Palestinian Women Get Breast Cancer Too

What I discovered [in the peace negotiations] was that a West Bank Palestinian could not build, work, study, purchase land, grow produce, start a business, take a walk at night, enter Israel, go abroad, or visit his family in Gaza or Jordan without a permit from us. About one third of the Palestinian population had been detained or imprisoned by Israel. And the whole population had been grossly humiliated by us. -- Uri Savir, Israeli peace negotiator, former Director General of the Israeli Foreign Office

Since the Occupation began in 1967, Palestinian daily life has been regulated by a system of I.D.F. military orders that regulate, as Uri Savir discovered, almost every aspect of everyday life. By the end of the first intifada, West Bank Palestinians were subject to a total of 1300 military orders, requiring them to seek Israeli permission for even the most routine activities. Freedom of movement was one of the few Palestinian activities that did not traditionally require an Israeli permit, but since 1991 Israel has added an additional series of restrictions, taking away the right to travel too. First, Palestinians lost the right to travel outside the Territories (a restriction known as "Closure"). Then in 1996, at the height of the Oslo years when the burden of Occupation was supposedly lessening, they lost the right to travel beyond their own area within the Territories (a.k.a. "Internal Closure").

By restricting freedom of movement to smaller and smaller areas, Israel has progressively sealed off the Palestinian population into small enclaves. Today, urban Palestinians cannot leave their respective cities without a "freedom-of-movement" permit. And those Palestinians who live on land that Israel particularly covets, such as the East Jerusalem area or in the shadow of the Wall, have even less mobility than that: in those areas, Palestinians may require an Israeli permit to go to work in their own fields, to sleep in their own home, to visit their own wives and children, even to climb their own stairs.

Such an intrusive system of control over Palestinian everyday life has several advantages from the perspective of the occupying authorities. First and foremost, the I.D.F.’s military orders give a “legal” veneer to just about every illegal act that the Palestinians are supposedly protected from by the Fourth Geneva Convention, but which Israel carries out anyway in order to make permanent its hold on the Territories. Would you like to force Arabs out of East Jerusalem? Just demolish their houses, then they'll have to leave! It’s not ethnic cleansing – that would be a war crime. It’s only a matter of knocking down those houses built without a permit. Just don’t ask why so few East Jerusalem Palestinians are granted a permit to build a home in the first place [Footnote 1]. And that “abandoned” farmland on the West Bank that is so useful for expanding settlements? It’s not as if the Palestinian farmers are forced to give up farming, it’s just that their shallow wells ran dry when the nearby settlement drilled a deep-water well. Maybe the local Palestinians could have drilled a deep well too… but you can’t do that without an Israeli permit. And you really don’t want to know how few West Bank farmers have received permits from Israel to drill a new well over the last 38 years of Occupation [2].

Another advantage of requiring permits for the minutiae of everyday life is that the issuing or denial of a permit becomes a powerful tool for recruiting informants. Your wife needs a permit to receive treatment at a Jerusalem hospital? Or course she can have one… if you cooperate with Shin Bet. You need to renew the work permit that your job depends on? Of course, “you help us and we will help you”. And from an economic perspective, a restrictive regime requiring that Palestinians seek Israeli permits to produce goods, to import raw materials and to export finished products, stunts the development of the local Palestinian economy and ensures that Palestinians remain a captive market for Israeli goods.

Above all, the systematic control over Palestinians' everyday life is a constant reminder to them of who is in charge in the relationship between occupier and occupied [3]. The fact that very little can be done without a permit, and that the permit system is slow, unresponsive, bureaucratic [4], humiliating and arbitrary is a constant lesson to Palestinians that their dignity, their time, and their right to simply go about the normal business of everyday life count for nothing [5]. In this respect, the permit system is the institutional embodiment of Israeli Defence Minister Moshe Dayan’s 1967 message to the Palestinian refugees in the Occupied Territories: "You shall continue to live like dogs, and whoever wants to can leave". [6]

Palestinians respond in different ways to Israeli control of everyday life. Some are defiant that they will live normal lives, regardless of the bureaucratic obstacles in their way – like Salim and Arabiya Shawamreh who since 1991 have been trying to build a home on their own land in Anata (near Jerusalem), but have faced a succession of shifting excuses from the Israeli authorities who continue to deny them a permit. Having nowhere else to live but on their own land, they built a home anyway, and saw that demolished. So they built again, and then again, and then again. Four times their modest family home has been demolished, and four times they have rebuilt, as an assertion of their right simply to live in their own home on their own land.

But many Palestinians are not defiant, and simply avoid the inconvenience and humiliation of the permit system by reluctantly relinquishing the right to do the everyday things for which they would need to ask for a permit [7]. And, as Gideon Levy noted in February 2004, the most visible freedom that Palestinians have given up on is their freedom of movement:

This is their daily routine: from home to work, to school, to the clinic, via this daily humiliation. From checkpoint to checkpoint, kilometers on foot, no matter what the weather, no matter what their age, no matter what their state of health. The lame and the halt, the blind and the crippled, the children and the aged, the women in labor and the toddlers, the educated and the ignorant, the rich and the poor - all of them in this march of the living, from checkpoint to checkpoint, from humiliation to humiliation, caged in their own land.

