Erez Crossing. Photo by Amir Cohen, Reuters, 5 Oct. 2014
The degree to which residents are able to develop medical services in the Gaza Strip, or obtain them outside Gaza, still depends on Israel. Despite its 2005 withdrawal of troops from the Gaza Strip and evacuation of all settlements there, Israel retained a significant amount of control over Gaza, which means Israel retained responsibility for the safety and wellbeing of all Gaza residents. Aid to medical patients is part of Israel’s legal and moral obligation toward Gaza’s residents; it does not constitute a gesture of good-will.
For nearly a decade Gaza has been under an Israeli-imposed a blockade, preventing free movement of people and goods both to and from Gaza. The blockade has resulted in Gaza’s economic collapse and has isolated its residents from the rest of the world. Gaza’s health care system has also been hard-hit by this policy.
As a result of decades of occupation and obstructed development, Gaza’s health care system was not able to fully meet the needs of local residents even before the blockade was imposed in 2007, and relied on referring patients with serious conditions for treatment outside the Gaza Strip. The lengthy blockade made matters worse. Gaza now has a shortage of operating rooms, basic equipment, fuel for heating and for running generators, which are essential given the frequent blackouts. In addition, the prohibition on travel outside Gaza prevents physicians from traveling abroad for professional training, keeping abreast of medical innovations and improving the treatment and care provided to Gaza residents. At the same time, demand for medical services has greatly increased, both because of population growth and because of the great number of residents who were wounded during Israel’s military operations in Gaza and require lengthy follow-up treatment.
Given this state of affairs, Gazans who have medical conditions that cannot be treated in Gaza have one of two options: Either leave Gaza through Rafah Crossing and travel to Egyptian hospitals to get treatment; or else, leave via Erez Crossing in the northern Gaza Strip to reach hospitals in Israel or the West Bank (including East Jerusalem). Both options are extremely difficult to realize.
Line to register for passage via Rafah Crossing. Photo by Ibrahim Abu Mustafa, Reuters, 2 June 2016
Not only is the journey to Egypt long and costly, in recent years it has also become dangerous. Nonetheless, as it allowed some Gazans to receive treatment outside Gaza, they availed themselves of this option. However, after Egyptian president Muhammad Morsi was deposed in July 2013, Egypt shut down Rafah Crossing, its border crossing point with Gaza. Ever since, Egypt and been opening the crossing for just a few days every few months and imposing strict limits on the number of travellers, thereby effectively blocking this option. Patients who still wish to travel through Rafah must register in advance with the Passenger Registration Office of the Gaza Ministry of Interior, which allocates a limited number of visas for patients. Prior to each opening of the crossing, the Ministry of Interior posts on its website the lists of patients cleared for travel. World Health Organization (WHO) figures for January through October 2016 show that 20,000 medical patients filed applications to travel to Egypt, but only 1,023 of them actually travelled on the 25 days the crossing operated.
Exiting Gaza through Erez Crossing for treatment in the West Bank (including East Jerusalem) or in Israel involves a very long and arduous process. Patients are initially required to receive the approval of a medical committee in Gaza. Then they must secure authorization from the Palestinian Authority in Ramallah that the cost of treatment is covered; the PA in Ramallah also decides which medical institution to refer them to. In most cases, guarantee of funding is first provided for West Bank hospitals, which are less costly. Only later, if required, are patients referred to Israeli hospitals. Once these approvals are given, patients must file for an Israeli entry-permit by applying to the PA’s Ministry of Civil Affairs, which liaises with the Israeli authorities. Patients who require repeat treatments must file a new application each time.
Israeli entry-permits are granted subject to security screening of the patient and whoever is accompanying them. In some cases, patients are required to report for questioning by the ISA at Erez Crossing, prior to application approval. Decisions on whether to deny or approve the application are made arbitrarily: no reasons are stated when applications are denied and patients cannot know whether their application was denied for security reasons or because they failed to meet some other unknown criteria.
According to WHO figures, the proportion of applications approved by Israel has gradually declined since the end of Operation Protective Edge in the summer of 2014:
WHO figures – Applications by Gaza patients for Israeli entry-permits via Erez Crossing for the purpose of medical treatment in the West Bank, Israel or Jordan:
|Year||All applications||Approved||Denied||Still pending, past appointment date||Of these - number of applications by minors (denied and pending)||Of these - number of applications by patients 60 and older (denied and pending)|
The table above shows that thousands of patients receive no response by the date of their appointment. When this happens, their application becomes moot and they must book another appointment at the hospital, file another application for a permit and wait, again, for an answer, in the hopes that this time, their application will be approved.
