For cancer patients in Gaza travel permits become a matter

The crowded hall is packed full with tired bodies standing in front of the Director’s office, as people clutch their papers and medical reports and attempt to get the attention of the officials. Crying is not entirely uncommon, as people wail of the consequences of delaying their treatment while they wait for Israeli approval for a medical permit. 

Intisar Farra, 30, sits on  a chair at the Civil Affairs office with her little daughter, who is lying down on her mother’s lap from heat exhaustion. Intisar looks worried and unwell as she waits for an answer regarding the reason for the recent rejection of her application for renewal of her medical permit.

Intisar is a mother of 4 children and lives in the Nuseirat refugee camp in the southern Gaza Strip. She was diagnosed with cancer 2 years ago.

When she first started her treatment, she managed to obtain medical permits 3 times for treatment at the Augusta Victoria Hospital in Jerusalem, and at the Al-Najah Hospital in Nablus. But from January 2022 onward, she was prevented from proceeding with her treatment. As a result, her condition has been getting worse by the day. 

“I started experiencing new health problems due to the delay in my treatment. My lungs, ovaries, and spleen have all been damaged, which poses a threat to my life. I have a family and kids I want to raise,” she said. 

As for why Intisar was denied her medical permit, she has not been able to find out. She has been sent a message indicating that her name is on a banned list, and there is nothing that can be done to know the reason for her denial.

Patients in Gaza are made to endure long and tortuous procedures to obtain medical treatment in Israel or the West Bank, an option that many are forced into given the limited treatments available in Gaza. First, they must secure a place in a Palestinian Authority (PA) fund for the treatment of patients from Gaza, and then they must apply for an Israeli permit to enter West Bank hospitals. The process of applying for such medical transfers is yet another process that is directly hampered by the blockade that has been imposed on Gaza ever since 2007.  But in the case of the medical sector, this kind of obstruction puts peoples’ lives on edge. 

“Over 150 patients are transferred from Gaza to the West bank every day,” Mousa Abu Ghayyad, the coordinator of the Ministry of Health in Gaza said.  But not all of those transfers end up getting medical permits from the Israeli side–about 70% of them. The rest of them are flagged for an Israeli security check, always for unexplained reasons. 

“Those who are waiting for the Israeli response will be examined by the Shin Bet [the Israeli Security Agency],” he said. 

Physicians for Human Right Israel (PHRI) criticized the way Israel deals with Palestinian patients applying for medical permits for treatment in the West Bank in a recent press release. It called on Israel to grant patients more than a one-day permit, which it viewed as insufficient for carrying out treatment. 

“Israel refuses to issue long-term permits to Gazan cancer patients or those with chronic conditions. Such permits would allow patients to regularly leave the Gaza Strip for medical treatment, including chemotherapy and radiation therapy. Instead, Israel issues only one-day permits which it restricts to the confines of the hospital grounds. This makes it difficult for patients to provide for their personal needs during a prolonged hospitalization and negatively impacts their emotional state and chances of recovery,” the PHRI statement read. 

The permits issued by the District Coordination and Liaison office (DCL) are valued only for one day, after which patients must reenter a long process in reapplying for a new permit for each treatment. PHRI asserted that the “lack of continuity in permits means that the schedule set by the hospitals is not met, leading to delays in diagnosis, treatment, and follow-up, which in turn jeopardizes patients’ lives, harms the quality and efficacy of medical treatment, and constitutes a significant health hazard.” 

The tortuous process of obtaining a medical permit

Two simple reasons compel Gazans to seek treatment outside of Gaza–the lack of diagnostic equipment, and the lack of medication and treatment capabilities. Cancer patients require treatment sessions of 21 days without interruption, yet Israeli security checks put them on hold for a long time before an approval or rejection is issued. Before that, they will have already filed endless paperwork and followed several bureaucratic procedures to get to this point. 

On the Palestinian side, the 2007 Hamas-Fatah split has made things more complicated for applications for treatment in West Bank hospitals–which are generally more developed than the hospitals in Gaza. Patients applying for these transfers go through a protracted process of administrative paperwork, starting with filling out what is known as “Application No.1,” which must include a doctor’s report including all the patient’s information and details of required treatments–on the condition  that the treatment be unavailable in Gaza. 

Next, patients must go to the PA office in Gaza, which at this stage becomes responsible for transfers. The patient file is then reexamined by a higher medical committee affiliated with the PA, which makes a recommendation on whether the patient should receive coverage, typically by issuing a report.

The third step in this convoluted process redirects the patient’s file to the concerned PA office in Ramallah, where yet another medical committee decides on whether the patient will be covered. Approval at this stage means that the patient is now responsible for finding a hospital to host them, with which they themselves must make the necessary arrangements. 

All of this is before patients go through the process of obtaining a medical permit from the Israeli side.

The Palestinian Center for Human Rights helps patients in critical condition who were denied Israeli medical permits by securing them timely treatment, which helps buy them time for an alternative arrangement. “Last year, the center managed to help over 1040 people whose applications for medical permits were rejected by Israel, and so they were able to receive their medication,” said Muhammad Bseiso, a representative of the Palestinian Center for Human Rights.

“Patients should not have to face these obstacles to secure treatment–they’ve already been through enough on account of their illness,” he added in between his enumerations on the various reasons for Israeli rejections of medical permits.

It is therefore no mystery why some patients succumb to their illness in light of all of these pressures and systematic delays to their treatment. 

