My six day experience in the Middle East
http://www.100md.com
《英国医生杂志》
1 studentBMJ
The studentBMJ editor travels to Israel and the occupied territories, trying to make sense of an impenetrable situation. This is her diary
Introduction
The team
Accompanying me is Andy Aitchison, a freelance photojournalist, and Michelle Hawkins from MDM UK. We've communicated daily on the phone, trying to arrange the complex logistics, but only manage to meet for the first time at the airport.
Before leaving I received a brief warning that I'd probably be in for harsh scrutiny on arrival at Ben Gurion airport. So I was relieved to be welcomed only with a glower, a few quickfire questions, and the request for evidence that I was from the press.
Jean Sebastién Dy, the general administrator of MDM in Jerusalem, and Sebastién Laplanche, general coordinator, meet us at the airport and take us to our accommodation in an MDM marked car with flags flying from the back. Our base is the newly refurbished MDM staff house in East Jerusalem, the predominantly Palestinian part of Jerusalem. Most of the other NGOs and UN buildings are located in the vicinity. Jean Sebastién says: "The Palestinian areas are friendlier than the Israeli parts, and we're also here to work with the Palestinian community."
Sunday
Passing the Dead Sea and Jericho, both below sea level, we travel on the smooth highway alongside the fertile banks of River Jordan, looking over to the mountains of neighbouring Jordan. The road, primarily for the use of settlers, is named Gandi Highway—the nickname of Rehavam Ze'evi, the assassinated ultranationalist Israeli tourism minister, who supported a transfer policy advocating that all Palestinians be forced into Jordan.
Mobile service for women and babies
We're on our way to Ein al-Beida, a village in the north Jordan valley, where MDM jointly runs a mobile woman and baby preventive health service with British medical relief agency Merlin and the Union of Health Work Committee (UHWC). It focuses on cancer screenings for women, developmental evaluation for children, nutritional assessments and counselling for families, and personalised health education sessions in the home.
Before we enter the road to the village, a red Israeli government sign warns that Israeli citizens are forbidden from going any further by order of the IDF commander. Entrance is allowed only after prior coordination with the responsible authorities. A multitude of similar signs is dotted around the West Bank.
The UHWC team are late. They've been held up at a checkpoint. Although there are supposed to be fewer travel restrictions for health workers, I'm told that they can't always move around freely and are often held up at checkpoints. Nevertheless, it's easier for them than for patients. The facilities may exist in towns, but, after the escalation of violence during the second intifada, the IDF tightened security and further increased the number of checkpoints, making it impossible for Palestinians in the West Bank to travel freely. I'm told that sometimes Palestinians are forbidden from travelling on many of the main roads in the West Bank.
The wall in Abu Dis makes travelling to Jerusalem's Augusta Victoria Hospital (tower is in top left of photo) and Dome on the Rock more complicated
Credit: ANDREW AITCHISON
People don't understand preventive health care
Most of those scheduled for appointments fail to turn up. As a reminder, their names are read out over the village mosque loudspeaker, which the muezzin normally uses to issue his prayer call. Suzanne Abujeradeh, outreach coordinator for the northern West Bank, explains that Palestinians generally do not understand the importance of preventive health and will try to access health care only when they are ill. We decide to trudge down the muddy dirt tracks to visit the families in their homes instead—a delegation consisting of two healthcare workers, Elham Aqab and Noujoud Shalabi, Michelle, Andy, Nadia Dibsy (our translator and advocacy officer for MDM), and me. No one seemed the slightest bit perturbed by our international ensemble and welcomed us in with sweet tea and Arabic coffee.
Looking after children
The responsibility for looking after the children falls to their mothers and grandmothers. Iron deficiency anaemia occurs in over half the young children in Ein al-Beida, as parents sell their fresh produce and feed their children tea and bread, Elham says. She explains that the trick is to convince the grandmothers to change the feeding habits—the mother in law exerts a rather large influence over parenting behaviours.
Back at the clinic, the other health workers are running a health education workshop. The children who attend are accompanied by their mothers all dressed in their smartest clothes and shoes, although the heavy rainfall has turned the paths into a mud bath. In an attempt to combat the prevalent anaemia, the health workers have brought boxes of fresh food and show how to prepare it.
On the way back to Jerusalem we pass gated Israeli settlements. They have their own healthcare and urgent care centres; some have helicopter access to hospitals in Jerusalem and Beit Shalom to the north. But Kimberley says it's almost impossible for Palestinians to access the settlements. She adds that many Palestinians she meets would relish the chance to receive treatment from Israeli doctors—their training and facilities are held in high regard.
Tuesday
Nablus, in the north of the West Bank, is surrounded by steep hillsides forming a basin, containing the main town area. Bordering the town are watchtowers and a wire fence patrolled by Israeli soldiers, while the two main entrance points at either end are marshalled by checkpoints. As we passed through the Huwara checkpoint on the outer edge of Nablus, the atmosphere changed; the tension was palpable. It was the only time I was advised not to mention my surname.
A soldier climbs on board a PRCS ambulance to check a pregnant woman for explosives at the Az Za'ayyem checkpoint
Credit: ANDREW AITCHISON
Into Nablus
Ours was the only car queuing to be let through by Israeli soldiers, but we didn't move for about half an hour and watched the soldiers at work. Palestinians of different ages queued behind a fencing barrier to our right, some holding piles of textbooks, others clutching bags of food. Tightly pressed up against each other, people shout angrily as someone pushes in ahead. A few look into our car, their faces blank. By the time we've crossed the checkpoint, only three people on foot have been searched and passed through into Nablus.
