Whether swimming at the beach or trying to get urgent medical care, children in the Gaza Strip were boxed out of their right to health care in 2017, with both Israeli and Palestinian authorities contributing to record lows.
On her fifth pregnancy, Naela Abu Nasira was an experienced and collected expectant mother going about her life in Khan Younis, approximately 15 miles south of Gaza City. Her children, including two who had been born early by cesarean, were all healthy and above the age of five.
Two months before her due date, Abu Nasira gave birth to a baby boy in Tahrir hospital, in Khan Younis. Her amniotic fluid had looked low and her white blood cell count was up by April 27, 2017, putting into motion an urgent cesarean section.
Her child was taken to the nursery and given respiratory support. It was standard practice for premature infants. Sheâ€™d seen two premature-born children sail through this treatment so Abu Nasira didnâ€™t worry too much.
â€śThe doctor said he was completely healthy, but he would need some more time in the nursery,â€ť Abu Nasira told Defense for Children International – Palestine.
When she saw her son, he looked â€śnormalâ€ť Abu Nasira said. â€śThere was only a small tube attached to his mouth, and the doctor was pumping milk through the tube to feed him,â€ť she told DCIP.
That was on April 30. Five days later, Abu Nasira received a phone call from the hospital saying her baby had died.
She went to the hospital to see her childâ€™s body and found him covered in dark bruises and needle marks. â€śThere were more than 15 needle marks all over his body,â€ť said Abu Nasira.
She also found wounds on both sides of his face.
â€śWhen I visited the baby in the nursery, I only saw a feeding tube in his mouth and a single small adhesive bandage to attach the tube to his mouth. But the wounds were all over his face, not just on one side,â€ť Abu Nasira told DCIP.
Shocked and angry, Abu Nasira buried her son. She told DCIP that she suspected the wrong type of adhesives had been used on her sonâ€™s face. She lodged a complaint with the Ministry of Health, citing, â€śThe Ministry of Health’s argument has always been that there is no suitable adhesive in the nursery department.â€ť
She also questioned hospital staffsâ€™ attentiveness and competence. â€śMy son needed nothing but some attention and care,â€ť Abu Nasira said, â€śnot to be turned into some field experiment by nurses or doctors, who did not know how to insert a needle into his vein.â€ť
In even the best of circumstances, medicine is a fast developing field which means hospitals and other health care facilities have to sprint to stay abreast of new research, treatments and technologies. Keeping budgets on pace with best practice can be just as great a challenge.
Instead of advancing, medical care and access in the Gaza Strip is moving backwards, against time. Ten years of Israelâ€™s air, land and sea blockade on the Gaza Strip has played a strong hand in this de-development, bottlenecking the entering stream of both material and human resources into a weak trickle.
Current best practice may not even be in reach in the Gaza Strip, where the blockade has seen shelves wiped clean of some pharmaceutical drugs and supply cupboards sit empty. Even during periods of easement, goals often only reach as high as restocking, replacing parts of worn out equipment, or rebuilding bombed buildings.
â€śThere is a constant shortage of equipment, medicines and treatments,â€ť said Dr. Shireen Abed, director of the pediatric ward at Al-Nasr Children’s Hospital in the northern Gaza Strip. â€śCertainly and without any doubt the blockade has impacted patients’ access to medical equipment,â€ť she told DCIP.
Indeed, when combined with the extensive damage wrought on the Gaza Stripâ€™s medical infrastructure during multiple wars, itâ€™s unsurprising that broad sectors of its health care system are now in pieces.
A significant indicator of the still unfolding health crisis is the increase in the infant mortality rate, the number of infants per 1000 live births who die before turning one.
The UN Relief and Works Agency (UNRWA) first discovered the increase in 2013. So rarely does infant mortality swing up after aid and awareness mechanisms have steadily brought it down over decades, that the group took two additional years to confirm and release their finding.
TheÂ reportÂ showed that after fifty years of steady decline, infant mortality increased by 2.4 percent in refugee families in the Gaza Strip in 2013 compared to 2008. A follow up UNRWAÂ studyÂ found that the leading causes for death in an infantâ€™s first year were: preterm birth, congenital anomalies, and infections.
