GAZA CITY in Gaza Strip aEUR “What does it take to have a 70-year old man get heart bypass surgery in Gaza? He is isolated from the rest, and there are only two remaining heart surgeons in the territory.
It is not easy to navigate through a crowd of patients who are facing their own health crises. To convince Palestinian officials to spend limited funds on his surgery abroad, it takes a serious enough medical condition or political connections.
It takes convincing Israeli border officials to grant security clearance to allow a patient to travel an hour from Gaza to a hospital that can easily perform his surgery.
As the past few years have demonstrated, no place on Earth is immune to a health emergency. The protracted emergency in Gaza is not caused by a pandemic, but by people aEUR’ enemies trapped in a 15 year standoff with no sign of an end. While the deaths in Gaza’s military conflicts are headlines, health care barriers are a common contributing factor to illness or death.
Hospital patients may be rushed to Gaza by border officials quickly. Other times, they wait for months before being granted permission to leave. According to World Health Organization statistics, most patients with severe cases are allowed to cross into Israel. However, thousands of patients are subject to unpredictable delays and denials from Israel every year. This is a risk that has been proven fatal by a WHO 2021 study.
But it wasn’t always this way. Seaside Gaza was once a gateway to the outside world. Many believe that the word “gauze” is derived from Gaza, where it was manufactured and exported many centuries ago. In the late 1990s, Gaza had a brief airport. Last month, 15 years ago, Hamas, a Palestinian Islamist group, took control of Gaza. Egypt and Israel, which were both neighbors, also closed Gaza’s borders to prevent trade and travel.
Israel claims the blockade remains necessary to stop Hamas. Hamas has attacked Israel and is considered terrorist by the U.S. The Gaza blockade is collective punishment for Palestinians. The United Nations claims that Gaza is suffering from poverty, hunger and electricity cuts, as well as contaminated water. Even in quiet periods, when there is no active fighting, basic health services are limited.
NPR journalists approached one man in a Gaza hospital waiting room in the late 2021. They then followed him and his family for months as they pleaded for permission to leave Gaza.
This is his story aEUR”, and many other stories.
Yousef Al Kurd kept Gaza’s daily life alive with his music.
After studying engineering in Germany, he returned to Gaza for a 30-year job fixing loudspeakers in schools, mosques and pushcart sellers.
Raji, his son, calls Raji “a legend”.
He retired in 2018 and helped his sons set up their electronics workshop. This is where he suffered a sudden cardiac arrest on April 1, 2020. Al-Kurd was a 70-year-old diabetic smoker who survived but required open heart surgery. Al-Kurd pushed off the surgery, fearful of the procedure, and concerned about COVID, according to his children.
Al-Kurd’s children rushed him to the hospital a year later when his health was worsening. They sought out their doctor, Shifa Hospital’s chief of cardiac surgery, and were able to locate him.
Al-Kurd’s son Ibrahim stated, “We discovered that he had gone overseas.”
The top Gaza-based cardiac surgeon had fled to Spain. His family didn’t respond to requests for comment. However, his colleagues stated that he was part of a recent exodus. They fled Egypt four years ago after Egypt relaxed its border restrictions. They are now seeking better lives in Europe or the United Arab Emirates.
In June 2021, Dr. Saher Abu Gaili, a 40-year-old doctor and chief cardiac surgeon in Gaza was elevated to head of cardiac surgery at Shifa Hospital. A few months later, however, another doctor from the department succumbed to cardiac arrest. Another died from COVID.
Abu Ghali, a small man in the hospital’s office, said that “From four we became three and now it is two.”
This means that Gaza has only two heart surgeons to serve its two million residents. The accepted ratio for serving this population in Europe and the U.S. is 55 surgeons.
Abu Ghali stated, “This is not the sole problem.” You don’t have all of the instruments. You don’t have the right resources.
Israel bans imports of medical equipment, including X-ray equipment that Hamas might convert to military purposes. WHO claims that Gaza doesn’t have enough medical supplies because the Palestinian Authority in West Bank, which is responsible for health services, but competes with Hamas for power, says WHO.
For example, cannulas are thin tubes that are used in heart bypass surgery. They are discarded after being used only once in hospitals all over the world.
Abu Ghali stated, “Here, each cannula has been re-sterilized more then 100 times.”
“This is real. He laughed. You can’t use it more than once, so you won’t be able to operate. You won’t ever operate.”