Yet however adaptive they are, their patience, too, has already run out and they have come to the end of their tether: the roads, the checkpoints, the alternative ways through the fields and rocky terraces - lately they are almost empty. In the past few months, the roads and checkpoints of the West Bank have become empty of Palestinians. In one sphere, at least, their consciousness has been burned: They have given up the right of movement. The truth is that it was hard to understand how they had put up with everything.

There is however one group of Palestinians that does not have the luxury of "opting out" of the permit system by choosing not to travel, and that is the chronically sick – especially those in the underprivileged Gaza Strip [8] – who have no choice but to travel if they are to receive medical attention.

When Israel took control of the Gaza Strip in 1967, its national hospitals became Israeli government hospitals under the control of the Israeli Ministry of Health. Between 1967 and 1991, the Ministry of Health rejected all applications to build new facilities, even private hospitals, in the Gaza Strip, resulting in a severe shortfall of hospital beds available for a rapidly-growing population [9]. According to Israel’s Physicians for Human Rights, there were 790 hospital beds in the Gaza Strip in 1970. By 1993, the population of Gaza had doubled, but the number of hospital beds had risen to only 900 [10]. Those hospitals that did exist were underfunded, and a delegation of U.S. physicians that reported in 1988 on the health situation in the Occupied Territories for American Doctors for Human Rights noted that: "The conditions of the hospitals we visited are very low even if compared with low-level health services in the Third world countries."

In 1995, the creaking public health system in the Gaza Strip became the responsibility of the Palestinian Authority. By 1997, the number of hospital beds in the Strip had risen to 1,000, but this still represented only half the number of beds per 1,000 persons that the W.H.O. recommends as a minimum requirement for adequate medical care. To meet that shortfall, and especially to provide the advanced treatments that did not exist when the P.A. took over the Strip and that are prohibitively expensive to develope (e.g. heart surgery, neurosurgery, transplant surgery, bonemarrow testing, radiotherapy, etc.), the P.A. relies upon hospitals elsewhere. Each year, the P.A. pays for about 8,000 Gazans to receive medical treatment in hospitals outside the Gaza Strip: about two-thirds of them go to Egypt, about one-sixth to Israel and the remaining one-sixth to Occupied East Jerusalem, the West Bank, or Jordan.

Which brings us back to the question of permits. Because to receive life-saving medical care in Egypt, Palestinian patients from Gaza need a travel permit from the Israeli military authorities, that will allow them to pass through the Philadelphi checkpoint on the southern edge of the Gaza Strip. Similarly, patients trying to reach hospitals in Israel, East Jerusalem or the West Bank have to apply for a permit to pass through the Erez crossing in northern Gaza. There is no preferential permit system for desperately-ill patients; they rely upon the same slow-moving, under-staffed, bureaucratic permit system that every other Palestinian does. It’s the same system for everyone. The difference is that while it might be inconvenient and humiliating to wait an unconscionable amount of time for a permit to build a home, start a job, complete an education, or just visit relatives, a similar wait for urgent medical treatment moves beyond the inconvenient and becomes a matter of life and death. As in the case of Attra Hamdan Zaro who died at home in Rafah last August, while her family was seeking Israeli permission for her to travel to Egypt for the heart surgery that might have saved her life. And even if you get your permit, your right to travel still depends on the goodwill of the all-powerful soldier at the checkpoint. You might be a wheelchair-bound 65-year-old cancer patient with a permit to enter Israel for treatment, but that doesn’t help you if the I.D.F. soldier on duty says you can go through, but not your wheelchair. And being a kidney patient on your way for medical treatment doesn’t get you through a checkpoint if you run into a soldier there who simply announces: "I don't feel like letting him through. Everyone here is sick."

Since last summer, Israeli journalist Gideon Levy has been following the progress of Fatma Barghout, a 28-year-old accountancy student from Gaza. Fatma is a breast cancer patient, whose aggressive, metastasized cancer cannot be treated in the Gaza Strip. For her repeated surgeries and cycles of chemotherapy and radiation treatment, Fatma relies on the Sheba Medical Center, which is on the other side of the Erez crossing in Tel Hashomer, Israel. Additionally, Akiva Eldar reported on the particular challenges facing breat cancer patients in the Gaza Strip for yesterday's edition of Ha'aretz, using Fatma Barghout's case history as a example. I am posting Eldar's report as a timeline of events, with Levy's articles interposed at the relevant point in time.

This is what it is like to be a young woman with breast cancer, if you live in the Gaza Strip.

"Fatma Barghout was only 26 when in April 2003 she discovered a suspicious lump in her breast. The accountancy student from Gaza immediately went to see a surgeon at the Shifa Hospital in Gaza. After he examined the X-ray and the biopsy, the doctor told Fatma that it was a benign tumor. However, the tumor continued to grow. In June Fatma went to the surgeon's private clinic and asked him to remove the lump, even if it was not malignant. A laboratory test at the hospital again showed that the growth was benign. She was pregnant, and the doctor promised that after she gave birth, everything would be fine.

