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Medical Fraud Grows in Gaza as Residents Seek Exit Permits

Middle East
Patients waited to receive medical-transfer documents in Gaza City in August.
August 31, 2015

GAZA — The medical report details some worrying conditions: chronic dyspnea — a shortage of breath that could be a sign of heart or lung disease — and bronchial asthma. It says the patient, a 28-year-old woman from Gaza City, relies on “continuous medication” and an inhaler.

But the woman has neither affliction, nor an inhaler, although she said she was prone to coughing fits around smokers. What she does have is a work retreat she wants to attend in Morocco, and family in Europe she has not seen for ages.

Unable to get Israeli permission to exit Gaza for these reasons, she said she paid a doctor 200 shekels — about $50 — to write a fake medical report and a hospital worker another 250 shekels to obtain approval stamps, hoping to join the hundreds of Palestinian patients allowed out each month for treatment, mostly to Israel and the West Bank.

“I don’t feel bad lying because they don’t give you any other options,” said the woman, who spoke on the condition her name and some details not be published for fear it could hurt her chances or lead to arrest. “I do feel bad about the doctors that are doing this, because they’re dealing with this as a business. They’re exploiting the situation.”

Interactive Feature | Take a Walk Through Israel and Gaza, a Year After the War Meet a wounded Israeli soldier, a 5-year-old stuck in Gaza and a 24-year-old in Gaza who finds comfort in horse-jumping. For them and many others, daily life is full of reminders of last year’s Israel-Gaza war.

With Egypt having all but shuttered its border with Gaza, Israel allowed about twice the number of Gazans to exit through its Erez crossing in the first half of 2015 as in the same period the year before. But the permits are reserved mainly for merchants and medical patients, and some Gazan doctors and residents, as well as officials involved in the issuing of permits, say they have seen a parallel uptick in fraudulent referrals, slowing approvals for legitimate cases.

There is no firm data on how prevalent the practice is. The World Health Organization reported that 2,148 Gaza patients applied for permits in June, the highest monthly number since the agency began monitoring the process in 2006; 80 percent got through, a drop from the previous three months. The nonprofit Physicians for Human Rights wrote to the Israeli authorities last week complaining that eight patients who it had helped apply for medical transfers were denied permits in August, up from a typical two per month.

“We have a lot of cases of both fake papers and fake requests, and also just people that don’t really need to get this treatment outside,” said the Israeli official who heads the permit division, speaking on the condition of anonymity because of his sensitive role. “Sometimes we find ourselves digging deep in certain requests just to make sure they’re real, and other real requests are waiting.”

Patient applications from Gaza nearly quadrupled in less than a decade, to more than 18,000 in 2014 from 5,470 in 2006; there were 10,034 requests in the first half of 2015. Dr. Bassem al-Badri, a Palestinian dermatologist who runs Gaza’s medical-referral office, and Anita Vitullo, manager of the W.H.O.’s health-advocacy project for Palestinians, both said the main drivers are Gaza’s swelling population and the shortage of medicine, equipment and personnel in its overburdened hospitals, especially since last summer’s war with Israel.

But Dr. Badri said that “about 10 percent” of applicants did not actually need treatment, and that there were doctors in Gaza who charge patients $200 to $2,000 for unnecessary referrals. He blamed Israel for the growing black market, calling it “one of the crimes of the occupation.”

“If the siege continues,” he said, referring to Israeli restrictions imposed after Hamas, the militant Islamist movement, took over Gaza in 2007, “so the pressure will increase day by day, year by year. The increase of need will increase the ways to pass outside. One of the ways is to pay money.”

Ms. Vitullo agreed, saying: “When you have a very strict permit system, I think you can expect it. I think people are desperate and will try any means.”

Desperation permeates the storefront in Gaza City where residents file for referrals. Relatives of the sick line up long before the 8 a.m. opening, carrying the coveted doctors’ orders in plastic pouches; one recent morning they included the parents of a 7-year-old girl needing an ear operation who had just been turned back from Erez.

