In March 2020, Israel announced that as part of its fight against the coronavirus, it would further reduce the already miniscule number of Palestinians permitted to leave the Gaza Strip for medical purposes. In doing so, Israel shirked its duty to allow ill residents access to essential treatment unavailable within the Gaza Strip, and left them to their fate.
Gaza’s healthcare system has been in a state of collapse for years due to Israeli policy. Already, it cannot meet the population’s needs due to a shortage of medicine, equipment, doctors and professional training. Before the pandemic, thousands of Palestinians a year applied to leave Gaza to receive medical treatment unavailable at home, either in hospitals in the West Bank (including East Jerusalem) or in Israel. The Israeli authorities hampered the approval of these requests, including by restricting permits to treatment they define “lifesaving” and only if they are unavailable in Gaza.
This reality, which barely met the minimum requirement for the medical care residents of the Gaza Strip need, ceased to exist with the outbreak of the pandemic. Three main factors contributed to this situation:
Further stringent restrictions imposed by Israel: Since the pandemic broke out, residents who need vital treatment outside Gaza have faced insurmountable obstacles due to the new movement restrictions Israel imposed in March 2020. Israel, like many other countries, has lifted some of the restrictions it imposed on the area under its control during the pandemic – including allowing Palestinians from the West Bank who have work permits to enter its sovereign territory. Yet the restrictions on Gaza remain in place.
Patient concerns due to the pandemic: The uncertainty of the past year, and especially its first few months, led some residents who need medical care not to apply for permits to leave Gaza. They preferred to postpone the appointment if their medical condition allowed it, rather than risk a long ride on public transportation to unfamiliar hospitals and enter lengthy quarantine upon their return.
The Palestinian Authority’s cessation of security coordination with Israel: In May 2020, the Palestinian Authority (PA) announced it would halt its security coordination with Israel, in response to Israel’s intentions to annex parts of the West Bank. Accordingly, the PA’s Ministry of Civil Affairs stopped forwarding applications to leave Gaza for medical treatment. Many patients who were scheduled for treatment found themselves unable to obtain a permit. In November 2020, the PA resumed its coordination with Israel.
Throughout the coordination hiatus, Israel did not acknowledge its obligation to provide an alternative solution for these patients. International organizations, human rights organizations and Palestinian hospitals in the West Bank and in East Jerusalem intervened in critical cases to help patients obtain permits from Israel, but this fell far short of meeting their needs.
Due to these changes, the number of applications to enter Israel or the West Bank from Gaza for essential medical care dropped sharply, from a monthly average of some 2,000 to only several hundred a month. In March 2021, traffic at Erez Crossing was at some 6% of its volume in prior months.
In comparison, from March 2019 to February 2020 (just before the pandemic), according to World Health Organization figures, almost 24,000 Gazans applied for permits to enter Israel for vital medical treatment. Some 65% of the requests related to treatment at hospitals in East Jerusalem, about 22% to hospitals in the rest of the West Bank, and some 13% to hospitals in Israel. Of all these applications, more than a third (about 8,500) were rejected or not answered before the scheduled appointment, including at least 2,274 minors and about 996 persons over 60. Among the persons who were rejected or went unanswered, at least 1,996 had cancer, 597 had a heart condition, and 210 required neurosurgical treatment.
Allowing Palestinians from Gaza to enter the West Bank or Israel for medical care is not an act of charity on Israel’s part. Israel created this reality and is therefore responsible for it. It is the authority that controls all passage into and out of the Gaza Strip (except for Rafah Crossing), that determines the level of medical care available within Gaza, that has chosen to imprison more than two million people and keep them cut off from the world, and that prevents residents from receiving crucial treatment they cannot receive within Gaza due to Israeli policy.
B’Tselem’s field researchers in the Gaza Strip collected testimonies from Palestinians who were denied permits to leave Gaza for essential medical care.
Two-year-old Yamen al-Akhras has cancer and has been waiting since January for a permit to travel to Nablus for medical treatment. B’Tselem field researcher Muhammad Sabah collected a testimony with his father, Ibrahim (29), a father of three from Yabna Refugee Camp in Rafah, on 28 February 2021:
My son Yamen started showing signs of pain when he was six months old. He cried all the time and we were always busy trying to calm him down. At first, we thought he had dislocated his hip at birth. Then we thought it might be something to do with teething. We took him to doctors who tested him, and they all said everything was fine and that the test results were good.
