The UN will temporarily step in to help Palestinians who need medical treatment outside Gaza leave the enclave, in a change that could help thousands of patients who have been unable to access much-needed care due to the combined impact of COVID-19 and an ongoing dispute between the Palestinian Authority and Israel.
Nickolay Mladenov, the UN’s special representative for the Middle East, tweeted the news on 7 September, announcing that a “temporary arrangement” to be managed by the World Health Organization had been agreed.
According to a UN update published the following day, the WHO will take over the process of facilitating travel permits, which Palestinian residents of Gaza and the West Bank require if they need to travel for medical care either to Israel or occupied East Jerusalem, and those in Gaza need for the West Bank.
Two million Palestinians live in Gaza, and about 2.7 million in the West Bank. Gaza has been through three wars with Israel since 2008 and is subject to what the UN calls a blockade by Israel, including strict restrictions on movement.
The Palestinian medical infrastructure is poor, especially in Hamas-run Gaza, forcing patients in need of specialised care to seek it elsewhere. That means acquiring a permit, which became increasingly difficult in March due to COVID-19-related travel restrictions.
The situation was compounded in late May when – following Israel’s announcement that it planned to formally annex large chunks of the West Bank – the Palestinian Authority, which governs the West Bank, announced it was cutting off bilateral ties with Israel, including what is known as “security coordination”.
Because security coordination includes communication between the PA-run liaison offices that approach Israeli authorities to apply for travel permits on behalf of Palestinians in both the West Bank and Gaza, this avenue for medical treatment was cut off for many people. This has been especially true for Gazans, who have no way to contact the Israeli authorities themselves, given the lack of any relations between Hamas and Israel.
In March 2020, exit permit applications for Gazans declined to 1,279, from an average of about 2,000 each month. In April, the number nosedived to 159 (113 were approved) and in May, to 160 (105 were approved). Numbers are unavailable for more recent months, but analysts and activists say the security coordination issue will pose a major long-term problem even after the pandemic subsides, especially if the UN fix is not sustainable.
“With such limited tools, and the need to do something, anything, to respond to the impending threat of annexation, it’s understandable that the PA felt they had to make some sort of assertion of independence,” Yara Asi, a Palestinian global health expert who teaches at the University of Central Florida, told The New Humanitarian.
“Unfortunately, the one they’ve chosen – to end security coordination – has harmed some really vulnerable people, namely those with medical conditions that require advanced care that cannot be found in Gaza or the West Bank.”
If the new WHO agreement goes ahead successfully, it should provide some relief for people like Azmi Abu Amra, a 54-year-old Palestinian from Deir al-Balah in central Gaza, who began to complain to his family of pain in his back and waist last March, and whose case was described by the WHO in a recent report.
The WHO said that the father of 11, who worked as a labourer until the pain made that untenable, was admitted to hospital this May with jaundice and pain. After doctors examined him, they diagnosed him with cancer of the bile duct.
Treatment for Abu Amra’s cancer, and for many other complicated conditions, is not available in Gaza. The enclave, which has been blockaded by Israel and Egypt for more than 10 years, lacks both equipment and providers. It is unable to import replacement parts for broken machines or send technicians outside Gaza to train on new equipment, leaving hospitals with limited functionality. In addition, many hospitals and clinics that were bombed in the 2012 or 2014 wars with Israel have still not been rebuilt.
Doctors referred Abu Amra for treatment at a hospital in East Jerusalem, and scheduled an appointment for 15 June.
After receiving the necessary paperwork from the Gaza Ministry of Health, he made his way to the Palestinian Liason Office to secure a border permit. But the office told him that because the PA had stopped working with Israel, it was unable to request a permit on his behalf.
Abu Amra’s 27-year-old son, Alaa, said his father’s health continues to deteriorate as he misses one medical appointment after another. He now has difficulty moving. “We went to the coordination office to apply for [a permit for] my father, but I was told they stopped contact with Israeli authorities.” They also approached a local rights group, but that too was a dead end. “We are trapped and there is no way for us to [leave],” Alaa told the WHO.
