The can­cer pa­tient

The Washington Post Sunday - - FRONT PAGE - BY WIL­LIAM BOOTH AND SUFIAN TAHA

“The thing that ex­hausts me the most is the back and forth.” A mother leaves her kids to get care.

jerusalem — The pa­tient in Room 120 was strug­gling, you could see right away, on what her on­col­o­gist called “the can­cer jour­ney.” She was three long years into this trip.

To­day she felt a pain jab­bing its fist into her right side. But Maweya Abu Salah was not done yet. She was a mother who wanted to see her chil­dren again.

“I just feel a lit­tle down,” she told us. “Come, come. Sit down.” She ar­ranged her­self un­der the bed­spread.

Out­side her win­dow at the Au­gusta Vic­to­ria Hos­pi­tal in East Jerusalem, the spring flow­ers were in epic bloom. She praised God and her nurses. She was go­ing home, if not to­day, in a day or two, she said.

Salah was quick to tell any­one who passed by about her kids: the ac­coun­tant, the chemist, the math teacher. And the youngest, just 13 years old, a bless­ing, a hand­ful.

The chil­dren wanted to be by her side. One son ap­plied for a per­mit to ac­com­pany his mother to the hos­pi­tal but was re­fused, Salah said. An­other son was in Jor­dan and de­nied en­try into Is­rael. In the days to come, her el­dest daugh­ter tried, too, but was turned away.

They were Pales­tini­ans stuck on the other side of Is­rael’s borders and bar­ri­ers.

One of her doc­tors told us, “This hap­pens ev­ery day.”

Only Salah’s hus­band of 34 years had a per­mit to come to the hos­pi­tal and spend the night. He was alone, too, on his own jour­ney, cat­nap­ping by his wife’s bed in a vinyl re­cliner, or pac­ing the cor­ri­dors af­ter mid­night, when all was still, ex­cept for the beep­ing of ma­chines.

“I need the kids here as much as she,” Ja­mal Abu Salah said.

There are many ways to tally the hu­man costs of the Is­raeli oc­cu­pa­tion, which be­gan 50 years ago in June.

Is­rael has faced rock­ets and three wars with the Is­lamist move­ment Ha­mas in Gaza, whose mem­bers deny Is­rael’s right to ex­ist. Is­raelis en­dured two Pales­tinian up­ris­ings, the sec­ond marked by sui­cide-bomb at­tacks against civil­ians. More re­cently there was a wave of knife and ve­hic­u­lar as­saults. Thou­sands of Is­raelis have died in Pales­tinian at­tacks. This is why Is­raelis say they need walls and per­mits.

On the other side, Pales­tini­ans in 2017 live their lives un­der a cone of con­trol that they say Is­raelis or Amer­i­cans would rebel against.

There are check­points, walls — and more than a hun­dred kinds of per­mits that a Pales­tinian needs to en­ter Is­rael.

Per­mit is a blood­less term. An au­to­mo­bile needs a per­mit. What is a per­mit for a Pales­tinian?

A per­mit is re­quired for a sick Pales­tinian to go to a Pales­tinian hos­pi­tal in East Jerusalem. A per­mit is re­quired for a son to be by his mother’s side in a can­cer ward here.

Is­rael an­nexed East Jerusalem years ago. Pales­tini­ans con­sider this half of the city “oc­cu­pied ter­ri­tory.” Is­rael says all of Jerusalem is theirs — “eter­nal and un­di­vided.”

Is­rael of­ten high­lights its gen­eros­ity to­ward the Pales­tini­ans, es­pe­cially their ac­cess to topflight Is­raeli hos­pi­tals — care that the Palestin- ians, or their Amer­i­can and Euro­pean pa­trons, pay for.

Left un­said is the fact that Pales­tini­ans come to Is­rael be­cause health care in the West Bank is sub­stan­dard. It’s even worse in the im­pov­er­ished Gaza Strip, which suf­fers from strict trade and travel re­stric­tions im­posed by Is­rael and Egypt and is ruled by the Is­lamist mil­i­tant move­ment Ha­mas, a ter­ror­ist or­ga­ni­za­tion.

Last year, the Pales­tinian Health Min­istry sent 4,500 pa­tients from the West Bank and Gaza to Is­raeli hos­pi­tals. It sent an ad­di­tional 20,000 to the six hos­pi­tals in East Jerusalem, in­sti­tu­tions such as Au­gusta Vic­to­ria Hos­pi­tal, a 120-bed fa­cil­ity run by a Lutheran char­ity and staffed by Pales­tini­ans.

