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Update Regarding Coordination for Travel by Patients and Accompanying Persons Out of the Gaza Strip (July 2020)

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This document lists the main obstacles blocking Gaza patients’ access to critical care, as existing Israeli restrictions are compounded by difficulties arising from the cessation of coordination.

Background

In response to Israel’s plan to annex parts of the West Bank, the Palestinian Authority decided to halt security coordination with Israel. The decision also applied to coordination of medical permit applications by patients from the Gaza Strip, which had been carried out by the Palestinian Civilian Affairs Committee (the Palestinian Authority agency in charge of coordinating transit permit applications by Palestinians).

This document lists the main obstacles blocking Gaza patients’ access to critical care, as existing Israeli restrictions are compounded by difficulties arising from the cessation of coordination.

The situation on the ground

Since June 10th, PHRI has been receiving calls from patients in the Gaza Strip who need urgent life-saving treatments or ambulance transportation using the back-to-back system (where one ambulance takes the patient to the crossing, and another completes the journey to the hospital and vice versa). Calls have come from cancer patients, cardiology patients, humanitarian cases involving babies and adults and more. Over the course of June and July, PHRI provided assistance in 195 urgent medical exit permit applications (most coming from cancer patients). This is five times the normal caseload, and PHRI is not only intervening in cases of rejected or unanswered medical exit applications, as was the norm previously. In these new circumstances, PHRI also makes the initial application to the CLA instead of the Palestinian Civilian Affairs Committee doing so.

Work on these cases includes the bureaucratic onus of filing the initial application with the military, providing medical and other documents, keeping in touch with patients to complete missing information or apprise the patients of any progress. In addition, PHRI coordinates with hospitals to reschedule appointments when patients do not receive a permit for their scheduled appointment. We also coordinate back-to-back ambulance transportation between different institutions.

Main trends harming patients at this time:

  • Applications can be submitted only for patients whose condition is considered urgent: As has been the case since the coronavirus outbreak. Only urgent cases – cancer patients, heart disease patients, humanitarian cases involving babies and individuals seeking back-to-back ambulance transport coordination may file an exit permit application. All other patients in need of a medical exit permit cannot even submit an applications as they do not meet the criteria. The applications PHRI has processed were from people who needed an exit permit urgently. In June, PHRI received calls from 16 women with breast cancer asking for help obtaining a permit for radiation therapy, which is completely unavailable in the Gaza Strip, as well as from the families of four infants with heart conditions who had to be urgently transported by ambulance . In three of the cases PHRI processed, patients who did not get a permit to exit Gaza for treatment died.
  • Many applications are not approved: Even though Israel has limited processing of medical exit permits to urgent cases only, still only half of the applications filed through PHRI were approved. Many remain unanswered, meaning patients miss their appointments and have to repeat the entire complicated, bureaucratic application process.
  • Delays at Erez Crossing: Sometimes, even after the application is approved, patients are held up at Erez Crossing. Some were sent back, missed their appointments and had to submit new permit applications. For instance, a leukemia patient was detained at Erez Crossing for four hours. He was questioned by the Israel Security Agency while lying in an ambulance – in violation of medical ethics, and despite having received a permit from the Civil Liaison Administration (CLA) after PHRI’s intervention.
  • Lack of transparency and accessibility to the application submission system: In late June, the Coordinator of Government Activities in the Territories (COGAT) introduced an online form that organizations, hospitals and lawyers could use to submit medical exit permit applications for patients. After PHRI intervened, COGAT allowed Gaza patients to use the form directly, but it is not clear whether any applications have been filed using the form and, if so, how many. There is no automatic confirmation of submission, and there is no way to follow up on the application. COGAT also did not publicize the online form to the population in Gaza.
  • Last minute responses: Many applications are not answered until the last minute, sometimes on the day the patient has to exit. This precludes patients from preparing properly and making arrangements for the time they are in hospital, adding a great deal of stress to their already difficult situation.
  • New requirement for test results as a condition for a medical exit permit: The Israeli side has recently introduced new requirements, including providing the results of certain tests, such as MRI scans and biopsies. We have so far been told that the medical need is not disputed, and the permit hinges only on a security screening. The demand to furnish test results is, therefore, perplexing and adds to the difficulties endured by the patients.
  • False claims that the treatment is available in the Gaza Strip: To receive a permit to exit for medical treatment, the applicant has to prove the treatment is not available in the Gaza Strip. While PHRI strongly opposes this requirement, it is important to note that many treatments are available in Gaza in theory only, but, given the dire state of the local health care system, the treatments are not actually offered due to the severe shortage in equipment and medication, or lack of training by medical crews.

Ethical and legal framework

The right to health is enshrined in various international conventions, such as in Article 12 of the International Covenant on Economic, Social and Cultural Rights. In 2019, the UN Committee overseeing the implementation of this convention called on Israel to “Review the medical exit-permit system with a view to making it easier for residents of Gaza to access…” Health organizations from the world repeatedly highlight the need for access to health services with a special focus on the most vulnerable populations. The World Medical Association, for instance, has emphasized that women and children have a right “to full and adequate medical care.”

Conclusions and recommendations

A temporary application coordination mechanism between the Palestinian and Israeli sides was set to begin operating recently, with a representative from the World Health Organization serving as a go-between. For unknown reasons, the arrangement has been delayed, and each day that passes takes its toll in human life.

Ultimately – regardless of which actor carries out the coordination – Israel is responsible for the lives of these patients as it wields power over their ability to access treatment. To safeguard the lives and health of Gaza’s residents, the closure must to be lifted, and patients should be given free and safe passage between Gaza and the West Bank.

Until a comprehensive solution is found, Israel must:

  • Lift criteria-based limitations and allow patients, including those who do not require emergency care, to access treatment.
  • Improve the online form, so patients are able to see the status of their application and responses are received within a reasonable time frame that corresponds to the urgency of their medical condition.