Permission denied: Gaza children struggle to get medical care

With severe medicine shortages and an overstretched health care system in Gaza, children in need of medical treatments can only find them outside the strip. Yet Israel’s convoluted, arbitrary permit process leaves them waiting in pain, often missing life-saving care.

By Jen Marlowe

Al-Shifa Hospital in Gaza weeks into Operation Protective Edge, on August 9, 2014. (Basel Yazouri/Activestills.org)
Al-Shifa Hospital in Gaza weeks into Operation Protective Edge, on August 9, 2014. (Basel Yazouri/Activestills.org)

GAZA — Noha Saleh called me at seven in the morning on March 18 from Erez, the only crossing point from the Gaza Strip into Israel. Her 12-year-old son, Mohamed, had a surgical appointment in Jerusalem later that day to re-attach severed nerves in his leg. Seven became 8:00 and then 9:00, and still there was no word from the Israeli army. With the help of Physicians for Human Rights Israel, we were told that Mohamed’s permit was still “pending.” Noha and Mohamed returned home, dejected. This was the fourth appointment Mohamed had missed because the Israeli army hadn’t issued them the requisite travel permits.

Defense for Children International-Palestine had put me in touch with Mohamed in February because I wanted to know what happens when children need to leave Gaza for medical care.

To learn why children need to leave Gaza for medical treatment and why their needs cannot be met in the strip, I sat down with Mahmoud Deeb Daher, head of the World Health Organization’s sub-office in Gaza. Difficult cases have been referred to Israel since the start of the occupation, said Daher. When the Palestinian Authority was established in 1994, large-scale investments were made in the Palestinian health care system, but then, in 2000, the Second Intifada erupted. “The whole focus became towards the relief and the emergency, so this development that was steadily going up, was reversed,” said Daher. Since then, Gaza has faced repeated crises, including three wars. “The system is struggling to maintain its functionality.”

The siege, financial crisis, and political deadlock between the PA in Ramallah and the Hamas government in Gaza have led to chronic shortages of essential drugs. Ongoing electricity shortages force hospitals to ration power. Israel’s policies regulating imports and exports to Gaza, particularly those restricting “dual use” items, lead to long delays in arrival, repair, or calibration of medical equipment. As of May 7, the PA announced it will stop sending drugs to Gaza’s hospitals altogether, though the WHO affirms that a shipment of drugs was received in mid-May.

Salaries of government workers (including medical workers) are routinely withheld or reduced due to the internecine power struggle or because of financial difficulties. There is also a new shortage of specialists, said Daher. Highly-skilled physicians are emigrating, retiring, or dying.

And that doesn’t take into account the stream of casualties from the Great Return March. Nearly 17,000 people have been injured since March 30, 2018. There are approximately 1,500 patients with lower limb injuries (including heavy fractures and bone and muscle loss) who require between two to six surgeries each. “These are an additional burden on the system that has been already over-exhausted and over-stretched,” said Daher.

Mohamed Saleh in his home in Jabalia, Gaza. (Jen Marlowe)
Mohamed Saleh in his home in Jabalia, Gaza. (Jen Marlowe)

Mohamed Saleh, the 12-year-old turned away at Erez, is one of 3,905 children wounded during the Great Return March. Mohamed boarded a protest-bound bus on October 5. “I swear he escaped [from] me, he jumped out of the balcony,” his mother Noha told me at their home in Jabalia. “I kept telling Mohamed, ‘I don’t want to lose you! I don’t want you to go!’ but he said, ‘No, Mama, I want to go with my friends!’”

An Israeli soldier shot Mohamed above his right knee, severing arteries and nerves. The arteries were reconnected at Gaza City’s Shifa Hospital. But no hospital in the strip has the capability to conduct nerve transplant surgery so Mohamed was referred to Makassed hospital in East Jerusalem.

Rifaat Muheisen, manager of Gaza’s Coordination Department at the Ministry of Civil Affairs, outlined the labyrinthine process for permit applicants like Mohamed. First, the patient’s doctor submits a referral form to the Palestinian Ministry of Health in Gaza, referring the patient to a hospital in the West Bank, East Jerusalem, or Israel. Then, the referral is reviewed by a committee of doctors; if the committee agrees that treatment isn’t available in Gaza, the request is sent to the PA’s Service Purchasing Unit (SPU) in Ramallah to obtain financial coverage.

Next, the SPU arranges the hospital appointment. Finally, Muheisen’s office emails the appointment notification, medical reports, financial coverage certification, and copies of the patient’s and companion’s ID to the Coordination of Government Activities in the Territories (COGAT) — the Israeli military body responsible for administering the occupation and Gaza siege — requesting permits for them to enter Israel.

