Gaza – Al Hayat Al Jadida- Memories of the anguished night of 13 April still haunt 27-year-old Ziad Abu-Hudaf with nightmares that awaken him from his sleep.
The Emirates Hospital in Rafah, one of seven government hospitals in the Gaza Strip – whose maternity wards have a total of 114 incubators between them and serve a population with the highest fertility rate in the world – would not admit his wife. She was about to give birth to premature quadruplets. With only six functioning incubators, the hospital could not accommodate four new infants.
A feeling of anxiety seared through Ziad’s body as his wife screaming in agony. He grabbed his mobile phone and asked friends and relatives to help him save the lives of his children and find a clinic with vacant incubators.
After a four-hour race against time – inquiring at hospitals and clinics including the European, Nasser, Shuhada al-Aqsa medical centers – they were informed that the maternity hospital at the Shifa Health Center in Gaza City would admit his wife. Her condition worsened as they made the 40-kilometer drive.
Ziad barely had time to breathe a sigh of a relief, when his wife delivered the four boys, and doctors told him that the premature babies, conceived by in-vitro fertilization (IVF), did not have fully developed lungs.
Doctors did not tell Ziad that the condition of the quadruplets – Mohammad, Mahmoud, Anas and Abd al-Rahman – could be remedied through surfactant replacement therapy, which promotes lung growth and breathing in premature babies.
The therapy, considered a common neonatal emergency for premature babies, must be initiated within 24 hours of birth at most. But even if surfactant can be found in Gaza Strip hospitals, the amount needed to treat one infant costs the equivalent of around US$1,000 – an amount that cannot, realistically, be afforded by many, in a territory where 38.3 percent of residents live below the poverty line. This portion of the population lives on an income of less than US$12 a day per family of five.
With his hopes for the newborns’ survival fading, Ziad was informed of the death of one of his sons six hours after he was born. The other three died, in turn, over the course of 15 days. It had taken him and his wife three years to save the US$5,000 needed for IVF treatment; it was the second time they had attempted the procedure in hopes of having a child.
The ordeal that culminated in the Abu-Hudaf tragedy is an unnecessarily common occurrence, experienced by thousands of couples in the Gaza Strip, where the average family has seven children and the months of pregnancy are filled with anxiety.
Medical appliances, such as respirators and diagnostic scanners in particular, are often old and do not undergo regular maintenance; there is a general shortage of drugs and medical equipment necessary to assist in a healthy childbirth.
And with premature births, already present complications are compounded by a severe shortage of incubators; the current number needs to be tripled to meet the population’s needs. Moreover, the health ministry in the Gaza Strip no longer provides surfactant, as of 2005, because of the high cost. There are also few specialized doctors and nurses with the expertise to administer the therapy.
Dr. Medhat Muheisen, the Gaza Strip health ministry’s director-general of hospitals, acknowledges that more incubators are needed, but says the supply has improved and the number has been increased by 20 percent over the past year to reach the current figure of 114.
“We urgently need at least 50 more,” he says, “and we’re waiting for donations from donors to provide them. The Gaza health ministry’s budget does not allow for expenditure on new projects unless it comes from donors,” he explains.
Currently, a system capable of anticipating the number of premature infants is not in place because mothers-to-be often have unmonitored pregnancies. Thus, the necessary surfactant quantities cannot be procured in advance. World Health Organization (WHO) studies affirm that over 75 percent of pre-term infant deaths could be prevented with appropriate care and treatment.
The issue stems from the health ministry’s policies in the Gaza Strip. Unlike its counterpart in the West Bank, it opted out of regularly providing surfactant, but included it on its list of “complementary medicines.” Such medicines can only be obtained with the permission of a special committee, on the recommendation of an expert panel, if requested by doctors. Yet, such requests are rarely made, according to the findings of this one-year-long investigation.
So while it can be bought in the West Bank, pharmacies in the Gaza Strip tend to avoid the risk of stocking the costly medication.
Gaza parents whose babies are born prematurely must therefore turn to the International Committee of the Red Cross (ICRC) to either obtain the lung-restorative liquid from the West Bank, or transfer the mother to a clinic there, equipped with incubators. This, in turn, entails bureaucratic procedures which, because of the Israeli blockade of the Strip, can take anywhere between a few days and a month.
Doctors often do not even inform new parents that infants, born prematurely, need surfactant, unless they think that the family has the necessary connections, to influential persons, to obtain it. Those who are assumed to be “without connections,” are simply not told about the therapy; more than 20 such cases were documented during this investigation.
Unlike in the case of Abu-Hudaf, Ahmad al-Ghalban, 34, whose wife also had a multiple pregnancy following IVF treatment, managed to secure her transfer to al-Maqased Hospital in the West Bank. Four of the quintuplets she gave birth to survived after they were given the surfactant treatment necessary for their lungs to develop.
