Bitter Palestinian rivalry adds to the agony of Gazas vulnerable

Cancer patients desperate for drugs: a stricken territory suffers fresh misery

In Shifa hospital, Gaza, tiny premature babies, some with multiple infections, others with congenital diseases, lie packed together in incubators, struggling for life amid a tangle of tubes as lights flicker. With electricity virtually cut off, their life support is powered by a generator with a variable current.

The health of several of the babies is so poor they should have been transferred out of Gaza to modern intensive care units elsewhere, but permission to leave has been refused.

The decades-long agony of Gaza has moved into a new phase in which the very weakest lives of all are being sacrificed in a political power struggle played out beyond Gazas barrier wall.

In a disturbing new twist, the offensive bringing misery to the two million people who live here, most of them refugees, has been triggered by the Palestinian leadership in the West Bank, in collaboration with Israel.

A blockade, military and economic, imposed by land, air and sea, was first imposed by Israel 11 years ago to isolate and weaken Hamas, the Islamic resistance movement that took power in Gaza, but not in the West Bank, after winning elections.

In the West Bank, Mahmoud Abbas, president of the Palestinian Authority, rejected the result. When Israel moved to cut off Hamas in Gaza, Abbas who also hates Hamas added to the Gaza Strips misery by regularly starving it of overseas aid, which his authority administers because of a boycott of Hamas by the international community.

In recent weeks, believing Hamas to be weakened and sensing support from Israel and the US president Donald Trump, as well as others in the region, Abbas has moved to crush Hamas once and for all, using electricity cuts as his main weapon, knowing that power shortages would quickly cripple medical services, as well as water supplies.

Nowhere is the new intensified stranglehold more painful to observe than on the wards of Shifa. During the 2014 war, which killed more than 2,300 Palestinians, including about 500 children leaving 1,000 permanently disabled the beds were full of the injured. Today the doctors are struggling to save lives not damaged by bombs but by the impact of the blockade.

Mohammad Shanty, who suffers from cystic fibrosis, sits next to his mother after receiving oxygen therapy during a power cut in their family house. Photograph: Mohammed Salem/Reuters

Kidney dialysis, intensive care and neonatal units are all in crisis. The Palestinian Authority in Ramallah on the West Bank has refused to pay for medicines, which are now critically depleted even for those in most need. Payments due to Israel each time patients are transferred are also being blocked, so that babies in need of critical care as well as cancer patients are refused permits to leave for treatment in the West Bank and Israel. Doctors say 10 cancer patients who have died in the past month could have been saved if they had been transferred.

As emergency cases back up in Gazas hospitals, other crises that have built up over the 11 years of siege and conflict are being brought to light. The immediate crisis in cancer care is exacerbated by the steep rise in cancer cases across Gaza, for which medical services were ill-equipped to start with.

According to Dr Khaled Thabet, head of oncology at Shifa, cancer rates in Gaza are rising steeply. He cites 90 cases per 100,000 people in 2016 compared with 65 in 2010. The rates are worryingly high given the unusually young population, with 60% of Gazans under 25. He blames the impact of three consecutive wars on Gaza, which have left poisonous elements in the soil and water, including depleted uranium. Daily use of insecticides by Israel to clear border areas is also blamed. Such is the shortage of clean water there are fears of cholera.

I challenge the international scientists to come here and study the situation themselves, but they refuse, he says. It is a disaster. The UN comes here and says Gaza itself is dying and will be uninhabitable by 2020. But it does nothing.

The new crisis has also shed light on the huge rise in babies born with congenital disabilities, who are all waiting in the queue to leave Gaza for specialist treatment. Studies proving the rise and connecting the defects to siege and war have been ignored by the outside world, say doctors here.

In the Shujaiya area, blasted by shells in 2014, a young woman called Heba abu el Comboz, who has Downs syndrome, talks to children in need every day. Many of them live locked up in rooms and are never allowed out, she says. There is nobody to care for them and their family dont want anyone to seethem.

