The Gaza Strip
The blockade Israel has been imposing on the Gaza Strip for more than 15 years has crushed Gaza’s healthcare system. The level of medical services available falls far short of residents’ needs, and there is a constant shortage of medicines and medical equipment. In 2022, as in previous years, patients who need medical care unavailable in Gaza are the ones to pay the price: Israel forces them to file for permits to leave the Gaza Strip in an exhausting bureaucratic process, extending also to the persons accompanying them. The criteria for approving these requests are unknown and the grounds for rejection are never disclosed. Many of the requests go unanswered, and patients must apply time and again without knowing whether they will ever get the permit they desperately need to reach hospital in the West Bank, East Jerusalem or Israel. In keeping with its past policy, Israel rejected thousands of applications in 2022, denying more than 20,000 requests by patients and persons escorting them to access medical care in hospitals outside Gaza. Some applicants received no answer at all by the scheduled appointment. According to World Health Organization (WHO) figures, 20,411 applications for medical exit permits from the Gaza Strip were submitted in 2022. About 51% were for treatment in East Jerusalem hospitals, about 31% for hospitals elsewhere in the West Bank, and about 18% for hospitals within Israel. The Israeli DCO rejected 6,848 (34%) of the applications, in some cases directly informing patients their application was denied and in others providing no response before the scheduled appointment. Of the applications submitted, 9,641 were for women, 2,935 (30%) of which were rejected; 6,254 were for minors, 1,906 (30%) of which were rejected; and 3,875 were for patients over the age of 60, 843 (22%) of which were rejected. Additionally, 219 patients were called in for interrogation by the Israel Security Agency at Erez Crossing as a condition for examining their application, including 66 cancer patients, 38 women, and 26 patients over the age of 60. The vast majority of these – 91% – were rejected. Requests by Gazan patients to enter the West Bank or Israel for medical care DENIED in 2022 Patients are sometimes unable to travel alone for medical treatment, due to their condition or age. Israel permits applying for people to escort them, but often rejects the requests – again, either directly or indirectly. When escort requests are denied, the patients must repeat the process with no guarantee of success. Over the course of 2022, 26,520 applications were filed for escorts, 16,365 (62%) of which were rejected. The arduous process of obtaining medical permits to leave Gaza for patients and escorts can exacerbate the patients’ conditions and even result in death. In 2022, B’Tselem documented four cases of patients who passed away after they were repeatedly denied requests to access medical treatment in the West Bank: Fatimah al-Masri, who was 19 months old when she died; Muhammad a-Lidawi, a 31-year-old father of five, Akram a-Sultan, 61, and Mahmoud al-Kurd, a 45-year-old father of six. This number obviously does not give the full picture, as some patients never apply in the first place – for example, people living in Gaza without legal status. Others have despaired of the exhausting bureaucratic process. Israel’s policy choices have created a reality in which the healthcare system in Gaza cannot function properly, meet the needs of local residents and offer proper care – 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 bureaucracy that often seals their fate. B'Tselem's field researchers gathered testimonies from patients who were left without treatment after their requests to reach hospitals in the West Bank and in Israel went unanswered or were refused. These are their stories: Iyad Abu Jalalah, a 51-year-old father of five from Jabalya R.C., has metastatic cancer and a herniated disc. He is currently at the Turkish Hospital in the Gaza Strip. Israel has rejected three applications he submitted to receive treatment at a hospital in East Jerusalem. In a testimony he gave B’Tselem field researcher Khaled al-'Azayzeh on 21 February 2023, he said: In May 2021, I began to feel a burning sensation while urinating. I went to a doctor, who referred me for tests at al-Karamah Hospital in northern Gaza. The doctors said I had an enlarged prostate and treated me for two months, but the situation did not improve. I decided to see a private doctor, and he also gave me various treatments that didn’t help. A few months later, in December 2021, I had a prostate biopsy at a-Shifaa Hospital in Gaza, and it turned out I had a cancerous tumor. They did a CT scan and found there were metastases in the pelvic area and in the lymph nodes. I started getting chemotherapy injections about once a month at the Turkish Hospital in Gaza. In December 2022, my condition deteriorated again, and they found I had a herniated disc in my back as well. I couldn’t move or stand on my