Wednesday, July 16, 2014

Blog # 35 Final blog for June 2014 HAHRP trip July 7, 2014 Footnote

Final blog for June 2014 HAHRP trip

Blog # 35 July 7, 2014

Footnote

I have been home almost a week, my brain is nearly in Eastern Standard Time though my nights are filled with hours of anxiety and wakefulness, and I am indulging in my usual addiction to the news, mainstream and otherwise. Commenters talk about the current upsurge in violence “after a period of relative calm,” clearly they have not been paying much attention, have they? The American citizen who was brutally beaten by Israeli security is under house arrest (for what exactly?) and a reporter uses the expression, “apparent excessive use of force” by the Israelis.  Has he seen the videos proliferating on the internet, they are not that subtle. On NPR, some talking head reports on the lack of progress between “the two governments, Israel and Palestine,” as if we are talking about two equal states that just need to calm their extremists down and settle their squabbles.  The horrific murder of the three settler boys from Hebron is mentioned without context; there is apparently no ugly occupation, no crushing siege of Gaza, no angry extremists that even Hamas may not be able to control anymore, no regular Israeli incursions, arrests, murders, home demolitions, no fanatic, racist Jews screaming “Death to the Arabs.” Liberal Israeli Jews may squirm and condemn their fascistic xenophobic brethren, but these folks have been allowed to flourish under every government and in fact, I fear, are the product of a country that has taken Zionism and Jewish exceptionalism and privilege way beyond the boundaries of human conscience.

Interestingly, Netanyahu sent a condolence call to the dead Palestinian child’s family, but as we know, he does not have a good track record when it comes to justice. I think for the first time in my life, I read a report in the “Boston Globe” that actually uses the words attributed to the Israel defense minister to describe the revenge killers who burned Mohammed Abu Khdeir to death as “Jewish terrorists.” His cousin, Tariq Abu Khder, visiting from Tampa, is in the news a lot. It seems that beating a Palestinian with American citizenship is hard to hide. But, course, then there was Rachel Corrie.  Forgive my cynicism.

I stop by a local liquor store that is owned by a Palestinian family from Taybeh, just to say hello, to express some sympathy, when a customer with red hair and an Irish face overhears the conversation and remarks, “Wow. You’ve been there!” He asks where the Palestinian owner is from, and the guy says vaguely, a small village near Jerusalem.  Obviously being Palestinian from the occupied territories may not be good for business in Brookline. The customer’s face lights up and he says, “You guys sure make great music.” It takes me a moment to realize that he thinks this little village is in Israel, probably does not even know that there is a place called Palestine, and is basically clueless.  When he leaves, we restart our conversation about “extremists on all sides” and the possibility that this is the beginning of the Third Intifada.

One of the medical students on the exchange program from Al Quds University is staying with me while doing rotations at a variety of Harvard hospitals (and fasting all day for Ramadan). He loves to walk and explore the neighborhoods, has already joined a gym, and is very focused on shopping; he has a long list of relatives and needs a gift for each of them from the great bastion of capitalism and discount outlet stores. He was at the hospital when a (presumably highly educated) resident said, “We have some other students from Israel.” He calmly replied, “I am from Palestine.” He met the Israelis and reassures me, “They are OK.”

Meanwhile, all the parties are behaving according to the script. Israeli forces are attacking Gaza, militants are shelling Sderot, Palestinian youth are rioting in East Jerusalem and Hebron, Jewish gangs are causing havoc. The unity government between Fatah and Hamas is just about dead and the Palestinian Authority, which most often works in collaboration with the Israeli occupation forces, is its’ usual less than productive self. Israel remains a powerful, energetic, gorgeous, ugly, profoundly racist state and American Jews mostly line up to support “our homeland.” I note that several major temples in the Boston area are sponsoring memorial services for the dead “Yeshivabochas” and I wonder, when will we have the decency and wisdom to mourn for all of our children and the political will to stop the uncritical support of Israeli policy and the blindness to the suffering, resistance, and resilience of our Palestinian brothers and sisters.   All of our futures depend on this.

Tuesday, July 15, 2014

Blog # 34 June 28, 2014 part three Tell them you're Italian!

Blog # 34  June 28, 2014 part three

Tell them you’re Italian!

Al Manara, the famous square in Ramallah with the circle of lions sculpted in the center, is bustling with chaotic traffic, shoppers, drenching heat, and street venders.  I can see the sign for “Stars and Bucks,” the Arab Bank, banners for the World Cup.  I think about that odd puff piece in the “New York Times” months ago describing the city as “the Paris of the Middle East.” I think not. Too much Middle East, not enough Paris. I am waiting for a woman picking me up from her village of Aboud and I don’t know what she looks like. I am on a bit of a mission.  Her cousin in the states is my friend; I have promised to visit his village, “the most beautiful village in Palestine.”

Suddenly this burst of energy emerges from the crowds, a trim, smiling woman of uncertain age, and after a quick search for a functional bathroom (we stop off at a friend) and a bag of za’tar covered flatbread, we are wending are way to the services (she calls them Fords, because, well they are Fords).  She walks so fast and determinedly, regaling me with a steady stream of commentary, criticism, politics, I can only think; I have come to visit a Palestinian energizer bunny. The Ford only leaves when it is full and as you can imagine, there are not a whole lot of folks heading towards Aboud.  We wait and chat, sweating from the heat.  It is important to drink enough water to prevent heat stroke, but not too much because then we will just be in search of another bathroom. This is a delicate balance. The driver (bless him) finally turns on the air conditioning.    

We head north(ish), this being the occupied West Bank, pass the now famous to anyone paying attention town of Nabih Saleh (see “New York Times” article) where I joined internationals and villagers in 2012 on a Friday afternoon, and watched the town’s youth chant the words of Martin Luther King and Gandhi, throw stones, and run like crazy, while Israeli youth (in full military gear) shot an amazing amount of tear gas and rubber bullets. The Friday ritual of resistance still continues. We pass Halamish, the nearby Jewish settlement that is busy stealing land and water from the folks in Nabih Saleh who having been living here for centuries.  But that’s another story.