She guides us down a dusty track to a neighbour, who also has Downs, called Allam. Seven-year-old Allam sits beside her sister, Latifa, 15, who has a mental disability but who has never been diagnosed and receives no support.

Unlike some in Gaza, the family cannot afford to buy battery-run generators to boost electricity, so at night they sit in candlelight. Water has also been cut off, with the system functioning only once a week. Inhabitants are forced to pay for deliveries by water tankers. The girls father used to work in Israel earning good money until the siege, says theirmother.

Across the wasteland is a huge cement wall, a newly constructed section of Israels barrier, which Tel Aviv says is necessary to prevent rocket attacks on towns inside Israel.

Our prison, says Heba, smiling. When she was invited to an international conference for people with Downs syndrome, Israel refused her a permit to leave.

We are a civilised people. We have the highest education in the Middle East. We are being bombed and besieged back to the middle ages, says Raji Sourani, director of the Palestinian Centre for Human rights.

A baby born with congenital heart disease in Shifa hospitals neonatal unit. Photograph: Sarah Helm for the Observer

Outside, in the more affluent Rimal area of Gaza City, the shops seem full and the streets buzz, but the expensive goods are imported largely from Israel or through the tunnels that are still being dug under the border with Egypt, despite Israels attempt to destroy them. At the end of the street the Mediterranean laps, green with raw sewage as far as Tel Aviv.

In the centre of Gaza City, scores of international donors and aid agencies sit in air-conditioned offices. If they are protesting about what they see, nobody is listening. Restricted in their movements for security reasons, they see little on the ground and fear to speak out in case Israel bans them from Gaza.

It is a plan, says one local activist, whose anguished words are echoed up and down the Gaza Strip. The world outside doesnt want to know. Everyone wants us to die. Thats it. Because the last three wars did not destroy us they all want us to destroy ourselves.

Every household seems to tell a new story of suffering, particularly in the refugee camps. Rema Frainah, of Aisha, a local community group, says domestic abuse has reached critical levels as a despairing population is crushed together in unbearable conditions.

Meanwhile, in the neonatal unit, the light above a premature seven-month-old stops flashing, but this is not an electricity cut. The baby has given up the struggle. A young father is standing by. Shock, then anguish, passes across his face. We meet him later at home in the Jabalia refugee camp, birthplace of the 1987 intifada, where his wife and 15 members of his family live in a house where plastic flaps at the window. His wifes mother, Maher, says premature births and miscarriages are more common than ever. She has a nephew with brain damage, and two doors down a neighbours son was recently born with hepatitis. So the husband divorced the wife, she says, and the baby died.

She talks also of the majnoun the mad people who are everywhere. Then she laughs. We are all mad. What do you expect?

A shuffling man appears, paralysed down one side. This is Mahers husband. He was a boy stone-thrower in the first intifada, she says, referring to the uprising of 1987. The Israelis arrested him and beat him up. He has been brain-damaged ever since.

I ask them whether they think there will be a new intifada. Are they going to rise up against Hamas? They laugh. Of course not. Who would notice? They want us to get rid of their enemy. Why should we? For us, nothing will change.

Read more:

Hyperkalemia : High Blood Potassium means an abnormally elevated level of Potassium in the Blood

(High Blood Potassium)

Medical Author:
Melissa Conrad Stöppler, MD
Medical Editor:
William C. Shiel Jr., MD, FACP, FACR
What is hyperkalemia?
How does hyperkalemia affect the body?
What are the symptoms of hyperkalemia?
What causes hyperkalemia?
Kidney dysfunction
Diseases of the adrenal gland
Potassium shifts
How is hyperkalemia diagnosed?
How is hyperkalemia treated?
Related hyperkalemia (high sodium blood levels) article: Hyperkalemia – on eMedicineHealth
Patient Comments: Hyperkalemia – How Was Diagnosis Established
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What is hyperkalemia?