feet, and I was admitted to the oncology department at the Turkish Hospital. I’ve been lying in the same bed ever since. That month, I received a referral for spinal radiation at al-Mutal’a Hospital (Augusta Victoria) in East Jerusalem, and I submitted an application through the Palestinian Authority Civilian Affairs Office for an entry permit to Jerusalem for myself and for my wife Ghada to go with me. Two days later, we got a message from the Israelis that our applications were still under review, so I missed the radiation appointment. After that, I made another appointment, for 5 January 2023, and submitted an application, but the Israeli occupation rejected that one, too. I tried to get a referral for al-Hussein Hospital in Jordan, but the hospital told my doctor they didn’t provide the care I needed. It turned out I could only get it at al-Mutal’a Hospital in East Jerusalem. I made another appointment at al-Mutal’a, for 29 February 2023, and submitted another permit application, but again, I got a message close to the time of the appointment that the application was still under review, and I missed the appointment again. I asked my doctor at the Turkish Hospital for another referral, but he said he’d been told by al-Mutal’a that they would not give me another appointment because of all the refusals I’d received. The pain in my back is so strong I can’t move. My wife and son help me roll over in bed. The only treatment that can help is the radiation that’s available at al-Mutal’a, and if it stops the cancer from spreading, the doctors will be able to operate on me and repair the herniated disc in my spine, and then maybe I’ll be able to stand and walk again. The radiation is available in Egypt, too, but because it’s a long and complicated trip and I can’t move by myself, so it would require more than one escort. Going to Egypt also costs a lot of money, we can’t afford it. At al-Mutal’a, the [Palestinian] Authority will cover the treatment and I won’t have to pay for it. As of 8 March 2023, Abu Jalalah is still at the hospital in Gaza, and due to Israel’s repeated refusals to issue him a permit, the hospital in Jerusalem is not prepared to schedule him a new appointment. His family has contacted the Palestinian Centre for Human Rights for help. Rahifa al-Qasir, a 27-year-old mother of a four-year-old girl from the Radwan neighborhood in Gaza City, has leukemia. Israel has denied her applications to travel to Israeli hospitals for treatment. She spoke about this to B’Tselem field researcher Olfat al-Kurd on 23 January 2023: In July 2017, blue spots appeared on my body. I went to the UNRWA clinic, where they did a blood count [CBS] and found an abnormal increase in the number of white blood cells. The doctor gave me an urgent referral to a-Shifaa Hospital in Gaza, where they ran more tests: blood count, liver function and platelets. The results revealed I have chronic leukemia. I went to a doctor at a-Rantisi Hospital in Gaza, where I started pill treatment and monitoring. I got married that year. Even though I felt better, thank God, the doctors gave me a referral for al-Mutal’a Hospital in East Jerusalem for September 2017. We submitted applications for me and for my mother, Hayat (49), to go with me. The day before the appointment, we both got a message that our applications were still under review. I made a new appointment and again submitted applications for both of us. This time, we got permits and went to the hospital, where they did a biopsy on my spine and the results confirmed I had leukemia. We went back to Gaza after two days. I continued the treatment in Gaza. I was stable, and about four years ago, I gave birth to Randah. The pregnancy was normal and Randah was born healthy. I nursed her for a month or so and then went back to treatment. In 2019, I got a referral for a-Najah Hospital in Nablus. I was feeling relatively fine at the time, so I submitted an application just for me, got a permit and traveled alone without an escort. After about a year, in 2020, my condition deteriorated, and the doctors gave me an urgent referral for a-Najah Hospital in Nablus. In December 2020, I got permits for me and for my aunt Raedah (55), and we went there for five days. They ran tests and told me there was no treatment for me at the hospital, and I was discharged. My aunt was told that when we returned to Gaza, I should say goodbye to my family. My aunt asked the doctors at the hospital in Nablus to refer me to a hospital in Israel, in the hope they would be able to treat me there, and they referred me to Ichilov Hospital in Tel Aviv. I was taken there by ambulance, and the doctors there said I had to undergo apheresis therapy (plasma exchange). I was admitted to the ICU there for five days, and when my condition stabilized, I received chemotherapy there for four months. Meanwhile, my brother ‘Abdallah (18) applied for a permit to come to Ichilov to give me a bone marrow donation. At first, Israel denied his application, and then, after the hospital sent the Israeli