Soon we arrive in the small village of Aboud, surrounded by settlements, the population is half Muslim and half Christian.  This fact interests me. To my surprise, my new friend lives alone in a large U shaped house with more rooms than she can fill, a large TV and pleasant kitchen.  The windows are all closed and she has sprayed against mosquitos so the smell of pesticide hangs heavy. Her enduring-the-heat strategy involves strategically opening and closing different shades and windows, sitting on porches on opposite sides of the house, and when all else fails, turning on the fan which I do since I seem to be having a permanent hot flash. The walls are scattered with crosses and virgins and saints and various homages to her beloved mother and father and a cast of cousins. She turns on the music and the Beatles blasts through the house, “It’s been a hard day’s night and I’ve been working like a dog…” She thinks that a salty yogurt drink will revive me and heads toward the kitchen to prepare her version of chicken and rice.

Over the course of the next 24 hours, I learn a lot. My friend loves Frank Sinatra.  She loves to dance and in a previous life, she wore miniskirts and worked like a demon for five years at Malden Hospital near Boston after training as a nurse in Britain, against her father’s wishes.  She and her extended family were all born in Aboud, she received her nursing diploma during the First Intifada, traveling on a Jordanian passport.  She flew back home in the days when a Palestinian could fly into Tel Aviv airport, only to discover that everything had changed. She remembers telling a nasty Israeli official, “The pendulum will swing, and we will get it back.” After an emotional reunion with relatives in Jerusalem, her father took her back to the village.  She only had a three month visa (important reminder: to be in her own home).  When she saw the large Israeli flag at the entry to her village, the reality of occupation hit her like a jolt of lightening. She stayed five months, her visa expired, and through sheer luck and a lot of chutzpah, she ended up living with a group of nurses from the UK and working long shifts at Malden Hospital in the days when nurses wore crisp uniforms and probably smiled and said, “Yes, doctor” a lot.  It sounds like she really enjoyed herself and her freedom.

Her first love married someone else; ultimately she returned home, the responsible daughter, to care for her aging parents and now she is in a most unusual situation; an aging (lonely) Palestinian woman without any children, her swarm of relatives mostly lost to the diaspora.  She once had a job offer at Hadassah Hospital in Jerusalem, but Netanyahu nixed that when he forbid employing staff from the West Bank. I feel her regret. “Being a single woman in the village is like being in prison.” When she talks of her long dead mother, her eyes fill with tears. Her stories are peppered with feisty bravado, she tosses around quirky expressions like, “Okay Charlie!” and has had her share of taking wild chances, standing up to soldiers at checkpoints.  “They control everything, they control the oxygen you breathe.”

“Kids were throwing stones and the soldiers were beating a kid.  [I said] What are you doing? You are a kid with a gun. He is a kid with a stone.  Be a gentleman. Put the gun away. And if I catch you throwing stones again, you will hear from me.”

Once she was interviewed on the street by CNN and asked what she thought of the Israeli withdrawal from Gaza. “So what. I will be happy when they pull out of East Jerusalem, end the settlements, [let the refugees back]! Every night she prays for peace and listens to Voices of Peace, a radio station located “somewhere in the Mediterranean.” Obviously she prays a lot and whichever God is in charge of this place seems to be hard of hearing.

My new friend cannot believe I am Jewish and she cannot believe she has an actual Jew in her home, eating her chicken and her chopped up cucumbers and tomato. “The first Jew in Aboud!” she exclaims happily.  (I guess the IDF doesn’t really count here.) Her voice gets a bit conspiratorial and she advises me not to mention this fact in the village. She is worried about her Muslim neighbors, “They are a bit fanatic.” She seems to be in the some-of-my-best-friends-are Muslims camp, but I also sense a deep distrust. So much for peace, love, and understanding, united against the common enemy. (private thought) She talks of an upsetting night when a large truck and ten jeeps arrived at midnight and as she peered out the window, she saw her Muslim neighbor, blindfolded, handcuffed, dragged into the truck by Israeli soldiers.  She suggests that I tell people I’m Italian.


When the heat abates a bit, she takes me on a speed walking tour, stopping to schmooze with family and friends. She complains about the garbage thrown by ill behaved (read Muslim) teens and when I comment on how hot it must be for women in hijabs and long coats, says, “They’re used to it.  It’s their religion.” The town has wide streets, two Christian neighborhoods and one Muslim, and from what I can gather, three functional churches, a mosque, and ancient church ruins.  We only tour the Christian sector. Some of the walls have lovely religious murals and others harken back to a simpler time when people were out harvesting their crops and looked happier. We pass donkeys and their babies, elegant homes with lush gardens, abandoned properties, the site of my American friend's family home (his bedroom is now a driveway for an ancient yellow probably Dodge Dart). A young man gallops by, riding his horse bareback.

She is very angry about the ongoing land and olive grove confiscations and tells me the story of finding an IDF soldier asleep under a tree.   Her friend walked up to the sleeping soldier and yelled, “We gave you the road.  You have beach in Tel Aviv in your bikini.  Leave us alone.”  The soldier had a gun and started threatening her friend who yelled, “Go ahead, shoot me.  I will die defending my land and you will be a murderer.” We come to a premature end to the road, obstructed by a ten foot tall pile of dirt and rocks, courtesy of the nearby settlers in their orange roofed houses.  I ask my new friend if I can take her picture in front of this land grab and she says quickly, “No.”  She is too upset for photo ops.

We stop at a series of stone patios, friends and relations drinking tea, eating water melon, smoking cigarettes, hugging children.  I feel like I am in an old French movie or maybe visiting Uncle Morris and Aunt Bessie in Queens, ordinary schlumpy folks, full of opinions and quarrels and family loyalty, eat, eat, habibti. The women dye their hair black/brown and have thin pencil eyebrows. One guy, an engineer with a couple of charming, engaging young daughters, lived in the Bay area for years but then felt he had to come back.  He tells me honestly, he could not tolerate the diversity, the Mexicans, the Asians, the Blacks.  “I am not racist but I want to be with my own people.”  He didn’t like the rat race, enjoys the slower pace, wants more time with his wife and kids. “Have some more watermelon?”

The next morning we see more of the churches, including the Church of the Virgin Mary “Abudia” which dates back to the fourth century.  In the hushed entry, the priest chanting melodiously in the sanctuary, my friend lights candles and prays.  We watch Sunday school children play with a gigantic multicolored parachute and act out Jonah and the whale.  (What do this kids know about oceans?) We pour through exquisite Aboudi embroidery.  (I am trying to find something without God or Jesus and am thrilled to see “Home Sweet Home.”) The tour of the friends and relatives continues and it is close to heart breaking.  A sweet widow carrying for her emaciated dying mother in a dark bare room, the faint smell of urine, three children; her son is apprenticed to a blacksmith. Another woman’s brother built a palatial estate and visits in the summer. His elderly dementing sister sits in the front door, half dressed, camping out on the first floor.  She presses candy into our hands when she realizes we are not staying. Another friend tends to her ill brother with severe multiple sclerosis and an angry personality, her face is tight with sorrow.  She wants me to send a package of her home made za’atar to my friend in American and asks that I tell him to call and tell him, “to come home.”  Another white haired woman on her way to church says to me, “You are better than my relatives.  They never visit.” This is a tough place to be old or sick or alone. Despite all of its natural beauty, the village has an air of stagnation and suffocation that comes with small places, no secrets, and not much in the ways of prospects for happiness.

