At least 20 people in Gaza have died as a result of malnutrition and dehydration, the Gaza health ministry said Thursday. But that number, which included a 15-year-old and a 72-year-old overnight, reflects only deaths in hospitals, the ministry said; the actual toll is likely far higher.

“We believe that dozens of people die silently as a result of starvation without reaching hospitals,” ministry spokesman Ashraf al-Qudra said.

Hamas said unresolved issues the delegation will discuss with its political bureau include humanitarian aid, the end of fighting and the return of displaced Gazans. Egyptian state media reported talks would resume next week. State Department spokesman Matthew Miller told reporters on Wednesday that he was still optimistic a deal could be reached.

A Hamas official told The Washington Post that the group has rejected Israel’s offer of a six-week truce while it keeps troops in the strip and gets all remaining hostages back. “We want a permanent cease-fire, and we want the withdrawal of the Israeli army from the Gaza Strip,” said the official, who spoke on the condition of anonymity because he was not authorized to discuss ongoing negotiations. A cease-fire that lasts only through Ramadan and the release of the hostages, he said, would leave Gazans without a guarantee for protection after it ended.

The need for more aid has become increasingly urgent. Social media this week has been flooded with images of an emaciated child, Yazan al-Kafarna, who journalists in Gaza say died of malnutrition. Gazans say in videos that they paid money for aid airdropped by the United States, now apparently available on a black market that has emerged in the absence of a body to monitor distribution.

Gaza has long relied on aid. Before Hamas attacked Israel on Oct. 7, killing around 1,200 people and taking 253 hostage, Israeli authorities say, an average of around 500 trucks entered the enclave daily. Israel and Egypt tightened access after the attack, and the number fell to 170 in January and 98 in February.

The increasingly scarce deliveries have come under Israeli fire and been overrun by starving Gazans.

The U.N. World Food Program said this week it was seeking new routes to deliver aid into northern Gaza. The agency deemed its most recent attempt “largely unsuccessful.”

The WFP said a 14-truck convoy headed to the north on Feb. 20 was stopped for three hours at an Israel Defense Forces checkpoint, then rerouted to a different road where it was “stopped by a large crowd of desperate people who looted the food” before its arrival to its destination.

Aid groups say convoys have been attacked and looted in the north, and accused Israeli forces of stopping trucks and targeting police officers who guard the convoys. More than 100 people were killed last week when a crowd descended on a rare aid convoy in Gaza City, one of the bloodiest incidents of a conflict that the health ministry says has killed more than 30,000 Gaza residents. Doctors and eyewitnesses blamed Israeli gunfire; Israeli officials blamed a stampede.

The United Nations has warned that famine in Gaza is “almost inevitable.” Carl Skau, WFP’s deputy executive director, said airdrops are “a last resort and will not avert famine.”

“We need entry points to northern Gaza that will allow us to deliver enough food for half a million people in desperate need,” he said.

Of the 20 people in Gaza known to have died of malnutrition and dehydration, the health ministry reported, 17 were children.