DCO a message that the transplant was urgent, I got the permit and ‘Abdallah came. He underwent the procedure and stayed in the hospital for about two weeks to recuperate. Then he went back to Gaza with my aunt. She had to say goodbye to her father, who was on his deathbed. I stayed in the hospital alone, even though I was still in very serious condition. I couldn’t move or drink, and I felt like I was going to die. I was treated there for another month and a half, and then I returned home. In Gaza, my situation did not improve, and I received several referrals for Ichilov, but each time, only I was approved to come, and they wrote that my aunt’s application was “under review.” I called the hospital to say I couldn’t make it on my own, and they contacted the Israeli DCO, which issued a permit for my aunt too. At the end of 2021, I got another referral for Ichilov, and my aunt was denied a permit again. I went by myself. This happened several times. Every time, I stayed in the hospital for two days, received treatment and returned to Gaza. One time, I went there and back on the same day. In January 2022, my condition worsened again, and I couldn’t travel alone anymore, so my mother applied to escort me. That year, I went almost every month with my mother, about nine times. I missed three appointments because Israel rejected my mother’s applications and I was unable to travel alone. Now I go to Ichilov for treatment once every three months. In the meantime, I’vev also developed a serious problem of dryness and excessive tearing in my eyes, and I need to get surgery at the eye department at Ichilov. I submitted an application to attened surgery at Ichilov on 16 January 2022, and it was approved, but I had to go alone after my mother’s application to come with me was denied. The operation failed, and I was scheduled for another, more complex operation. I hope I won’t have to go to the hospital alone again. I made an appointment for an eye exam on 25 January 2023, an appointment for surgery on 16 February 2023 at the eye department at Ichilov, and an appointment for comprehensive tests for leukemia on 30 January 2023, also at Ichilov. I applied for a three-month stay permit for my mother and me, but Israel has meanwhile denied my mother’s application to come as my escort, and I’m afraid she won’t get a permit and I’ll have to go through it alone. My husband is in prison, and I live with our little daughter in my family’s house. Our financial situation is not good. I was prescribed two types of eye drops, but they are very expensive and I can’t afford to buy them. I also need ointment that costs NIS 60 (NIS 1 = USD 0.28), and I don’t even have enough money for that. If I don’t get the proper treatment, my eyesight could deteriorate. As of 9 March 2023, al-Qasir’s condition is stable, but her eyesight has been limited since the operation. Israel has refused to issue her mother permits, so she went alone for the tests at Ichilov on 25 and 30 January 2023. She has to travel for more appointments at Ichilov – at the eye clinic on 13 May 2023, and for leukemia follow-up on 31 July 2023. Jaber Abu Hasanein, a 75-year-old resident of a-Shati R.C. in the northern Gaza Strip, has diabetes and lung cancer. He needs tests and pulmonary catheterization. He was referred to a hospital in East Jerusalem, but his applications for a permit for himself and for his escorts were denied. In a testimony he gave B’Tselem field researcher Muhammad Sabah on 6 November 2022, he said: Three years ago, I started getting dizzy spells, headaches and general weakness and I couldn’t walk. I got tests, and it turned out my left foot was diabetic. I got medication and painkillers and tried to keep my blood sugar stable but a few months later, my foot had to be amputated. In September, blue and red spots began appearing on my right leg, and I got headaches and felt weakn again. My temperature went up and I had trouble breathing. My sons took me to a-Shifaa Hospital in Gaza, and it turned out I also had a diabetic infection in my right leg. The hospital ran more tests, and it turned out I had pulmonary edema, bacteria and fibrosis, which was why I was having trouble breathing. They tried to catheterize me but it didn’t work, probably because my body was too weak. Later, a test revealed I also have a cancerous tumor in the left lung, and on 17 October 2022, I got an urgent referral for St. Joseph Hospital in East Jerusalem, to have an MRI scan to diagnose my disease and also to undergo pulmonary catheterization there. The doctor at the hospital prepared a referral for me, and I made an appointment for 31 October 2022. I filed an application for a travel permit for myself and for my wife to escort me. While I was waiting for approval, I suffered terribly. I was having trouble breathing, could barely move, and was hardly eating and drinking. The evening before the trip, we got a message saying my wife’s application had been rejected. The next day, we filed another application, this time for my nephew, ‘Imad