Israel continues to impede medical care for Gazan patients needing treatment in the West Bank or in Israel
10 February 2022
The healthcare system in the Gaza Strip has been in a state of collapse for years due to Israeli policy. It cannot meet the population's needs due to a shortage of medication, equipment, doctors and professional training. The system is unable to provide residents with a wide range of treatments – including life-saving care. The rounds of fighting in the Gaza Strip in recent years, which have injured thousands, have taxed this crumbling system even further.
Consequently, patients who need medical care that is unavailable in Gaza have to apply for permits to reach hospitals in the West Bank (including East Jerusalem), in Israel or in other countries. Every year, thousands of patients apply to the Israeli authorities for these permits.
Israel is in no rush to approve the requests and grants permits only for treatments it defines as "life-saving", and then only if they are unavailable in Gaza. Many patients whose illnesses do not meet this definition, yet cannot be treated in Gaza, have no recourse but to keep suffering — although the treatment they need is available mere miles away. Patients who do meet Israel’s stringent definition are subjected to a tortuous bureaucratic process that is based on unknown arbitrary criteria, and even then are not guaranteed a permit.
During the coronavirus pandemic, Israel tightened its restrictions even more, permitting patients to leave Gaza only in emergencies. At the same time, the Palestinian Authority (PA) ceased its security coordination with Israel for a certain period, making it even more difficult for patients to leave Gaza. Many refrained from applying in the first place for fear of becoming infected. Israel has since lifted the additional restrictions, and the PA has resumed security coordination. According to figures released by the World Health Organization (WHO), in 2021, 15,466 patients applied to leave the Gaza Strip for medical treatment. More than half of the requests (8,661 or 56%) were for treatment in East Jerusalem hospitals, 30% (4,639) were for hospitals in the rest of the West Bank, and only 14% (2,165) of the applicants sought treatment within Israel.
In the vast majority of cases, the applicants receive a text message a day before their hospital appointment, notifying them whether their request has been approved, denied or is still "under review." Of the requests submitted in 2021, 37% were denied, went unanswered or were "under review." Of the permit requests for minors, 38% (4,145) were denied or went unanswered, as were 24% (2,906) of the requests for patients over 60. Patients who do not receive a permit by the time their appointment arrives must start the process from scratch – schedule a new date with the hospital, obtain a commitment for financial coverage from the PA, and contact the PA Civilian Affairs Department in the Gaza Strip, which forwards the request to Israel via the Israeli District Coordination Office (DCO). Then the waiting begins all over again, running the same risk that that the permit will not be granted in time, if at all.. Given these circumstances, some patients choose not to reapply or forgo requesting an escort – which means that if their request is approved, they have to travel to hospital and undergo the treatment alone.
Israel allows patients to apply for a person to go with them since, by definition, they have life-threatening illnesses that make it difficult to travel alone, especially after treatment. Israel does not make its criteria for approving escorts known, but in the past has usually approved first-degree relatives. Older escorts also appear more likely to be approved – although clearly, elderly persons are less capable of giving patients the help they need. Patients usually have to file a request for an escort more than once, after Israel rejects their application for the suggested escort. This is reflected in WHO figures for 2021: of 18,632 requests for escorts, 60% were denied or left unanswered.
Israel’s policy choices have created the reality of a dysfunctional healthcare system that cannot offer proper care within the Gaza Strip – including life-saving treatments. Although the needed care is available mere miles away, the Israeli authorities hinder patients’ access to it by means of a tortuous, arbitrary bureacracy that often seals their fate.
B'Tselem field researcher Olfat al-Kurd collected testimonies from patients who cannot receive the treatment they need as Israel has not replied to their requests to travel to hospital in the West Bank. These are their stories:
In a testimony she gave on 14 November 2021, Fatmeh al-Qahawaji (40), a mother of six from Khan Yunis who has rheumatoid arthritis, said:
I have six children between the ages of 12 and 21. I've had rheumatoid arthritis for ten years. It weakens my immune system and causes swelling in the joints and severe bouts of pain every week or two. The pain gets so bad that I literally scream. When the problems started, I saw a lot of doctors in Gaza and had a lot of tests done, but no one diagnosed the disease. It was the worst time of my life. My whole body ached badly and I didn't know what was happening to me. Finally, one doctor ran a special blood test and 20 days later, gave me the diagnosis.
