Ramallah, September 14, 2022—At least three Palestinian children in the Gaza Strip died this year while navigating the complex medical referral permit system required to receive care outside of Gaza.
Saleem Al-Nawati, 16, Luai Al-Taweel, 14, and one-year-old Fatima Al-Masri are three Palestinian children from the Gaza Strip who died from severe medical issues while attempting to receive medical care outside of Gaza, a process that requires navigating a complex and drawn-out medical referral permit system required by Israeli authorities since Israel closed the Gaza Strip.
In 2007, Israeli authorities closed the Gaza Strip and isolated it from the outside world. Since then, Palestinian children have had to navigate life amidst continuous besiegement and frequent deadly Israeli military offensives. Those with chronic illness bear even more acutely the impact of Israel’s ongoing 15-year closure of the Gaza Strip.
As a result of the Israeli closure of the Gaza Strip, Palestinian children with kidney failure, like 11-year-old Ibrahim D., struggle to receive the medical care they need to survive.
Israel controls the Gaza Strip by land, air, and sea, preventing or severely limiting necessary resources from reaching two million Palestinians trapped in Gaza, of which 48 percent are children. Israel’s military-imposed closure has resulted in an acute, human-made humanitarian crisis. Chronic unemployment, fuel and water shortages, and extreme poverty are all exacerbated by frequent Israeli military offensives, and the repeated obliteration of Gaza’s fragile infrastructure, which cannot provide sufficient healthcare, education, and other services to Palestinian children.
Israel ratified the United Nations Convention on the Rights of the Child in 1991 obligating itself to ensure that health and other relevant services are available and accessible to all children, with special attention to under-served areas and populations. Israeli authorities’ practice of obstructing access to urgent health services for Palestinian children violates international humanitarian law and international human rights law.
Due to Israeli closure policies, the Palestinian government has developed and implemented a referral system in an attempt to address human-made humanitarian shortfalls in available public health services. The Palestinian Ministry of Health’s Service Purchase Unit is responsible for purchasing the services required, either from national private, civil, or charitable medical facilities or from other countries if the service is not available in the Palestinian medical market.
The State of Palestine is also responsible for realizing a child’s right to health, regardless of whether or not the government purchases services from private service providers on their behalf. The State of Palestine’s obligations, like any other state, includes a duty to oversee the private sector’s provision of services and to ensure that private sector providers recognize, respect and fulfill their responsibilities to the child, applying due diligence procedures where necessary.
Part 1 Saleem Al-Nawati, 16, died from leukemia while being examined by doctors after waiting for too long
Doctors in the Gaza Strip diagnosed 16-year-old Saleem Al-Nawati from Rimal neighborhood in Gaza City with leukemia in 2021 and recommended that he be transferred for treatment immediately to hospitals in the occupied West Bank, since hospitals in Gaza lack the required medicine to treat leukemia patients.
Over a period of several months, Saleem and his family made three failed attempts to secure the necessary referral permit that would allow Saleem to exit the Gaza Strip and obtain medical treatment at An-Najah Hospital, located in the occupied West Bank city of Nablus. In the meantime, Saleem had scheduled the hospital appointment and secured financial coverage as they waited for a permit to be approved by Israeli authorities.
Then, on December 26, 2021, the Palestinian liaison office called Saleem’s uncle, Jamal Al-Nawati, and told him to head to Israel’s Erez crossing located near Beit Hanoun on the Gaza perimeter in order to collect his permit and exit the Gaza Strip.
Israeli and Palestinian officials staff District Coordination and Liaison Offices throughout the occupied West Bank and Gaza Strip to coordinate the movement of Palestinians in and out of the West Bank and Gaza Strip. Palestinians living in the Gaza Strip are required to apply at a coordination office to obtain permits to enter Israel, which is necessary to travel to the West Bank.
When Al-Nawati arrived at the liaison office, he was informed that An-Najah Hospital would not receive Saleem. He was told that Saleem’s name was included in a list sent by An-Najah Hospital containing eight cancer patients’ names from the Gaza Strip stating that due to unpaid debts by the Palestinian government the hospital would not receive the patients.
Despite this, Al-Nawati and Saleem decided to travel to the West Bank and advocate for him to receive treatment at An-Najah Hospital.
“I decided to take the permit and venture to travel to complete proper treatment for Saleem,” Jamal told DCIP. “I actually went to An-Najah Hospital in Nablus on the morning of December 27, 2021 to advocate for Saleem to receive treatment. I had his complete medical file and financial coverage, yet they refused to receive him.”
According to Al-Nawati, the director of the transfers department refused to receive Saleem on the pretext of accumulating debts on the Palestinian Ministry of Health, even though a specialized doctor came and examined Saleem and recommended that he be admitted to the hospital.
Delays as a result of several failed permit attempts and complicated bureaucratic procedures resulted in the disease spreading to other parts of Saleem’s body and his health deteriorated.
