Waiting for an exit permit that never comes

Ramallah, March 21, 2021—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 14-year closure of the Gaza Strip.

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 whom 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.

Defense for Children International - Palestine spoke to the families of several chronically ill Palestinian children in Gaza, for whom survival is dependent upon successfully navigating the numerous and complex restrictions imposed on them by Israeli authorities. 

Mother of three, Najwan A., 37, and her family found themselves at the mercy of Israel’s closure of Gaza when her second child, Yahiya, fell ill just a year after Israel’s massive 2008 military assault on Gaza, Operation Cast Lead. 

Najwan and her husband, who live in Tel al-Hawa, a neighborhood in southern Gaza City, noticed swelling across Yahiya’s body when he was four months old. The Al-Rantisi hospital in Gaza City ultimately diagnosed him with proteinuria, or the excessive loss of protein through the urine, usually caused by kidney problems.

Yahiya was subsequently treated with human albumin three times a week, at a cost of $100 USD per treatment. Human albumin is produced by the liver and may be administered medically to treat low albumin levels caused by dialysis. The Palestinian Ministry of Health in Gaza initially covered the cost of Yahiya’s treatment, but growing medicine shortages triggered a health crisis in the Gaza Strip that persists to this day, and the family was forced to pay for the treatment. 

According to Palestinian Ministry of Social Development in Gaza, almost 75 percent of the population lived in poverty in 2019. Unemployment rates, too, were at approximately 75 percent, and 70 percent of people were food insecure. As such, parents in the Gaza Strip are often unable to pay in full for essential medical treatment.

“Doctors often used to reduce the amount of [human albumin] liquids and solutions due to the unavailability of the drug and our inability to buy it, mainly during the Israeli aggression on Gaza in 2012, which was one of the most difficult moments in my son’s life,” said Najwan.

“We would need the [dialysis] machine, and in Gaza it would be damaged or unavailable,” she told DCIP.

“We also suffered from a lack of drugs, whether those made available by the Ministry of Health or those found in pharmacies, and we had to buy those drugs at our expense, which caused us a financial crisis.” 

The family also had to pay 60 NIS ($18.50 USD) three to four times a week for injections to prevent jaundice. Yahiya was briefly transferred to a hospital in Egypt, but his condition did not improve, and he was taken home to Gaza before being transferred to the Augusta Victoria Hospital in Jerusalem.

Early in 2020, Yahiya, now 12, lost his ability to walk and started using a wheelchair.

“Medical supplies are not available, so we often buy special tape and sterilizers,” Najwan said. “And there is the transportation problem. We often took a taxi to get him to the hospital in Gaza four times per week for dialysis sessions, and we paid 20 NIS ($6 USD) each time. But about a month ago, Interpal [Palestine Relief and Development Fund] provided a bus to transport Yahiya and other dialysis patients to and from the hospital.”

Najwan was forced to quit her job as an English teacher at an UNRWA school to care for her son. 

“He is in bad psychological condition because he is sitting in a wheelchair the entire time,” she told DCIP. “He wants to play with other children as he did before his bone pains…He also dropped out of school after the first grade. Because of dialysis, he skipped many of his classes and was left behind.” 

Three years ago, the Mabarrat al-Rahma Society provided Arabic and math lessons to children, including Yahiya, at the hospital. However, the program for dialysis patients ended in March 2020. 

“Yahiya has become very edgy and does not accept things easily,” said Najwan. “He needs me next to him all day long.” The medical issues with Yahiya’s bones could be treated with Zemplar, a solution that is unavailable in Gaza due to the cost. 

“We also reject the referral [for treatment in Israel] at the present time because anyone entering Gaza will be placed in quarantine for 21 days, and this is impossible for my son and me to bear,” said Najwan. 

Palestinian children in Gaza share how Israel’s blockade affects their lives.

Israel’s closure of the Gaza Strip has plunged Gaza’s health sector into crisis. The closure restricts essential and lifesaving medical and pharmaceutical resources from entering Gaza as well as patients and companions leaving Gaza. Israel has, for several decades, maintained strict restrictions on travel to and from Gaza, as well as the import of vital materials, and the export of goods, blighting the economy. 

Egypt, too, has kept its border with Gaza mostly closed since 2013, opening it only intermittently. Both Egypt and Israel claim security reasons for the closure of the Gaza Strip, a practice that amounts to collective punishment under international law. 

Israel’s repeated military offensives, including three particularly devastating ground and aerial assaults in 2009, 2012, and 2014, devastated Gaza’s infrastructure, including it’s healthcare system. According to Medical Aid for Palestinians, 17 hospitals and 56 health centres were damaged or destroyed in Israel’s 2014 military offensive against Gaza, Operation Protective Edge. 

