GAZA CITY, Gaza Strip — What does it take for a 70-year-old man to get heart bypass surgery in Gaza, when he is cordoned off from the rest of the world in a territory with just two heart surgeons left?
It takes jostling through crowds of patients facing their own heath crises. It takes a dire enough medical condition, or political connections, to convince Palestinian officials to spare limited funds to pay for his surgery abroad.
And it takes pleading with Israeli border officials for security clearance just to be allowed to drive an hour or two out of Gaza to a hospital that can perform his surgery easily.
No place on Earth has been spared a health crisis, as the last few years have shown. Yet Gaza's protracted emergency is driven not only by a pandemic but by people — enemies locked in a 15-year standoff with no end in sight. The victims of Gaza's deadly military conflicts capture headlines, but a frequent contributing factor to illness and death in Gaza are the barriers to health care.
Sometimes hospital patients are rushed past the Gaza border quickly, but other times they spend months begging for permission to leave, nursing ailments at home. Most patients with serious cases eventually do get to cross into Israel, according to World Health Organization statistics. But thousands each year face unpredictable Israeli delays and denials that a 2021 WHO study has shown to be deadly.
It wasn't always like this. Seaside Gaza used to be a portal to the outside world. Some believe the word "gauze" comes from Gaza, where it was made and exported centuries ago. Gaza even had an airport briefly in the late 1990s. But 15 years ago this month, the Palestinian Islamist group Hamas seized control of Gaza following an election victory, and neighboring Israel and Egypt locked down Gaza's borders, choking off trade and travel.
Israel says the blockade is still necessary to contain Hamas, which has waged attacks on Israel and is considered a terrorist group by the U.S. and European Union. Palestinians call the Gaza blockade collective punishment. Gaza is sinking in poverty, hunger, electricity cuts and contaminated water, the United Nations says. Basic health services are constrained even in the quiet times when there's no active fighting.
In a crowded Gaza hospital waiting room in late 2021, NPR journalists approached one man at random, then shadowed him and his family for months, as they begged for permission to leave Gaza for surgery widely available in hospitals a short drive away.
This is his story — and the story of many others.
The heart attack
Yousef Al-Kurd kept the soundtrack of daily life humming in Gaza.
He studied engineering in Germany before returning home to a 30-year career in Gaza fixing loudspeakers for mosques, schools and pushcart vendors.
"A legend," his son Raji says.
When he retired in 2018, he helped his sons with their own electronics workshop, which is where he had a sudden heart attack on April 1, 2020. Al-Kurd, a 70-year-old smoker with diabetes, survived, but he needed open heart surgery. Al-Kurd put it off, scared of the procedure and worried about COVID, his children say.
A year later, his health had worsened, and Al-Kurd's sons rushed him back to the hospital. They went looking for their physician, the head of cardiac surgery at Shifa Hospital, Gaza's main medical center.
"We discovered he had gone abroad," Al-Kurd's son Ibrahim said.
Gaza's top cardiac surgeon had emigrated to Spain. He and his family did not return requests for comment, but his colleagues said he joined a recent exodus of doctors. They have escaped through Egypt, which relaxed its border restrictions four years ago, seeking better lives in Europe and the United Arab Emirates.
Few surgeons remain
After the chief cardiac surgeon left Gaza, 40-year-old Dr. Saher Abu Ghali was promoted to the head of cardiac surgery at Shifa Hospital in June 2021. But a few months later, a doctor in the department died of cardiac arrest. Then another died of COVID.
"From four, we became three and now we became two," Abu Ghali said from his small office in the hospital.
That means there are only two heart surgeons for the two million residents of Gaza. In the U.S. and Europe, the accepted ratio to serve that population size is about 55 surgeons.
"This is not the only problem," Abu Ghali said. "You don't have all the instrumentation. You don't have all the resources."
Israel restricts the import of medical devices, like some X-ray equipment it says Hamas could convert for military uses. The Palestinian Authority in the West Bank, in charge of health services but rivals for power with Hamas, doesn't give Gaza enough medical supplies, WHO says.
Take, for instance, the thin tubes used for heart bypass surgery called cannulas. In hospitals around the world, they are used once and discarded.
"Here, every cannula is re-sterilized more than 100 times," Abu Ghali said.
"This is true. This is Gaza," he said with a laugh. "If you want to use it once and throw it out, you will not operate. You will never operate."
Israel doesn't let Palestinian doctors out of Gaza very often to update their skills with training abroad. To compensate for the gaps in care, Israel does allow delegations of surgeons, Palestinian citizens of Israel, to enter Gaza to conduct surgeries a few days a month. Other foreign surgeons visit, too. But it's not enough to meet the demands.