al-Khawajah, to accompany me, but then we found out from the Civil Affairs Section that Israel had denied my application. When I realized I wouldn’t be able to get to the hospital, I was in a terrible state. My children asked the Palestinian Centre for Human Rights in the Gaza Strip for help, but they haven’t gotten me a permit yet. My condition keeps getting worse. For now, I’m just taking painkillers. Kifaya Daghmash, a 45-year-old resident of Gaza City who is a widow and a mother of two, has breast cancer. Her applications to travel for chemotherapy in East Jerusalem have been rejected by Israel five times. She spoke about this to B’Tselem field researcher Olfat al-Kurd on 1 November 2022: In 2017, I was breastfeeding my son Khaled when I felt a small lump in my left breast. I went to the doctor, who referred me for an X-ray, then I was urgently referred to a-Shifaa Hospital. At the hospital they did a biopsy, and it turned out I had a cancerous lump in my breast. About two weeks later, my left breast was removed. After the surgery, I had eight chemotherapy sessions at a-Rantisi Hospital in the Gaza Strip. In 2018, I was referred for radiotherapy at al-Mutal’a Hospital in East Jerusalem. Israel denied all the applications I made to go for the treatment. I only got a permit on 23 September 2019 and went with my husband Kamal. I was in the hospital for two days and received 16 radiation sessions. After I returned to Gaza, I continued chemotherapy at a-Rantisi Hospital and at the Turkish Hospital. The doctors said my condition was stable at the time. Two years ago, my husband died of kidney failure. In March 2022, I had an X-ray, and it turned out I also had cancer in my spine. I was referred for radiotherapy at al-Mutal’a Hospital in East Jerusalem again, and got an appointment for 8 June 2022. I filed an application for myself and for my sister-in-law Sa’diyah (73) as my escort, but the day before the appointment, I was informed that both of our applications were still under review. I tried not to lose hope and waited for them to approve the applications, but we didn’t receive any message and I missed the appointment. I made another appointment for 18 July 2022, and they approved my permit. Although this time, they also approved the application I submitted for my sister-in-law as my escort, I decided to go alone. On the day of the appointment, I got to Erez Crossing at around 6:00 P.M., and the soldier at the inspection point asked me to wait in the waiting room. I waited there for several hours, and at some point, the Israel Security Agency called me and asked me questions about my neighbors in the Gaza Strip: where they work and what cars they have. They told me they would send me a phone number and that as soon as I got it, I should call it and a name would appear on the screen. I got the number and when I called it, no name appeared on the screen. After about half an hour, at 6:30 P.M., the soldier called my name, gave me back my ID card and told me to go back to Gaza. I had no choice but to go back home. I made another appointment for 21 August 2022, and decided to travel without an escort this time, in the hope that they’d let me get to the treatment that way. I set out that morning at around 7:00 A.M. and headed to Erez Crossing. When I got to the Palestinian side of the crossing, I was given the permit on the Palestinian side, but when I got to the Israeli side, the soldier asked me to sit aside and wait again. I was very tired that morning. I was made to wait on a metal bench for several hours, and it was terrible. I told the soldier I had to get to the hospital urgently, and I also asked someone who was there to translate what I was saying to her. I told her I couldn’t wait any longer. She gave me back my ID card and told me to return to Gaza again. I made another appointment for 25 September 2022, but it was postponed because of the Jewish holidays, so I made another appointment for 20 November 2022, but this time I was denied. I’ve been suffering from this disease for five years. I have pain all over my body and can hardly sleep at night. My blood pressure is very high and I also have diabetes. I’ve already received a permit! I don’t understand why the Israeli army sends me back every time! It’s so hard for me. I can’t leave the house and see people anymore. I’m exhausted and irritable and find myself yelling at my children. I just want to get treatment and be healthy, so that my children don’t become orphans. ‘Aishah a-Neder, a 36-year-old resident of the a-Zeitun neighborhood, has lymphoma and breast cancer. Her applications to travel for chemotherapy in a West Bank hospital were rejected by Israel four times. She spoke about this to B’Tselem field researcher Olfat al-Kurd on 24 October 2022: I started having severe pain in November 2021 and went to a private doctor, who referred me for scans. It turned out I had an infection in my right breast. When I went back to the doctor, who took a biopsy, it turned out I had a chest infection. The pain continued