As the ceasefire between Israel and Hamas appeared to be holding, Insaf Ismail returned to her home in Gaza City, where she lives with her two daughters, to inspect the damage. The windows and doors had blasted inwards – collateral damage from a nearby bombing – leaving an apartment strewn with shards of glass, window frame debris, shredded curtains, and a balcony door flung across the dusty bedlinen.
Insaf is a 43-year-old woman living in Gaza, a Palestinian refugee from Aljourah, near Ashkelon in Israel. She is no stranger to suffering. Insaf was diagnosed with breast cancer in 2016. Her husband abandoned her – women with breast cancer can face serious stigma in Gaza – and Insaf filed for divorce. Through her chemotherapy treatment and as a single mother with no income or money for rent, Insaf raised two beautiful daughters, aged 12 and 19.
In Gaza, cancer is the second leading cause of death and breast cancer is the most common cancer. While most breast cancer is treatable when detected early, a large number of cases in Gaza are discovered at a late stage. Delayed diagnosis, poor underlying health and nutrition, and limited access to treatment services, mean that the chances of surviving breast cancer in Gaza are significantly worse than in countries with strong healthcare systems and healthy populations. There is no radiotherapy inside Gaza and there are often shortages or complete stock-outs of chemotherapy medicines – leaving women needing to seek critical care outside of Gaza in Israeli hospitals, or in neighbouring countries such as Jordan and Egypt.
But access outside is never assured. Many requests for permits to travel out of Gaza are denied by Israeli authorities, or women may be forced to wait months to have their applications accepted, missing crucial medical appointments. The World Health Organisation reports that in March 2021, before the recent hostilities in Gaza, only 66 per cent of Gaza patient permit applications were approved; and one third of patients had received no answer to their application by the date of their hospital appointment. Often, family members who apply to accompany their loved ones to appointments outside Gaza are refused permits to exit. There is no transparency around why permits may be rejected.
Insaf had personal experience of the realities of cancer sickness and treatment for Gazans before her own diagnosis: “My older sister already had breast cancer in 2008 and died after 11 months”, she said. “She went to Jordan for radiotherapy for metastases on her brain. There is no radiotherapy in Gaza. We were not with her. My mum was not with her. She passed from Jordan.” Insaf’s sister died without her family beside her – an incredibly painful and harsh experience now keenly felt by others around the world due to the COVID-19 pandemic – but one which Gazans have long known.
When Insaf was diagnosed with cancer herself six years ago, she knew what to expect: “I was thinking and imagining what I would face like my sister. Nobody could explain or express the pain that I felt in that moment.”
Thankfully, Insaf was diagnosed early and had no need for radiotherapy abroad. Still, she experienced first-hand a healthcare system under serious strain in Gaza: “I had chemotherapy for 4 months. There was only one physician for 200 cases per day. A lot of people coming the same day. It was so rushed. There were always shortages of medicines for chemotherapy. I witnessed many different chemotherapy medicines.”
There are few palliative care services in Gaza to support those diagnosed with cancer or other serious and terminal illnesses with pain and symptom management, and with emotional, social and spiritual support for patients and their families. Insaf’s chemotherapy treatment was successful at that time. She volunteered with a local organisation, the Aid and Hope Program for Cancer Patient Care, to help other women along their illness journeys. Established in 2009, the Aid and Hope Program aims to assist female cancer patients, particularly those with little or no income, through facilitating their treatment and travel applications, and providing important psychosocial and financial support not available through government health or social services. The program fills an important void in the absence of formal palliative care.
Before the recent eleven days of bombing, more than half of families in Gaza were living in poverty and unemployment rates stood at around 55 per cent. Half of all essential drugs needed to support sick patients were already permanently at zero-stock. Now the immediate bloodshed may have halted, but the impacts on the life of Gazans will endure for years, even decades. Gazans are more traumatised than ever, with thousands of homes lost, many loved ones gone, and a healthcare system further degraded. How many times must we hear the healthcare system is at breaking point, before we understand it is not ok for it to break further? How many times can you glue together a fractured ceramic mug without the cracks and leaks becoming harder and harder to repair?
In times of conflict or acute crisis, scant medical provisions are often diverted towards the urgent needs of those who are injured; and much needed psychological support for a population in acute-on-chronic torment and grief. Care for those with existing serious illnesses such as cancer may be suspended, and the supply of medicines dried up.
Sadly, during COVID-19, breast cancer returned to Insaf.
Last week, she courageously wrote: “I am Insaf. I am writing this during the toughest of times, while the Israeli’s missiles are being stricken intensively above us. I live in Gaza, the city of agonizing and unjust wars. You won’t ever be able to imagine the fear and terror that encompass my daughters, for whom at some point, losing me to cancer was their biggest fear. Yet, war came knocking us down to the ground, adding a bigger fear of losing each other at any second either because of the non-stop bombing or the lack of cancer treatment. A brief note of what each second feels like for us. No more words left.”
To wait for bombs or cancer to kill you – Insaf’s future is uncertain. Her new illness is more collateral damage of a population under occupation. The bombs have stopped, but the underlying root causes of ill health and the barriers to accessing timely and quality healthcare have not. Those with serious or terminal illnesses must never be forgotten, in wartime or in relative calm.
An assured ceasefire and the safe passage of urgent humanitarian assistance for healthcare, electricity, water and building supplies is paramount now. Beyond the barbarity of the bombing, Gazans need hope reignited for their future. Insaf wants the future of her daughters to look brighter.
If you are someone who understands the importance of good healthcare, and cancer care, and palliative care, Palestinians need you to listen and stand up for their right to health. If you are someone who protests for Black Lives Matter, or for the rights of Indigenous Australians, or against any other form of systemic racism and colonialism, Palestinians need you to listen and stand up for their justice and freedom.
It is not hard to understand, and it is not complicated. We all want safe homes, good health and happy lives for ourselves. We all want to know when it’s our time to go, we will have the best care surrounded by loved ones and our families will be looked after. Palestinian lives – and their health – matter too.
It’s fine to die
with a white pillow, not the pavement, under our cheek,
with our hands resting in those of our loved ones,
surrounded by desperate doctors and nurses,
with nothing left but a graceful farewell,
paying no attention to history,
leaving this world as it is,
hoping that, someday, someone else
will change it.
Excerpt from It’s Also Fine, the late Mourid Bargouti, translation by Radwa Ashour
From Midnight and Other Poems (2009)