Walid Nam­mour, di­rec­tor of the Vic­to­ria hos­pi­tal, told us, “Be­lieve me, we would go to the moon to get our peo­ple the care they need.”

Nam­mour praised Is­raeli doc­tors. He called an Is­raeli med­i­cal co­or­di­na­tor, “who works round the clock” to help get med­i­cal per­mits for his Pales­tinian pa­tients, “a saint, an an­gel.”

Nam­mour said the co­op­er­a­tion be­tween Jewish, Chris­tian and Mus­lim med­i­cal work­ers is a model for how to put aside decades of ha­tred and sus­pi­cion, and to make peace to­gether.

“As a Pales­tinian, I feel dis­crim­i­nated against ev­ery­where I go, but never in an Is­raeli hos­pi­tal,” he said. But all was not right. “Ev­ery­thing comes back to the oc­cu­pa­tion,” Nam­mour said.

A per­mit to get chemo­ther­apy

We met Maweya Abu Salah on a Sun­day af­ter­noon in April, tag­ging along with one of her on­col­o­gists on his rounds.

Salah had just turned 51. She was wait­ing for an oxy­gen bot­tle, but pleased to have vis­i­tors be­cause vis­i­tors are rare.

To come to Vic­to­ria hos­pi­tal for treatment, Salah and Pales­tini­ans in the West Bank and Gaza need two things. They must get a re­fer­ral from the Pales­tinian Health Min­istry, which is es­sen­tially a prom­ise to pay for ser­vices ren­dered — a cum­ber­some process. They also need a travel per­mit from Is­rael’s mil­i­tary and in­tel­li­gence au­thor­i­ties. Pa­tients, es­pe­cially those from Gaza, are some­times re­quired to sub­mit to in­ter­views with Shin Bet in­tel­li­gence of­fi­cers be­fore get­ting a per­mit.

Pales­tinian med­i­cal pa­tients vis­it­ing Is­rael are usu­ally al­lowed one es­cort, some­times two, a close rel­a­tive.

The Is­raelis can refuse per­mits to younger fam­ily mem­bers, es­pe­cially males, for se­cu­rity rea­sons. Doc­tors at the Vic­to­ria hos­pi­tal said some­times even moth­ers and fa­thers can be de­nied per­mits to ac­com­pany their sick chil­dren.

“These are the sad­dest cases,” the di­rec­tor said.

For what would be her last ad­mis­sion, Salah and her hus­band first trav­eled from their home in the north­ern West Bank by car, then bus, cross­ing from the West Bank to Is­rael via the Qa­lan­dia check­point, from Ramallah into Jerusalem, then an­other bus and fi­nally a taxi to the hos­pi­tal. The 70-mile trip took four hours. “If the sit­u­a­tion was nor­mal, we’d just take the fam­ily car,” Salah said. “But this is our life, what can you do? We have to thank God for what we have.”

Salah did not want to com­plain. But she did want to make one point. “I will say that the thing that ex­hausts me the most is the back and forth.”

One of her doc­tors, in English, whis­pered to us, “You know that this is an end-stage can­cer pa­tient mak­ing these crazy bus trips, right?”

He looked at Salah, smiled and said in Ara­bic, “She re­fuses to use the wheelchair!”

Three years ago, Salah felt a mys­te­ri­ous ache and went to the Pales­tinian Author­ity’s pub­lic hos­pi­tal in Jenin. A Pales­tinian doc­tor per­formed an ul­tra­sound. There was some­thing sus­pi­cious about the right kid­ney.

A for­eign sur­gi­cal team vis­it­ing Jenin “opened me up and then sewed me back up,” she said.

It was not un­til Salah was awarded a med­i­cal per­mit by the Is­raeli mil­i­tary to travel to a hos­pi­tal in Tel Aviv that a def­i­nite di­ag­no­sis was reached. The Is­raelis per­formed a PET-CT scan and did a biopsy that con­firmed kid­ney can­cer.

“They were very nice to me,” she re­mem­bered.

Three months later, Salah was given a re­fer­ral and an­other Is­raeli per­mit to go to St. Joseph’s Hos­pi­tal in East Jerusalem, where Pales­tinian sur­geons re­moved her can­cer­ous kid­ney.

Then she be­gan her treatment here at Vic­to­ria hos­pi­tal, where doc­tors had ac­cess to the lat­est drug ther­a­pies.

The Pales­tinian Health Min­istry re­ports that half the med­i­cal pa­tients from Gaza were de­nied ac­cess to Is­rael and East Jerusalem last year, while al­most all the pa­tients from the West Bank were ac­cepted, though some­times af­ter lengthy de­lays. Is­raeli of­fi­cials say they try to fa­cil­i­tate es­sen­tial med­i­cal vis­its. They is­sued al­most 112,000 per­mits to Pales­tinian pa­tients last year. But they say they care­fully watch whom they al­low to ac­com­pany the pa­tients.

