Israeli tanks moved deeper into Rafah in the southern Gaza Strip on Tuesday, pushing closer to the dense urban centers President Biden has warned Israel against invading, and prompting one of the largest civilian exoduses of the seven-month war.

Local reporters, a witness, and the Reuters news agency, citing residents, said Israeli forces had entered the neighborhoods of al-Jneina, al-Brazil and al-Salam – all in the eastern part of Rafah but well within its city limits.

The Israel Defense Forces said in a statement that it was continuing operations against “terror targets” in eastern Rafah, without specifying the exact locations. The Biden administration said Tuesday that it does not take issue with the current operation.

“When we talk about a Rafah operation that we would take issue with, we’re talking about an operation that is major, that is a direct invasion into Rafah that is targeting and invading into the urban and dense centers,” said State Department spokesman Vedant Patel.

Nearly 450,000 people have fled Rafah over the past week, after Israel started its incursion, according to UNRWA, the U.N. Relief and Works Agency for Palestinian refugees. The border city’s population had swelled from about 275,000 to well over 1 million during the course of the war, as civilians sought refuge there from fierce fighting elsewhere in the territory.

Aid workers in Rafah, which borders Egypt, said Tuesday that streets in the eastern part of the city were deserted. Thousands of tents used to house the displaced had disappeared, their footprints still outlined by soot from the fires families burned to heat water and keep warm.

Israel has framed its plans to attack Rafah as necessary to its goal of eliminating Hamas, a grass-roots political and military organization that controlled Gaza for nearly 17 years. For months, the Biden administration has said it would not support an invasion of Rafah without a credible plan to protect and evacuate civilians.

But Israel made no effort to address those concerns, and now aid groups say the operation is compounding an already sprawling humanitarian crisis – the worst many veteran relief officials say they have seen in decades.

With much of the enclave facing mass starvation – and famine underway in the north – the U.N. humanitarian affairs office said Monday that the military escalation had reversed efforts to scale up food deliveries, as well as nutrition interventions primarily targeting children.

More than 35,000 Palestinians have been killed in the conflict, according to the Gaza Health Ministry, which does not distinguish between civilians and combatants but says the majority of those killed are women and children.

Most families across Gaza have been forced to leave their homes, or have been displaced multiple times.

“The difference with this displacement is that people are just so tired,” said Louise Wateridge, a spokeswoman for UNRWA. “We’re seeing this sense of helplessness and hopelessness that is consuming.”

Reached by phone in central Gaza, Salma Kaddomi, 33, said that her family recently fled Rafah, moving for the 12th time since the war began and leaving her elderly father sleeping on the floor of a tent.

“I am angry at everything,” she said. “There is no safety anywhere. We’ve returned back to the same place we were before we left to go to Rafah.”

Earlier in the war, hundreds of thousands of people fled Israeli bombardment in northern Gaza. But now, as another exodus is underway, there is little to no food or fuel, people have long ago exhausted their resources and there are fewer spaces for the displaced to set up their tents.

People are deciding where to run on a “family-by-family basis,” Wateridge said Tuesday.

In an interview with NBC this weekend, Secretary of State Antony Blinken conceded that even a full-scale Israeli assault would probably fail in its stated goals. Hamas fighters have already regrouped in areas Israel declared free of the militants, including in the north, and U.S. and regional officials have struggled to come up with a coherent plan for who would govern Gaza after the war.

In Rafah, the city’s threadbare health-care network has essentially collapsed, with clinics shuttering, staff evacuating hospitals in a panic, and doctors being forced to choose between showing up to treat the wounded or helping their own families find refuge.

The French medical charity group Doctors Without Borders said Tuesday that it was forced to withdraw its staff from Rafah’s Indonesian Field Hospital.

The organization “has seen a pattern of systematic attacks against medical facilities and civilian infrastructure since the beginning of the war,” it said in a statement. “In light of this, as well as the advancing offensive, we have made the difficult decision to leave Rafah Indonesian Field Hospital at a time when people’s medical needs are great.”

In the nearby European Hospital, the largest still open in southern Gaza, medics said the workforce was heavily depleted, and the doctors who remained were often visibly traumatized.

“In the ICU, the monitors are constantly bleeping. Medications are running out on infusion pumps and it’s being missed because there’s not enough nurses per patient,” said Mohammed Abdelfattah, a Palestinian American critical care doctor from Southern California who traveled on a medical mission to Gaza.

A clearly marked U.N. convoy traveling from Rafah to the European Hospital was attacked Monday, the United Nations said, killing an Indian staff member and injuring another employee. The United Nations informed Israeli authorities of the convoy’s movement, spokesman Rolando Gomez told reporters in Geneva on Tuesday.

In a statement, the IDF said it had “not been made aware” of the vehicle’s planned route.

Nearly 200 aid workers have been killed since the start of Israel’s military operation, many of them in Israeli airstrikes or shelling. The conflict began on Oct. 7, after Hamas attacks killed some 1,200 people in Israel.

The IDF said Tuesday that it had carried out an overnight strike in the Nuseirat refugee camp in central Gaza, killing 15 “operatives from terrorist organizations.”

Gaza’s civil defense force, however, said that at least 21 people were pulled from the rubble, and that rescue operations were ongoing, because the force had only a single bulldozer.

Nassar Al-Ghariz, a spokesman for the civil defense in central Gaza, said two Israeli strikes were launched overnight, hitting a school and a three-story building in which displaced Palestinians had been sheltering.

Fighting has also flared in northern Gaza this week, as IDF troops move back into areas they had previously withdrawn from, citing the reemergence of Hamas fighters there.

On Tuesday, IDF spokesman Rear Adm. Daniel Hagari said that 14 Israeli soldiers were injured in fighting across Gaza, including four who were seriously hurt in a gun battle in the north and a separate blast in the south.

The United Nations’ highest court will hold hearings this week on South Africa’s request that the court order Israel to halt its Rafah offensive and do more to protect civilians in Gaza.

The International Court of Justice said Tuesday that it will hear arguments from South Africa on Thursday and from Israel the next day, the latest twist in a closely watched case. In January, the ICJ ordered Israel to do more to prevent the killing of civilians in Gaza but did not call for a cease-fire, disappointing Palestinians hoping for a reprieve from the violence.

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