June 25, 2014 Teaching in the Ghetto part one

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, 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, and 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 fourteenth 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, United States, 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 shortcomings 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 medical 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 another in Bethlehem (remember the policy of collective punishment). There are repeated mass arrests of students and professors (collective punishment?still illegal under international law). “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 (twenty-five of eighty) 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 [the exams are] 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 know why.” He lived in Hebron, guilty as charged. “This happened to students’ families as well, imagine preparing for exams, the students seventeen to eighteen years old,” and then the “oasis of democracy in Mideast” enters their bedrooms at night, finger on the trigger. So what does a seventeen-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 one thousand 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 who 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 United States, I am required to do fifty 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 a 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 and the phosphorus bombs 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 United States who are trying to understand.