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Left behind By Amira Hass Tags: medical care, Gaza  According to Gaza gallows humor, the Palestinian Authority government in Ramallah and the Hamas government in Gaza are competing to see which of them can heap more hardships on those living in the quarantine facility known as the Gaza Strip. Otherwise, it is difficult to understand the steps that each of the two governments has taken. In January, the Ramallah government stopped referring patients for medical treatment to Israel; on March 22 the Gaza government replaced the employees in the Referrals Abroad Department, which handles referrals for medical care. In place of the previous staff, which had answered to the government in Ramallah, it placed its own people. Israel, Egypt and Ramallah do not recognize the signatures of the new staff, and so referral for medical care outside Gaza has effectively ground to a halt. Both Palestinian health ministries swear that their actions have been guided solely by the interests of the patients and of Palestinian society. The patients and their families, however, are not so easily convinced that this has indeed been the only agenda. Since he first felt a pain in his back three years ago, until two weeks ago, when a third tumor was diagnosed at the base of his spine, 35-year-old Raed Al-Shawwa, a father of four, had undergone multiple procedures and operations (two large tumors, two major operations) and has faced ordeals familiar to many patients (misdiagnoses, inappropriate treatment). He has also, however, endured the kind of suffering exclusive to patients in Gaza: he spent weeks and days waiting for Israel to allow him in for treatment, was summoned to appear before Shin Bet security service officials at the Erez checkpoint (by now a routine requirement for patients from Gaza), spent a long day in the Shin Bet offices (since the operation he has had trouble sitting down for more than 20 minutes), and shuttled between clerks and doctors to collect the necessary signatures for the departure and referral (a bureaucracy with no fewer than four tiers: the health care system in Gaza; the Referrals Abroad Department, which is subordinate to the Health Ministry in Ramallah; the Israeli mechanism that muse issue exit permits from Gaza; and the hospital's own red tape - all of which must be traversed anew for each round of treatments in Israel). Advertisement After the second tumor was surgically removed, in September 2008, it was decided that Shawwa needed radiation therapy as well. Treatment, however, was then postponed for several months (which he could ill-afford), because after establishing his therapy plan, the hospital demanded that he return in 10 days for the radiation itself. His attempts to explain that getting the necessary permits would take at least 10 days were to no avail. Gaza residents are not allowed to stay in Israel between treatments. Shawwa returned to Gaza, and in November Israel would not grant him a permit to reenter. His appointment for radiation was canceled and rescheduled to January 25, 2009. During the Israel Defense Forces campaign in Gaza, however, patient referral services were shut down. The appointment was once again rescheduled, this time to February 25. But when Shawwa went to the Referrals Abroad Department in early February, he was stunned to hear from the clerks there that "treatment in Israel had been discontinued." Radiation therapy is not available in Gaza. After long years of delay, Israel had allowed the necessary equipment to be delivered, but it will not permit the transfer of the materials used in its operation. Shawwa began to consider seeking treatment in East Jerusalem. Then came the blow of the Gaza government expelling the employees of the Referrals Abroad Department. There is no one to coordinate the visit (not even to the West Bank or East Jerusalem, which, absurdly enough, are considered "abroad" by the Israeli-Palestinian permit bureaucracy), and the Ramallah government will not cover medical expenses if the letters of referral are signed by doctors and department heads who do not meet with its approval. Issue of passports Meanwhile, Shawwa's ongoing pain grew worse. A new test revealed a third tumor in the same location as earlier ones. Aside from the troubling prospect of finding a new doctor, treatment plan, hospital and country, yet another problem arose: to travel abroad, he needs a new passport. Blank passports are supposed to be sent from Ramallah to Gaza. Some 1,800 passport requests, including many from patients, have piled up in Gaza, but the Ramallah government has for months been refusing to send the blank documents. Shawwa, like many others, found a way to send his old passport to Ramallah for renewal. Sometimes Hamas officers at the Palestinian checkpoint near Erez go through the belongings of the few travelers on their way to the West Bank to make sure that they are not carrying expired passports in order to renew them. And most people, in any case, do not have the connections necessary to convey the expired