Israel’s regular obliteration of Gaza’s infrastructure, combined with its closure policy, has created a humanitarian crisis characterized by acute water and electricity shortages, further compromising the health of patients, who cannot expect treatment in sanitary conditions, or for vital and lifesaving electricity-powered machines to run without interruption. 

In 2018, when back-up generators failed at the Pediatric Specialized Hospital in Gaza City, medical teams had to manually ventilate four children until the machinery was fixed.

Dr. Reem Sammour, Head of the Drug Store Division at Al-Rantisi hospital, told DCIP that a lack of medicine is the greatest obstacle facing doctors with child patients diagnosed with cancer or kidney problems. 

“There is no regularity in providing medicines with full monthly quotas,” Dr. Sammour told DCIP. 

Of the ten classes of drugs that should be made available for the treatment of children, only two are available, according to Dr. Sammour. A shortage of calcium pills and vitamin D, among other drugs, including blood-thinning drugs, affect children, like Yahiya, with kidney problems, in particular. 

What the hospital does not have, the parents must buy, according to Dr. Sammour, who also noted a severe shortage of beds for children on dialysis; 14 beds serve 44 children under 15 years old, who use these beds for between three and a half and four hours each treatment.

Dr. Sammour told DCIP that three important medicines for the treatment of cancer are, likewise, unavailable: Mercaptopurine, Methotrexate and Tioguanine. 

Six-year-old Jana, who lives in Beit Hanoun, a city in the northeast Gaza Strip, has had cancer for four years. Her mother, Neda S., noticed swelling in Jana’s abdomen when she was two. Doctors at Beit Hanoun Hospital discovered that Jana had low hemoglobin levels in her blood and transferred her to the care of Al-Rantisi hospital located in Gaza. 

There, she was diagnosed with leukemia and transferred after three days to An-Najah hospital in the northern occupied West Bank city of Nablus, where she was hospitalized for a month. Neda remained with Jana for the duration of her chemotherapy treatment. Two days after the pair returned to Gaza, Jana completed her course of treatment at Al-Rantisi hospital, where she frequently suffered from a fever for several days at a time.

In 2019, doctors told Neda that Jana had recovered from leukemia. 

“This news made me very happy, but I took her back to the hospital once a month for analyses and checkups to make sure she was fine,” Neda told DCIP. 

“That lasted for about nine months. But in January 2020, she started having swelling back in her abdomen, so I took her to Al-Rantisi hospital, and new tests were conducted. Results showed she had leukemia in the chest near ​​the lungs, and she returned to the hospital for chemotherapy treatment.” 

Doctors at the hospital successfully acquired another referral to An-Najah hospital in Nablus, but Neda’s husband felt that the risks and quarantine requirements for travelers in response to COVID-19 were too great. 

“Some of the chemotherapy doses are not available in Gaza due to the Israeli blockade,” Neda said. “I stay with her at the hospital, while my husband takes care of the children at home. This is very difficult for us as a family. Most of my children are in elementary school and they need me next to them, as their academic performance has been affected a lot. But I am busy with Jana and her therapy. They got used to my absence, as I am absent for days and sometimes for weeks.” 

Travel to and from the hospital has financially exhausted the family, costing 40 NIS ($12.50 USD) per round-trip. As of March 2021, Jana’s condition is stable, but Neda remains fearful about the future.

In early 2019, with funding from the Palestine Children’s Relief Fund, Al-Rantisi hospital opened a dedicated pediatric cancer department. The department includes 16 new patient rooms, and 13 beds for the day care clinic, but due to the ongoing closure, it cannot guarantee adequate or uninterrupted care for child patients. In August 2020, the Ministry of Health in Gaza warned that 45 percent of its basic medicines and 65 percent of laboratory and blood banking supplies had been depleted. The shortages are exacerbated by power outages of 16 to 20 hours per day.

Ahmad, one of a group of children evacuated from Gaza to Jerusalem hospitals for treatment in 2014, was injured by shrapnel after a missile hit the UNRWA school where he was sheltering, in Beit Hanoun, northern Gaza. He witnessed his sister killed in the same attack.

Israeli authorities require Palestinians from Gaza to obtain Israeli-issued permits to access healthcare in the occupied West Bank, including East Jerusalem, as well as inside Israel and in Jordan. Each year, several thousand Palestinians are forced to navigate the arbitrary and complex process of applying for Gaza exit permits from Israeli authorities, a process that can severely delay their access to urgent and lifesaving treatment.