The road into Nablus circuits the gaping carcasses of buildings that, I am told, have been destroyed by tanks; the road itself is cracked by the passage of heavily armoured tanks. Apparently Nablus was once an attractive town.
Our first stop is the dispensary in the old town. Established in 2002 by Nablus municipality, it's now completely funded by MDM and provides primary health care, medication, and lab tests, but facilities are basic. A lone biochemist collects the samples and operates the old fashioned centrifuge and microscope, while Dr Bashar Jaber, a general practitioner, runs the clinic. The waiting room is cold and crowded, and, judging by the coughing and sniffling sounds, there's a virus doing the rounds.
I chat to Dr Jaber for a while—he's hoping to sit his Professional and Linguistic Assessment Board (PLAB) exam in London soon. We chat about the United Kingdom for a while—his uncle coincidentally taught at one of my placements at medical school. The conversation then shifts to medicine.
Current health problems
Nowadays, Dr Jaber says he sees a lot of people with mumps and measles, whereas 15 years ago such infections were rare. He puts this increase down to incursions and curfews, which impede physical and financial access to health care.
Another explanation I'm given is that boxes of vaccines have been denatured as the army search them for explosives. The result has been outbreaks of measles—children have received ineffective injections leading to a breakdown in herd immunity.
Administrative delays
Dr Jaber also talks about his time as a doctor in East Jerusalem, practising at the Augusta Victoria hospital. For the first two months of his rotation, he didn't have a permit to enter East Jerusalem, so he took a circuitous journey to Abu Dis to jump over the wall. At other times, he says, he was turned away from Qalandiya checkpoint or had to spend weeks sleeping in the hospital to ensure he would be able to make it to work. Not only did he have a West Bank ID—worse still, it was issued in Nablus. But if there were difficulties for him, for Palestinian patients with a West Bank ID attending the hospital it was even more complex, particularly for those with chronic illnesses requiring regular treatment—each session requires a permit from the Israeli authorities, he says. For most patients, this entails a visit to the civil administration headquarters in their town, bringing with them a written report by their doctor. The hospital also needs to send an accompanying fax. Delays in this process may happen, he adds, which can influence the disease progression in people requiring interventions at specific times.
I ask him candidly what the solution is, commenting about the lack of airtime on my dictaphone. He laughs and explains diplomatically that his nostrum would start with "a change of politicians on both sides."
International intervention is needed
The community in the surrounding area is poor, and its movement is restricted by frequent curfews and incursions by the Israeli army. Sandrine Pont-Turco, MDM's field coordinator in Nablus, says that international NGO intervention is needed in Nablus because NGOs are able to set up direct links with the "IDF or IOF" (IOF is the so called Israeli occupying force—a term used to describe the IDF by some Palestinians) on a regular basis and also the District Coordination Office (DCO). This enables NGOs to liaise with the army during incursions and curfews to ensure the safe passage of staff and patients. She cites the six day curfew in the old city in August 2004 as an example. People were unable to attend the dispensary, so staff from both MDM and the Palestinian Scientific Medical Association went to collect patients from their homes, while briefing the army coordination officer about their movements.
Sandrine also explains that they are able to help fund clinics and arrange for mobile facilities to visit surrounding villages. "Nablus is a closed city," she says. "People from villages find it difficult to get in to access services."
On the edge of Nablus, close to the biblical site where Joseph was pushed down a well by his brothers, is Balata, a Palestinian refugee camp home to hundreds of people displaced during the 1948 and 1967 Israeli-Arab wars and their descendants. Houses built close together with little space between them are easing the spread of infectious diseases. Roads in the camp are in a pitiful state and every so often an earth mound restricts access.
Mental health issues
Escorted by two guides, Andy disappears between the ramshackle houses to take photos; a group of children behind him chant "Madrid." Some play with toy guns made from bits of wood, others have their hands on realistic copies. Young men hang around the "martyr's cemetery"—where people killed in the course of conflict are given the status of a legend—with little to do and looking bored. Bassam Marshoud, a Palestinian psychologist working with MDM, explains that because there's restricted movement, there are few jobs and people can't go elsewhere to work, making young people feel hopeless, worthless, useless, and humiliated. It's clearly not something that has gone unnoticed by political organisations, which flypost the area with leaflets featuring young, bearded, musclebound men toting rifles.
Working in a formal setting with children...
A group of four social workers arrives at the MDM house to receive training from Sylvie Mansour, a consultant psychologist working with the Palestinian Authority to improve mental health facilities, which are in desperate need of developing. Nablus has seen an increase in social problems both in children and in adults since the second intifada. Domestic violence has escalated as women become the brunt of men's frustration precipitated by unemployment and the perceived futility of the future. Sylvie also says it's worse for young men, who are traditionally the head of the house and are raised with the expectation they can do what they want, unlike girls, who have had relatively restricted freedom. "When they realise that going to university will have little bearing over their job prospects and that they can't do what they originally planned, it's when their mental health problems start," she says.
Children truant from school to earn money for their family or because they don't see the point in attending school when their prospects will be determined by other forces. At best, they ask why go to school when they won't be able to leave Nablus. At worst, they question the value of living. Violence between children has risen too, as they emulate what they witness both on the television and on the streets.
However, Sylvie is careful not to "psychiatrise" children or see them as potential cases. She wants to establish schemes that give children something to latch on to and works with their mothers to illustrate how they can protect their children. She is also working to change people's perception of mental health problems they encounter. Rather than believe that their disquiet is as a result of their own inadequacies, she wants to make people realise that the situation in which they live is a major factor. "Given the circumstances," she says. "Who wouldn't be crazy?"