When Yamen turned one, he still couldn’t stand or walk, so we took him for tests at the European Hospital in Gaza and at a-Najar Hospital in Rafah. Again, the results were good and the doctors didn’t find anything. We didn’t give up and went to the UNWRA clinic in Rafah. The pediatrician there diagnosed a dislocated hip. We went to another doctor, and he also said that Yamen had a dislocated hip and installed a pelvic fixator for six months. When the six months, were up, we went for a checkup and he said there was no improvement. He set a date for hip dislocation surgery at the cost of USD 1,000, which is a lot of money for us.
We wanted a second opinion, so we went to another pediatrician who gave us an MRI referral. We did the MRI, and it turned out that Yamen has spinal cancer. When my wife Hala and I heard that, we were shocked. The pain and sadness were immense. It hadn’t occurred to us that our son had cancer. He was probably born with it. After all the suffering he went through, and we went through with him, we felt we might lose him. We were terrified of the suffering that awaited him and the thought that we might lose him.
The doctor asked to do more tests, and Yamen was referred to a-Rantisi Children’s Hospital in Gaza, where he received a round of chemotherapy. Then he was referred to a-Najah Hospital in Nablus, because the treatment he needs isn’t available in Gaza, and they scheduled an appointment for 26 January 2021. I applied for a permit for him and for Hala. We waited for the permit, but it didn’t arrive. On 25 January, the Ministry of Civilian Affairs notified us that our application was still under review. We missed Yamen’s appointment.
We were stressed and very worried that he’d never make it to the hospital for treatment. We filed a new application through the Ministry of Civil Affairs, this time for Yamen, for my wife Hala and for Yamen’s grandmother, because we hoped we could get a permit for one of them. We waited anxiously. We were stressed the whole time. Yamen was suffering and crying constantly, and could only sleep on his stomach because of the pain. We kept trying to ease his pain.
The evening before the appointment, the Ministry of Civil Affairs notified us that our application was still under review. We were shocked. There’s no justification for that. It’s a baby with cancer who needs urgent treatment, and any delay causes the disease to spread and increases his suffering. We waited patiently and asked the hospital for another appointment. Now we’re waiting again for an answer from the hospital.
Manatallah al-Hanafi (15) from Rafah has a cancerous tumor in her thigh. Israel is barring her from getting treatment at in Ramallah. B’Tselem field researcher Olfat al-Kurd spoke with her mother, Amal al-Hanafi (43), on 7 March 2021:
In early 2018, we discovered that Manatallah has a cancerous tumor in her right thigh, right by the artery. She was in seventh grade, and I remember waking up at night because she was crying in pain. At first they gave her painkillers for a month, but that didn’t help. I took her to an orthopedist who said she didn’t have anything. She kept getting worse and cried from the pain all day long.
We went to another orthopedist, and he sent her for an MRI at al-Quds Hospital in Gaza, which we paid for privately. The scan revealed that Manatallah had a 7-centimeter-wide cancerous tumor in her thigh. We were shocked. I broke down when I heard that. Manatallah tried to calm me down and said she’d be strong and would cope with the disease and the treatments, and that we’ll all pass away one day.
My husband applied for treatment abroad, and the Palestinian Authority authorized coverage for treatment at Palestine Hospital in Egypt. Manatallah went there with my husband Khaled, and on 23 December 2019 had surgery to remove the tumor. She stayed in Egypt and received treatment for 45 days, and came back confined to a wheelchair. I was shocked when I saw that.
Two weeks later, the pain came back just like before the operation. We went back to al-Quds Hospital in Gaza, and the doctor referred her to al-Istishari Hospital in Ramallah.
We filed an application through the Ministry of Civil Affairs and set an appointment for 26 April 2020. My husband was supposed to go with her. But the day before the appointment, we received a message that my husband was denied entry. He asked human rights activists for help, and meanwhile we set a new appointment for 10 May 2020. This time, we asked for a permit for me as the escort.
We got the permits and traveled to al-Istishari Hospital. By then, Manatallah’s condition was very bad and she’d developed chronic pneumonia. At the hospital, they put her straight in the ICU, where she spent about 17 days. The doctors said her immune system was very weak and gave her all kinds of treatment to strengthen it. During her time in the ICU, her condition improved.
After 17 days in the ICU, Manatallah had surgery to remove the tumor that had developed again in the same spot. The operation was very complicated and took eight hours. I waited anxiously by the operating room. I felt terrible. I was alone, scared and worried about Manatallah.
After she recovered, Manatallah and I stayed for three months at the hospital’s patient hotel for follow-up. Her physical and mental state improved, and she could walk again.
While we were there, the Israel Security Agency summoned my husband to Erez Crossing. They told him they wanted to ask him general questions, but he refused to go.
