January 14, 2011 An NGO is not a health care system

For the second week of the delegation, we divide into different interest groups and the medical folks are based in Nablus, working with Palestinian Medical Relief Society. On the second day we are standing in the waiting area of the Community Based Rehabilitation offices when a staff member, a beautiful somewhat demure woman with large black eyes and a graceful white hijab framing her face, beams and offers us chocolates. I decline, (I am still recovering from breakfast), but she insists. “You must, my father just got out of prison and we are celebrating.” We learn he was imprisoned for four years. I take the chocolate.

A nurse practitioner, another ob-gyn and I spend four days working and observing in PMRS clinics in Qalqilyia, Tulkarem, and Mythaloon (near Jenin). PMRS provides 40% of the health care in the Occupied Territories and as I have previously described, is a major NGO working on empowerment and education issues as well.  This experience provides us with the opportunity to work in solidarity with Palestinian colleagues and to bear witness to their lives, as well as to see a very intimate picture of health care and women’s lives in this society.

The daily morning van or car rides involve bumpy travel through stunning scenery, terraced hills, rows of olive trees and other crops, checkpoints that are rarely staffed, and Jewish settlements perched on hills, surrounded by barbed wire, walls, and security apparatus. There are massive USAID road building projects which I am told ironically legitimize the double road system in the West Bank, one for Israelis (Jewish settlers) and this one for Palestinians.

The incredible fragmentation of care between PMRS, the Ministry of Health, UNRWA (for refugees), and the private sector is staggering. Pregnant patients may get free care at an UNRWA clinic, but stop in at PMRS for a prenatal ultrasound. Labs are done at a variety of locations (with variations in quality) so communication and follow up are problematic. Some of the private care that patients reported is best described as creative and unrelated to general medical practice, but clearly lucrative. A 42 year old woman was given a fertility drug to treat abnormal bleeding because her ovaries were “too small.” Bizarre. There is no preventive care outside of pregnancy. Drugs prescribed are often not taken due to cost and lack of insurance. Patients may deliver in an UNRWA hospital, Ministry of Health or private hospital. Fortunately PMRS, in conjunction with a number of other NGOs and organizations, created a prenatal record that each patient carries with her and theoretically contains all her critical information and testing. This is totally dependent on the clinician. They do not get delivery summaries from UNRWA hospitals. There are a variety of protocols for care which seem to be followed differently in each center.

The women all wear hijabs, occasionally their faces are totally covered except for their eyes, and they flip back the cover when they enter the office. The patients sometimes come alone or often with children, a sister, mother, mother-in-law, or husband, and their level of empowerment is reflected in the interactions that even I can understand. For the exam, the relevant body part is revealed and there is a general reluctance to have pelvic exams. There are no clean drapes and the general level of hand washing and office hygiene is fairly third world, and there is minimal privacy. It seems that IUDs are popular for family spacing, with some women also choosing birth control pills. Condoms and withdrawal are also occasionally mentioned. Tubal ligations are forbidden for religious reasons and permission is sometimes sought from the local mufti who usually refuses. In the more rural areas, some women are second or third wives (I am told the maximum is 4, but Bedouins may have more, official and unofficial wives) and this seems to be a complex societal phenomenon, frowned upon by the more educated.

I observe that women are valued primarily as wives and mothers and there is intense social pressure to be married and pregnant, sometimes as young as 15. I am told that a young wife is more easily controlled by her husband and mother-in-law. Then there is the expectation that the woman will produce sons, and if there are daughters, infertility, or multiple miscarriages (which are common as many marry close relatives and have genetic issues), a man may take another wife. I am told that in Hebron, each wife actually chooses the next one. (There seems to be a lack of understanding as to who is really responsible for the gender of the child.) In some areas there is a shortage of available men due to deaths in the Second Intifada and marriage may appear to offer a young woman freedom from her father and her brothers and financial security. Then there are economic reasons for more wives and children, commonly seen in rural agrarian populations. In general the women we see are having large families. To me, the newly married women look very young, often unprepared for sexuality, childbirth, and parenting, but they exist within an enmeshed and involved family system. It seems to be that sometime in their early thirties, women often appear to age rapidly, a combination of many pregnancies and their enormously difficult lives.

