The Data in this literature review wascollected by searching in electronic databases such as PubMed and Google Scholar. The keywords used in the searching process are Mental Health AND consequences AND limited access OR Access Limitations AND health care services OR health care AND barrier AND Gaza strip OR West Bank AND Palestine. The search processshows in Appendix A. full-text articles critically appraised were included while the duplicated papers were extracted.The papers in this review follow the IMRAD style (Introduction, method, results, and discussion section). More than 25 related materials founded including review studies, 3 WHO reports, and 2 Palestinian government statistical reports. the characteristics of the included article studies are presented in table Appendix B.
Inclusion and exclusion criteria
Studies were eligible for inclusion if they satisfied the following criteria: the articles discussed the access limitations to health care services either in West Bank or Gaza Strip and mental health consequences.
Violation of the right to access health care services for Palestinians from West Bank and Gaza
One necessary life element is having access to health care services, it's also a fundamental human right [9]. Inadequate access to health care can be determined to health [10]. No individual shall get denied to access healthcare services in his/her country, or to get arbitrarily denied when need to leave their country to get health care abroad, the right to have sufficient healthcare is one of the most respected and widely recognized human rights and dedicated in major international laws and conventions as a 'fundamental human being' the indispensable right to exercise most other human rights.' [11] The minimum basic obligations of the right to health, the right to access health facilities and services on a non-discriminatory basis, particularly for vulnerable or marginalized groups. [12]
Referrals and access to tertiary care have a dimension in human rights. In most countries, referral to tertiary care is a simple internal procedure primarily affected by the availability of service capabilities and insurance considerations. In the oPt, it has become a complex process due to the need to cross barriers or border crossings and restrictions on the movement of Palestinian patients and ambulances imposed by the Israeli government. Access to tertiary health care is limited by many obstacles. Data on the referral and authorization process are available from different sources. According to the measures adopted by the security cabinet of the Israeli government, the number of road closures, barriers ,and roadblocks increased, in addition to scrutiny and delay in the existing barriers increased. Military barriers were set up next to Augusta Victoria and Makassed and St. Joseph hospitals in East Jerusalem, which negatively affected its work, such as delaying the arrival of staff and patients. [13]
The Israeli military occupation of the West Bank and Gaza Strip and the annexation of East Jerusalem, oPt contrary to international law; limit the movement of Palestinians within and between these areas. Access to specialized health care by multidisciplinary communities is hampered by the Israeli authorities' access to permits and restrictions on travel routes, with increased cost and time resulting from the blockade of the Gaza Strip and the presence of Israeli settlements in oPt and the Separation Wall around Jerusalem all of these obstacles affect the patients right to access health care services. [10]
In 2018, the Human Rights Council reported that the situation of the Palestinians in the West Bank and the Gaza Strip posed a 'serious' threat to the peace process due to the Israeli occupation. [10] and in 2017, Right to health access indicators for the West Bank: 74,400 West Bank referrals to East Jerusalem and Israel, 18% of patient companion applications denied access, 90% of the 2,125 ambulances trips requiring entry to Jerusalem denied direct access, 40,220 referrals to East Jerusalem hospitals from the West Bank and Gaza, 174,444 people in Area C served by mobile health clinics, 12% patients denied health access to East Jerusalem and Israeli hospitals. And the Right to health indicators for Gaza:12,075 patients exited via Erez, 56% of patient companion applications denied or delayed access through Erez, 1,405 exited Rafah terminals (Israeli barrier) for health reasons, Rafah terminal open for the exit for 21 days over the year, 46% of patient applications denied or delayed health access out of Gaza via Erez[10]. Only one companion is entitled to a permit at that time for Gaza patients, which places a burden on escorts while patients are hospitalized for a long period. Other relatives may also want to visit patients, especially during long stays in the hospital and if the patient is about to die. This is particularly difficult for child grandparents and other elderly companions who have health needs themselves. As a result, people suffer in the organizing process to bring an ambulance to the barrier and preventing them from entering Jerusalem and checking process at the barriers that reflect mental health suffering. [8]
