June 24, 2013 Nablus: Resilience and Resourcefulness

The drive to Nablus is uneventful, unlike the experience of two of our delegates who got stuck in a massive four hour happening at a checkpoint that involved many IDF and tanks and lots of waiting and cigarette smoking and no clear explanations. The Al Yasmeen Hotel on the edge of the Old City, seems to have perked up since our last visit, with many more guests and meetings, although, despite an attentive and friendly staff of attractive young men, and five separate attempts to book our rooms, they managed to screw it up anyway. Small potatoes in the occupied territories.

I have been looking forward to my day with Dr. Khadejeh Jarrar, the head of women’s health care from Palestinian Medical Relief Society. We are going to three villages with a team from Medical Relief, UNDP (United Nations Development Program), a representative of the Palestinian Authority, and members from the local community councils to discuss how to create a more organized system of health care between three towns that are trying to collaborate. Since I am always stunned by the disorganization of health care delivery in these parts, the NGOization of different compartments of care, and the consequences to patients living in this disjointed and confusing world, this should be interesting to see in action.

Nablus is a gorgeous old city built on the palm and up the fingers of mountains that hold it like a giant cupping of hands. The traffic is of the chest pain variety, there are billboards for all sorts of international companies: two happy, handsome guys drink Coca Cola, blond women with hair flying sell all sorts of products including sexy wedding dresses to the covered women in the streets, and Israeli military bases dot the hilltops. There are mountains of pita bread and water melons on every corner and a clear feeling of being watched by the guys above us.

We head to the town of Burin, population 10,000, where part of the mosque is in Area B and part in Area C so there is a threat that it will be demolished; this kind of humiliation and downright meanness takes real creativity. We enter the local community health center where the hallway is lined with mostly women who represent the community or work professionally in the clinic, plus the representatives of the previously named organizations. The Director of the Burin Charitable Association seems to be chairing. The clinic is trying to provide services to the towns of Burin, Madama, and Asira al Qiblia. It seems that there is a lot of physical community support for the center, (painting, curtains, etc) but there are many complaints and conversations of the following types:

1. The doctor comes to the clinic two times per week, which is an inadequate number of days and which results in a stressed out doctor, crowded clinic, short visits, and inadequate care, patients get angry, urgent patients cannot be seen quickly and there is a high level of frustration. The UNDP representative explains that their role is to support marginal communities to get access to care and given the occupation, perhaps they can build on the capacities of PMRS and the Ministry of Health working together. The nurse suggests that many services do not need a physician and that, for instance, the clinic had figured out how to provide vaccinations. If fact, much of primary care that involves monitoring, height, weight, etc can be done by a nurse or midwife.

2. For pregnant women, there is no female doctor, no reliable ultrasound; Burin currently is seeing 35 pregnant patients, but they predict that number should be 75, so women are going elsewhere.

3. There is a lack of available medications. I think back to my trip to the West Bank in October, 2012 when I struggled to find digoxin, a basic cardiac medication, for an older US delegate whose medications were stolen. (I finally located a private doctor who had a secret stash and we traded other hard-to-get medications for a week of digoxin in what felt like an illicit drug deal). A patient who is on the council tells the story of her epileptic son who was unable to get his (not sure if free or inexpensive) medications from the Ministry of Health, she was told to drive to Nablus, so she just paid for it herself in a local pharmacy. Another person discusses the lack of insulin, a basic medication for diabetes, to be found in the Ministry of Health pharmacies. Once a medication arrives, it is distributed to all the Ministry of Health clinics, but how does it get to the patients? The clinic uses a computerized data base and can easily organize home visits and screening. Another person talks about how time consuming it is to make a referral to the Ministry of Health and wonders if they could have direct computer access to their appointment system. (I have certainly had many conversations back in the US non-health care system that remind me of this one.)

4. Several complain that there is no ambulance, no public transportation, and private transportation is expensive. If someone fractures a bone or goes into labor, it is difficult to get all the way to the Ministry of Health hospital in Nablus. One diabetic, hypertensive man called an ambulance which never came. He was taken in a private car and died on the way to the hospital. It seems there is little coordination between the Red Crescent and the Ministry of Health. One elderly lady was hit by a settler and injured; the IDF told them she was stable, but the Red Crescent ambulance took her anyway. Yesterday, a motor vehicle killed two people and injured four on the main road of Nablus.

5. Then there is the special issue of the nearby Jewish settlements that frequently block access between the villages, burn farms and olive trees, grow wild pigs and release them into the Palestinian farms where they cause massive destruction, and no one knows how to get rid of them. The biggest complaint is the frequent Israeli settler attacks; the lack of available ambulances, the PA police are paralyzed and afraid to do anything, safe transport is desperately needed. I discover that the clinic does not even have a phone land line.