In 2018, there were 25,896 permit applications (of whom 7,591 were for children). That year, in 61 percent of the cases, the applicants received a text message from Muheisen’s office informing them that permission was granted. Mohamed’s application was among the other 39 percent whose requests were still “pending” or were outright denied. Mohamed’s first appointment, which he didn’t receive a permit to attend, was on November 18, 2018, the second was in December, and the third in mid-February 2019.

“Why do they refuse a kid like him? [Denying] me, no problem, but my son, this child, what trouble did he cause?” asked Mohamed’s mother, Noha.

The severed nerve caused Mohamed agonizing electric jolts, Noha told me. He would sometimes scream, pull his hair, and bite himself from the pain. “When pain hits my son, everyone goes to bed, and it’s me who stays up next to him.” Noha’s voice trailed off as she described her helplessness watching her son suffer.

Until 1991, Gaza residents could exit the strip without individual permits, WHO’s Daher explained. After the 1991 Gulf War, permits were required but were easy to obtain. Starting with the Second Intifada, permits were granted only for limited purposes including commerce, study, and medical care. In June 2005, a woman from Jabalia with a medical permit was caught at Erez with an explosive belt, leading to additional restrictions and search procedures.

By September 2005, when Israel declared its disengagement from Gaza complete, the strip was effectively sealed. The November 2005 Agreement on Access and Movement was supposed to guarantee safe passage between Gaza and the West Bank, but was never implemented. But it was when Hamas gained control of Gaza in 2007 that Israel placed Gaza under a full military blockade.

COGAT’s June 2010 Civilian Policy Towards Gaza Strip was intended to ease the humanitarian situation, and it did for some time. “In October 2015, we started to notice reversal of the situation,” said Daher, who doesn’t know what triggered the change. Thousands of commercial permits were withdrawn, further restrictions on humanitarian workers implemented, the age for intelligence checks on patients decreased, and permit processing time increased.

Muheisen said that in recent months, COGAT has begun refusing permits on the basis of their assessment that the requested treatment is available in Gaza. While refusing a patient due to security concerns is COGAT’s prerogative, Muheisen argued that the army could not reject an application based on its assessment of the availability of that treatment. Israel, after all, doesn’t have full knowledge of the constantly shifting medical landscape in Gaza.

Mohamed’s case corroborates Muheisen’s assessment. In an email, a COGAT spokesperson informed me that Mohamed’s initial request was denied because there was “suitable medical treatment in Gaza.” I asked why COGAT was making determinations regarding treatment availability — wasn’t that the purview of the Palestinian Ministry of Health? The spokesperson did not answer. (Regarding Mohamed’s second request, COGAT claimed that the PA Civil Affairs office didn’t provide requested follow-up documentation in a timely manner.)

The Israeli army’s permit regime in Gaza is often arbitrary. The army might approve a cancer patient for their first chemo treatment, “but they may reject their permit application the next time, then may give the permit the third time, reject their permit the fourth or fifth,” Al-Mezan Center for Human Rights fieldworker Yamen El Madhoun explained. Patients are also at risk of arrest when they exit the strip, said El Madhoun. In 2018, one patient and four companions were arrested at Erez after receiving permits, while another 130 patients were called in for Shin Bet interviews, which were sometimes used to pressure patients into becoming informers.

Palestinians arrive at the Erez Crossing between Israel and Gaza on September 3, 2015. (Yonatan Sindel/Flash90)
Palestinians arrive at the Erez Crossing between Israel and Gaza on September 3, 2015. (Yonatan Sindel/Flash90)

There are other new hurdles. Until 2017, patients and companions between 16-35 underwent security clearance by the Shin Bet. Now, patients and male companions under 55, as well as female companions under 45, must undergo security clearance. The process can take weeks and can lead to stark choices: a young mother applying as her sick child’s companion risks delaying his treatment, or a grandparent, possibly old and ill, must accompany the child in her stead. Israel agreed in January to expedite security clearance for mothers with children under five, but as of March, Muheisen hadn’t seen much improvement.

Ghada Magadli, Physicians for Human Rights Israel’s Freedom of Movement Coordinator, believes this psychologically impacts children and their recovery. “If the kid is alone at the hospital and he’s in pain, he needs a surgery, then of course he needs his mother or his father, someone that he trusts, someone that he knows to be beside him.”

Magadli added: “If you have a family member who works in the Health Ministry, then you can be labeled as someone who has ties to Hamas. If you have a family member who stays in the West Bank without the Israeli permit, then you can be labeled as a security threat.” A sick child’s permit may thus be contingent upon a relative who is in the West Bank without a permit returning to Gaza “This is one way to use the need of this mother and of this kid to reach Israeli political objectives.”.

A COGAT spokesperson blames Hamas and the PA for Gaza’s collapsing health care system, writing in an email that Hamas “prefers to invest in terror and in strengthening itself militarily — along with a massive drop in the budget for medical assistance from the Palestinian Authority.” The spokesperson wrote patients are exploited by terror organizations using tactics such as “smuggling of explosives, terror funds, and other means of advancing terror activity.” I asked for specific incidents but received no response.

