Bassma al-Assar was forty-one years old when she was diagnosed with breast cancer in Gaza. Her oncologist referred her to Augusta Victoria Hospital in East Jerusalem — one of the only facilities in the occupied Palestinian territory with the equipment and specialists her treatment required. She applied for an Israeli exit permit. She waited. The permit never came. She died in Gaza in 2019, according to documentation collected by the World Health Organization’s Health Access Monitoring Project.
Her case is not exceptional. It is, by the weight of evidence, routine.
A System Built on Permission
Since Israel imposed its blockade on Gaza in 2007, patients requiring specialist care unavailable inside the Strip have been required to obtain two documents before they can leave: a Palestinian Authority referral and an Israeli-issued exit permit, processed through the Erez crossing. The system, documented extensively by WHO Palestine, has functioned as a medical chokepoint. Oncology patients, cardiac patients, and children requiring surgery have all been caught inside it.
WHO’s Health Access Monitoring reports — published quarterly and covering data since 2012 — track the outcomes of every permit application submitted by Gaza patients. The pattern they reveal is consistent and damning. In 2018, the overall permit approval rate for patients seeking care outside Gaza stood at roughly 54 percent, the lowest recorded since WHO began systematic monitoring. That figure recovered modestly in subsequent years, but cancer patients have historically faced higher refusal and delay rates than patients with other diagnoses.
WHO classifies permit outcomes in three categories: approved, denied, and delayed beyond the appointment date — a third outcome that functions, in practice, as a denial. When delays are counted alongside formal refusals, the effective non-access rate climbs sharply. In the first half of 2023, WHO recorded that approximately one in three patient permit applications resulted in either denial or delay past the point of clinical usefulness — a proportion that rises further when the applicant is a first-degree companion, typically a parent or spouse, whose permit is processed separately and may be refused even when the patient’s is approved.
Cancer Patients and the Permit Lottery
The oncology corridor between Gaza and East Jerusalem has been documented in particular detail by Physicians for Human Rights – Israel (PHRI) and by the Gaza-based Al Mezan Center for Human Rights. Augusta Victoria Hospital, on the Mount of Olives, and Hadassah Ein Kerem have long served as referral destinations for Gazan cancer patients whose tumours require radiotherapy, chemotherapy combinations, or surgical interventions not available at Gaza’s overwhelmed Al-Shifa or European Gaza Hospital.
PHRI’s published case documentation includes patients whose permits were refused on the grounds of an unspecified “security block” — a classification applied by Israel’s Shin Bet internal security service that cannot be appealed through any transparent process. In a 2017 report, PHRI found that the security-block category was applied disproportionately to young men between eighteen and forty, an age cohort that overlaps heavily with the demographic most affected by certain cancers, including testicular and lymphatic malignancies. Patients in that group faced denial rates significantly above the population average.
The Israeli human rights organisation HaMoked has litigated individual permit refusals and documented cases in which patients were asked, during Shin Bet interrogations conducted as a condition of permit consideration, to become informants in exchange for medical access — an arrangement that amounts to coercing patients at their most vulnerable. HaMoked’s case files, published in annual reports, describe multiple instances of patients who refused and were subsequently denied permits.
Ambulances at the Checkpoint: The West Bank Dimension
Gaza is not the only theatre of medical obstruction. In the West Bank, the Palestinian Red Crescent Society (PRCS) operates ambulance services across a landscape fragmented by more than 700 checkpoints, roadblocks, and earth mounds as counted by OCHA’s periodic closure surveys. The organisation’s own monitoring, published in its annual humanitarian reports, documents systematic delays at Israeli military checkpoints that affect emergency response times.
PRCS figures show that ambulance delay incidents — defined as a vehicle held at a checkpoint for more than thirty minutes — numbered in the hundreds annually during the peak closure years of the early 2000s, but have continued into the present decade at a lower but clinically significant rate. In documented cases, patients in obstetric emergencies, cardiac events, and trauma situations have deteriorated or died during checkpoint delays. OCHA’s Humanitarian Country Team has recorded specific incidents of women giving birth at checkpoints because ambulances could not pass in time.