Israel does not allow Palestinian doctors to leave Gaza often in order to improve their skills through training abroad. Israel allows a few Palestinian citizens to visit Gaza once a month to perform surgeries. This is to make up for any gaps in the care. There are also other foreign surgeons who visit. It’s not enough to satisfy the needs.
Yousef Al Kurd required coronary bypass surgery. This is a simple procedure that can be performed in well-equipped hospitals all over the world. However, Dr. Abu Ghali, a trained Italian surgeon, stated that he could not do it due to Gaza’s limited supplies and surgeons.
It’s dangerous to do it safely in Gaza. We need heart surgeons. We need vascular surgeons. Ghali stated that we need the instruments.
Al-Kurd was recommended by the doctor to go to an Israeli-occupied West Bank hospital that is better equipped. This Palestinian territory is not under Israeli blockade and Hamas control.
Although it is only two hours by car from the destination, getting there can be painful.
A resident must first get approval from Palestinian health officials before he or she can leave Gaza to receive medical treatment. Then, an Israeli travel permit is required.
Both are not easy to get.
The Palestinian Authority provides universal health care through its public health-care system. It also pays for treatment costs when Gaza is not able to provide them. The money comes from the United States and other international donors. Israel allows only the most extreme cases.
Patients with cancer are the most common patients who seek medical care in Gaza. There is very little chemotherapy and no radiation therapy in Gaza. Al-Kurd, a heart patient, is the second most popular reason for patients seeking treatment abroad.
Even with extremely critical patients, the triage process is very strict.
Let’s take this example: In early December, at Palestinian health ministry headquarters in West Bank, a senior health official ran to Dr. Haitham al-Hidri’s office. He was responsible for financial coverage for Palestinian medical referrals.
A Gaza doctor had just called to report that a 25-year old patient with a serious vascular problem in his jaw was being treated at the Gaza hospital. It was too much for the Gaza surgeon and he wanted Dr. Al-Hidri to approve sending him to an Israeli hospital immediately.
Dr. Al-Hidri called Gaza’s young man to ask if it was really urgent.
“If he is bleeding, I will let him out. I won’t let him go if he isn’t bleeding. He is under my care. Al-Hidri said to him over the phone, “You must give the final word.”
After a few minutes, Al-Hidri gave up and hung up.
“He is not in active hemorhage. The doctor said that there was some oozing. It’s not a major emergency. He said, “We can wait.”
Al-Hidri decided to not take any chances. Al-Hidri approved the coverage and coordinated the quick transfer of the patient to an Israeli hospital. He stated that Israel grants permits to most urgent cases.
It was a well-kept secret for years that patients who wanted treatment outside Gaza could pay to have their referrals expedited by officials at the Palestinian health ministry.
Patients in West Bank public hospitals could be referred to private Palestinian or Israeli hospitals with the right connections.
Dr. Al-Hidri claimed that he had cleaned the house before he took the job in 2019. He fired the clerks who took bribes.
Al-Hidri was suddenly removed from his position and reassigned in the early part of this year.
Mai Al-Kaila (health minister) described it as a “normal rotation of leadership for a sensitive role that oversees large spending.
A health official spoke on condition of anonymity to talk about the sensitive issue. He claimed that Al-Hidri was creating files alleging corruption within the ministry. This meant that many thousand patients, some of whom have important political clout were transferred to private hospitals, and given unnecessary private medical treatment. It cost tens to millions of dollars to international donors.
Two health officials leaked recent medical records to NPR, supporting allegations of patronage. The documents show that at least three patients who had high-ranking ties to the Fatah president of the Palestinian Authority received expensive, subsidized private medical care in Israel and the West Bank to treat conditions such as a stroke or kidney cyst. Officials claim that Palestinian public hospitals are able to treat these ailments.
“To be transferred” is the handwritten Arabic note on each document that Health Minister Mai Al-Kaila signed.
Although the minister of health acknowledged that she had approved private medical care for Palestinians in the past, she denied that these approvals were political favors. She stated that public hospitals are overwhelmed and her approach to the matter is “humanitarian.” She refers the “poorest of the poor” into private hospitals when “prominent persons in the country” lobby for them.
Al-Kaila stated to NPR that “in our system, ministers have the power (to grant exceptions).” “I work health and pure health without discrimination for anybody.”
Yousef Al Kurd, a heart patient, did not have any political connections. However, he had a valid medical need to leave Gaza for bypass surgery.
Al Mezan, a Palestinian hospital located in Hebron in West Bank, was the place where he had his surgery. He had to cross Israel in order to get there. This meant he had to apply for an Israeli travel permit.
Israel is wary about allowing anyone to enter Gaza from Hamas-controlled Gaza.
