Referral of patients from the Gaza Strip – WHO monthly report (November 2011)

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Destinations and reasons for referral for medical treatment

During November 2011, the Referral Abroad Department (RAD) of the Palestinian Ministry of Health (MoH) referred 1,071 patients to health facilities for specialized treatment not available in MoH facilities in Gaza: of those, 228 patients were referred for specialized treatment in facilities located within the Gaza Strip (in NGO or private hospitals) and 843 patients were referred outside of Gaza to hospitals in East Jerusalem (35.5%), Egypt (29%), Israel (19%), the West Bank (12%) and Jordan (4.5%). Of the 843 outside referrals, 601 patients required access through Erez crossing and 242 through Rafah border crossing. The decrease in number of referrals in November compared to previous months 2011 is due to the long holiday closure of the RAD office November, November 6 to 10 for the Moslem Eid al Adha feast.

The main reasons for 50% of all referrals, representing 53% (NIS 9.3 million) of estimated cost in November, were: cardiovascular (14%), oncology (12%), ophthalmology (9%), urology (7%), orthopaedics (5%) and neurosurgery (3%).

In early November the MoH began a review of referrals to Israeli hospitals and attempted to refer cases instead to other facilities in Palestinian or Egyptian facilities, in order to reduce referral costs. This led to delays in processing referrals to Israeli hospitals. The RAD office in Gaza reported that they were experiencing difficulties in securing referrals for 40 patients to Israeli hospitals in early November 2011. Two children, Mohammed and Hiba Azzam Sahwail, died during the period of delay while waiting for referrals to Israeli hospitals. (Cases are detailed below.)

Permit applications for patient referrals through Erez

During November 2011, the Israeli District Liaison Office (DCL) processed 711 patient applications for permits to cross Erez checkpoint to access hospitals in the West Bank including East Jerusalem, Israel and Jordan (see Table 2) compared with 864 last month, reflecting the holiday closure.

Of patients applying for permits to travel through Erez, 84% (598) were financially supported by MoH, 7.7% (55) by the Nour al Alam Foundation, 2.5% (19) by Physicians for Human Rights – Israel, 2.0% (14) by Peres Center for Peace, and the remaining 3.5% (25) by other charity organizations or were self-funded.

* Approvals are typically communicated to the patient only 24 hours in advance of their scheduled appointments.

** Permit applications for patient access through Erez can only be submitted within 10 days of hospital appointments. When there is no timely response from the Israeli Liaison Office, the applications are registered here as “delayed”, meaning that the Palestinian Liaison Office received no response to the permit application prior to the patient’s hospital appointment date. Some patients in this category may eventually receive permit approval — but after their hospital appointment has passed. They must then reschedule their appointment. Other patients in this category may eventually receive denials or may not receive any response.

*** These are requests for interrogation as communicated by Israeli authorities through the Palestinian Liaison Office. This may be underreported since Israeli authorities sometimes contact patients directly for interrogation.

93% (662 patients) of all applications for permits were approved, substantially higher than the 2010 average of 78%. Of the remaining 7% of all patients, almost 2% (12 cases) were denied permission to cross Erez checkpoint. Another 5% (37 patients, including 10 children) had their applications delayed beyond their hospital appointment. Of these, 27 were called for interrogation by the Israeli General Security Services (GSS) as a condition of their application. Following their interrogation, 10 were approved a permit, 3 were denied a permit, 14 patients were still waiting for a GSS response and one patient was detained after the interrogation. Another patient was detained at Erez crossing when returning back to Gaza after treatment. (See cases below.)