“The healthcare system… pushes thousands of patients with life-threatening conditions to seek treatment outside of Gaza through an onerous, complex, and opaque permit process imposed by the Israeli authorities.”
While some exceptions have been made for urgent cases, according to reports from rights groups and the UN, two babies and a 22-year-old man recently died while waiting for permits to leave Gaza for treatment. The first infant was eight-month-old Omar Yaghi, who died on 18 June of cardiac complications before he was able to receive a permit to travel for an operation to Sheba Medical Center in Israel. On 22 June, nine-day-old Anwar Harb, who also suffered from heart problems, died before he could receive treatment in East Jerusalem.
“The healthcare system… push[es] thousands of patients with life-threatening conditions to seek treatment outside of Gaza through an onerous, complex, and opaque permit process imposed by the Israeli authorities, which severely deprives Palestinians of their right to health, and in the most serious cases of their right to life,” Samir Zaqout of the Gaza-based Al Mezan Center for Human Rights told TNH.
Authorities in Gaza and the West Bank did not respond to requests for comment, but COGAT, the Israeli body that administers parts of the West Bank and handles border crossings between Gaza and Israel, sent the following statement to TNH:
“The Unit for Coordination of Government Activities in the Territories (COGAT) works tirelessly, in cooperation with all the relevant parties, in the shadow of the halt of coordination by the Civil Committee and following the outbreak of COVID-19 – in order to provide the most appropriate response to the different needs of the residents of the Gaza Strip. We will note that the unit allows, also at these times, an entrance of residents of the Gaza Strip, for life-saving medical treatments. The reduction of movements in [the crossing between Gaza and Israel for] medical-humanitarian cases is done in order to prevent the spread of COVID-19 in the region.”
Lockdowns and workarounds
Before the PA stopped official bilateral communications with Israel, the numbers of people travelling outside the West Bank and Gaza for medical care had already been falling due to COVID-19-related lockdowns and travel restrictions.
Jordan and Egypt effectively shut their borders, while Israel had already severely limited the number of exit permits provided for medical treatment, narrowing down the eligibility criteria to cancer patients and life-threatening emergency cases only. During that time, the Palestinian territories had also introduced their own coronavirus travel restrictions.
These travel restrictions limited access to all sorts of health needs, from picking up prescriptions to getting a woman in labour to the hospital quickly, especially in the more rural villages that have few health facilities. While some restrictions had been eased, both the West Bank and Gaza are experiencing a resurgence of COVID-19 cases, prompting new local lockdowns.
For people from the West Bank who need treatment elsewhere, there has been a workaround for the permit issue. While the PA-run liaison offices are not operating, they have been able to apply for permits directly to the Israeli District Coordination and Liaison Office, which monitors and coordinates the movement of Palestinians in the occupied territories.
But health experts and rights groups warn that this process is flawed, as there is now no oversight to support appeals on behalf of patients and companions whose permits are denied or delayed.
“With the diffusion of the permit application system, we can no longer easily track the number of permit applications, the number of delayed or denied permits, and the average time taken for permit approvals, which were really important barometers in terms of assessing Palestinian health access,” Asi said.
This process does not exist in Gaza, leaving many Palestinians from the enclave to turn to rights groups for help, with limited success.
Physicians for Human Rights Israel, which has been helping Gaza patients try to get permits since the PA-Israel coordination mechanism collapsed, said it saw 195 applications between June and July – a five-fold increase in the number it normally handles.
While rights groups welcomed the UN’s decision to relieve them of this task and act as a liaison between the PA and Israel, some see the fix as little more than a temporary band-aid.
“Ultimately, since Israel has control over the crossings and decides all matters regarding patients’ travel for treatment, Israel must act to safeguard patients’ lives until a solution is found,” said Ghada Majadle, director of the occupied territories department at Physicians for Human Rights Israel.
“In the long run, such a solution necessitates lifting the blockade imposed on Gaza and ensuring free access between the Gaza Strip, the West Bank and East Jerusalem. Until that time, Israeli authorities must rescind the stringent criteria it has imposed and also allow patients in non-emergency situations to leave Gaza for treatment.”