The social workers tell me there's a shortage of psychiatrists, and for them a lack of experts and supervisors to train them and help out in crisis intervention. They want more training to know how to best deal with such complex social issues and need mental health books as a point of reference. However, they say, checkpoints, incursions, and curfews frequently impede travel, and the difficulty in attending training will remain.
That afternoon we visit a psychological theatre group at a local school, the aim of which is to help psychologists spot children with potential mental health problems. Flags feature heavily, both painted on the wall and flying from masts. In the entrance hall, a picture of Yasser Arafat looks down from the stairwell and a mural showing a child's face in the centre of a target with "Intifada" written across the top is daubed on a wall.
A team of four psychologists lead the workshop, fighting to make themselves heard over the raucous banter of schoolboys aged between 8 and 12—their task is made that bit harder when the children spot Andy's camera. The children have heard the open ended fictional story of Zania, a Palestinian schoolgirl. They then discuss the narrative in groups.
This week the children are given pieces of paper and crayons for them to convey their thoughts about the story pictorially. Palestinian flags are a centrepiece in their drawings, waving patriotically from rooftops and tanks. One child has drawn a duck swimming down a red river, saying that it represents the gunning down of his neighbours. Their houses were then bulldozed and the streets cleaned, forming torrents of bloodied water, he says.
I'm told by one of the psychologists that the week before they had to talk about Zania and provide an ending to the story—the denouements to their stories centre on grim reality in Nablus involving politicking and warfare. One child said that he saw his family and friends gunned down and then their house knocked down by a bulldozer. He'd based it on what happened in his street. Children are clearly highly politicised. One child, no older than 10, was wearing a knitted jumper with a black and white kaffiyeh clad fighter raising a clenched fist in front of a Palestinian flag.
... and with adults in an informal one
In the evening we attend the literary cafe hosted by Bassam on behalf of MDM. The idea of the cafe is to encourage Palestinians to talk about their thoughts and feelings that are evoked by writings of eminent poets and writers. Mental health problems carry stigma in Palestine, particularly for men. While women tend to have a secure network to share their concerns, the same isn't true for men, who are supposed to be emotionally strong.
Reading today is Palestinian poet and academic Muhammad Rishah. He sits at the front of the cafe, looking on to the crowd. The audience consists of mainly men, who draw deeply on hookahs containing a flavoured tobacco. The cafe owner comments that he's relieved that crack isn't available in Nablus—he thinks people would turn to it to numb their pain.
His poems focus primarily on the conflict; they're powerful and political. They focus on struggle, destruction, resistance, identity, occupation, and bloodshed. One poem asks, "Who taught a Palestinian child to throw a stone?"
All three British people in the group become embroiled in political conversations at the literary cafe and left feeling uncomfortable. Feelings of resentment towards the United Kingdom run deep both because of the Iraq occupation and because Britain, they say, had a pivotal role in the formation of Israel. I asked why.
Britain's historical role
After the first world war, Britain became the mandatory power of Palestine. Before this, the 1917 Balfour declaration penned by then British foreign secretary, Arthur James Balfour, pledged to try to establish a national home for Jewish people in Palestine. However, with increasing clashes between Jews and Palestinians, Britain limited the number of Jewish refugees fleeing from Nazi Europe. The tension escalated further and the United Kingdom handed over responsibility for solving the Zionist-Arab problem to the newly formed United Nations in 1947. Later that year, a partition plan for Palestine was approved by the UN General Assembly, which saw the land split into Jewish areas and Palestinian areas, with Jerusalem coming under international control. Britain, however, abstained from the vote. The Arab League, Palestinian institutions, and some Jewish leaders objected to the plan and it was never realised. The land was eventually won and lost as Israeli claimed independence after the 1948 Arab-Israeli war.
So, they said, because Britain created the situation, what were they going to do to help the plight of Palestinians? "What is your country going to do to alleviate my suffering?"
Children from the Balata refugee camp in Nablus show off their toy rifles
Credit: ANDREW AITCHISON
A world apart
On the way home we hear the mortar fire signalling the first incursions of the evening. On the balcony of the MDM house, we look down into the old town, watching the flares go up and listening to the sound of bombs. That evening I received a phone call on my mobile phone from a friend wanting to meet up in Islington in a cafe on Saturday—it felt surreal even to contemplate a coffee and a chat.
Thursday
I figure that while I'm in Jerusalem, I might as well see the sites that are in part at the centre of the conflict. The old city is home to the Western Wall, Dome of the Rock, and Church of the Holy Sepulchre, which are all confined in a walled area measuring about one square kilometre.
It's raining torrentially, and rivers flow down the cobbled streets. As it's a Friday, Muslims hurry down the labyrinthine paths to pray at the al-Aqsa Mosque, which sits just above the praying Jews at the Western Wall. After a short walk along Via Dolorosa you reach the church marking the site of Jesus' crucifixion, where Christians spend time in silent contemplation. I find the religious fervour overwhelming. I've heard there's a travel psychosis called Jerusalem syndrome, affecting people hypnotised by the Holy City. They start to preach and behave as biblical characters, and the syndrome is estimated to affect up to 20 people a year.
Some light relief
Breaking the intensity are traders, desperate to flog some of their gear—nylon kaffiyehs made in China, rubber Osama bin Laden key rings, bronze Judaic memorabilia. I'm a sucker for it all. One shopkeeper tells me that trade has dried up, as tourists are too frightened to come to Jerusalem. If it's a ploy to fleece more money off me, it works. After a week of scrutinising every sentence, trying to soak up every detail, listening to political outpourings, I appreciate the mindless banter.
Competing interests: None declared.
