Ran takes me into the Open Clinic for some reality-based learning.
The rooms are basic health center with shelves of paper charts and two volunteers engaged with their computers. The dress is casual shorts and tank tops, the waiting room rows of black plastic chairs.
Today is appointments only with the specialist, so I will not be seeing the usual flood of humanity, the human refuse as Lady Liberty would say.
Ran explains that in Israel, much like the United States, if someone presents with a life-threatening emergency to a hospital, they must receive care. (Good!) But everything else, including things that are in the long term life threatening, like out of control diabetes, is turned away if the patient has no insurance. (Health care as a privilege not a right.) And of course long-term rehabilitation, mental health, and medical follow up for chronic disease are hindered by access, language, poverty, and culture. Since 1998, the Open Clinic has seen thirty-five thousand patients, and many travel from far to be seen. PHR used to serve mostly migrant workers (after Palestinians from the territories were no longer permitted to work in Israel and employees started importing low-level workers from Thailand, the Philippines, and the rest of the Third World.) Now PHR is mostly seeing asylum seekers and these folks are different: their communities are weaker, their leaders are under arrest; they are usually not working and suffer from all the ills of poverty as well as trauma and displacement. They are alive often because they are basically physically resilient young men. While much of the medications are donated and thus free to the patients, they often need shekels to get home, to eat. They are a more desperate population than the migrant workers. The clinicians are seeing more diabetes and hypertension, there are three thousand volunteers, but eight hundred or so are really active in the organization doing regular clinics.
The Open Clinic sees five thousand patients a year, “less patients but bigger problems than before,” and includes general medicine, ob-gyn, pediatrics, and mental health. I sit down with the clinic coordinator, a feisty, dedicated young woman, former engineer, masters in international relations, and now a paid employee. Her job is to negotiate for the patients, to find the least costly, most possible appointments for specialists, labs, hospital procedures, surgery, and cancer therapy. Working with Assaf, a social care organization, they address medical as well as social issues like homelessness. She also is involved with the United Nations High Commission for Refugees (UNHCR) and helps refugees resettle in countries like Sweden, Denmark, or Norway, obtain citizenship and then medical care for severe chronic illnesses. I try to imagine fleeing something horrific in Sudan, running/hiding/walking across the Sinai, detention in Holot, some terrifying disease in a strange country, and then you end up in a place where everyone is blond, there is no sunlight half the time, winters are really cold, and the language is beyond comprehension. And you are sick and alone? This is staggering; the coordinator admits to many sleepless nights and desperate phone calls.
She talks about how the clinic is seeing many young patients with kidney failure and diabetes, maybe a consequence of toxic pesticide use, of Africans dying of AIDS in Israel in 2014, “This is ridiculous.” And then in 2010, Sister Azezet, who volunteers at the clinic, noticed many pregnant women coming in asking for lateterm abortions with unusual injuries and trauma. The Sister interviewed 1,300 women and discovered the rape and torture camps, the human trafficking in the Sinai, and brought this to international attention. “No one asked, what happened to you?” This is health care in its broadest social context.
The law in Israel now states that if an employer hires a migrant worker, they have to pay for health insurance. But when the employee gets sick, they get fired, and poof, no insurance. So the Open Clinic sees many Eritreans (they now have an interpreter), as well as migrant workers from the Philippines, China, and India.
And then there are the folks from Nigeria, the Congo, Ivory Coast, and Guinea who have overstayed their work permits and live in the shadows, at risk for deportation at any time. Add to that a small number of Russians who arrived with the big migration but are not recognized as Jews and thus have no health insurance (really? Insurance for Jews only?) and the Palestinian women from the territories who married Palestinian men with Israeli citizenship and are unable to obtain legal status.
PHR is doing advocacy work on behalf of the asylum seekers now detained in Holot; they have gone to the Supreme Court applying for release from the center, stressing the illegality of detaining these men. She notes that public opinion is definitely against the refugees, who have been defined by Israeli government mind-makers as “infiltrators”; PHR is accused of supporting criminals, rapists, and disease carrying Africans, the scary, faceless, black other. “It is hard to humanize them.”
The first woman the coordinator sees today is a fifty-five-year old Filipino woman who has been in Israel for eleven years, has had no contact with her family during this time, speaks fluent Hebrew, and has recently had surgery for metastatic uterine cancer. She needs further treatment and the coordinator and I understand that she will most likely die alone and unhappy in Israel. I look at the pack of Marlboros next to the computer and the jumbo size bottle of Coke; this is burnout kind of work and the coordinator pours her heart into each case. The next patient, an Eritrean woman with a four-year-old son, also speaks Hebrew fluently, has a mass in her neck, brings lab results, and gets sent off to an ENT doctor. She is followed by an Eritrean man who speaks sort of English, has back pain, and is unable to work, now is dizzy. She asks him to come back tomorrow for the general doctor. I suggest we check his blood pressure and it is significantly elevated.
I then join the gastroenterology specialist; he is a good-hearted soul who is more in the classic doctor mode. He assesses each patient to see if there is anything life threatening or GI and does not sink his time into the vast psychosocial morass that is probably the source of much of the medical complaints. The first patient surprises me, a friendly, well-organized African American woman from Kansas City, Missouri, with lists and notes, who made aliyah with her family three years ago and is now living in Ashkelon, awaiting citizenship and health insurance. She has multiple medical problems, including a life threatening liver disease, and her granddaughter whose name is Aliyah is having her Bat Mitzvah in a week.
“Can I drink wine for the blessing?” I would love to know the rest of her story!
She is followed by a series of Sudanese and Eritrean men with various levels of disease, lots of stress, experiences in the Holot detention camp, working or out of work, worrying about deportation, “I am not guilty, why keep me there?” Some speak Hebrew or a variant of English or Tigrenya. They are all thin, frightened, obviously depressed and sometimes angry; their eyes give them away.
They are trying to negotiate a system that they do not understand, a language they do not speak, and a country that wants them to go away. The doctor does the best he can given the limited resources, the lack of communication between institutions, the need to beg and borrow to get medications, testing, results. No one is happy and I am haunted by the pained expressions and sorrow framing these difficult interactions. They say a society is only as strong as its weakest link and this link is clearly broken.