In August Fatma went to the private clinic of the head of the oncology department at Shifa Hospital. The tumor was already quite large and she felt additional lumps in her armpit. The doctor prescribed an antibiotic. At the next visit he suggested that she change her bra. Fatma went back to the first surgeon. This time the findings of the biopsy were clear: a malignant carcinoma. One-hundred-and-forty-six days after she discovered the lump in her breast, Fatma began chemotherapy treatments at Shifa Hospital. After nine cycles of treatment she sent a biopsy to the Sheba Medical Center at Tel Hashomer. The examination showed that the patient was in a critical phase, and Fatma was summoned urgently to the oncology department.

Fatma's story is taken from a new report issued by Physicians for Human Rights-Israel (PHRI) on the situation of cancer patients in the territories. Cancer patients' chances of survival depend crucially on access to specialists and the availability of sophisticated medical equipment. Support by family members and encouragement by friends are also of inestimable importance. Fatma Barghout came from Gaza, which is poor in doctors and medical equipment. While she was being treated in Israel, she was left all alone most of the time with the cruel disease. Almost all alone. Members of the physicians' non-profit organization and the staff of the oncology department at Sheba Medical Center spared no efforts to save her life. However, they were unable to break down the walls of the bureaucracy of the occupation.

November 2003. Three times, Fatma applied to the Civil Liaison Office in Gaza with a request to obtain an entry permit to receive treatment in Israel. Three times she got no answer, neither positive nor negative. On November 31, 2003, she asked for the help of PHRI. With the help of a member of its directorate, Professor Rafi Walden, she was given an appointment for treatment on the 25th of the month. Fatma submitted another application for an entry permit, and again received no answer.

December 2003. After it was contacted by PHRI, the State Prosecutor's Office stated that Fatma would be allowed to enter Israel on December 7 for the purpose of receiving treatment at Tel Hashomer. Fatma began a series of daily chemotherapy treatments at Sheba Medical Center, for a period of two weeks. Her request for a permit for someone to accompany her was rejected, and she came for the difficult treatments on her own, always after an exhausting wait at the Erez crossing point.

February 2004. On February 9, 2004, Fatma was scheduled for surgery to remove the breast tumor. As always, she came to the Erez crossing point, alone, early in the morning. At 5:30 P.M. she was still waiting at the crossing point, until the woman soldier who was dealing with the entry permit finished her kitchen duty. At 6:30 in the evening Fatma went through the crossing point. In the operation that was performed on the following morning, the doctors found that the tumor had metastasized, and they had to remove the entire breast as well as two lymph glands. This time, too, Fatma was all alone - despite the doctors' request, the security authorities did not allow family members to be at her side.

March 2004. At the end of March, after a week's delay because of difficulties in obtaining a permit to enter Israel, Fatma began radiation therapy at Tel Hashomer - the success of the treatments depends to a large extent on their being given in succession, at least five times a week. During that period the Erez crossing point was frequently closed, and cancer patients missed many treatments. Another cancer patient from Gaza, whom Fatma met in the waiting room before treatments, missed eight treatments in a row. Physicians for Human Rights submitted to the Civil Liaison Office requests for permits for the two women to stay in Israel until the treatments were completed. The applications were refused until the non-profit association, together with another NPO, One in Nine-Women for Women with Breast Cancer, petitioned the High Court of Justice. Fatma was given a permit for one month only and went to live in the home of Maskit Bendel of PHRI in Tel Aviv. The doctors said that the treatment had been successful. It seemed as though Fatma's life had been saved".

...Fatma Barghout is lying in the oncology department of the Sheba Medical Center at Tel Hashomer. The cancer has spread through her body. Breast cancer that has metastasized in all directions, to her back and her legs, causing her terrible pain. She is 28 years old, the doctors have already told her that she will need chemotherapy forever, as long as her forever lasts. The tribulations caused by the occupation only add to her sufferings as a young cancer patient. Hours of waiting at the checkpoints on the way to radiation treatments. Two operations without any family member allowed to be at her side to help her. The battle over every entry permit to receive another cycle of chemotherapy or radiation in the Israeli hospital, for which there is no substitute in Gaza.

Why? Because Fatma Barghout has no papers. No ID card, no passport, no transit permit. A girl without an identity, like her entire family, like tens of thousands of other Palestinians, who returned to the territories after a stay abroad, and were unable to reinstate their residency. Now they are illegal residents in their homes and in their country, lacking papers and rights.

Barghout is one of them, and for her the significance is particularly cruel. This week she wanted her father at her side, she wanted him so badly, and her father couldn't come. He was not allowed to come. Last week, after the members of Physicians for Human Rights managed with great effort to obtain an entry permit for her father and two of her sisters, the Border Policemen at the Erez crossing declared that the three could cross only if they posted a bond of NIS 30,000 per person, an unheard-of sum for them. After 12 hours of desperate waiting, at a distance of one and a half hours from their loved one, the father and his two daughters returned home. The hand that allows Barghout to be hospitalized in Israel and to benefit from a friendly attitude and good health care (at the expense of the Palestinian Authority), is the same hand that hardheartedly mistreats her.

