Gaza: Cancer crisis killing civilians
Tuesday, May 10, 2011
“If you go to Shifa hospital now, there are so many cancer patients begging for a referral outside. So many who can’t afford to pay for medical care outside of what the government hospital can give them… There are so many cases that are even worse than ours. I’ve already lost my wife. There are others who can still be helped,” Wael Zahra, widower.
Cancer is the main cause of death in Gaza and yet its healthcare system cannot provide adequate treatment for it.
Israel’s tight restrictions on the movement of people and materials in and out of the Gaza Strip, in place since militant extremists Hamas took power in 2007, has led to constant shortages in surgical equipment, critical drugs, including chemotherapy and painkillers. Radiotherapy isn’t available at all.
As a result of the blockade, Gaza’s Ministry of Health Medical Store is missing 170 items from a list of 460 essential drugs. Mohamed Zemili, the store’s director, says: “This shortage affects all departments in our hospitals, especially oncology.
“For instance, we are currently missing a drug used to strengthen the bones of cancer patients. We haven’t had this for three to four months. We’re also missing painkillers. Without these drugs, patients are suffering greatly.”
On February 9, 2011, this medical store was hit by an Israeli air strike, which destroyed most of the stock.
Most cancer patients in Gaza have to be referred outside for treatment. According to Gaza’s Ministry of Health, just over 950 cancer patients were referred in 2009, of which 533 were women, 420 were men and 124 were children. In 2010, the number of referrals rose to 1523, of which nearly 800 were women, 728 were men and 165 children.
There are two routes out of Gaza, the first is through Rafah crossing into Egypt, the second is through Erez crossing to Israel. Of the 500 patients who cross Rafah every month, the United Nations estimates 20 percent will not meet Israel’s security criteria. If Rafah crossing closes, as it did during the recent upheaval in Egypt, those patients are trapped in Gaza.
The Palestinian Authority in Ramallah covers the cost of treatment outside Gaza but anyone accompanying a patient has to pay for their own transport, food and accommodation. If a patient from Gaza is treated in Israel, anyone accompanying them is forbidden from leaving the hospital on security grounds. Some courses of treatment require patients to stay for up to six months.
With more than 40 percent unemployment, few people in Gaza can afford the costs of referral. Dr Ziad Khazander, head of oncology at Shifa Hospital, the largest government hospital in Gaza. He says of the 100 cancer patients referred out of Gaza every month, some cannot afford to travel for treatment.
“Circumstances here were better before the blockade. We were able to administer chemotherapy fine. We have seen an increase in mortality in cancer because patients are not receiving the right treatment and so they develop complications and those lead to an increased likelihood of dying.”
Ahli Arabi hospital in Gaza City is the only health service providing free breast cancer screening. Working through 50 grassroots organisations, Ahli Arabi screened 1200 women between late September 2009 and the end of 2010.
Suhaila Tarazi, director of Ahli Arabi, says the results were frightening: “Twenty percent of the cases we screened needed further investigation, either an ultrasound or biopsy. Of those, 8% had breast cancer and had to have mastectomies.
“In particular in the northern areas close to the border with Israel, like Beit Hanoun and Beit Lahia, we discovered a lot of cases. The head of our grassroots organisation in Beit Hanoun was one of eight women screened who were diagnosed with cancer. She is currently receiving radiotherapy in Israel.
“We could only include a limited number of women because of the restricted budget. Many women in Gaza discover they have cancer too late and die.”
ACT provides financial help for cancer patients and their families referred for treatment from Gaza to the Augusta Victoria Hospital in East Jerusalem. ACT member Norwegian Church Aid funds emergency servies at Ahli Arabi.
The faces of cancer in Gaza
Wael Zahra is the widower of Tahrid Zahra who died in late January 2011 in Shifa Hospital from cancer aged 33. On the wall of Zahra’s sitting room is a poster-sized letter of condolence from the Hamas Ministry of Public Relations. Zahra smokes heavily as he tells the story of his wife’s death.
"The pain started in her back. She had it all the time. Before the war [Operation Cast Lead, late December 2008 to mid January 2009], I took her to a specialist who said she needed physiotherapy. We did that but the pain increased. So we went to another specialist at Shifa hospital who said she had a problem with her blood and we needed to do some tests.
So we waited for the results. Then they said the problem wasn’t with her blood it was with her bones so they did more tests. All this took time, we were waiting and waiting and nothing was getting any clearer.
Then in December 2008 the war came. Israeli planes were bombing Gaza and we were going from doctor to doctor trying to get answers. The war ended on January 18, 2009, and Tahrid was diagnosed with breast cancer in early February. I went straight to the Ministry of Health and begged them to refer us outside of Gaza for treatment but they said there were thousands of people who needed referral and we just needed to wait our turn.
Soon after she was diagnosed, the pain spread from her back to severe pains in her legs. She could hardly move them. They started her treatment here in Gaza at Shifa Hospital with chemotherapy but there were complications because of the drug shortages.
We would arrive at the hospital to start her course of treatment and they would say there are no chemotherapy drugs here today, come back tomorrow. So we would go home and come back the next day only to be told the same thing. This went on and on until I decided we would call every day to check before leaving the house. Then we would call and they would say we have drugs come to the hospital, so we’d go but they’d only give her calcium pills and painkillers.