Worse, the study found that the neonatal mortality rate, death before the age of 4 weeks, had jumped â€śfrom 12 per 1,000 live births in 2008 to 20.3 in 2013.â€ť
Causes for the increase in the neonatal and infant mortality rate could be diverse and intersectional.
Last year, DCIP documented 12 Palestinian children from the Gaza Strip who died as a result of a mix of inadequate access to health care, including poor hospital conditions, low availability of specialized treatments, or as a result of being delayed or denied treatment abroad.
Of this number, nine were infants and eight were less than two weeks old. Abu Nasiraâ€™s son, who didnâ€™t live long enough to receive a name, was a part of this growing statistic.
Direct risks to infant care like equipment shortages are easy to point out. Abed told DCIP, for example, that her hospital has only 13 Â incubators and six respirators. â€śWhat if the infants in the 13 incubators need respirators at the same time? We would be helpless,â€ť Abed said.
Abed added that the equipment they do have â€śis old and outdated, minimizing the care provided to infants in nurseries, which could increase infant mortality.â€ś
Food shortages could also be affecting outcomes during the sensitive prenatal period. Nutrients such as iron, folic acid and fatty acids are all getting harder and harder to come by in the Gaza Strip. Substantial deficits in these can lead to birth defects and other risks.
Last yearâ€™sÂ electricity crisisÂ did infants in the Gaza Strip no favors, either, compromising clean water, basic hospital services and hygiene. Several mothers whose infants died in 2017 told DCIP maternity ward conditions were unsanitary.
One mother said she was placed in a bed with unchanged sheets and used her bag for a pillow. Another said she saw cockroaches.
â€ś[M]edicine and blood were all over the place,â€ť said Jilan Ahmad. She gave birth in July of 2017 during the electricity crisis, in Shifa hospital, in the northern part of the Gaza Strip. â€śThere were also cockroaches, in addition to the noise made by visitors and the screams of labouring women,â€ť Ahmad told DCIP. Her son, Ali, died at only five days old.
Both Israeli and Palestinian authorities also compromised childrenâ€™s health during the course of 2017, by delaying or preventing sick children from exiting the Gaza Strip for medical treatment.
Less easy to demonstrate or measure are diffuse factors in the Gaza Strip, that could damage infant outcomes, such as pervasive poverty or conflict related stressors. Although harder to prove, these too could be triggers of the rateâ€™s change.
In her exchange with DCIP, Abed also noted a possible correlation between congenital heart defects and past wars. â€śIn the study that I was part of, we found out that there was a rise in infant mortality due to congenital defects, most notably heart defects in the years after the wars.â€ť Abed said these findings are preliminary and inconclusive. â€śWe still need to prove such findings by examining the toxins left by the wars, but these tests are not available in Gaza, â€ť Abed said.
More data is no doubt needed to improve infant survival rates in the Gaza Strip. The infant mortality rate is often used as a barometer of overall health conditions in a populace. And by this measure, children in the Gaza Strip are losing ground.
Life often hangs in the balance in those first few hours and days after birth. Any mother who knows the pain of watching a baby being carted, tiny and soundless, into the intensive care unit will say, she never felt so helpless.
One hour after giving birth to her second child, Ghaben began to worry. She tried to nurse her son. Instead of taking the breast, he turned blue. By the next day, Bara, her son, was admitted into the intensive care unit in Shifa hospital, Gaza City.
Bara had been born on June 20 with a couple of extra appendages, but otherwise seemed healthy. He was born on time, without a cesarean and weighed a little under seven pounds, within the normal range.
Like her delivery, Ghaben said her pregnancy had been uneventful. Sheâ€™d gone to an UNRWA clinic for regular appointments, and taken her supplements. Her husband, Mohammad, who had studied nursing but could only find work in the agricultural sector, kept her well supplied with fresh produce.
Just a day after giving birth, Ghaben learned that Bara had a serious heart defect. His aorta was obstructed, preventing normal blood flow to his body. It was treatable, but not in the Gaza Strip.
Between Israelâ€™s decade-long blockade limiting the entry of pharmaceuticals, medical equipment and specialized staff, and large-scale damage to medical infrastructure during Israelâ€™s 2014 offensive, some treatments are now entirely unavailable in Gaza.
In order to get the surgery for Bara, his parents would need to cross several hurdles. The first of these, obtaining a medical referral from a doctor, which they secured quickly.
