Less than 90 kilometres from the Israeli medical centres whose world-class cancer care draw patients from around the world, Eyyad Abu Jalalah lies on a bed in a shared hospital room, immobile. It is not just the lower-body paralysis that keeps him here.
It is also the rejection letters he has received from the Israeli authorities who govern his ability to receive treatment his doctors have recommended.
Mr. Abu Jalalah has an aggressive form of prostate cancer. His doctors say he needs radiation therapy to shrink the tumour. But that treatment is not available in the Gaza Strip, the Palestinian territory where Mr. Abu Jalalah lives, separated from Israel by walls and fences that can only be crossed with Israeli permission.
“I applied five times, and they refused,” says the 51-year-old, who sold vegetables in a local market before cancer began to take hold. “Every time, the rejection is for ‘security reasons.’” Members of Mr. Abu Jalalah’s family have fought against Israel. An uncle was held in an Israeli jail until he was released in a 2011 prisoner exchange. A brother was killed during intense fighting the following year.
“But how is that my fault?” Mr. Abu Jalalah asks.
He is among the hundreds of Palestinians caught between metastasizing cells and rigid politics. Cancer is the second leading cause of death for people here, but Gaza does not have a functioning radiotherapy unit. One linear accelerator donated by Saudi Arabia was installed in Gaza in 2004, but has never been used. Local administrators were never able to secure all of the parts to make it functional.
That has increased Gaza’s dependency on Israel for health care. Roughly 1,800 cancer patients need to travel outside Gaza to get proper care, say Isam Hammad, an importer of medical equipment to Gaza. Roughly a quarter of those have reached palliative stages that leave them unable to travel. Others have encountered Israeli rejection. Last year, the World Health Organization reported that 39 per cent of Gaza patient permits were rejected, and 62 per cent of permits for medical travel companions. Cancer rates rose in Gaza by 2.5 per cent between 2016 and 2021.
In 2022, the Al Mezan Center for Human Rights documented nine people, three of them children, who died without being able to access care outside Gaza.
In a letter to the Israeli government, United Nations special rapporteurs described the deaths of the three children, two of them with cancer, and raised alarm “at the delay in issuing exit permits to Gaza residents by the Israeli authorities, particularly to those suffering from life-threatening illness.”
In February of this year, Al Mezan issued a statement calling on Israel to “immediately and unconditionally lift its closure and blockade of the Gaza Strip, which is the main obstacle to Palestinian patients’ access to medical care outside the Gaza Strip.”
Cancer referrals are the largest reason for Palestinian requests for medical transfers.
Israel’s security services have, however, described what they say is misuse of medical travel permits. Last year, Shin Bet accused a Gazan man of entering Israel to scout recruits for Hamas.
An organization considered a terrorist group by Israel, the U.S., Canada and the European Union, Hamas governs Gaza. Israel and Egypt have maintained a blockade of Gaza for more than 15 years, and Israel controls the movement into the area of numerous “dual-use” items – those that can have both military and civilian application – including chemicals, pesticides, communications gear, metal-working equipment, compasses, balloons and even water skis.
Mr. Hammad, however, called it an imperative to find ways to bring in needed cancer-treatment equipment. He has plans for a US$14-million radiotherapy department at the Turkish Palestinian Friendship Hospital in Gaza City, where it would be built on three hectares of land. He began to pursue the project in 2018, but was interrupted by the pandemic. This year, he expects to begin global fundraising during Ramadan, which starts in late March.
Mr. Hammad knows better than most how difficult it will be. Importing medical devices to Gaza is rarely easy. An interventional catheterization lab, used to locate blood clots in stroke patients, has been stuck at the Port of Ashdod since July. Shipping and storage costs have now reached US$54,000.
He says it took international pressure for X-ray systems to be allowed into Gaza earlier this year, after a half-year delay. Mr. Hammad argues that it is wrong to hamper their imports. Such systems are “not designed for rockets and bombs,” he says.
Nuclear medicine offers even greater complications. A positron emission tomography – computed tomography (PET/CT) device, which Mr. Hammad would like to see in the radiotherapy unit, requires radioactive material that rapidly degrades. It would need to be delivered to Gaza in four or five hours for the PET/CT machine to function properly.
At the moment, even basic medicines don’t arrive on time. The shelves at the friendship hospital’s pharmacy are neatly labelled, even those that are bare. There is no capecitabine, a chemotherapy drug. Nor is there any levofloxacin or azithromycin, both antibiotics, or amitriptyline, which is used for neuropathic pain, or even loratadine, the antihistamine often sold as Claritin.
“It is empty shelves,” says Nancy Nashwan, head of the outpatient pharmacy. Shortages of cancer drugs commonly force the transfer of patients to Israel. Dasatinib, for example, is not available at all. Neither is tamoxifen.
“A doctor can start a medication regimen, and in the middle of this regimen the drug is cut,” says Dr. Nashwan. One patient was partway through receiving a course of treatment with Zytiga, a hormone therapy treatment, when the drug became unavailable. He was transferred to the West Bank to complete the treatment. Shortages in pain medications – in February, Dr. Nashwan received only 30 per cent of needed analgesics – can result in patients receiving only a fraction of the required amount. “It is very unethical,” she says.
At least some of the problems are budgetary. The friendship hospital has only 45 per cent of the pharmaceutical funds needed, says Mr. Hammad. He tracks survival rates for breast cancer, which have fallen to 55 per cent today from 63 per cent a little less than a decade ago.
He recently watched a friend die without proper care after more than a year and a half of struggling to secure the right drug for his lung cancer. Bureaucratic approvals were slow; the cancer spread to his brain, liver and bones. Israel denied the man entry to seek radiation treatment, Mr. Hammad says, reversing course only when ordered to do so by a court. He arrived in the Augusta Victoria Hospital in East Jerusalem on Dec. 15, 2022. A video taken there shows his friend with a gaunt face, his thin arms jerking. By that point, his lungs were unable to extract sufficient oxygen, Mr. Hammad says. His friend died Dec. 18.
The inability to provide proper care weighs on providers in Gaza.
“When I go to home, I can be aggressive with my family because these cases can cause stress, emotional pressure,” says Omar Abu Mosa, a nurse who cares for Mr. Abu Jalalah.
Dr. Zaki Hosni El-Zaqsu, a consulting oncologist at the friendship hospital, says it is common for chemotherapy patients who require a three-drug treatment plan to receive only one or two of those drugs.
Delays in treatment, meanwhile, give time for cancers to spread. “And it also increases the pain,” says Dr. Mohamed Abunada, a specialist in neurology and pediatrics who is the hospital’s medical director. Patients sometimes die before they can be transferred for proper care.
He knows that many obstacles remain to bringing a radiotherapy unit here. But he holds out hope that some equipment will arrive by 2024.
That is little consolation for Abeer Abu Hilal. A mother of four, she discovered something was wrong when her youngest, then eight months old, refused to nurse from her right breast. A mammogram revealed a cancerous mass.
When chemotherapy failed to eradicate the cancer, doctors told her to seek radiation. She received one course of treatment in October, and wants her mother to join her for a second course. Her lower body has become paralyzed. A nurse grabs her foot and turns it. She feels nothing. She can no longer change her own clothing.
“I want her to clean me, to help me. I need a mother,” says Ms. Abu Hilal, speaking from a bed at the friendship hospital in Gaza, with her mother by her side.
But Israeli authorities rejected her mother’s application on security grounds.
“We need radiotherapy here instead of going to Jerusalem or the West Bank,” Ms. Abu Hilal says.