I have been
looking forward to my day with Dr Khadejeh Jarrar, the head of women’s health
care from Palestinian Medical Relief Society. We are going to three
villages with a team from Medical Relief, UNDP (United Nations Development
Program), a representative of the Palestinian Authority, and members from the
local community councils to discuss how to create a more organized system of
health care between three towns that are trying to collaborate. Since I
am always stunned by the disorganization of health care delivery in these
parts, the NGOization of different compartments of care, and the consequences
to patients living in this disjointed and confusing world, this should be
interesting to see in action.
Nablus is a
gorgeous old city built on the palm and up the fingers of mountains that hold
it like a giant cupping of hands. The traffic is of the chest pain variety,
there are billboards for all sorts of international companies (two happy,
handsome guys drink Coca Cola, blond women with hair flying sell all sorts of
products including sexy wedding dresses to the covered women in the streets),
and Israeli military bases dot the hilltops. There are mountains of pita
bread and water melons on every corner and a clear feeling of being watched by
the guys above us.
We head to
the town of Burin, population 10,000, where part of the mosque is in area B and
part in area C so there is a threat that it will be demolished, (this kind of
humiliation and downright meanness takes real creativity). We enter the local
community health center where the hallway is lined with mostly women who
represent the community or work professionally in the clinic, plus the
representatives of the previously named organizations. The Director of
the Burin Charitable Association seems to be chairing. The clinic is trying to
provide services to the towns of Burin, Madama, and Asira al Qiblia. It seems
that there is a lot of physical community support for the center, (painting,
curtains, etc) but there are many complaints and conversations of the following
types:
1. The doctor comes to the clinic two times per week, which is an inadequate number of days and which results in a stressed out doctor, crowded clinic, short visits, and inadequate care, patients get angry, urgent patients cannot be seen quickly and there is a high level of frustration. The UNDP representative explains that their role is to support marginal communities to get access to care and given the occupation, perhaps they can build on the capacities of PMRS and the Ministry of Health working together. The nurse suggests that many services do not need a physician and that, for instance, the clinic had figured out how to provide vaccinations. If fact much of primary care that involves monitoring, height, weight, etc can be done by a nurse or midwife.
2. For
pregnant women, there is no female doctor, no reliable ultrasound; Burin
currently is seeing 35 pregnant patients, but they predict that number should
be 75, so women are going elsewhere.
3. There
is a lack of available medications (I think back to my trip last October, when
I was told there was no digoxin, a basic cardiac medication, available in the
West Bank). A patient who is on the council tells the story of her
epileptic son who was unable to get his (not sure if free or inexpensive)
medications from the Ministry of Health, she was told to drive to Nablus, so
she just paid for it herself in a local pharmacy. Another person
discusses the lack of insulin to be found in the Ministry of Health
pharmacies. Once a medication arrives, it is distributed to all the
Ministry of Health clinics but how does it get to the patients? The
clinic uses a computerized data base and can easily organize home visits and
screening. Another person talks about how time consuming it is to make a
referral to the Ministry of Health and wonders if they could have direct
computer access to their appointment system. (I have certainly had many
conversations back in the US non-health care system that remind me of this
one.)
4. Several
complain that there is no ambulance, no public transportation, and private
transportation is expensive. If someone fractures a bone or goes into
labor, it is difficult to get all the way to the Ministry of Health hospital in
Nablus. One diabetic, hypertensive man called an ambulance which never
came. He was taken in a private car and died on the way to the hospital.
It seems there is little coordination between the Red Crescent and the Ministry
of Health. One elderly lady was hit by a settler and injured; the IDF told them
she was stable, but the Red Crescent ambulance took her anyway.
Yesterday, a motor vehicle killed two people and injured four on the main road
of Nablus.
5.
Then there is the special issue of the nearby Jewish settlements that
frequently block access between the villages, burn farms and olive trees, grow
wild pigs that get released into the Palestinian farms and cause massive
destruction and no one knows how to get rid of them. The biggest complaint is
the frequent Israeli settler attacks; the lack of available ambulances, the PA
police are paralyzed and afraid to do anything, safe transport is desperately
needed. I discover that the clinic does not even have a phone line.
