DEIR AL-BALAH, Gaza Strip (AP) — Israeli forces opened fire near two aid distribution sites run by the Israeli-backed Gaza Humanitarian Foundation as crowds of hungry Palestinians again sought food, killing at least 10 people, witnesses and health workers said Saturday. The violence came a day after U.S. officials visited a GHF site and the U.S. ambassador called the troubled system “an incredible feat.”

Another 19 people were shot dead as they crowded near the Zikim crossing from Israel in the hope of obtaining aid, said Fares Awad, head of the Gaza health ministry’s ambulance and emergency service.

Nearly a week has passed since Israel, under international pressure amid growing scenes of starving children, announced limited humanitarian pauses and airdrops meant to get more food to Gaza’s over 2 million people. They now largely rely on aid after almost 22 months of war.

But the United Nations, partners and Palestinians say far too little aid is coming in, with months of supplies piled up outside Gaza waiting for Israeli approval. Trucks that enter are mostly stripped of supplies by desperate people and criminal groups before reaching warehouses for distribution.

Experts this week said a “worst-case scenario of famine” was occurring. On Saturday, Gaza’s health ministry said seven Palestinians had died of malnutrition-related causes over the past 24 hours, including a child.

Aid is “far from sufficient,” Germany’s government said via spokesman Stefan Kornelius. The U.N. has said 500 to 600 trucks of aid are needed daily.

Families of the 50 hostages still in Gaza fear they are going hungry too, and blame Hamas, after the militants released images of an emaciated hostage, Evyatar David.

“The humanitarian aid flowing into Gaza, meant to alleviate suffering, must reach Evyatar, Guy and all the other hostages too,” David’s brother Illay told a large rally in Tel Aviv.

Near the northernmost GHF distribution site near the Netzarim corridor, Yahia Youssef, who had come to seek aid, described a grimly familiar scene. After helping carry three people wounded by gunshots, he said he saw others on the ground, bleeding.

“It’s the same daily episode,” Youssef said. Health workers said at least eight people were killed. Israel’s military said it fired warning shots at a gathering approaching its forces.

At least two people were killed in the Shakoush area hundreds of yards from where the GHF operates in the southernmost city of Rafah, witnesses said. Nasser Hospital in Khan Younis received two bodies and many injured.