In 2019, Israel denied 363 exit permit applications for Palestinian children referred for medical treatment, and delayed 1,763 applications for children past their appointment date, according to Medical Aid for Palestinians. Of patients referred outside the Gaza Strip, 31 percent required cancer treatments. 49 percent of 26,798 permit requests for patient accompaniers were denied or delayed. 

In some instances, Palestinian children are forced to travel to hospitals outside the Gaza Strip without their parents. In April 2019, five-year-old Aisha Al-Lulu was accompanied by a stranger to a Jerusalem hospital to undergo surgery for a brain tumor. Her parents were denied travel permits by Israeli authorities. Aisha died on May 15, 2019, shortly after returning to Gaza.

Prospects for securing permits for patients nose-dived when the Palestinian Authority (PA) halted its security agreement with Israel on May 19, 2020, in response to Israel’s plans to unlawfully annex parts of the West Bank. This suspension of almost all bilateral contact between the PA and Israel significantly affected humanitarian and other operations throughout the Occupied Palestinian Territory. This has been particularly detrimental for coordination related to managing the spread and treatment of Covid-19. 

Although the PA continued to issue financial approvals for patient referrals, it ceased its coordination with Israel of permit requests for both patients and companions. 

Additionally, in response to Covid-19, Israeli authorities limited exit permits exclusively to cancer patients and emergency cases. The UN reports that “in March 2020, patient exits declined to 1,279, from a monthly average of 1,777 in January and February. April recorded only 159 applications, of which 113 were approved, and May, 160 applications, of which 105 were approved.”

On November 17, 2020, the Palestinian Authority declared that they resumed security coordination with Israeli authorities.

Eight-month-old Omar Yaghi was the first Palestinian patient in Gaza to die while waiting for an exit permit following the suspension of coordination between Israel and the PA.

Omar, born October 9, 2019, showed signs of cyanosis, a blue discoloration of the skin, in the hours after he was born. Cyanosis is often a symptom of poor circulation or a lack of oxygen in the blood. His father, 34-year-old Ahmad Y., from Al-Zahra, south of Gaza City, told DCIP that a cardiologist at Al-Nasser Pediatric hospital in Gaza City diagnosed Omar with a congenital heart defect, in addition to torsion of the arteries and a hole in his heart. 

Following a 10-day wait for a travel permit, during which Omar was in intensive care, he was taken to Tel HaShomer hospital near Tel Aviv on October 25, 2019, accompanied by his paternal grandmother.

After 12 days, he and his grandmother returned to Gaza. Omar returned to Tel HaShomer hospital for a follow-up appointment on February 12, 2020 and his family was reassured that he was doing well, and were asked to re-visit Tel HaShomer hospital once more on March 4, 2020.

During the March 4 appointment, doctors at Tel HaShomer hospital decided that Omar required major heart surgery, but advised that he needed to be a little older to withstand such a massive procedure. As such, he was scheduled for surgery on April 8, 2020. This coincided with Israel’s tightening of exit and entry through the Erez crossing in light of Covid-19. 

Consequently, doctors postponed his surgery date to May 24, 2020. A few days before the resecheduled surgery was due to proceed, the Palestinian Authority cut security coordination ties with Israel, including a suspension on the issuing of travel permits to Palestinians in Gaza who needed medical care. 

With the help of human rights organizations, Ahmad managed to secure Omar a new appointment for June 21, 2020. On June 18, Omar woke up at approximately 1:30 a.m. with difficulty breathing. 

“I felt that this was unlike all the other times, that it was far more dangerous,” Ahmad told DCIP. “We were waiting for his big surgery, but Israel’s policies towards patients and their tribulations are inhumane.” 

Omar died that morning, awaiting surgery that could have saved his life. “Israel controls Gaza and the lives of patients,” said Ahmad, speaking to DCIP six days after his son’s death. “It is killing them, slowly.” 

Gaza’s ongoing electricity crisis makes accessing proper medical care very difficult for Palestinian children like six-year-old Yamen.

Like Ahmad, 49-year-old father of ten, Anwar H., from Shuja’iyya, east of Gaza City, lost his first grandson, also named Anwar, to a treatable heart condition while waiting for a travel permit. 

“I was shocked when I received the call,” Anwar’s grandfather told DCIP on June 25, 2020. “The real shock was about the reality we live in. My grandson’s surgery was simple. If we lived under normal conditions he would still be among us.” 

Baby Anwar, born June 13, 2020, was his grandfather’s first grandchild. 

“I was so happy,” the grandfather told DCIP. In the hours after his birth, the family noticed that Anwar’s skin was red. Nurses at Al-Shifa hospital advised the family that he could have a heart condition and transferred him to an incubator while tests were completed. 

