For Some Gazans in Need of Medical Treatment, the Wait for an Exit Permit Ends in Death

Yara Bakheet, 4, and Aya Abu Mutalq, 5, are among 20 patients who died this year after their exit permits were not granted in time

Aisha Hassouna and her daughter Lara, whose 4-year-old twin sister Yara died in July, in the Gaza Strip.
Khaled al-Azayzeh

In January, 4-year-old Yara Bakheet fell ill. She vomited frequently over an entire week and became dehydrated, and after a series of examinations at the European Hospital in Khan Yunis, Gaza, the doctors told her mother, 28-year-old Aisha Hassouna, that her daughter was suffering from heart failure.

An appointment was made for her at Al-Makassed Hospital in East Jerusalem where, the mother was told, there were suitable resources for treating her child.

The medical records, the appointment slip and the commitment to pay, together with an application for a permit for Yara and her father to exit Gaza, were submitted to the Israeli Coordination and Liaison Administration, which grants exit permits subject to the opinion of the Shin Bet security service. 

Exit permit delays for Gazans seeking medical treatment in Israel:
Requests without a response

The mother told a field researcher for the B’Tselem human rights group that the first application was denied. Yara missed her appointment. A new appointment was made for February 16. The family went through the whole bureaucratic rigmarole again: documents, copies, appointment, commitment to pay, application form and a trip to the Palestinian liaison office, which sent the documents to the Israeli officials and officers.

This time, to ensure that the application for the permit would not be denied because of the identity of the accompanying adult, the mother’s grandmother was selected as the accompanying adult: 72 years old. The application was granted and the two set out for Jerusalem.

The great-grandmother herself suffers from high blood pressure and diabetes. Worse, little Yara didn’t know her well and refused to accept help from her at the hospital. The little girl thought her parents had abandoned her, and during the whole time she was at Al-Makassed, where she underwent catheterization, she refused to speak to her parents on the telephone. “I felt like my heart was crushed with longing for her voice,” said Hassouna, Yara’s mother.

Yara returned home gaunt and remained angry at her mother who had not been at her side. Her condition became even more obvious when Lara, her twin sister, was nearby.  After treatments and hospitalizations in the Gaza Strip, it was decided to send Yara to Al-Makassed again. An appointment was made for June 2 and the documents and stamps made their way again to the Israeli liaison office.

A week before the appointment the family’s mobile phone received an instant message saying the request was still under consideration. The appointment was missed. The days passed, Yara’s condition worsened and when she experienced shortage of breath and choking she was again taken to the European Hospital. Another appointment was made at Al-Makassed, for July 20, to implant a pacemaker that is not available in Gaza. But Yara died at the European Hospital on July 13.

Yara is one of 20 severely ill patients who died this year in Gaza after their application for an Israeli exit permit to receive medical treatment was not granted in time. A new B’Tselem report to be published this week discusses this growing phenomenon of unexplained delays in the issuing of exit permits for medical treatment.

The patients did not receive official refusals, but only the message “Your application is under consideration.” The Israeli liaison officers send this message to the members of the Palestinian liaison office, who send an instant message to the family, sometimes on the evening before the appointment.

It’s hard to determine if and when a death is caused directly by a delay in issuing an exit permit for treatment. But it’s clear that the waffling, the expectations and disappointment, the constant uncertainty, the tension and the need to go through the whole exhausting bureaucratic procedure all over again each time aren’t salubrious.

Worse over the past four years

In June, when Yara was supposed to go to Jerusalem to have a pacemaker implanted, 1,920 requests from patients for exit permits from Gaza were submitted. The World Health Organization notes that 951 of those applications were approved, 20 were refused (less than 1 percent) and 949 (49.4 percent) went unanswered by the date of the hospitalization or treatment. Of the latter, 222 of the applications were for children under 18 and 113 for people over 60.

In September, 42 percent of the 1,858 applications for permits for medical treatment remained in limbo. Of them, 140 were for children under 18 and 99 for people 60 or over.

The Erez crossing
Eliyahu Hershkovitz

This has been a clear trend during this past year, about which Haaretz reported on November 9: Applications for exit permits for any purpose are delayed with no reply for weeks and months. By September this year their number had reached about 16,000.

The percentage of unanswered applications for exit permits for medical treatment has nearly tripled over the past four years. According to the World Health Organization, which the B’Tselem report cites, in 2014, 15.4 percent of applications went unanswered; in 2015, this number was 17.6 percent. By September 2017, there were 8,555 that remained unanswered, accounting for 43.7 percent of nearly 20,000 applications.

“Security reasons” was the explanation for the refusal of 2.9 percent of the applications, while about 53 percent were granted. About three quarters of the applications were for treatments at Palestinian hospitals in the West Bank and East Jerusalem.

The Shin Bet said in response, “Over the past year, we have seen an increase in the practice whereby terrorist organizations, headed by Hamas, exploit the departure of Gaza residents (including for medical treatment) to promote terrorist activity, including by transferring explosives, money for terrorism and other means of promoting terrorist activity.