Everyone
agrees that the health committees should empower the local people to demand
their rights for quality services and PMRS supports this idea. On the
positive side, the Director of the Charitable society proudly shows off his
computerized records for all the activities in the center: the monthly visits
monitoring patients with chronic diseases, the educational consults for the
kindergarten teachers, the cooking and breakfast programs, the theater that is
being built, safety awareness programs, summer camps, the machine that is
available for villagers to make honey. The PA representative is from the fire
department and talks about the civil protection, safety courses, first aid and
CPR courses, the volunteer teams that support the villagers during settler
attacks, the training for evacuating the entire village in case of emergency.
We visit a room filled with handmade soap, handicrafts and pickled fruits. This
is a pretty impressive and well organized village.
Madama, on
the other hand, is in crisis. Their main source of water has been taken
over by settlers and they are reduced to carrying water of questionable quality
from a well in the town in large plastic buckets by hand or on donkeys.
We meet with the village council and besides the water disaster, contamination
from the sewer system, and the prevalent infectious diarrheal diseases, all the
complaints are worse. Although PMRS and the Angelican Hospital both have
clinics two days per week, they are on the same two days, there is little
coordination between all the players, the Ministry of Health is hopelessly
bureaucratic, there is little available medicine, and no capacity for supports
such as fire departments and ambulances. The stakeholders at the meeting agree
to set up a committee, create an action plan, and learn from the more successful
experience in Burin.
Asira al
Qiblia is the poorest and most marginalized of the three villages, a small,
dusty, crumbling town. It seems that there are no health councils, paved roads,
or water. They suffer from daily settler attacks and attacks on their
water system and infrastructure, so the villagers have lots of injuries and a
generation of traumatized children. Of the 3,500 villagers, (350 households)
approximately 100 families have health insurance. They buy water at
exorbitant prices, (a tank of 3,000 liters for 30 shekels which lasts 5
days.) The monthly cost of water per family is more than their total
monthly incomes and many have sold their cattle because of the lack of
water. In addition there are three nearby stone quarries so there is the
issue of dust related respiratory diseases and allergies as well as large
trucks loaded with stone.
This is
where I tend to shake my head in utter despair, but instead we are all invited
to one of the women’s homes for a feast. Palestinian resilience is always a
source of inspiration for me. The living room is filled with stuffed
couches and chairs, and decorated with intricately embroidered pillow cases,
lamp shades, and scenes of traditional weddings. We are soon sitting
around a long table facing enormous platters of mujadara (some kind of fabulous
grain and lentil combo) and thin cigar shaped yalanji (grape leaves) along with
the usual labneh (yogurt) flavorful salads, pita, pickled vegetables, water,
Sprite, aromatic tea flavored with mint, and small cups of Turkish coffee and a
crowd of women all encouraging us to eat more, (sounds of my grandmother).
These
village women are warm and tough. One speaks good English, went to
college, and tells us that women in the countryside want to improve their lives
and have projects like making honey, growing herbs, and raising sheep.
Many of the women attended university and many of their men are unemployed. In
Asira on 1/14/13, 70 women formerly registered an organization called The
Palestinian Foundation for Women; they are fixing up a donated house that has
no water, electricity, or plumbing facilities, and they are creating a women’s
center for training in crafts such as embroidery and knitting as well as how to
use more modern methods to make olive oil soap. She tells me most married
women are working, particularly as teachers, and they all giggle and kvell
about the new Arab idol from Gaza. The older woman who cooked the vast
quantity of food will not let us leave without doggie bags for the road and
will not take no for an answer (like I do not have a refrigerator). I
give her a thank you gift of an olive oil hand cream made in Davis, California
by a friend of my daughter’s and she gets out her local version in a plain
white bottle but smelling fragrantly of almond and apricot oil which is pretty
divine. Despite the challenges this village is facing, it seems that the
self esteem and integrity of the women is solid. They are not looking for
charity; they just want the opportunity to raise their families and live
productive, creative lives which seems utterly reasonable.
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