GAZA – Not long after Texas surgeon Mohammed Adeel Khaleel arrived at a Gaza City hospital in early August, 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.

“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,” Khaleel, a spinal surgeon on his third volunteer stint in Gaza, said in an interview.

On Friday, the Integrated Food Security Phase Classification, or IPC, the leading authority on global hunger crises, said for the first time that parts of Gaza are in famine and warned that it is spreading. For months, U.N. agencies, aid groups and experts had warned that Israel’s blockade and ongoing offensive were pushing the territory to the brink.

In the 24 hours following the famine announcement, eight people in Gaza died of malnutrition-related causes, bringing the overall toll of such deaths during the war to 281, according Gaza’s Health Ministry, which is part of the Hamas-run government and staffed by medical professionals. A U.S. medical nonprofit working in Gaza says one in six children under 5 is affected by acute malnutrition.

Israel rejected the famine announcement, calling it an “outright lie” and pointing to its recent efforts to allow in more food after it eased a complete 2½ month blockade in May. It has accused Hamas of siphoning off aid — allegations disputed by the United Nations, which says Israeli restrictions and a breakdown of law and order make it extremely difficult to deliver food to the most vulnerable.

Khaleel, who spoke to The Associated Press ahead of the announcement, said the evidence of deprivation was already clear.

“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.

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 that 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.”

The sick, wounded and young are most vulnerable

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.

Now he is one of 20 people at Shifa brought in for abdominal wounds and increasingly malnourished because of a shortage of intravenous nutritional supplements, the doctor said.

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 it (the supplements), but I have not found any,” he said.

Israeli officials have pointed out that some of those said to have died from malnutrition had preexisting conditions. But doctors and other experts say that is to be expected, as famine first preys on the most vulnerable, including babies and small children.

Doctors and others see signs of hunger everywhere

Outside the hospital, the shortage of nutrients is equally dire, doctors and civilians say.

“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.

In Gaza City on Friday, Palestinians displaced from elsewhere recounted a desperate search for food.

“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 Shijaiyah.

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.

Hunger agency says famine is expected to spread

In its announcement Friday, the IPC said famine in Gaza City is likely to spread across the territory without a ceasefire and a flood of humanitarian aid.

Some of the IPC’s conclusions were echoed in a report by a group that organizes medical missions to Gaza, which described a “catastrophic rise in severe malnutrition” among children and pregnant women.

One of every 6 children in Gaza under 5 is now affected by acute malnutrition, said the report by U.S. nonprofit MedGlobal, based on observations by its staff in four of Gaza’s five governorates. The group warned that all young children in Gaza are at risk of starving without intervention.

Khaleel, the Texas doctor, said he would leave it to others with more expertise to measure exactly what constitutes famine.

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.”

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Geller reported from New York. Associated Press writer Sally Abou AlJoud in Beirut, Lebanon, contributed to this report.