passports or passport requests to Ramallah. Among them is an old woman who received a donation - the chance to have eye surgery in the Gulf states. Lacking a passport, she could not go. Egypt recognizes passports renewed by officials of the Interior Ministry in Gaza, but only for the purpose of staying in Egypt (or going on to Saudi Arabia). However, the Rafah checkpoint is closed, and it is opened only on rare occasions. Two weeks ago it was supposed to let through 300 patients, but the Egyptians ultimately refused to allow most of them in. According to sources within the Gaza government, a Palestinian Authority representative instructed the Egyptians to turn back patients who had not applied through the department that answers to Ramallah. In response, the Gaza government closed the checkpoint to everyone, and three days later it fired the employees of the referrals department. A source in the Ramallah Health Ministry indirectly confirms the allegations made in Gaza. He says that the Egyptians turned back patients "that weren't Ramallah's," fearing that they were not really sick. Similar charges are made in Gaza against the coordinators from Ramallah, who, sources in Gaza say, use health permits as a means to transport relatives of Fatah activists who fled the strip. Use of existing permits for other purposes is the constant risk that accompanies such severe restrictions on movement as those imposed by Israel (and by Egypt, which in this matter operates in coordination with Ramallah and Israel). Following protests from Palestinian and Israeli human rights organizations and some media coverage of the affair, the health minister in Ramallah, Fathi Abu Moghli, denied issuing any blanket directive to halt referrals for treatment in Israel ("There is no policy of zero referrals to Israeli hospitals"). The denial is inconsistent with the experiences of Shawwa and many other Palestinians. In official and unofficial responses, spokesmen in Ramallah gave various reasons for the decision: Treatment in Israel is far more costly than in countries such as Jordan and Egypt, and this budgetary burden comes at the expense of developing the health care system within the Palestinian territory - a major goal in the Palestinian Authority's development plans. 'False claims, untrue allegations' After the World Health Organization protested the halt in referral services early this week, the Health Ministry in Gaza issued an official statement denying the "false claims and untrue allegations" (that is, the claim that the power struggle between the Palestinian leaderships was being waged on the backs of the patients). According to the statement, the Referrals Abroad Department had been plagued by cases of corruption, bribery and the levying of unnecessary fees. These claims are rejected in Ramallah. The ministry also alleged that the department had refused to cooperate with it (that is, that it agreed neither to work with hospital directors appointed by Hamas to replace those associated with the Palestinian Authority nor to set up a doctors committee that would be acceptable to both sides). The Gaza government has made it clear to all involved that it is willing and able to pay for medical treatment abroad (including in Israel). This is yet more proof that the Gaza leadership has the necessary funds and has reached its own arrangements for covering health-care costs with hospitals and medical organizations in the Arab world. The Gaza government is persistent, and it is patient: It is demanding that the Rafah checkpoint be opened, under new terms rather than those decreed by Israel, Egypt and the Palestinian Authority (which Israel did not uphold, anyway). Ramallah, Israel and Egypt are also biding their time. But the patients are not; they are running out of time. Raed Al-Shawwa was told early this week that he needs to undergo surgery within the next two weeks. He has all but given up on the idea of getting treatment in Israel, and even if Physicians for Human Rights Israel could coordinate his entry (as it does in the few cases where patients are still covered by Ramallah's financial commitments), he cannot afford to have the procedure done privately. He is worried about the quality of health care in Egypt. His friends have made inquiries, and the Turkish Red Crescent is willing to pay for treatment in Turkey. But when will his passport arrive from Ramallah? Will the Egyptian and Hamas authorities be willing to open the Rafah checkpoint so he can fly through Cairo? Or, perhaps the Shin Bet and the Israeli Coordination and Liaison Office will come through in time with permission for him to pass through Erez and then the Allenby border crossing so that he can fly via Amman (since Palestinians are not allowed to travel through Ben-Gurion airport in Israel)? Bookmark to del.icio.us   A plague on Egypt Report: Iran behind planned terror attacks against targets in Egypt by Hezbollah. Determined diplomacy Obama: U.S. 'strongly supports' two-state solution, vows to continue peace process.

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