The visit is sweetened by a stop at my friend’s family home across from her place, where a relative (not sure who) lives with his (quietly depressed?) wife and three gorgeous, lively daughters. The children adore her and I can see that she loves and indulges them like a grandmother.  “Very lovely,” she beams.

There is only so much tea a person can take and it is time to return to Ramallah.  My friend explains that the Ford driver’s basic attitude (he will only leave when the vehicle is full) is, “Why hurry? Aboud to Ramallah to Aboud.  We are all in prison.” My friend gives me one more piece of advice, “Okay Charlie, my dear,” I should prepare for a lonely end of life.  That is our fate.

I meet up with a thirty something activist friend in Ramallah, and as we sip our mint lemonade and hide from the Ramadan fasting police, she talks about life choices; she is tired of being beaten and tasered, she is really worried about injury and death, she wants to stop smoking, to have babies, to live.  How to do all of that in this very complicated place?




Monday, July 14, 2014

Blog # 33 June 26, 2014 part three Speak truth to power and choose joyfulness

Blog # 33 June 26, 2014 part three

Speak truth to power and choose joyfulness

We are late for our meeting with the Palestinian National Institute of Public Health, a recently established agency set up by the World Health Organization in cooperation with the Ministry of Health, Palestinian universities, the Norwegian Institute of Public Health, and “other stakeholders.” We are greeted by Dr. Salwa Massad, the lively speak-truth-to-power research manager with curly defiant reddish hair and bright orange nail polish and Noora Tijani, a slightly more subdued public relations specialist in a patterned hijab and long jean coat. The Turkish coffee appears with a folder of official information, and we plunge in.  Salwa got her masters at Birzeit and her PhD at University of Wisconsin.

The institute is responsible for public health surveillance, assessment, research, health systems analysis, and capacity building.  Salwa wants to talk about a mammogram screening project started in 2009. I am very curious about breast cancer screening, since it has seemed somewhere between hopelessly complicated and undeveloped and inordinately difficult during my previous attempts to provide clinical care and I would love to know what the public health researchers have to report.

The Institute did an evaluation of mammogram screening programs in the West Bank but found that they could not assess efficacy because there was an underreporting of cancer diagnosis.  But things were even more complicated. They looked at 6,700 women, ages 30-84, screened in the West Bank in twelve screening clinics in 2011, they found 21 reported to the cancer registry and called all of them and also found 21 more who were not registered in the registry but were being treated. So we already have a data problem here. On further research they found that the Augusta Victoria Hospital in East Jerusalem is the only location for radiation therapy (the Israelis I am told do not allow radioactive therapies into the occupied territories), so most women go to August Victoria, but the hospital refuses to notify the Ministry of Health cancer registry; too much paper work, too little time, so there is a problem with tremendous underreporting. (big sigh)

The Institute wanted to determine if mammography screening picks up cases of breast cancer early, but found only 1% of cases have the stage of cancer noted, so it is not possible to determine if it was early detection or not. Only four doctors actually read mammograms in the West Bank, the waiting times for results are long. If cancer is suspected, the woman may need an ultrasound or aspiration, but the Ministry of Health only offers these services in Ramallah, thus women go to private clinics, but then cannot afford them and are (as we say in the medical bizz) lost to follow up, ie left to die of their cancer.  Fine needle biopsies are also only free in Beit Jallah, but again many women cannot get there and thus are also “lost to follow up.”  Add to this the tremendous cultural stigma around a cancer diagnosis, (all the screening is done confidentially), many women do not even tell their husbands.  I suspect it is pretty impossible to get cancer treatment if you are not willing to tell even your sexual partner. Just speculating of course.

And then there is the whole issue of what is the underlying cause of death on death certificates. The Institute reviewed the notification forms for people dying in hospitals, 400 in the West Bank and 200 in Gaza. “The results are scary, so unreliable, so the Ministry of Health installed electronic medical records,” but as we say of our own electronic records, garbage in garbage out. Salwa talked about deceased patients that were still alive in the system with medical status noted as “improved,” or patients that had four different dates of death but were still being billed for physical therapy and counseling.  A little scary and pretty outrageous and utterly dysfunctional and third world.

So why does this happen, I ask.  Salwa reports that doctors (in general) see no value in the numbers and  data and followup information; they are so overwhelmed they barely do their paperwork.  If 100 patients come to an emergency room every day and many of them have mental health issues, “so I just put whatever, default is ‘improved,’ or not registered as death, and who will look at the data so why waste my time?” The doctors are often not well trained, have no oversight, and no threat of malpractice. Medical students lack mentoring and support, so they do not learn how to do better and the system perpetuates itself.

Salwa explains that the mammography studies were helpful, the Ministry of Health is training more doctors to read films, they are at least aware of the need for maintenance of mammographic equipment (rather than just calling when the thing finally breaks), they know about the shortage of films and the subsequent quality issues.

I am having trouble swallowing and breathing, listening and typing.

And then there is that annoying question of quality.  It turns out that mammography readings are often substandard.  The first clinicians to see the films are nurses who have had five days of training, are not mentored, and Salwa says that most of the technicians are these nurses, so mammogram studies themselves are inadequate.  Yikes.

Now the Institute is doing a study in Tulkarem, a city surrounded by the separation wall, located on the Green Line, and the host to many Israeli chemical companies and nearby settlement industries that do not want to be bothered with those expensive environmental regulations and worker protections that are the law of the land in Israel. Between the fumes, smoke, chemicals, industrial waste, etc, etc, there is a high incidence of allergies, skin disease, eye problems, and cancer, but this has never been adequately studied and given the mammogram studies, you can imagine that this would be a challenge.  The Institute has decided to do something very clever: they are measuring toxics in the land and water, so they are doing environmental studies from which much can be extrapolated, but they are skipping the deficits in accurate health statistics. (Environmental racism anyone?) In addition, they do not have accurate information about the factories and are not even allowed to enter them.  (Got something to hide maybe?)

