June 22, 2013 Symbolism meets solidarity: the Saturday mobile clinic

I have to interrupt this message: Last night around midnight, the streets all over Palestine erupted with joyous crowds, cars honking in a delirious cacophony. A young man from Gaza, Mohammed Assaf, was voted the winner of Arab idol and either Abu Mazen or UNESCO (not clear) named him an Ambassador of Good Will. A victory for Palestine, and I might add, a victory for the entertainment industry and adoring women everywhere.

Bright and early, three of us take a service, a van that takes multiple passengers, to Khalil otherwise known as Hebron, through open checkpoints and ominous but quiet guard towers. We meet up with Dr. Othman, a dentist and Dr. Hassan Abu Amro, an optometrist trained in Saudi Arabia, in preparation for traveling to the village of Idha, eight kilometers from Hebron, just along the Green Line. We are traveling to the Saturday Mobile Clinic with Physicians for Human Rights – Israel and Palestinian Medical Relief Society. We start listening to familiar stories.

Idha is surrounded by three Jewish settlements including Adora and Telem. Because of permits and checkpoints, travel in and out has become extremely difficult. The quantity and quality of water in Idha is problematic due to the large allotments going to the neighboring settlements, and the village is plagued by rats which can be seen jumping amongst the vegetable stands. Poverty is on the increase and the separation wall has wreaked havoc with the economy and people’s personal lives for the past five to six years.

In desperation, the villagers started collecting garbage, metal, car parts, and burning tires to get the metal and sell the metal to the Israelis. The burning garbage and tires created a massive, toxic smog and predictable health problems. Combined with the polluted water, PMRS is seeing more diarrhea, asthma, miscarriages, diabetes, hypertension, and smoking. “That’s stress.” PMRS and Red Crescent clinics, the private sector, and Ministry of Health hospitals cannot handle the community’s medical needs. Hassan also notes that no one wants to talk about cancer but the Dimona nuclear reactor is near Hebron. Israelis nearby receive some kind of prophylactic pills (?thyroid) to reduce their risks, but nothing is offered to the local Palestinians.

More fragments of conversation:

Yesterday 15 settlers with guns blocked a nearby road, threw stones and were protected by the IDF for two hours. This also happened in Beit Ommar.

The IDF is becoming more aggressive (how can this be possible?) and are training dogs to attack when they hear certain words like Allahu Akbar (Did you pray today?)

There is a proposed law in the Knesset to make it legal for settlers to fire on Palestinians (which of course they are already quite adept at doing), a sort of legal white washing stand your ground.

Both men are thoroughly disgusted with the Palestinian leadership and elite power holders. They are “thieves;” they have stolen international aid money and will steal more if Kerry reinvigorates the (useless) negotiations and aid programs.

Nabil Shath, a Palestinian negotiator, recently explained to his Israeli associates that the PA is spending more money on Israeli security than on Palestinian health and security combined.

Hassan is warm, obviously intelligent and insightful. He worked in Saudi Arabia for 17 years, and lived in a special compound so his wife and four children had more personal freedoms than those outside the compound. If they left, he had to drive his wife; she had to cover herself, etc. They came back in 2000 because he felt there was going to be a state and he wanted to serve his people, but now he worries, “For my kids and their lives, their futures. What should I tell them? Sometimes I stand stunned. Am I going to create more hate? But still they can see what is on the ground.” His 23-year-old son, trained as an electrical engineer in Egypt and now unemployed, feels totally frustrated and wants to leave.

We drive into the village and see large bales of hay and huge mountains of charred metal fragments. For reasons that are not entirely clear to me, the mobile clinic is being “honored” by a large number of fully armed Palestine National Security forces who line the streets, direct the vehicles, and line up for photos with clinic staff. We crowd into a large room and on the stage there are municipal and PA dignitaries, Saleh who directs the mobile clinic from PHR Israel, and Alan, one of our doctors, sitting in front of a large photo of a smiling Arafat. We hear a history of the town and a thousand thank yous in Arabic and Hebrew as a large crowd of patients gathers outside.

And then we start seeing patients. How can I describe this? A local family doctor who will be my interpreter and see obstetric patients, a nurse from the US, and I set up our “office” in a classroom. We have a real exam table, an ancient ultrasound machine, and I have brought a flashlight, large bottle of Purell, various surgical instruments (to remove IUDs, sutures, etc), and a measuring tape. I suddenly realize there are no drapes (not unusual) but even more striking, no gloves and no speculums and no basic lab work. A challenging moment for a gynecologist. (The gloves are finally located.)

And then the work begins, a veritable flood of women in hijabs, blue, black, plaid, sparkling decorations, and long jilbabs, buttoned up to the neck and long sleeves, one naqap totally covering a lovely woman’s face. She flips it back when she enters the room. I try guessing ages and realize that everyone ages prematurely under the stress of poverty and occupation. The heat is oppressive, and we are dripping with sweat. I feel for the women who are covered. The women present alone, in twos and threes, some with small children, some argumentative, some focused, and everyone has an earnest story and a long list of medical issues that frequently include back pain, abdominal pain, vaginal discharge, symptoms of urinary tract infections and hot flashes. There are questions about irregular bleeding, pain on intercourse, infertility. Everyone who is not trying to get pregnant has an IUD. I try to reach across the language and cultural barriers; instead of, “Are you sexually active?” I ask, “Are you married?” I already know that many women take hormones to delay menses when they travel to Mecca. I am listening carefully, empathically, woman to woman. There is no medical charting, no vital signs, no prevention, but soon we are in a rhythm of brief history taking, strategic exams, lots of education and empathy, and then a wild search through the available donated medications and decision making for referrals for a variety of testing. I am sure many symptoms are stress related and there is no simple treatment for that. My basic strategy is: Is this very serious? What is the most likely diagnosis given an utter lack of adequate information? What is the most we can do quickly here? The hardest part for me is the women with menopausal symptoms. I have always wondered how women covered in multiple layers deal with hot flashes and it is a challenge to give culturally appropriate advice. And of course we have lots of antibiotics and antifungals, and steroid ointment, but no free hormone therapy and I have no idea what is available in local gynecology offices. I have heard there is a rich herbal tradition in Palestine, but that is way beyond my US, first world experience.

Hours later, the clinic is over and the women still waiting are angry and disappointed, but turned away by PA soldiers with guns. I have seen 24 patients and the entire staff has seen over 700. I feel a bit run over and my pregnant colleague is wilting, more than tired. The organizers are pleased and we are hosted by the village with chicken, rice and Turkish coffee with more officials and more men with guns.

The power of working in this Saturday clinic for me, year after year, is hard to explain. Symbolism meets solidarity. There were women who actually received appropriate care by my first world standards, and I found one woman with a breast mass and one with a pelvic mass who definitely need further care. But more importantly, the women understand that a doctor from some faraway place came to their forgotten village to provide care and see them as deserving human beings. They are not invisible. I am also working in solidarity with the Israelis (Jewish and Palestinian) and the West Bank clinicians who are swimming against the cultural and political tides of their own societies and I want to stand with them as well. It is really the most concrete thing I can do.

Share this to: