JERUSALEM (AP) — Jalal al-Masri and his wife spent eight years and their life savings on fertility treatments to have their daughter Fatma. When she was diagnosed with a congenital heart defect in December, they waited another three months for Israeli permission to treat her outside of Gaza.
Approval never came. The 19-month-old died on March 25.
“When I lost my daughter, I felt that there was no life in Gaza,” al-Masri said in a trembling voice. “My daughter’s story will happen again and again.”
Israel is granting permits to Palestinians from the Gaza Strip, which has been under a crippling Israeli-Egyptian blockade since the Islamic militant Hamas seized power in 2007, for what it defines as life-saving treatment.
But the families have to negotiate an opaque and uncertain bureaucratic process. Applications are submitted through the Palestinian Authority, reports must be stamped and paperwork processed. In the end, al-Masris only received a text message from the Israeli military saying that the application was being “under review.”
COGAT, the Israeli military agency that oversees the permitting system, did not respond to multiple requests for comment.
Of the more than 15,000 patient permit applications from Gaza in 2021, 37% were delayed or denied, according to the World Health Organization.
Al-Mezan, a Gaza-based human rights group that has helped al-Masris and other families, says at least 71 Palestinians, including 25 women and nine children, have died since 2011 after their applications were rejected or delayed.
That doesn’t necessarily mean Israel’s decisions were responsible for the deaths — even the best hospitals can’t save everyone. But the families of the sick faced the added stress of negotiating complex bureaucracy — and the uncertainty of how things might have turned out differently.
In December, doctors in the city of Khan Younis diagnosed Fatma with an atrial septal defect, a hole in her tiny heart. Gaza’s healthcare system has been affected by the 15-year blockade and four wars between Israel and Hamas. So they referred her to a Palestinian hospital in Israel-annexed East Jerusalem that offers pediatric cardiac surgery for treatment.
Her father took the medical report and dashed to a small office in Gaza City run by the internationally recognized Palestinian Authority. Hamas expelled the PA from Gaza in 2007 and limited its authority to parts of the Israeli-occupied West Bank, but it continues to serve as a liaison between Gaza residents and the Israeli authorities.
A few days later, al-Masri was informed that the application had been approved. The PA made an appointment at Makassed Hospital in East Jerusalem on December 28 and agreed to pay for the treatment. The toddler’s grandmother would accompany them.
All they needed was a security clearance from Israel.
Israel conquered Gaza along with the West Bank and East Jerusalem in the 1967 Middle East War. The Palestinians want all three territories to form their future state. Israel withdrew troops and settlers from the Gaza Strip in 2005, but still severely restricts the movement of people and goods in and out of the narrow strip of coastline.
Israel says the blockade is necessary to contain Hamas, which western countries consider a terrorist group because of its long history of deadly attacks on Israelis. Critics see the blockade as a form of collective punishment for the two million Palestinian residents of the Gaza Strip.
Israel refuses permits to Palestinians whom it sees as a security threat. But in the case of 19-month-old Fatma and her grandmother, all they said was that the application would be considered.
The hospital kept the appointment open until January 6. Then Jalal applied again. The same story.
He made a third appointment for February 14. Still no approval.
He made a fourth for March 6th.
This time he was told Israel needed 14 more days to process the application, so he pushed the deadline back to March 27. The PA’s financial backing ran out, so he applied again. The Israelis said they needed a new medical report because December’s had expired.
“I’ve spent the last three months running back and forth,” he said. “I’ve said to everyone I’ve seen, do the impossible, just get them out. Take her alone, unaccompanied, and take her to the hospital.”
He made a sixth appointment for April 5th.
On Friday, March 25, Fatma woke up early. She played with her father and kissed her newborn baby brother. She wanted chicken wings for lunch, so her father went out to get some.
Anything for his little girl.
While he was out, his brother called and said Fatma was tired. When he got home, his relatives were waiting outside for the ambulance. At the hospital, she was pronounced dead upon arrival.
The cause of death given in the medical report was cardiac arrest, caused by the enlargement of the heart caused by the atrial septal defect.
Jalal would have included Israel in the chain of events.
“This is a premeditated killing. My daughter was the victim of blockade and closure,” he said. “What did she do to deserve this? She had all the papers.”
dr Merfeq al-Farra, a pediatrician who saw Fatma several times at his clinic, said the hole in her heart caused pulmonary hypertension, putting her at risk of stroke.
“If the hole is 4 millimeters, we can treat it in Gaza, but the hole in her heart was large, 20 millimeters, and this requires specialized open-heart surgery on children, which is not available in Gaza,” he said . “That’s why the hospital issued her at least four urgent referrals.”
dr Abraham Lorber, former chief of pediatric cardiology at Israel’s Rambam Health Care Campus, said ASD alone is rarely fatal. Doctors often recommend elective surgery later in life to prevent symptoms from developing. Sometimes they discover the congenital defect in adults.
That may have led Israeli officials evaluating Fatma’s treatment history to conclude that her life was not in danger.
But Lorber, who didn’t treat Fatma, said ASD can make other heart and lung conditions worse. In this case, it needs to be treated quickly, especially if the patient has difficulty breathing.
“It would not just be about correcting ASD. The patient probably would have needed other interventions, not just surgery,” he said. “This patient most likely had underlying conditions.”
Regardless of the diagnosis, he said, their chances of survival would have been much better in the Jerusalem hospital.
On that day in the emergency room in Gaza, Jalal would have tried anything.
“I told the doctor, take my heart and put it inside her,” he said. “I felt like I died, not her.”
Ten days after his daughter’s death, he received another text message from Israel. The application was still pending.
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Akram reported from Hamilton, Canada.