June 25, 2014 Medicine: If It Doesn’t Kill You, It Makes You Strong part two

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 and the resultant delays, some had six exams in one day). Many are about to graduate, so they are so done with all the frustrations 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 Qalandia 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-Najah 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, but are very busy, have active private clinics, and teaching medical students is often low on their list of priorities. In addition, unlike hospitals in the United States, 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 short miles away and you can be sure they have enough fentanyl and IV 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. If they only come back.