The Institute is also analyzing a death study and planning an environmental study in the Jordan Valley -  Dead Sea area, including areas of Jericho.  They are investigating a health profile in the Jordan Valley, looking at communicable disease, malnutrition in children, parasites, scorpion and snake bites, and the mental health of residents. FYI the Jordan Valley is a closed military zone with several pockets of Palestinian communities.

The Institute is working with Juzoor, a health and social policy NGO grounded in the socioeconomic determinates of health and wellness and the RAND Corporation investigating risk taking behaviors among Palestinian youth.  They are studying 2,500 men and women 15-24 years old in the West Bank (they couldn’t do it in Gaza) looking at drugs, alcohol, sex outside of marriage, smoking, violence, and mental health.  I am impressed.  This is very first world. 

They are finding that the sexually active youth are mostly interested in internet sex and phone sex, oral and anal sex is next, but vaginal sex is the least common due to the importance of female virginity at the time of marriage. We understand that there are honor killings, but the numbers are hard to get.  Salwa explains that it is even more complicated than that.  For instance, an apparent honor killing in Hebron, may not really be about “honor;” perhaps the woman was asked to give up her inheritance to her brother, she refuses and he kills her, takes the money and calls it an honor killing.  Or a woman’s husband dies and her brother-in-law wants  to marry her, so his first wife asks her own brothers to kill potential wife #2 and call it an “honor killing.” Or if a father or brother rapes a girl and she gets pregnant, then they kill her to protect the father or brother.  There is no data on this horrific crime, it probably happens more in rural than urban areas, sometimes people call it a suicide, the reports are all “just stories.”

Now that we are deep into forbidden topics, Salwa notes that there is an increasing rate of suicide, especially amongst the youth, “even with engaged women.”  Apparently the police says suicide is increasing, but they don’t want to report it, “so people won’t panic, don’t believe the numbers.” Fortunately there are good hotlines such as Sawa, (“the Listening Ear for Palestinians Experiencing Violence), for desperate people who are abused, harassed, or raped. I think about what happens to societies that are increasingly stressed and brutalized, how anger and despair turn inward, how women frequently bear the brunt of male humiliation, rage, and impotence. This unfortunately happens everywhere and we are seeing it here.

83 men and women in the West Bank were asked about health services for youth, and they reported that they do not trust counseling institutes, are worried about confidentiality, are much more willing to speak to peers.  UNRWA is training community based mental health workers, “this is good program.” There are school health officers who focus on smoking and nutrition and for adults, community based organizations, like Palestinian Medical Relief Society. Drug use is common in the cities, mostly in Jerusalem and area C, (under Israeli control), mostly hashish which is affordable. Addiction carries a social stigma, the Israeli authorities punish dealers more forcefully if they sell to Jews than to Arabs. Drug use has increased with the increasing brutality of the occupation. (We call that self-medication.)

We wonder if anyone is studying the environmental impact of checkpoints, increased emissions, air quality, the impacts of water restrictions, the repeated exposure to tear gas, chemical weapons, sewerage. The answer is no. Obvious environmental issues are not a priority when the population does not have enough food and water.

Their research is funded by Norwegians, “they do not interfere, but they monitor.” Thank you, decent and thoughtful Norwegians. This public health institute started in September 2012 with WHO.
The idea is to do research and inform policy with stakeholders, always in partnership, like the Ministry of Health or local citizens. But the politics is critical.  “In Gaza phosphorus bombs, what happened? No one cared.” Beneath the Al Aqsa Mosque, right wing Jewish organizations are excavating, “Muslims all over the world, crying, became normalized [the frog in the pot of boiling water phenomenon]. We are used to it, powerless, can’t fight continuously.  We need to write about it, facebook, social media, tools that are not controlled and create awareness, buzz marketing, attract attention. Youtube gets thousands of views and shares in two days. This is a power, political support is hopeless.” Salwa’s energy and enthusiasm are infectious. The Tulkarem environmental study, “Everybody is excited about the study, we did a field study, farmers and stake holders are supportive. There are many organizations and funders for women.  Honor killing used to have one month punishment, now there are no more reduced sentences, this is recent change.”

She suggests we check out the Diakonia International Humanitarian Law-Resource Center in Jerusalem which does advocacy around justice and international law. So many good people doing good work in a complicated place.

Salwa reminds us that this is difficult and humbling work.  She did her PhD on mental health and quality of life (QOL) in preschoolers in Gaza.  She found that 50% of mothers suffered from depression, (not exactly a surprise), the QOL of preschoolers in Gaza was worse than kids in the US with cancer or renal failure. The risk of malnutrition was solely related to maternal mental health, (maternal resilience and food availability?). Amazingly, she tried to measure the QOL of the mothers and 40% said, “excellent.” This made no sense to her, (I mean this is Gaza) so she called the women and the conversations were basically, “How is life?” “Hamdullah, excellent,” and then women would list a thousand overwhelming complaints.  When she pressed further, they would respond, “You can only complain to God.” So an assessment of wellbeing is totally culturally determined.

It is time to go.  I am trying to wrap my brain around this amazing conversation and these two amazing women. I am feeling that it’s really not about what is happening to you, it is how you deal with it.  Salwa and Noora suggest that it is actually possible to choose joyfulness as an act of resistance.

The medical student who introduced us to the Institute suggests we go for a “quick visit” to his village of Taybeh, a Christian town half an hour from Ramallah. Soon we are in a clunky, dusty service heading northeast, and then we are sitting at a table laden with flavorful soup made from mlokhyaa, chicken with rice, salad drenched with olive oil, lemon, salt, and pepper, dried mint, and then another eggplant, parsley, tahini concoction and of course, cold Taybeh beer, chatting with his welcoming mother, father, and sister who just happened to have a feast waiting for us. 

 And then there is the tour of the family’s garden, lush bunches of grapes, almonds (very sweet eaten raw), figs, olives, mulberries, apples, pomegranates. And just a “quick tour” of the Old City, gorgeous views, churches (actually dating to the time of Christ), ruins, multiple layers of conquerors.  The town gathers for celebrations and still sacrifices sheep! We stare at the stones stained blood red and the hand prints (dipped in the blood) marking the ancient stone walls.  And in the distance, Jordan, the Dead Sea, a Muslim village, Israeli military posts and settlements, all leaning into this tiny, complicated paradise.