On the other hand, Palestinians in Gaza and the West Bank, including East Jerusalem, faced demolitions of homes [46]and schools, arbitrary arrest and detention, and restrictions on freedom of movement affecting all aspects of Palestinian life, from access to medical care that leads to a significant and negative impact on the psychological well-being of the population and mental health. Also these restrictions lower welfare levels, the economy, and impact on psychosocial aspects. [10]
Health care access condition in Palestine (oPt)
Ministry of Health referrals approval procedures can take a long time. It took days to months in some cases. According to report of a field assessment of health conditions in the occupied Palestinian territory in 2017Security requirements for the Israeli permit process: Patient files are checked individually and patients may be required to attend a special security interview as part of the licensing application process. West Bank patients must obtain valid magnetic biometric cards from Israeli military authorities in the West Bank before applying for a health access permit. Even patients with serious conditions, unless there is an emergency, must apply personally. Multiple permits to continue the course of medical treatment, For example, cancer patients who require accurate periods of chemotherapy or radiation therapy must apply for a new permit for each appointment at the hospital with a risk of being rejected or delayed each time, which can have serious health consequences. Patients must walk through barriers and carry their personal belongings, unless they are transported in an ambulance. This process can take a long and tiring time for elderly, seriously ill ,and disabled patients who use medical equipment and new mothers with infants.
Patient referrals process needs:
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Medical decision.
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Medical approval.
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Financial approval.
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The appointment date from the hospital indicated by patients according to the urgent situation.
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Applying for a license from the Israeli Authority.
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The process of authorization: Israeli coordination up to the date of the permit according to the patient's appointment.
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Gaza patients need to cross the Erez checkpoint to obtain health care in the West Bank.
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Receiving health care.
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Traveling backward.
Rearguing the last point,Gaza patients visiting the West Bank through the Erez checkpoint must also cross the Qalandia checkpoint (located between West Bank and East Jerusalem south Ramallah city), which increases the probability of delays and violence. [8]
Patients applying for permits from the Israeli authorities face additional financial burdens, including travel costs and accommodation costs for their comrades, as well as the emotional stress of a process lacking transparency, unpredictable and often long, as the process needs time waiting for months. On the other hand male patients aged 16 to 55 years and female patients aged 16 to 45 years face additional, long security clearance processes, while all patients and fellow patients called for security questioning as a prerequisite for allowing treatment. [8]
A survey conducted in 2007 and 2008,examined the impact of a lifetime and past 30-day experiences of political violence on the mental and physical health of adult Palestinian women from the West Bank, Professional translators in the West Bank translated the survey from English into Arabic, reported that their access to health care had suffered as a result of the political violence of the occupation forces, 27.5% reported being threatened by Israeli forces and Palestinian mental health affected.[14]
The health situation in the oPt remains affected by the Israeli occupation. The long-term blockade and serious restrictions imposed by the occupation, affect the physical and mental health of the population as well as the further development of quality health services, especially in the Gaza Strip by increased stress levels. This was exacerbated by the internal Palestinian political division and the financial crisis of the Palestinian Authority.[13]
A cohort study conducted by Vitullo A, et al 2012. used quantitative and qualitative approaches aiming to describe and analyses the experiences of Palestinians in the West Bank and Gaza Strip who applied for permits from the Israeli authorities during 2011, either to access health care or for travel to work in Palestinian hospitals in East Jerusalem, data for patient referrals were obtained from the Palestinian Ministry of Health; data for permit applications and responses were obtained from the Palestinian General Authority of Civil Affairs, West Bank and Gaza Strip, and hospitals in East Jerusalem. The results conclude that the Palestinians who have been transferred to Jerusalem or from the Gaza Strip to West Bank hospitals need permission to enter and access health care services.However, there are restrictions to grant Palestinians permission from the Israeli government that does not have any standards for it and the clearest denial is for security issues. Patients who are between the ages of 18 and 40 years old, had the highest rate of rejected or delayed military permits. Interviews conducted with families of patients in Gaza, whose permits were denied or delayed showed that six patients died while waiting for permits that affect the patient’s quality of life negatively and lower mental health. [15]