“This past April, two Palestinians who had been allowed entry into Israel so that one of them could receive medical treatment for cancer were caught at the Erez crossing. Their baggage was found to contain medical tubes, inside of which explosives were hidden that apparently were meant for a Hamas attack in Israel.

“Given the great danger this activity presents, strict security checks are performed on everyone applying to leave Gaza. Naturally, these checks take time, and efforts are constantly being made to reduce that time and prioritize the handling of all entry applications, with an emphasis on humanitarian applications whose subject is entering Israel to receive life-saving medical treatment.”

Nearly 20 percent of the applications that have gone unanswered in 2017 were for children and adolescents under 18, and about 8 percent (725) were for people 60 and over.

One of the latter is Fatma Biyoumi, 67, who suffers from a serious blood disease. Following tests and treatments in Gaza, appointments were made for her for October 24 and November 4 at An-Najah Hospital in Nablus. In the absence of a reply, she missed the appointments. A new appointment was made, this time for a date in August at Augusta Victoria Hospital in Jerusalem, and the reply remained “under consideration,” even though Israeli nonprofit group Physicians for Human Rights accompanies her in her requests for an exit permit.

A new appointment has been made for December 17, and Biyoumi and her family are living in a state of constant suspense: Will the application be approved, or will it be approved at the last minute in order to increase the suspense, and will there be enough time to plan?

In its statement to Haaretz on Thursday, the Shin Bet said Biyoumi “has been summoned for questioning, after which it will be possible to complete the process of her security evaluation.” Biyoumi, it turns out, was questioned by the Shin Bet at the Erez crossing on Wednesday.

Huwaida, 48, who suffers from blood cancer, has an appointment for December 6, after having received the “under consideration” reply to all her previous applications: for treatment on August 13, September 11, September 24, October 9, October 29, November 8 and November 22. She too has sought help from Physicians for Human Rights, and she too is living tensely in the fear of yet another disappointment.

The Shin Bet told Haaretz that “after she was questioned and her case was examined, an answer was sent to the liaison office saying there is no security obstacle to approving her request.”

Disappointment the day before

Aya Abu Mutlaq was 5 when she died. She suffered from cerebral palsy from birth and was treated in Gaza. In October 2016 it was decided to send her for treatment at Al-Makassed. An application was submitted for a permit for her and her father, because her mother had given birth only two months earlier. The appointment was for February 4, and on February 3 the family received an instant message stating that the application was still under consideration. The appointment was postponed to March 16. Again, just one day before the appointment, a message was received saying the Israeli side was still considering the application.

The little girl’s condition deteriorated. A new appointment was made for April 27, but she died on April 17. Her father had exited Gaza three times in the past to Ramallah and Jerusalem – for treatment for a knee problem. He couldn’t understand why, out of the blue, when his daughter needed him to accompany her, the application was delayed until she died.

According to the World Health Organization, about half the people applying to accompany patients do not obtain exit permits – something that often postpones the patient’s treatment. Under new procedures at the Coordinator of Government Activities in the Territories, the amount of time the liaison office takes to deal with applications for exit permits has increased significantly – up to 70 days not counting weekends and Jewish holidays. For medical conditions (but not in life-or-death situations), the maximum amount of time that has been set is 23 days.

Close tracking by Physicians for Human Rights of the cases of nine female cancer patients shows that the Liaison Office does not keep to the time limit that it set for itself. Eight of the nine women did not make it to their appointments for medical treatment in recent months because their requests for permits were “under consideration.”

But according to the Shin Bet, “an examination of the cases mentioned in Haaretz’s query” – which dealt with 11 patients who died and several others who have been awaiting approval for several months – “revealed that most of their requests for entry into Israel have been approved, and some have already used their permits to enter Israel and receive medical treatment.”

On November 29, Ghada Majadala and Mor Efrat of the Israeli physicians’ organization sent an urgent letter to Maj. Gen. Yoav Mordechai, the head of the Coordinator of Government Activities in the Territories, and to Moshe Bar Siman Tov, the director general of the Health Ministry. In the document, which focuses on the nine women suffering from cancer, Majadala and Efrat noted that the cancer treatment available in Gaza is inadequate.

In recent months there has been a drop in the stock of medications used in conjunction with chemotherapy, they wrote, and it is difficult to perform surgery to remove tumors because of the shortage of fuel and electricity. Moreover, in Gaza there are no radiation or radioactive iodine treatments, nor is there equipment for following the progress of the disease. In addition, both the Majadala-Efrat letter and the B’Tselem report note that the Palestinian Authority is now pursuing a policy of reducing the number of patients sent for treatment outside Gaza.

In their letter, copies of which were sent to the Israel Medical Association and to the nurses’ ethics committee, Majadala and Efrat wrote that the waiting causes not only suffering but also exhaustion in the battle with the bureaucracy. “A non-reply does not enable patients to use their right to appeal a refusal if one is given,” they wrote. “Not replying for many months attests to a policy of contempt for the patients’ suffering.”