The doctors told me it was essential to give her calcium but a lot of the time they didn’t have any in stock so they’d tell me to buy it myself. What could I say?
Because of the shortages in government hospitals, I often had to go private. It’s impossible to remember the details of every drug and every treatment I had to pay for - there were so many tests and so many drugs. There was the chemical treatment, the tests with the spinal chord fluid and each treatment cost around 700 NIS (US$204).
All this time, I kept going back to the ministry and begging for a referral for treatment abroad as she was getting sicker and sicker. They told me they only refer critical cases and I’d say, “look at her, she is critical!” In February 2010 they finally put in a referral request for treatment in Egypt. In July, we got approval to go through.
Crossing through Rafah was very difficult. When we first turned up with all our documents and our referral letter, the Egyptian border police turned us away. So we went all the way back home to and had to go back the next day. The second time they let us through.
We spent a month in Egypt. Only God knows how we managed it. The government in Ramallah paid for the hospital treatment but the rest of the costs we had to pay for ourselves. We didn’t get a penny of support for travel even.
In Egypt, the doctors blamed me. They said I had brought my wife too late, there was nothing they could do but they would try radiotherapy.
After one month of treatment we went back to Gaza. For a week, she was much better. The pain in her back had gone. Then suddenly she deteriorated. It was only the painkillers that had been helping her. Once they were out of her system, she felt sick again.
I would call the doctors in Gaza and to tell them she was deteriorating, that she was in pain, and they would give us calcium pills. Then she started throwing up 24 hours a day. I would go to the doctors for help and they would just look at me in this inhumane way. They said they couldn’t help any more, coldly, like I was just another case.
In the last few months, the cancer spread to her brain. She was in a lot of pain. I couldn’t sit there and do nothing. I couldn’t face taking her back to Egypt I wanted to take her to Israel. So I started the whole referral procedure again.
Finally, two months ago in December, our application was approved by Israel. She smiled for the first time in so long when I told her we had referral. She was so happy.
The very next day I went to Shifa hospital to pick my wife up and take her to Erez crossing. At that point she couldn’t move very easily. As we were leaving the hospital she slipped and fell. Her leg broke from her thigh down to her foot because her bones were so weak.
I went back to the administration unit at the Ministry of Health to get the referral document amended so she could travel in an ambulance because she couldn’t move at all. But they said no, "we only use ambulances for critical cases." I told them my wife has a broken leg, she has cancer in her brain but still they told me no, that she was not as critical as the cases they needed ambulances for.
At that point, I just went mad. I yelled at them, told them my wife was dying and that we couldn’t make it to Israel without an ambulance. They said nothing. I took all our referral documents, tore them to shreds and threw them at the people responsible.
All it takes is one phone call for someone with connections and they have an ambulance out of here. But we don’t have any connections.
I had to go back to the hospital and tell my wife we had lost our appointment at the Israeli hospital. She said, "I know my fate now." At that point she collapsed, she couldn’t take it any more. She was in complete despair and became very, very depressed. Her health deteriorated quickly. First her kidneys failed then her lungs. Then last week she died. She was 33 years old.
I don’t know if it’s just our fate or if there’s something to blame. The blockade? The Israelis? The bureaucratic system? The Ministry of Health? In any other country, if my wife had cancer, they would treat her very quickly but we have no real access to health services here in Gaza.
In my case it’s too late. But there is so much that needs to be done to help others escape our fate. If you go to Shifa hospital now, there are so many cancer patients there begging for referral. So many who can’t afford to pay for medical care outside of what the government hospital can give them, outside of what’s covered by the Ministry of Health. There are so many cases that are even worse than ours. I’ve already lost my wife. There are others who can still be helped."
Wafer Abu Habel, 43, has ovarian cancer. She was in Egypt two weeks ago for surgery to correct fistula, a complication caused by an aggressive tumour. The operation seems not to have worked as she was back in hospital in Gaza within days of her return with chronic diarrhoea.
She is in a lot of pain. The painkillers the doctors have given her aren’t working. Talking is an effort so her mother, Sobhaya Abu Habel, answers for her.
"I’ll do whatever it takes to help her and go wherever I have to go, except Egypt. We tried to get through Rafah three times. There was no ambulance to take us to Rafah so we went by taxi just us two, with a wheelchair. It was very difficult.
On the third time we got through. We spent two and a half months there. We had to rent a flat and go back and forth from the hospital. The flat alone cost US$1000 a month.
We are both widows. I have six daughters and a son. Wafer has no children. We had to borrow the money from friends to pay for all this.
We prefer to go to East Jerusalem to get treatment. Some of our costs are covered there and we had a very tough time in Egypt. It was so expensive we struggled to buy food.
The treatment we get here in Gaza is better than in Egypt. It’s just that they don’t have the facilities here or the medication. They have good intentions but they don’t have the means to treat us.
The blockade is very terrible in all sectors not just in health. People here have not work, no money. We are living below zero.”