In addition, the number of patients required to undergo questioning at Erez Crossing after applying for a permit has gone up over the past year:
|Year||Summoned for questioning||Of this number – women summoned for questioning|
*According to WHO figures for January through October 2016, some 35% of all applications (7,267) were filed by cancer patients, and more than a quarter of these (28.09% = 2,042 applications) have either been denied or have yet to be answered.
|Month||Applications by cancer patients||Applications denied||Applications still pending past the appointment date|
* Figures include radiation, oncology and hematology patients.
Following are accounts by several of these patients:
Khalil Nabil Qassem Rihan, 49, a married father of eight, lives in Deir al-Balah. He has thyroid cancer. He spoke with B’Tselem field-researcher Khaled al-'Azayzeh on 31 October 2016:
Two years ago, I was diagnosed with a thyroid tumor. Because it can’t be treated in Gaza, the doctors gave me a Ministry of Health referral to a hospital in East Jerusalem. I got a permit to exit Gaza and went to the St. Joseph (French) Hospital with my cousin, Sami Ahmad Rihan, who’s 47 years old. He went with me because I have no brothers and my sons are still young. The doctors at the hospital ran some tests and took a biopsy from my neck. I went back to Gaza, and two days later, the hospital informed me that they recommended I make an appointment for further treatment at Assuta Hospital [in Israel]. I filed another request with the Ministry of Health for a referral for treatment in Israel, and made an appointment at the hospital. I got a permit and went there with my cousin.
The doctors at Assuta ran a nuclear scan and recommended I make an appointment at Meir Hospital [also in Israel]. I made an appointment for 7 December 2014. I had no trouble getting a permit, and I went again with my cousin. I stayed in hospital for 27 days. I underwent an operation to remove my thyroid gland. Two days later, I went back to the Gaza Strip. After that, I went twice more to Meir Hospital, in April and August – for more tests. Both times, we got permits without any trouble.
On 4 September 2016, I had another appointment for tests at Meir Hospital. As usual, I applied for an entry permit for myself and for my cousin Sami. The appointment date came, and I had not yet received a permit yet. Instead, I got a text message on my phone from the Palestinian Authority’s Ministry of Civil Affairs that they were running security checks. I scheduled a new appointment for 18 September 2016, but again, the date of the appointment came, and instead of a permit, I got the same text message about running security checks. I made another appointment for 30 October 2016, and filed a third application. On the day, I got a text message saying the applications for me and for Sami Rihan, who was to accompany me, had been rejected. No reasons were given. The application was denied, even though I’d gone to hospitals in Israel many times before, without any trouble.
The doctors said I must undergo a nuclear scan and tests every six months, to confirm that the cancer hasn’t come back. Also, whenever I go to Meir Hospital I’m given supplies of radioactive iodine. The hospital determines the dosage when I am there, as necessary. Radioactive iodine is not available in the Gaza Strip.
Nabil Rihan was given a new appointment for 7 December 2016, but his application for an Israeli entry permit was denied yet again.
Khaled ‘Abd al-Fatah al-‘Ati Mubarak, 52, a married father of six, lives in a-Nuseirat Refugee Camp. He has brain cancer. He spoke with B’Tselem field-researcher Khaled al-‘Azayzeh on 24 May 2016:
In early 2015, I was diagnosed with a brain tumor. Three months later I had an MRI at the European Hospital in Rafah, and the tumor was found to have grown. The doctors told me there was no treatment available in the Gaza Strip. They gave me painkillers and a referral for treatment at al-Makassed Hospital in East Jerusalem. I made an appointment for 18 February 2016 and applied for an entry permit at the Gaza liaison office.
On 16 February 2016, two days before my scheduled appointment, someone who speaks Arabic phoned me and said he was from the DCO at Erez Crossing and that I had to go there that day for an interview.