References
Summerfield D. Palestine: the assault on health and other war crimes. BMJ 2004;329: 924.(Deborah Cohen, student editor1)
婵犵數濮烽弫鎼佸磿閹寸姴绶ら柦妯侯棦濞差亝鍋愰悹鍥皺椤︻厼鈹戦悩缁樻锭婵炲眰鍊濋、姘舵焼瀹ュ棛鍘卞┑鐐村灥瀹曨剟寮搁妶鍡愪簻闁冲搫鍟崢鎾煛鐏炲墽鈽夐柍钘夘樀瀹曪繝鎮欏顔介獎闂備礁鎼ˇ顐﹀疾濠婂吘娑㈠礃椤旇壈鎽曞┑鐐村灦鑿ら柡瀣叄閻擃偊宕堕妸锕€鐨戦梺绋款儐閹歌崵绮嬮幒鏂哄亾閿濆簼绨介柛鏃撶畱椤啴濡堕崱妤€娼戦梺绋款儐閹瑰洭寮诲☉銏″亹鐎规洖娲㈤埀顒佸笚娣囧﹪宕ｆ径濠傤潓闂佸疇顫夐崹鍨暦閸洖鐓橀柣鎰靛墰娴滄瑩姊虹拠鏌ヮ€楃紒鐘茬Ч瀹曟洟宕￠悙宥嗙☉閳藉濮€閻橀潧濮︽俊鐐€栫敮鎺椝囬鐐村€堕柨鏃傜摂濞堜粙鏌ｉ幇顒佲枙闁稿孩姊归〃銉╂倷閸欏鏋犲銈冨灪濡啫鐣烽妸鈺婃晣闁绘劙娼ч幖绋库攽閻樺灚鏆╅柛瀣█楠炴捇顢旈崱妤冪瓘闂佽鍨奸悘鎰洪鍕吅闂佺粯锚閸氣偓缂佹顦靛娲箰鎼达絿鐣甸梺鐟板槻椤戝鐣烽悽绋块唶婵犮埄浜濆Λ鍐极閸屾粎椹抽悗锝庝簻婵″ジ姊绘担鍛婃喐闁稿鍋ら獮鎰板箮閽樺鎽曢梺鍝勬储閸ㄥ綊鐛姀銈嗙厸闁搞儮鏅涘瓭婵犵鈧尙鐭欓柡宀嬬秮婵偓闁宠桨鑳舵禒鈺冪磽閸屾氨孝闁挎洦浜悰顔界節閸ャ劍娅㈤梺缁樓圭亸娆撴偪閳ь剚淇婇悙顏勨偓鏍箰妤ｅ啫纾婚柣鏂挎憸椤╃兘鏌熼幍顔碱暭闁抽攱鍨块弻娑㈡晜鐠囨彃绗岄梺鑽ゅ枑閸ｆ潙煤椤忓嫀褔鏌涢妷顔惧帥婵炶偐鍠栧娲礃閸欏鍎撻梺鐟板暱濮橈妇鎹㈠鑸碘拻濞达絽鎳欒ぐ鎺戝珘妞ゆ帒鍊婚惌娆撴煙閻戞﹩娈曢柛濠傜仛閵囧嫰寮崹顔规寖缂佺偓鍎抽妶鎼佸蓟閿熺姴绀冮柕濞垮劗閸嬫挾绮欓幐搴㈢槑濠电姷鏁告慨顓㈠箯閸愵喖绀嬮柛顭戝亞閺夊綊鏌ｆ惔銏╁晱闁哥姵鐗犻幃銉╂偂鎼达絾娈惧┑顔姐仜閸嬫挸鈹戦埄鍐憙妞わ附濞婇弻娑㈠箻閺夋垹浠哥紓浣虹帛缁嬫捇鍩€椤掍胶鈯曞畝锝呮健閹本绻濋崑鑺ユ閹晠宕ｆ径瀣瀾闂備浇妗ㄧ欢锟犲闯閿濆鈧線寮撮姀鈩冩珕闂佽姤锚椤︿粙鍩€椤掍胶鈽夐柍瑙勫灴閺佸秹宕熼锛勬崟濠电姭鎷冮崨顔界彧缂備緡鍠楅悷锔炬崲濠靛鐐婇柕濞у啫绠版繝鐢靛О閸ㄧ厧鈻斿☉銏℃櫇闁靛牆顦Ч鏌ユ煛閸モ晛鏋戦柛娆忕箻閺岋綁鎮㈤悡搴濆枈濠碘槅鍨崑鎾绘⒒娴ｈ姤銆冪紒鈧担铏圭煋闁圭虎鍠楅崑鈺傜節闂堟侗鍎忕紒鈧崘鈹夸簻妞ゆ挾鍠庨悘锝夋煙鐎电ǹ鍘存慨濠勭帛閹峰懐绮电€ｎ亝鐣伴梻浣告憸婵敻骞戦崶褏鏆︽繝闈涳功閻も偓濠电偞鍨兼ご鎼佸疾閿濆洨纾介柛灞剧懅閸斿秴鐣濋敐鍛仴闁糕斂鍨藉顕€宕奸悢鍝勫箺闂備胶鎳撻顓㈠磿閹寸偟鐟规繛鎴欏灪閻撴洟鏌￠崒姘变虎闁哄棴缍侀弻鈥崇暆鐎ｎ剛鐦堥悗瑙勬礃鐢帡锝炲┑瀣垫晣闁绘﹢娼ч獮鈧紓鍌氬€搁崐鐑芥倿閿曞倶鈧啴宕ㄥ銈呮喘閺屽棗顓奸崨顖氬Е婵＄偑鍊栫敮鎺楀窗濮橆兗缂氶柟閭﹀枤绾惧吋銇勯弮鍥т汗缂佺姴顭烽弻銊モ攽閸繀妲愰梺杞扮閸熸潙鐣烽幒鎴僵闁告鍋為幉銏ゆ⒒娴ｈ棄鍚瑰┑鐐╁亾缂傚倸鍊归懝楣冨煝瀹ュ鏅查柛銉㈡櫇閻撳姊洪崜鑼帥闁哥姵鎹囬崺鈧い鎺嶇缁楁帗銇勯锝囩疄妞ゃ垺锕㈤幃鈺咁敃閿濆孩缍岄梻鍌氬€风欢姘缚瑜嶇叅闁靛牆鎮垮ú顏勎╅柍杞拌兌閸旓箑顪冮妶鍡楃瑨闁稿妫濆銊╂偋閸垻顔曟繝銏ｆ硾椤戝洤煤鐎电硶鍋撶憴鍕８闁搞劏濮ゆ穱濠囧醇