By Raffi Berg

BBC News, Ashkelon, southern Israel

Dr Lobel says his hospital treats hundreds of Gazans every year Crying out in pain, Ahmed lies in a hospital bed in Barzilai Medical Centre, his blood-encrusted lower limbs heavily bandaged. Two weeks earlier, the 17-year-old became another victim of the violence between Israeli forces and Palestinian militants when he lost his left leg, he says, in an Israeli missile strike against militants in Bureij refugee camp in the Gaza Strip. At first, he was taken to Gaza's Shifa hospital, but with the territory's health system under severe strain after months of Israeli blockade and internal strife, his only hope for life-saving treatment lay in Israel itself. "We got our permit from the Israeli authorities within 24 hours," said Ahmed's father, Muhammad. "An ambulance took my son from Shifa to the Erez crossing, where he was transferred to an Israeli ambulance and brought to Barzilai. I used to work in Israel so I wasn't afraid, but for him it is his first time," he said. Since his arrival at the medical centre in Ashkelon, Ahmed has undergone three operations and he is awaiting a fourth. 'No distinction' While some 1,600 Gazan patients had permit requests denied by Israel in 2007, more than 7,000 were allowed in for medical treatment - a 50% increase on 2006 - according to the World Health Organization (WHO). MEDICAL PERMITS FROM GAZA 2006: 4932 granted; 538 denied 2007: 7176 granted; 1627 denied Source: WHO However, WHO says the proportion of permits denied also increased, from 10% in 2006 to 18.5% in 2007. Under the 1994 Israeli-Palestinian peace accords, the Palestinian Authority assumed responsibility for health services in the West Bank and Gaza. However, with tertiary care virtually non-existent in Gaza, Palestinians there are forced to seek such treatment in Israel or beyond. Barzilai is one of three hospitals in Israel to which most of the cases come, but its proximity to Gaza - just 12km (seven miles) - means it gets those which are most severe. "We treat hundreds of Gazans here each year," says Dr Ron Lobel, Barzilai's deputy director. He says there are some five to 15 Gazan patients there at any given time. "Most are extremely ill, a lot have bullet wounds, but we also treat Palestinians with cancer, kidney and liver diseases who can't get treatment in Gaza." He says doctors never ask patients how they got their injuries or if they belong to a militant group. "Even if they're terrorists they're treated like any other person being brought into the emergency room - we make no distinction between treating Israelis or Palestinians." Most treatment is funded by the Palestinian Authority's health department, although many cases are treated by Israel for free. Ironically, Barzilai's closeness to Gaza also means the hospital is within range of militants' rockets. "It's absurd," says Dr Lobel. "We're treating Gazans while coming under fire from their own back yards." In February, a rocket landed near the hospital's emergency room on the same day that a Palestinian woman from Beit Lahiya in Gaza gave birth there to premature twins. Tough process Although Ahmed's transfer went smoothly, it can be a different experience for many other cases. Applying for treatment in Israel from Gaza is a complicated process - a patient is first put in touch with the Palestinian Referral Abroad Department (RAD), which has to arrange an appointment with an Israeli hospital before issuing a referral abroad request; the patient must then contact the Palestinian health District Co-ordination Office (DCO), which in turn asks the Israeli health DCO for a permit to pass through Erez crossing. The Erez Crossing is the only way out for Palestinians seeking treatment From there the request is sent to the office of the Co-ordinator of Activities in the Territories (West Bank and Gaza), where Israel's domestic security service examines whether the patient poses a security risk. If the permit is granted, the patient goes to the Palestinian side of the Erez crossing, where a Palestinian Liaison Officer co-ordinates with an Israeli Liaison Officer to get the patient across. Even at this point, a patient might end up not crossing if delays there mean they have missed their allotted hospital appointment time, or if the Israeli side of the crossing closes for security reasons. If a patient fails to cross, he or she must start the referral process again from the beginning. According to the WHO, 32 Gazans died between October 2007 and March 2008 while waiting for travel permits. "WHO believes there is a right for everybody to get health care," said Mahmoud Dahar, the organisation's director in Gaza. "Israel has the most sophisticated security measures at the Erez crossing, so if people are going to carry out attacks, they will be stopped there. No requests should be turned down." 'Loophole exploited' But Israel says it has to balance Gaza's humanitarian needs with its own security. "The Israeli policy is to facilitate all the medical needs for Gaza," said Maj Peter Lerner, spokesman for the Co-ordinator of Activities in the Territories. The terrorists make life very difficult for genuine medical cases

Maj Peter Lerner Office of Co-ordinator of Activities in the Territories "The only reason a permit would be denied is for security concerns." He says militants have repeatedly tried to exploit Israel's humanitarian policy to carry out attacks in Israel. In June 2007, two Palestinian women who had received medical entry permits were arrested at the Erez crossing after it was discovered they planned to blow themselves up in an Israeli hospital, Israeli authorities said. In 2004, a female suicide bomber who claimed she had surgical plates in her legs blew herself up at the crossing after bypassing the metal detector, killing four Israelis. "This is why the crossing can't be the first point of verification, there has to be some sort of clearance process beforehand," said Maj Lerner. The crossing itself has been bombarded over 200 times by mortars, rockets and sniper fire since last June, automatically closing every time. "It's a dilemma we're dealing with - the terrorists make life very difficult for genuine medical cases, but at the end of the day the vast majority who need treatment in Israel are actually approved."



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