Next, they needed to secure financial approval from the Palestinian Ministry of Healthâ€™s Service Purchasing Unit (SPU), previously called the Referral Abroad Department. The SPUÂ reviews individual casesÂ to determine eligibility and determines a receiving hospital.
Once they had that referral, they could make an appointment at the approved medical facility and apply for an Israeli permit to cross through the Israeli controlled border, to reach the appointment.
Doctors worked quickly to help the family submit an urgent medical referral request to the SPU, one day after Baraâ€™s birth, on June 21. By the next day, Bara developed a rash and his legs took on a bluish hue.
The surgery to expand his aorta needed to happen quickly but they had not heard back from SPU. Without the SPU approved referral, their hands were tied.
Growing more desperate as the days passed, the family tried other channels. A paramedic who coordinated with patients from the Gaza Strip at Erez crossing told them, informally, medical referrals were not coming out of Ramallah.
â€śMy son was dying in the hospital and we could not do anything for him,â€ť Ghaben recalled.
Seven days after starting his life, Bara died in Shifa hospital. After Mohammad Ghaben collected his sonâ€™s body, the family finally heard the news they had been waiting for. The referral had been approved.
â€śHe [my husband] was told by the director of the nursery department that the medical referral to Al-Maqassid Hospital in East Jerusalem was approved only four hours after the death of my son,â€ť Ghaben said. â€śBut that was useless because Bara died while waiting for it.â€ť
â€śThe cause of death is aortic obstruction,â€ť Ghaben said, â€śand the ban on referrals abroad by the Palestinian Authority in Ramallah.â€ť
Widespread censure of the Palestinian Authority erupted after Baraâ€™s death on June 27, and the death of another infant who had shared his incubator. Mosab Ararir, who was born with his heart outside of his chest, died on June 26 in Shifa hospital. He was only one week old.
Although it is unclear whether Mosab could have survived with the treatment, his parents did all in their power to try. Two doctors verified his need for external treatment and the family tried to attain an SPU referral.
â€śMy husband went to the Referral Abroad Department,â€ť said the childâ€™s mother, Tasneem, â€śand was told that the referrals were banned at the time.â€ť
Pointing to an AprilÂ statementÂ in which Palestinian Authority officials said it planned to â€śslash the health care budget for Gaza; it will only pay for salaries of medical personnel, not for the ongoing management of the health care system,â€ť it appeared that medical referrals had become collateral in a political standoff.
With the Palestinian Authority claiming that Hamas was collecting taxes on imports and not contributing to ongoing costs, an adviser told Haaretz: â€ś[Hamas] must decide whether it will control things in every sense, including ongoing expenses, or let the Palestinian government rule.â€ť
That same April, the number of SPU referrals for Palestinians in the Gaza Strip to receive external treatment severely dipped.
After two years of steady referrals, averaging 1991 to 2040 referrals per month in 2015-2016, theÂ graphÂ starts to plummet in the second quarter of 2017. By June, when Bara and Mosab were born, it fell below 500, to 477. According to the World Health Organization (WHO), this represents theÂ lowest documented numberÂ of referrals since 2008, when WHO began tracking the figure.
SPU processing times also jumped in the middle of 2017, from 99 percent of successful applicants receiving referrals within a week in May 2017, to just 32 percent in September 2017.
These lapses are significant, especially in cases where earlier treatment could have been life-saving.
On June 28, the Palestinian AuthorityÂ rejected culpabilityÂ in blocking patients from exiting the Gaza Strip, saying the poor overall conditions combined with Israelâ€™s rejection of Palestinian applications to pass through Erez crossing were to blame, local media reported.
But according to interviews with DCIP, Ararir and Ghaben never got far enough in the application process to apply for the Israeli permit.
The referral delays came during a period where Palestinian political divisions and funding disputes resulted in an electricity crisis, with far reaching implications on childrenâ€™s access to health. Wastewater poured into public beaches, hospitals delayed surgeries and children who relied on medical equipment struggled to survive.
