DEIR AL-BALAH, Gaza Strip — One of the last functioning hospitals in the Gaza Strip has emptied in recent days after Israel ordered the evacuation of surrounding areas and hinted at a possible ground operation in a city that has been largely spared throughout the war, officials said on Monday.

Al-Aqsa Martyrs’ Hospital in Deir al-Balah is the main hospital in central Gaza. The Israeli military has not ordered an evacuation, but patients and people seeking refuge there fear it could become involved in fighting or be the target of an attack.

In addition, at least 19 people were killed in Israeli attacks in Gaza City and Khan Younis on Monday, according to local authorities, and fighting between Israel and Hezbollah flared up again across the Lebanese border.

Over the course of the 10-month war, Israeli forces have entered several hospitals in the Gaza Strip and accused Hamas of using them for military purposes. Palestinian health authorities have denied these allegations.

According to the United Nations, Israeli evacuation orders currently apply to around 84 percent of Gaza territory. The United Nations estimates that around 90 percent of Gaza’s 2.3 million residents have been displaced from their homes. Many have been displaced multiple times.

The evacuation orders have reduced the size of the humanitarian zone Israel declared at the start of the war, while pushing more Palestinians into it. Thousands of Palestinian families have crowded into tent camps along the beach, where aid groups say food and clean water are scarce and disease spreads quickly.

The latest available satellite images from PlanetLabs, analyzed by the Associated Press, show an increase in the density of tents along the boardwalk since July 19.

AP reporters saw people fleeing the hospital and surrounding areas on Monday, many on foot. Some pushed patients on stretchers or carried sick children, while others carried bags of clothing, mattresses and blankets. Four schools in the area were also evacuated.

“Where do we get medicine?” asked Adliyeh al-Najjar as she rested outside the hospital gate. “Where should patients like me go?”

Fatimah al-Attar fought back tears as she left the hospital grounds toward the tent camps. “Our fate is death,” she said. “There is no place we can go. There is no safe place.”

The UN Office for Humanitarian Affairs, known as OCHA, said the Israeli military had issued three evacuation orders since Friday for over 19 neighborhoods in northern Gaza and Deir al Balah, affecting more than 8,000 people staying in those areas.

The mission covers an area that includes UN and other humanitarian centers, Al-Aqsa hospital, two clinics, three wells, a water reservoir and a desalination plant, said Jens Laerke, a spokesman for OCHA.

“This essentially turns an entire life-saving humanitarian center upside down,” said Laerke.

Doctors Without Borders, an international aid group with the French acronym MSF, said an explosion on Sunday about 250 meters from the hospital sparked panic and accelerated the exodus.

“For this reason, MSF is considering suspending wound care for the time being while trying to maintain life-saving treatment,” said Platform X.

The hospital said it had treated more than 600 patients before the evacuation order, which applies to residential areas about a kilometer away. About 100 patients are still in the hospital, including seven in intensive care and eight in the pediatric ward.

The Israeli military said it was engaged in operations against Hamas in Deir al-Balah and was working to destroy what infrastructure remained there. It said the evacuation orders were issued to protect civilians and did not include surrounding hospitals or medical facilities. It said it had also informed Palestinian health authorities that the facilities did not need to be evacuated.

Although the army exempted hospitals from previous evacuation orders, patients and others have still fled, fearing for their safety.

The Israeli military said on Monday that its forces had expanded their operations on the outskirts of Deir al-Balah, discovering weapons in a residential building and blowing up a 700-meter-long underground Hamas tunnel.

Local health officials said an Israeli airstrike hit a group of people on the coast of Gaza City, killing at least seven men while fishing.

Another attack hit a vehicle in the Israeli-declared humanitarian zone near the southern city of Khan Younis, killing at least five people, according to a Kuwaiti field hospital where the bodies were taken.

The Israeli military did not immediately respond to a request for comment on the attacks.

On Monday night, an attack hit a house in Maghazi, a refugee camp near Deir al-Balah, killing at least seven people, including four children and a woman, according to hospital records and AP journalists who counted the bodies. Ambulances recovered the bodies and took them to Al-Aqsa Hospital.

The war began on October 7, when Hamas-led militants attacked Israeli military bases and farming communities. The militants killed about 1,200 people, mostly civilians, and abducted about 250 hostages to Gaza.

According to the Gaza Health Ministry, the Israeli retaliatory offensive has killed over 40,000 Palestinians and caused severe destruction across much of the territory. Hamas still holds about 110 hostages, about a third of whom are believed to be dead, after most of the rest were released under a ceasefire last year.

Israel continues to launch attacks on Gaza while the US, Egypt and Qatar try to broker a permanent ceasefire and the release of the remaining hostages. Despite months of high-level negotiations, major gaps remain.

Hospitals repeatedly became battlefields, both literally and in the competing narratives surrounding the war.

The Israeli army has raided several medical facilities since the war began, providing evidence that militants were present in some of them. Medical personnel deny the allegations and accuse the army of reckless disregard for civilians.

Hospitals can lose their internationally protected status if they are used for military purposes. However, any measures taken against them must be proportionate and aimed at protecting the civilian population.

According to the World Health Organization, only 16 of Gaza’s 36 hospitals are partially functional, although they treat victims of Israeli airstrikes on a daily basis. Difficulties in importing and distributing humanitarian aid in Gaza have led to widespread hunger and disease outbreaks, putting additional strain on the health sector.

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Magdy reported from Cairo. Associated Press writer Melanie Lidman in Jerusalem contributed.

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Follow AP’s war coverage at https://apnews.com/hub/israel-hamas-war