Ehab Sharif, 30, said he had been trying for weeks to get a permit for his 54-year-old father, Khaled, who has diabetes, high blood pressure and failing kidneys. “People are dying and nobody looks at us,” he complained. “Everybody needs paper and paper and paper. I want to burn this place.”

Nafiz Fati Ahmad Alouh, 45, a father of six who has received a diagnosis of essential thrombocythemia, a rare blood disorder, said he had been treated at a Jerusalem hospital in April but had since been struggling to get another permit because he needed medicine available only in Germany. “When I die, they’ll say it’s God’s destiny,” Mr. Alouh lamented. “It’s not God’s destiny, it’s negligence.”

Upstairs, Dr. Badri sits behind a large desk adorned with a Palestinian flag, surrounded by men thrusting papers in front of him for signatures. Urgent trauma and cardiac cases are generally approved and whisked out by ambulance within hours. Others are reviewed by a 10-doctor panel that meets twice a week in Gaza, and again by the Palestinian Ministry of Health in the West Bank, which said it spent more than $53 million on outside treatment for Gazans in 2013.

Only then, and once an outside hospital has set an appointment, are applications sent to the Israeli Coordinator for Government Activities in the Territories, whose permit department has more than half its employees vetting medical referrals (none are doctors; one has a medical management degree). The unit’s chief said it has a list of about 20 “problematic doctors that are very, very generous in giving papers and signing them, with no real need,” and gives extra scrutiny to their referrals.

In June, the W.H.O. reported, Israel denied 140 applicants, deeming 21 “unlikely to return to Gaza” or able to get treatment inside the territory; the others did not submit requests seven days ahead of their hospital appointments. Ten men were summoned for security interviews, one was approved.

Fraud is not a new phenomenon. In 2008, the Shin Bet security service in Israel reported that Nasrin Galu, 25, admitted paying $500 to a kidney specialist to refer her to a West Bank hospital because she wanted to see her children who live nearby. In December, the Israeli news site Mako reported on the arrest of a man who had papers saying he was injured in a construction accident but told interrogators he had never seen a doctor and only paid a nurse, who charges $1,500 to $3,000 per referral, at the Shifa Hospital in Gaza City

The woman who does not have chronic dyspnea, then, got off cheap.

She said the chest specialist who wrote her referral never examined her. “I told him I need a diagnosis from you so I can travel abroad,” she recalled of their 10-minute encounter. “He said pay me 200 shekels and I will call you tomorrow.”

The doctor, who works at Shifa and runs a private clinic in the evenings, denied the woman’s story, and said he always examines patients — charging 50 shekels, or about $13 — before writing a referral. “It’s impossible,” he said, “because it has to be documented and signed by many doctors.”

That task, according to the woman, fell to a Shifa lab technician who she met twice at a market, first to hand over the doctor’s diagnosis, then to get it back with the required stamps, including the director of Shifa and head of its chest department.

This lab technician, too, denied any involvement, saying, “I have no connection to medical reports.”

Dr. Naser al-Tatar, director of Shifa, declined to comment on the woman’s story, and called fraud “a very small problem” compared to the hospital’s lack of M.R.I. and PET scan machines, chemotherapy agents and kidney drugs.

But a surgeon at Shifa, speaking on the condition of anonymity for fear of reprisals, said buying fake or exaggerated diagnoses was “becoming a norm,” with lab technicians and hospital administrative staff serving as “brokers.” The doctor said a colleague had gotten a medical transfer for a hemorrhoid that could have been treated inside Gaza in order to go to Germany for a job, and another did similar with an anal fissure.

In fact, he admitted, he also has a scan showing disk problems in his back, in case he cannot otherwise get an exit permit for an upcoming medical conference.

Majd Al Waheidi contributed reporting from Gaza and Myra Noveck from Jerusalem.

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(via NY Times)