Hospitalization without borders

Hospitalization without borders At any given time, some 30 Palestinian children are being treated for serious illnesses at the Sheba Medical Center. But to get there, they must overcome both bureaucratic and security obstacles

Before going home to the Jabalya refugee camp in Gaza with his daughter Wala, Imad al-Tanani made sure he filled in all the forms and provided all the necessary details to allow them to return to Sheba Medical Center at Tel Hashomer three weeks later, for a follow-up. Wala, 9, diagnosed with leukemia, spent five months in the hemato-oncology department of Sheba's Edmond and Lily Safra Children's Hospital.

"I can't wait to go back home," Tanani said two weeks ago. "I live in the most dangerous place in the world, but I want to go home." He knew that all the windows in his house had been shattered by the bombings and that the whole area was in ruins, but he missed his six other children, whom he had not seen for some time. Wala's medical condition also permitted her to be released.

Up until the Monday before last, Wala was one of about 20 Palestinian children from Gaza hospitalized in the hemato-oncology ward at the Safra hospital. Prof. Amos Toren, the department head, says that usually about 30 such children are treated by him and his staff, but during the army operation several young patients were released and returned home - back to the Qassam rockets launched by one side, and to the bombs and artillery fire used by the other side. Hardly any new youngsters came to replace them.

Normally, Safra hospital admits one new patient from Gaza a day. But in the past few weeks, only one patient from the Strip was hospitalized: 5-year-old Mustafa al-Astel . He was recently diagnosed with leukemia and left Gaza together with his mother, Naama, just as Operation Cast Lead began. The family's 13 other children remained in Khan Yunis; Astel keeps in touch with her husband by phone. Like Tanani, Astel also sleeps next to her son's bed. She does not speak Hebrew and is being assisted by the department's social worker, Raid Baloum.

Baloum's work consists of translating and mediating between the doctors and the Palestinian patients. Aside from the language barrier, he says, Astel had a hard time in the first days. In addition to worrying about her sick son and her family back in Khan Yunis, she found it difficult to understand how the department functions, whom to turn to when there is a problem or with whom to consult.

Baloum, a resident of Taibeh, joined the staff of the children's hemato-oncology department about a year ago, to help improve the service provided to Palestinian patients. He spends half his time working there, and the other half helping Palestinian children in the hospital's other departments, who are suffering from birth defects, diabetes and other conditions.

Children from Gaza are usually hospitalized in Safra hospital's hemato-oncology department for long periods of time, sometimes months. The length of the stay is usually unrelated to medical considerations and has more to do with the difficulties involved in getting in and out of the Strip. For cancer-sufferers and their families, the disease is yet another burden added to the existing security and other problems they must deal with.

"Children from Gaza receive the best medical care, like any other child," says Prof. Toren. "But the treatments for leukemia are very aggressive. An Israeli child can return home after completing a series of them, and if he feels unwell or if there are problems, his parents can bring him to the hospital immediately. The children from Gaza have to receive permits each time, and have to cross the checkpoints. Sometimes they don't manage to get to us."

Indeed, security considerations can endanger the patient's life. Baloum says one of the boys hospitalized in the hemato-oncology department is in very serious condition: If he does not undergo a bone-marrow transplant within 10-14 days, he may die. Several tests already carried out at Safra hospital indicate that his 11-year-old brother is the most suitable donor. The boy returned home after the tests, however, and when he wanted to come back to make the donation, he was refused entry into Israel "for security reasons."

Providing emotional support for the Palestinian families of sick children is the main part of Baloum's work. He says he helps them deal in an ongoing way with the illness and also with moments of crisis, and maintains contact with relatives in the Strip. He also acts as mediator between the patients and the various authorities: the hospital, the Israel Defense Forces, the Palestinian Health Ministry, Israeli liaison authorities, etc.

Even when they are not caught in the middle of combat, Gaza's hospitals have a hard time treating patients suffering from serious illnesses. But sending such patients to Israel requires undergoing a series of steps, with difficulties liable to crop up at any stage.

The Palestinian Authority pays for hospitalization in Israel, by means of promissory notes. Nonprofit associations and organizations like the Peres Center for Peace also provide financial assistance. After a child from Gaza is diagnosed with cancer, for example, local doctors fill in forms explaining that the youngster requires outside treatment - i.e., treatment unavailable in Gaza. A liaison officer then takes the form to the PA's Ramallah offices. The promissory note is issued in Gaza and sent to the family. With this in hand, the family then requests a security permit to travel to Israel. The identity of the person accompanying the child during the hospitalization - mother, father or anyone else - is largely determined by the decisions of those in charge of the security permits. Once they are discharged from hospital, the patients are given letters that allow them to return for follow-up or additional treatments. But such documents don't always help.