Yousef Al-Kurd needed coronary artery bypass surgery, a fairly straightforward surgery for well-equipped hospitals around the world. But Dr. Abu Ghali, who trained in Italy, said he couldn't do it with Gaza's limited surgeons and supplies.
"It's difficult to be done safely in Gaza. We need heart surgeons. We need vascular surgeons. We need the instrumentations," Ghali said.
The doctor recommended that Al-Kurd go to a better-equipped Palestinian hospital in the Israeli-occupied West Bank, a Palestinian territory not controlled by Hamas and not under blockade.
It's less than two hours away by car, but getting there can be agonizing.
The first hurdle
To leave Gaza for medical treatment, a resident first needs approval from Palestinian health officials and then an Israeli travel permit.
Neither is easy to obtain.
The Palestinian Authority offers universal care under its public health-care system and pays for treatments when they are not available in Gaza. But the money, which comes from U.S. and international donors, is tight. And Israel only allows out the direst cases.
Most people seeking medical care outside Gaza are cancer patients; there's very little chemotherapy in Gaza and no radiation therapy. The second most common patients requesting treatment abroad are heart patients like Al-Kurd.
The triage is strict, even with very critical patients.
Take this case: on day in early December, at the Palestinian health ministry's headquarters in the West Bank, a health official rushed into the office of Dr. Haitham Al-Hidri, who at the time oversaw financial coverage for Palestinian medical referrals.
A doctor in Gaza had just called: a 25-year-old patient was on the operating table in Gaza with a life-threatening vascular problem in his jaw. The Gaza surgeon couldn't handle it and wanted Dr. Al-Hidri's approval to send him to an Israeli hospital right away.
Dr. Al-Hidri called the young man's doctor in Gaza to find out: is it truly urgent?
"If he's bleeding, I'll let him out. If he's not bleeding, I won't let him out. You're the doctor in charge of him. You must give the last word," Al-Hidri told him on the phone.
They spoke for a few more moments, and Al-Hidri hung up the phone.
"He is not in active bleeding. Some oozing," the doctor explained. "So it's not top emergency. We can wait," he said.
But in the end, Al-Hidri decided not to take chances. He approved the coverage and coordinated the patient's quick transfer to an Israeli hospital. He said Israel does grant permits for most of the especially urgent cases.
For years, it was an open secret that patients who wanted to get treatment outside of Gaza could bribe clerks in the Palestinian health ministry to advance the referral.
With the right connections, patients in public hospitals in the West Bank could get preferred treatment in private Palestinian and Israeli hospitals – paid for by the Palestinian Authority.
Dr. Al-Hidri said he cleaned house when he entered the job in 2019: he fired clerks who took bribes and blocked unnecessary medical referrals, saving the cash-strapped Palestinian Authority tens of millions of dollars.
Suddenly, early this year, Al-Hidri was removed from his post and reassigned.
The health minister, Mai Al-Kaila, called it a "normal rotation" of leadership for a "sensitive" role that oversees large expenditures.
But a health official, speaking on condition of anonymity to discuss the delicate issue, claimed the reason for the reshuffle was that Al-Hidri was preparing files alleging corruption in the health ministry, namely that several thousand patients, many of whom with important political clout, were transferred to private hospitals and granted unnecessary private medical treatment, costing tens of millions of dollars of international donor money.
Recent medical documents leaked to NPR by two health officials appear to support allegations of patronage. According to the documents, at least three patients with high-level ties to Palestinian Authority president's Fatah party received subsidized, costly private medical care in Israel or the West Bank to treat ailments like a stroke or kidney cyst, which officials say Palestinian public hospitals have the ability to treat.
"To be transferred," is the handwritten note in Arabic on each document, signed by Health Minister Mai Al-Kaila herself.
The health minister acknowledged she has approved private medical care for Palestinians, but denied the approvals were political favors. She said public hospitals are overburdened and her approach is "humanitarian," referring the "the poorest of the poor" to private hospitals when "prominent people in the country" lobbied on their behalf.
"In our system, the minister has the power (to grant) an exception," Al-Kaila told NPR. "I am working health and pure health, without discrimination for anyone."
A black hole
Heart patient Yousef Al-Kurd did not have political connections. But he did have a legitimate medical need to leave Gaza for bypass surgery.
His surgery was scheduled at Al Mezan, a Palestinian hospital in the West Bank city of Hebron. To get there, he needed to cross through Israel, which meant applying for an Israeli travel permit.
Israel is wary of letting in anyone from Hamas-controlled Gaza.