On 7 August 2020, we came back to Gaza. We waited at Erez Crossing from 9:00 A.M. to 4:00 P.M., when we were allowed to cross. Then we went into quarantine for 21 days at the Blue Beach Hotel in Gaza. The quarantine was tough for both of us, and Manatallah’s mental state deteriorated.
On 11 January 2021, Manatallah was supposed to go back to al-Istishari Hospital for tests. We submitted an application, but the day before the appointment, we both got a negative answer from the Israelis. We checked with an attorney from the Al-Mezan Center, and he suggested we do another MRI scan. The scan showed that the tumor was back, in the same spot.
We set another appointment for 22 February 2021 and submitted an application. The same day, we received a message that the application was still under review. We were in touch with a human rights organization, and they asked us to set another date and reapply for a permit. We haven’t received a new date to this day. We’re eagerly waiting for an appointment to take care of Manatallah. She desperately needs treatment. I worry about complications for her health, and want her to get back to a normal life.
Manatallah stopped going to school because of the illness, and now because of the coronavirus, she doesn’t leave the house at all.
Manatallah al-Hanafi has been scheduled another appointment for 15 May 2021. She has applied for a permit and is currently awaiting a reply.
Maram Darwish (22) from Beit Lahiya in the northern Gaza Strip has cancer, but since the pandemic began, has not received a permit to leave Gaza for radiation therapy in the West Bank. She gave her testimony to field researcher Olfat al-Kurd on 1 March 2021.
In January 2019, when I was in my fourth year of medical studies at al-Azhar University in Gaza, my pulse quickened and I started suffering from phlegm, a severe cough and chest pain. I took medication for the phlegm and the coughing, but didn’t feel any improvement. My mother insisted that I undergo an examination and an X-ray at the UNWRA clinic in Jabalya Refugee Camp. I got examined and did a chest X-ray, and it turned out that I had a 35-centimeter-wide lump in my lung. I was immediately transferred to the Indonesian Hospital in the northern Gaza Strip, where I had a CT and an echocardiogram, and it turned out that I had a tumor in my lung. I had a very severe cough and was kept at the Indonesian Hospital for three days.
I applied for a permit to leave Gaza for treatment at a-Najah Hospital in Nablus. I got the permit easily and went there with my father, Nafez, on 6 October 2019. I was treated there for a month and then went back to Gaza in relatively good condition. On 22 November 2019, I was supposed to go to a-Najah for treatment again, this time with my mother Maha (54), but the Israeli DCO informed me that my mother was denied entry. We submitted an application for my father and it was approved, and we went for treatment at a-Najah on 26 November 2019. We stayed there for about three months. By that time, all the muscles in my body were aching but I tried to stay positive in order to overcome the disease.
On 1 March 2020, I went to Nablus again with my father to do a culture test. I stayed there until 22 March 2020, and the doctors decided that I should come back in June 2020 for radiation therapy. Then the coronavirus broke out and I couldn’t get a permit. In November 2020, I was scheduled another appointment, this time at al-Mutala’ Hospital (Augusta Victoria) in East Jerusalem, but both my father and I were refused. This happened twice. In January 2021, I had another appointment, and again my application was denied.
The Ministry of Civil Affairs informed me that I had to come for a meeting at Erez Crossing. When I got there, no one was waiting for me. One of the officers simply told me, “Go to Jerusalem.” I said, “Alone? Without my father? I didn’t bring any documents or money for the trip.” I got really frightened and stressed and told the officer that I wanted to go back to Gaza.
I went home. Two weeks later, an officer from the Israeli DCO called my father and set up a meeting with him. In the meeting, they asked my father about my brothers, about our home and about all sorts of people from our area. They asked, “If we send Maram alone for treatment, will you agree?” My father refused and said it would be difficult to send me for treatment without an escort. At the end of the meeting, they told him to go home and that God willing, he’d be able to go with me next time. Now I have another appointment for 15 March 2021. I urgently need radiation therapy and to have the catheter inserted into my chest a year and a half ago removed. Now we’re waiting to see if we’ll get the permits.
Maram Darwish was not granted an entry permit to attend her appointment on 15 March 2021. She scheduled a new appointment for 4 May 2021.