Hyperkalemia is common; it is diagnosed in up to 8% of hospitalized patients in the U.S. Fortunately, most patients have mild hyperkalemia (which is usually well tolerated). However, any condition causing even mild hyperkalemia should be treated to prevent progression into more severe hyperkalemia. Extremely high levels of potassium in the blood (severe hyperkalemia) can lead to cardiac arrest and death. When not recognized and treated properly, severe hyperkalemia results in a mortality rate of about 67%.

Technically, hyperkalemia means an abnormally elevated level of potassium in the blood. The normal potassium level in the blood is 3.5-5.0 milliequivalents per liter (mEq/L). Potassium levels between 5.1 mEq/L to 6.0 mEq/L reflect mild hyperkalemia. Potassium levels of 6.1 mEq/L to 7.0 mEq/L are moderate hyperkalemia, and levels above 7 mEq/L are severe hyperkalemia.

How does hyperkalemia affect the body?

Potassium is critical for the normal functioning of the muscles, heart, and nerves. It plays an important role in controlling activity of smooth muscle (such as the muscle found in the digestive tract) and skeletal muscle (muscles of the extremities and torso), as well as the muscles of the heart. It is also important for normal transmission of electrical signals throughout the nervous system within the body.

Normal blood levels of potassium are critical for maintaining normal heart electrical rhythm. Both low blood potassium levels (hypokalemia) and high blood potassium levels (hyperkalemia) can lead to abnormal heart rhythms.

The most important clinical effect of hyperkalemia is related to electrical rhythm of the heart. While mild hyperkalemia probably has a limited effect on the heart, moderate hyperkalemia can produce EKG changes (EKG is an electrical reading of the heart muscles), and severe hyperkalemia can cause suppression of electrical activity of the heart and can cause the heart to stop beating.

Another important effect of hyperkalemia is interference with functioning of the skeletal muscles. Hyperkalemic periodic paralysis is a rare inherited disorder in which patients can develop sudden onset of hyperkalemia which in turn causes muscle paralysis. The reason for the muscle paralysis is not clearly understood, but it is probably due to hyperkalemia suppressing the electrical activity of the muscle.

What are the symptoms of hyperkalemia?

Hyperkalemia can be asymptomatic, meaning that it causes no symptoms. Sometimes, patients with hyperkalemia report vague symptoms including:

muscle weakness, or
tingling sensations.
More serious symptoms of hyperkalemia include slow heartbeat and weak pulse. Severe hyperkalemia can result in fatal cardiac standstill (heart stoppage). Generally, a slowly rising potassium level (such as with chronic kidney failure) is better tolerated than an abrupt rise in potassium levels. Unless the rise in potassium has been very rapid, symptoms of hyperkalemia are usually not apparent until potassium levels are very high (typically 7.0 mEq/l or higher).

Symptoms may also be present that reflect the underlying medical conditions that are causing the hyperkalemia.

What causes hyperkalemia?

The major causes of hyperkalemia are kidney dysfunction, diseases of the adrenal gland, potassium sifting out of cells into the blood circulation, and medications.

Kidney dysfunction

Potassium is normally excreted by the kidneys, so disorders that decrease the function of the kidneys can result in hyperkalemia. These include:

acute and chronic renal failure,
lupus nephritis,
transplant rejection, and
obstructive diseases of the urinary tract, such as urolithiasis (stones in the urinary tract).
Furthermore, patients with kidney dysfunctions are especially sensitive to medications that can increase blood potassium levels. For example, patients with kidney dysfunctions can develop worsening hyperkalemia when given salt substitutes that contain potassium, when given potassium supplements (either orally or intravenously), or medications that can increase blood potassium levels. Examples of medications that can increase blood potassium levels include:

ACE inhibitors,
nonsteroidal anti-inflammatory drugs (NSAIDs),
Angiotensin II Receptor Blockers (ARBs), and
potassium-sparing diuretics