Yousef Hamamreh, head of cancer care at East Jerusalem’s Augusta Victoria hospital, refuses to sit at the desk in his basement office – he says he doesn’t deserve the respect and honour it conveys.
He is failing at treating patients, he says – not just those who call him on the phone, appealing for help, but also those who make it to the hospital, only to discover the medicines they need are not available.
At the top of his mind are the hospital’s 600 active patients in Gaza, two thirds of whom staff haven’t managed to speak to since the start of the Gaza war on October 7th. They are among about 10,000 Gazans with cancer who are getting “zero treatment”, Hamamreh says. “Even pills [such as] tamoxifen, which is $10 (€9.15)a month and is a very essential treatment for breast cancer, it is not available in the Gaza Strip nowadays.”
The slow and preventable deaths of Gazans with cancer may never be counted among the war casualties, even if they are a direct result of that conflict. And Hamamreh is also worried about cancer patients from the Israeli-occupied West Bank. They must secure referrals and travel permits to travel to East Jerusalem for certain treatments, such as radiation therapy, and even then adequate care is not guaranteed, because of a crushing financial crisis.
That crisis is partially related to Israel withholding taxes from the Palestinian Authority (PA) since last October, though the issue precedes that. The PA, which exercises limited control over the West Bank, including by overseeing healthcare, owes Augusta Victoria 275 million shekels (€66 million), according to Hamamreh. This has forced the hospital to turn away roughly 1,400 new patients over the past two years, reducing capacity to less than 50 per cent, he says.
Hamamreh is keen to point out that he’s not a politician, and does not want to publicly attribute blame for the situation. He wants only to emphasise that innocent people with chronic but treatable conditions are the victims, suffering inside a tornado of more powerful forces.
Others do attribute blame for Palestine’s healthcare crisis. The Israel-based NGO Physicians for Human Rights Israel posted a statement from its mobile clinic director, Salah Haj Yahya, on its Facebook page on July 24th in the wake of the International Court of Justice’s finding that Israel’s occupation of Palestinian territories is illegal and should be ended. “I didn’t need the [ICJ’s] ruling to understand that the Israeli occupation is a crime,” Yahya said. “Movement restrictions and roadblocks, along with increasing fears of settler and military violence, make it difficult for Palestinian physicians to reach distant clinics regularly. Patients also hesitate to travel from their villages to larger cities due to the risks involved. Moreover, entry permits into Israel for medical care are rarely granted.”
Yahya said Israel’s “confiscation of Palestinian tax funds, the loss of livelihoods for workers who previously worked in Israel [and have been barred since October 7th], and the collapse of private businesses” had led to a “catastrophic financial crisis” for the PA.
“A critical shortage of medicines in the Palestinian public healthcare system is driving patients to seek treatment in the private market, where soaring prices are unaffordable for most families,” she said. “We have encountered diabetic patients unable to access insulin and kidney transplant recipients struggling to buy costly medications necessary to prevent transplant rejection. The daily horror these patients endure is heartbreaking.”
A World Bank update in May said “the fiscal situation of the Palestinian Authority has dramatically worsened in the last three months, significantly raising the risk of a fiscal collapse”, with a financing gap of €631 million at the end of 2023 projected to almost double to €1.1 billion in the coming months. Alongside the losses in income, Palestinians regularly complain that the PA has been plagued by corruption, meaning money that should go towards services disappears into the pockets of elites. The PA’s health ministry did not respond to a request for comment.
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The Augusta Victoria Hospital, one of East Jerusalem’s biggest, is situated high on the Mount of Olives. It opened shortly after the 1948 Arab-Israeli war, to care for Palestinian refugees, and now specialises in cancer care and kidney disease. Today, Hamamreh says, they treat only Palestinians from the West Bank and Gaza, though they haven’t received any new patients from Gaza since last year. About 20 patients from Gaza who were in the hospital on October 7th are still staying either there or in associated hotels.
[ What is daily life really like in the West Bank?Opens in new window ]
Two years ago, US president Joe Biden made a speech at the Augusta Victoria, announcing a commitment of $100 million in funding for the network the hospital is part of. “When people get a cancer diagnosis,” Biden said, “in that moment, all that matters is that you’ve got someone that you can turn to and [who] radiates hope and help.”
“Palestinians and Israelis deserve equal measure of freedom, security, prosperity, and dignity,” he said. “And access to healthcare when you need it is essential to living a life of dignity for all of us.”
But a look at the challenges that Palestinians with cancer face in accessing healthcare offers key insights into the effects of military assault and occupation.
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Some 150km from the Augusta Victoria, at Jenin Government Hospital, director Wisam Baker says it lacks the capacity to provide a range of treatments including neurosurgery, thoracic surgery, cardiac surgery, cardiac catheterisation and certain cancer care. He said he knows of patients who have been refused permission to go elsewhere to access them. “If there is a delay in treatment, they sometimes die.”
Hamamreh, at the Augusta Victoria, says “100 per cent” of the patients they treats need special permits to travel there.