The three doctors we work with are very different: one from Rumania, who married a Palestinian when they were both in training, one Palestinian born in Kuwait who spent years getting a Palestinian ID and lived illegally in Tulkarem, one from the area and trained in Jordan. The Rumania doctor has a gentle caring style and her patients clearly relate well to her. She travels every day from Tulkarem and describes the daily checkpoint feeling of humiliation “like an animal in a cage, I feel like a cow,” as if her soul was branded by this experience. In the past she has waited for hours at these checkpoints, or hiked through orchards to get to work, but lately the checkpoints have been easier. She does antenatal and postnatal care, gynecology, family planning, and treats sexual problems, occasional domestic violence, and bedwetting in children. She is trained by UNRWA to treat children if they come with their mothers. She says that it is very difficult for women in this society to be open about their family problems.

This doctor has lived in Palestine for more than 20 years and arrived as a young wife, totally unprepared to be greeted by the First Intifada and a strict mother-in-law. She was determined to work and described herself as “a kangaroo,” bringing young children to the office and seeing patients and mothering simultaneously. She has three children: a doctor son in London, a doctor son in Egypt, and a daughter studying architecture in Tulkarem. She talks about Palestinian men’s “stupid proudness.” She has a Palestinian ID and has retained her Rumanian passport, “my only chance for freedom.” She also works with her gynecologist husband in a private clinic in Tulkarem. There is a wistfulness in her voice, a sense of pain, frustration, resignation, and perhaps a profound ambivalence about the life choices she has made and the patriarchal society in which she has found herself. She talks about her “Romeo and Juliette” experience in Rumania as a young woman. She keeps shaking her head and reiterating that her family comes first and that she has done everything for her children.
I have described the other two doctors more extensively in my book, Broken Promises, Broken Dreams.

The first two women do more listening and explaining, the third is very business-like and sees a large volume of patients efficiently. They are all dedicated and hardworking and have faced many struggles as working mothers. The style of medicine is this strange combination of first and third world with the restrictions of occupation and poverty added to the mix. I learn that much that I am seeing is called the “syndromic approach,” developed by WHO for resource poor areas. Nonetheless, I find it somewhat bewildering that almost every woman receives and expects an ultrasound exam, (very first world), but there are none of the very inexpensive materials needed to correctly diagnose vaginal infections. Basically the recommendation is to treat for everything that is likely and if that doesn’t work, to do a “high vaginal swab.” I wonder what the risks are of such an overuse of antibiotics, suspect that it would be cost effective to diagnose and treat more accurately, and I still do not understand the high vaginal swab concept. Clearly coming from the first world, I am trained in evidence-based medicine whenever possible, quality improvement programs, and closer monitoring and training, which clearly are not possible here.

We learn that breast cancer is common amongst Palestinian women and is seen in women sometimes in their 20s. Good statistics are nonexistent. Because there is no preventive care, diagnosis usually occurs when the disease is advanced, and mastectomy is done most commonly. There is no radiation treatment available in the West Bank as the Israeli government does not allow radioactive medical materials to enter the region, another example of health care being highjacked by the occupation. Treatment is hard to get in Israel and expensive in Jordan. Chemotherapy is available but there are limited supplies and frequent shortages. Five months ago USAID brought in a mobile digital mammography van which is supposed to do widespread screening. I am told that there have been problems with patients getting their results and it is unclear how successful this program is, although it is promising. The Ministry of Health is also developing mammography programs in the major cities.

One of the most uplifting experiences is meeting with two health workers. These women seem feisty, savvy, and well trained; their job is to make home visits and do family care, addressing both physical as well as mental health needs. One who describes herself as a political activist, smiles and says, “The women are ruling these days.” The other talks about how she has to build a relationship with the family in order to understand their issues. She describes a young boy who developed bedwetting, personality changes, phobias and stuttering when his home was invaded twice by the IDF when they arrested two of his older brothers. She mentions a case where a young boy was sexually abused by a 15 year old cousin, and a big problem with crystal meth in Qalqilyia. She has had success in treating all of these patients.

We leave the clinic in Tulkarem and decide to have lunch in a local restaurant that looks like a cave with a huge mosaic/three dimensional clay relief of the Old city. There is a large family enjoying themselves in the restaurant as well. When we are finished, one of the men comes up to us and asks if we are from Machsom Watch, the Israeli women who monitor checkpoints. We explain what we have been doing and he explains that he is a member of the Bereaved Parents Circle, Jews and Palestinians who have lost family to violence and who come together to heal personally and within their own communities, educating about the need to end violence. Despite our protestations, he insists on paying for our meal, thanking us for caring about Palestine, bearing witness and hopefully making the lives of invisible people more visible to the international community.

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