Before the war in Gaza broke out Yenan Musallam was running a successful carpentry business in Bethlehem thanks to the life-saving kidney dialysis he received three times a week.
But after Israel put the West Bank into lockdown in the wake of the Hamas attack on October 7, access to the treatment and medicines he has needed since his kidneys began to fail when he was a teenager quickly became much more difficult.
The 24-year-old’s time allocation for dialysis has been cut by 25 per cent and the machine he is assigned to now only has filters suitable for children rather than adults, making it far less efficient at cleaning his blood. Bicarbonate supplement – which slows the onset of renal failure – is also having to be rationed.
“Drug shortages are now worse than before the war. Before the war maybe one item was not available and now it is three. The dialysis is three hours instead of four,” he said.
As a result, Mr Musallam is forced to spend much of his time at home conserving his energy as he desperately searches for a kidney donor with his A+ blood type.
“The doctors in the hospital asked us to search for a kidney because I am young. If I stay like this with dialysis, when I get older my situation will be worse. So I need a transplant as soon as possible.”
Yet just 20 minutes drive away – past the vast concrete barriers, military checkpoints and barbed wire fences that separate the occupied Palestinian territories from Israel, there are no such shortages.
The young carpenter is among thousands of Palestinians being subjected to what has been described by aid groups as a form of health apartheid. While the destruction of Gaza’s health facilities is well known, the West Bank has suffered a more insidious deprivation of basic healthcare.
The victims include cancer patients who are unable to access essential drugs and people with chronic conditions being prevented from travelling freely to their appointments. In one confirmed case, a mother has been separated from her newborn children.
The issue, say critics, is systemic. By withholding tax revenues and preventing the free movement of people within the West Bank via a system of permits and checkpoints, the Palestinian health system – essential for maintaining a stable society – is being gradually undermined by Israel.
The small workshop in the yard behind Mr Musallam’s family home, where he used to carve delicate mementos for pilgrims visiting the town of Jesus’ birth, now lies unused and empty bar a few unfinished keepsakes in a plastic bag.
Even if he could work, there would be hardly anyone for him to sell his wares to, as the Israeli security blockade has cut off the flow of tourists to Bethlehem and violence has surged.
Since October 7, more than 500 Palestinians have been killed by Israeli fire in the West Bank, according to the Palestinian Health Minister and also the UN’s Office for the Coordination of Humanitarian Affairs (OCHA) – more than three times the number of killed throughout the whole of 2022.
Most died during Israeli military raids and violent protests. But the death toll also includes bystanders and Palestinians killed in attacks by Jewish settlers that have prompted several countries, including Britain, to introduce sanctions. Thousands of others have been injured, adding to the burden on the healthcare system.
Hidden casualties of war
The impact of the war has been devastating for the healthcare system and the chronically ill, according to doctors in Ramallah, Bethlehem, Nablus and Hebron.
Cancer patient Ahmed Nemer Assi represents one of many unseen victims.
His forehead creased into deep ridges as his composure dissolved and he broke down on a bed at the Palestinian Medical Complex (PMC) in Ramallah.
“I have pancreatic cancer. In December, they opened me up from side to side but after the surgery I have not been getting any better,” the 70-year-old told The Telegraph.
He blamed his poor state in part on a lack of medicine. Capecitabine, a tablet that slows or stops the growth of cancer cells – and one of three main drugs on his treatment regime – is currently unavailable in the ailing Palestinian health system.
Private sourcing of the pill is beyond the financial reach of the retired truck driver. He has been placed on an Israel travel blacklist that denies him access to better hospitals in East Jerusalem, and he still does not know why.
In a cruel twist of fate adding to his distress, his wife was diagnosed with ovarian cancer last year and has been sent to the troubled Palestinian city of Nablus where doctors are now battling to save her.
A few metres along the corridor, the prognosis for Mary Hussary, 65, is better.
But she described the trauma of having to undergo a risky surgery to remove an ovarian tumour entirely on her own after her mother and brother were denied a permit to join her at a private hospital in Palestinian East Jerusalem on Christmas Day.
“I did two operations without anybody from my family,” she said. “You leave the operation room and wake up in intensive care and there is nobody … it was too hard from me. I vomited after the anaesthesia, and nobody was with me.”
Just six days after two major surgeries, she had to pass through a fortified checkpoint to get home. She was dropped off on one side by a family friend and picked up at the opposite end by her nephew.
Ms Hussary is now cancer free, although in the months after the operation, the PMC once ran out of chemotherapy drugs, briefly threatening her progress.
Dr Mohamed Mansra, the PMC’s head of oncology, said he had lost three patients in the last week due to a lack of medication, including one who was just 25.