I learn later that the medical students hosting us are competing to see who makes the best visit to their village. They are all winning.

Sunday, July 13, 2014

Blog # 32 JUne 26, 2014 part two The darkest aspects of human experience

Blog # 32 June 26, 2014 part two

The darkest aspects of human experience

I have been thinking a lot about torture lately, given the three murdered Israeli settlers and the most likely revenge killing of a Palestinian teen burned to death and then his American cousin beaten to a pulp (check the photos) by Israeli security and if you should come across the website of PCHR (the Palestinian Center for Human Rights), this is merely the tip of an enormous iceberg of human violence and suffering.

As I write this blog entry (belatedly), it is actually fitting that on June 26, a number of us were invited to a conference hosted by the Treatment and Rehabilitation Center for Victims of Torture in Ramallah and we are sitting in a large auditorium at the Red Crescent Society in Al Bireh.  A lovely Al Quds medical student is translating quietly as we lean towards her and some of the talks are thankfully in English.  I will do the best I can here.

There are many professional looking types, men and women, and two rows of guys in army green and berets, apparently soldiers from the Palestinian Authority also have a lot to learn about torture, prevention, and treatment.  On the stage I recognize Dr. Mustafa Barghouti who founded the Palestinian Medical Relief Society and is a political leader (you might hear him on NPR for instance as an articulate voice of reason), Dr. Mahmoud Suheil, the psychiatrist who is the head of the center, and a man from the European Union who spoke at a Birzeit Heritage festival we attended a few days ago.  We all stand for a bout of patriotic music, the cameras roll, and the conference officially begins.

Today is the annual international day in support of victims of torture. The EU speaker talks about how torture is abhorrent, against moral and ethical values, “it destroys the victim and dehumanizes the torturer, and undermines the state that tolerates it.  Torture is also a crime under international human rights law and unlike many other human rights, there are no exceptions or no justifications to make the unacceptable, acceptable.” He notes that, “these are easy words, the real question is how to combat torture effectively.”

He suggests that torture has to be addressed at different levels that include legal regulations where torture is prohibited by law and mechanisms need to be in place to make sure this is applied. It is also critical to have transparency, bringing to light behaviors at police stations and other places of detention.  He asserts that civil society has a role to play here; this work requires public awareness of what torture does to people; this is a constant task, human rights values need to be frequently restated.

In 2013 President Abbas decreed a prohibition on torture and in April 2014 Palestine ratified the UN convention against torture.  (The US and Israel signed decades ago for what it is worth.) He notes these are important developments but more needs to happen as Palestinian civil society has regularly reported the use of torture by its own security forces as well as by Israeli forces. He notes that the European Union has regularly criticized Israel regarding the conditions under which Palestinian prisoners are held and the use of administrative detention, he congratulates the treatment center and its partners that “deal on a daily basis with some of the darkest aspects of human experience.” I wonder where is the voice of the US at an important conference like this?

The next series of speakers are talking in Arabic and their main points revolve around the destructive Israeli practices of child arrests, the killing of young children, and the re-arresting of prisoners who were freed in previous deals. There is then a long presentation on Palestinian and international rules, laws, contracts, etc, the bad things that have happened, the need for respect for women’s rights, the illegal torture of Palestinians in Palestinians prisons and appalling Israeli policies and house demolitions. 

I am looking through the conference literature and learn that the Treatment and Rehabilitation Center was founded in 1997 to defend human rights, to build a society free from torture through community awareness and education.  Their tasks focus on: violence against prisoners, the wounded, families of martyrs, victims of the Apartheid Wall, road blocks, settler attacks, etc.  They also offer treatment and support to victims and their families and focus on therapy and rehabilitation, medical and psychological. I am puzzled as someone appears to be setting up an electric piano on the stage.

A woman talks of transitional justice, the need to create official strategies to identify torture, to fix societies that are suffering and to compensate victims. For victims, the torturer needs to be punished and the victim compensated.  She notes that with the ongoing history of torture, this will lead to a loss of trust between individuals and society. She acknowledges that the divisions between Fatah and Hamas have created many victims and many people have been hurt.

After apologies to all the people who were unable to get to the conference due to the heightened delays and blocks at checkpoints, it is apparently time for the entertainment. A singing group from an Najah University in Nablus, two women in gorgeous embroidered Palestinian dresses and one man playing the thing that looked like an electric piano but clearly is something else, pour their hearts into the music, giving voice and feeling to a society filled with pain and joy. This is all pretty extraordinary.

The second part of the conference is focused on treatment for prisoners and their families, “who are not sick, but suffering.” They talk about men released from prison after over ten years who have never seen a smart phone, have had years of solitary confinement, physical, and psychological suffering, whose families were not allowed to visit.  “But what about the feeling about the father, thinking about his kids, what has happened to them, what kind of treatment they can do to support them. They are suffering from beating, abused, not eating or inedible food.  Some have abdominal pains due to bad food and no exercise and that makes it worse.  The air is stagnant, six people in a room, health worsens.”

The Center is doing awareness campaigns about the torture prisoners are facing, they have branches in places like Nablus, Jenin, and Ramallah, they offer outreach, go to the homes of the prisoners and families, talk to them, many do not have money to go to the center.  The staff also uses psychotherapy, ie. cognitive behavioral therapy, and send staff to Norway to practice and learn to do therapy.  Their group includes a psychiatrist, psychologists; they discuss each case and plan treatment, possible medications, psychotherapy, etc.  The main goal is to make the victim feel better so he/she can go back to a normal routine and return to society.

The speaker gives a poignant example: one person spent thirteen years in prison, his oldest child was five and now he is 18, “so he will not feel like the father, lost that feeling.  The child is used to the absence of the father, he [the father] is not used to being ignored and not asked and is shocked, so he feels like a piece of furniture.  He is not asked to participate in family as they are used to being without him.”

When the psychiatrist determines that the released prisoner is ready, he/she is offered professional rehabilitation: the prisoners are paid a monthly income and offered courses to be able to work in their desired field, “so they will be productive in building a future, they want to become productive.” Specialists follow the prisoner and evaluate the results and adjust the treatment program. The
speaker is intelligent and articulate, the audience nods in agreement, and I have a sense that this a group of sincere, decent, professionals honestly working to better the lives of victims and their difficult society.

“The wife of the prisoner, she is the hero, but in the shadow.  She is fighting alone to raise the kids, work, so the center is trying to offer the wife work options, ie, sewing in a salon, which is in her home, so her kids are close, she can care for the kids and have an income while the husband is in prison.”