The following day, a doctor told Anwar’s grandfather that Anwar had a problem with two of the arteries in his heart, and that he urgently needed surgery. He advised the grandfather to speak with Dr. Mohammad Nassar, a cardiologist at the Gaza European Hospital in Khan Younis. 

“Because Gaza doesn’t have the capacity or proper equipment, [Dr. Nassar] told me I needed to get Anwar out of Gaza,” Anwar’s grandfather explained. 

On June 15, 2020, medical reports about Anwar's condition were submitted to the Ministry of Health in Ramallah, and a request was made to Makassed hospital in Jerusalem to operate on him. 

Two days later, without any word from the hospital department responsible for securing treatment outside Gaza, Anwar’s grandfather approached the Palestinian Center for Human Rights. Despite the urgency of the situation, he was informed by the Center that he lacked the necessary financial means and the application could not be completed. 

“I didn’t know what to do,” Anwar’s grandfather told DCIP. “I was making phone calls even though my grandson was in critical condition.”

With Anwar still on a ventilator in the ICU, activists and human rights organizations based in Israel helped Anwar to acquire a referral to the Caritas Baby hospital in Bethlehem, scheduled for June 22, 2020. 

On the day of the appointment, after unsuccessful attempts with the Ministry of Health, Red Crescent, and Red Cross to arrange an ambulance to transport Anwar out of the Gaza Strip, his grandfather hired an ambulance himself. The organizations he’d reached out to cited a lack of coordination with Israeli authorities as the reason they could not provide an ambulance transfer.

Just half an hour after he had sent information to Israeli authorities to coordinate the ambulance’s exit from Gaza, he received a call from Al-Shifa hospital, informing him that Anwar had died. 

“I felt like a ball being thrown around by others as they wished,” said Anwar. “Ending the coordination of patient referral is a crime that all relevant parties must confront.”

Palestinian children in Gaza share their hopes and dreams for a better future.

At least two other Palestinian children in Gaza have died in the last year while awaiting referrals, according to documentation collected by DCIP.

Majd T., four years old, died on October 12, 2020. He suffered from kidney and liver problems since birth and required three dialysis sessions a week at Al-Rantisi hospital in Gaza. During the coronavirus pandemic, Majd had a blood clot, and as his condition worsened, doctors determined that they needed to replace the dialysis line insertion. The family applied for a referral to have the procedure performed outside Gaza in the West Bank or Israel, but referrals were stopped because of the pandemic. Majd was transferred to the Indonesian hospital in North Gaza where the dialysis line was inserted, but his heart stopped during the surgery. He was admitted to the intensive care unit where he stayed until he died.

On February 16, 2021, 11-year-old Ali R. died at the Indonesian hospital in North Gaza. Like Majd, he suffered from kidney failure and had three dialysis sessions a week at Al-Rantisi hospital in Gaza. He had traveled to Jerusalem for the dialysis line insertion. 

On February 10, Ali’s dialysis tube broke down and his family tried to get him an urgent referral for a replacement from the Treatment Abroad Department in the Palestinian Ministry of Health, but the department did not respond. Ali was transferred to different hospitals throughout Gaza but doctors could not locate veins into which the dialysis line could be inserted. He spent six days without dialysis. The increasing level of toxins in his body caused severe swelling, and he died on February 16. 

Israel has certain obligations under international humanitarian and human rights law to provide for the civilians under its control. Israel ratified the UN Convention on the Rights of the Child (CRC) in 1991, thereby obligating itself to implement a comprehensive range of rights and protections for children. Article 24 of the CRC compels States Parties to “recognize the right of the child to the enjoyment of the highest attainable standard of health and to facilities for the treatment of illness and rehabilitation of health. States Parties shall strive to ensure that no child is deprived of his or her right of access to such health care services.” 

They are likewise obligated to “ensure the provision of necessary medical assistance and health care to all children with emphasis on the development of primary health care.” 

Under Article 56 of the Fourth Geneva Convention, Israel, as the occupying power, is obligated to ensure and maintain “medical and hospital establishments and services, public health and hygiene in the occupied territory.”

Moreover, the Committee on Economic, Social and Cultural Rights, the body responsible for monitoring the International Covenant on Economic, Social and Cultural Rights includes safe drinking water and adequate sanitation, safe food, adequate nutrition and housing, among other factors, as the “underlying determinants of health.” Israel’s closure of Gaza presents a clear obstruction to the attainment of these determinants by the population of Gaza and amounts to collective punishment of a civilian population.