Obtaining a transfer to a hospital in the West Bank is a complicated process that begins with filing an application, which must then be approved by the ministry’s external transfers department, before an Israeli permit to transit to the West Bank is sought. This may entail a waiting period of several days or weeks, and could well be denied.
The head of the incubators’ section at Shifa maternity hospital, Dr. Hanan al-Wadiyeh, recalls how one well-connected father, who was told his premature newborn needed surfactant treatment, managed to have the necessary quantity delivered from Egypt via the tunnels that run below the border.
Dr. Hassan al-Loh, Shifa maternity hospital’s director, says that even when surfactant therapy is available in the Gaza Strip, it is prohibitively costly for the vast majority of people, retailing, in pharmacies, at near US$1,000 per dose, whereas the health ministry in the West Bank procures surfactant doses for one-half of that amount.
Dr Abul Karim Ayyoub, head of the incubators section at the Nasser Health Center maternity clinic, says that parents of premature infants are not told of the surfactant shortage so as to avoid conflict, and so that parents do not request a transfer for treatment outside the Gaza Strip. The prenatal intensive care ward at Shifa is the biggest in the territory with 38 incubators, but even it cannot cope with demand; premature infants are placed in another ward that is not equipped with intensive care services.
Obtaining official statistics on preterm-related infant mortality rates is difficult in the Gaza strip. The health ministry there only records the number of births.
According to the ministry’s annual report, there were 57,804 live births in the Gaza Strip.
WHO studies in 2012, on premature births, indicate that survival rates vary greatly by country. In low-income countries, like the Gaza Strip, around 50 percent of those born in the 32nd week of pregnancy (two months pre-term) die due to lack of adequate medical care. In high-income countries, the survival rate is close to 100 percent. The WHO estimates that there are some 15 million premature births (before the completion of 37 weeks of pregnancy) annually in 184 countries worldwide, and that around 1.1 million of infant deaths are pre-term related. It does not provide a breakdown of the proportion of deaths by country.
Based on the findings of visits to four of the seven maternity hospitals, it would appear that, in the Gaza Strip, the mortality rate for prematurely-born infants stands at around 25 percent.
At Shifa hospital, figures collated by Dr. Wadiyeh indicate that around one-half of the 1,367 cases admitted to the incubators section were premature infants, and around one-quarter of them died. Of the 457 pre-term infants admitted in the first seven months of 2012, 132 died.
At Nasser Medical Center in Khan Younes, in the south of the Gaza Strip, premature birth numbers were first recorded in 2011. Over 25 per cent of prematurely born babies admitted in June and July 2012 died.
At the European Clinic, Majed Hassanein informally recorded the admission of 49 pre-term infants in the first eight months of this year, 20 of whom died – a rate of over 40 percent.
Over the same period, figures show that 35 prematurely-born infants were admitted to al-Nasr Hospital after being transferred from nearby hospitals or private clinics. Four of those admitted died.
The health ministry in the Gaza Strip cannot explain why surfactant was dropped from the list of medications it provides for free. The ministry’s director-general of stores, Dr. Zaki Abu-Qamar, says it does not feature among the 500-plus drugs on the primary list in the Gaza Strip, but is on the “complementary” list of medicines that require special approval to obtain.
“We are not able to buy medicines independently of the health ministry in Ramallah’s tenders,” he explains. “We rely on the medicines passed on to us from Ramallah. There is a big shortage of the main drugs… especially the expensive ones.”
Abu-Qamar adds that the Gaza Strip health ministry requested ten surfactant doses from the ministry in Ramallah earlier this year and that he re-submitted the request every two months. The ministry claims it has been unable to accommodate the request because surfactant is out of stock. Such is the claim, even though five doses were donated by the ICRC.
The director-general says that there is a lack of coordination between the relevant ministry committees in the Gaza Strip and the West Bank on the provision of primary and complementary medicines. This is because of the political rift between the Hamas and Fatah movements that rule the respective territories. He says officials in Ramallah refuse to deal with their counterparts in Gaza, and the ICRC and WHO are forced to act as mediators.
But this claim is refuted by Dr. Rizq Othman, the Ramallah health ministry’s director of stores. He says that surfactant is available, but is not sent to Gaza because specialists do not request it.
Dr. Wadiyeh of Shifa hospital, contradicts this statement, insisting that she and her colleagues have formally listed surfactant as one of their requirements. The European Clinic has also been waiting for several months for the fulfillment of their request for six surfactant doses, to be supplied monthly.
Parents meanwhile continue to suffer as they await the trials of giving birth, fearing they could meet the same fate as the Abu-Hudaf children, or those of 45-year-old Salim Abu-Diyyeh. Abu-Diyyeh managed to secure a supply of surfactant through the ICRC from the West Bank to save his prematurely born quintuplets – but it arrived too late.
This investigation was conducted with the support of ARIJ – Arab Reporters for Investigative Journalism – under the supervision of Husam Izzedin, Saad Hatar and Imad al-Rawashdeh