When Palestinian preschooler Aisha a-Lulu came out of brain surgery in a Jerusalem hospital room, she called out for her mother and father. She repeated the cry over and over, but her parents never came.
Instead of a family member, Israeli authorities had approved a stranger to escort Aisha from the blockaded Gaza Strip to the east Jerusalem hospital. As her condition deteriorated, the child was returned to Gaza unconscious. One week later, she was dead.
A photo of Aisha smiling softly in her hospital bed, brown curls swaddled in bandages, drew an outpouring on social media. The wrenching details of her last days have shined a light on Israel's vastly complex and stringent system for issuing Gaza exit permits.
It is a bureaucracy that has Israeli and Palestinian authorities blaming each other for its shortfalls, while inflicting a heavy toll on Gaza's sick children and their parents.
"The most difficult thing is to leave your child in the unknown," said Waseem a-Lulu, Aisha's father. "Jerusalem is just an hour away, but it feels as though it is another planet."
So far this year, roughly half of applications for patient companion permits were rejected or left unanswered by Israel, according to the World Health Organization. That has forced over 600 patients, including some dozen children under 18, to make the trek out of the territory alone or without close family by their side.
The system stems from the Hamas group's takeover of Gaza in 2007; Israel and Egypt responded by imposing a blockade that tightly restricted movement in and out of the strip.
The blockade, which Israel says is necessary to prevent Hamas from arming, has precipitated a financial and humanitarian crisis in the enclave. For years, Gaza's 2 million residents have endured rising poverty and unemployment, undrinkable groundwater and frequent electricity outages. Public hospitals wrestle with chronic shortages of drugs and basic medical equipment.
In what it portrays as a humanitarian gesture to help Gaza's civilians, Israel permits Palestinian patients to seek medical treatment at hospitals in Israel and the West Bank once they pass a series of bureaucratic hurdles. COGAT, the Israeli defense body that issues the permits, says it insists that all patients cross with an escort, usually a close relative, unless they wish to go alone or require immediate treatment that doesn't allow time for security screening.
According to WHO, the approval rate has plummeted in recent years.
It said that in 2012, Israel allowed in 93% of patients and 83% of their companions for treatment. For the month of April 2019, the figure stands at just 65% of patients and 52% of their companions.
A COGAT official disputed the figures, saying they don't take into account that the number of permit applications has grown as Gaza's health care system deteriorates, and that Israel has started issuing permits less regularly but for prolonged stays. The official, speaking on condition of anonymity under agency rules, said COGAT has tried to ease restrictions by designating a permit specifically for parents of child patients.
The agency said it issued 4,000 permits for patient escorts in the first quarter of 2019, including 1,398 for parents of sick children.
After being diagnosed with brain cancer, Aisha received immediate approval to get out of Gaza for what was hoped to be life-saving surgery, but when her parents approached the Palestinian Civil Affairs Commission for escort permits, their process ground to a halt.
To their bewilderment, Palestinian officials told them not to apply, saying it was too risky. At 37, Waseem is below the age that Israel deems acceptable for swift entry on security grounds. Today, all men under 55 require extra screening, which means waiting, usually for months, according to Mor Efrat, the Gaza and West Bank director for Physicians for Human Rights Israel. As for Aisha's mother, Muna, a quirk of her upbringing in Egypt left her without an official Israeli-issued ID card required to receive a permit.
Aisha's parents said they scoured for alternatives, applying for an aunt and her 75-year-old grandmother, but Israel rejected both.
The girl's only remaining hope, the Palestinian office told them, was to apply for as many older women as possible from their extended social network. A permit for Halima al-Ades, a remote family acquaintance whom Aisha had never met, was approved.
Alon Eviatar, a former high-ranking official with COGAT, said the goal remains the same. "On the ground, this means to make daily life as difficult as possible for Hamas, without crossing the red line to humanitarian disaster," he said.
Eviatar acknowledged that the Israeli permit system was ineffective, inefficient and overburdened. "We are desperate for an alternative, to get Gaza to take care of itself and stop relying on Israel," he said.