Harel Chorev of Tel Aviv University, said that “It is not obvious that Israel will provide its enemies the treatment they require.” They can even go to Egypt as an example.
According to the World Health Organization, about 1 in 5 Gazans do go to Egypt’s hospitals. However, those hospitals are far away and Palestinian health authorities prefer to keep their patients in their system. This allows for public money to be invested in the Palestinian territories, rather than abroad.
In rare cases, Israel has accused Hamas-spying patients of smuggling explosives and spying on them. Some patients were granted Israeli permission to leave Gaza for medical treatment, but they never returned.
Trust is the key to everything. However, trust is broken when you send someone with cancer with TNT or explosives. Once he’s caught, it causes a lot of damage,” Chorev stated.
Israeli officials claim they only allow humanitarian and extraordinary cases. Last year, more than 10,000 permits were granted. It is sometimes difficult to determine who is approved and who is denied for security reasons.
Ron Goldstein, of Physicians for Human Rights Israel (an advocacy group that helps Gazans get permits), said that “it’s really a dark hole for us to comprehend the criterias.” “Many, many… cases aren’t security issues. When we intervene, the person suddenly receives the permit.”
The majority of permits are granted by Israel, although about a third were denied or delayed in 2021 according to the World Health Organization. WHO estimates that thousands of patients have had to cancel surgery or chemotherapy while they wait for Israeli security clearance to travel. WHO stated that these patients are often more sick than they were before.
This is what happened to Yousef al-Kurd. According to the Palestinian office that submits permit applications, he applied for a permit in Israel on September 12. However, Israel did not grant him an expedited permit to allow him to go for his September 15 surgery appointment. Ibrahim, his son, rebooked for the October 12 surgery but was still denied a permit. He booked a third appointment for the 1st of November but did not receive a permit on time.
Israel claimed that it was reviewing the request throughout. Al-Kurd only needed an Israeli travel permit; Israel would not provide the treatment.
Ibrahim, Al-Kurd’s son, said that “The Israelis always delay.” “This is only slaughtering us.”
Al-Kurd was advised by his doctor that he should not wait more than one month for surgery. After six weeks of waiting without any response, Al-Kurd’s son contacted the Palestinian Centre for Human Rights Gaza. Mohammed Al-Alami, Al-Kurd’s lawyer, sent an urgent letter to Israeli border officials requesting travel approval.
There were two more weeks without a permit.
The lawyer called his Israeli contact and asked: “Why the delay?” What security risks does a 70-year old man pose?
Al-Alami stated that the Israeli officer had told him Al-Kurd had six registered phone numbers under his name. According to the lawyer, Israel monitors patients’ calls and multiple numbers raise questions. According to the Al-Kurd family, there is a logic explanation. Each family member uses a different phone number similar to a family plan. He sent this information to his Israeli contact.
“Every day, as this. Al-Alami stated that every day is a good day.
In order to obtain Israeli permits, you will need to plead your case. NPR spoke with a Palestinian official who requested anonymity out of fear of reprisals for his job. He said that he took pictures of patients with a bulging neck tumor and their sick baby to win the sympathy Israeli officers.
The World Health Organization has been documenting barriers for Palestinians to health care access for years. Advocate groups claim it is easier to get exceptions than to change the rules, a principle that covers the whole dynamic of Israel’s control over Palestinian lives.
COGAT, an Israeli agency responsible for processing travel permits for Gazan patients, told NPR later that Al-Kurd had requested missing paperwork aEUR”, which it claimed was a common reason behind permit delays. Their lawyer and the family claimed that nothing was missing, and COGAT had never informed them.
Al-Kurd was waiting for a permit when suddenly his blood pressure dropped. He was unable to urinate. A couple more days went by.
The family received a text message Saturday afternoon with good news: The permit was approved for the next day.
Al-Kurd finally made it to the hospital for the critical surgery.
After more than two months spent waiting and pleading, this glimmering hope finally arrived. Al-Kurd was becoming more ill.
Yousef Al Kurd and Fayeza left their children behind the next morning at 5:05 a.m. As thousands of Palestinian workers with Israeli work permits passed first, they waited for hours at Hamas’ checkpoint.
They then reached Israel’s only civilian border crossing with Gaza, the Erez crossing. This crossing is one of the most fortified border crossings in the world.
Hamas, which is committed to armed struggle with Israel, is contained on one side. 2 million Palestinian civilians are also protected. Since Hamas’ overthrow, Israel has declared its policy of “separation” – securing Gaza from the West Bank and restricting movement between the main Palestinian territories.
