Dana Moss and Mor Efrat
In early 2017, 39-year-old Faida Abeed from Deir al Balah, Gaza, felt a lump in her breast. She was diagnosed with breast cancer and underwent chemotherapy treatment and excision of the tumor. The necessary follow-up treatment is radio-iodine therapy and for that she would need to leave Gaza as the treatment is unavailable in the Strip. In October 2017, after receiving confirmation that she had financial coverage for the treatment, she applied for an exit permit from the Israeli authorities to leave Gaza for East Jerusalem, a journey of about 100 kilometers. East Jerusalem, part of the Palestinian healthcare system, is where the most specialized Palestinian hospitals can be found. She was refused, a decision that left her unable to access the needed treatment. She applied five more times without success.
Physicians for Human Rights Israel (PHRI)—an Israeli human rights organization focused on the right to health—actively lobbied the Israeli army unit responsible for issuing permits (COGAT) for a permit for Faida. Yet only after her case was taken to the High Court of Justice in late 2018 was Faida given a permit. In the past 18 months, PHRI has lobbied for over 55 women from Gaza Strip, who, like Faida, were diagnosed with cancer and denied exit permits. As these cases highlight, Israel continually places obstacles in the path of patients needing access to treatment, in violation of the right to health.
The healthcare system in Gaza has deteriorated over the past 11 years of siege and numerous military operations and attacks by Israel. This-combined with a consistent and historic lack of investment in Gaza’s hospitals and medical system-according to WHO left nearly 16,000 patients last year needing to exit the Strip to receive treatment that is unavailable locally.
In 2012, according to WHO, more than 90% of patients from Gaza received a permit to exit the Strip and receive treatment elsewhere. In 2017, only 54% of patients from Gaza received a permit in time for their hospital appointment. The increased restrictions on permits affected all patient groupings and is reflected in the range of patients that are now requesting PHRI assistance to reverse Israeli permit rejections. In the past, PHRI received requests for permit help mainly from young men, but recently PHRI is also helping middle-aged women with life threatening conditions, specifically cancer.
Indeed, WHO notes that “the single largest referral specialty for patients from the West Bank and Gaza was oncology, for treatment and investigation of cancer” (see page 20). In Gaza, cancer accounted for one in four patient referrals outside the Strip. Cancer treatment in Gaza is reflective of the inadequate state of its medical system in general. Radiotherapy treatment, including radiodine treatments for thyroid cancer, is unavailable and there is a lack of chemotherapy drugs. Imaging technology to track disease progression is likewise lacking. A shortage of medical equipment, combined with electricity cuts, have reduced the number of operations that can be performed to remove tumors. As a result, when patients are denied an exit permit to receive cancer treatment, it may be tantamount to a death sentence. WHO documented five cancer patients who died in August 2017 while awaiting a permit decision from the Israeli authorities.
Since mid-2017, PHRI has advocated extensively on behalf of female cancer patients such as Faida who were unable to secure treatment locally and whose request for a permit was denied. This work has included direct communications with COGAT and partnering with major cancer awareness organizations in Israel, who have also lobbied the Israeli army and Knesset, the Israeli Parliament. Health professionals have joined the campaign, with more than 30 senior Israeli oncologists launching a public appeal focusing on the life threatening risks caused by permit rejections. These appeals resulted in the first Knesset debate on the topic of female cancer patients in Gaza, as well as a 100% success rate in overturning permit refusals, thereby demonstrating the arbitrary nature of security justifications for permit denials.
This success, however, was short lived. It was not much later when 13 patients reached out to PHRI and al Mezan, a Gaza based Palestinian human rights organization, after they were denied permits on the basis of a new justification, “family proximity to Hamas”. According to statistics provided by the Israeli Ministry of Defense in response to a Freedom of Information Act request by Gisha, the Legal Center for Freedom of Movement, in the first three months of 2018 over 800 permit requests from Gaza residents were denied on the grounds “first-degree relative is a Hamas operative”, compared to 21 in all of 2017.
This criterion appears to be a result of Israel’s Security Cabinet decision made in January 2017, and used extensively since the beginning of 2018. It orders “several operative measures to serve as leverage over Hamas with respect to returning captured and missing persons”, namely two Israelis currently held hostage by Hamas and the bodies of soldiers who died in Gaza. After repeated appeals to COGAT that had little impact, PHRI, together with other human rights organizations, contested the permit refusals in the High Court of Justice. In August 2018 the Court took a refreshingly critical stance, and ruled that Israel cannot impose a collective punishment on patients simply because they are related to Hamas and that the Cabinet decision was illegal, disproportionate, and contrary to Jewish values.
Unfortunately, since the ruling, several women with cancer have reached out to PHRI and other human rights organizations after their permit was denied for various different reasons, including one patient who had previously been denied on the basis of “family proximity to Hamas”. In other words, the same problem under a different guise.
This situation has been gaining International attention. The 2018 Concluding Observations of the UN Committee on the Elimination of Discrimination against Women raised the subject of permit denials, and recommended that Israel “remove any restrictions on freedom of movement” (Art.31 a). In August 2018, the Special Rapporteur on Health and other UN experts wrote a communique to the government of Israel, asking for information on permit denials and noting their concern and in November 2018, the British Medical Association wrote to the Secretary of State, Jeremy Hunt, to urge him to take up the issue of medical permit denials with the Israeli authorities.
This is not the first time that right to health of residents of Gaza has been used for political purposes and Israel is not the only party to do so-the Palestinian Authority and Hamas have also engaged in such politics. Among the challenges that patients-whose bodies serve as symbolic sites for the power struggle between these different actors-have had to undergo are humiliating interrogations as a means of information-gathering by the Israeli army in order to receive a permit; the denial of financial coverage by the Palestinian Authority in its clash with Hamas, and manipulation so that they serve as messengers by Hamas as part of the latter’s strategy of launching attacks in Israel.
Israel, as the effective occupying power, controls the movement of goods and people through Gaza’s airspace, sea, water and land crossings. Accordingly, Israel deserves the brunt of the blame for the denial of access to healthcare for people living in Gaza. Until all Palestinian residents in need of medical treatment are unequivocally granted freedom of movement by the Israeli authorities to obtain that treatment without delay, patients will continually bear the burden of policies that impact and impede their right to health. Meanwhile, the phones at PHRI keep ringing, as women diagnosed with cancer whose permit requests have been denied seek assistance in accessing treatment only a few kilometers away.
Dana Moss is International Advocacy Coordinator, Physicians for Human Rights Israel
Mor Efrat is Director, Occupied Palestinian Territory Department, Physicians for Human Rights Israel