GAZA: Fuad Skik has been waiting in vain since December for permission from Israel to leave the Gaza Strip for cancer treatments, illustrating a problem that has concerned global health officials.
"At the end of 2016, I asked for an Israeli exit permit and I registered my wife to accompany me, but I still have not received a response," the 53-year-old said, adding that his cancer had since spread.
Palestinian officials say the problem for those in situations similar to Skik's has recently become worse due to an increase in the number of those needing treatment and the slow process of getting permits.
For many, this means delays and for some a refusal means they can't even go.
Israeli authorities say more permits are being granted than in the past and note that careful consideration must be given to each due to security risks.
Israel and Palestinian militants in Gaza have fought three wars since 2008, and Israel tightly controls who and what enters and exits the enclave of some two million people.
It has maintained a blockade on the strip run by Islamist movement Hamas for 10 years.
In recent days, the problem has been further complicated by Hamas also restricting exits for Gazans as it investigates the assassination of one of its officials, a killing it blames on Israel.
The World Health Organization and others have pointed to the effect the Israeli blockade has had on medical crossings, a crucial issue for impoverished Gaza, which lacks proper medical equipment in many cases.
Many patients seek treatment in Israel, and some in the occupied West Bank, the other Palestinian territory separated geographically from Gaza.
Slowed by security
Permission from Israeli authorities is required to cross, and the WHO has in particular highlighted the case of a 17-year-old who died in January while waiting.
According to the WHO, more than 53 percent of nearly 3,000 patients who requested an exit permit in January were refused or did not receive a response.
The number was more than 61 percent for those meant to accompany them.
The Israeli defence ministry unit that oversees such permits says more have been granted than in the past.
According to its numbers, 22,380 patients and those accompanying them were provided permits in 2013, while 30,768 were granted in 2016.
The defence ministry unit, known as COGAT, also alleged there has been "an increase in attempts by Hamas to take advantage of Israeli assistance for terrorist aims," requiring careful scrutiny of applications.
It is a difficult explanation to accept for those legitimately sick and required to wait.
The Gaza Strip does not have the capacity for radiation therapy and lacks chemotherapy drugs.
For those reasons, some six out of 10 cancer patients in Gaza require treatment not available in the enclave, said Mahmoud Daher of the WHO.
Further complicating the problem, cancer rates are seen as rising in the Gaza Strip.
"Every year there are between 1,600 and 1,800 (cases detected), or 20 percent more than in past years," said Khaled Thabet, head of the oncology department at the Rantissi hospital, which treats patients from the northern Gaza Strip.
Teen dies waiting
In 2006, 8,000 Gazans required medical treatment outside the strip, while the number rose to 22,000 in 2016, he said, adding that only 60 percent were able to obtain a permit.
The Palestinian Centre for Human Rights (PCHR) says that it requested 1,040 refused applications in 2016 be re-examined, leading to 418 approvals.
But in the case of 17-year-old Ahmed Shbair, it was already too late.
He died in January after failing to receive permission to exit for treatment for a congenital heart condition, said Mohammed Bseiso, a lawyer with the PCHR.
His family made four requests for permits beginning in November, with he and his mother were interrogated by Israeli authorities, according to the WHO.
Two of the requests were refused, while a third had not been given a response. He applied for a fourth time just before dying, the WHO said.
Some are seeking to provide medical services that Gazans would otherwise seek elsewhere.
Tharwat al-Helou recently opened the first private clinic in the Gaza Strip, with a plan of eventually having 90 beds.
Such clinics could alleviate shortages in the strip, which has slightly more than one bed per 1,000 residents, said Abdellatif al-Hajj, who oversees hospitals for the Gazan authorities.
As an example, the number is five to six times higher in Israel.
But clinics will also face the difficulty of receiving Israeli permission to import equipment due to the country's concerns over "terrorist" activities.