TEL AVIV, Israel (AP) — The head of the United Nations World Food Program says northern Gaza has entered “full-blown famine” after nearly seven months of war between Israel and Hamas. But a formal, and highly sensitive, famine declaration faces the complications of politics and of confirming how many people have died.

Cindy McCain in an NBC interview broadcast Sunday said severe Israeli restrictions on humanitarian deliveries to the territory that has long relied on outside food assistance have pushed civilians in the most isolated, devastated part of Gaza over the brink. Famine was now moving south in Gaza, she said.

A WFP spokesman later told The Associated Press that one of the three benchmarks for a formal famine declaration has already been met in northern Gaza and another is nearly met — important details on how far the effort to document deadly hunger has progressed.

Israel faces mounting pressure from top ally the United States and others to let more aid into Gaza, notably by opening more land crossings for the most efficient delivery by truck. Aid groups say deliveries by air and sea by the United States and other countries cannot meet the needs of Gaza’s 2.3 million people, a growing number of them reaching the stage of malnutrition where a child’s growth is stunted and deaths occur.

Famine had been projected in parts of Gaza this month in a March report by the Integrated Food Security Phase Classification, a global initiative that includes WFP as a partner. It said nearly a third of Gaza’s population was experiencing the highest level of catastrophic hunger, and that could rise to nearly half by July.

The next IPC report is expected in July. Israel strongly rejects any claims of famine in Gaza, and its humanitarian agency called McCain’s assertion incorrect. A formal declaration could be used as evidence at the International Criminal Court as well as at the International Court of Justice, where Israel faces allegations of genocide in a case brought by South Africa.

Here’s what we know about famine and the hunger crisis in Gaza.

According to the IPC, an area is considered to be in famine when three things occur: 20% of households have an extreme lack of food, or essentially starving; at least 30% of children suffer from acute malnutrition or wasting, meaning they’re too thin for their height; and two adults or four children per every 10,000 people are dying daily of hunger and its complications.

In northern Gaza, the first condition of extreme lack of food has been met, senior WFP spokesman Steve Taravella told The Associated Press. The second condition of child acute malnutrition is nearly met, he said. But the death rate could not be verified.

Doing so is difficult. Aid groups note that Israeli airstrikes and raids have devastated medical facilities in northern Gaza and displaced much of the population. Along with restrictions on access, they complicate the ability to formally collect data on deaths.

A document explaining famine published in March by the IPC noted, however, that an area can be classified as “famine with reasonable evidence” if two of the three thresholds have been reached and analysts believe from available evidence that the third likely has been reached.

“The bottom line is that people are practically dying from a lack of food, water and medicines. If we are waiting for the moment when all the facts are in hand to verify the final conditions to scientifically declare a famine, it would be after thousands of people have perished,” Taravella said.

Shortly after Hamas attacked Israel on Oct. 7, Israel sealed its borders with Gaza and for weeks prevented aid from entering. Aid groups have said assistance since then has been restricted to a trickle far below the 500 trucks of aid that entered before the war. Since March, as Israel has pointed to progress, an average of 171 trucks per day have entered Gaza, according to the U.S.-established Famine Early Warning Systems Network.

Once inside Gaza, food and other aid doesn’t always reach the most vulnerable. Aid groups say access is limited, particularly in the north, due to ongoing fighting and a chaotic security situation.

Northern Gaza, including Gaza City, was the first target of Israel’s invasion and became the epicenter of the hunger crisis, with many residents reduced to eating animal feed and foraging for weeds. The IPC report in March said around 210,000 people in the north were in catastrophic levels of hunger.

The very young, the very old and those with health problems are the most affected. On Sunday, a 6-year-old from northern Gaza with cystic fibrosis was taken to the United States on a humanitarian flight after his mother made a video pleading for help. Fadi Al-Zant’s jutting ribs and thin arms showed advanced malnutrition.

Humanitarian groups say it will be difficult to deliver life-saving aid without a cease-fire. Even with a pause in fighting, some experts say the situation in northern Gaza will have life-lasting consequences, especially for newborns and pregnant women.

While Israel has allowed more aid in recent weeks under international pressure, a humanitarian official for the U.S. Agency for International Development told the AP that since March, northern Gaza has not received anything like the aid needed to stave off famine. USAID made the official available on condition of the official’s anonymity, citing security concerns over his work in conflict.

Secretary of State Antony Blinken has welcomed Israel’s recent steps to increase deliveries but stressed such moves must be sustained. That’s not easy. Israel on Sunday closed its main crossing point for delivering aid after a Hamas attack killed soldiers.

Some Palestinians say the increase in aid has eased things slightly, especially by lowering the cost of food.

Gaza City resident Said Siam said prices have dropped in recent weeks. Still, the 18-year-old said he and family members have each lost at least 10 kilograms (22 pounds) since the start of the war, mostly eating one meal of pumpkin soup each day. Fruits, vegetables and fresh meat are still scarce.

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Knickmeyer reported from Washington.

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