It's hard for her to sit, and she changes positions in order to ease her pain. Speaking, even in a very low voice, is hard for her too. Before we entered her room, she got dressed and put on makeup. Her beauty remains, despite everything she has been through. She was born in Jeddah, when her father, who is a teacher, found work there. The Gazan math teacher taught in schools in the Saudi Arabian cities of Jeddah, Medina and Riyadh, and his wife and 11 children followed him wherever he found work, in a typical Palestinian saga of wandering.

Ten years ago they returned to Gaza. They weren't entitled to ID cards, because their parents weren't in Gaza at the time that Israel determined for granting residency, immediately after the occupation, and so they have been living illegally in their city for the past decade, one family out of many thousands. The visitors' permit they received from Israel in August 1994 to visit Gaza for a month, which was extended for only one additional month, is the only document they have.

In Gaza, Barghout registered for university and completed her studies in accounting. She managed to work in two places, among them an association for helping children in Gaza. But in April 2003 her world fell apart. First a small lump in her breast that the doctors at Shifa Hospital in Gaza didn't take seriously, which grew and metastasized quickly. Her diagnosis was delayed by several months, and the lost time was apparently crucial. Only in August did she send a biopsy to Tel Hashomer.

There are no radiation treatments in Gaza. There is no oncology institute worthy of the name. There are no oncological surgeons. Most cancer patients go to Jordan or to Egypt. Because she has no papers, Barghout couldn't leave, and she certainly couldn't return. She submitted a request for an entry permit to Israel so that she could go to the Sheba Medical Center; in fact, she submitted one request after another - and received no answer at all. Meanwhile, she began chemotherapy at Shifa Hospital. In December she discovered Physicians for Human Rights, which turned to the High Court of Justice on her behalf. After the discussion in a preliminary court session, she was suddenly permitted to enter Israel. With that her troubles had only begun.

Cycles of chemotherapy, two operations in February followed by radiation treatments, and in the background the constant battle for every entry permit. Every bag of chemicals that was injected into her vein was preceded by her efforts to get an entry permit, plus a frustrating wait. Every radiation treatment was preceded by a campaign of pleading. After the assassination of Hamas leader Sheikh Ahmed Yassin, for example, the checkpoint was completely closed and she couldn't get to her treatments. The same was true after the assassination of Yassin's replacement, Abdel Aziz Rantisi.

Even when she received a permit, it was always for one day, with a wait of four to eight hours at the checkpoint, even on days when she was already having difficulty standing up. Once, she says, the soldiers sent her back in disgrace, once they shouted at her, and she was almost always alone, because members of her family couldn't get permits. Only twice did she come by ambulance: all the other times she had to get from one taxi to another, because she couldn't make the ambulance that leaves Gaza at 7 A.M.

Patients in Gaza receive notice about their entry permits only on the day of treatment itself, or the evening before. In the case of Barghout, who lacks papers, the notice comes even later. She tells of sleepless nights of waiting, wondering whether or not she would receive a permit, and about a telephone call that would come at 9 or 10 A.M. informing her that she had a permit to enter and remain in Israel until 7 P.M. that same day. After another four to five hours' wait at the checkpoint, there wasn't much time left for the treatment, and certainly not for recovering from it. What would have happened had she gotten back late? "I never dared to try," she says.

A Bedouin taxi driver from Be'er Sheva drives her from Erez to Sheba for NIS 100-150. She gets home with whatever taxi she finds, for NIS 240. Where does the money come from? "From the money I saved from my work." As we noted, the treatments and hospitalization are paid for by the PA, as part of the family's health insurance.

During the entire period of radiation treatments, nobody from her family was by her side. Israel didn't allow it. On May 25 she completed the treatments, and again there was some hope. The prognosis was good. Barghout returned to her home in Gaza to convalesce. But in less than a month, severe pains spread to her back and her legs. At first she thought they were muscular pains, but massages didn't help. Then she went to a Gazan doctor who sent her blood to be tested, and decided that she needed another cycle of chemotherapy.

About three weeks ago she returned to Sheba. When exactly? She looks at the hospital bracelet attached to her hand - on July 22. She arrived in an ambulance in serious condition, because of the severe pains, and was no longer able to stand on her feet. The first 10 days were hell. Her mother received a permit this time to be with her, and since then her mother has been at her side in the hospital, day and night. Both their permits have expired, and Barghout is worried. For now she'll remain in the hospital for at least another week, with her mother, who now can no longer leave the hospital premises. The chemotherapy that she is receiving once a week, which she will have to continue forever, is not available in Gaza...

She is grateful to the medical staff: When she was in great pain last week, two doctors and a nurse cried along with her. "I want to thank one person from the bottom of my heart. She is not only humane, she's a great person. When I was here for radiation treatments she shared her home and her bed, her food and the good times with her friends. I don't know how to tell her that. She's such a good woman, Maskit."