“We have a lot of shortages of medication, which includes immune therapy like Pembrolizmab, or Keytruda, and for breast cancer there is one tablet medication called Ribociclib (Kisqali), which is not available now for more than one month,” he said. “I have 37 patients on Kisqali.”
It’s a desperate scenario that is being replicated across the West Bank for a number of chronic diseases, including kidney failure.
The disintegration of the West Bank’s medical system has been frustrating for doctors who have seen their patients’ health decline as complications spike.
Dr Ibrahim Al-Heeh, at the Hilhul clinic on the outskirts of Hebron, said he had recently been overwhelmed by 85-90 chronically ill patients a day.
The clinic’s working hours had been reduced from five days to two as doctors now receiving only half their usual monthly wage of about $1,500 struggled to both feed their families and pay for transport.
He then began reeling off the list of short supplies.
“We are missing antibiotics, analgesics, [medicines for] diabetes, hypertension, cancer, neurological disease, and life-saving medication like anticoagulants and statins,” he said.
One urgent need was tacrolimus, or prograf, which is used to stop organ rejection in people who have had kidney transplants.
It was only available from the ministry of health, where stocks had reached precarious lows – forcing the sick to try to bring supplies from Turkey, Israel or Jordan.
The scarcity of a drug that could mean life or death for Maryam Tarauar, 52, has made her recovery from a kidney transplant three years ago even more stressful.
Her doctor recently upped her dosage of prograf to four pills a day but her monthly allocation from the ministry has dipped as low as ten to 20.
Ms Tarauar’s husband Ibrahim is doing everything he can to find the drugs from business contacts in Turkey. Each $150 box of 100 pills is draining the family’s savings but they still donate their precious supplies to other transplant recipients in need.
“I have friends in the same situation. We share and help each other,” said Ms Tarauar at her home in the village of Bani Na’im. “Other patients call me a lot to see if I have extra pills.”
Under a longstanding arrangement, Israel collects tax on goods that pass through Israel into the West Bank on behalf of the Palestinian Authority – which administers some of the territory under Israeli military rule – and it normally transfers this revenue to Ramallah.
However, since the Hamas-led terrorist attack, Bezalel Smotrich, the hardline Israeli finance minister, has withheld hundreds of millions in funding and threatened to allow a waiver shielding Israeli banks that deal with Palestinian ones to expire.
The move has paralysed the PA, forcing it to slash the salaries of civil servants including government health workers, meaning clinics have reduced their working days. It has little left in the coffers to purchase life-saving medicines.
Last week Israeli officials said the government had made a 450-million-shekel ($116m) payment for duties collected for April and May, and that a further payment of about 530m shekels ($144m) for June had been approved.
But Mohammad Mustafa, the PA’s prime minister, has said Israel still owes 6 billion shekels ($1.6bn) in back payments – a vast sum.
A separate ban on tens of thousands of Palestinians from working in Israel for the last nine months has deepened the economic hardship and ability of many families to even attempt to pay privately for healthcare or source their own medicine.
Thousands of Israeli-issued travel permits for seriously ill patients and their family members to pass through armed checkpoints to visit better-equipped hospitals in East Jerusalem have also been put on hold or denied.
Israel’s strategy to exert tighter control over the West Bank since October 7, has added to long-running international criticisms about its harsh treatment of Palestinians since it captured the West Bank, East Jerusalem and Gaza in the 1967 Six-Day War.
Rights groups including Amnesty International and countries like South Africa have accused Israel of an occupation that subjects Palestinians to “apartheid” conditions under a regime that systematically exploits their resources and arbitrarily restricts their basic rights and freedoms.
“Israel has maintained effective control over Palestinians’ right to health for more than half a century through occupation, annexation and blockade,” said Aseel Baidoun, Advocacy and Campaigns Senior Manager for Medical Aid for Palestinians (MAP).
Israel rejects such claims and justifies its policies in the West Bank as necessary to defend its own citizens. It considers the territory to be disputed and says its future should be decided in negotiations.
The Telegraph approached COGAT, the agency responsible for implementing the government's civilian policy in the West Bank and Gaza, and the Israeli embassy in London for comment.
The human cost of such measures has been enormous.
In his top floor office in the Augusta Victoria hospital on the Mount of Olives in East Jerusalem, CEO Dr Fadi Atrash looked in despair at the medical records on his desk.
“This woman,” he said, pointing to the first file, “she should be receiving a biological treatment for her breast cancer that would give her a more than 70 per cent chance of being cured. But we are unable to afford it because of the financial situation.”
