Desperate Palestinians clutching pots and plastic buckets scrambled for rice at a charity kitchen in Gaza City on Saturday, a day after the United Nations declared a famine in parts of the war-battered territory, a charge that Israel vehemently denied.

On Friday, the United Nations Integrated Food Security Phase Classification (IPC) system officially declared a famine in parts of the Gaza Strip, saying that nearly a quarter of the enclave’s two million residents are experiencing famine, and that number is expected to rise by the end of September.

Israel swiftly denied the report, saying that the IPC relies on Hamas sources, and accused the system of having “twisted its own rules” in declaring a famine, calling the report an “outright lie” and “a modern blood libel.”

In the 24 hours following the UN announcement, eight people in Gaza died of malnutrition-related causes, according to Gaza’s Hamas-run health ministry, whose figures cannot be verified and do not distinguish between combatants and civilians. According to the ministry, the overall toll of such deaths during the war is 281.

Israel has largely dismissed these figures and has pointed out that many of those included were suffering from preexisting conditions prior to their deaths, describing the reports as “an orchestrated campaign” by Hamas to discredit Israel.

In Gaza, one Palestinian woman said the UN famine declaration came “far too late.”

The children are “staggering from dizziness, unable to wake up because of the lack of food and water,” said the 34-year-old Umm Mohammad, at a charity kitchen in Deir al-Balah.

In Gaza City, which Israel plans to seize as part of an expanded military offensive, footage showed women and young children among the chaotic jostle of dozens clamoring and shouting for food.

“We have no home left, no food, no income… so we are forced to turn to charity kitchens, but they do not satisfy our hunger,” said Yousef Hamad, 58, who was displaced from the northern city of Beit Hanoun.

“We’re starving. We eat once a day. Will we be more hungry than we are now? There’s nothing left,” said Dalia Shamali, whose family has been repeatedly displaced from their home in nearby Shejaiya.

She said they spent most of their money over the last two years moving from one part of Gaza to another as the Israeli military issued evacuation orders. With Israel allowing more food in recently, the price of flour and other food items has been dropping, but the family still can’t afford them, Shamali said.

In the city, an American surgeon working at a local hospital described the levels of desperation he has witnessed since arriving in the Strip earlier this month.

“The level of hunger is really what’s heartbreaking. You know, we saw malnutrition before, back in November, already starting to happen. But now the level is just, it’s beyond imagination,” said Mohammed Adeel Khaleel, a spinal surgeon from Texas on his third volunteer stint in Gaza.

He said that shortly after he arrived at the hospital, a 17-year-old was brought in with gunshot wounds to both legs and one hand, sustained when he went to collect food at an aid site.

In the emergency room, Khaleel said he noted the ribs protruding from the teen’s emaciated torso, an indication of severe malnutrition. When doctors at Al-Ahli Hospital stabilized the patient, he raised his heavily bandaged hand and pointed to his empty mouth, Khaleel said.

Khaleel, who spoke to The Associated Press ahead of the UN famine announcement, said the evidence of deprivation was already clear, but said he would leave it to others with more expertise to measure exactly what constitutes famine.

“Just the degree of weight loss, post-operative complications and starvation that we’re seeing. That wouldn’t surprise me at all if it was called famine,” said Khaleel, who traveled to Gaza as an independent volunteer via the World Health Organization.

But he knows what he saw in three weeks of treating patients in Gaza, most of the time at the hospital in Gaza City. Again and again, medical workers cut open patients’ clothing to treat injuries, revealing a loss of muscle and fat caused by hunger that left skin stretched tight over protruding bones.

“These patients, a number of them that we’re seeing are just exposed ribs, severely skinny extremities,” he said. “And you know that they’re just not getting calories in.”

At Gaza City’s Shifa Hospital earlier in the week, nutrition director Dr. Mohammad Kuheil led an AP journalist to the bedside of a thin-limbed girl. Aya Sbeteh, 15, was wounded in an airstrike. But her recovery has been set back by weakness from lack of food, which her family says has reduced her weight by more than a third.

“All we have are grains like lentils, sometimes,” said her father, Yousef Sbeteh, 44. “Even flour is unaffordable.”

Another patient, Karam Akoumeh, lay with sunken cheeks, his thin skin stretched like plastic wrap across his rib cage. His intestines were seriously damaged when he was shot while going out to collect flour, his family said, compromising his digestive system and requiring hard-to-find intravenous nutritional supplements.

According to the UN, over 1,000 Palestinians have been killed by Israeli gunfire while seeking aid in recent months. Israel has disputed the figures and has said it only fires warning shots if crowds get too close to its forces.

Akoumeh’s father, Atef, said the lack of supplements compounded the hunger that reduced Karam’s weight from 62 kilograms (136 pounds) to just 35 kilos (77 pounds).

“I checked throughout all Gaza’s hospitals for [the supplements], but I have not found any,” he said.

“There are no protein sources, only plant-based protein from legumes. Meat and chicken are not available. Dairy products are not available, and fruits are also unavailable,” said Kuheil, the doctor in charge of nutrition at Shifa.

Earlier this week, Israel warned medical facilities in northern Gaza to prepare for mass evacuation ahead of the IDF’s planned offensive to capture Gaza City. On Saturday, a major hospital in southern Gaza began working to reopen, after it was shut for months due to IDF operations.

According to the IDF, Gazan medical officials were told that “the hospital infrastructures in the southern Gaza Strip are being adapted for the absorption of the sick and wounded, alongside an increased entry of necessary medical equipment in accordance with the requests of the international aid organizations.”

The planned campaign has sparked a major international outcry, with governments and humanitarian groups warning of potentially disastrous consequences for Gaza’s civilians, noting widespread malnutrition that has recently worsened significantly amid the 22-month war, which was sparked by Hamas’s October 7, 2023, onslaught.

The Hamas-run Gaza health ministry says more than 62,000 people in the Strip have been killed or are presumed dead in the fighting so far, though the toll cannot be verified and does not differentiate between civilians and fighters. Israel says it has killed over 22,000 combatants in battle as of August and another 1,600 terrorists inside Israel during the October 7 onslaught.

Israel has said it seeks to minimize civilian fatalities and stresses that Hamas uses Gaza’s civilians as human shields, fighting from civilian areas including homes, hospitals, schools, and mosques.

Israel’s toll in the ground offensive against Hamas in Gaza and in military operations along the border with the Strip stands at 459.