The International Committee of the Red Cross has repeatedly raised checkpoint delays with Israeli military authorities, citing Article 16 of the Fourth Geneva Convention, which obliges parties to an occupation to facilitate the free passage of medical personnel and supplies. The obligation is reflected in identical language in customary international humanitarian law as codified by the ICRC’s 2005 study. Despite those representations, PRCS continues to log delays.
Infrastructure Hollowed Out by Siege
The permit system operates against a background of deliberate structural deprivation. UNCTAD’s recurring reports on the Gaza economy have documented how the blockade has prevented the importation of specialist medical equipment, spare parts for imaging machines, and reagents for laboratory diagnostics. WHO’s Gaza Strip pharmaceutical shortage reports have at various points listed over a hundred essential medicines as having fallen below a thirty-day buffer stock — the minimum the organisation considers sustainable for a functioning health system.
Gaza’s electricity crisis, which has meant between eight and twenty hours of daily power cuts in different periods since 2010, directly affects hospital operating theatres, dialysis units, and neonatal intensive care. The UN’s humanitarian coordinator for the occupied Palestinian territory has described the convergence of equipment shortfalls, medicine gaps, and power cuts as producing a health system that is, structurally, in permanent emergency.
That structural emergency is what makes permit refusals fatal rather than merely bureaucratic. A patient denied access to East Jerusalem for radiotherapy is not being rerouted to an equivalent facility. In most oncology cases, no equivalent facility exists inside Gaza. The permit refusal is, in those circumstances, the termination of the patient’s treatment pathway.
Named, Counted, and Unheard
WHO’s quarterly reports name individual patients only in anonymised form, but the aggregate numbers translate into identifiable human costs. Between 2012 and 2022, WHO recorded tens of thousands of permit applications from Gaza patients seeking care outside the Strip. In the years when approval rates were lowest, the gap between applications submitted and approvals granted ran to thousands of individuals per year — each representing a person who needed care they could not reach.
Al-Assar’s name appears in PHRI’s documentation precisely because documentation is the only form of accountability available. There is no mechanism within the permit system for a family to appeal a delay until it is too late, no tribunal that adjudicates a security block on medical grounds, and no legal obligation under current Israeli administrative practice to give reasons for a refusal. The patient waits. The appointment passes. The cancer advances.
For Palestinian patients in Gaza, the right to health is not abstract. It arrives — or does not arrive — in the form of a piece of paper from a military bureaucracy that answers to no medical standard and no independent review.
Sources
- World Health Organization (WHO) Palestine, Health Access Monitoring Reports, quarterly series, 2012–2023. emro.who.int
- Physicians for Human Rights – Israel (PHRI), Holding Health to Ransom: GSS Interrogation and Extortion of Palestinian Patients at Erez Crossing, 2008; and annual case documentation reports.
- HaMoked: Center for the Defence of the Individual, annual reports on permit refusals and Shin Bet interrogation practices. hamoked.org
- Al Mezan Center for Human Rights, Gaza Strip: Health Sector Factsheets.
- Palestinian Red Crescent Society (PRCS), Annual Humanitarian Reports, ambulance delay monitoring data.
- UN Office for the Coordination of Humanitarian Affairs (OCHA oPt), Closure counts and key humanitarian concerns, periodic surveys. ochaopt.org
- International Committee of the Red Cross (ICRC), Customary International Humanitarian Law, Volume I: Rules (Henckaerts & Doswald-Beck, 2005), Rule 25 (medical personnel) and Fourth Geneva Convention, Article 16.
- UNCTAD, Report on UNCTAD assistance to the Palestinian people, recurring series, on blockade and health infrastructure.
- WHO Gaza Strip, pharmaceutical shortage situation reports, various years.
