunger levels among Gaza residents after the October 7th military escalation. The study aims to provide population-based data that could be valuable for informing policymakers and humanitarian organizations on addressing hunger and food insecurity.

2) Detailed Comments:

Title:

The title contains redundancy in the word "Hunger." A clearer, more concise alternative is:

Catastrophic Hunger in Gaza: A Population-Based Study of Unprecedented Food Insecurity Post-October 7th.

Abstract:

• Background: The start is strong, but the ending mentions informing policymakers about strategies to mitigate hunger, which is not discussed in the paper. The purpose should instead emphasize providing insights into hunger levels and food insecurity rather than strategies.

• Methods: Sociodemographic data should be included in this section for completeness.

Introduction:

• The background of the Gaza crisis is well covered, but the section should include the most recent reports on hunger and malnutrition in Gaza.

• Definitions of key terms like hunger, famine, starvation, and food security should be included to distinguish these closely related concepts.

• The introduction goes into detail about the Household Hunger Scale (HHS) but merely mentions the Household Food Insecurity Access Scale (HFIAS) and the Household Food Security Survey Module (HFSSM). A more balanced coverage is needed.

• It’s important to clarify that the study's purpose is to inform policymakers rather than to create strategies, aligning with the abstract.

Materials and Methods:

• This is a cross-sectional study conducted in the Gaza Strip from May to July 2024, during the ongoing war in the region.

• There is no clear description of how data were collected or whether the data collectors were trained.

• The method of data collection (e.g., paper-based, Google Docs) should be specified. It's unclear how the questionnaire was administered (online or in-person), though later in the results section it is mentioned that households were interviewed.

• Participant eligibility criteria, informed consent processes, and an explanation of household hunger categories are absent.

• The HFIAS tool explanation could be made easier to understand through a table or appendix.

• The full questionnaire should be included in the appendix, and details about its development, validation, and scope (e.g., anthropometrics, sociodemographics) should be clearly outlined. It wasn’t clear how the questionnaire was built until we discovered that it was a combination of the 3 scales along with other questions.

• More details are needed on how anthropometric data were collected and organized.

• The translation of assessment tools should mention who performed the translations and their qualifications.

• After viewing the data, a major flaw is the inconsistency in the data categories and geographical or current address names, which should be standardized to allow for proper analysis.

Results:

• Some data, such as economic status, were not mentioned in the methods section but appear here for the first time. How was economic status categorized? What are the boundaries, and according to what?

• The presentation of results would benefit from visual aids like graphs or figures, particularly for illustrating shifts in BMI and weight loss.

• The conclusion contradicts the results by stating that camp dwellers have higher hunger severity, which is not reflected in the results.

• When discussing the governorates, it is unclear whether the household location refers to where they are currently due to continuous displacement or where they originally came from.

• The phrase "with particular attention toward the three or more months by about one-third of the respondents" is unclear. How was this determined? Was it part of the questionnaire or a note from interviewers?

• Results should be summarized clearly before diving into further detail.

Discussion:

• The discussion is too lengthy and redundant in parts, especially when detailing the situation in Gaza before the war, which is not particularly related to the research aim. It should focus more on the study’s findings about hunger and food insecurity, backed by current evidence.

• The omission of study limitations, such as challenges faced during data collection in a conflict zone (e.g., safety, displacement, internet access, movement), especially in Northern Gaza, is significant. For example, the Rafah invasion and evacuation occurred at the beginning of the research period. How did this affect the research?

• More references are needed to strengthen some statements, and comparisons to similar studies would enhance the discussion.

• Non-participation challenges due to internet and war-related issues, such as the inability to reach people in tents either in the field or online, should be highlighted.

• The discussion should emphasize how the study’s results can inform humanitarian organizations in addressing hunger.

• Contradictions arise when Southern Gaza is shown to have higher hunger rates than Northern Gaza, which contradicts previous reports of more severe conditions in the north. Please support your results and expand on this topic.

Conclusion:

• The conclusion needs to be aligned with the rest of the paper, summarizing and validating the findings. It should not introduce new elements, like the cessation of hostilities, for the first time here.

References:

• Some references, such as those for ICRC protocols and the Global Nutrition Cluster, need corrections and consistency.

Images/Tables (if any):

• Tables 6-8 could be included as supplementary files, with only the significant p-values mentioned in the main text.

• Figures representing weight changes and hunger severity would improve clarity.

Language Quality:

• The overall language is clear and acceptable, though minor improvements could enhance readability.

Reviewer #4: Research Design and Rationale:

1. Clarity of Research Objectives:

o The abstract clearly states the aim to inform policymakers and humanitarian organizations, but could you clarify how the findings are specifically intended to inform policy or interventions in Gaza? Are there any particular groups or strategies you envision targeting with the findings?

2. Justification of Study Location:

o Why did you choose to conduct this study in Gaza specifically during this period of conflict? Could you elaborate on how the timing of the study (May to July 2024) may have influenced the findings, given that the situation in Gaza has been highly dynamic?

3. Previous Literature:

o How does your study compare to existing research on food insecurity in conflict zones, especially in Gaza? Are there any notable discrepancies with previous studies that report lower levels of food insecurity, and how do you explain these differences?

Sampling and Data Collection:

4. Sampling Strategy:

o The study surveyed 1209 households out of an initial 1503. Could you provide more details about the reasons behind excluding 294 households? Was this due to missing data, or were there other factors that may have affected the final sample?

5. Demographic Representation:

o You mention the mean age of participants is 38 years, with 53.5% being female. Were these demographics reflective of the overall Gaza population? Did you find any significant gender or age-based differences in food insecurity and hunger levels?