Al-Kurd was asked by the scanner to raise his arms during the crossing. He fell to the ground. Israeli attendants quickly rushed him to a wheelchair. His family was not informed that they could arrange several ambulances for him to be transported to the hospital.
There was also a driver at the other end of the border crossing: Arnon Avni (69), an Israeli graphic designer, political cartoonist, who volunteers with Road to Recovery. This group of Israelis drives Palestinian patients to their appointments. NPR reported that Al-Kurd arrived at the border crossing as the group was waiting for patients to pass through. Al-Kurd offered to take his wife along for the ride.
Avni said “Let’s get them in,” and he threw his grandchildren’s booster seats into the trunk. He also coaxed Al-Kurd to put the seatbelt on, who was groaning in pain.
The driver entered the destination into his navigation app: An Israeli security checkpoint in Israel-occupied West Bank, just over an hour away.
Al-Kurd was not a native speaker of Avni’s language, but they did share some similarities. Avni’s father, who had a heart attack, was about their age.
Al-Kurd stated, “The pains are severe”, as the car traveled along Israeli roads.
Fayeza, his wife of 58 years, was visiting Israel for the first time.
She said, “It’s a different world.” She said it was clean, spacious, and open. It is not cramped like the Jabalia refugee camps in Gaza where she lives.
“What’s the bridge?” Avni asked her. He said it was just an overpass. She laughed, she hadn’t seen one before.
Avni, the driver’s seat, said that “I see all my passengers on my journeys.” “All of them feel exactly the same…the roads and the cars, as well as the new cars. It’s quite something. It’s almost like I could travel to New York or something similar.
Avni lives in Kibbutz Nirim, right next to Gaza. Last year, mortar shells landed near his home. Five decades ago, a Palestinian from Gaza planted explosives inside their kibbutz, which led to the death of his brother.
He said, “Some people call my traitor.” “I believe we do the right things for Israel.”
A road sign warning Israelis to not enter Palestinian territory is posted at the Tarkumiya checkpoint in Hebron. This prevents Al-Kurd (and his wife) from making it all the way to the hospital. He dropped them off at the other end of the checkpoint.
They said their goodbyes, and a van from Palestine took the Al-Kurds into the hospital.
Al-Kurd did not get the surgery he hoped for.
He suffered multiple-system failure hours after arriving at the hospital. His son Ibrahim, who was in Gaza at the time, received a call from the hospital two days later. He recorded it.
“Ibrahim! How are you?” The doctor replied.
“Oh, God,” Ibrahim replied.
The doctor stated, “I’m with you mother now,” and then pauses. “Your father, may you rest in peace.”
According to health experts, it is difficult to say if Al-Kurd could be saved if he had received his Israeli travel permit sooner. There were many factors.
Al-Kurd was himself a high-risk patient due to his diabetes and smoking habits. He was also afraid of open-heart surgery, and COVID, so he waited a year before he could get the surgery in Gaza he had requested. The Gaza medical system is very poor and patients were not followed up when their condition deteriorated.
Ibrahim, Al-Kurd’s son, blames the Palestinian doctor who did not consider the case urgent and forced Israel to allow his father to cross the border immediately. However, experts in health say this may not have been helpful. Even urgent cases can be delayed or denied by Israel.
The World Health Organization analyzed Gaza cancer patients between 2015 and 2017 and found that they were almost one-and-a half times more likely than others to die within months or years of receiving their Israeli permits.
Benjamin Bouquet, a WHO doctor and co-author of the study, stated that “this is the only population-level study to examine the effects on survival or on the health outcomes of patients who face delays and denials in permits.”
The international community is making new efforts to assist Palestinians in securing their health care. According to the International Monetary Fund, one of the main causes of the current financial crisis in Palestine is the high cost of sending patients abroad.
The European Investment Bank and the WHO signed a partnership in May to reduce Palestinian dependence upon Israel.
Rik Peeperkorn directs the WHO office for the Palestinian territories. He said, “The entire referral system is an immense burden on the Palestinian healthcare sector.”
Al-Kurd’s death has seen more Gazan medical patients die, including children with congenital heart defects or cancer.
Raji Al-Kurd (24), gathered his family in their living area a few weeks after the death of his father. He asked a question.
He said, “Put your feet in mine,” “Wouldn’t you love to see your loved one facing those circumstances?” Would you rather see your loved one facing these circumstances?
This report was contributed by Sami Sockol in Jerusalem, and Nuha Musleh from Ramallah.
