Five times in the course of the past year, the world’s leading hunger monitor warned that Gaza could be teetering on the precipice of famine. Each time, the watchdog stopped short of concluding one was under way.

Gregory Shay, a retired pediatric pulmonologist from California, spent October treating children in Gaza, and to him, it looked like famine was gripping the territory.

Shay worked at Nasser Hospital in the southern Gaza city of Khan Younis. Most of the children he treated subsisted on bread and rice, recalled Shay, a volunteer with the U.S.-based non-profit organization MedGlobal. Without vegetables, fruit or meat, he said, the children lacked the vitamins or minerals needed to stave off disease.