閺囩偟鍊為梺闈浨归崕鐑樺閺囥垺鐓熼柣鏂挎憸閻苯顭胯椤ㄥ牓寮鍢夋棃宕崘顏嗏棨濠电姰鍨奸崺鏍礉閺嶎厼纾婚柨婵嗩槹閻撴洟鏌曟径妯虹仩妞も晩鍓欓埥澶愬箻閻熸壆姣㈢紓浣介哺鐢岣胯箛娑樜╃憸蹇涙偩婵傚憡鈷戠憸鐗堝俯濡垵鈹戦悙鈺佷壕闂備浇顕栭崰妤冨垝閹捐绠板┑鐘插暙缁剁偛顭跨捄铏圭伇婵﹦鍋撶换婵嬫偨闂堟稐绮跺銈嗘处閸樹粙骞堥妸锔哄亝闁告劑鍔嶅Σ顒勬⒑閸濆嫮鈻夐柛妯恒偢瀹曞綊宕掗悙瀵稿帾婵犵數鍋熼崑鎾斥枍閸℃稒鐓曢悗锝冨妼婵″ジ妫佹径鎰叆婵犻潧妫欓崳褰掓煛閸℃瑥鏋戝ǎ鍥э躬椤㈡稑顫濋崡鐐╁徍婵犳鍠栭敃銉ヮ渻娴犲鈧線寮撮姀鈩冩珳闂佺硶鍓濋悷锕傤敇婵犳碍鈷掑ù锝堟鐢盯鏌熺喊鍗炰簽闁瑰箍鍨归埞鎴犫偓锝庡墮缁侊箓鏌ｆ惔顖滅У闁哥姵鐗滅划濠氭晲閸℃瑧鐦堟繝鐢靛Т閸婃悂顢旈锔界厵闁哄鍋勬慨鍌涙叏婵犲啯銇濇鐐村姈閹棃鏁愰崒娑辨綌闂傚倷绀侀幖顐︽偋濠婂牆绀堥柣鏃堫棑閺嗭箓鏌ｉ悢绋款棎闁割偒浜弻娑㈠即閵娿儱瀛ｅ┑鐐存綑鐎氼剟鈥旈崘顔嘉ч柛鈩冾殘閻熸劙姊虹紒妯洪嚋缂佺姵鎸搁锝夊箮缁涘鏅滈梺鍓插亞閸犳捇宕㈤柆宥嗏拺闁荤喓澧楅幆鍫㈢磼婢跺缍戦柣锝囨暬瀹曞崬鈽夊▎鎴濆笚闁荤喐绮嶇划鎾崇暦濠婂喚娼╂い鎺戭槹閸嶇敻姊洪棃娴ュ牓寮插⿰鍫濈；闁稿瞼鍋為悡銉╂煟閺傛寧鎯堢€涙繈鏌ｉ悢鍝ユ嚂缂佺姵鎹囬悰顕€寮介鐐殿啇濡炪倖鎸鹃崑鐔哥椤栨粎纾藉ù锝嗗絻娴滅偓绻濋姀锝嗙【闁愁垱娲濋妵鎰板箳閹寸媭妲梻浣呵圭换妤呭磻閹邦兘鏋旈柕鍫濐槹閳锋垹绱撴担璐細缂佺姵鐗犻弻锝夊煛婵犲倻浠╅梺浼欑悼閸忔﹢寮幘缁樺亹闁肩⒈鍓﹀Σ浼存⒒娴ｈ棄浜归柍宄扮墦瀹曟粌顫濇０婵囨櫓闂佺鎻梽鍕煕閹达附鍋ｉ柛銉岛閸嬫捇鎼归銈勭按闂傚倷绀侀幉锟犲蓟閵婏富娈介柟闂寸閻撴繈鏌熼幑鎰靛殭缂佺媴缍侀弻锝夊箛椤撶喓绋囧銈呭閹告悂鍩為幋锔藉亹閻犲泧鍐х矗闂備礁鎽滈崳銉╁垂閸洜宓侀柛鈩冪☉绾惧吋鎱ㄩ敐搴″箹缂傚秴锕獮鍐煛閸涱厾顔岄梺鍦劋缁诲倹淇婇柨瀣瘈闁汇垽娼цⅴ闂佺ǹ顑嗛幑鍥蓟閻斿皝鏋旈柛顭戝枟閻忔挾绱掓ィ鍐暫缂佺姵鐗犲濠氭偄鐞涒€充壕闁汇垻娅ラ悷鐗堟瘎闂佽崵鍠愮划搴㈡櫠濡ゅ懏鍋傞柨鐔哄Т閽冪喐绻涢幋娆忕仼缂佺姵濞婇弻锟犲磼濮樿鲸鐨戦梺鍝勵儏閹冲酣鍩為幋锔藉€烽柛娆忣槸濞咃綁姊绘担绋跨盎缂佽尙鍋撶粚杈ㄧ節閸パ咁啋濡炪倖妫佹慨銈呪枍閵忋倖鈷戦悹鎭掑妼濞呮劙鏌熼崙銈嗗The studentBMJ editor travels to Israel and the occupied territories, trying to make sense of an impenetrable situation. This is her diary
Introduction
The team
Accompanying me is Andy Aitchison, a freelance photojournalist, and Michelle Hawkins from MDM UK. We've communicated daily on the phone, trying to arrange the complex logistics, but only manage to meet for the first time at the airport.