In a descriptive study of the quality of life assessment using a tool from WHOQoL-Bref, conducted by Mataria A, et al, 2008.the design of multi-stage cluster samples for 1,023 adult Palestinians, from the general population living in the conflict zone in the West Bank and Gaza Strip from the end of 2005 to 25 January 2006,concluded that Palestinians suffered from poor quality of neighborhoods due to restrictions on access to health care services due to barriers in the Separation Wall and closures, and in some cases lead to psychological and physical distress and death. [16]
Additionally, some of the patients need ambulances to access health care services according to their condition, the majority (90%) were ambulances transported from the back to the back (from ambulance to ambulance because the West Bank ambulance can’t cross the barriers) at barriers to East Jerusalem to avoid long delays and searches. Ambulances from the West Bank will meet registered ambulances in Jerusalem and transport patients who require transport to hospitals in East Jerusalem. Ambulances can experience time-consuming delays, by being detained by the Israeli military and civilian personnel at barriers, even when the referred hospital and the future hospital have received prior coordination from the Israeli Civil Administration restriction to transport the patient from barriers. To avoid delays in negotiating access to barriers in Jerusalem, the Palestinian Red Crescent Society, the main provider of emergency services to Jerusalem, is using 'successive' procedures to transfer 93% of patients from the West Bank to East Jerusalem. This means that an ambulance license painted in the West Bank will transport a patient by stretcher to a Jerusalem-plated ambulance waiting for an abyss at the barriers.An operation that takes place in the open, delaying the transfer of the gasping patient for at least 10 minutes and often longer due to security checks by barriers staff inspection. In some cases people need to get out while they are sick to cross the barrier and then another ambulance on the other side is there waiting for them. [8]
Besides ambulance delays due to Israeli barriers and road closures, the most vulnerable groups in Palestine include women during pregnancy and childbirth; children and infants; the elderly ,and the chronically ill patients or disabled. Knowing that access to health services can be difficult and risky is also an additional psychological stress that can directly affect health. [17][18]
Health care access limitations regarding women and children
The Palestinian population living in the occupied territories is subjected to ongoing violence as a result of this ongoing crisis. Palestinians, particularly women and children, are suffering from severe psychological distress. Although these patients need immediate and urgent care, usually mental health and social support, access to health care remains difficult because of the settlement policy and the creation of pockets [19]. An example of the unique characteristics of this health conflict is the monitoring of birth rates at Israeli army barriers for those who are unsuccessfully trying to reach a health facility to provide Birth. The well-being of people living in this conflict zone is largely affected due to difficulties in access to health-care services, mortality and morbidity increased too [20].Another study conducted in 2007 for 2,158 women living in the West Bank and Gaza Strip by Regression analysis demonstrated the association between dissatisfaction with the place of birth and the selected determinants. Concluded quality of life, well-being, mortality, and morbidity were adversely increased by limited access to health-care services resulting from continued closures and blockades. [21]
Moreover, in a study analyzing data collected from four surveys conducted by the Palestinian Central Bureau of Statistics covering fifteen years (2000–2014) for children (no. 16793) and women (no. 8477) in five areas of the OPt, the conclusion that the location is important with the results shown The negative impact of the severity of the conflict on access to care, particularly in the southern West Bank for maternal health services and the central West Bank vaccination. The government's policy of reducing the number of people who have been displaced by the conflict has been reduced. Besides, psychological barriers to access to services are increasing because safety concerns can prevent people from trying to access services that increase the psychological stress of patients and adversely affect their quality of life, and had fear concerns and unstable life conditions. [22]
