Most of the estimated 1.5 million Palestinians who live in the Gaza Strip rely on aid distributed by international organizations.
But aid workers in Gaza say they are facing increasing pressure from two sides. Israel's security cordon around Gaza restricts access and limits the flow of food and medicine. And the militant group Hamas, which rules Gaza, is trying to exert its authority over aid distribution.
On a recent afternoon at a U.N. food distribution center in Gaza City, men and women load sacks of food onto donkey-drawn carts.
Ibtihal Doulash, 75, says she receives flour, cooking oil, sugar and other essentials. With seven children and more than 40 grandchildren, she says, her family would starve without the regular rations.
"We need this because there is no work here. The Egyptian border is closed. The Israeli border terminals are often closed. And there is no work in the Gaza Strip. It's only this food that gives us some help so we can survive," she says.
Delivering Aid To Gazans More Difficult
At least 85 percent of Palestinians in Gaza receive some kind of aid from international donors. The United Nations is the largest donor, but other organizations also provide help.
Charity officials say getting aid to Gaza residents has always been challenging, but the situation has gotten worse.
Israel says it allows more than 100 truckloads of humanitarian aid enter Gaza every day.
But aid organizations complain that what can be brought in is determined arbitrarily by Israeli authorities. One group says that one day it was stopped from bringing in catheters, the next day it was lentils. No reason was given as to why the items were banned.
"Rules and regulations have changed and many of them are not written, so we can't pre-plan," says Bill Corcoran, president of the nonprofit organization American Near East Refugee Aid. "We're finding that even though we had an assumption of something being permitted to enter through the port, suddenly when it arrives at the port, it is not. As a result, the processing time has stretched from two weeks to three months almost. So we are rather stuck."
Hamas Puts New Pressure On Aid Groups
Adding to those constraints are new demands from Hamas, which controls Gaza. Some charities say that Hamas is trying to use aid distribution to its political advantage.
Hamas displaced the rival Fatah faction of Palestinian Authority President Mahmoud Abbas as the governing power in Gaza after Hamas won elections in early 2006. Hamas later took full control of the territory after fierce street fighting with Fatah militias.
Speaking off the record for fear of retribution against local staff, some foreign aid workers say they are being asked to provide Hamas with recipient lists, staff salaries and locations of distribution centers. They worry that Hamas is trying to bolster its standing in Gaza by influencing the distribution process.
One aid organization said its offices were visited six times in a month by Hamas officials, and on one occasion those officials were armed.
Several of the nongovernmental organizations, or NGOs, have received letters giving them a deadline to formally register their presence with the Hamas government in Gaza.
But Hamas is considered a terrorist organization by the United States and the European Union.
Michael Bailey of the British charity Oxfam says many American and European aid groups are not allowed to deal with Hamas directly.
"European law makes it quite clear that we may not do anything that directly benefits Hamas, because Hamas is a terrorist organization on the list. That is why we are very careful that the aid that we are delivering is going to people in need," Bailey says.
A spokesman for Hamas' interior ministry denied allegations that they were putting unfair pressure on aid groups. He said Hamas will not try to interfere in their operations.
But Hamas spokesman Ihab al-Ghusain says that NGOs must be registered with the Hamas authority by the end of the month or there will be consequences.
"There will be some legal action against those who aren't licensed. It might be a warning or we might have to ask them to shut down that office," he says.
That would be disastrous for innocent Palestinians who rely so much on international aid, Corcoran says.
"And in many countries, all we ask for is to be left independent, left alone to act as professionals in humanitarian relief and development and that's not happening right now from either side," Corcoran says. "We are caught in a horrible location right now."