"It is not self-obvious that Israel will provide its enemy the treatment they need," said Harel Chorev, an Israeli researcher at Tel Aviv University. "They can go to Egypt, for example."
About 1 in 5 Gaza patients does go to hospitals in Egypt, according to the World Health Organization, but those hospitals are much farther away, and Palestinian health authorities prefer to keep patients inside their own system so public money is invested in the Palestinian territories instead of abroad.
There have been isolated cases where Israel has accused patients of smuggling explosives or spying for Hamas. Some patients have been given Israeli permission to leave for medical treatment and then never returned, going on the lam in the West Bank for better economic conditions or to escape family vendettas and personal troubles in Gaza.
"The whole thing is about trust. But once you break that trust — once you break it and you send someone with cancer with TNT (explosives), and he's been caught, you know, obviously, it does a lot of damage," Chorev said.
Israeli officials say they allow in only humanitarian and exceptional cases — more than 10,000 permits last year. Who is approved and who is denied on security grounds is often a mystery.
"It's really a black hole for us to understand the criterias," said Ron Goldstein of Physicians for Human Rights Israel, an advocacy group helping Gaza patients get permits. "Many, many ... cases are not really security issues because, when we intervene, suddenly the person receives the permit."
Israel does eventually grant most permits, but about a third of applications was delayed or denied in 2021, the World Health Organization said. WHO estimates thousands of people have had to reschedule surgery or chemotherapy as they await Israeli security clearance to travel. In the meantime, WHO said, these patients often grow more ill.
That's what happened with Yousef Al-Kurd. He applied for a permit from Israel on September 12, according to the Palestinian office that submits permit requests. But Israel didn't grant him an expedited permit in time for his surgery appointment on September 15. His son Ibrahim rebooked the surgery for October 12 but still received no final word on a permit. He made a third appointment for November 1 and did not get a permit in time for that one, too.
The whole time, Israel said it was reviewing his request. Al-Kurd just needed an Israeli permit for travel; Israel would not be involved in providing the treatment.
"The Israelis always postpone," Al-Kurd's son Ibrahim said. "This is just slaughtering us."
Al-Kurd's doctor said he shouldn't wait for surgery for more than a month. When six weeks passed with no answer, Al-Kurd's son turned to the Palestinian Centre for Human Rights in Gaza, whose lawyer Mohammed Al-Alami sent Israeli border authorities an urgent letter requesting travel approval.
Two more weeks went by with no permit.
So the lawyer called his Israeli contact by phone, and asked her: Why the delay? What's the security risk with a 70-year-old man?
Al-Alami said the Israeli officer told him Al-Kurd had six phone numbers registered under his name. The lawyer thinks Israel reviews patients' phone calls, and that multiple phone numbers raise questions. The Al-Kurd family said there's a logical explanation: Each family member uses a different number, akin to a family phone plan. The lawyer sent that information to his Israeli contact.
"Every day, like this. Every day," Al-Alami said.
Pleading is part of the job in trying to get Israeli permits. One Palestinian official, who asked not to be named fearing repercussions to his job, told NPR he takes pictures of patients with their bulging neck tumor or their sick baby, which he said tends to win Israeli officers' sympathy.
For years, the World Health Organization has documented barriers to accessing health care for Palestinians. Advocate groups say it is easier to win exceptions to the rule than to change the rule, a principle that applies to the entire dynamic of Israel's supervision over Palestinian lives.
COGAT, the Israeli agency in charge of processing travel permits for Gaza patients, later told NPR that Al-Kurd's request was missing paperwork – which it said was a common reason for permit delays. But the family and their lawyer said nothing was missing and that COGAT never told them anything was.
As Al-Kurd awaited a permit, his blood pressure suddenly dropped. He lost the ability to urinate. A couple more days went by.
Then the family got a text message on a Saturday afternoon with some good news: The permit had been approved for the following day.
Finally, Al-Kurd could get to the hospital for the crucial surgery.
This glimmer of hope came after more than two months of pleading and waiting. But Al-Kurd's health was getting worse.
The next morning at 5:30 a.m., Yousef Al-Kurd and his wife, Fayeza, said goodbye to their children and left home. They waited hours at the Hamas checkpoint as thousands of Palestinian laborers with Israeli work permits crossed first.
Then they reached Israel's sole civilian border crossing with Gaza: the Erez crossing, one of the world's most heavily fortified border crossings.
Hamas, committed to armed conflict with Israel, is contained on the other side. So are 2 million Palestinian civilians. Israel's stated policy since Hamas' takeover is "separation": sealing Gaza off from the West Bank and limiting passage between the two main Palestinian territories.