Moreover, restrictions lead to stress and psychological effects have shown from the story of HallaShoaibi of the University of Michigan in Ann Arbor in the United States, estimates that in the period studied (2000–2007), 10% of pregnant Palestinian women were delayed at barriers while traveling to the hospital to give birth. One result has been increased dramatically in the number of home births, with women preferring to avoid road trips while in labor due to fear of not being able to reach the hospital in time. Their fears are well-founded. Shoaibi said 69 babies were born at barriers during those 7 years. 35 babies and 5 of the mothers died an outcome which she considered to amount to a crime against humanity. [23]Barriers continue to have economic, medical and psycho-social effects on Palestinian pregnant women [24]. By year review about worst abuse against Palestinian children in 2017 twelve Palestinian children died from Gaza due to insufficient access to health care, eight of whom were less than two weeks away due to these pediatric cases prevented from leaving Gaza for medical treatment by rejecting or delaying patients ’requests and their families suffered. [25]
A Regression analysis established the association between dissatisfaction with the place of birth and selected determinants of 2158 women residing in the West Bank and Gaza Strip. The study reported dissatisfaction with their childbirth location referred to the following reasons: 37.5% of respondents stated that the availability of health insurance and the low cost of services were among the main reasons; 19.3% stated that they were unable to reach the preferred place of birth due to sudden birth; 13.7% stated that reaching the Israeli army impeded access (closures, blockades, and barriers that prevent the movement of people and goods). 14.1% reported that there was no other place available for them to give birth. And 11.7% other reasons, Palestinian women are concerned about frustration at the lack of certainty of their ability to access the maternity care center. This means living with constant anxiety during their pregnancy where they will go when labor begins, and how they will return to their families. Lead to inducing a severely stressful atmosphere. [26]
According to a report of a field assessment of health conditions in the oPt, data collected in November 2015, indicates that some accessibility to some special health services is two to four times more likely to be rejected: orthopedics, neurosurgery, general surgery, and psychiatry, among others. East Jerusalem hospitals remain the main referral hospitals for Palestinians. The system of permits and barriers adversely affects patients in need of care in the six East Jerusalem hospitals or in Israeli hospitals that provide specialized health services that are not available elsewhere in the oPt. The government's efforts to address the problem of child labor are also being addressed. 11% of women in the West Bank have unmet family planning needs. Barriers to access to health-care facilities are a serious, permanent and well-documented problem including mental health problems. [27]
Finally In a literature review study in 2017 for Palestinian children, explored that 5 million Palestinian refugees currently live in Palestine, Jordan, Syria, and Lebanon, about 40% of whom are children. Palestinian child mortality rates are similar to neighboring Arab states. They are largely affected by the occupation, which has increased violence against children, mental health problems ,and malnutrition, particularly in Gaza, which is suffering from a health crisis. Children's access to health care in Palestine is restricted as a result of the requirement to obtain an allowance paper to travel to Jerusalem, where there are specialized hospitals for example; Augusta Victoria Hospital in East Jerusalem provides the only treatment for pediatric patients, including hematology, oncology, radiation and kidney diseases. Because of permit restrictions and limited access to males, most children receive care with a grandmother or aunt (sometimes the parent's age is less than 50), which increases the psychological burden of children and violates their parents' rights to care supported by their parents, additionally; they feel insecure, had nightmares and aggressive behaviors lead to mental health problems. [6]
Health Care Access limitations for the Political Palestinian Prisoners in Israeli prisons
A Report of a field assessment of health conditions in the oPt in 2015 shows the population of the oPt suffers from threats to their mental health including prisoners. The main issues of concern regarding the physical safety of the detainees and the 6,066 Palestinian security prisoners held in Israeli prisons are lack the access to adequate medical care promptly, whether by diagnosis or treatment and lack of adequate medical care besides inadequate nutrition, housing conditions and denial of family visits and contacts. Physical and psychological abuse lead to severe mental health problems and great pain. The use of arbitrary punishments and administrative detention without trial are important problems for many prisoners. The evaluation team was unable to access Israeli prisons and Palestinian prisoners there and was unable to independently verify the reported conditions[13]. Moreover, the prisoner experiences mental health problems as a result of care negligence as an acute hysterical reaction in case of interrogation methods employed by Israeli interrogators, and acute depression and severe introversion related to the prisoners being disconnected from their families, and suicide as a result of severe psychological stress, and anxiety ,insomnia occurred too.
