Below is one PHR-Israel case study representing a current trend in the provision of exit permits to Gazans for medical reasons. Case studies such as this one have been provided by PHR-Israel to raise awareness about border restrictions in Gaza that prevent Gazan patients from receiving critical health care. Full names are withheld for reasons of medical confidentiality and can only be released for purposes of access to medical care.

Case Study 3

(Provided by PHR-Israel)

August: Diplomatic pressure fails to reverse a prohibition on medical access from Gaza
Yousef I.A.L, male, 41, is a father to six children from the Jabalia refugee camp in the Gaza Strip. In 2005, Yousef underwent surgery replacing a mitral valve and also removing a cancerous tumor from his heart. He currently suffers from chronic renal failure and is awaiting a kidney transplant. He also suffers from recurrent venous and arterial thrombosis, including pulmonary embolism and critical ischemia in the legs and hip, from diabetes, high blood pressure, and nerve atrophy which began in childhood. Over the past three months, Yousef has lost over 30kg of his body weight and together with the overall deterioration in his physical condition there is a concern for the recurrence of cancer in his body.

On May 13, 2009, Yousef was referred by the Palestinian Health Ministry for treatment at Al Makassed Hospital in East Jerusalem after the hospitals in Gaza could not provide him with the required care. The patient was since invited five times by Al Makassed Hospital, three times by the Department of Cardiology (June 21, July 1, and July 19) and the other two by the Department of General & Vascular Surgery (June 3 and June 18). Yet Yousef was not able to attend any of these appointments. The Israeli secret police (ISA/GSS/Shin Bet) rejected three applications that Yousef had submitted to the Israeli authorities at Erez, based on a “security prohibition” against him. In addition, an application to exit Gaza submitted by the Palestinian coordinating mechanism in May 2009 did not receive any response from the Israeli army. Only after PHR-Israel contacted the army in July 2009 it was told that the application had been denied by the secret police. Applications submitted by PHR-Israel on behalf of the patient on July 21 and August 12 were also denied on the same grounds.

To assess the patient’s medical condition, PHR-Israel consulted with two of its volunteer Israeli medical doctors who are experts in the fields of Yousef’s condition. These physicians were provided with his medical files. Professor Raphael Walden, an expert on vascular medicine and Deputy Director at Sheba Medical Center in Tel Hashomer, wrote that “treating the patient in Gaza is impossible and his life is in danger….” Prof. Dina Ben Yehuda, Head of the Hematological Department at the Hadassah Medical Center in Jerusalem, wrote that “the patient requires evaluation in a tertiary hospital to find the reason for his thrombosis as well as for the possibility of performing surgery on his ischemia.” Despite the fact that this information was brought to the attention of the Israeli military authorities and secret police, Yousef’s applications were denied. It is worth mentioning that Yousef entered Israel and East Jerusalem at least seven times in the past to receive treatment. On August 19 PHR-Israel applied to the embassy of the EU presidency (Sweden) in Tel Aviv as well as the Norwegian embassy, to members of Knesset and to well known public personages in Israel to apply pressure on the Israeli authorities to enable access to lifesaving care to this patient. One week later, the Israeli coordinator of operations in the OPT (COGAT), Mr. Uri Singer, informed the embassy representatives by telephone that their response to this request was negative. The patient remains in Gaza in imminent danger of his life.

The Israeli-imposed border restrictions in Gaza continue to choke off needed medical assistance for Gazan patients. Humanitarian and medical aid can barely squeeze into the blighted region, and sick Gazans with referrals for medical treatment outside of Gaza may not be granted permission to exit.

Additionally, the Gaza War earlier this year triggered major setbacks in health sector operations, according to data published by the World Health Organization in July 2009. Bureaucratic complications and political disputes led to delays in processing applications, culminating with the closure the Referral Abroad Department from March 22 to April 27. The report indicates that in the six months following the war, only half of the applications to exit Gaza via Erez Crossing for medical reasons were approved. The only other way out — the Rafah Crossing leading into Egypt — is open infrequently and only for short periods of time.

Physicians for Human Rights-Israel, a Jaffa-based Israeli organization, has been documenting these permit constraints in order to advocate for patients in tremendous need of care outside of Gaza. According to PHR-Israel, more than 100 Gazan patients apply to PHR-Israel for assistance in medical access from Gaza every month.

Below is one PHR-Israel case study representing a current trend in the provision of permits. Case studies such as this one have been provided by PHR-Israel to raise awareness about border restrictions in Gaza that prevent Gazan patients from receiving critical health care. Full names are withheld for reasons of medical confidentiality and can only be released for purposes of access to medical care.

Case Study 1

(Provided by PHR-Israel)

May and June: Bureaucratic hurdles decreased medical access at Erez Crossing. These months were characterized by severe delays in the handling of Palestinian patients’ requests for permission to exit Gaza for medical care.

