Due to blockade measures, a significant number of patients in Gaza, especially those suffering from conditions like cancer or other chronic illnesses, have to obtain medical referrals, the costs of which are covered by the Palestinian National Authority, to enable them to seek treatment in the occupied West Bank, Israel, or Egypt.
If the treatment request is in the occupied West Bank or within Israeli-held 1948 Palestine, the patients, after obtaining approvals and financial coverage from the Palestinian Authority, must apply for a permit from Israel to allow them to leave the Gaza Strip through the Beit Hanoun crossing, which is the only land crossing available for Palestinians who want to travel between Gaza and the rest of the occupied Palestinian territories.
The permit system
Israeli permits for patients can be delayed or denied multiple times before being approved — an indication of the arbitrary nature of the permit system and its impact on access to necessary healthcare services. From 2019 to 2021, only 65 percent of patients’ permits were approved in a timely manner that allowed them to make hospital appointments. In most cases, there is no explanation for the delay or denial of permits. “Many patients die due to long waiting times,” says Radwan.
Approval rates also vary among different population groups, with men between the ages of 18 and 40 experiencing the lowest approval rate at 47 percent. In terms of medical specialty, the lowest approval rates were for urological surgery at 44 percent, orthopedic surgery at 45 percent, and ophthalmology at 48 percent.
Some individuals undergo arbitrary detention and are subjected to interrogation for days or weeks while attempting to cross the Beit Hanoun border crossing during their journey in search of treatment. Even if they have a valid permit, they are pressured to provide information about other individuals wanted by Israeli security forces. For example, in January 2014, Israeli security forces arrested a 28-year-old patient with visual impairment at the crossing while he was on his way to the West Bank for specialized treatment for an eye disease. He was released after 30 days and returned to Gaza without receiving treatment.
Mosaab’s mother also notes how they have faced similar arbitrary impediments in the face of the Occupation. “We were supposed to travel within a week inside the occupied territories [1948 Palestine] for him to continue his chemotherapy or undergo tests, but we could not leave the house in the first place. We stayed for a very long time — months — waiting for a hospital in Haifa to approve his admission for us to be able to take him out. My son’s condition had deteriorated by the time we obtained the permit, especially since the Occupation refused to allow his family to accompany him. A neighbor had to accompany him. So, we had to beg our neighbors to accompany him for treatment.”
Crossing into Egypt
Israel often refuses to allow family members to accompany Gazan patients who seek treatment outside of the strip, claiming they include members affiliated with Hamas or Palestinian Islamic Jihad.
Accompanying patients is of utmost importance, especially for children, disabled patients and those in need of psychological support. However, a request to accompany them may affect medical approvals, as is evident from the period between 2019 and 2021 when only 46 percent of companion permits were approved in a timely manner for the patient’s scheduled medical appointment.
Entry into Egypt to seek treatment is not much easier. From 2007 to 2011, the crossing remained open for six hours each day. This changed after July 2013, when the crossing was opened for intermittent periods determined by Egyptian authorities. Meanwhile, Egypt built a barrier and demolished tunnels that were used to pass vital supplies into Gaza in circumvention of the siege, after imposing a state of emergency and curfew in North Sinai due to clashes with armed militants in the peninsula. Although there has been an improvement in movement through the Rafah border crossing in 2022 — around 23,000 passengers per month — compared to the previous year — approximately 15,000 travelers per month, it is still far from the pre-siege monthly rate recorded in 2005, which reached 40,000 people crossing via Egypt for medical treatment.
According to authorities, 3,117 patients traveled through the Rafah border crossing in 2014 with referrals from the Palestinian Health Ministry or with special medical reports from private sector doctors. In 2015, only 1,306 patients were able to travel for health reasons due to the limited opening hours of the crossing. In 2018, 8 percent of referrals outside of Gaza were to Egypt, with about 1,510 patients crossing the Rafah border terminal.
Leaving as the only solution
In 2018, 1,510 patients crossed, with only 8 percent of Gaza patients and their companions who obtained medical referrals to seek treatment in Egypt during the year being able to travel.
Before the ongoing Israeli aggression on the Gaza Strip, leaving was the only solution for some patients looking to receive treatment.
Egyptian authorities have continued to impose restrictions on the number and nature of individuals allowed to travel. As a result, many Palestinians in Gaza are forced to pay exorbitant “coordination fees” in order to move through the crossing and avoid security bans or delays. Additionally, according to the Euro-Med Human Rights Monitor, Egyptian police treat Palestinian travelers in an inhumane manner, subjecting them to frequent physical searches. These practices result in prolonging travel time between the crossing and Cairo International Airport for those intending to seek treatment outside of Egypt, amounting to 72 hours, in some cases, for a journey that should not take more than six hours under normal circumstances.
Before the ongoing Israeli aggression on the Gaza Strip, leaving was the only solution for some patients looking to receive treatment, given the deteriorating health situation in the enclave due to the siege. As for others, they have no choice but to seek treatment within Gaza.
The Palestinian health sector in Gaza consists of three main entities: the Palestinian Health Ministry, the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) and non-governmental organizations. The health ministry provides most of the health services.
Shortages due to the siege
As a result of the siege, the provision of public health services in Gaza has faced major obstacles due to a shortage of human resources, essential medicines, and equipment, leading to crucial gaps in infrastructure. The strict restrictions on planning, which prohibit the establishment of permanent or semi-permanent health facilities, have worsened the deterioration.