Health care access difficulties for Palestinians living in West Bank
Most of the Palestinians from the West Bank can no longer access specialized health care services in East Jerusalem, and in some cases in certain military conditions, can’t access hospital in other cities in West Bank due to movement restrictions that reflect thelack of freedom, as a result, affect their quality of life. [18]The over-60 age group accounted for 23.3% of referrals in 2015, although they accounted for only 4.5% of the population, reflecting the burden of non-communicable diseases. For Palestinians from the West Bank — except for East Jerusalem — and the Gaza Strip, medical referral centers in East Jerusalem can only be accessed after a permit from the Israeli authorities, a complex process that can lead to delays and denial of adequate care. In 2015, more than half of the referrals were from the Ministry of Health to destinations requiring access permits. [15]
In 1998–2007, Analysis of the Geographic Information System (GIS) for Childhood Cancer, recorded and access to health care in the West Bank, Palestine shows low- and middle-income countries, it is difficult to record high-quality diseases in the development of inadequate health care infrastructure and instability whether politically or economically. This article explored the potential of GIS to add value to understanding childhood cancer patterns in the West Bank, despite a variety of obstacles to disease registration. The result shows that the cancer patient faced many difficulties in receiving cancer care that transports them from hospital to hospital because of the lack of all services established in all areas such as bone marrow transplantation and radiation therapy only at Augusta Victoria Hospital in East Jerusalem besides they need to get a premession to cross the Israeli checkpoint and if they have security issues they are not allowed to enter East Jerusalem. The large proportion of cases with death certificates compared to other records is another indicator of the number of cases that do not reach or exceed major treatment centers in the West Bank. [28]
A review studyfor 43 articles in Palestine in the West Bank in 2016, aimed to examine the mental health needs of Palestinians and the availability of services, concludes that unstable conditions for Palestinians affected their mental health due to lack of access to basic needs, such as health care services due to geographical difficulties, 'Separation Wall', lack of freedom and restrictions on movement and political conflict between Palestinians and 'Israeli' Jews. There is a need for mental health care and resilience improvement for Palestinians. [29]
A qualitative study conducted in partnership with the Palestinian Medical Relief Society (PMRS), a Palestinian health care non-governmental organization in the West Bank in 2011, Data collection included participant observation, analysis of secondary data, and semi-structured interviews with key informants,concluded that Palestinians face difficulties in accessing health care services, either by preventing or delaying them due to restrictions on the movement of patients and health-care workers, who need permission from the Israeli authorities to cross barriers through the Separation Wall.Some of the patients’ companions are not allowed to cross barriers due to Israeli security issues or the absence of a clear reason for delay, depriving them of basic health care needs. On the other hand, this difficulty limits access to medicines and medical equipment. Delays caused by the checkpoint led to the death of Palestinian patients, with ambulance drivers reporting that they faced violence and were denied access to patients in some emergencies, particularly injuries caused by the Palestinian-Israeli conflict, in which civilians were physically and verbally abused by soldiers.Health care providers in ambulance risk for injury and death. As a result, the Palestinians have become unsafe and increase the level of stress of 'moral suffering' and there is an impact on the work of health-care providers who need access to health-care places through barriers or road closures on a daily basis [5]. For example, nurses in Palestine face many difficulties toaccess their workplace due to barriers [30].Doctors, community health workers, and nurses reported that the persistent psychological pressures of the occupation accelerated the deteriorating effects of many chronic diseases. One of the doctors said, "At barriers, they try to humiliate you because you are a doctor". The medical staff faced delays, harassment, torture and abuse. This occurred primarily at checkpoints but also elsewhere [6].Access to mobile health clinics in 2017, seven mobile health clinics run by three health providers were denied access to communities in Area C of the West Bank due to health attacks. [9]