There are more presentations about the legalities and international laws and the groups that monitor conditions. There are human rights committees that write reports in cooperation with organizations like Physicians for Human Rights Israel, “track all the kinds of violations and torture, in order to find the truth, and follow those reports to see more details, in front of government to take action.  The torturer should know that he is going to be punished and is not protected.”

Another speaker notes that in the news recently, “there is an increase of family fights that result in killing, so violence has increased in Palestine, girls are being raped.  So the laws must be followed, the killer needs to be punished, otherwise the family takes justice in their own hands and this is dangerous.”

There is more discussion about the deaths of Palestinians in Israeli prisons due to inappropriate medical care, the lack of punishment or accountability, the current prisoner hunger strike, the fact that Israeli violations are allowed because they are in power, the possible forced feeding legislation. “It is the worst occupation in history. It is not impossible emotionally to hope for Palestinian society without torture.”
“Even any kind of reporting to Israeli institutions lead to nowhere.  So it is time to do it ourselves by legal means.”

Another speaker clearly is more agitated.  He talks about the continued cases of torture by Palestinians in Palestinian jails. Of the havoc in Israeli jails and the need to use international committees and the media. “If the torturer is not punished, the Palestinian can track them down using international organizations and other countries and laws.  Using the law we can find those murdered in Israeli prisoners who abuse prisoners and try to stop this. During interrogation they torture them until they die.” He describes “Israel [as] a country of killing, torture, destruction, but we are strong and it is our turn to act, to make the laws and the policy.”  I can sense his outrage, voice rising in anger and frustration. He ends with the three kidnapped Israeli settlers and the difference in the international response when Palestinians are the victims. “When Israeli kills our children or rearrests prisoners, this is war, it is our right to ask for help through media as well.”

The last speaker (before more singing) is a freed prisoner.  I brace myself for some horrific litany of pain and suffering, the conference has already felt quite overwhelming and my professional boundaries are fraying.  The young man begins by reading from the Quran; he explains, “One can face many difficulties, but if there is a huge trauma those who are patient, Allah promises them with heaven.” He talks about the years when water was his only mirror, his speech is urgent and passionate, and soon I realize that it is all poetry and metaphor, filled with feeling and woundedness, the child inside longing for freedom and land, a symphony of words, all beauty and inspiration. A true survivor.

Saturday, July 12, 2014

Blog # 31 June 26, 2014 First/third world medicine

Blog # 31  June 26, 2014

First/third world medicine

The newly built Ministry of Health Palestine Medical Complex is filled with all the expected contradictions of building a health care system under occupation in what is ironically a third world kind of setting. We are getting the grand tour from a medical student who did his internship here, “lots of experience, low quality.” The impressively clean, modern, white stone facilities were built in 2010, merging a Ministry of Health hospital and a private hospital (donated by an American) in Ramallah.  At the gate there is a sign: "Palestine Medical Complex is Smoking Free Area,” (insha’allah as they say here).

I have a particular interest in quality improvement, (I understand why things are the way they are, but how does health care move forward, even here), and we are soon meeting with Rebhe Bsharat, a PhD in a white coat, short mustache, and warm friendly manner  who is in charge of quality and education for nursing. He reviews the different wings of the hospital, including pediatrics, surgery, emergency, general medicine, the ICUs, dialysis units, triage beds, etc, etc.  All the trappings of a 21st century medical center.  They have 126,000 emergency visits, 200,000 outpatient visits, 27,600 admissions, and 7,000 surgical cases per year.   

Quality assurance (which is part of the quality improvement lingo) has been a focus at the hospital for the past three years.  Apparently the World Health Organization has a program for “Patient safety friendly hospitals” with lists of standards to be met. In the US over the past few decades, the whole focus on improving the quality of care has been to turn from blaming the “bad doctor who screwed up,” which encourages a culture of secrecy and condemnation, to assuming that most clinicians are doing the best they can under challenging circumstances. Thus the task is to analyze how the system of care makes errors more likely, (different medications with similar names and labeling sitting next to each other on the shelf), and how to make systematic changes to reduce error, (make the labels different colors and put the medications on different shelves.)  This obviously has the potential to encourage a culture of joint cooperation and more creative thinking and has the potential to actually make care safer.

Rebhe admits that there a lot of challenges because this approach involves changing the culture and attitudes of the providers.  I am so excited to learn that one of their quality improvement programs is focused on hand washing.  As a point of explanation, one of my major concerns having worked and observed in clinics and hospitals all over the West Bank, is the fact that almost no one washes their hands before or after seeing patients.  As you may imagine, this drives me crazy. This is a preventable risk factor. As a firm believer in the germ theory, it seems to me that even under occupation, clinicians could and should wash their hands and if there is no water, I have been known to leave bottles of Purell on doctors’ desks as a personal contribution to fighting infection.

So you can imagine my delight on seeing a poster in a ward headed with a logo and “Palestine Medical Complex,” with a circle filled with bugs and a slash across it, followed by large letters: no germs allowed, WASH YOUR HANDS and some official signature.  It really doesn’t take much to make me happy. As expected, the initial surveys revealed that 20% of doctors and 50% of nurses washed their hands, so now there are weekly lectures, monthly meetings, and patient safety protocols, all good things. Older doctors (like doctors everywhere) pushed back but the trends are good.

Rebhe explores some of the challenges nurses face.  He lives in a small village and because it takes between 30 minutes and three hours to get to work, (depending on the checkpoints), the previous shift just has to continue working until the next shift shows up. There are 300 nurses, half have a two year diploma, half have a BA, 55% are women, 20% are over 40.  Many work here for ten years or so and then return to their cities or villages.  They all need continuing education programs, want better patient education publications and discharge planning and these are in the pipelines. Rebhe was trained in Baghdad and Turkey as high level degrees are not available in the occupied territories and his thesis was on effective planning for cardiac surgery. Meanwhile he is trying to get folks to wash their hands.

We tour the wards and I am impressed with their order and cleanliness, (an incredible contrast to older Ministry of Health hospitals I have seen).  The pediatric unit has 40 beds, but only 30 are used due to lack of staff. They receive referrals from all over the West Bank.  There is supposed to be one nurse for five patients, but the reality is one nurse for twelve patients, (safe staffing anyone?) Bears, ducks, Disney-like princesses, and Winnie the Pooh (how did he get here?) cheerfully decorate the walls. There are no psychiatrists or social workers and frequent shortages of medications. Today the Ministry of Health doctors are on strike, the outpatient unit is closed and only emergencies are being seen. The month long strike is over salaries and no resolution is in sight. (Jolt of reality.) Politics and medicine, the challenges continue on so many levels, and the patients and staff pay the price.  It seems they keep on hoping, keep on praying, keep on showing up for work (sometimes) and for care (always). Alhamdulillah. What else is there to do?