For Ghaben, Octoberâ€™sÂ unity agreementÂ signed by both Hamas leaders in the Gaza Strip and Palestinian Authority leaders in Ramallah, signaling a possible return to the earlier pace of SPU referrals, came too late. â€śMy baby was denied treatment, Ghaben told DCIP. â€śThey killed him, and I hold everyone responsible.â€ť
Ibrahim Hijazi was born with a hole in his heart in 2008. As if this wasnâ€™t unlucky enough, he was born in the Gaza Strip one year after Israel began what would become a decade of harsh measures largely cutting the area off from the rest of the world.
As Ibrahim reached the toddler stage, his parents discovered that their child had a severe hearing impairment. Ibrahim received a cochlear implant and his family signed him up for speech support at a rehabilitation center. His father, Mohammad, said these interventions only brought scant gains in hearing and a handful of words.
By the age of four, Ibrahimâ€™s seizures started and no one knew the cause. His father said the seizures would come on when Ibrahim exerted himself or was startled. Even the sudden appearance of a cat could trigger a seizure.
Doctors in Gaza City said Ibrahimâ€™s test results were inconclusive. Ibrahim needed further tests but many diagnostic tests are no longer available in the Gaza Strip due to years of tight Israeli regulations on the entry of people and goods, as well as repeated wars, both of which have caused steep medical services and equipment shortages. They recommended Ibrahim travel to Al-Maqassid hospital, a Palestinian-run facility in occupied East Jerusalem, to get the tests done.
In June 2016, Ibrahimâ€™s family began trying to secure permission for the now seven-year-old child to travel, with his mother as an escort, to Al-Maqassid, only approximately fifty miles from Gaza City. As a minor, an adult escort was needed.
After clearing the first set of hurdles on the Palestinian side, an appointment was set for Ibrahimâ€™s diagnostic tests in November of 2016. But by the time of the appointment, Ibrahimâ€™s motherâ€™s application was still pending a security check, so Ibrahim missed the appointment.
Ibrahim and his mother reapplied for permission to exit Gaza through the Erez border two months later but lost that appointment as well. This time, Ibrahimâ€™s mother was denied a permit.
Being the only member of the family skilled in assisting Ibrahim through his seizures and able to communicate with him, the family was at a loss as to how to proceed.
A third appointment came and went without any response regarding their permit application. This time, the family had asked a local rights group, Al-Mezan Center for Human Rights, to appeal to Israeli authorities and demonstrate the specific nature of the Ibrahimâ€™s escort needs.
Last February, when Mohammad spoke to DCIP, he said he had lost hope. He couldnâ€™t find a way out for Ibrahim.
Far from representing a marginal experience, Ibrahimâ€™s story demonstrates how children in the Gaza Strip are losing in their fight for tertiary health care.
Miraculously, basic health care and vaccinations are still available in the Gaza Strip, largely due to UNRWA and their international partnersâ€™ efforts. Although operating with limited electricity, inadequate staff, deteriorating or war-damaged buildings, many preventative health care services are still being delivered.
However, â€śchronic shortages in medical and pharmaceutical supplies and equipment,â€ť as a Â recent UN report categorized it, combined with declining tertiary care are causing a whole host of medical problems to be undiagnosable or untreatable in the Gaza Strip.
Radiology, for example, is wholly unavailable. Children who suffered complex physical traumas during Israelâ€™s 2014 strikes on the Gaza Strip, whenÂ no places were safeÂ for children, also often require outside treatment.
These tertiary health care needsâ€”in concert with the immense and entirely man-made humanitarian crisis caused by the blockade and repeated warsâ€”are beginning to push major health care indicators, such as theÂ infant mortality rate, down a slippery hill.
A medicine- and equipment-starved health care system also means more people need to leave Gaza for treatment. In fact, the Office for the UN Special Coordinator for the Middle East Peace Process (UNSCO) reported that this number has tripled in ten years.
Between October and November 2015, medical equipment, pharmaceuticals or diagnostic services accounted forÂ 74 percentÂ of medical exit permits in a study pool of 1000 applications.
At the same time that needs are swelling, Israeli medical permit approvals are decreasing. On average, Â Â Israel only approved about 54 percent of all Gaza Strip medical requests to cross through Erez, according to WHO, in 2017. This is the lowest recorded approval rate since WHO began tracking the figure in 2008.
As recently as 2012, Israel approvedÂ 92.5 percentÂ of Gaza Strip medical requests Â to cross through the Erez border.
