Cause of death: the occupation

The illness: breast cancer; Cause of death: the occupationBy Akiva Eldar

Fatma Barghout

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.

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.

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.”

Women suffering from cancer in Gaza face little chance of surviving

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.