Thursday, July 10, 2014

Blog # 30 June 25, 2014 part two Medicine: If it doesn't kill you, it makes you strong

Blog # 30  June 25, 2014 part two

Medicine: If it doesn’t kill you, it makes you strong

The meeting with the medical students is not that polite. Now I will grant you they had just finished their exams, (because of the Hebron curfew some had six exams in one day), many were about to graduate, and they are living in a variety of ghettos trying to get an education in an impossible place (and FYI, my recollection of medical school is also filled with anger and frustration and I did not cross one checkpoint). They have a lot to say and are obviously happy that there are some curious people interested in listening. One student describes Al Quds as “six years of hell.”  The students from East Jerusalem discuss the frustrations of crossing the Kalandia checkpoint twice a day, most everyone has had some frightening experience with a gun toting Israeli who is also their age and sees every Palestinian as a terrorist, everyone complains about the uptight culture of medicine, (sounds a lot like the hierarchical culture of hospitals in the 1970s), physicians who act “like Gods,” and of course, there are longstanding conflicts with the administration.

As we try to tease apart the miseries of medical school in general, from the miseries of this medical school in this place in particular, certain themes emerge.  Al Quds (as opposed to an Najar in Nablus) has no teaching hospital so students get dispersed all over. Students with IDs or permits for East Jerusalem get better clinical rotations and there are no standards or clear cut expectations in the clinical curriculum so the teaching is enormously variable and sometimes totally inadequate. (Pediatrics at Al Mokassed hospital is a glowing exception.) The doctors are often brilliant, have trained in high power institutions abroad, they are very busy, have active private clinics, and teaching med students is often low on their list of priorities.  In addition, unlike US hospitals, residents (where they exist) are not required to teach the students, so “everything is personal connection.”

The students would love to see the institution improve and are aware that Al Quds has funding issues; that the Israeli authorities are not allowing them to build a teaching hospital in Jerusalem.  It sounds, nonetheless, like there is an unacceptable level of chaos: students talk about being “dumped” in hospitals in Bethlehem and Hebron, then having to rent crowded apartments due to the challenges of getting around. They talk about arbitrary grades, lack of mentors and guidance, and lots of small problems.  Everyone plans to train “outside” and everyone “plans to come back.”  I love their passion, their rage, and their idealism.

We talk about the challenges for patients. Due to lack of funding, patients having surgery sometimes have to buy their anesthetics, IVs, and pain medicine and bring them to the hospital before the procedure. (As a quick orientation here, the world class Hadassah Hospital  is a few miles away and you can be sure they have enough fentanyl and saline to do surgery, but I digress.) Some hospitals have no electricity for two hours per day, (this would certainly crimp a specialist’s style, not to mention some poor patient on a respirator).  If a Ministry of Health hospital is unable to perform some type of care, they will refer the patient to a private hospital but the government then fails to pay for the care, so private hospitals have growing loans and debt as they struggle to survive.

And beyond the occupation’s political impact on health care, we start talking about the additional social determinants of health: how all the pollution from prolonged bus and taxi routes, endless idling at checkpoints, huge quarries and stone cutting dust, piles of uncollected garbage, the contaminated (radioactive) water dumped by the Dimona reactor south of Hebron (that would be dumped on Bedouins if I recall), how all this makes people sick. And then they face a health care (non)system that is ill prepared to deal with the totality of disease and its profound and complex etiologies.

No wonder these medical students are not only articulate and smart and ready to take on the world; they are also profoundly angry about all the right things. If these are Palestine’s future doctors, I feel very hopeful for the next generation.  

Tuesday, July 8, 2014

Blog # 29 corrected June 25, 2014 Teaching in the ghetto

Corrected.....    Blog # 29  June 25, 2014

Teaching in the ghetto

The Jerusalem neighborhood of Abu Dis ended up on the wrong side of the wall; every time bus #36 from East Jerusalem turns this particular corner and there is the monstrous “barrier” (which is quite a euphemism ) up close and personal, all eight meters high of poured concrete stretching along the edge of the road, (or rather defining the edge of the road and in some ways, the edge of existence), I have the distinct impression that military/city planner types are giving us and all the wrong-side-people, a gigantic concrete finger in the eye. Most of Al Quds University is on the wrong side too, (if you live in Jerusalem and of course on the right side if you live in Ramallah or Tulkarem or Jenin or Hebron). For students who are old enough to remember, getting to school from East Jerusalem used to be easy and quick. Now, the journey involves a long tunnel, skirting Ma’ale Adumim, (one of the largest Jewish settlements or shall we just be honest and say colonies on the West Bank), swinging through Bethany, (the biblical one which seems more industrial, auto shops and less Jesus, Lazarus, and lepers) and making a huge snaking swing east and south to get to the bedraggled neighborhood of Abu Dis. Let’s not even mention the increased use of fuel, the challenged shock absorbers that need constant repair, the choking air pollution, the lost time and rising aggravation, and the need to plan life around buses and permits and when is it safe in the first place to try the daring trip to school. What do these people have to complain about anyway????

We meet with Hani Abdeen, the dignified and somewhat burned out dean of the medical school, neat mustache, wire rimmed glasses, striped shirt, very old school, and I feel like this should be called: soldiering on against all odds. Al Quds Medical School was founded in 1994 and graduated its 14th class last week, for a total of 720 graduates to date.  Hani is very pleased with his students. He brags that they do very well on qualifying exams for residencies all over the Western world: Canada, US, Europe, “The students are doing a good job, under duress people excel.  We do not have a large faculty, all the resources, teaching materials, yet with all these short comings students do well. In the USMLE (US Medical Licensing Exam) Palestinian students are in the top 1% of foreign graduates.”  What doesn’t kill you makes you stronger.

This is of particular interest to me as the health and human rights project was involved in starting an exchange program between Harvard and Al Quds Medical School and the students rotate through Harvard hospitals and receive, “glowing reports.” Hani is very worried that while the medical school is doing a good job, they are essentially, “training doctors for America, there is a big brain drain. Once they see how good life is, the standards of medicine, they leave and stay where they train.” He notes this is a problem for all of the third world.