Everyone agrees that the health committees should empower the local people to demand their rights for quality services and PMRS supports this idea. On the positive side, the Director of the Charitable society proudly shows off his computerized records for all the activities in the center: the monthly visits monitoring patients with chronic diseases, the educational consults for the kindergarten teachers, the cooking and breakfast programs, the theater that is being built, safety awareness programs, summer camps, the machine that is available for villagers to make honey. The PA representative is from the fire department and talks about the civil protection, safety courses, first aid and CPR courses, the volunteer teams that support the villagers during settler attacks, the training for evacuating the entire village in case of emergency. We visit a room filled with handmade soap, handicrafts and pickled fruits. This is a pretty impressive and well organized village.

Madama, on the other hand, is in crisis. Their main source of water has been taken over by settlers and they are reduced to carrying water of questionable quality from a well in the town in large plastic buckets by hand or on donkeys. We meet with the village council and besides the water disaster, contamination from the sewer system, and the prevalence of infectious diarrheal diseases, all the complaints are worse. Although PMRS and the Angelican Hospital both have clinics two days per week, they are on the same two days, there is little coordination between all the players, the Ministry of Health is hopelessly bureaucratic, there is little available medicine, and no capacity for supports such as fire departments and ambulances. The stakeholders at the meeting agree to set up a committee, create an action plan, and learn from the more successful experience in Burin.

Asira al Qiblia is the poorest and most marginalized of the three villages, a small, dusty, crumbling town. It seems that there are no health councils, paved roads, or water. They suffer from daily settler attacks and attacks on their water system and infrastructure, so the villagers have lots of injuries and a generation of traumatized children. Of the 3,500 villagers, (350 households) approximately 100 families have health insurance. They buy water at exorbitant prices, a tank of 3,000 liters for 30 shekels which lasts 5 days. The monthly cost of water per family is more than their total monthly incomes and many have sold their cattle because of the lack of water. In addition there are three nearby stone quarries, so there is the issue of dust related respiratory diseases and allergies as well as large trucks loaded with stone lumbering through the town.

This is where I tend to shake my head in utter despair, but instead we are all invited to one of the women’s homes for a feast. Palestinian resilience is always a source of inspiration for me. The living room is filled with stuffed couches and chairs, and decorated with intricately embroidered pillow cases, lamp shades, and scenes of traditional weddings. We are soon sitting around a long table facing enormous platters of mujadara (some kind of fabulous grain and lentil combo) and thin cigar shaped yalanji (grape leaves) along with the usual labneh (yogurt), flavorful salads, pita, pickled vegetables, water, Sprite, aromatic tea flavored with mint, and small cups of Turkish coffee and a crowd of women all encouraging us to eat more; sounds of my grandmother.

These village women are warm and tough. One speaks good English, went to college, and tells us that women in the countryside want to improve their lives and have projects like making honey, growing herbs, and raising sheep. Many of the women attended university and many of their men are unemployed. In Asira on January 14, 2013, 70 women formerly registered an organization called The Palestinian Foundation for Women; they are fixing up a donated house that has no water, electricity, or plumbing facilities, and they are creating a women’s center for training in crafts such as embroidery and knitting as well as how to use more modern methods to make olive oil soap. She tells me most married women are working, particularly as teachers, and they all giggle and kvell about the new Arab idol from Gaza. The older woman who cooked the vast quantity of food will not let us leave without doggie bags for the road, (God forbid we feel hungry), and will not take no for an answer. The fact that I do not have a refrigerator and am likely to face more vast quantities of food at my upcoming visits does not seem to matter. I give her a thank you gift of an olive oil hand cream made in Davis, California by a friend of my daughter’s and she gets out her local version in a plain white bottle but smelling fragrantly of almond and apricot oil which is pretty divine. Despite the challenges this village is facing, it seems that the self esteem and integrity of the women is solid. They are not looking for charity; they just want the opportunity to raise their families and live productive, creative lives which seems utterly reasonable.

Just as I am promising myself never to eat again, I discover that tonight’s social activity is a family dinner with one of the main organizers of the Farah Center in Nablus where many of the delegates are spending their clinical days. A few hours later I am in the arms of another warm and welcoming Palestinian family, four lively children, a stunning view of the sun setting over the Nablus hills as lights start twinkling in the dusk, and of course a tasty dinner of overwhelming proportions. We laugh and joke into the evening playing a goofy, fast paced card game called Uno. Another resilient family refusing to be silenced in the midst of occupation.

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