Though the security agency is opaque about providing actual statistics, in a May 2017 publication the Shin Bet lists four examples of residents of Gaza exploiting their medical permits for “terrorist purposes.” Three of the four cases involved transferring money to people in the West Bank; the fourth was a woman caught with explosives in a pill bottle. In November 2018, the Shin Bet released a statement about foiling a terror plot involving a message delivered to a West Bank operative by women from Gaza entering Israel for medical treatment. The handful of cases are used as justification for increasingly onerous restrictions impacting thousands of Palestinians in Gaza—many of them children.

***

I opened a bag of toys, inviting 10-year-old Abdallah Abu Kash to pick. He chose a doll for his sister. I’ve been visiting Abdallah in his Wadi Gaza home since 2015; he is the reason I became interested in children seeking treatment outside of Gaza. In 2015, I interviewed Abdallah’s father, Abdelrahman, for an article about Gaza’s water and sanitation crisis. Abdelrahman told me then about his son’s rare chest and lung disorder, which compromised his breathing and posed a real danger to his life.

Abdallah had been allowed to go to Makassed but his referral wasn’t renewed for ongoing treatment. The Palestinian Center for Human Rights coordinated appointments at Ichilov Hospital in Tel Aviv, but most of the costs fell on Abdallah’s desperately poor family. Abdelrahman asked if I could help, so two friends and I began fundraising.

Abdallah and his mother, Mahasin Aldhheik, regularly received permits, first to Makassed, then to Ichilov. But in February 2017, 42-year-old Aldhheik received a text message that she and Abdallah were “under security check.” She has received the same message with each subsequent application. Abdallah attended only one of his quarterly appointments since then, alongside his grandfather, who doesn’t know the intricate details of Abdallah’s illness.

Abdallah answered my questions in a quiet but clear voice. He likes playing football, and says he wants to be a translator when he grows up. And when he can’t go for treatment, “I just keep wondering why I didn’t get the permission…that’s all.”

Abdallah is weakest in the winter and often cannot attend school. “He opens the window in the early morning when it’s freezing, just to watch the other children walk to school, even when he’s really sick,” Aldhheik said. “When they return from school, he stands next to the window again to watch them.” It is on those days that Abdallah can be mischievous. “He keeps annoying you because he feels irritated inside. Bothering his sisters while they study…”

“No, I don’t!” Abdallah interrupted in protest.

“…jumping from one spot to the other.” Aldhheik understands. “He’s not feeling easy, emotionally,” she said.

I contacted the COGAT spokesperson via WhatsApp on May 16, asking why Aldhheik wasn’t issued a permit. The spokesperson responded via email, saying “the mother’s request did not meet the criteria” and “the request was closed.” I asked which criteria Aldhheik hadn’t met. There has been no response.

On April 8, Magadli from PHRI emailed me an assessment by a physician who had examined Abdallah’s medical file. “His health status is deteriorating, both in terms of his breathing and his general bodily status…I assess that there is a real danger to his life.” The doctor recommended Abdallah be hospitalized in Israel in order to stabilize, properly diagnose, and treat him. Starting March 26, however, the Palestinian Ministry of Health terminated medical referrals to Israeli hospitals, in response to an Israeli decision to withhold millions in tax dollars it collects on the PA’s behalf, though the WHO noted in an email that there are exceptions made.

Abdallah underwent a series of tests in Gaza on May 12 and is awaiting a referral decision. If the PA gives Abdallah a referral, it will be for a Palestinian hospital. Until then, his mother hopes that those in power realize her 10-year-old son is not a combatant, but “merely a sick child with no power whatsoever…Put yourself in my shoes; if this was your son, how would you feel?”

The risk to Abdallah’s life underscores a grim reality: permit delays can be lethal. In 2018, al–Mezan documented eight patients who died waiting for treatment; in 2017, 54 patients died, including three children.

The Abu Mutlaq family, with Ghalib holding a photo of his deceased daughter Aya in the town of Abasan, southern Gaza Strip. (Jen Marlowe)
The Abu Mutlaq family, with Ghalib holding a photo of his deceased daughter Aya in the town of Abasan, southern Gaza Strip. (Jen Marlowe)

I visited Aya Abu-Mutlaq’s family in Abasan, a rural town in southern Gaza Strip. Aya’s parents, Abeer and Ghalib, served tea as roosters pecked the dirt outside their yard. Ghalib sifted through Aya’s medical reports and appointment notifications. He held up a passport-sized photo of Aya, her eyes tightly shut but her mouth stretched in what might be a smile. Ghalib and Abeer’s words overlapped as they relayed their little girl’s ordeal.