I immediately started treatment, because the disease was already in an advanced stage. I was given various medications, including cortisone, which I still take. Five years ago, in 2016, I also started biological therapy. I was prescribed a series of 48 shots. I managed to get 36 of them and felt an improvement, but then the therapy stopped because the Ministry of Health in Gaza ran out of the medication. I was referred to a-Najah Hospital in Nablus to continue the treatment. In 2017, I applied three times for an entry permit, and was denied every time. This happened in 2018 and in 2019, too. In 2020, I didn't apply because of the pandemic. My immune system is weak and I was afraid of getting infected.
Meanwhile, I’ve developed complications and now have trouble with my eyesight. I'm terrified that I'll start suffering from the side effects of the cortisone, which can also affect the liver and kidneys. Because of my condition, I can't care for the children and the house, and my mother, Samira Abu Ta'imah (60), has moved in to help us. Whenever I have a bout of pain, I stay in bed and can't even stand up. At night, I scream and cry in pain, and my children close their doors so they won’t hear it.
In 2021, my condition grew worse and the doctor said had I to get treatment at a-Najah Hospital. I was given an appointment for 29 October 2021 and applied again for permits for myself and for my mother to go with me. A few days before the appointment, I got a text message saying I had to meet with the Israeli intelligence at Erez Crossing. I went there on the date they gave me and waited from 11:00 A.M. to 5:00 P.M. Then a soldier came and said, "Cross the checkpoint now and go straight to hospital." I refused, because I was alone, without my mother who was supposed to go with me for the treatment, and I also had no money or even a change of clothes. On the way home, I received a text saying our requests had been denied.
I was given a new appointment for 22 November 2021 and applied again for a permit. This time, I asked to go to hospital alone, unaccompanied, because maybe that way I'd get the permit. I really hope I get it and can go to Nablus to get the biological therapy. It’s vital, so I can start functioning again and live without this constant suffering. I'm physically and mentally exhausted from this frustrating situation.
My children need me and the house needs care. My mother is elderly and can’t do everything for me. I'm very sad that she had to leave her home and come live with us. Since I got sick, she hasn't left my side for a moment. Besides the housework, she also takes care of me, monitors my health and handles all the bureaucracy.
Update: Fatmeh al-Qahawaji was scheduled another hospital appointment for 14 December 2021, but the day before received a text message saying her application was still "under review."
In a testimony he gave on 9 November 2021, Nofal Hararah (64), a married father of six who has cancer, related:
I've had bone cancer and colon cancer for six years. I’ve also had heart problems and a tumor in my shoulder. Since the cancer was diagnosed, I've been treated at a-Shifaa Hospital and a-Rantisi Hospital in the Gaza Strip, as well as in hospitals in the West Bank and in East Jerusalem. From 2019 to 2021, I stayed in Ramallah for treatment.
On 1 August 2021, I came back to Gaza. I was supposed to travel to al-Mutala' Hospital (Augusta Victoria) in East Jerusalem for radiation and to have the tumor in my colon removed. I was exhausted after all the treatments and couldn't undergo the surgery without a companion. I filed an application for me and for my wife, so she could go to the hospital with me. I went to the Civilian Affairs Department and they helped me set an appointment for 29 August 2021. A day before the day on which we were supposed to leave, I got a text message saying that our request was "under review." I went back to the Civilian Affairs Department and made a new appointment for 4 October 2021. Again, I got a text the day before saying our requests were “under review.” This time, the hospital called me and set a new date for 23 December 2021.
I've very nervous because I haven't received the permit yet. I didn’t expect this to happen, because I was treated in the West Bank and had no trouble coming back to Gaza. It's very stressful. I'm a sick, elderly man and can’t get this treatment in Gaza. The cancer is spreading and has reached my stomach. My condition is growing worse every day. I’m in severe pain, day and night. I pray to get the permit and go to hospital to be treated.