I went to the crossing and waited for more than three hours before they took me to a room where an intelligence officer was seated. He asked me about my disease, where I was going, and who my attending doctor was. He also asked about cell phone numbers he pulled out of a copy of my telephone bill. The interview lasted close to two hours, and he asked me a lot of questions, mostly about my relatives and neighbors.
Two days later, the day of my appointment arrived, but no one got back to me about the permit. I called the liaison office and they just said my application had been denied for security reasons. I didn’t file another application and didn’t make another appointment at the hospital. I just take painkillers for my headaches, and the cancer goes untreated.
Nadia Yusef Muhammad Abu Nahleh (al-Bakri), 52, a married mother of three, lives in Gaza City. She has breast cancer. She spoke with B’Tselem field-researcher Muhammad Sabah on 27 September 2016:
In February 2009, I was diagnosed with breast cancer. I got an Israeli entry permit and on 14 February 2009, I went for tests at Tel Hashomer Hospital [in Israel]. The doctors did tests and said I’d have to have chemotherapy over the course of six months. I went to Tel Hashomer each time for chemotherapy. Three weeks after the chemotherapy ended, I had an operation and then I had radiotherapy.
Until January 2016, I went to Tel Hashomer for treatment and tests once every three months, but since then, I haven’t received a permit. Since March 2016, I’ve applied for an entry permit three times, on 30 March, 10 July and 20 September, but all of them were denied. I’ve been getting treatment at Tel Hashomer for seven years, and until this year, my application had never been denied. There are no charges against me or anything like that.
The treatment had good results, but I have to keep getting tested because I had Stage 4 cancer, which requires follow up and lab tests. The doctors also have to monitor the side effects of the hormonal treatment I’m getting.
As of 7 December 2016, Nadia Abu Nahleh had not received a permit to exit Gaza. She was told via the Ministry of Civil Affairs that she would be summoned for questioning at Erez Crossing.
Rania Atiyyah Zaki al-Anshasi, 40, a married mother of four lives in Rafah. She has breast cancer. She spoke with B’Tselem field-researcher Muhammad Sabah on 7 September 2016:
About a year ago, I was diagnosed with breast cancer. I started treatment in Egypt, because my husband lives and works there. The doctors decided to give me four rounds of chemotherapy every three weeks. After every session, I stayed home and couldn’t move or do anything. I got the last dose on 12 December 2015, and then I went back to Gaza and completed treatment at the European Hospital in Khan Yunis. The doctors decided to give me four more rounds of chemotherapy once every three weeks. Later I got one dose a week.
I continued with chemotherapy through January 2016. The doctors said I also have to get radiotherapy at al-Mutala’ Hospital (Augusta Victoria) in East Jerusalem. I applied for a permit, but it was denied. On 12 June 2016, after I’d filed two more applications that were also denied, my application was approved and I managed to get to al-Mutala’ Hospital. I went there and got radiotherapy every day for 16 days. Then I returned to the Gaza Strip.
I had imaging done and it was found that there were no more cancer cells left, but the doctor at al-Mutala’ said I had to get 17 doses of drug treatment, once every 21 days, at al-Mutala’. Everything worked well until the fourth injection. I got it on 28 July 2016 at al-Mutala’, and I was supposed to get the fifth one on 17 August 2016. I applied for a permit, but got no response. I inquired with the Civil Affairs Department and I was told the Israelis said my name was being screened. I applied again on 6 September 2016, but the appointment date passed and I got no answer.
I need the treatment to stop cancers cells from growing and to keep the disease from spreading. The delay in treatment might cause the disease come back. I have to get the permit so I can finish the treatment.
On 7 November 2016, after more than a two-month delay in her treatment, Rania al-Anshasi received an exit permit.
Ghadir ‘Abdallah Muhammad al-Masri, 37, a married mother of five, lives Khan Yunis. Her seven-year-old son ‘Abdallah has adrenal cancer. She spoke with B’Tselem field-researcher Muhammad Sa’id on 22 September 2016:
In September 2015, I noticed a lump near ‘Abdallah’s waist, on the right side. We went to a-Nasser Hospital in Khan Yunis. The doctors ran some tests, pushing for rush results, and he was found to have a cancerous tumor on the adrenal gland. The doctors told my husband and me that his condition was serious and that he had to be referred for treatment outside Gaza.
We were shocked. Our lives were turned upside down, and the house became really sad. I could lose ‘Abdallah any day.