Issam Z, male, 44, a resident of Gaza, suffered from severe ischemic heart disease. He was referred for open heart surgery – unavailable in Gaza – in Al Takhasussi hospital in Nablus, West Bank. However, although he had all necessary documents by February 2009 (referral letters from both hospitals and a financial undertaking from the PA to cover the costs of the procedure), he did not succeed in coordinating his exit from Gaza.  Since the Palestinian coordinating mechanism for medical permits was not functioning throughout March and April, his request was not forwarded to the Israeli side, while at the same time, the Israelis were refusing to process applications direct from the patients.

In late April Issam applied to PHR-Israel for assistance, who appealed to the Israeli coordinating authority at Erez Crossing, on April 27, 2009, asking for a speedy processing of the patient’s request to exit Gaza, in the light of his condition and the lack of a Palestinian go-between. On May 5 the Israeli authorities informed PHR-Israel that the Palestinian coordinating mechanism had returned to functioning and therefore they were stopping their handling of his application. They demanded that Issam re-apply via the Palestinian side. On May 14 the Israeli army informed PHR-Israel that the application for exit from Gaza had been approved, only to reverse this decision without explanation several days later. On June 3, after several vain attempts by the patient to re-apply for exit, PHR-Israel demanded of the Israeli army that they expedite the process of dozens of cases that had been delayed in this way since May, including that of Issam. On June 7 the patient’s family informed PHR-Israel that Issam had died of his illness at his home in Gaza.

This preview of Volume 11 Number 1 includes an interview with Anand Grover, the UN Special Rapporteur on the right to health, as well as Critical Concepts articles covering participation as it relates to health in countries including Indonesia, Guatemala, and Palestine.

The full table of contents, including an exciting array of essays on both “Critical Concepts” and “Health and Human Rights in Practice,” is provided below.  Be sure to visit the Health and Human Rights website this fall to view the entire issue.

The journal is also accepting submissions for a forthcoming theme issue on ”‘International assistance and cooperation’ and Health and Human Rights Obligations Beyond Borders” (due October 15, 2009). Additional submissions information can be found at: http://www.hhrjournal.org/index.php/hhr/about/submissions.

Articles currently available:

The power of community in advancing the right to health: A conversation with Anand Grover [PDF, HTML]

Suffering and powerlessness: The significance of promoting participation in rights-based approaches to health [PDF, HTML] by Alicia Ely Yamin

Health through people’s empowerment: A rights-based approach to participation [PDF, HTML] by Pol De Vos, Wim De Ceukelaire, Geraldine Malaise, Dennis Pérez, Pierre Lefèvre, and Patrick Van der Stuyft

Social participation within a context of political violence: Implications for the promotion and exercise of the right to health in Guatemala [PDF, HTML] by Walter Flores, Ana Lorena Ruano, and Denise Phé Funchal

Participation and the right to health: Lessons from Indonesia [PDF, HTML]
Sam Foster Halabi

See below for a list of additional articles that will be included in the full issue.

A card before you leave: Participation and mental health in Northern Ireland, by Frank V. McMillan, Nicola Browne, Stephanie Green, and Dessie Donnelly

Witnesses to hunger: Participation though photovoice to ensure the right to food, by Mariana Chilton, Jenny Rabinowich, Christina Council, and Jennifer Breaux

Unexpected agency: Participation as a bargaining chip for the poor, by Clara Rubincam and Scott Naysmith

HIV/AIDS in Cuba: A rights-based analysis, by Tim Anderson

Global goes local: Integrating human rights principles into a county health care reform project, by Roslyn Solomon

How are the current proposals for health insurance reform treating an industry that siphons off roughly $10 billion in annual profits? We now have two health reform bills reported out of congressional committees (”America’s Affordable Health Choices Act” in the House and the “Affordable Health Choices Act” in the Senate – using terminology pushed by Democratic pollsters, no doubt). Neither of them meets key human rights standards, and both cast private insurance corporations in the role of gatekeepers that control people’s access to care. At the same time, opposition is mounting against all and any reform measures.

Yet there continues to be great hope among many long-time health policy advocates that will we see meaningful health reform later this year. Advocates count on this reform to solve or at least alleviate the current health care crisis, which results in an estimated 22,000 preventable deaths due to lack of insurance each year, as well as skyrocketing costs that bankrupt families and public budgets alike. Pundits optimistically point to the many new measures the reform bills introduce: reining in the “free” insurance market through tougher regulation, including through a so-called Exchange mechanism; setting up a public insurance plan; expanding Medicaid; requiring employers to contribute to costs; and mandating everyone to buy insurance. All Americans (though not all immigrants – documented or not) will get health insurance – or so the hopeful want to believe.

Their hope is born out of desperation. Most advocates are painfully aware that health care is treated as a market commodity in the United States, and that market rules are stacked against those with little purchasing power. And these are usually the very people who need health care the most: poor people and people with serious health issues. In a blatant affront to the basic human rights principle of equity, minority groups and poorer communities in rural and inner city areas suffer disproportionally from market barriers to health care.