The total number of hospital beds in the entire strip comes in at 2,500, that is one bed per 1,000 citizens, Dar al-Shifa Medical Complex director Mohamed Abu Selima told Mada Masr. Before the siege, there was one bed for every three citizens.
According to the Palestinian Health Ministry’s Central Drugs Store, there has been a decrease in the availability of essential stocks in Gaza compared to the West Bank. Only an average of 55 percent of medicines were available in more than a month’s supply over the last three years. According to Ayed Yaghi, the director of the Palestinian Medical Relief Society branch in Gaza, 24 percent of the items used in operating rooms and intensive care units (such as holders for surgical towels, scissors, needle holders, surgical tweezers, etc.) have not been available since before the recent Israeli aggression.
In terms of medical devices, Gaza suffers from a severe shortage because Israel refuses to allow their entry. Additionally, medical personnel who perform operations in the occupied West Bank are not allowed to travel to Gaza and vice versa. There is also a ban imposed by the Occupation on training doctors outside Gaza, Raed al-Nems, the spokesperson for the Palestinian Red Crescent Society in Gaza, tells Mada Masr.
Due to the siege, hospital administrations and medical teams in Gaza are forced to make careful operational calculations in order to continue functioning. They prioritize vital healthcare services that require electricity from generators in order to conserve the limited fuel available. Government hospitals in Gaza consume approximately 61,000 liters of fuel daily, Radwan tells Mada Masr.
There is a severe shortage of medications for chronic diseases, with the deficit from the needed amount coming in at 42 percent compared to only 16 percent before the siege, according to Yaghi.
“Prior to the war, we had a significant shortage in human resources in relation to the number of oncology consultants in Gaza,” says Ziad al-Khuzendar, the medical director of the Basmat Amal Foundation for Cancer Patients Care and an oncology consultant. “There were only four of them, while there are 13,000 cancer patients in the Gaza Strip. Therefore, after diagnosis, the majority of cases, 60 percent of them, are referred to Egypt or hospitals in the West Bank due to the shortage of radiation therapy and diagnostic facilities. Additionally, most of the chemotherapy treatments are not available. Most cases are rejected by the occupation inside the occupied territories.”
Impossible choices
Yaghi adds that the Occupation prohibits the entry of devices necessary for radiation therapy on frivolous grounds, including the presence of radioactive materials. “There are many cases of children and elderly people dying as a result of this,” Yaghi says.
The Occupation also prohibits the entrance of kidney dialysis machines, of which there are only 160 in the sector, about a third of which are out of service. The Palestinian Health Ministry is unable to replace or repair them due to a lack of spare parts, according to Radwan and Yaghi.
Even though the healthcare situation in Gaza was already extremely bad before the recent aggression, it is currently far worse.
The siege also had an impact on various segments of Gaza’s population in need of healthcare. According to statistics from the Palestinian Health Ministry in 2021, 31 percent of pregnant women and 45 percent of breastfeeding mothers suffer from anemia. Additionally, 60 percent of refugee children in the strip, aged between six and 11 months, suffer from anemia. About 80 percent of Gaza’s population — most of whom are refugees — rely on humanitarian aid to meet their basic food needs for survival.
The current and ongoing targeting of hospitals has led to the closure of 15 hospitals and 32 healthcare centers, the killing of 130 healthcare workers and the destruction of 25 ambulances, according to Nems and the health ministry.
“We have started to choose and prioritize among the wounded due to the current situation,” Abu Selima says. “This means that we leave the minor and moderate injuries and choose the most critical cases. There are cases with no hope that we have to leave behind. The number of injured has exceeded the capacity of beds, so we provide treatment to patients on the ground and perform surgeries on the roads. We have also increased the number of beds in each room, meaning that a room with three beds now accommodates six.”
Even though the healthcare situation in Gaza was already extremely bad before the recent aggression, it is currently far worse, according to Yaghi. “The current situation in the healthcare system cannot be compared to the previous time in terms of the severity of overcrowding in hospitals due to the large number of wounded,” he says. “We are talking about more than 15,000 injured in a very small place, and patients or wounded are being received on the ground, waiting for hours until they are allowed to be admitted.”
The current aggression has also strained the supply of medicine. “What we consume in one day in terms of medications these days would previously last us for three weeks, especially since the Gaza Strip has been cut off for 17 days now and we are yet to receive any aid,” Abu Selima says. “Everything we had in the health ministry’s warehouses has been exhausted and consumed.”
He adds that a sound healthcare system cannot cope with this number of wounded, let alone a healthcare sector that is already depleted and lacking many medications and medical equipment.
Palestinians are in danger
With the water cut off, all Palestinians in the strip are in direct danger. Water is necessary to secure the health conditions in the internal medicine wards, operating rooms, and emergency departments, as well as for infection prevention. Also severely lacking are sterile saline water supplies, which are necessary for cleaning the wounds of the injured and maintaining the lives of patients undergoing catheterization, surgery, or intensive care.
For other patients, such as those diagnosed with cancer or kidney failure, the stakes are much higher. “Their situation is critical because cancer patients receive some of their treatment outside of Gaza, whether in Jerusalem or Egypt, and now all the crossings are unfortunately closed. In addition, kidney failure patients, for example, rely on ventilators, so the lack of fuel has put them at risk, along with children and newborns who require surgeries,” Nems says.
Those still able to make it to the hospital for the four-hour dialysis treatment have had their sessions cut to two hours. For a healthcare system that was already struggling to cope, the relentless bombing and the complete siege have resulted in a situation that Yaghi has described as “a catastrophe.”
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