The doctors gave us a referral for treatment at al-Mutala’ Hospital in East Jerusalem, and we applied for a permit to exit Gaza. ‘Abdallah went back and forth between the European Hospital and a-Nasser Hospital for almost a month. All this time, we were waiting for an answer about the permit. We called the office that handles applications every day to hurry the permit along. In the meantime, all the doctors gave ‘Abdallah were painkillers. They said the treatment he needed wasn’t available in Gaza.
In November 2015, we got an exit permit for Erez Crossing, and I took ‘Abdallah to al-Mutala’ Hospital in Jerusalem. We stayed there for three months straight, and then went back to Gaza. The doctors said ‘Abdallah had to get further treatment in Tel Hashomer Hospital [in Israel] after three months, so we started working on get a new entry permit. We were very concerned we wouldn’t get one, so my husband went to the Ministry of Civil Affairs almost every day.
In March 2016, we got a permit to go to Tel Hashomer Hospital. We were there for almost a month, and then again returned to Gaza. They made another appointment for ‘Abdallah, for 22 August 2016, to get the third treatment. The doctors recommended to avoid any delays in getting treatment.
This recommendation made us even more worried, because we know the Israeli authorities delay permits for many patients for no reason. Our whole lives revolved around getting these permits. It really impacted my husband’s work at the time, because he wasn’t available to work. We contacted the Civil Affairs Department repeatedly to find out the status of our application. Then, a few days before the scheduled appointment date, the Civil Affairs Department suddenly called and said we had to change the person accompanying ‘Abdallah, that the person had to be over 50 years old, so it would be easier to get the permit. I had to put my mother down as the accompanying person, even though she’s almost 80, and even though I really wanted to go with ‘Abdallah and be there with him. It was particularly problematic, because my mother herself needs someone to be with her and care for her.
Even though we put my mother down as the accompanying person, the Israeli side refused to allow us passage on the day of the appointment and we had to reschedule it. We called the hospital at Tel Hashomer and got an appointment for 8 September 2016. We filed a new application for an entry permit and waited. We were really nervous. The application was denied again.
We’re very worried that this delay will have a negative impact on ‘Abdallah’s condition, because the doctors kept stressing how important it was that he gets the treatments on time. Now we’re waiting for the new appointment, which is scheduled for 6 October 2016. We got a call from the Civil Affairs Department saying that this time the Israeli side approved the application for an entry permit. I’m still nervous. I won’t be able to relax until I know he made it to the treatment.
‘Abdallah al-Masri got an exit permit together with his grandmother in early October.
S.F., 31, a married mother of three, lives in Deir al-Balah. She has kidney cancer. She spoke with B’Tselem field-researcher Khaled al-‘Azayzeh on 7 November 2016:
In April, I started feeling unwell, and I had a swelling on the left side of the abdomen. I made an appointment with my gynecologist and she referred me to a surgeon. An ultrasound found a lump in my left kidney. They did some more tests, and then operated on me and removed the kidney. I stayed at a-Shifaa Hospital for five days.
When they checked the lump they had taken out, it was found to be cancerous. The doctors told me that the tumor had not spread and was only in the kidney that was removed, but that I should undergo a nuclear scan as soon as possible, which is only available at Assuta Hospital in Israel. I got a referral from the Ministry of Health and payment coverage, and I scheduled an appointment for 27 September 2016 at Assuta Hospital. I applied for a permit to enter Israel, but the day before my appointment, I got a text message from the Ministry of Civil Affairs saying that my application and my aunt Seniora’s application, who was supposed to accompany me, were still “under review”. The day of the appointment passed and I didn’t get the permit.
I made a new appointment for 3 November 2016 and filed another application for a permit. This time I also got a text message the day before the appointment saying our case was being reviewed. I missed the appointment again. I haven’t filed another application yet because I’ve lost hope and I’m worried it’ll be denied again.
I’m very anxious and worried. I feel that I’m still sick, and every time I feel pain anywhere in my body, I’m worried the cancer is back. I’ll calm down only after I do the nuclear scan. But it can’t be done here, only in Israel or in Egypt, and it’s almost impossible to get there because Rafah Crossing is closed. Even if it opens, there are thousands of people who need to cross. Even if I could, I’m worried about the security situation in Sinai and the expense of traveling there.