Health care access difficulties for Palestinians living in Gaza Strip
According to report of a field assessment of health conditions in the occupied Palestinian territory in 2017, the Palestinian Coordination Office in Gaza obtained data on Israeli responses to requests for patient permits to travel outside Gaza to obtain health-care services through the Erezbarrier. The Palestinian General Authority for Civil Affairs obtained data on Israeli responses to all applications for health service permits and were classified by provincial coordination offices. The Gaza Strip has been under land, sea and air blockade for more than 15 years, with significant consequences for the health sector and access to health services. The majority of referrals in Gaza (77%) require access through the Israeli-controlled Erez crossing to access hospitals in East Jerusalem and other parts of the West Bank and Israel. All these patients must apply to the Israeli security services for permits to leave Gaza to obtain primary health care. In 2017, the patient's permit approval rate reached its lowest level since 2006, with 54% of patient requestions accepted - that is, nearly half of patients' requests were rejected or received no final response by the time of the hospital time. Access to emergency and emergencies can be handled on the same day, although processing time for these applications can take longer. For patient applications that have been reported as 'non-urgent', processing time is much longer. The Israeli authorities had previously required Palestinian patients to apply for permits priot 10 working days at least [8]. 6% of referrals by the Ministry of Health in Gaza were to health care facilities in Egypt, requiring exit through Rafah. Access outside Gaza via Rafah remained limited in 2017, limited to humanitarian cases, including patients seeking health care in Egypt. [9]
In a cohort study done by Vitullo A, et al in 2012, Of the 168 278 applications for health services permits provided to the Israeli authorities, 16.4% (12.8% for patients and 19.5% for companions) were rejected or received no response. For patients in the Gaza Strip, requests for exit through the Erez checkpoint for a referral to medical care increased by 17% over one year to more than 22,000, while the proportion of applications rejected nearly doubled (from 2.89–5.72%). The number of referrals from the Gaza Strip to Egypt continued to decline in 2015 due to the closure of the Rafah border. The reconstruction of health facilities, particularly in the Gaza Strip, has been hampered by a lack of funds in addition to restrictions on the import of building materials and medical equipment. October 2015, escalating violence in the OPt has led to new roadblocks and barriers, restricting the movement of ambulances with consequent delays in access to health care. [15]
Increased bureaucratic delays in processing patient permit applications in 2017, and 596 patients and 91 sick companions were called in for security questioning as a precondition for access to health services outside the Gaza Strip [3]. On the other hand, there is failure in the health care system in the Gaza strip due to low infrastructure and workload especially in case of fire injury during demonstration events with Israeli Jewish at the Gaza Borderlines with Israel all of that lead to mental health deterioration. [31]
Restrictions on access to basic health services are one of the main obstacles to the right to health for Palestinians living in the West Bank and Gaza Strip. Restrictions affect cancer patients at a weak point in their lives when they need specialized care and services for diagnosis and treatment. Regarding cancer patients from Gaza, most of them referred to West Bank and East Jerusalem due to chronic shortages of medicines and lack of medical equipment in the Gaza Strip, after they diagnosed with cancer need to wait several months to receive treatment which the process of getting access permission from Israeli authorities to cross the barriers severely stressful. [32]
The following are examples showing patient's experiences for Oncology patients from the Gaza Strip with limitations to health care access, which reflect their suffering and that affect mortality and morbidity:
Samira, 64, was diagnosed with uterine cancer in 2016. She underwent surgery but then needed follow-up treatment not available in Gaza. Doctors referred Samira to radiotherapy in East Jerusalem. It takes her more than 6 months and 5 requests for permits to finally exit Gaza in June 2018. "All this time, I was suffering from abnormal bleeding. It was a matter of life and death. Why was the permit rejected?" She says.