Sadly, “even if they train, but should come back, we are starved of medical personnel.” Hani notes that there is not one well trained hematologist or nephrologist in the occupied territories, and this is true in much of surgery, medicine, and ob-gyn as well. I am surprised to hear him say, “One way to address this: how to change ratio male to female.  He notes that now the med school class is 60% female and he wants to increase this to 75% females, “because they stay, they are more loyal to their societies, stay with families and are more of use to the Palestinian population!”  His theory is that females, “do much better on post high school exams, have less diversions, are more focused, while males have other goals, politics, etc.” He wonders if women, “may be more intelligent, or more driven to try to prove themselves.” I am not sure how to wrap my brain around this reverse sexism, but I have to agree, this is a creative solution to a vexing problem.  I secretly wonder if once again, women hold up (more than) half the sky, put up with the less dynamic careers and keep the family functional.

“We don’t have good residency training, do not have the hospitals, and Israelis do not let us. Everything you build, then there is a fracas and then the whole thing collapses again.  This is a big problem.  Two days ago, the IDF entered the university at night, wreaked havoc on the infrastructure,” and they did the same at a university in Jenin and in Bethlehem, (remember the policy of collective punishment).   There are repeated mass arrests of students and professors, (collective punishment-still illegal). “Obviously what is happening, the Israelis are not interested in Palestinians having their own entity, all they want is ethnic cleansing, get rid of Palestinians and evict them. We are trying to develop, but nipped in the bud…We are fed up with all this talk about human rights. This is how it is on the ground…It makes your blood boil, there is a limit; what are the Israelis trying to do? They have Nobel laureates, etc, in Israel, but don’t they understand what is going on?”

The grinding reality is revealed by the fact that three weeks ago students were about to start two weeks of final exams. But students from Hebron (25 of 80) couldn’t get permits, so the exams were delayed and now as the clampdown continues, (people with IDs from Hebron are unable to travel), students are taking their exams at home from a computer or on pen and paper (you know, that little problem of needing electricity and internet connection while occupied), so the work is multiplied.

“Imagine [a student] prepared for exam, then cannot take it, then bunched together, this creates psychological trauma, [but] we do not have enough psychiatrists. There is not one child psychiatrist in the occupied territories.” Students get supports from tutors, secretaries. “One of our faculty’s house was ransacked in the night, I do not why.” He lived in Hebron, guilty as charged.  “This happened to students’ families as well, imagine preparing for exams, the students 17 to 18 years old,” and then the “oasis of democracy in Mideast” enters their bedrooms at night, finger on the trigger. So what does a 17 year old do with all that trauma and rage?

Hani describes what is going on, “It is madness.  We need to educate Israeli society, the majority is ignorant of what is happening in the West Bank.  The separation wall is a psychological barrier. They have succeeded, everyone behind the wall is a terrorist, and they are not interested in knowing what is happening. What is needed, to educate Israelis, how to get out of their isolation ghetto mentality.  We are also in a ghetto, two ghettos, this is more important than educating the Arab world. Human life is sacred, if you want to live with neighbors peacefully, then why are you doing this… Arabs, what have they done to Israelis? How many [Israelis] killed in buses? They [IDF] killed over a 1,000 people in Gaza. This is disproportionate killings; they are all the same, even doctors are participating in force feeding prisoners.”

Hani’s exasperated frustration is palpable. He states he is, “disenchanted with building bridges, when it comes to the crunch, they are professional killers. It is heart breaking as a medical professional, those people who they are detaining have not participated in any crimes.” There is “no court of law.”

We try to focus on the medical school, a six year program that starts after high school.  Hani describes a traditional curriculum that is changing to a more integrated organ-based approach next year. The first three years involve basic sciences, the last three years are clinical. They are also planning on a graduate entry program, four years of medical training after college, like most US programs. Students at Al Quds do their clinical rotations at affiliated hospitals like Al Mokassed, Augusta Victoria, St. Johns, and the Red Crescent Hospital in Jerusalem and hospitals in Hebron, Ramallah, and Jericho in the West Bank. He says there is a curriculum for the different clinical settings, but this is in theory only.  The hitch is that the first rate hospitals are all in East Jerusalem, so only the students that can get permits to enter Jerusalem can go on these rotations and the rest of the students are forced to train in what are seen as second rate facilities.

But medical care is even more complicated. The Ministry of Health runs community based clinics and the NGO, Palestinian Medical Relief Society, has clinics that are focused on providing health care to poorly served communities.  Hani suggests that all of these settings have issues around quality of care and he wants his students to learn medicine “in a proper manner.” The quality issue is a big one.  There are “no post graduate courses here,” no continuing medical education courses, (in the US I am required to do 50 hours of CMEs per year and that is part of the task of staying up to date). Additionally, “Everyone  doesn’t have a computer, cannot travel, cannot access villages, so logistics are big problem.” The school has no connection with UNRWA, the UN agency that provides health care in the refugee camps, and that care tends to be low quality, overwhelmed and underfunded.

In Gaza, the medical school, Al Azhar, is under the tutelage of Al Quds and the Hamas run Islamic University also has the same curriculum. (Yes there are medical students filled with aspirations and drive in Gaza and they get caught in the incursions along with everyone else.) Hani reports that the graduates do well despite the conditions, (although the last time I checked, the Gaza hospitals were still recovering from being bombed to smithereens and unable to rebuild basic infrastructure like drinkable water and stocked pharmacies so I suspect he is being a bit upbeat here).  There is also a medical school in Nablus, called an Najah.

Hani notes that the French government offers scholarships to two to three postgraduate students a year for PhDs in medical science or specialty training, others go to Jordan or the United Kingdom, “but they never come back.” He explains that the students make commitments to return, but then they buy themselves out.  They are the top 1% in Palestine, high achievers, they want to be good doctors, but “our hospitals and infrastructure are not conducive to that. Nursing is not that good, physical therapy is not that good. It is not a solid team, so it is much harder to do medicine here.  The pay is better, standard of living, career development all better outside.”

I wonder why Hani is still here.  He trained in the United Kingdom, but “my mother was ill and alone so I came back [thinking] I will stay for a year and then I got myself sucked up.” The immense need, the possibility to build something better, the inertia and grinding difficulty of getting through each day let alone planning a career or an escape, the small victories and sense of place, and then family and commitment and decades later…. He finds himself still here, talking politics and medicine with some curious folks from the US who are trying to understand.