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. Associated Press reported.

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, according to Associated Press.