Nisreen and her 13-year-old twin sons evacuated their house in Abasan, Gaza, during the recent 50-day conflict with Israel - and returned to rubble.
"We found our house had been bombed and bulldozed. We couldn't even see where it used to be. My sons were so shocked, so sad," says Nisreen. "We lost everything."
She and her sons now live with her mother in a one-room building, where a sheet of corrugated iron covers a large hole in damaged wall.
But that's not what worries Nisreen most. What worries Nisreen is the cancer diagnosed in her spine in March, a likely metastasis of the breast cancer she fought in 2008. Nisreen needs treatment that is unavailable in Gaza, but she doesn't know when - or if - she will be granted access to travel to Jerusalem for radiotherapy that could save her life.
Each month more than 1,500 Gaza patients travel to the West Bank, East Jerusalem, Israel, or Egypt to receive specialized medical treatment in oncology, ophthalmology, heart surgery, and other tertiary services not available in Gaza. Of those who apply for travel permits, nine in ten are approved, some delayed and some denied altogether. But during the recent conflict, the percentage of successful applications dropped significantly, and has still not returned to pre-conflict levels.
Earlier this year, her doctor referred her for an isotope scan in the West Bank, and initially she was refused a permit to travel. But the Palestinian Centre for Human Rights advocated for her, and she was eventually granted permission.
Now her doctor in Gaza says she urgently needs radiotherapy. At the moment she is waiting to see if she will be approved for financial coverage from the Ministry of Health, which she needs before she can even apply for her travel permit.
"I'm worried about if I will get financial coverage, and if I will get the permit," Nisreen says. "And I'm worried about my cancer."
While she waits, her condition deteriorates. "I take tramadol [pain relief], but it's not helping anymore," she says. "It's hard to sleep. It hurts to lie on my back; it hurts to lie on my side."
Nisreen was first diagnosed with breast cancer in 2008, when she was in her early 30s. She had a mastectomy in Gaza, but her chemotherapy appointments were often delayed due to the drugs being out of stock. In late 2008 she was referred to Egypt for follow-up radiotherapy, which is not available in Gaza. However, she was initially sent to a triage medical center near the border where radiotherapy was not available, and had to convince a doctor to refer her to Cairo where she stayed for six weeks, eventually receiving 20 sessions of radiotherapy.
Now Nisreen is sick again she is fearful her sons face an insecure future. "After the conflict, there's a lot less charity to go around because there are now so many orphans," she says.
World Health Organization advocates for patients' unrestricted access to medical care, and monitors delays and denials of patients' permits to travel, as well as the impact on their health. WHO also provides support to the operations of the Referral Abroad Department. Beyond this, WHO is working to improve the health system in Gaza, so more patients have unimpeded access to life-saving treatments.