-- Gideon Levy, Staying Alive; 13 August 2004.

July 2004. "However, a month later Fatma's condition began to deteriorate rapidly. In July, she returned to Tel Hashomer in an ambulance, this time accompanied by her mother (thanks to the intervention of the physicians' association). The doctors discovered that the cancer had spread to her spine and determined that she had to undergo another series of chemotherapy treatments. Fatma was hospitalized for a series of painful treatments and wanted to say good-bye to her family. Her father and two of her sisters were allowed to join her mother, but the border control authorities demanded a guarantee of NIS 30,000 for each of the members of the family. Three weeks later, under a threat by the physicians' association to petition the High Court of Justice and with the intervention of Meretz MK Yossi Sarid, Fatma's sisters entered Israel. The father remained in Gaza.

The devoted team at Tel Hashomer succeeded in stabilizing Fatma's condition, and she was sent back to Gaza to continue chemotherapy, but the Palestinian Health Ministry approved the expensive treatments only one month later. During that time, her condition deteriorated until she found it difficult to breathe and suffered from terrible pains. The doctor who had been treating her in Israel ordered her to return urgently. The permit, which this time was given at the last minute, did not include an accompanying person and the coordination of her departure in an ambulance. Fatma, who was no longer able to walk, remained at home. In the meantime, because of the Rosh Hashanah holiday, the Jewish New Year, a complete closure was imposed on the Gaza Strip that continued until Operation Days of Atonement at the end of that month.

A delegation of doctors from the Physicians for Human Rights and One in Nine went to the Civil Liaison Office. They were promised that Fatma and her mother would be permitted to enter Israel. The next day Fatma and her mother arrived at the Erez crossing point. After a long wait on the floor (there are no benches or chairs at the crossing point), she was taken for a security check. As her silicon breast "buzzed," the soldiers ordered Fatma to strip off her outer dress. An officer who saw what was happening scolded her for her behavior and sent her back to Gaza. The NPO was told that Fatma and her mother had not passed the security check. A few days later Fatma and her mother left in an ambulance in the direction of the crossing point, along with six other patients, including two cancer patients. Because of exchanges of fire in the area, the ambulance had to turn around and go back. Fatma was admitted to Shifa Hospital in Gaza and hooked up to a respirator. There were chemotherapy medications left over from a patient who had died, enough to last for two days".

One out of every nine women gets breast cancer. There are doctors who say that statistic has worsened lately and now stands at one out of every eight. The disease is particularly violent in younger women and the primary growth in the breast spreads rapidly to the liver, the lungs, the bones and the brain. Is there anything worse than being a young woman with cancer whose chances are slim? It turns out that there is - being a young Palestinian woman with cancer whose chances are slim.

For 10 days now, F., a 28-year-old resident of Gaza, has been trying to get to Sheba Medical Center at Tel Hashomer for urgent chemotherapy in the oncology department. The story of what has happened to her during these 10 awful days sounds unbelievable, even to someone who has already heard horrible stories. The reality has succeeded in superseding even what the sickest imagination could invent.

F. has been undergoing treatment at Sheba's oncology department for many months: she has had surgery twice, radiation and chemotherapy. In Gaza, there is not a single oncology department and F. is not allowed to go to Egypt for treatment; she is one of the tens of thousands of Palestinians to whom Israel has refused to issue identity cards because they were not in the territories at the very beginning of the occupation. Without papers and without treatment in Gaza, F. is totally dependent on Israel's good graces.

About two months ago, she was hospitalized at Sheba for several weeks and she had the chemotherapeutic drug Taxol injected into her veins, which reduced her suffering considerably. The attitude toward her at the hospital was admirable. F. was liked by everyone around her.

Israel prevented members of her family from being at her side for most of the time she was hospitalized, and she was left all by herself after the operations and during the period of radiation treatments. A handful of Israeli women, among them one of the activists of Physicians for Human Rights-Israel, tried to relieve her loneliness and her suffering.

Each of her entrances into Israel was accompanied by hassles and humiliations. One time they demanded of her father a deposit of NIS 30,000 so that he could accompany her.

F. was supposed to have returned to Sheba for treatment on September 14. There was a closure and her application was refused. They promised her a permit for September 19. In the meantime, her condition deteriorated, her pain increased and her breathing became labored. She contacted the physicians' association and begged to be allowed to return to the hospital.

At Sheba they said she should come as soon as possible. On September 14, Physicians for Human Rights applied to the humanitarian hotline of the Liaison and Coordination Administration with a request that she receive an entry permit. The permit arrived only on the following day at 6 in the evening, restricted to that same day and without an accompanying person. It was evening and F. was no longer able to travel by herself. The following day the validity of the permit had already expired.

At the association they decided to wait until Sunday, for which the permit had already been promised. On Sunday, the permit did not arrive until evening. In turns out that it was necessary to submit a renewed application. On Monday there was a delay on the Palestinian side, which was late in resubmitting her medical documents. Her changes of going out on Monday were scotched, as well.