The issue is not a new one. A 2017 briefing paper by the British-based charity Medical Aid for Palestinians said roughly 52,000 Palestinians needed Israeli permits to access care in 2015 alone. “Security services frequently deny travel permits without explanation, citing ‘security reasons’,” the paper said. “There have also been cases where patients from entire geographical areas were denied exit permits, in what the UN has said may amount to collective punishment, or where permits were denied as a result of political events or Israeli holidays.”
In Gaza, the percentage of patients approved to leave the strip for medical care in East Jerusalem dropped from 92 per cent in 2012 to 62 per cent in 2016, the paper said.
In a 2021 report by its director general Tedros Adhanom Ghebreyesus, the World Health Organisation said that in the first two months of 2020, more than 1,000 patient permit applications from Gaza and more than 1,500 from the West Bank were either denied by Israel or not given a definitive response by the time of the patient’s hospital appointment.
The report said that “all aspects of life, encompassing underlying determinants of health, have been profoundly affected by the chronic occupation and situations of long-term displacement and blockade for Palestinians in the West Bank, including East Jerusalem, and the Gaza Strip”.
Palestinians’ health was worsened, it said, by a wide range of associated issues, including Israel demolishing West Bank infrastructure related to water provision and sanitation, and the contaminating discharge, by Israeli settlers, of wastewater on to Palestinian land. The report called for Israel to “re-examine the permits system to ensure unhindered access for patients requiring health services as recommended by medical practitioners”.
A study published last year by the National Library of Medicine, a US government agency, found that cancer care for Palestinians was “fragmented, with limited access to the services needed. Patients face referral delays in accessing treatment which worsen their health condition in some cases. Some patients reported difficulties in getting Israeli permits to access radiotherapy treatment in East Jerusalem, and others experienced interruptions of their chemotherapy treatment sessions due to the unavailability of chemotherapy medications caused by Israeli-side delays”.
Even with valid permits, patients can be stopped or face lengthy waits at checkpoints.
In early 2023, the UN Office for the Co-ordination of Humanitarian Affairs documented more than 600 obstacles to movement in the West Bank, including earth walls, road barriers, trenches and checkpoints staffed by Israeli forces or private security companies. In the weeks after October 7th, the number of road obstacles in the West Bank increased by at least another 140, according to Palestinian NGO the Applied Research Institute – Jerusalem.
Palestinians who are sick can feel that they’re walking a tightrope. Some told me they are aware that if they have posted anything negative about Israel on social media, for example, they could be blocked from travelling.
A spokesperson for the Israeli government’s Co-ordination of Government Activities in the Territories (Cogat) unit said civil administration officials review every request for medical treatment. “Contrary to what has been claimed, the only consideration in granting permission to transfer a patient from the territories of the Palestinian Authority to receive treatment in Israeli hospitals [which they included East Jerusalem in] is if there is no suitable medical treatment in the Palestinian Authority and the hospitals in Israel are willing to provide medical treatment. Any claim to collective punishment is baseless and false.”
The spokesperson said: “Palestinians flagged by the Israel Security Agency as security risks, and seeking treatment in Israel, are assessed on a case-by-case basis. If a patient poses a security risk, he/she can receive treatment in Jordan or another third country.”
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As Hamamreh leaves his office to walk around the hospital, a patient begins crying upon seeing him. She tells him she waited four months to get treated and she is so grateful to finally be here. Ghada Abuarqoub (49) has an eight-year-old son, and a job at the Palestinian Ministry of Youth and Sport, though she’s on sick leave now. Her breast cancer was first diagnosed in 2018 and she was treated in a government hospital in Bethlehem, but there was no follow-up, she says. Convinced the cancer was progressing, she managed to get an urgent permit from the Palestinian health ministry to be referred to Jerusalem. There, medics deduced that the cancer had spread to her lungs and spine. She was admitted to Augusta Victoria for two weeks, and now has to come back weekly.
A nurse hooks up a bag of red liquid – her chemotherapy – and sticks a needle into the back of her hand to deliver it. Abuarqoub wipes more tears from her eyes.
She travelled today in a private bus organised by the hospital, which departed from close to her home in Hebron, 53km away. They waited at a checkpoint for only 20 minutes, she says; on her previous visit the wait was an hour. The time it takes is at the whim of the soldier at the checkpoint, she says. Every three months, she applies for a new permit in a process that takes a day, supported by a letter from Augusta Victoria. Being here is bittersweet, she says, because she knows there are so many other Palestinians who need help. She begins to cry again.
Nearby is Waad Nawash (32), who travels to the Augusta Victoria from Bethlehem, less than 20km away. Passing the checkpoint en route takes about an hour each time, she says. Time spent “just waiting, [there are] no questions”. Nawash was diagnosed with brain cancer in 2016. Her mother holds her hand, as drugs drip into her bloodstream.
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Hamamreh works full-time in the hospital, though he says his salary is 50 per cent of what it was before the financial crisis. But he reserves each Friday for prayer. That’s when he asks God to change his reality and to deliver something to make his patients’ suffering go away.
“It’s very hard for me,” he says. “Especially [with] breast cancer patients, they are suffering a lot without medication and I hope you can understand what that means... We’re talking about cancer... the time period [to start treatment and get a positive outcome] is very short.”
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