While only three children were outright denied permission to cross the Israeli border in November, 192 childrenâ€™s permits were delayed, WHO reported. In addition, Israel denied or delayed 205 adults requesting permission to cross the border as the escort to a minor in need of medical care outside of the Gaza Strip the same month.
These delays came on top of new Israeli guidelines which came into effect mid-November, WHO said, which set 26 days as the period of security clearances and made permit denials valid for six months.
The new year has not offered any reason for optimism, as new cases of children being unable to exit Gaza for treatment are already emerging. This January, DCIP met with Nabhan al-Masri,10, from Beit Lahia in northern Gaza, who suffers from a metabolic disorder. Between 2012 and early 2017, he exited the Gaza Strip for regular treatments at Al-Maqassid hospital. Now, nearly a year has passed since he was last granted a permit, putting his future into jeopardy.
Advancements in pediatric medical treatments and technologies are worthless to the child who cannot reach them in time. This is why WHO stressed, â€śAccess is a fundamental element of the right to health, as important as availability, acceptability and quality of health care, â€ť in its 2014-2015 report.
Five-year-old Aya Abu Metleq illustrates this point painfully. Her appointment was delayed by Israeli authorities more than two months because of unapproved applications to cross Erez, for treatment of cerebral palsy and a nutritional malabsorption condition.
She died in her bed in the early morning of April 17, just 10 days before a third scheduled medical appointment in Jerusalem.
Neda al-Sayes, 11, plays near but doesnâ€™t touch the water.
She was on a beach with her siblings in the blockaded Gaza Strip when DCIP visited her family. Her six-year-old brother Mohammad al-Sayes fell ill and died following a family trip to Gazaâ€™s Mediterranean waters just months before, and she knows now to avoid seawater.
The family had gone to a beach just northwest of Gaza City on July 19. The sun was beginning to set as they settled in amid other beach-going families.
â€śIt was summer break, the electricity was cut off, and everyone was feeling bored. It was a good chance to do something good with the family,â€ť Mohammadâ€™s uncle, Mohammad Salem Ibrahim al-Sayes told DCIP.
But on this particular evening, Palestinians in the Gaza Strip were in the throes of a severe electricity crisis. The Gaza Strip had aroundÂ five hoursÂ of electricity that day. Without proper power, a wastewater treatment plant in the nearby Sheikh Ajlan area was pumping partially treated sewage directly into the sea where the al-Sayes family swam.
Pollution levelsÂ in the wastewater were nearly five times the international pollution standard, according to United Nations Office for the Coordination of Humanitarian Affairs (OCHA).
Mohammadâ€™s uncle said Mohammad swam for about 10 minutes and slept in his motherâ€™s lap for the rest of the evening. Unbeknown to her at the time, the six-year-old would be among at least five children in the family to fall ill and require medical care after swimming that evening.
All but Mohammad would recover.
When he showed symptoms of severe diarrhea, fever, and vomiting on the morning of July 21, the family began an untenable navigation of Gazaâ€™s dilapidated health sector.
Mohammad arrived to Al-Durrah Childrenâ€™s Hospital nearly unconscious and dehydrated. Doctors performed a CT scan but struggled to diagnose him. He deteriorated rapidly despite receiving antibiotics and IV fluids.
A second CT scan on July 23 revealed swelling in his brain. Doctors recommended he be urgently transferred out of the Gaza Strip abroad for diagnostic testing.
â€śHis condition could not be treated in Gaza because the doctors could not identify the problem,â€ť al-Sayes told DCIP.
A Palestinian Authority decision to partially cut financial support to the Gaza Strip last spring sparked a downturn in conditions already devastated by a decade-longÂ Israeli blockade. Water and sanitation standards plummeted and access to medical care was slashed, leaving children with a higher risk of illness but a lower chance for treatment, according to DCIP research.
Between April and July, the Palestinian Authority notified Israel that it would no longer fund portions of electricity to the Gaza Strip. The Palestinian Authority also made monetary cuts to Gazaâ€™s health network and slashed civil servant salaries in the Gaza Strip byÂ 30 to 70 percent.
