U.S. Secretary of State Antony Blinken embarked on a Middle East mission on Wednesday as strain showed in the relationship between President Joe Biden's administration and the government of Israeli Prime Minister Benjamin Netanyahu.
In Gaza, where hopes were dashed for a ceasefire in the nearly six-month-old war in time for Ramadan last week, residents of Gaza City in the north described the most intense fighting for months around the Al Shifa hospital.
Israel claimed to have killed 90 gunmen in a battle under way there for a third day; Hamas denied fighters were present and said those killed in the hospital were civilians.
Blinken was due in Saudi Arabia on Wednesday and Cairo on Thursday to talk to regional leaders about efforts to secure a truce. In Saudi Arabia, he was expected to meet the ruling crown prince, Mohammed bin Salman.
Unusually, no stop in Israel was announced at the outset of his trip, and Israel's foreign ministry said on Tuesday it had not been notified to prepare for one.
A U.S. State Department official did not immediately respond to a request for comment on whether a stop in Israel might be added to the itinerary later. Blinken has visited Israel on each of his five previous visits to the region since the war began.
Recent days have seen an intensification of fighting in northern parts of Gaza captured by Israeli forces early in the war, including Al Shifa, once Gaza's biggest hospital, now one of the few even partially functioning in the north.
"We are living through similar dreadful conditions to when Israeli forces first raided Gaza City: sounds of explosions, Israeli bombardment of houses is non-stop," Amal, 27, living around a kilometre from Al Shifa hospital, told Reuters via a chat app.
The Israeli prime minister on Tuesday rebuffed a plea from Biden to call off plans for a ground assault of Rafah, the city on the southern edge of Gaza sheltering more than half the enclave's 2.3 million people.
Netanyahu told lawmakers he had made it "supremely clear" to Biden in a phone call "that we are determined to complete the elimination of these battalions in Rafah, and there's no way to do that except by going in on the ground".
Israel says Rafah is the last major holdout of armed fighters from Hamas. Washington says a ground assault there would be a "mistake" and cause too much harm to civilians.
More than a million Gazans, ordered into Rafah earlier in the war by advancing Israeli forces, have nowhere further to flee. Israel says it has a plan to evacuate them.
The public tension between the Biden and Netanyahu administrations has little precedent in Israel's history, with the U.S. a close ally since its founding in 1948. Last week, Chuck Schumer, leader of Biden's Democratic Party in the Senate and the highest-ranking Jewish U.S. elected official, called for Israelis to replace Netanyahu. Biden called it a "good speech".
Long-running ceasefire talks have resumed this week in Qatar after Israel rejected a counter-proposal from Hamas last week. Both sides have discussed a truce of around six weeks during which Hamas would release around 40 Israeli hostages in return for hundreds of Palestinian detainees.
But despite months of talks mediated by the United States, Egypt and Qatar, they still differ on what would follow any truce. Hamas says it will release hostages only as part of an agreement that would end the war; Israel says it will discuss only a temporary pause.
The war began on Oct. 7 when fighters from Hamas, which controls the Gaza Strip, rampaged through Israeli towns, killing 1,200 people and capturing 253 hostages, according to Israeli tallies. Nearly 32,000 Palestinians have been confirmed killed since, according to Gaza health authorities, with thousands more dead feared lost under the rubble.
The international hunger monitor, relied on by the United Nations, warned this week of mass death from famine in Gaza without an immediate ceasefire. Israel says it is letting food in through more routes by land, sea and air, and blames aid agencies for failing to distribute it; they say Israel must provide better access and security.