and I went to the doctor again. He gave me an ointment for the infection site, but it didn’t help and the pain continued. I went to another doctor, at a-Shifaa Hospital in the Gaza Strip, and he referred me for a CT scan and X-rays. It turned out I had lymphoma and a cancerous tumor in my right breast. I was referred for chemotherapy at a-Sadaqa Hospital in Gaza. I was prescribed a total of eight chemotherapy sessions, and there are four remaining treatments that are not available in Gaza hospitals. On 23 July 2022, I got a referral for al-Istishari Hospital in Ramallah and made an appointment for 7 August 2022, with the option of extending my stay there for three months. Every time I went with my mother to the Civil Affairs Section to check if the application had been approved, I was told it was still under review. The appointment date passed, and I made another application for a new appointment on 26 August 2022, but it also remained under review and I missed the appointment again. I submitted another application for an appointment I got for 4 September 2022, which was also denied. In the meantime, I’ve been getting chemotherapy at a-Sadaqa Hospital every 21 days since May 2022. On 18 October 2022, I got chemotherapy at a-Sadaqa Hospital. That day, I was told by the Civil Affairs Section that the other application I’d submitted to reach my treatment at hospital in Ramallah was still under review. I asked the Palestinian Centre for Human Rights in the Gaza Strip for help, but they were unable to help, and the Civil Affairs Section told me I’d received another refusal from Israel and my application would not be reviewed again. Now, I can’t move my right hand. I suffer from pain at night and hardly sleep. I get dizzy and I’m itchy all over my body, day and night. I keep losing weight. I just want to get the treatment I deserve. I’m not a threat to anyone. ‘Aishah is receiving care at the Turkish Hospital in the Gaza Strip, and her condition is stable. She is waiting for a CT scan that will help physicians determine whether she needs a mastectomy or radiation availale outside Gaza. Raghad Zo’rub, a 15-year-old resident of Khan Yunis, has scoliosis and needs spinal surgery that cannot be performed in the Gaza Strip. All applications submitted on her behalf to receive an entry permit to East Jerusalem have been rejected. In a testimony she gave B’Tselem field researcher Olfat al-Kurd on 27 September 2022, her mother, Halah Zo’rub, 44, said: About three years ago, I noticed Raghad’s back was bent. I asked her to try straightening it and I saw something was wrong on the right side. I took her to an orthopedist at Naser Hospital in Khan Yunis, where they did an X-ray and it turned out she had scoliosis in her back with a 38-degree deviation. The doctors said her condition could get worse and referred her for an MRI and then for spinal surgery. For a year, Raghad had physiotherapy three times a week at Naser Hospital, but she didn’t get better. Then the Covid pandemic started, and the physical therapy department was closed. Raghad had to do the exercises on her own, which was hard for her and she didn’t stick to them. Because of Covid, I was afraid to take her to other hospitals. She kept getting worse and lay in bed most of the time. At some point, she couldn’t walk or stand on her feet anymore. In July 2021, I sent all of Raghad’s medical documents to al-Istishari Hospital in Ramallah, and they told me she needed spinal surgery. We got a financial coverage guarantee from the Palestinian Authority, and I set her a surgery appointment at al-Makassed Hospital in East Jerusalem. But the night before the appointment, on 22 December 2021, I got a message that the application was still “under review.” I didn’t know how to break it to Raghad. My husband went to the Civil Affairs Section to find out why it hadn’t been approved and was told they would get back to us in a week, but we haven’t heard from them. Raghad’s condition keeps getting worse, and she’s having trouble moving her body. In the meantime, she’s also developed digestion problems and can’t eat properly. I made Raghad another appointment for 2 March 2022, but again, the day before, we were told the application was still under review and we missed the appointment again. The same thing happened when I made another appointment for 18 May 2022. I couldn’t believe this was happening to us again and again. I don’t know what to do anymore. I made another appointment for 23 November 2022. Raghad’s mental health isn’t good. She just wants to lead a normal life, like all her friends. She’s devastated by her situation. This operation can save her life, and it can’t be done in any hospital in Gaza. I applied for the European Hospital in Gaza, too, in the hope that maybe, some of the doctors who come from abroad to perform complex surgeries will be able to operate on her. I haven’t gotten an answer from them yet. Raghad successfully underwent the surgery at al-Makassed Hospital in East Jerusalem on 23 Nov. 2022.
4 April 2023