In effect, there is no single body that properly coordinates the hospitalization of Palestinian patients in Israel. Prof. Toren implies that some of the obstacles involved could be avoided if there were a better connection between the doctors in Israel and their colleagues in Gaza.

"Once, we used to travel to Gaza to visit and examine patients who had been treated in our department and were sent home," he says. "Today, follow-up procedures encounter many problems. There is no communication with the local doctors - we can't get information from them and instruct them how to respond to changes in the patients' condition. The patients and their escorts are good people, but communication with them and with the doctors in Gaza is very difficult and the follow-up is not good."

Baloum says he invests much time and effort trying to improve this situation. He often arranges for visits by medical clowns, who work in the children's hospital. One of them is Shlomi Yona, a member of Rof'ei Hahalom (Doctors of the Dream), who has been working in the hemato-oncology department for three years. Yona speaks Arabic and often works with the Palestinian children, but says no words are needed for his work.

"Faced with the difficulty of dealing with the disease, the fears and the pain, I approach the children from an entirely different angle. I come to them with a smile. By singing and acting, I make their problems seem a little more distant," he explains.

In spite of bureaucratic, security and other problems, when Wala al-Tanani fell ill, her father preferred that she receive treatment in Israel. Before returning home the Monday before last, Imad al-Tanani said he had been told that there was massive destruction all around his home. On that Tuesday morning, he saw it for himself.

An abnormal system

Oped by Ezzeldeen Abu al-Aish

Haaretz, January 30, 2009

My affiliation with Israeli hospitals began some 20 years ago, after I read a book by Israeli researchers in the field of fertility, which was of particular interest to me. I had just returned to Gaza after completing a residency in obstetrics and gynecology in London, and working thereafter in Saudi Arabia. I got in touch with Prof. Mark Glazerman at Soroka Medical Center, Be'er Sheva, who agreed to receive female patients of mine for consultation and treatments not available in Gaza. Periodically I would bring patients in my own car, and sometimes in a small minibus that carried between 12-15 women to Soroka. I realized that cooperation with the Israeli health-care system would benefit many of the patients.

In 1994 the United Nations requested that I take charge of women's health care in Gaza. After three years of unsatisfying administrative work, I wanted to go back to practicing medicine. I learned Hebrew at an ulpan and, in 1997, I applied for a residency at Soroka. I loved every day spent at that hospital, and all of the people there. To this day, we maintain good friendships. Later on I completed a master's degree in the United States from the Harvard School of Public Health, and served in Kabul as an adviser to the Afghan health-care system. Later I returned to the Gaza Strip.

I found a poor health-care system in the Strip. Anyone who steps into a pediatrics ward at Sheba Medical Center or Sourasky Medical Center will encounter a large number of Palestinian children. Many are happy to receive treatment in Israel, which has one of the best health-care systems in the world. Cooperation between the two systems exists, although not to a satisfactory degree.

This cooperation can be compared to "medical tourism," except that in places where such tourism exists, the person plans for the treatment, comes to the hospital, and even has fun. Here, one finds an abnormal system of medical tourism, between two peoples engaged in conflict - a fact that exacerbates the patients' suffering. The convoluted bureaucracy involved in obtaining guarantees of insurance coverage, and security permits for crossing into Israel from the Gaza Strip complicates matters. Even when someone manages to get treatment in Israel, he has difficulty returning for a follow-up appointment and continued treatment, because nobody promises to grant him those permits.

Another problem is the lack of communication between the physician who sends the patient from Gaza and the physician who handles the case in Israel. Frequently the patient's condition deteriorates upon returning to Gaza, and the doctor there is not up to date regarding his treatment history.

This system has been in place for years, but no one has looked into ways of improving treatment so as to make things easier for Gazans. In a research project I have initiated, we are studying the mechanism for transferring patients, with the aim of streamlining it.

I recently received a job offer from the University of Toronto. However, the tragedy we suffered changes all our plans, and I am now incapable of thinking about the future.

Dr. Ezzeldeen Abu al-Aish lost three daughters to IDF fire during Operation Cast Lead. His surviving children have received treatment in Israel.

Haaretz - Online