Humanitarian workers and government officials working to deliver urgently needed aid for Gaza say a clear pattern has emerged of Israeli obstruction, as disease and near-famine grip parts of the besieged enclave.

The Israeli agency that controls access to Gaza for the multi-billion-dollar aid effort has imposed arbitrary and contradictory criteria, according to more than two dozen humanitarian and government officials interviewed by CNN.

CNN has also reviewed documents compiled by major participants in the humanitarian operation that list the items most frequently rejected by the Israelis. These include anesthetics and anesthesia machines, oxygen cylinders, ventilators and water filtration systems.

Other items that have ended up in bureaucratic limbo include dates, sleeping bags, medicines to treat cancer, water purification tablets and maternity kits.

Israel’s throttling of aid came into sharper focus Thursday when its military opened fire as desperate Palestinians gathered around food aid trucks in western Gaza City, according to eyewitnesses. This triggered panic and some people were shot while others were plowed by trucks whose drivers tried to flee, eyewitnesses say. At least 112 Palestinians were killed and hundreds more were injured, according to health officials. The IDF said it had fired warning shots to disperse a crowd after seeing that people were being trampled.

A White House readout of a phone call between US President Joe Biden and Qatari Emir Tamim al-Thani on Thursday said both leaders agreed the horrific event underscored “the urgency of bringing negotiations to a close as soon as possible and expanding the flow of humanitarian assistance into Gaza.”

US Senator Chris Murphy said the situation was “a result of the complete breakdown in social order in Gaza, which is spiraling out of control without a massive influx of humanitarian aid and a pause in the fighting.”

For months, queues of trucks bound for the enclave have been backed up along the highway leading from the Egyptian town of Arish, a major logistical hub for aid, to the Rafah crossing with Gaza. In a satellite image from February 21, a queue of trucks can be seen stretching out for 4 miles from the crossing.

Across the border, Israel’s bombardment edges closer to some two million people hemmed in between the southern Gazan city of Rafah and Egypt’s frontier. Further north, at least six children have died in hospitals in recent days from dehydration and malnutrition, according to Gaza’s health ministry.

“While there’s a war being fought in Gaza, we are fighting a different war here,” said one humanitarian worker at Egypt’s Rafah crossing with Gaza. “It is a war to bring humanitarian aid to Gaza.”

Most of CNN’s sources requested anonymity for fear, they said, of reprisals and further Israeli restrictions on an already choked aid pipeline.

Several sources said a substantial portion of the donations they handled were either rejected or held up by a long wait for clearance by Israel’s Coordinator of Government Activities in the Territories, or COGAT, which manages the flow of aid into the strip.

“It is perfectly engineered chaos,” said one CNN source who oversees donations from four different relief organizations at one of the transit routes. Over 15,000 tons of their relief supplies await Israeli approval to enter Gaza, the source said. More than half consists of food items.

“It’s deliberately opaque, deliberately ambiguous,” said another senior humanitarian official. “You can receive clearance from COGAT and arrive to find police or finance and customs officials who will send the truck back.”

COGAT has not yet responded to CNN’s request for comment on the findings of its investigation.

COGAT insists that it facilitates the delivery of humanitarian aid. In a post Thursday on X, formerly known as Twitter, it said: “There is no limit to the amount of aid that can enter Gaza.”

Israel has long barred certain items from entering Gaza. In 2007, it imposed a blockade on the strip after Hamas took over. A year later, COGAT released a list of banned “dual use” items, making slight modifications to the document in the years that followed.

These are goods which, it said, could be repurposed for military use and would be barred from entering Gaza, such as concrete, agricultural fertilizer, certain chemicals and other miscellaneous items like binoculars, underwater cameras and water skis.

But those criteria appear to have been abandoned in the aftermath of Hamas’ brutal October 7 attack on Israel, which left about 1,200 people dead and over 250 people held hostage, according to Israeli authorities.

The Israeli military responded with an intensive air, sea and land assault on Gaza that has sent the death toll soaring to over 30,000 people, according to Gaza’s health ministry, devastating most of the strip’s buildings and houses, as well as large swathes of its commercial sector and farmlands.

In a January 13 press conference, Israeli Prime Minister Benjamin Netanyahu boasted about permitting “minimal humanitarian aid” to enter Gaza.

“We provide minimal humanitarian aid,” Netanyahu said. “If we want to achieve our war goals, we give the minimal aid.”