Before leaving I received a brief warning that I'd probably be in for harsh scrutiny on arrival at Ben Gurion airport. So I was relieved to be welcomed only with a glower, a few quickfire questions, and the request for evidence that I was from the press.
Jean Sebastién Dy, the general administrator of MDM in Jerusalem, and Sebastién Laplanche, general coordinator, meet us at the airport and take us to our accommodation in an MDM marked car with flags flying from the back. Our base is the newly refurbished MDM staff house in East Jerusalem, the predominantly Palestinian part of Jerusalem. Most of the other NGOs and UN buildings are located in the vicinity. Jean Sebastién says: "The Palestinian areas are friendlier than the Israeli parts, and we're also here to work with the Palestinian community."
Sunday
Passing the Dead Sea and Jericho, both below sea level, we travel on the smooth highway alongside the fertile banks of River Jordan, looking over to the mountains of neighbouring Jordan. The road, primarily for the use of settlers, is named Gandi Highway—the nickname of Rehavam Ze'evi, the assassinated ultranationalist Israeli tourism minister, who supported a transfer policy advocating that all Palestinians be forced into Jordan.
Mobile service for women and babies
We're on our way to Ein al-Beida, a village in the north Jordan valley, where MDM jointly runs a mobile woman and baby preventive health service with British medical relief agency Merlin and the Union of Health Work Committee (UHWC). It focuses on cancer screenings for women, developmental evaluation for children, nutritional assessments and counselling for families, and personalised health education sessions in the home.
Before we enter the road to the village, a red Israeli government sign warns that Israeli citizens are forbidden from going any further by order of the IDF commander. Entrance is allowed only after prior coordination with the responsible authorities. A multitude of similar signs is dotted around the West Bank.
The UHWC team are late. They've been held up at a checkpoint. Although there are supposed to be fewer travel restrictions for health workers, I'm told that they can't always move around freely and are often held up at checkpoints. Nevertheless, it's easier for them than for patients. The facilities may exist in towns, but, after the escalation of violence during the second intifada, the IDF tightened security and further increased the number of checkpoints, making it impossible for Palestinians in the West Bank to travel freely. I'm told that sometimes Palestinians are forbidden from travelling on many of the main roads in the West Bank.
The wall in Abu Dis makes travelling to Jerusalem's Augusta Victoria Hospital (tower is in top left of photo) and Dome on the Rock more complicated
Credit: ANDREW AITCHISON
People don't understand preventive health care
Most of those scheduled for appointments fail to turn up. As a reminder, their names are read out over the village mosque loudspeaker, which the muezzin normally uses to issue his prayer call. Suzanne Abujeradeh, outreach coordinator for the northern West Bank, explains that Palestinians generally do not understand the importance of preventive health and will try to access health care only when they are ill. We decide to trudge down the muddy dirt tracks to visit the families in their homes instead—a delegation consisting of two healthcare workers, Elham Aqab and Noujoud Shalabi, Michelle, Andy, Nadia Dibsy (our translator and advocacy officer for MDM), and me. No one seemed the slightest bit perturbed by our international ensemble and welcomed us in with sweet tea and Arabic coffee.
Looking after children
The responsibility for looking after the children falls to their mothers and grandmothers. Iron deficiency anaemia occurs in over half the young children in Ein al-Beida, as parents sell their fresh produce and feed their children tea and bread, Elham says. She explains that the trick is to convince the grandmothers to change the feeding habits—the mother in law exerts a rather large influence over parenting behaviours.
Back at the clinic, the other health workers are running a health education workshop. The children who attend are accompanied by their mothers all dressed in their smartest clothes and shoes, although the heavy rainfall has turned the paths into a mud bath. In an attempt to combat the prevalent anaemia, the health workers have brought boxes of fresh food and show how to prepare it.
On the way back to Jerusalem we pass gated Israeli settlements. They have their own healthcare and urgent care centres; some have helicopter access to hospitals in Jerusalem and Beit Shalom to the north. But Kimberley says it's almost impossible for Palestinians to access the settlements. She adds that many Palestinians she meets would relish the chance to receive treatment from Israeli doctors—their training and facilities are held in high regard.
Tuesday
Nablus, in the north of the West Bank, is surrounded by steep hillsides forming a basin, containing the main town area. Bordering the town are watchtowers and a wire fence patrolled by Israeli soldiers, while the two main entrance points at either end are marshalled by checkpoints. As we passed through the Huwara checkpoint on the outer edge of Nablus, the atmosphere changed; the tension was palpable. It was the only time I was advised not to mention my surname.
A soldier climbs on board a PRCS ambulance to check a pregnant woman for explosives at the Az Za'ayyem checkpoint
Credit: ANDREW AITCHISON
Into Nablus
Ours was the only car queuing to be let through by Israeli soldiers, but we didn't move for about half an hour and watched the soldiers at work. Palestinians of different ages queued behind a fencing barrier to our right, some holding piles of textbooks, others clutching bags of food. Tightly pressed up against each other, people shout angrily as someone pushes in ahead. A few look into our car, their faces blank. By the time we've crossed the checkpoint, only three people on foot have been searched and passed through into Nablus.