Last Tuesday, at 3:30 in the afternoon, the telephone call came with the news that a permit had been given for the patient and her mother. F. set out for the roadblock with her mother. For hours she sat debilitated on the ground and waited. Finally she was called to go through the metal detector. The soldiers shouted to her from a distance that she had "something in her chest" and ordered her to strip in front of them. She stood there wearing only an undergarment, her mother burst out crying at the sight of her sick, humiliated daughter and the soldiers scolded her to shut up. Finally an officer came, reprimanded the soldiers and ordered F. to get dressed immediately.

F. has had a mastectomy. At 8 P.M. the Liaison and Coordination Administration informed Physicians for Human Rights that there was "a security problem" with F. The soldiers suspected her of carrying explosives in her chest. For some reason they had not arrested her, but had sent her home. Apparently it was the prosthetic breast that had set off the metal detector.

From that moment a danse macabre began, the end of which is not in sight. MK Yossi Sarid (Yahad), one of the few Knesset members who has taken an interest and tried to help, contacted the defense minister's bureau that same evening. At the bureau they asked for documents concerning F.'s prosthesis. The minister's adviser phoned Dr. Danny Rosen, who knows F. well, and asked about the kind of material on her body. At the bureau they also asked for a guarantee in F.'s handwriting that she would come to the roadblock without the prosthesis. This guarantee was given. Day followed day, and yet another phone call and yet another request for a form, and F. is still stuck in Gaza, her suffering increasing and her chances running out.

The Israel Defense Forces spokesman says that, "in light of a number of attempts by terrorists to enter Israel in the guise of needing medical treatment, the I.D.F. must be extra cautious with regard to anyone who does not pass the security check, even if he has the appropriate medical documents in his possession. The claim concerning inappropriate conduct by the soldiers at the crossing point has been investigated and found to be without any basis. However, the consideration of the request by the senior command levels is still underway."

No danger of a suicide terrorist can justify such behavior. It is possible to protect ourselves against female terrorists without losing our humanity. F.'s story is not exceptional, even if part of it is particularly shocking; there are hundreds of Palestinian patients in a similar condition and every injustice always has a security excuse. There is terror, everyone is only carrying out orders and they are going by the book. But a book that prevents medical treatment to dying patients, hassles them and humiliates them, is a wicked book, and a society in which only the metal detector speaks is a sick society.

-- Gideon Levy, When You Have Breast Cancer in Gaza; 30 September 2004.

October 2004. "On October 12, Fatma was told that she had to submit a request for an exit permit through the Palestinian health coordinator. The transfer was delayed for one day because the Palestinian coordinator was stuck. The next day the fax at the Civil Liaison Office was out of order. Finally the people from PHRI, with the help of colleagues in Gaza, succeeded in obtaining the use of a Red Cross all-terrain vehicle, a kind of ambulance, the only vehicle capable of driving on the ruined roads. Fatma started chemotherapy at Tel Hashomer an entire month after the date that had been set for her.

November 2004. Fatma died at home on November 24. The Barghout family wanted to bury her in the new cemetery in Gaza, the only one where there were burial plots available. Because of shooting by Israel Defense Forces soldiers in the area, it was impossible to get near it. Fatma was buried in the old Gaza cemetery. Her body was interred with the remains of two other women. "The death of Fatma Barghout will be a statistic in the next report of the Palestinian Authority," wrote Maskit Bendel, who accompanied Fatma until she died, and formulated the report. "This is the story of one of hundreds of women whose stories are known by only a very few people."

Last Friday evening, Fatma Barghout, the cancer patient I wrote about in this column... died in her home in Gaza. She was treated devotedly by the oncology department of Sheba Medical Center, Tel Hashomer, but was cruelly harassed by the soldiers at the Erez checkpoint time and again. At the end of the summer Israeli friends took her on a tour - to Jerusalem's Al-Aqsa Mosque, the Old City of Jaffa, Banana Beach, the Ramat Gan safari, the Ramat Aviv mall, the Carmel market in Tel Aviv and Hayarkon Park, and [she] saw, astonished, what few of her generation in Gaza have ever seen: green lawns, exclusive stores, fancy restaurants, girls in bikinis - and above all, normal life of the kind she dreamed of but never had.

She returned for repeated, desperate treatments in the hospital, which did not help her. In her last days she asked that her bed be turned around to face in the direction of Mecca. Her captivating smile yielded to a wan grin in a face tormented by pain. When she came through the Erez checkpoint, a place that had been so damaging to her, last Thursday, on her last trip home, she was unconscious. She was 28 years old at her death.

-- Gideon Levy, Full-court press; 31 December 2004.

"Sixty percent of all cases of breast cancer in Gaza are diagnosed at a late stage, when the cancer has already spread. In Israel, this figure is only 5 to 7 percent.

A bleak picture has emerged for the members of Physicians for Human Rights-Israel who are researching the state of the health system in Gaza. It is unable to cope adequately with the diagnosis and treatment of cancer. For years, Israel has prevented Gaza Strip physicians from taking specialized training at Israeli hospitals. Under closure, Palestinian doctors from Gaza are prevented from leaving for specialized training and further study and medical students cannot complete their studies at universities in the West Bank and abroad.