The international community has repeatedly criticized Israel for issuing insufficient permits, and security clearances, for aid trucks to Gaza. There have also been instances where the Israeli military struck food deliveries. Looting by desperate civilians and criminal gangs in some of the hardest hit areas in the north of Gaza has intensified that crisis, bringing UN food deliveries there to a grinding halt.

Exacerbating the situation is an apparent ghost list impeding the delivery of a wide range of items.

“I’ve never seen a supply chain that ought to be so simple be so complicated,” said Save the Children US president and chief executive Janti Soeripto. “The level of barriers being put in place to hamper humanitarian assistance; we’ve never seen anything like it.”

Soeripto, who visited the Egyptian side of the Rafah crossing with a UN convoy in January, told CNN she saw several items that Israeli inspectors had turned back.

She said toys were rejected because they were in a wooden box rather than a cardboard box, sleeping bags were denied because they had zippers, and sanitary pads were turned back because a nail clipper was included in the hygiene kit.

In January, US Senators Chris Van Hollen and Jeff Merkley saw maternity kits and water filtration systems among the items Israel turned back from its inspection point in Nitzana.

“In no rational world could (these) be deemed dual use or any kind of military threat,” Van Hollen told CNN weeks after his trip to Egypt’s side of the Rafah crossing.

“We learned that when a truck with just one of those items is turned down, the entire truck gets turned around and has to go back to the beginning of the process, which can take weeks,” Van Hollen said.

“We talked to the heads of international aid organizations that had been working in conflicts worldwide for decades,” the senator added. “They said they’d never seen a more broken system.”

The situation prompted Van Hollen to spearhead US congressional efforts to hold Israel accountable for its handling of humanitarian aid, which he described on the Senate floor earlier this month as a “textbook war crime.”

Israel’s elusive guidelines on restricted items

Publicly, COGAT claims that it has abided by its 2008 banned items list. In private, COGAT has said that that document is now obsolete, according to a humanitarian official in direct contact with the Israeli unit.

COGAT enforced the 2008 list when the war first erupted on October 7, the official said. “About three weeks in, they said that list is not valid for this response. This is a different context. They said ignore the list.”

CNN’s weeks long investigation has documented multiple examples of the erratic process that followed, with officials sometimes falling back on the 2008 guidelines and other times citing them as redundant.

In one instance on February 14, COGAT rejected a truck-load of sleeping bags “because they were the color green, and green means military and according to the 2008 list, military is dual use,” the same humanitarian official told CNN.

“No one can argue that sleeping bags are going to win a war,” the official said. “We did push back on that and warned them that it would look pretty silly if this got out.”

Four sources described another incident when Israel rejected a shipment of dates – a rich source of nutrients desperately needed by a hungry population. Two of the sources said it was because the seeds were picked up as a suspicious object in the x-ray inspection imaging.

Other trucks carrying dates have been allowed into Gaza, according to UN data. But humanitarian workers have said they are worried about a repeat, and several have resorted to pitting dates prior to inspection.

Donations must pass two COGAT hurdles before entering Gaza. Aid organizations must first get clearance for their shipments from COGAT, then the trucks must clear Israeli inspection points. Items have been rejected at both of those stages, according to CNN’s sources.

COGAT provides a range of reasons for these denials. Sometimes it cites bureaucratic issues, such as an incorrect manifest, other times the items are in whole or in part deemed to be dual use, sources said. Some of the reasons provided to humanitarian organizations appeared to be expressly political. Most of the time, COGAT doesn’t provide a reason for the rejections at all.

“Where do you draw the line?” one humanitarian source involved in the aid operation told CNN, referring to Israel’s elusive criteria on dual use items.

The confusion prompted Israeli rights group GISHA to file a Freedom of Information Act request on February 7 asking the Israeli government to release details of any new restrictions on aid imposed since October 7.

“At the moment, there is very little transparency about the policy and procedures by which the government is operating,” Tania Hary, executive director of GISHA, told CNN. “We believe that Israel, as an occupying power in Gaza, has an obligation to provide for the civilian population’s needs in the strip.

“The Israeli public has a right to know what is being done in its name in Gaza.”

Anesthetics, crutches and other ‘frequently rejected items’

CNN has obtained documents from three major participants in the humanitarian operation that list what they called the “most frequently rejected items.” Among them are essential medical supplies: anesthesia machines and anesthetics, crutches, generators, ventilators, x-ray machines and oxygen cylinders.