Inside the crossing, Al-Kurd was asked to raise his arms in a full-body scanner. He crumpled to the floor. Israeli attendants rushed him a wheelchair. No one told his family that they had the option to arrange a series of ambulances to ease his transport to the hospital.
But there was a driver on the other side of the border crossing: Arnon Avni, 69, an Israeli graphic designer and political cartoonist who volunteers with Road to Recovery, a group of Israelis who drive Palestinian patients to their medical appointments. The group was waiting at the checkpoint for patients coming through, and NPR pointed out Al-Kurd's arrival Al-Kurd and his wife took up the offer for a ride.
"Let's get them in," Avni said, throwing his grandchildren's booster seat into the trunk and coaxing the seatbelt over Al-Kurd, who was moaning in pain.
The driver put the destination in his navigation app: an Israeli security checkpoint in the Israeli-occupied West Bank, a bit more than an hour away.
Al-Kurd and Avni didn't share a language but did have some things in common. They were about the same age, and Avni's father died of a heart attack.
"The pain is severe," Al-Kurd said as the car made its way along Israeli roads.
His wife, Fayeza, 58, was in Israel for the very first time.
"It's another world," she said. It's clean, it's wide, it's open, not like the cramped quarters of the Jabalia refugee camp where she lives in Gaza, she said.
"What's that bridge?" she asked Avni. It's just an overpass, he said. She chuckled; she'd never seen one before.
"I see the eyes of all of my passengers on my travels," Avni said from the driver's seat. "All of them feel the same...the roads, the cars, the new cars. It's something else. It's like for me to travel to New York, or something like that."
Avni lives right next to Gaza, in Kibbutz Nirim. Mortar shells landed outside his home last year, and five decades ago, a Palestinian from Gaza planted explosives in their kibbutz which killed his brother.
"Some people call me a traitor," he said. "I believe that we do the right thing for Israel."
At the Tarkumiya checkpoint near Hebron, an Israeli road sign warns Israelis not to enter the Palestinian territory, so Avni couldn't take Al-Kurd and his wife all the way to the hospital. He dropped them off on the other side of the checkpoint.
They said goodbye to each other, and a Palestinian van whisked the Al-Kurds to the hospital.
Hope quickly fades
Al-Kurd didn't end up getting the surgery he'd been waiting for.
Hours after he arrived in the hospital, he had multiple-system failure. Two days later, his son Ibrahim, in Gaza, got a phone call from the hospital, which he recorded.
"Ibrahim, how are you?" the doctor said.
"Oh, God," Ibrahim replied.
"I'm with your mother now," the doctor said, then pauses. "Your father, may he rest in peace."
What could have been done?
Health experts say it's hard to know whether Al-Kurd could have been saved if he'd received his Israeli travel permit more quickly. There were a lot of factors.
Al-Kurd himself was a high-risk patient with his diabetes and smoking habit. What's more, he went a year without getting the surgery in Gaza that his doctor had initially ordered, afraid of open-heart surgery and afraid of COVID. In Gaza, the medical system is poor, and there was very little patient follow-up when his condition got worse.
Al-Kurd's son Ibrahim blames the Palestinian doctor for not marking the case as urgent, compelling Israel to let his father cross immediately. But health experts say that may not have helped; even some urgent cases get delayed and denied by Israel.
But even some urgent cases get delayed and denied by Israel.
The World Health Organization studied Gaza cancer patients from 2015 to 2017 and found they were nearly one and a half times more likely to die within months and years if their Israeli permits were delayed or denied.
"This is the only study that's been done at the population level to look at the impacts on survival or on health outcomes of these patients that face delays and denials of permits," said Benjamin Bouquet, a WHO doctor who co-authored the study.
There are new efforts by the international community to help Palestinians shore up their own health care. The International Monetary Fund said one of the biggest sources of a current Palestinian financial crisis is the exorbitant costs involved in sending patients elsewhere.
In May, the European Investment Bank inked a partnership with the WHO to help reduce Palestinian dependence on Israel and other countries for health care like oncology treatment.
"The whole referral system is an enormous burden on the Palestinian health sector," said Rik Peeperkorn, who directs the WHO office in the Palestinian territories.
Since Al-Kurd died, more Gaza medical patients, including young children with such conditions as cancer or a congenital heart defect, have died while waiting for permissions to get treatment outside Gaza.
Gathered with his family in their living room a few weeks after his father's death, Raji Al-Kurd, 24, posed a question.
"Put yourself in my shoes," he said. "Would you like to face those circumstances? Would you like to see one of your beloved facing those circumstances?"
Sami Sockol in Jerusalem and Nuha Musleh in Ramallah contributed to this report.