Aya was born on January 15, 2012 with cerebral palsy. “You couldn’t understand what she is suffering because she couldn’t speak…you couldn’t figure out what she wanted from you,” Ghalib said. Aya also had a defect in her larynx, preventing her from swallowing normally. All her nutrition was through a feeding syringe. By the time she turned five, Aya had stopped eating almost entirely. A pediatric specialist referred her to Makassed. Aya and Ghalib were still under security check when her appointment arrived on February 5, 2017.

This puzzled Ghalib. He had traveled to Makassed in 2014 for knee surgery and hadn’t experienced security issues. He requested a new appointment date, going through the entire referral process again. The new appointment was March 19. By the time the date rolled around, Ghalib and Aya were still under security check, so Ghalib requested a third date — set for April 27. Meanwhile, Ghalib and Abeer watched their daughter’s health decline. They couldn’t switch Aya’s companion; only her parents knew how to carry and feed her, and Abeer was breastfeeding her four-month-old son.

Early in the morning on April 17, Abeer picked Aya up. The little girl was blue. Abeer ran frantically with Aya to the nearby hospital, where the doctor informed her that her daughter had passed away two hours before.

More crushing for Ghalib than Aya’s death was the fact that her treatment had been repeatedly delayed. “That’s what really broke me. She’s a child, that’s the point, and it broke my heart.”

COGAT referred my questions about Aya’s case to the Shin Bet, which has yet to respond.

***

Samira al-Ghoul is the 48-year old grandmother of 2-year-old Kareem, who was born two months premature with a host of health problems. At six months, Samira noticed that Kareem’s head was abnormally large and took him to Rantisi Hospital in Gaza, where doctors detected fluid in his brain. He underwent surgery but suffered complications. Then the seizures began, as did his difficulty keeping food down.

Kareem was referred to Makassed in late 2017. “Now the problem came from the Israelis, they started refusing me,” said Samira. “Why? Who knows.” She’s been applying for 15 months, she said, and received nine refusals.

Kareem slept in Samira’s arms at Rantisi. If he cried, “I’d touch him, saying, ‘You are my love, Kareem,’ and he’d stop crying.” Samira struggled not to cry as she told her story. “I have five grandchildren. But Kareem is my whole life, because I’m the one who took care of him.”

Kareem’s 25-year-old mother, Nariman, suffers from diabetes, high blood pressure and a heart murmur, but felt she had to apply to accompany Kareem to Makassed. When I visited Samira in al-Shati Refugee Camp on February 27, Kareem and Nariman had already been at Makassed for two weeks, with the latter feeling ill and exhausted.

Kareem and Nariman returned to Gaza in early March, where his condition steadily worsened. Kareem has a new appointment at Makassed on June 27. Samira is trying once again to obtain a permit to accompany Kareem.

Palestinian patients at Rafah’s UAE Crescent hospital, southern Gaza Strip, on January 13, 2019. (Abed Rahim Khatib/Flash90)
Palestinian patients at Rafah’s UAE Crescent hospital, southern Gaza Strip, on January 13, 2019. (Abed Rahim Khatib/Flash90)

On March 20, Noha called me. Mohamed’s new appointment was set for April 8, yet there was still no word about his permit. That afternoon, Mor Efrat from PHRI also called. A physician from Tel HaShomer hospital in Israel had reviewed Mohamed’s medical files and believed that Mohamed might lose his leg if he did not undergo surgery soon. PHRI would move on two fronts, Efrat said. They would appeal to the army for the permits while petitioning an administrative tribunal in Be’er Sheva. The court scheduled a hearing on Mohamed’s case. In the meantime, I began raising funds for Mohamed’s medical needs.

The day before the hearing, the army granted the permits. Magadli believes the outcome is evidence of the occupation’s capriciousness. “The fact that we are able to reverse 50 percent of the army’s decisions… it says something about the reliability of allegations of security threats.”

I picked Mohamed and Noha up from Erez early one April morning to go to Makassed. Two days later, Mohamed underwent a grueling 11-hour surgery. The outcome won’t be clear for months. Mohamed has another surgical appointment in July, and Noha worries his permit may be denied again. The uncertainty upsets Magadli as well. “The fact that they will go through this procedure again and again…that is something very frustrating, knowing that they would probably need your help again.”

Magadli’s hope for the future, however, isn’t just a less restrictive permit regime. “I would love to witness the day [when Palestinians have their own] functioning health system, and they won’t need permits in order to have the basic right of accessing health and receiving treatment.”

Salsabeel Hamdan contributed reporting to this story.

Jen Marlowe is the Communications Associate for Just Vision and a filmmaker, journalist, author, and human rights activist. Her work includes the play There is a Fieldthe book “The Hour of Sunlight: One Palestinian’s Journey from Prisoner to Peacemaker” and the film “One Family in Gaza.”