He added: “I can buy treatment for one patient, but I have referrals for five. How do I choose? It’s not easy because breast cancer is touching more and more younger women.”
As the second largest hospital in East Jerusalem, Augusta Victoria usually provides specialty care for Palestinians from across the West Bank and Gaza Strip with a dedicated cancer centre and dialysis unit.
But since the start of the war, there have been no arrivals from Gaza and, in the first three months, only about 30 per cent of West Bank patients were able to reach the hospital due to travel permit issues, said Dr Atrash.
“The impact on health is obvious [...] We have seen more and more people in advanced stages [of disease] because from October to December they couldn’t seek medical advice,” he said. “People have suffered, and some died earlier than anticipated of the disease because of the lack of treatment.”
He estimated that while more than 85 per cent of permits were now being granted for his own hospital, patients were being deterred by long and harrowing journeys through checkpoints and unstable areas where they feared attacks from Israeli settlers. Some could not afford the journey.
Many permits were also still being denied for family members trying to accompany the sick, said Dr Atrash.
According to the World Health Organisation, between October 2023 and May 2024, 44 per cent of 28,292 patient applications to seek care outside of the West Bank were denied or remained pending, with 48 per cent of companion permit applications in a similar position.
A comparison with the same 2022-23 period showed a 56 per cent decrease this year in patient permit applications and 22 per cent decrease in approvals.
Restrictions on anyone travelling from Gaza to East Jerusalem hospitals has even meant that Palestinian babies born just before the war have been separated from their mothers who were granted humanitarian entry permits to give birth there due to their high-risk pregnancies.
The mothers returned to Gaza to reapply for permission to collect their children when they were healthy enough. But they became stranded by the blockade of the enclave after the October 7 attacks.
In Makassed hospital, five such babies, including triplets whose mother had undergone six years of IVF treatment to conceive, are still under the care of staff and volunteers who make as many video calls to their families as Gaza’s patchy internet access allows.
The triplets’ mother, currently in Rafah, “said she was afraid to die while the babies are here,” said a doctor who did not want to be identified. “It’s heartbreaking.”
A global cry for help
The Gaza war will have a long-term effect on the West Bank’s health system, warned Dr Ahmed Bitawi, the PMC’s chief operating officer.
The medical complex is known for performing specialised surgeries but daily surgical hours have been cut from 24 to eight, only dealing with emergencies, he said. As a result, it has also had to put its role as a teaching hospital for trainee doctors on hold.
MAP’s Aseel Baidoun added that attacks on healthcare, including against frontline workers, health facilities and the obstruction of ambulances, had skyrocketed since October.
By the end of May, the WHO said it had documented 480 attacks on health care facilities and ambulances in that eight-month period.
“The dangerous escalation in violence, combined with roadblocks, Israeli military check points and permit restrictions is stopping patients from seeking critical care, and staff from accessing hospitals,” said Ms Baidoun.
MAP, which provides emergency medical supplies, has called on the international community, including the British government, to take action to halt violence against Palestinians and attacks on healthcare.
Dr Mohamad Skafi from the Palestinian Medical Relief Society (PMRS) also appealed for increased foreign support for ten mobile clinics trying to meet the shortfalls in health ministry services.
“During the war, we have seen a 20 per cent increase in the number of beneficiaries at each clinic,” which had strained resources, and especially chronic disease medication, he said.
“The nurses and village health workers distributing it apologise to the patients but they get angry quickly and some cry saying ‘why you are coming here if you don’t have the medication’,” he said.
When the Telegraph visited on a Tuesday morning, dozens of villagers waited patiently in a mosque in Beit Jala for the weekly mobile clinic to arrive from Bethlehem shortly after 9am.
A seven-year-old boy lay limp across his mother’s lap, diabetic grandparents lined up for blood sugar tests, others for hypertension medication. A cerebral palsy patient, hoping for pills to treat painful acid reflux, was turned away empty-handed.
Sara Khalil Ali, 58, who was accompanying her daughter-in-law for her first ever pregnancy test, described her own four-year battle with stomach cancer.
Ms Ali had been granted a travel permit to go to Augusta Victoria Hospital in East Jerusalem for chemotherapy sessions but dreaded the arduous two-bus journey through Israeli checkpoints. She also despaired about how to pay for her treatment.
“My sons used to work in Israel in construction but now they don’t have permission. I have to ask people or charities for donations to pay for my medicine,” she said.
But against the strain of her condition, Ms Ali was given some welcome respite on Tuesday as she slipped behind the dark blue curtains of a makeshift treatment room to attend to her daughter-in-law.
She re-emerged between its folds with quiet relief. “She’s pregnant,” she said.
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