The Fatah-dominated Palestinian Authority and Hamas have been at odds since Hamas won parliamentary elections in 2006 and took power over the Gaza Strip. Multiple efforts at reconciliation failed while long-standing disputes around Hamasâ€™ taxation of electricity and fuel culminated in the Palestinian Authority imposing a series of restrictions.
Israel implemented the electricity cuts in June, two months after the Gaza Stripâ€™s sole power plantÂ shut down.Â UN rights expertsÂ by July said Israelâ€™s execution of the Palestinian Authorityâ€™s request to pull electricity funds had prompted an â€śunprecedented deteriorationâ€ť in critical services.
It was around this time Mohammadâ€™s family submitted paperwork to the Referral Abroad Department (RAD)â€” since renamed the Services Purchasing Unit â€”requesting an urgent medical transfer for Mohammad to the West Bank. After two days without a response from the RAD, which is part of the Ministry of Health in Ramallah, the family followed up and learned the request was rejected.
â€śWe made calls with some of our contacts at the referral office to speed up the referral process, but we were told that Mohammad’s condition could not be treated in the West Bank and that West Bank hospitals had no room to receive more patients,â€ť Mohammadâ€™s uncle said. RAD told the al-Sayes family that Mohammadâ€™s condition was â€śuntreatableâ€ť whether inside or outside of the Gaza Strip.
Director of Preventive Medicine at the Palestinian Ministry of Health in the Gaza Strip, Dr. Majdi Dheir, said that Mohammad may have suffered from lethal toxic encephalopathy due to shigellosis, also known as Ekiri syndrome.
Ekiri is a rare complication with a high fatality rate, according to theÂ Journal of Microbiology, Immunology and Infection. Both Dheir and Mohammadâ€™s treating physician indicated that exposure to stool in contaminated seawater is a possible cause of shigellosis.
When Mohammad died, on July 29, he left behind nearlyÂ one millionÂ other Palestinian children who are denied the right to health due to the Gaza Stripâ€™s current conditions.
According to the Office of the UN High Commissioner for Human Rights, the right to health is an inclusive right that goes well beyond access to proper medical care. Equally essential are â€śunderlying determinants of health,â€ť like water and sanitation standards, as well as the proper functioning and availability of goods and services.
While the Palestinian Authority cut payments for a portion of the Gaza Stripâ€™s electricity, Israel is stillÂ primarily responsibleÂ for maintaining Palestiniansâ€™ right to health there.Â International humanitarian lawÂ obligates Israel, as the Occupying Power, to ensure this right is met.
Israel does not stand alone in this responsibility however. SecondaryÂ duty bearersinclude the international community, Palestinian Authority, and local authorities such as the Hamas-led government and the Gaza Stripâ€™s Ministry of Health.
Reconciliation efforts between the Palestinian Authority and Hamas relaunched in September and the Palestinian AuthorityÂ beganÂ to re-implement control in the Gaza Strip. But in December, UN Official Robert Piper said that â€śmost of the measures adopted by the Palestinian Authority since March 2017, which triggered the latest deterioration in the humanitarian situation in the Gaza Strip, are yet to be reversed.â€ť
OCHAÂ reported in December that around 130 critical water and sanitation facilities were working at reduced capacity. Oxfam also told DCIP at the time that the Gaza Stripâ€™s wastewater plants were operating below WHO standards.
With recent funding cuts by the United States to UNRWA,Â OCHAÂ estimates that emergency fuel will be depleted by mid-February, severely reducing the capacities of 12 public hospitals, 55 sewage pools, and 48 desalination plants. Beit Hanoun hospital already shut down on January 29.
Skull and crossbones signs forbidding fishing and swimming remain on some Gaza Strip beaches.
While al-Sayes said the family did not see warning signs where they played, untreated sewage is inescapable in Gaza. It not only flows into the sea but also contaminates riverbeds and groundwater.
The Gaza Stripâ€™s overused aquifer, the main source of freshwater, is severely tainted by contaminated seawater and aÂ UN reportÂ estimated last year that over 96 percent of the Gaza Stripâ€™s groundwater is undrinkable. At leastÂ 500,000 peopleare vulnerable during winter flooding which is likely to contain sewage.
Months after Mohammadâ€™s death, the al-Sayes family, living between a polluted coastline to the west and a militarized border on the east, is unable to escape what they see as a fatal landscape.