For doctors and patients inside Gaza, the implications are excruciating. There are numerous reports of preventable deaths for lack of oxygen and ventilators. Over 1,000 children have undergone leg amputations in Gaza, according to UNICEF, some without anesthesia. That figure was compiled by UNICEF at the end of November and has not been updated since.

One doctor, Hani Bseiso, amputated his 17-year-old niece’s leg with a kitchen knife in his home, using only the clothes on his back to stop the bleeding and dish soap to clean her wounds. “An Israeli tank missile hit her when she was on the sixth floor of our building,” Bseiso told CNN. “I didn’t know what to do. I didn’t have anesthesia or any kind of medication.”

“There was no anesthesia. My anesthesia was the Quran which I was reciting,” the niece, Ahed Bseiso, later told a journalist working with CNN in Gaza. The amputation, carried out on her uncle’s dining table, was filmed and shared widely on social media.

“He brought the kitchen knife and cut my leg off with it. And in that moment, I said praise be to God. Because he brought me patience.”

Medicines in Gaza began to run out shortly after the war erupted on October 7. Injuries from intensive bombardment skyrocketed while Israel stifled aid deliveries.

“Towards the end of my 43 days in Gaza, we had run out of anesthetic, and we were doing procedures with no anesthetic at all,” said British-Palestinian surgeon Dr. Ghassan Abu-Sittah from his clinic in London, two months after his return from Gaza.

“We were having to do extremely painful cleaning procedures to stop wound infections on children with no anesthetic and no analgesic.”

In the absence of appropriate medical supplies, Abu-Sittah concocted a solution to fight infection: dish soap mixed with vinegar and saline.

“I would pour that over the wound and scrub the wound down,” Abu-Sittah said. “It was probably the darkest moment of my life. The child was screaming. The parent was crying, and you’re trying to just block all of this out and do it as quickly as possible.

“But knowing that if you hadn’t, that child would be dead by the end of the day.”

Another humanitarian source inside Gaza said that in early February he witnessed a six-year-old child with burns covering 40% of her body. She was at a hospital in Rafah, the best supplied population center in Gaza, where medics could only give her aspirin to ease her agony.

Another woman, Um Adel, said her granddaughter died due to a lack of oxygen at a hospital in the southern Gazan city of Khan Younis.

“We were in Khan Younis. We couldn’t sleep during the day or the night because of the bombardment,” she told another journalist working with CNN in Gaza. “My granddaughter died because she was ill and there was no oxygen or any kind of medication for her. May her soul rest in peace.”

Israel’s restrictions have also impacted medicines for the chronically ill. For weeks, COGAT temporarily prevented insulin pens for children with diabetes from entering Gaza, according to the UN Humanitarian Coordinator for Palestine Jamie McGoldrick and one other source.

“On the goods that are being prohibited, it’s a full range,” said McGoldrick in a January 24 press conference. “Some of it is medical material such as basic drugs and material for treating not just trauma but for chronic illnesses.

“One example would be most recently the pens that are used for insulin for children,” he added. “In terms of the rationale for it, I really can’t explain it because I don’t know.

“These are essential commodities for us to address the emergency which is currently unfolding in a very dramatic fashion.”

Another source told CNN that in February COGAT reversed its decision to bar insulin pens from entering Gaza. CNN’s research also found examples of goods considered to be “frequently rejected items” being green-lit by COGAT – such as on January 3 when the World Health Organization said it brought in anesthesia supplies. But sources have stressed that these instances are rare.

At one of the waypoints of aid in Jordan, stacked boxes of donations extend for around eight miles, a backlog that would require around a thousand trucks to deliver, Jordan’s charity officials estimate.

The director of programs and planning for the Jordanian Hashemite Charity Organization (JHCO), Marwan al-Hennawy, slits open a box of food to show what should be reaching people in Gaza; this one contains rice, chicken stock, tuna and dates. It is enough to feed a family of five for two weeks.

Behind him are dozens of wheelchairs wrapped in dusty plastic. “We have 220 wheelchairs and we’ve been trying to get them in since the start of the war,” he told CNN during a rare tour of the warehouses of aid meant for Gaza.

Al-Hennawy scans the sea of boxes around him. “It’s painful to look around and see all this,” he says. “I feel like I’m trapped. I know Gazans desperately need this help but I can’t get it to them. It’s like a nightmare.”