“My treatment is not avail­able in the West Bank,” Salah told us. “It should be, but I don’t know why.”

She said, “I will say it, health care in the West Bank is re­ally not so good.”

This was the last time we would see Salah con­scious.

A dire lack of op­tions

In many ways, Is­rael’s mod­ern med­i­cal mir­a­cle helped Salah sur­vive. But the oc­cu­pa­tion also threw ob­sta­cles in her path.

Her pri­mary on­col­o­gist, Yousef Ha­mam­reh, was trained by Is­raeli men­tors at nearby Hadas­sah Med­i­cal Cen­ter, which is con­sid­ered one of the lead­ing med­i­cal cen­ters in the world. Pales­tinian doc­tors at Vic­to­ria con­fer of­ten on cases with their Is­raeli coun­ter­parts.

There are just seven Pales­tinian on­col­o­gists in East Jerusalem, and six in all of the West Bank, in­clud­ing two about to re­tire. There are three in Gaza. That’s it.

“This for a pop­u­la­tion of over 4 mil­lion peo­ple,” Ha­mam­reh said, for all the West Bank and Gaza. “This is not right.”

When we spoke in his base­ment of­fice, he made cups of strong cof­fee and un­plugged the phone on his desk, which had been ring­ing and ring­ing. “I’m a doc­tor, not a politi­cian,” he said. Ha­mam­reh said there are no PET-CT scan­ners in the West Bank or Gaza, be­cause the Is­raelis will not al­low them. The scan­ners, which have rev­o­lu­tion­ized medicine in the past decade, pro­duce ra­dioac­tive byprod­ucts that Is­raeli se­cu­rity forces fear could be han­dled im­prop­erly or even de­ployed by ter­ror­ists in a dirty bomb.

And so ra­di­a­tion ther­apy is not avail­able for can­cer pa­tients in the West Bank and Gaza, for the same rea­son as the PET scan­ners, which means that ev­ery woman who needs ra­di­a­tion for breast can­cer or man for a ma­lig­nant pros­trate must se­cure per­mits. Chemo­ther­apy is a dif­fer­ent chal­lenge. Ha­mam­reh said many widely pre­scribed can­cer drugs are not read­ily avail­able in the West Bank, be­cause the Pales­tinian Author­ity does not pay its bills.

“It’s much worse in Gaza,” he said. “Their shelves are empty.”

There are no tar­geted bi­o­log­i­cal agents, ei­ther, no im­munother­apy, all tools of mod­ern can­cer treatment.

Hos­pi­tals in Jor­dan and Egypt no longer ac­cept pa­tients re­ferred to them by the Pales­tinian Author­ity, be­cause they are not re­im­bursed.

In the past two years, U.S. tax­pay­ers have paid off $60 mil­lion of the Pales­tinian Author­ity’s debt to the East Jerusalem hos­pi­tals. Ear­lier this month, the Vic­to­ria hos­pi­tal threat­ened to stop tak­ing new re­fer­rals, in­clud­ing can­cer pa­tients, be­cause the Pales­tinian gov­ern­ment owed it $40 mil­lion.

Pales­tinian health of­fi­cials blame the oc­cu­pa­tion.

Nam­mour said: “The money is there. But it’s not their top pri­or­ity.”

‘She’s shut­ting down’

On Wed­nes­day, three days af­ter our first visit with Salah, we found doc­tors at her door. Things were bad. “If she were an Is­raeli, I would have released her for pal­lia­tive care, for end-of-life man­age­ment. She’d get home vis­its, by a so­cial worker, a psy­chother­a­pist, on­col­ogy nurse, a di­eti­tian,” said Wasim Shar­bati, one of her doc­tors. It was too late now. “She’s shut­ting down,” Shar­bati said. Her hus­band, Ja­mal, stood a few feet away. He is 62 and has spent his life con­struct­ing homes, ho­tels and of­fices for the Is­raelis. The day be­fore his wife fell into un­con­scious­ness, he had rushed back and forth from a work site in Tel Aviv, un­der a dif­fer­ent per­mit, one for work. His nails were still caked with plas­ter dust. “We were wish­ing to go home,” he said. His wife lay on the bed, mak­ing a gur­gling sound.

Ja­mal combed her hair. He felt her forehead. He smoked out­side and paced in­side. He made phone calls. It was all very sud­den. There was no time to bring his chil­dren across.