Photograph of Saleem Nawaty and paraphernalia from his life, including the many sports medals he won. (Photo: Mohammed Salem)
Photograph of Saleem Nawaty and paraphernalia from his life, including the many sports medals he won. (Photo: Mohammed Salem)

A deadly permit system

In front of the Nawaty family home in the north of Gaza, a father of 47 years, Omar Nawaty, sits among dozens of relatives and friends, who are being served dark coffee and dates. They sit on plastic chairs in a large circle outside, while inside the family home the women of the family sit around the mother. This was the last day in the three-day funeral wake of Saleem Nawaty, a popular 17 year-old high school student who was a Taekwondo coach’s assistant at a sports club in Gaza. 

The PA was in debt to the hospitals, and they would no longer treat patients there under a PA transfer.

People are streaming into the Nawaty home to offer their condolences to Saleem’s family. Some hug them or shake their hands, while others exchange a few solemn words. Saleem had gone to a West Bank hospital for medical testing in order to secure a diagnosis, after Gaza hospitals suspected cancer but had no means to diagnose him. The moment he arrived at the hospital, tragedy struck.

Jamal Nawati, Saleem’s uncle, was accompanying his nephew in lieu of his ailing father. He and his nephew were only given a permit for one day, after applying for a permit three times inside of a month. And when they finally arrived in Nablus, the Al-Najah Hospital explained to them that it cannot receive Saleem, because of the PA’s debts to the hospital. They then went to Ramallah, having already overstayed the one-day permit, in an attempt to secure treatment there. Yet even in Ramallah, the answer was the same: the PA was in debt to the hospitals, and they would no longer treat patients there under a PA transfer.

The one day was over. At that point, it was time to decide–overstay the permit, or go back to Gaza?

None of the hospitals agreed to host Saleem for the required 15 days of treatment. The hospitals told him that there was no budget to cover his treatment. On that same day, Saleem collapsed in front of the Palestine Medical Complex in Ramallah.”

Jamal Nawaty, Saleem’s uncle.

“What should we do with one day?” Jamal said. “We arrived in the afternoon, and the day was almost done. If I’m going to go back without treating Saleem, I will then have to go through a long process to get another permit for myself and for him. The boy would be dead by then.” 

And so they stayed. And they kept going back to the hospital for 13 consecutive days. 

“But none of the hospitals agreed to host Saleem for the required 15 days of treatment,” said Jamal. “The hospitals told him that there was no budget to cover his treatment. On that same day, Saleem collapsed in front of the Palestine Medical Complex in Ramallah. He died two hours after that fall, from the depression of hearing the bad news. The disease got to him.”

“After he collapsed from illness and stress, the doctors took him for treatment, and two hours later, they informed me of his death.” Saleem’s uncle is sure that the hospital could have given Saleem the help he needed, but that it gave priority to settling a score with the PA. 

Still, he holds the PA fully responsible for his nephew’s death.

Saleem’s case illustrates how Gazans have to overcome two hurdles to secure cancer treatment–namely, Israel and the PA.  

Saleem was unable to obtain a permit to be diagnosed at the Al-Najah Hospital in Nablus. He applied for a permit 3 times, but Israel refused him each time. His father recounts that period bitterly: “For over a month we tried to secure a permit, and every time he was refused he would be disappointed. He wasn’t waiting day by day–he was waiting from one second to the next, counting down the moments to receive a reply from the Israeli side. The rejection shocked him.”  

As I sit amongst the somber gathering, Saleem’s bereaved father to my side, I peer over to the walls of the room in which we were being hosted, adorned with photos of Saleem alongside golden and bronze medals and plaques, and certificates of appreciation–a promising young man killed by a deadly permit system.

When healthcare providers are in debt

The PA funds the treatment of patients who can’t find treatment in Gaza. A PA-affiliated office in Gaza is responsible for the transfer process, but many of the actual West Bank hospitals will no longer receive patients given the PA’s continuous non-payment of its ever-increasing debts to those hospitals.

Saleem’s rejection letter from the Ramallah hospital: “There is no possibility of receiving the patient at the Palestine Medical Complex.” (Photo: Mohammed Salem)

Kamal Hijazi, head of the Al-Najah hospital in Nablus, maintains that the hospital only rejects patients that it is unable to treat, due to shortages in funds, which has led to an inability in securing the necessary medications. In such cases, those patients are transferred to another hospital that can offer them treatment.

The hospital’s shortage of funds is also directly related to the PA’s unpaid debts–the hospital carries out highly expensive treatments for cancer patients that the PA sends its way, and at the end, the PA does not foot the bill.  

“The PA debts to Al-Najah hospital have reached NIS 400 million. This has affected our ability to treat the patients, and has resulted in preventing them from receiving proper care, especially cancer patients who need immunotherapy and chemotherapy, both very expensive treatments,” Hijazi said. 

“One cancer patient’s course of treatment costs the hospital between NIS 500,000-1,000,000, depending on the patient’s condition. Other treatments are less expensive, which allows us to negotiate with the supplier to pay them in installments.”

When a patient comes to the hospital, and the hospital knows it can’t offer them treatment that it does not have, the hospital switches them to another hospital, and informs the sender of these details.

Hijazi asserts that the hospital has contacted the PA Ministry of Health several times to demand payment of its debts. “We have received no response,” Hijazi says.

The hospital has also sent several formal letters to the PA, but no written response has been forthcoming either. 

Mondoweiss reached out to the PA Ministry of Health several times for comment, but received no answer.

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