The road into Nablus circuits the gaping carcasses of buildings that, I am told, have been destroyed by tanks; the road itself is cracked by the passage of heavily armoured tanks. Apparently Nablus was once an attractive town.
Our first stop is the dispensary in the old town. Established in 2002 by Nablus municipality, it's now completely funded by MDM and provides primary health care, medication, and lab tests, but facilities are basic. A lone biochemist collects the samples and operates the old fashioned centrifuge and microscope, while Dr Bashar Jaber, a general practitioner, runs the clinic. The waiting room is cold and crowded, and, judging by the coughing and sniffling sounds, there's a virus doing the rounds.
I chat to Dr Jaber for a while—he's hoping to sit his Professional and Linguistic Assessment Board (PLAB) exam in London soon. We chat about the United Kingdom for a while—his uncle coincidentally taught at one of my placements at medical school. The conversation then shifts to medicine.
Current health problems
Nowadays, Dr Jaber says he sees a lot of people with mumps and measles, whereas 15 years ago such infections were rare. He puts this increase down to incursions and curfews, which impede physical and financial access to health care.
Another explanation I'm given is that boxes of vaccines have been denatured as the army search them for explosives. The result has been outbreaks of measles—children have received ineffective injections leading to a breakdown in herd immunity.
Administrative delays
Dr Jaber also talks about his time as a doctor in East Jerusalem, practising at the Augusta Victoria hospital. For the first two months of his rotation, he didn't have a permit to enter East Jerusalem, so he took a circuitous journey to Abu Dis to jump over the wall. At other times, he says, he was turned away from Qalandiya checkpoint or had to spend weeks sleeping in the hospital to ensure he would be able to make it to work. Not only did he have a West Bank ID—worse still, it was issued in Nablus. But if there were difficulties for him, for Palestinian patients with a West Bank ID attending the hospital it was even more complex, particularly for those with chronic illnesses requiring regular treatment—each session requires a permit from the Israeli authorities, he says. For most patients, this entails a visit to the civil administration headquarters in their town, bringing with them a written report by their doctor. The hospital also needs to send an accompanying fax. Delays in this process may happen, he adds, which can influence the disease progression in people requiring interventions at specific times.
I ask him candidly what the solution is, commenting about the lack of airtime on my dictaphone. He laughs and explains diplomatically that his nostrum would start with "a change of politicians on both sides."
International intervention is needed
The community in the surrounding area is poor, and its movement is restricted by frequent curfews and incursions by the Israeli army. Sandrine Pont-Turco, MDM's field coordinator in Nablus, says that international NGO intervention is needed in Nablus because NGOs are able to set up direct links with the "IDF or IOF" (IOF is the so called Israeli occupying force—a term used to describe the IDF by some Palestinians) on a regular basis and also the District Coordination Office (DCO). This enables NGOs to liaise with the army during incursions and curfews to ensure the safe passage of staff and patients. She cites the six day curfew in the old city in August 2004 as an example. People were unable to attend the dispensary, so staff from both MDM and the Palestinian Scientific Medical Association went to collect patients from their homes, while briefing the army coordination officer about their movements.
Sandrine also explains that they are able to help fund clinics and arrange for mobile facilities to visit surrounding villages. "Nablus is a closed city," she says. "People from villages find it difficult to get in to access services."
On the edge of Nablus, close to the biblical site where Joseph was pushed down a well by his brothers, is Balata, a Palestinian refugee camp home to hundreds of people displaced during the 1948 and 1967 Israeli-Arab wars and their descendants. Houses built close together with little space between them are easing the spread of infectious diseases. Roads in the camp are in a pitiful state and every so often an earth mound restricts access.
Mental health issues
Escorted by two guides, Andy disappears between the ramshackle houses to take photos; a group of children behind him chant "Madrid." Some play with toy guns made from bits of wood, others have their hands on realistic copies. Young men hang around the "martyr's cemetery"—where people killed in the course of conflict are given the status of a legend—with little to do and looking bored. Bassam Marshoud, a Palestinian psychologist working with MDM, explains that because there's restricted movement, there are few jobs and people can't go elsewhere to work, making young people feel hopeless, worthless, useless, and humiliated. It's clearly not something that has gone unnoticed by political organisations, which flypost the area with leaflets featuring young, bearded, musclebound men toting rifles.
Working in a formal setting with children...
A group of four social workers arrives at the MDM house to receive training from Sylvie Mansour, a consultant psychologist working with the Palestinian Authority to improve mental health facilities, which are in desperate need of developing. Nablus has seen an increase in social problems both in children and in adults since the second intifada. Domestic violence has escalated as women become the brunt of men's frustration precipitated by unemployment and the perceived futility of the future. Sylvie also says it's worse for young men, who are traditionally the head of the house and are raised with the expectation they can do what they want, unlike girls, who have had relatively restricted freedom. "When they realise that going to university will have little bearing over their job prospects and that they can't do what they originally planned, it's when their mental health problems start," she says.
Children truant from school to earn money for their family or because they don't see the point in attending school when their prospects will be determined by other forces. At best, they ask why go to school when they won't be able to leave Nablus. At worst, they question the value of living. Violence between children has risen too, as they emulate what they witness both on the television and on the streets.
However, Sylvie is careful not to "psychiatrise" children or see them as potential cases. She wants to establish schemes that give children something to latch on to and works with their mothers to illustrate how they can protect their children. She is also working to change people's perception of mental health problems they encounter. Rather than believe that their disquiet is as a result of their own inadequacies, she wants to make people realise that the situation in which they live is a major factor. "Given the circumstances," she says. "Who wouldn't be crazy?"