Musa a-Rashidi (52), a father of seven from Gaza City, needs surgery to remove cysts on his vocal cords that suffocate him in his sleep, but Israel has denied him a permit to reach hospital in Ramallah. He gave his testimony to B’Tselem field researcher Khaled al-‘Azayzeh on 1 March 2021:
In 2018, I started suffering from mucous cysts on my vocal cords, which make me hoarse and suffocate me in my sleep. I paid NIS 2,000 (~615 USD) to have them removed at a private hospital in Gaza. About a year later, the cysts returned and the suffering became worse. I went back for treatment and follow-up with specialists at a-Shifaa Hospital in Gaza.
I choke in my sleep, wake up and vomit. I keep a trash can by my bed just for that. When I wake up, I can’t even talk because of the phlegm that builds up on my vocal cords. I feel like I’m choking all the time and take medicine regularly to dissolve the phlegm and help with the hoarseness.
I need to have laser surgery at a hospital in the West Bank, because the equipment isn’t available in Gaza. I got a referral for al-Istishari Hospital in Ramallah, and they scheduled an appointment for 24 November 2020. I applied for an entry permit through the Ministry of Civil Affairs in Gaza, but the days went by and I received no answer. The date of the appointment passed and I asked the hospital to set a new one. They scheduled a new one on 8 December 2020. Again, I applied to the Ministry of Civil Affairs and again, got no response. On the day of the appointment, the ministry notified me that the Israelis had denied my request.
I was very frustrated. I’ve never had security issues with the Israelis and I don’t belong to any faction. I gave up and didn’t schedule another appointment, because every time you have to go to the Ministry of Civil Affairs and it takes a whole day to process the documents. In my condition, it’s tough.
I’m afraid that if I have another operation in Gaza, they’ll accidentally cut my vocal cords. But if I don’t have surgery, the cysts will grow and I won’t be able to talk at all and could choke to death in my sleep.
Because I can’t talk properly, I prefer to stay home and am cut off from the world. I don’t talk a lot with relatives or anyone else. When my phone rings, I ask my wife to answer it for me. My mental state is awful. I’m afraid to sleep and worry a lot before I fall asleep – because I’m afraid of suffocating and don’t know whether I’ll even wake up in the morning.
Riham al-Ghalban, a 21-year-old student from Gaza, has ulcerative colitis. Israel refuses to allow her to receive medical treatment in Nablus. B’Tselem field researcher Olfat al-Kurd collected her statement on 2 March 2021:
I’ve had this disease for five years. It started when I was in high school. I suffered from abdominal pain and acute diarrhea and had blood in my stool. I went for tests at Nasser Hospital and at the European Hospital in Khan Yunis, and every time, the doctors told me everything was fine and only gave me painkillers, but my condition didn’t improve.
I went to a-Salem Hospital in Khan Yunis, where I was examined but they didn’t find anything. A week later, I also underwent a colonoscopy, and it turned out that there were acute ulcers in my colon. I was hospitalized for a week at Nasser Hospital. Then I was monitored by the doctors, but nothing helped and I kept suffering. At some point, they started giving me rectal injections to stop the bleeding. I got them for a whole year, and there was a slight improvement in my condition, but then it deteriorated again. The doctors tried to give me a different type of rectal injection. I got them for a month, but they didn’t help. Then I got abdominal injections for six months.
When all that didn’t help, the doctors decided to refer me to a-Najah Hospital in Nablus. I received a referral and an entry permit through the Ministry of Civil Affairs, and on 12 January 2020 went there and had two rounds of biological treatment. I stayed for about three weeks. After that, my condition improved. Then I got another permit, and on 26 February 2020 I went to a-Najah and received one round of the biological treatment. I stayed there for three days.
On 8 March 2021, I had another appointment for treatment. But then the coronavirus broke out and I couldn’t go to a-Najah, because the checkpoint was closed. Al-Hayat Hospital in Gaza also started giving that treatment, so I got it there twice.
Then I received a referral to al-Mutala’ Hospital (Augusta Victoria) in Jerusalem and I was scheduled there for 17 December 2020. But both my mother, who was supposed to accompany me, and I didn’t get the permits. I was scheduled for 11 January 2021, and again the Israelis refused to issue us permits. I was devastated.
I need the treatment to recover from this disease. I’m constantly exhausted, I’m very skinny and keep vomiting. I can’t eat a lot of things, such as dairy, cereal and meat. I wish this suffering will end and I can go back to normal. I want to continue my studies, which have suffered a lot since I became ill.
Meanwhile, I have another appointment for 30 March 2021 and I’ve applied for permits. I’m still waiting for an answer from the Israelis. I need six rounds of biological treatment for the suffering to end.
Riham al-Ghalban was not granted a permit to attend her appointment on 30 March 2021. As of 18 April 2021, she is being treated in the Gaza Strip and is trying to make set another appointment.