by Anas M. Ismail
This article is part of our Conflict & Health in the Eastern Mediterranean Series. Read the Series Introduction.
Palestinians in the Gaza Strip live in a different reality. Since 2007, Gaza has been under a blockade imposed by Israeli authorities, which determines, via a system of security permits, what and who can come in and out. This regime also covers medical patients, many of whom need treatment that is unavailable in the Gaza Strip. For patients, including children, living in conflict settings, their survival depends more often on political considerations than it does on medicine and expertise. Such patients go through a tedious and painfully uncertain process to get necessary documents and permits needed to travel to hospitals abroad, mainly in the West Bank and Israel.
The 14-year-old blockade and the recurrent attacks on the Gaza Strip have left the healthcare system fragile and lacking equipment, health care personnel, and reliable supplies of electricity and water1. The blockade has become a social determinant of public health in the Gaza Strip2. The two million people living there face shortages in many diagnostic procedures and treatment options. This is particularly an issue for cancer, cardiovascular, paediatric, and neurosurgical patients.
The Palestinian Ministry of Health (MoH) estimated, in its annual report for 2018, that there were nearly 110,000 referrals of Palestinian patients for services outside MoH facilities, with a total cost of nearly $200 million. Of the referrals, more than 30,000 were for patients from Gaza and amongst those, oncology patients were by far the most referred category. Shortages which lead to this trend include, but are not limited to, PET/CT scans to detect cancer metastasis, chemotherapy and radiotherapy for cancer, cardiothoracic and neurosurgical surgeries, and other diagnostic and treatment modalities. The patients who need these procedures have to navigate the intricacies of the local healthcare system whilst simultaneously traversing Israeli border controls. This journey is illustrated in a video produced by the World Health Organization (WHO) office in the occupied Palestinian territories (oPt).
When a patient in Gaza is told that the diagnostic procedure or treatment option they need is not available locally, they receive a detailed official report with their case and what they need to be referred for. The report is approved by hospital directors and sent to the local MoH which liaises with hospitals in the West Bank or Israel to book an appointment for the patients. After that, the MoH sends the reports and the appointment to the ministry in charge of liaising with the Israeli occupation, the Ministry of Civil Affairs (MoCA). The MoCA then files a request for a permit for the patient and a companion to leave on the day of the appointment to the Coordinator of Government Activities in the Territories (COGAT), which is the unit in the Israeli Ministry of Defence that deals with civilian affairs of people in the oPt. The request could then be accepted, and the patient would travel along with a companion to the hospital, or the request could be delayed or even denied, depending on COGAT and a security check by the intelligence agencies.
The WHO keeps track of monthly referral activities, and it estimated in 2018 that only about 60% of patients’ permits are approved in time, with the remaining being either denied or delayed. For cancer patients, denial or delay means missing their chemotherapy and radiotherapy cycles, which is detrimental to their survival as shown in the video by Medical Aid for Palestine. In the case of denial or delay the patients have to go through the same cycle starting with a new report, a new appointment, and a new permit request. Some patients, like in the WHO video, go through this procedure multiple times. Furthermore, the report by WHO highlighted that only 48% of permits for companions are approved, meaning that 12% of patients, including children, travel on their own to receive care. Moreover, patients whose permits were approved and cross the border can be, and are often, subject to security interrogation.
Patient referrals have been even further complicated by politics and the coronavirus pandemic in recent times. In May 2020, the Palestinian Authorities ceased almost all coordination with Israel in response to Israeli plans for annexation of illegal settlements in the West Bank. At the same time this happened, the oPt was experiencing the first wave of the coronavirus pandemic. Citing public health measures, Israeli authorities introduced further restrictions on border crossing, making things even harder for Palestinian patients needing care outside Gaza. As a result, permits issued for patients from the Gaza Strip declined drastically. The number of applications for permits from Gaza patients had dropped from over 1,700 patient applications for permits in February 2020 down to around 160 in May 2020.
In desperation, patients turned to the WHO office and human rights organizations to obtain much needed permits to seek medical care in the West Bank and Israel. However, this alternative approach shortly ended following statements by Israel implying that human rights centres could replace MoCA. Patients seemed to be trapped in a deadlock with no clear mechanism of how to access the care they need. As the situation gathered attention, human rights organizations started advocating for patients. In a letter to the Israeli Defence Minister, Attorney General, and head of COGAT, five Israeli human rights organizations called for the removal of all obstacles preventing patients from Gaza accessing the care they need.
Patients in the Gaza Strip have had to handle the complexities of occupation and living in a protracted conflict, with all that has meant in terms of arbitrary security procedures, time-consuming bureaucratic processes, and political disputes. In addition to living with malign conditions, they have had to endure the stresses of both the fractured and inadequate local health system and the uncertainty attached to accessing badly needed care abroad. Under International Humanitarian Law, those needing medical care should be spared from ongoing conflict and should be allowed to receive the care they need. The blockade of the Gaza Strip, which is a form of illegal collective punishment, has so far detrimentally affected the fate of patients needing care outside. While the Israeli-Palestinian conflict may be far from reaching an end, the suffering of those patients should not be.
- Smith, Ron J. “Healthcare under Siege: Geopolitics of Medical Service Provision in the Gaza Strip.” Social Science & Medicine 146 (2015): 332–40. https://doi.org/10.1016/j.socscimed.2015.10.018.
- Smith, Ron J. “The Effects of the Israeli Siege on Health Provision in the Gaza Strip: a Qualitative and Theoretical Analysis.” The Lancet 391 (2018). https://doi.org/10.1016/s0140-6736(18)30403-3.
- Devi, Sharmila. “Funding Crisis Threatens Palestinian Refugee Agency.” The Lancet 396, no. 10264 (2020): 1714. https://doi.org/10.1016/s0140-6736(20)32527-7.
Dr Anas Ismail is studying an MSc in global health with conflict and security at KCL. He graduated as a medical doctor from Gaza. He is interested in studying impact of conflict on health, especially health services and delivery.
Dr Ismail is the Production Manager at Strife Blog and a Series Editor. Follow him on Twitter at @anas_anesto.