Update: On 28 December 2021, Hararah received another text message saying his applications were “under review”. In January, he and his wife were granted a permit, and on 17 January 2022, Hararah managed to reach August Victoria Hospital in East Jerusalem for treatment.
In a testimony she gave on 25 November 2021, Shifa al-Bahabsah (40), a resident of Khan Yunis and a mother of three (4-16) who has cancer, related:
In 2020, I felt a lump in my breast and went for a checkup. The doctors said it was probably a milk cyst that wasn’t dangerous. But a few months later, I started feeling severe pain in my breast. When I went for a checkup at the UNWRA clinic, the doctors said I had a tumor and referred me to Nasser Hospital in Khan Yunis. In February 2021, I was X-rayed and had a biopsy, and it turned out I had a malignant tumor. In March 2021, I was hospitalized for two days and underwent surgery to remove the tumor and the lymph node.
In April 2021, I started chemotherapy at the European Hospital, and now I'm supposed to start biological therapy. I can get some of it in Gaza, but some is available only at a-Najah Hospital in Nablus, so the doctor referred me there.
I contacted the Civilian Affairs Department and made an appointment for 13 September 2021 at a-Najah Hospital. I applied for a permit for me and for my maternal aunt, Rawyah Abu Shalhub (48), to go with me. The day before the appointment, I got a text message saying that both our applications were under review. Meanwhile, I was also referred for 16 courses of radiation therapy at al-Mutala' Hospital (Augusta Victoria) in East Jerusalem. The appointment was set for 7 November 2021 and I filed requests for both of us, but again, the day before the appointment I got a text saying our requests were under review. I can’t afford to go to Egypt for treatment. It’s very expensive.
I’m a wreck. I’m physically and mentally exhausted from the illness, and from trying to get treatment. Without a permit from Israel, I can't get the therapy I need. My life is in danger, and I don't understand why Israel won't allow me to get therapy. Time is going by and I'm afraid the disease will spread and it will be too late to treat it. I have three children who need me, and I’m afraid the cancer will metastize and they’ll be left without a mother. In the meantime, I’m weak and in pain and can't do the housework. I try to keep my spirits up for the children, but it's very hard.
Update: Shifa al-Bahabsah was given a new appointment for radiation therapy on 19 December 2021, but again received a text message the day before saying the permit applications were still "under review."
In a testimony he gave on 7 November 2021, 'Abdallah Hajaj (20), a resident of Gaza City who has liver problems, related:
I've been sick since I was a baby. When I was three months old, I was diagnosed with biliary atresia, a disorder in which the bile ducts are blocked at birth or soon after. I underwent bile duct surgery, in which they connected the liver with the duodenum, at a-Shifaa Hospital in Gaza. After that, I had ongoing abdominal pain in the liver area. I was examined every week and took painkillers regularly.
In 2012, when I was 10 years old, I started vomiting blood. It turned out I had more problems: esophageal pouches and abdominal blood clots due to cirrhosis of the liver and of the bile duct and enlargement of the spleen. The doctors urgently referred me to the Specialized Arab Hospital in Nablus. I was treated there several times, but when I was 12, the doctors said they no longer had the proper treatment for me and suggested my father take me to hospitals in Egypt.
My father, Salah Hajaj (55), took me to Egypt and we stayed there for a month. I had tests done, including a liver biopsy. The results came back a week later and they were good. After that, I went to Egypt every six months and sometimes stayed there for several months for treatment. From time to time, I was also treated at the hospital in Nablus. I had laparoscopic procedures, received abdominal injections, and had blood clots tied. The last time I went to Nablus for treatment was 8 December 2018.
In late 2019, I applied for a permit to go for treatment at hospital in Nablus, but Israel denied it. In 2020, I didn't submit any applications because of the pandemic. I last went to Egypt for treatment in March 2021. Then I stopped the treatment there, because my condition deteriorated and I couldn't travel. My family also couldn't shoulder the financial burden.
