RESUMO
BACKGROUND: Gaza has been under land, sea, and aerial blockade for more than 13 years, during which time Israel has continued its permit regime to control access for Palestinian patients from Gaza to health facilities in the West Bank (including East Jerusalem), Israel, and Jordan. Specific groups, such as patients with cancer, have a high need for permits owing to a lack of services in Gaza. The approval rate for patient permits to exit Gaza dropped from 94% in 2012 to 54% in 2017. We aimed to assess the effect of access restrictions due to permit denials or delays on all-cause mortality for patients with cancer from Gaza who were referred for chemotherapy, radiotherapy, or both. METHODS: This study matched 17 072 permit applications for 3816 patients referred for chemotherapy, radiotherapy, or both, from Jan 1, 2008, to Dec 31, 2017, with referral data for the same period and mortality data from Jan 1, 2008, to Jun 30, 2018. We stratified survival analysis by period of first application (2008-14, 2015-17), in light of varying access to Egypt during these times. Primary analysis compared survival of patients according to their first referral decision (approved versus denied or delayed) using Kaplan-Meier methods and Cox regression. Consent for the study was granted by the Palestinian Ministry of Health, and ethical approval was granted by the Helsinki Committee of the Palestinian Ministry of Health. FINDINGS: Mortality was significantly higher among patients who were initially unsuccessful in permit applications from 2015 to 2017 (141 events over 493 person-years, corresponding to a rate of 286 per 100 person-years) than among patients who were initially successful in the same period (375 events over 1923 person-years, corresponding to a rate of 195 per 100 person-years) with a hazard ratio of 1·45 (95% CI 1·19-1·78, p=0.0009) after adjusting for age, sex, type of procedure, and type of cancer. There was no significant difference in mortality risk between the two groups in the 2008-14 period, with a hazard ratio of 0·84 (95% CI 0·69-1·01, p=0·071). INTERPRETATION: Barriers to patient access to health care through denied or delayed permit applications had a significant impact on mortality for patients with cancer who applied for chemotherapy, radiotherapy, or both, in the period 2015-17. Relative ease of access through Rafah from 2008 to 2014 may have mitigated the health effects of access restrictions. FUNDING: WHO received funding from the Swiss Agency for Development and Cooperation.
RESUMO
BACKGROUND: Gaza has been under land, sea, and aerial closure for 13 years, during which time Palestinian patients from Gaza have been required to obtain Israeli-issued permits to access health facilities in the West Bank (including east Jerusalem), as well as in Israel and Jordan. Specific groups, like cancer patients, have a high need for permits due to lack of services in Gaza. The approval rate for patient permits to exit Gaza dropped from 94% in 2012 to 54% in 2017. We aimed to assess the impact of access restrictions due to permit denials/delays on all-cause mortality for cancer patients from Gaza referred for chemotherapy and/or radiotherapy. METHODS: This study matched 17,072 permit applications for 3,816 cancer patients referred for chemotherapy and/or radiotherapy from 1 January 2008 to 31 December 2017 with referrals data for the same period and mortality data from 1 January 2008 to 30 June 2018. We carried out separate analyses by period of first application (2008-14; 2015-17), in light of varying access to Egypt during these times. Primary analysis compared survival of patients according to their first referral decision (approved versus denied/delayed) using Kaplan-Meier method and Cox regression. FINDINGS: Mortality in patients unsuccessful in permit applications from 2015-17 was significantly higher than mortality among successful patients, with a hazard ratio of 1·45 (95% CI: 1·19-1·78, p<0.001), after adjusting for age, sex, type of procedure, and type of cancer. There was no significant difference in mortality risk for the two groups in the 2008-2014 period. INTERPRETATION: Limitations to patient access due to unsuccessful applications for permits to exit the Gaza Strip had a significant impact on mortality for cancer patients applying for chemotherapy and/or radiotherapy in the period 2015-17. The substantially higher number of annual unsuccessful permit applications from 2015, combined with severely limited alternatives to access chemotherapy and radiotherapy during these years, may be important factors to explain the difference in the impact of permits delays/denials between the two study periods.