Khadija, 32, mother of four, noticed something unusual with her breasts in December 2017. Doctors soon confirmed that she had breast cancer. In January 2018, Khadija applied for a permit to go to the Augusta Victoria Hospital in East Jerusalem a plastic surgeon - to see if cancer had spread and if so, to what extent. Her permission was rejected. She started receiving chemotherapy in Gaza, but there was a cosmetic need for optimal treatment surgery. In July, Khadija applied for a permit and was again rejected. She decided to change her medical destination to Egypt. Khadija's second attempt to leave Gaza into Egypt was finally successful. She underwent surgery in August 2018, 7 months after the diagnosis. These obstacles put her life at risk of death and increased her suffering [32]
Mohammed Abu Harbid, 54, was arrested in Erez on July 10 while returning to Gaza with the body of his brother Suleiman Abu Harbid, 58, who died in Tel Aviv's Akhlilov hospital from stomach cancer. His body was returned to his family in Beit Hanoun, Gaza, while Mohammed was detained for three hours in Erez, and his brother's funeral was lost. The brothers had traveled together to the hospital on June 16, 2013. [8]
The following are Examples of Gaza patients and patient-companions detained at Erez in 2013: Patients and their companions face the risk of being detained while traveling through the Erez checkpoint, or after a security interview. The Palestinian Human Rights Organization reported that 5 patients and 5 patient companions were detained in 2013; 3 patients and 4 companions were still in detention in 2014. In the following paragraphs, WHO reports on two patients and 3 of his fellow detainees.
Detained husband: A 35-year-old woman from Gaza applied for a permit to cross Erez, after which she was called to attend an Israeli security meeting. When she arrived in Erez with her husband, the Israeli authorities asked her husband to attend a security interview instead. He was arrested, detained and got released in 2014 after 6.5 months in prison and after a court appeal. The patient sought local treatment for her eye aches while awaiting her husband's release and was able to leave Gaza for surgery. At the time of the interview, the family was unsure whether they would risk a new application for access to the Erez crossing. Son of the detained patient: The son of a 48-year-old disabled patient from Gaza was granted permission to accompany his mother to a Jerusalem hospital for bone surgery, but was arrested at the Erezbarrier. The mother's medical treatment was postponed for 3 months. The son is still awaiting trial in Askelon prison.
Another example of a Patient detained for 12 days in Erez: Israeli security forces at Erez crossing detained a 24-year-old patient from Rafah suffering from hearing loss in both ears after he came for a security interview to obtain permission to travel to a hospital in East Jerusalem. He was interrogated for 12 days and then released. He had previously been referred for surgery in Egypt but was unable to travel there in August 2013 after the closure of Rafah. He remains untreated and at risk of total hearing loss.
Finally, a patient arrested at Erezbarrier: A 33-year-old patient with chronic hepatitis, from Beit Hanoun, was referred for treatment at a West Bank hospital due to an ophthalmology condition. Israeli security forces detained him at the Erez crossing on his way to a hospital in Ramallah. According to his lawyer, he is awaiting trial and is in stable condition, but was not examined by an ophthalmologist and was only a general practitioner in the first days of his interrogation. [33]
In summary, the mental health and well-being of Palestinians is affected in particular, patients, who need to access health care services through Israeli barriers[16]. Mental health is negatively affected by the consequences of the difficulties to access health care services. which increases the psychological burden especially among children [2], increase psychological stress [22], emotional stress [6][9], affect palliative care especially for cancer patients [2][6][11][5], patients feel inequality [6], insecure and lack of dignity [12], mortality and morbidity increased [16][21], difficulties face women in childbirth impact women’s psychological status [21][22][26][27], also some of the patients die before accessing health care [17][20][6][11][3].While patients from Gaza face more restrictions than patients from West Bank, affecting more negatively the Quality of life for Gaza patients.[6]