Patient Exit data for November 2011

Erez: Erez crossing was closed during weekends (Saturdays). According to the Palestinian Liaison Office at Erez, 639 patients crossed Erez checkpoint during November 2011, of which 38 needed to be transported by ambulance. Since Palestinian ambulances are not permitted to leave Gaza, patients must be transferred from a Palestinian ambulance, and carried on a stretcher to an Israeli ambulance at Erez checkpoint. In October 724 patients exited Gaza through Erez and 50 patients required back-to-back ambulance transfer at the checkpoint. Rafah: Rafah border crossing was open for humanitarian access for a total of 23 days in November 2011; it was closed for 4 days between 6 and 9 November during the Muslim holiday Eid Al Adha and on 3 weekends (Fridays). The current waiting time for non urgent referrals through Rafah is 2 weeks. An estimated 30 patients daily (total of 900) were able to leave Gaza through Rafah for treatment in Egypt in November. This includes patients who were seeking medical treatment at their own expense and, therefore, travelled without a RAD financial cover, referral document.

Two Children Died Waiting for Referral Treatment

Mohammed Azzam Sahwail: Mohammed Azzam Sahwail, a 9-year-old boy who suffered from growth retardation and muscle atrophy, died November 4 while waiting for a referral from the Palestinian MoH. An urgent request for a referral was submitted for Mohamed to the RAD office in Gaza on October 25, 2011, and on November 2 the MoH in Ramallah referred him for treatment at Makassed hospital in East Jerusalem. However, Makassed hospital decided that it lacked the capacity to treat his condition and could not admit him. The MoH did not suggest an alternative hospital for Mohammed and he remained in the Intensive Care Unit at Al-Nasser Paediatric Hospital in Gaza where he died.

Hiba Azzam Sahwail: Hiba Azzam Sahwail, an 8-year-old girl and Mohammed’s younger sister, also suffered from growth retardation and muscle atrophy. On November 27, 2011, she obtained an MoH referral for treatment at Makassed hospital in East Jerusalem and an appointment was scheduled for December 13, 2011. However, her health condition deteriorated and she was admitted to the intensive care unit at al-Nasser Hospital on November 29, 2011. When contacted for an urgent referral appointment, Makassed Hospital again informed the RAD that it lacked the technical capacity to deal with the case. A request was made to transfer her urgently to Ichilov Hospital in Israel but the MoH referred her instead to Al Mezan Center in the West Bank on December 1, 2011. Hiba died the same day, before being able to travel out of Gaza.

Two Patients Held in Detention

Detention of Ahmed Khamees Akeelah: Ahmed Khamees Akeelah, a 25-year-old man, suffering from retinopathy, was referred to St. John Eye Hospital in East Jerusalem for treatment and was given an appointment on December 1, 2011. On November 24, 2011, Ahmed applied through the district Liaison Office (DLO) in Gaza for a permit to cross Erez in order to access St. John Eye Hospital. Ahmed was called for interrogation on November 30, 2011, the day before his hospital appointment. Ahmed went into the interrogation but after two hours the Israeli authorities informed his brother, who had been accompanying him, that Ahmed had been arrested. The Palestinian Center for Human Rights (PCHR) followed the case at the request of the family, and was informed only that Ahmed was being held in Ashkelon jail, and could not have a lawyer’s visit until December 7, 2011.

Detention of Iyad Shabaan Dawas: Iyad Shabaan Dawas, a 39-year-old patient suffering from stomach cancer, was referred to Augusta Victoria Hospital by the MoH. Iyad and his cousin, who was his companion during the hospitalization, obtained Israeli permits to cross Erez and were able to access Augusta Victoria Hospital on October 25, 2001, the day of the hospital appointment. Iyad was treated in the outpatient department on the same day, and afterwards decided to visit a relative in the West Bank and travelled there with his companion. On November 4, Iyad’s companion returned to Gaza, while Iyad returned to Gaza on November 24, 2011, almost a month after his hospital appointment. On his way back through Erez crossing Iyad was interrogated and arrested. His family was informed by the Israeli authorities that he was being detained in Ashkelon jail.

Iyad’s family contacted PCHR and ICRC to follow up on Iyad’s detention but as of December 15 the family did not receive any further information about Iyad.

Annex 1: Data from January to November for 2010 and 2011