Reminders of the insurance industry’s power are everywhere: people who lack insurance, people whose claims are denied, whose coverage is rescinded, or who pay exorbitant premiums that may – or may not – preempt catastrophic bills but do not cover actual visits to the doctor. The business model of insurance companies only works if as many healthy people as possible buy policies and pay premiums that are as high as possible, and if those same people then forgo actually using the health care covered by that policy. None of this is news to mainstream health reformers, yet hardly anyone points to the emperor without clothes: because insurance corporations can profit only by restricting access to care, they act as hostile gatekeepers rather than as vendors of a value-adding service. In one of our news media’s rare instances of bluntness, a Paul Krugman blog in the New York Times explains that “private insurance basically spends a lot of money on socially destructive activities.”

Yet both Obama and congressional leaders remain worryingly silent on the role of the insurance industry, despite their rhetorical shift from health care to health insurance reform. Hence they struggle to devise a sustainable cost trajectory for their proposed reforms, which are weighted down by the immense costs of keeping private insurance corporations in business. These costs include profits and corporate salaries, plus the even greater amounts wasted on underwriting and marketing to exclude people who might actually need care, and on claims administration to deny care to those who have already paid for it. To help meet those costs, reformers have proposed a requirement on all individuals to purchase an insurance policy, which amounts to a massive bailout for an industry that has continued to make record profits and is accountable only to its shareholders. Such public subsidies to the industry, via policyholders, constitute the greatest cost factor in any of the bills under discussion, yet they fail to guarantee access to health care for all. Even under the best proposal, people would still have to pay up to 11% of their income in premiums for a skimpy policy, on top of co-pays and deductibles. These provisions illustrate that the economic costs of sustaining the private insurance industry can only be paid through the social costs of restricting access to care to those able to pay.

Always on public relations alert, all key industry players – hospitals, pharmaceuticals and insurers – claim to have made concessions that would curb the excesses of the market and sustain the policy consensus for commodified health care. Yet smoke and mirrors cannot hide that market-based health care is inherently unable to contain costs at the same time as ensuring access to quality care for all. Even the President accepts that universal coverage is not possible without a publicly funded and administered system, such as single payer, that automatically includes everyone. Such a system would treat health care as a public good rather than a market commodity, and enable access on the basis of need, not payment. Guided by the principle that basic human needs give rise to government human rights obligations, such a public health care system would be financed collectively in order to meet people’s health needs with equitably shared resources. Instead of providing profits and benefits to a few, a rights-based system would enrich everyone living in a healthier society.

Siwan Anderson and Debraj Ray analyzed figures from the year 2000 from sub-Saharan Africa, China, and India, to better understand at what age the missing women are dying, and what they’re dying from. As they explain in their paper, Missing Women: Age and Disease, “The possibility of gender bias at birth and the mistreatment of young girls are widely regarded as key explanations. . . . While we do not dispute the existence of severe gender bias at young ages, our computations yield some striking new findings.”

Their news? Anderson and Ray found that the majority of missing women died as adults (older than 15), not from sex selection in utero or childhood gender bias, as previously thought. The authors’ suggested percentages of “excess female deaths” occurring later in life are striking: 66 percent in India, 55 percent in China, and 83 percent in sub-Saharan Africa.

In China and India, many of these deaths are attributed to “injuries”-a term unsettling in its vagueness. In the Star article, Anderson says that the majority of China’s 141,000 excess female deaths from “injuries” were the result of suicide, usually by ingesting crop pesticides.

“Injuries” in India accounted for the deaths of 86,000 women ages 15 to 29. Here the researchers suspect dowry-related deaths, which can include “bride burnings”- a particularly brutal form of violence in which a woman is doused with kerosene and lit on fire.

The largest number of missing women is in sub-Saharan Africa, where more than one-third died of HIV/AIDS. Other factors here may also include lack of access to care and other psychosocial factors.

Two decades ago, Sen wrote that “[i]f this situation is to be corrected by political action and public policy, the reasons why there are so many ‘missing women’ must first be understood.” Anderson and Ray’s work now brings us closer to that understanding-and makes all too clear the ultimate toll gender discrimination can take on a woman’s life.

For more reading:

Economist Emily Oster’s challenge of Sen’s theory in 2005: “Hepatitis B and the Case of the Missing Women” (arguing that biology, and not gender discrimination, skewed the ratios in Asia)

Monica Das Gupta’s response to Oster’s controversial claim: “Explaining Asia’s Missing Women: A New Look at the Data” (families whose first-born was a daughter  later had sons, suggesting measures to ensure boys)

A 2008 report that the effect of HBV on sex ratio imbalance was insignificant: “Can Hepatitis B Mothers Account for the Number of Missing Women: Evidence from Three Million Newborns in Taiwan”

Oster re-examines the data and issues a 2008 retraction: “Hepatitis B Does Not Explain Male-Biased Sex Ratios in China”

Authors suggest that legalization of abortion accounted for an increase in sex ratio at birth in the 1980s-and a decrease in excess female mortality: “More Missing Women, Fewer Girls Dying: The Impact of Abortion on Sex Ratios at Birth and Excess Female Mortality”

Paper concludes that increasing female income-and holding male income constant-increases girls’ survival rates: “Missing Women and the Price of Tea in China: The Effect of Sex-Specific Income on Sex Imbalances”

Last month, the New York Times published a piece on the surprising birth bias for boys found in some Asian American communities:  “U.S. Births Hint at Bias for Boys in Some Asians“