Wafer Abu Habel said the travel was terrible. "I felt so tired on the journey to Egypt. It’s so difficult to move. I have such severe pain. I wasn’t able to walk into the hospital, I had to be carried.
I hope that I will be better. I hope that after three years of suffering like this, I will be better."
Sabah Saleem Sadah, 43, mother of four, from Beit Lahia, was diagnosed with breast cancer after going for a free screening at Ahli Arabi hospital.
"I discovered the lump by chance, just beside my left breast. I got a relative of mine who’s gynaecologist to check it. She said it was benign. There was no pain, no swelling so I didn’t worry.
Four months later, it hadn’t gone away and I became concerned. I decided that even though it was benign, I still wanted to remove it.
I went to the Kamal Adwan government hospital to do a chest xray and they referred me to a private diagnostic centre to do extra investigations. When I got to the private clinic they said the extra tests were going to cost me 100 NIS (US$29). I didn’t have the money so I went home.
About a month after that, I heard about the free screening at Ahli Arabi so I went. On July 31, last year they did a mammography but said there was no definite sign of cancer. So I went to Shifa hospital to their oncology department a week later and I had the biopsy. The doctor there is very busy and I only got to see him because a neighbour of mine knows him and he was helping me.
I waited almost a month to get the results. When I went back, the doctor said to me that he wanted to make sure the test results were actually mine and he needed to take another biopsy. I waited another 15 days for the results. When I went back, they told me it was cancer and that I needed to have a mastectomy.
When I heard about the operation, I started crying and screaming. I wouldn’t do it. I couldn’t able to sleep after that appointment. I hadn’t expected this - it was only a small tumour.
I went to another private doctor to make sure. The appointment cost 50 NIS (US$15). He told me that I could have the small tumours removed and keep the breast but it would cost me 1100 NIS (US$322) and I would probably have to have the mastectomy at some point in the future.
So I went another doctor to make sure at the Red Crescent Al Quds hospital. He did a biopsy, which cost 300 NIS (US$88), and then advised me I had two choices either to remove only the lumps then go abroad for radiotherapy or do a total mastectomy, which he said he would charge 3000 NIS (US$878) for, and then have chemotherapy treatment here in Gaza. I didn’t have the money.
So I finally had the mastectomy three months ago at Al Karam. It cost 50 NIS (US$15) a day to be there and I was there for two days.
Twenty days later I started a course of chemotherapy at Shifa hospital. I have to go every three weeks. So far I’ve had two doses out of six. Next Monday, I’ll go for my third. There haven’t been any delays with the drugs so far.
I was very afraid the first time I had the chemo. I was so dizzy afterwards that I couldn’t do anything but sleep for two days. I had no appetite at all. After the second dose, I spent five days in bed, vomiting and dizzy. I’ve lost a bit of my hearing now too. I always think about the chemo sessions. I’m very anxious to see that it’s working.
If I had not pushed, I don’t think I would have been diagnosed. There are many women in Gaza with cancer. After Cast Lead the numbers have increased.
I was at my father’s home with my family during the war and I saw the phosphorous bombing. The smell was very bad. I found one phosphorous at my home when I went back and another at my neighbours’ in their water tank. They had been drinking that water for three months before they found the phosphorous. The head of the family is 55, he’s sick now. We don’t know the real reason people have cancer but still.
Thank God they caught my cancer. The doctor said everything is ok now."
Naema Mustafa Shetwi, 45, is a mother of eight from Beit Lahia. She had a partial mastectomy following a free screening at Ahli Arabi Hospital.
"I didn’t feel anything was wrong, it was our community health worker who told me there was a problem. I had never heard about breast cancer screening before she told me about it.
Three years ago, I started bleeding from my nipples. When the bleeding started, I went to see a doctor at Shifa hospital and told him about my symptoms. He said it was probably just an infection and gave me a course of antibiotics. They didn’t help, the bleeding continued, but I didn’t go back.
My husband and my family knew that I was still bleeding but we all trusted that first doctor at Shifa. If he said everything was ok, it was ok – I must be fine.
And then last March I heard about the screening at Alhi Arabi and thought I should probably go along. It all went fine, I was very comfortable. I actually went home and forgot about it totally. Then in May, I heard back from the hospital. They said I should come back for an ultrasound. No one told me why.
They told me I had a lump in my breast. I took the results from this screening and went back to the first doctor I had first seen at Shifa hospital. He’s very well known, Dr Mohammed Arun, and has a good reputation.
He told me I had a lump that needs to be removed. I was very, very afraid when I heard this. Suddenly, I started taking it seriously and went to see a doctor at a private hospital who told me I could wait on a waiting list for a very long time for the operation or I could pay him 600 NIS and get it done more quickly. I know that compared to health, money is nothing but for me that amount of money is something. I spent the day of the operation in hospital, then I went home. They said it wasn’t cancerous.
That was last July. I sill have a lot of pain but I haven’t been for any follow-ups since the operation. Sometimes I get a temperature and I’m shivering. I don’t have any plans to go back to the doctor but I still worry that there is cancer.
The community health worker who told me to go for a screening went for one too. She found out she had cancer, in both breasts. Two other women I know were diagnosed too. I was so shocked.