“This is not fair. Her kids should be here,” Ja­mal Abu Salah said.

That night, Ja­mal said his wife sud­denly stirred and spoke to him. She seemed fright­ened and con­fused.

She asked her hus­band why her grand­chil­dren had come to the Is­raeli check­point alone. Of course, they had not, this was just a dream or a delu­sion. The grand­chil­dren were tod­dlers. They were at home.

“I was sur­prised by this,” Ja­mal said. “I didn’t imag­ine this would be on her mind. But she kept go­ing on about the check­point, the check­point, over and over.”

Ja­mal said his wife, at her last mo­ments, was not see­ing angels but Is­raeli sol­diers.

One last check­point

Maweya Abu Salah died on Thurs­day af­ter­noon.

A med­i­cal res­i­dent pat­ted Ja­mal’s arm and said, “We think she’s gone.”

A nurse handed him his wife’s gold rings. Ja­mal put his hands on his wife’s face. He read a prayer from the Ko­ran.

With help, he packed a bag with her shoes, her robe, her purse. He went into the hall­way, cried for a mo­ment and then be­gan fran­ti­cally call­ing his adult chil­dren.

They had to make ar­range­ments to get her home one last time.

Ja­mal hired a pri­vate Jerusalem am­bu­lance to take them to the check­point. But not even am­bu­lances are al­lowed to pass freely.

And so it was there, in a busy park­ing lot, that Salah’s body was trans­ferred from one am­bu­lance to an­other, one gur­ney to the next, in full view of the pass­ing cars and com­muters, a steady stream of Jewish set­tlers and Pales­tini­ans, com­ing and go­ing.

Ja­mal didn’t want his sons and daugh­ter to come to the check­point to see this.

He warned them away. “Go and rep­re­sent me in the vil­lage, I will bring her home.”

As her body was be­ing trans­ferred from am­bu­lance to am­bu­lance, an Is­raeli po­lice­man, with an armed Is­raeli sol­dier stand­ing by, checked her pa­pers one last time.

The of­fi­cer looked at her face. He looked at the pho­to­graph on her Pales­tinian ID, at her death cer­tifi­cate and her fi­nal per­mit.

Chil­dren say good­bye

On Fri­day, they buried her in Arraba, a pic­turesque hill town in the north­ern West Bank, with nearby ru­ins dat­ing to Ro­man times and ter­raced fields.

Hun­dreds turned out for the fu­neral. She was car­ried on the shoul­ders of fam­ily and friends to a ceme­tery be­side a grove of old olive trees. Her hus­band and two sons, Mo­ham­mad and Ali, the chemist and the ac­coun­tant, placed her in the tomb. The el­dest son, the math teacher, was stuck in Jor­dan. They shov­eled the earth upon her.

Af­ter­ward, Ja­mal told us that his 13-year-old daugh­ter, Si­war, was hys­ter­i­cal the night be­fore, pound­ing him on the chest with her fists, ask­ing, “How can Mother die with­out see­ing me first?”

Ja­mal said his daugh­ter told him, “You took her away alive and brought her home dead.”

Ali the son said: “I never gave up. I tried to get per­mits to be with her.” Seven times, he was re­fused, he said. Only once, for her first surgery, was he given per­mis­sion. It was his first and only trip to Jerusalem in his life.

The son spoke qui­etly. Mourn­ers were gath­er­ing for cof­fee, to share a meal, to of­fer con­do­lences.

“The only thing be­tween me and my mother was five miles and the check­point,” he said. “I was so close and so far.”

PHO­TOS BY LINDA DAVID­SON/THE WASH­ING­TON POST

Ja­mal Abu Salah weeps as wife Maweya Abu Salah lies in an East Jerusalem hos­pi­tal bed. The cou­ple’s chil­dren re­main in the West Bank.

Top, Mo­tasem Sayes, a doc­tor at Au­gusta Vic­to­ria Hos­pi­tal, tells Ja­mal Abu Salah that his wife has died. “This is not fair. Her kids should be here,” Salah said. Above, the body is moved from an Is­raeli am­bu­lance to a Pales­tinian one at the Qa­lan­dia check­point.

PHO­TOS BY LINDA DAVID­SON/THE WASH­ING­TON POST

Top, loved ones carry the body of Maweya Abu Salah to her fi­nal rest­ing place in Arraba, West Bank. Be­fore Salah’s death, “the only thing be­tween me and my mother was five miles and the check­point,” a son said. Above, friends and neigh­bors sit with Roa’a Abu Salah, 24, sec­ond from right, and Si­war Abu Salah, 13, as they mourn their mother in Arraba.

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