The social workers tell me there's a shortage of psychiatrists, and for them a lack of experts and supervisors to train them and help out in crisis intervention. They want more training to know how to best deal with such complex social issues and need mental health books as a point of reference. However, they say, checkpoints, incursions, and curfews frequently impede travel, and the difficulty in attending training will remain.
That afternoon we visit a psychological theatre group at a local school, the aim of which is to help psychologists spot children with potential mental health problems. Flags feature heavily, both painted on the wall and flying from masts. In the entrance hall, a picture of Yasser Arafat looks down from the stairwell and a mural showing a child's face in the centre of a target with "Intifada" written across the top is daubed on a wall.
A team of four psychologists lead the workshop, fighting to make themselves heard over the raucous banter of schoolboys aged between 8 and 12—their task is made that bit harder when the children spot Andy's camera. The children have heard the open ended fictional story of Zania, a Palestinian schoolgirl. They then discuss the narrative in groups.
This week the children are given pieces of paper and crayons for them to convey their thoughts about the story pictorially. Palestinian flags are a centrepiece in their drawings, waving patriotically from rooftops and tanks. One child has drawn a duck swimming down a red river, saying that it represents the gunning down of his neighbours. Their houses were then bulldozed and the streets cleaned, forming torrents of bloodied water, he says.
I'm told by one of the psychologists that the week before they had to talk about Zania and provide an ending to the story—the denouements to their stories centre on grim reality in Nablus involving politicking and warfare. One child said that he saw his family and friends gunned down and then their house knocked down by a bulldozer. He'd based it on what happened in his street. Children are clearly highly politicised. One child, no older than 10, was wearing a knitted jumper with a black and white kaffiyeh clad fighter raising a clenched fist in front of a Palestinian flag.
... and with adults in an informal one
In the evening we attend the literary cafe hosted by Bassam on behalf of MDM. The idea of the cafe is to encourage Palestinians to talk about their thoughts and feelings that are evoked by writings of eminent poets and writers. Mental health problems carry stigma in Palestine, particularly for men. While women tend to have a secure network to share their concerns, the same isn't true for men, who are supposed to be emotionally strong.
Reading today is Palestinian poet and academic Muhammad Rishah. He sits at the front of the cafe, looking on to the crowd. The audience consists of mainly men, who draw deeply on hookahs containing a flavoured tobacco. The cafe owner comments that he's relieved that crack isn't available in Nablus—he thinks people would turn to it to numb their pain.
His poems focus primarily on the conflict; they're powerful and political. They focus on struggle, destruction, resistance, identity, occupation, and bloodshed. One poem asks, "Who taught a Palestinian child to throw a stone?"
All three British people in the group become embroiled in political conversations at the literary cafe and left feeling uncomfortable. Feelings of resentment towards the United Kingdom run deep both because of the Iraq occupation and because Britain, they say, had a pivotal role in the formation of Israel. I asked why.
Britain's historical role
After the first world war, Britain became the mandatory power of Palestine. Before this, the 1917 Balfour declaration penned by then British foreign secretary, Arthur James Balfour, pledged to try to establish a national home for Jewish people in Palestine. However, with increasing clashes between Jews and Palestinians, Britain limited the number of Jewish refugees fleeing from Nazi Europe. The tension escalated further and the United Kingdom handed over responsibility for solving the Zionist-Arab problem to the newly formed United Nations in 1947. Later that year, a partition plan for Palestine was approved by the UN General Assembly, which saw the land split into Jewish areas and Palestinian areas, with Jerusalem coming under international control. Britain, however, abstained from the vote. The Arab League, Palestinian institutions, and some Jewish leaders objected to the plan and it was never realised. The land was eventually won and lost as Israeli claimed independence after the 1948 Arab-Israeli war.
So, they said, because Britain created the situation, what were they going to do to help the plight of Palestinians? "What is your country going to do to alleviate my suffering?"
Children from the Balata refugee camp in Nablus show off their toy rifles
Credit: ANDREW AITCHISON
A world apart
On the way home we hear the mortar fire signalling the first incursions of the evening. On the balcony of the MDM house, we look down into the old town, watching the flares go up and listening to the sound of bombs. That evening I received a phone call on my mobile phone from a friend wanting to meet up in Islington in a cafe on Saturday—it felt surreal even to contemplate a coffee and a chat.
Thursday
I figure that while I'm in Jerusalem, I might as well see the sites that are in part at the centre of the conflict. The old city is home to the Western Wall, Dome of the Rock, and Church of the Holy Sepulchre, which are all confined in a walled area measuring about one square kilometre.
It's raining torrentially, and rivers flow down the cobbled streets. As it's a Friday, Muslims hurry down the labyrinthine paths to pray at the al-Aqsa Mosque, which sits just above the praying Jews at the Western Wall. After a short walk along Via Dolorosa you reach the church marking the site of Jesus' crucifixion, where Christians spend time in silent contemplation. I find the religious fervour overwhelming. I've heard there's a travel psychosis called Jerusalem syndrome, affecting people hypnotised by the Holy City. They start to preach and behave as biblical characters, and the syndrome is estimated to affect up to 20 people a year.
Some light relief
Breaking the intensity are traders, desperate to flog some of their gear—nylon kaffiyehs made in China, rubber Osama bin Laden key rings, bronze Judaic memorabilia. I'm a sucker for it all. One shopkeeper tells me that trade has dried up, as tourists are too frightened to come to Jerusalem. If it's a ploy to fleece more money off me, it works. After a week of scrutinising every sentence, trying to soak up every detail, listening to political outpourings, I appreciate the mindless banter.
Competing interests: None declared.
References
Summerfield D. Palestine: the assault on health and other war crimes. BMJ 2004;329: 924.(Deborah Cohen, student editor1)