The Gaza strip must cope with a drug shortage, even though Israeli and Egyptian officials talk about easing the blockade that has left this crowded enclave effectively isolated since July 2007. A political rift between Hamas in Gaza and Fatah in the West Bank hinders communication and coordination between the two Palestinian health ministries -- adding to the hardships already faced by medical patients inside Gaza.

A remedy is needed for the time lag between placing orders to authorities in the West Bank and the delivery of pharmaceuticals and medical supplies for Gaza's 1.5 million inhabitants, who have lived under siege for years. In the Lancet medical journal I reported that Norwegian diplomats hope to initiate negotiations between Gaza and Ramallah in order to solve this medical crisis through better logistics and monitoring.

Dr. Tone Hegna and Dr. Åse Vikanes, who followed the delivery of 200 pallets of medical supplies from Ramallah to Gaza in early February 2011, confirmed that many drugs and basic disposables remain in short supply, and that a bad situation is made worse by inadequate storage, transport and incineration facilities.

"The situation is heartbreaking," Dr Vikanes said. "Doctors we met were impressive but seemed frustrated. As physicians, we could see that the big challenge was seeing what to do but not being able to do it. Doctors must improvise with what's available or about to expire, and not according to international guidelines. It's so unpredictable. Planning a treatment for cancer is very difficult, for instance. Drug supply is very unstable and there are no backups."

Because of such uncertainties, radiation therapy for cancer would tend to be prescribed inside Gaza even when chemotherapy might be optimal. Dr. Hegna told me she is dismayed because radiotherapy is no longer available in the enclave. New MRI and X-Ray machines, which Israeli authorities fear might be used for terrorist attacks, are in short supply. Israel struggles to balance its security concerns with sensitivity to the medical needs of Palestinians, and Gaza's health ministry referred 1,523 cancer patients through Egypt or Israel in 2010, of whom 165 were children.

Cancer patients at Shifa hospital had received just one or two out of four scheduled chemo treatments and eventually died from the lack of continuity. Oncologists said 100 of 260 cancer patients at Gaza's largest hospital are unable to receive effective treatment because the required combination of several medicines is unobtainable.

The survey conducted by Hegna and Vikanes found that more than one third of these essential pharmaceuticals are missing completely, and barely 7 percent of the remainder exceed two months supply. There's a shortage of sutures, latex gloves, exchange transfusion sets for newborns, and ethyl alcohol.

Four doctors from the Physicians for Human Rights, Israel, on a rare overnight visit to Gaza were appalled that the sole CT machine available in the Nasser Children's hospital has been out of service for months. They reported that new drugs are not in use and that no blood tests were carried out in January because of equipment shortages.

Dr Vikanes warned that the biggest potential threat arises from the treatment of infectious disease. Using up large stocks of expensive advanced antibiotics before they expire rather than prescribing standard antibiotics promotes bacterial resistance that puts the closed society of Gaza at risk. Meanwhile, too many cases of diarrhea, pneumonia and skin infections go untreated.

In order to keep enough drugs in stock, pharmacists at Gazan hospitals sometimes request doctors to reduce a patient's dosage below the recommended levels. Those diagnosed with kidney failure, congenital heart disease, or organ transplant patients drugs suffer disproportionately.

Patient referrals abroad doubled last year, partly due to Gaza's drug shortage, and this hits the Gaza health ministry's budget hard. For example, the antivenom serum to treat a viper's bite would cost a little more than $19. Without it, a referral to hospital outside the enclave becomes essential, at an estimated cost of $832 per night. Vetting a patient's accompanying family members for a permit to use the Erez crossing into Israel costs precious time, too.