I was scheduled for treatment at a-Najah Hospital in Nablus on 21 August 2021. I applied for permits for myself and for my uncle Salah (52) to accompany me. The day before, I received a text message saying our applications were "under review." They also summoned my uncle for a meeting at Erez Crossing on 22 August, which was the day after the appointment. Before the meeting, he got a message saying it had been postponed until 29 September 2021. We didn't get an answer until my appointment, so I made a new one for 25 October 2021. This time, I applied for myself and for my cousin Hazem Hajaj (31) to accompany me. Again, I was notified the day before that the request was under review. Since then, I’ve been given another appointment, for 14 November 2021, and have submitted another request, this time for me and for my uncle Mithqal Hajaj (42) to go with me.
I live on painkillers and urgently need to undergo tests and laparoscopic procedures. Every time I apply for a permit, I'm very stressed until I get an answer. When I'm told yet again that it's "under review", it’s terribly disappointing. I still hope I'll get a permit and can get the treatment. I have severe abdominal pain and don't leave the house. The medication I take is very expensive and I order it from Egypt, through relatives or other people who travel there. The disease rules my life. Because of all the trips to Egypt and the treatments there, I didn't graduate high-school and live in perpetual stress, waiting to hear if I can get treated.
Update: 'Abdallah Hajaj was granted an entry permit and traveled alone to hospital in Nablus, where he is being treated as of 3 January 2021.
Samar Abu Wardeh (42), a married resident of Khan Yunis, has cancer. In a testimony she gave on 21 November 2021, she related:
I have thyroid cancer. I was diagnosed in 2019. It started with a feeling that I was choking and with swelling around my neck. I had trouble swallowing food. I went to an ENT doctor who referred me for an ultrasound, and they found I had a tumor. I had a biopsy, and it turned out to be cancerous.
Two months later, I was scheduled for surgery to remove the tumor at Nasser Hospital in Khan Yunis. I had the surgery on 19 June 2019 and stayed in hospital for 21 days. After that, I went there twice a day for two months to get a calcium transfusion, which takes four hours every time. It was exhausting. Sometimes, my husband, Salah Abu Wardeh (47), came with me, and sometimes his children from his second wife, who are all in school, would accompany me.
In 2020, my doctor referred me for radioactive iodine therapy and PET scans at al-Ahli Hospital in Hebron. My husband applied for a permit to leave Gaza, but we couldn't get permits that year because of the coronavirus.
I ended up making an appointment at the hospital for 7 February 2021, but couldn’t get a new guarantee of financial coverage from the Civilian Affairs Department in time, so I postponed it until 12 September 2021. To raise my chances of getting a permit, we applied for me to go alone. I waited anxiously for an answer, but by the time the appointment arrived, I was only told the application was "under review," so I missed it.
I was given another appointment for 9 November 2021 and applied again for a permit. Again, I got a text message saying the application was “under review." Meanwhile, the financial coverage expired, so I had to start the whole process over.
Six months ago, I contacted the al-A’wan wa al-Amal (Support and Hope) organization, which helps cancer patients in the Gaza Strip. They said I could apply through them for treatment in Turkey or Jordan. I filled out the forms and submitted them, and they arranged for me to travel for treatment. But when I reached Erez Crossing along with 10 other women, they were all allowed through but me.
I'm at a loss and feel that my suffering is endless. I have cancer and need treatment at al-Ahli Hospital in Hebron. Why am I being denied it? How can the Israelis deny me this treatment? I really don't know what to do. Sometimes, I consider asking for a referral for treatment in Egypt, but getting through Rafah Crossing is complicated and the trip to Egypt is difficult in my condition. I don't think I can stand it. Besides, it will cost a lot and we can't afford it.
I've had this illness for two years now. I can't do a thing around the house, and my husband and his children do the housework for me. The illness causes a lack of calcium, which makes me weak and gives me severe headaches that almost never stop. I take a lot of medications, but they’re not enough. I need to be treated at al-Ahli Hospital so the cancer won't spread.
Update: As of 6 January 2022, Samar Abu Wardeh is trying to arrange treatment in Jordan.
Filmed by Khaled al-'Azayzeh and Olfat al-Kurd, B'Tselem