After the hospital refused to receive Saleem, Al-Nawati traveled to Ramallah and contacted the Palestinian Ministry of Health’s Service Purchase Unit. Officials there contacted An-Najah hospital in hopes they would receive Saleem's emergency case, but the hospital administration refused to receive Saleem or any new patients transferred from the Gaza Strip.
At the same time, the Service Purchase Unit contacted Al-Maqasid Hospital in Jerusalem to treat Saleem as an emergency case. Hospital officials there similarly refused to treat him due to the accumulation of debts on the Palestinian government.
“On December 29, 2021, I submitted a complaint to the Minister of Health, Dr. Mai Al-Kaila, to pressure the Palestinian hospitals in the West Bank and Jerusalem to accept Saleem’s case, whose health condition and psychological state were deteriorating as a result of the repeated refusal of hospitals to treat him,” Al-Nawati told DCIP. “The Minister recommended that he be transferred to an Israeli hospital. I waited for the Israeli hospital’s response and demanded that Saleem be put in a hospital in Ramallah until we receive a response.”
“We were directed from the Service Purchase Unit to the Palestine Medical Complex in Ramallah until the approval of the Israeli hospital arrived,” Al-Nawati told DCIP. “But the complex refused to receive Saleem without giving any reason.”
On January 9, 2022, Ichilov Hospital in Tel Aviv informed Al-Nawati they would receive and treat Saleem. For the purpose of coordinating, that same day, Al-Nawati contacted the General Authority for Civil Affairs in Gaza and sent them the medical report, financial coverage, and the approval of the Israeli hospital.
Israeli authorities responded to Saleem’s urgent request as “under examination” indicating that Ichilov Hospital contacted Israeli authorities to expedite the necessary permits. However, they were told to return to the Gaza Strip and submit a new application from there.
“Saleem and I returned to the Service Purchase Unit in Ramallah where a doctor examined Saleem and recommended that he be transferred immediately by ambulance to the Palestine Medical Complex, noting that his condition is very urgent and does not warrant rejection,” Al-Nawati told DCIP.
"We went there, and during his examination before the doctors, Saleem died at about 12:15 p.m. on Sunday, January 9, 2022."
Part 2Luai Al-Taweel, 14, received approval for a medical referral at his funeral
Fourteen-year-old Luai Al-Taweel from Nuseirat Camp northern Deir Al-Balah in the Gaza Strip, was diagnosed with brain cancer on December 26, 2021. His parents immediately began the process to obtain a medical referral. They filled out the required initial form, known as Referral Form No. 1, and approached the Palestinian Ministry of Health’s Treatment Abroad Department to obtain an appointment with a hospital outside of the Gaza Strip and to secure the necessary medical treatment.
Luai’s family successfully obtained an entry permit on January 26, 2022, to travel through Israel’s Erez Crossing located near Beit Hanoun and receive treatment at Al-Maqasid Hospital in Jerusalem.
Luai’s family were asked by Israeli authorities to suggest two adults that could accompany him to Al-Maqasid, and they suggested Luai’s mother, Muna Al-Taweel, and uncle, Osama Al-Taweel, as possible escorts.
Israeli authorities informed them on February 7 that Osama was approved to accompany Luai, though the request for Luai’s mother was still pending.
Luai and Osama traveled to Al-Maqasid Hospital in Jerusalem on February 8 and Luai was admitted to the Neurosurgery Department after submitting the necessary medical referral and financial coverage documents.
Scans and analysis up to that point showed that Luai had a tumor on the right side of his brain, so doctors swiftly scheduled surgery for the next day, February 9, to remove the tumor. However, after conducting news scans and tests, doctors at Al-Maqasid Hospital discovered the tumor had spread to the left side of Luai's brain. They canceled the surgery and took a biopsy to find out the type and degree of the tumor.
Initial results of the biopsy on February 17 indicated that Luai had a third-degree cancerous tumor that required radiotherapy treatment—a medical treatment that is only provided by Augusta Victoria Hospital in Jerusalem—and despite a somewhat swift permit process, obstacles began to mount.
"That same day I went to Augusta Victoria Hospital to show them the results, scans and documents,” Osama told DCIP. “The person in charge told me that Luai can be treated at their pediatric department and their hospital policy states that children should be escorted by women only.”
“I told her we came from Gaza and Luai's mother was rejected by the Israeli authorities,” Osama said. “I showed her the refusal letter.”
The hospital official replied to Osama saying, “We will see.”
Luai and Osama also needed to provide Augusta Victoria Hospital with the final biopsy result, not the initial findings so Osama returned to Al-Maqasid Hospital. He was told that the final biopsy results would not be available for at least two weeks from when the biopsy procedure occurred, so they discharged Luai as there was no treatment they could offer him.
"We had no choice but to go to my sister's house in Bi'r as-Sab'i and wait for the final results of the biopsy. Fortunately, my niece is a doctor and she took care of Luai,” Osama told DCIP.
On February 26, the final biopsy report was issued. Osama and Luai headed to Al-Maqasid Hospital to collect the final report and brought it to Augusta Victoria Hospital.
“Luai's condition was getting worse and he could not stand on his feet, so I had to use a wheelchair to move him around,” Osama said.