6. Data Collection in a Conflict Zone:

o Given the ongoing conflict, were there any particular challenges or limitations in collecting data in Gaza? For example, how did the security situation impact the study’s logistics or participants' willingness to engage?

7. Self-Reported Anthropometric Data:

o You collected self-reported anthropometric data, such as weight changes. How confident are you in the accuracy of these self-reports, considering the stress and trauma participants may be experiencing? Please insert this as limitations.

Interpretation of Results:

12. Hunger and Weight Loss:

• The average weight loss (from 74.6 kg to 64.1 kg) is striking. What do you believe are the key contributing factors to this weight loss beyond food insecurity, such as stress, healthcare access, or psychological impacts?

13. Statistical Impact of Confounding Variables:

• The abstract mentions that factors like displacement, age, economic status, and education significantly impacted hunger severity. Could you provide more details on the extent to which these variables influenced your findings? Were there any surprising or unexpected relationships?

Policy and Humanitarian Implications:

14. Recommendations for Action:

• Based on your findings, what specific recommendations would you propose to humanitarian organizations operating in Gaza to mitigate hunger and improve food security? Are there any quick-win interventions that could be implemented in the short term?

15. Long-term Policy Recommendations:

• Beyond immediate relief efforts, what longer-term policy changes do you think are necessary to address food insecurity in Gaza, particularly considering the ongoing conflict and blockade? Are there any impact on SDGs? Can you please indicate the importance of your study that shows the useless of international humanitarian rights and the SDGs.

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If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .

Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

Reviewer #4: Yes:  Maha Hoteit

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Attachments

Attachment

Submitted filename: Faris_Plosone.docx

PONE-D-24-35303R1Catastrophic Famine in Gaza: Unprecedented Levels of Hunger Post-October 7th.  A Real Population-Based Study from the Gaza StripPLOS ONE

Dear Dr. Faris,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Mar 20 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .

We look forward to receiving your revised manuscript.

Kind regards,

Marianne Clemence, Staff Editor, on behalf of,

Mohammed Alkhaldi

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments :

Comments from the Journal Office:

Thank you for your important submission highlighting the impact of the Gaza war on citizens. Following additional review by the staff editorial team, we are requesting a few revisions to the Discussion. PLOS One is primarily designed for the publication of scientific research, and our fourth publication criterion requires that “conclusions are presented in an appropriate fashion and are supported by the data” (https://journals.plos.org/plosone/s/criteria-for-publication). Whilst we have no concerns about the authors drawing attention to humanitarian concerns relating to the effects of war and blockade on food security, the results presented are not sufficient to support discussion regarding the interpretation of international law or political opinions. Inflammatory terminology, including in the keywords, should also be removed.

Therefore, we request that you please address the following as part of your revision. The manuscript will undergo further additional assessment by staff editors before the manuscript can be considered for publication. Therefore, please ensure that your revision is thorough, and that any new material is worded with care:

• Provide additional appropriate references to support lines 424-434 "The current...food availability."
• Remove lines 402-403 "Our finding indicate...Israeli policies", the end of line 425 "In retaliation for this political choice", lines 469-470 "The current...war laws"" and 484-485 "The deliberate...humanitarian catastrophe", and any other content that speculates on the motivations of any person or institution
• Remove lines 532-565 "The humanitarian crisis...population in Gaza" and any other content that analyzes the legality or legitimacy of any person or institution
• Remove lines 665-666 "The international community...Palestinian people" and 668-670 "Additionally, advocating for...in the region", and ensure in particular that the Conclusions section is restricted to interpretations that are directly supported by the data presented in the results of the manuscript.
• Remove the following key words, and any other language that might be perceived as inflammatory, from your submission: Zionism, War criminals

Thank you very much for your attention to these requests, and thank you again for your submission to PLOS One.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #4: All comments have been addressed

Reviewer #5: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #4: Yes

Reviewer #5: (No Response)

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #4: Yes

Reviewer #5: (No Response)

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #4: Yes

Reviewer #5: (No Response)

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #4: Yes

Reviewer #5: (No Response)

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #4: Dear Authors I have reviewed your responses to the comments and concerns raised during the review process. You have adequately addressed all issues, including providing additional clarifications and making the necessary revisions to the manuscript. You have demonstrated a comprehensive understanding of the feedback and have strengthened the quality and reliability of the study.

I am satisfied with the responses, and I believe the article now meets the standards required for publication. I recommend the manuscript for acceptance and publication in its current form.

Reviewer #5: (No Response)

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .

Reviewer #4: Yes:  Maha Hoteit

Reviewer #5: Yes:  Dr. Haleama Al Sabbah

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[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step.

Attachments

Attachment

Submitted filename: Feedback PLOS ONE.pdf

Catastrophic Famine in Gaza: Unprecedented Levels of Hunger Post-October 7th.  A Real Population-Based Study from the Gaza Strip

PONE-D-24-35303R2

Dear Dr. Faris,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager®  and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Marianne Clemence, Staff Editor, on behalf of,

Mohammed Alkhaldi

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #4: All comments have been addressed

Reviewer #5: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #4: Yes

Reviewer #5: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #4: Yes

Reviewer #5: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #4: Yes

Reviewer #5: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #4: Yes

Reviewer #5: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #4: The authors have addressed all comments, and the manuscript is now ready for publication.

All the comments raised were addressed

Reviewer #5: (No Response)

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .

Reviewer #4: Yes:  Maha Hoteit

Reviewer #5: Yes:  Dr. Haleama Al Sabbah

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