As battles raged on the outskirts of Rafah on Wednesday with Israeli forces closing in, Palestinians were on the move again, abandoning neighborhoods of the southern Gaza city and leaving them as ghost towns.

Israel has threatened a major assault on Rafah to defeat four of Hamas’s six remaining battalions holed up there, but more than a million people are sheltering in the city, prompting warnings from the United Nations of a humanitarian catastrophe.

Israeli forces tasked with destroying the terror group, on Tuesday seized the main border crossing between Gaza and Egypt in Rafah, cutting off a vital route for aid into the enclave, where malnutrition is widespread.

Israel is continuing to bring in aid through several crossings, while the US has completed the construction of a pier that will allow large amounts of aid to be transferred into the Strip.

Israel’s military said it was conducting a limited operation in Rafah to kill terrorists and dismantle infrastructure used by Hamas, which runs Gaza. It told civilians to go to an “expanded humanitarian zone” near Khan Younis, north of Rafah.

Three residents of Rafah told Reuters by phone that tens of thousands of people have fled the city, which was seen as the last refuge for Palestinians who have been displaced many times over as Israeli airstrikes pulverized Gaza.

People in the Jneina, Al-Shawka, Al-Salam and other neighborhoods were ordered by the Israeli army to leave in anticipation of an assault. Some 1.4 million people have been sheltering in Rafah, raising the prospect of major casualties.

“Some streets look like a ghost town now,” said Aref, 35, who asked not to be named.

“We don’t fear death and martyrdom but we have kids to care for and live for another day when this war ends and we rebuild the city,” he told Reuters via a chat app.

The war erupted on October 7 when Hamas terrorists rampaged through southern communities, murdering 1,200 people, mostly civilians, and taking 253 hostages back to the enclave.

The Hamas-run Gaza health ministry says more than 34,000 people in the Strip have been killed in the fighting so far, a figure that cannot be independently verified and includes some 13,000 Hamas gunmen Israel says it has killed in battle. Israel also says it killed some 1,000 terrorists inside Israel on October 7. Almost 270 IDF soldiers have been killed in the IDF’s Gaza offensive.

Many Rafah residents said they received warnings over their phones, and planes dropped leaflets.

Juliette Touma, director of communications of the UN Palestinian refugee agency UNRWA, estimated that around 10,000 Palestinians had left Rafah since Monday.

The Hamas-run Gaza government media office put the number of people fleeing at tens of thousands and warned against a “massacre.”

Residents said tanks, which had moved in to take control of the Rafah border crossing, had not entered built-up areas of the city and gun battles were still outside the city limits.

Suleiman Abu Kweik and his family are being displaced for the fourth time.

“Our homes have been destroyed. In Gaza [City] our house… they destroyed it. It was shelled. We went to Khan Younis. When they threatened Khan Younis, we went to Rafah,” he said.

Hamas said its operatives were battling Israeli forces in the east of Rafah. Lines of smoke from airstrikes and tank shelling rose from places east of the city, residents said.

“Some people are still staying in their homes, even in the red zone areas, but I daresay that tens of thousands have already left Rafah, including from areas west of the city, that are not included in the occupation army warning,” said Mohammed Emad, 34, a father of three.

Abu Ahmed Al-Najar said more than 60 families who lived in tent camps in Al-Jneina neighborhood in Rafah had all left the area late on Tuesday.

“Sixty-five families or 400 people are now homeless. People have no money, no tents, no one to support them,” he said.

Some people, like Mazen Ghadour, loaded their meager belongings onto old trucks.

“This is the third or fourth time we have had to move. We are eight families. We live in fear. There is no safe place in the entire Strip,” he said.

“God knows where we will go. We are going to the unknown. We are going to the unknown.”

Women are bearing the brunt of the war as hospitals face overcrowding and shortages, a doctor who just left Rafah said.

“In my 25 years of experience, I’ve never seen a conflict where people must run around in circles with nowhere to go,” Hairhound Lahna said.

A gynaecologist, Lahna was head of mission for Rahma Worldwide, an American non-governmental organization, and Palmed, a France-based association for “health in Palestine.”

The war has been “awful for women,” especially those forced to leave hospitals just hours after giving birth due to overcrowding, he told AFP on the phone.

“They find themselves in tents or shelters where people crowd together,” said the 57-year-old French doctor who worked in Khan Younis’s European Hospital, as well as a maternity ward in Rafah.

Lahna, clearly affected, recounted witnessing a mother’s death from blood poisoning four days after childbirth.

“We dish out antibiotics willy-nilly to cope with the situation” because the risk of infection is “enormous,” with women lacking enough water to wash themselves and unable to change into clean clothes, he said in the interview on Tuesday.

Gaza’s health care system is in tatters, with many hospitals targeted or hit by Israeli forces. Israel has published evidence that Hamas regularly operates from health facilities.

A UN Women report published this week said women and girls in Rafah and the rest of the Gaza Strip were in “a constant state of despair and fear.”

It found that 93 percent of those interviewed felt unsafe, 80% had feelings of depression, 66% were unable to sleep and 70% suffered from intense anxiety and nightmares.

In addition, more than half of them “have a medical condition requiring urgent medical attention,” the report said.

The scenes in the north of the narrow coastal strip “seem straight from Berlin after World War II” or the Chechen capital Grozny, said Lahna, describing it as “no longer liveable.”

Lahna said Kamal Adwan Hospital in the northern city of Beit Lahia, which he visited last week, was “a five-star hotel” compared with the destruction in the rest of the city.

The director of that medical center revealed in a Shin Bet interrogation published in December that his northern Gaza hospital was turned into a military facility under Hamas’s control and that at one point, it had housed a kidnapped soldier.

An emergency doctor doing volunteer work in Rafah and nearby Khan Younis said the situation was “catastrophic.”

Rafah’s Al-Najjar Hospital was a “red zone” with patients and staff fleeing “out of fear,” said Doctor James Smith.

The closure of the Kerem Shalom crossing with Israel on Sunday, after a Hamas-claimed rocket attack killed four Israeli soldiers, had cut off the supply of medicine and staff to support field hospitals.

“The smell of sewage is rife everywhere,” Smith said. “It’s been getting worse over the course of the last couple of days.”

Smith said he takes on jaundice cases, likely due to hepatitis that cannot be diagnosed for lack of available tests.

Other cases involved children and adults suffering from “complex respiratory problems, diarrheas and vomiting,” he said.