Two days later, on February 28, doctors informed them that Luai needed at least 27 radiation sessions and possibly chemotherapy in between radiation. Importantly, Luai would not be able to start his treatment until they received the necessary financial coverage papers from the Palestinian Ministry of Health.
Osama and Luai’s family in Gaza did everything they could to get the financial coverage papers but all of their attempts failed. They were informed by the Department of Treatment Abroad that Luai should return to the Gaza Strip to be examined by a tumor medical committee and that he would have to start the referral process again from the beginning.
Luai and Osama had no other choice but to return to Gaza.
They entered the Gaza Strip on Wednesday, March 2, and with Luai's health deteriorating, he was admitted to Shuhada' Al-Aqsa Martyrs Hospital in Deir al-Balah the next day. He was transferred to Al-Shifa Hospital in Gaza City soon after because there was no neurology department at Shuhada' Al-Aqsa Martyrs Hospital.
Al-Shifa Hospital could not treat his condition either so on March 6 Luai was transferred to the Turkish Hospital in Gaza City where they then requested an urgent referral.
“We were informed that he would be seen by a medical committee a week later on March 10, so that his referral abroad could be approved,” Osama told DCIP. "But Luai's health condition could not wait that long, so we took him to an oncologist at the Turkish Hospital.”
They headed to the Department of Treatment Abroad on March 7 to try to obtain an appointment with Augusta Victoria Hospital, however, around 5 a.m. on March 8, Luai died at the Turkish Hospital. The same day Osama received news from Augusta Victoria Hospital.
"During the funeral ceremony on Tuesday, around noon, I received a call informing me that Augusta Victoria Hospital had agreed to admit Luai to their department on Sunday, March 13," Osama told DCIP. "I told them that Luai had passed away."
Part 3Baby Fatima Al-Masri, her parent's only child, died while waiting for a medical permit
Fatima Al-Masri, from Khan Younis located in the southern Gaza Strip, was around one-year old in July 2021 when she began showing signs of fatigue and her lips turned blue when she cried.
Her parents Jalal and Du'aa Al-Masri brought her to the children's ward at Nasser Medical Complex in Khan Younis in the southern Gaza Strip where she was diagnosed with an enlarged heart.
Fatima was transferred to the European Gaza Hospital, also located in Khan Younis, where doctors in the cardiology department soon discovered a four-millimeter-wide hole in her heart.
She was hospitalized for nine days and doctors recommended nebulizer and bronchial treatments and told her father to bring Fatima back to the hospital after two months.
Fatima was Jalal and Du’aa’s only child after spending eight years trying to have children.
Two months later, in September 2021, Fatima’s father took her back to the European Gaza Hospital where the head of cardiology told Jalal that the hole in her heart had expanded to one centimeter in length. Doctors decided to transfer her abroad for treatment because she needed special treatment that was not available in the Gaza Strip.
Jalal and Du’aa completed the initial referral application, Referral Form No. 1, and started the process to obtain a referral from the Palestinian Ministry of Health’s Service Purchase Unit.
“On November 29, 2021, Fatima received a medical referral and financial coverage in order to be treated at Al-Maqasid Hospital,” Jalal told DCIP. “The appointment set by the hospital for her admission was on December 28, 2021.”
Jalal approached the Palestinian General Authority for Civil Affairs to apply for an entry permit. He suggested Fatima's grandmother, 45-year-old Yasmin Al-Masri, as her escort, hoping Israeli authorities would allow his daughter to travel without any obstacles.
One day before the admission date set by Al-Maqasid Hospital in Jerusalem, on December 27, Israeli authorities informed the family that their referral request was pending, effectively denying Fatima and her grandmother permits to travel through Israel’s Erez crossing located near Beit Hanoun.
“We set a new appointment with Al-Maqasid Hospital, which was on February 13, 2022, and we applied again for an entry permit, but our request was also declined on February 11, two days before the appointment,” Jalal told DCIP. “Another appointment was set on March 6, and I approached Al-Mezan Center for Human Rights to help me with Fatima's entry permit.”
But on March 5, Fatima’s request was declined by the Israeli authorities for the third time in a row. A new appointment with the hospital was set on March 27.
“As usual, I went to the Civil Affairs Department to submit the requested documents, but I was told that I should renew the medical reports and the financial coverage because they were issued some time ago, so I renewed them and had to set a new appointment with the hospital, which was April 5,” Jalal told DCIP. “For the fourth time, I applied for an entry permit, and we all waited impatiently for the Israeli authorities' reply.”
During all that long period of applying and getting rejected by the Israeli authorities, Fatima's condition was getting worse. At approximately 10:30 a.m. on Friday, March 25, Fatima went into a coma and her family took her to Nasser Hospital, but she died upon their arrival. Fatima was only 20 months old.
“It was a painful shock. I lost my only child, whom I waited for her to come after eight years of marriage and not being able to conceive,” Jalal said. “I lost her because of Israel's refusal to grant her an entry permit, despite her need for treatment because of her condition as a 'save life' case.”
