Global leaders and humanitarian groups have said Gaza is facing “a new phase of hell” after a newly-published report from The Integrated Food Security Phase Classification (IPC) concluded famine is taking place in Gaza City. It marks the first time that famine has been confirmed since the start of the Israel-Hamas war. Israel has maintained its denial that famine is taking place in the region.

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Famine is classified when 20% of households in an area face an extreme shortage of food, 30% of children are acutely malnourished, and there are between two-to-four deaths per 10,000 people each day, caused by starvation, according to the United Nations-backed IPC, who had warned in July that Gaza was facing “a worst-case famine scenario.”

In the report published Friday, the IPC added that the situation in North Gaza appears to be even more critical than that in Gaza City, but “limited evidence on the population status in this area” has prevented food security body from confirming famine there.

“Urgent steps should be taken to allow for a full humanitarian assessment in this governorate,” the IPC urged.

The IPC also reported that the governorates of Deir Al Balah and Khan Younis are in the “emergency” phase, just one level below the famine determination. Per the IPC, famine is likely to occur in those areas by the end of September.

Read More: The Malnutrition Crisis in Gaza Will Outlive the War, Experts Warn

Israel has strongly rejected the IPC report, saying “there is no famine in Gaza.”

“The entire IPC document is based on Hamas’ lies laundered through organizations with vested interests,” said Israel’s Foreign Ministry, claiming that the IPC had changed its “global standard” for determining famine by “cutting the 30% threshold to 15% for this report only.”

The IPC has told TIME the Israeli Foreign Ministry’s “statement that the IPC changed its protocols is completely false.”

Per the IPC, the 30% threshold of malnutrition amongst children uses a measurement called “Weight-for-Height Z-core (WHZ).” However, a separate measurement, “Mid-Upper Arm Circumference (MUAC),” requires only a threshold of 15% and has been used for almost a decade by the IPC.

“In the absence of WHZ data (which is the case of Gaza) widespread acute malnutrition may be identified when at least 15% of children aged 6–59 months have a MUAC below 125 mm or oedema [swelling in the body’s tissues],” the IPC spokesperson told TIME in an emailed statement.

TIME has reached out to the Israeli Foreign Ministry for comment.

Israel is facing mounting pressure from organizations and world leaders over its military operations in the territory, with its plan to fully occupy the Gaza Strip prompting widespread condemnation.

In response to the IPC assessment, the World Health Organization (WHO) said: “More than half a million people in Gaza are trapped in famine, marked by widespread starvation, destitution and preventable death. An immediate cease-fire and end to the conflict is critical to allow an unimpeded, large-scale humanitarian response that can save lives.”

The U.K.-based non-profit Medical Aid for Palestinians shared testimony from its staff and contacts in Gaza in an email to TIME on Friday, citing particular concern over instances of malnutrition and starvation.

“I have been working in intensive care units as a physiotherapist helping people to recover from complex and major trauma for 25 years, working both in the NHS [the U.K. healthcare system] and around the world in conflict zones,” said Dr. Rachael Moses, a physiotherapist working in Al-Shifa Hospital in Gaza City. “I have never seen as many patients so malnourished and starved as I have in Gaza’s ICUs—both babies and adults.”

Amid escalating calls for a cease-fire, here is how some world leaders are reacting to the declaration of famine in Gaza City:

Belgium

Deputy Prime Minister and Foreign Minister Maxime Prévot said that the IPC’s confirmation of famine in Gaza is “not a surprise.”

“It is the tragic consequence of what has been clear for months: an entire population is being pushed into starvation, destitution, and death,” said Prévot. “It is a disgrace that in the 21st century, children are dying of hunger because aid is blocked. In this case, famine is not a natural disaster, it is the result of choices.”

Denmark

The Danish Foreign Ministry shared a statement from Foreign Affairs Minister Lars Løkke Rasmussen, saying: “Over half a million people are affected—more will follow. We repeat: Israel must allow unimpeded, safe, and sustained access for aid and let U.N. and NGOs work.”

Ireland

Irish Taoiseach (Prime Minister) Micheál Martin called the famine declaration “entirely predicated and preventable.” 

“The withholding of food and water from civilians is collective punishment of the people of Gaza, and is a war crime,” Martin said, calling for a stop to Israel’s expansion of its military operations.

Tánaiste Simon Harris (Ireland’s Deputy Prime Minister) said “the heartbreaking and devastating scenes in Gaza cannot be ignored. It is sickening and despicable.”

“People in Ireland and across the world will not turn a blind eye,” Harris added, before calling for a review into trade agreements between the European Union and Israel.

Read More: The Tragedy Unfolding in Gaza

Saudi Arabia

Saudi Arabia’s Foreign Ministry voiced “deep concern” over the IPC’s report, stating that “the worsening humanitarian catastrophe in Gaza is a direct result of the absence of mechanisms to deter and hold accountable the repeated crimes of the Israeli occupation.”

The Ministry went on to call the famine “a stain on the international community.”

Slovenia

Deputy Prime Minister Tanja Fajon referred to famine as the “new phase of hell Gaza faces in this man-made catastrophe.”

“Dying because of starvation is a harsh reality for people in Gaza… This has to stop. We need an immediate cease-fire, release of all hostages and full, unimpeded humanitarian access,” urged Fajon.

United Kingdom

U.K. Foreign Secretary David Lammy said the confirmation of famine in Gaza City “is utterly horrifying and is wholly preventable.”

He called the humanitarian situation a “moral outrage,” citing the Israeli government’s “refusal to allow sufficient aid into Gaza.”

“The Israeli government must allow the U.N. and international NGOs to carry out their life-saving work without obstruction. Aid must reach those in need urgently and without delay,” concluded Lammy.

First Minister of Scotland, John Swinney, also responded to the declaration of famine. 

“Families and children are dying of starvation… There must be an immediate cease-fire, urgent aid into Gaza, and sanctions on Israel,” he said, referring to the situation as “genocide in plain sight.”

United Nations

U.N. Secretary-General António Guterres called the famine in Gaza a “man-made disaster” and a “failure of humanity itself.”

“People are starving. Children are dying. And those with the duty to act are failing. As the occupying power, Israel has unequivocal obligations under international law—including the duty of ensuring food and medical supplies of the population,” he said.

U.N. Human Rights Chief Volker Türk called Gaza’s famine a “war crime” and said Israel “has unlawfully restricted the entry and distribution of humanitarian assistance and other goods necessary for the survival of the civilian population in the Gaza Strip.”

The Israel-Hamas war

The Israel-Hamas war started after Hamas launched a terror attack on Israel on Oct. 7, 2023, killing over 1,200 people and taking around 250 hostages. Over 62,000 Palestinians have been killed since the start of the war, including 273 adults and 112 children that have died of starvation and malnutrition, according to Gaza’s Health Ministry.

In the absence of independent monitoring on the ground, the ministry is the primary source for casualty data relied upon by humanitarian groups, journalists, and international bodies. Its figures do not differentiate between civilians and combatants and cannot be independently verified by TIME.