The report, which is made public here for the first time, reveals that medications are not arriving in the Gaza Strip with regularity and that patients are not managing to get to medical treatments. Essential equipment for the treatment of cancer, such as radiology equipment, does not exist in Gaza because of Israel's opposition - Health Inforum says the opposition stems from the use of radioactive materials in the treatment.

The survival rate (a measure of access to diagnostic services, the quality of the diagnosis and the quality of the treatment) for breast cancer among Jewish women in Israel is 70 to 75 percent, and for Arab women in Israel, 60 to 65 percent. These figures are steadily rising and the rate of women who survive breast cancer in the world as a whole, particularly in developed countries, is increasing. However, the breast cancer survival rate for women from Gaza is extremely low - 30 to 40 percent, or even less. According to Palestinian Health Ministry figures, 60 percent of the women in Gaza who have been diagnosed with breast cancer were diagnosed after the cancer had already spread in their bodies. Of them, 42.2 percent were diagnosed after the cancer had spread to their lymph glands, and 17 percent were diagnosed after the cancer had spread to other areas of the body. In Israel, only 5 to 7 percent of the women with breast cancer are diagnosed after the cancer has spread to other organs. It is a reasonable assumption that the late diagnosis has a significant effect on mortality.

Other factors influencing low survival rates in Gaza are the especially virulent form of the disease and the young age at which it appears. In addition, diagnosis opportunities and medical treatment are inadequate and many patients do not succeed in leaving to obtain treatments not available in the Gaza Strip. Patients who were sent for treatments in Israel arrived at a relatively advanced stage of the illness, some of them after failed treatment attempts that harmed the chances of recovery".

-- Akiva Eldar, The illness: breast cancer; Cause of death: the occupation; 3 March 2005.

Footnotes:

[1] Despite a housing shortage among Palestinians exceeding 20,000 units, Palestinians, who comprise 30 percent of the population of municipal Jerusalem, were allowed to build only about 7.5 percent of the homes built during the years 1990-1997. Much of the land adjoining Palestinian neighborhoods has been put off limits for Palestinians. Palestinians are denied permits to build on this land - even on land they own, including land adjacent to an existing home. It is also difficult even to obtain permits to expand existing homes. While both Palestinians and Israelis build illegally, Palestinians are responsible for less than 20 percent of illegal construction, but nearly two-thirds of demolitions are of Palestinian homes. (Source).

[2] The answer is three, for the entire period 1967-1993. Permission for well-drilling must be obtained from the military authorities; permits have been granted for only 23 wells since 1967, only three of these being for agricultural use (Source). By way of comparison, Palestinian farmers stood to be cut off from 32 groundwater wells by the construction of the Separation Wall in the northern West Bank (Source). And this is the least intrusive section of the Wall.

[3] Freedom of movement is essential not just to conduct elections, but also for normal life. Israel has severely curtailed this freedom for the Palestinians of the West Bank and Gaza since the outbreak of the current intifada in September 2000 - and even for some years before then, too. As I've traveled in and around this city, I've seen for myself how the tight "movement controls" that Israel has maintained on the Palestinians have stunted the Palestinians' ability to lead normal lives. People are often, unpredictably, prevented from going to other towns to attend business or medical appointments, school, or family gatherings. Sometimes, they're "locked down" in their own homes for days or weeks. No vehicles can carry goods from one city to another. Instead, each truckload has to be unpacked and carried to another truck at each city's limits.

I made two roundtrips here last month from Jerusalem, which is about 10 miles away. Ramallah is almost entirely enclosed within a high fence topped with razor wire. On one of my trips, I drove with an international worker: by making a broad detour to the north, we could enter Ramallah through a special "international" entrance that most Palestinians are forbidden to use...

The Israeli government claims these movement controls are needed to prevent suicide bombers from reaching Israeli cities. But in addition, the Israeli chief of staff has told Israel's Hebrew-language press that the military's policies toward Palestinians have a clear purpose of political coercion. Such an attempt to impose collective coercion on an entire people is illegal under the Geneva and Hague Conventions. It is also counterproductive. Israel's movement controls have been the single major cause for the collapse of the Palestinian economy and the rise in Palestinian militancy. (Source)

[4] In the next street there is a grim, fortress-like building with security cameras, floodlights, iron bars on all the windows and a 7ft-high revolving cage for a door. It is what the Israelis call the "population administration" office - the place where Palestinians from east Jerusalem go to get birth certificates, renew their identity cards and collect all the other bureaucratic necessities. Needless to say, when the office opens in the morning the queues are interminably long.

... This sort of thing is part of the normal, daily grind for Palestinians. Foreigners may hear about it and read about it, but that is not the same as actually experiencing it. Sometimes I get a feeling that the real purpose of Israeli occupation is to turn the West Bank into a theme park where tourists will flock from around the world to discover what life was like in the old Soviet Union. In Blairite Britain we have gone to the opposite extreme. All branches of government are now required, on pain of punishment, to deliver service with a smile. Even the social security offices try to lay on a friendly ambiance and government employees spend millions of hours on performance reviews, quality control and efficiency measurement.

But the whole point about Israeli bureaucracy, at least where Palestinians are concerned, is that it is designed to be inefficient, with the rules changing frequently, so that nobody can ever be quite sure where they stand. That way, the Israelis show who is boss. The theory, I suppose, is that eventually this will produce a cowed, docile population who are willing to do whatever they are told. But a lot of the time it just makes them more angry. (Source)

[5] [I]t is not only the grab, the robbery of land, but you have a robbery of time. Palestinians' time has been robbed in the last thirteen years, because you have to wait for a permit and you don't get it, then you have to wait again. Then you waste time waiting at the checkpoint, then you waste time in submitting another request for a permit, then you waste time trying to go through all kinds of small, dangerous bypass roads. And time is a means of production. Time is so precious for one's development, internal development, community development; and this has been grabbed by the pass system. This very important means of life for every person, not just Palestinian, has been robbed of them. Sometimes I think it's more precious than land, because land you can get back one way or the other. The lost time, you will never get back. (Source)

[6] At a Rafi meeting of September 1967, there was a dispute between Peres and Dayan after Dayan explained more fully his position with regard to the Palestinian refugees in the occupied territories: "Let us approach them and say that we have no solution, that you shall continue to live like dogs, and whoever wants to can leave -- and we will see where this process leads." After they have lived "like dogs" under Israeli military occupation, Dayan continued, "It is possible that in five years we will have 200,000 less people -- and that is a matter of enormous importance." (Source)

[7] [P]eople... have lowered their span of expectations. They are not expecting much of their lives because they know that they will be disappointed. You cannot plan to go to see friends. I'm even talking about this before these terrible times of armed clashes between Israelis against Palestinians. People have lowered, so much, their expectations of themselves. They restrict themselves to their narrow surroundings -- family, work, home; family, work, home -- nothing more than that. (Source)

[8] Though internal closure and, most recently, the intrusive route of the West Bank Wall are making medical treatment as inaccessible to many West Bank Palestinians as it has long been for those in the Gaza Strip. Internal closure during the intifada has prevented hundreds of Palestinians from reaching potentially life-saving medical care; forcing kidney patients to be carried by hand cross country to receive dialysis, and leading to deaths among newborns, sometimes for conditions as easily rectified by trained personnel as breech deliveries.

And now, the Israeli decision to deviate from the Green Line in building the West Bank Wall is proving particularly destructive to the Palestinian health system:

The Apartheid Wall's first and second phases will affect 750,000 Palestinian people in nearly 40% of Palestinian communities and has had a serious effect on Palestinian healthcare. The healthcare system in the Palestinian Territories has been developed according to models proposed by the World Health Organization, whereby clinics providing differing levels of healthcare, are located in various villages, towns and cities and are supported by a carefully planned referral system. With the Wall’s construction, this referral system has been almost completely destroyed because whereas in the past patients would have been referred to alternative clinics to seek specialized health care, now they are unable to reach these clinics due to the movement restrictions created by the Wall. The Apartheid Wall has destroyed the normal coherence of the Palestinian health system. (Source)

The completed (northern) section of the Wall – from Salem checkpoint to Salfit - is the least intrusive part of the barrier’s planned route. But in this northern section alone 26 Palestinian communities have been cut off from any but the most basic medical treatment, resulting in scenarios like the child forced to receive an injection through the closed barrier from a doctor who cannot otherwise be reached, and causing extensive detours for patients trying to reach secondary care centers, like the one that probably cost two-year-old Mohamed Hashem his life.

[9] Since 1967, Gaza's health care system has faced very fundamental problems. Between 1967 and 1991, all requests to build new facilities, even private hospitals, were rejected by the Israeli Ministry of Health, resulting in a catastrophic shortage of hospital beds in Gaza. As the population soared during that period from fewer than 500,000 to more than 750,000 persons, the number of available hospital beds decreased from 1,030 in 1977 to 877 in 1992. By contrast, there are 27,000 public and private hospital beds in Israel to serve a population of about 4 million. (Source).

[10] Based on the written opinion of the team of jurists that examined the matter... the disengagement does not necessarily free Israel of responsibility for the evacuated territories. Nor can Israel claim that the Palestinian Authority should bear responsibility for deterioration in the health system in the territories. The PHR report states that in 1970 there were 790 hospital beds in the Gaza Strip. In 1993, although the population had in the meantime doubled, the number of beds was 900. Had Israel (which was fully responsible for the territories throughout this period) seen to it that the ratio of hospital beds to population was maintained at the same level as it had been in 1967, there would now be approximately 1,500 hospital beds in the Gaza Strip. (Source)

[11] Photo credits: The first photograph, showing a Palestinian woman trying to cross an Israeli checkpoint near Hebron, is by Hossam Abu Alan, for AFP. The photograph of Fatma Barghout is by Miki Kratsman.