Sunday, April 22, 2012

The blockade must end

Sunday 4-22-12

Yesterday several of us visited Shefa Hospital in central Gaza City.  This is the largest hospital in Gaza; it is a public hospital and provides free care to anyone in need. Shefa was badly damaged during "Operation Cast Lead".  During that time, they had to work for many days with no electricity and with bombs falling all around close by.  It is a large hospital campus--it would be impossible to have been targeted by accident.   Doctors and nurses there treated some of the worst injuries, and continue to do so with every Israeli attack. 

We met with one of the medical directors, Dr Ayman.  As he took us on a tour of several units in the hospital, he pointed out supply shortages and machinery that needed repair or to be updated.  For example, yesterday there were only 4 bags of normal saline IV solution left in their stock.  Dr Ayman also talked of the excellent training and dedication of the staff.  Dr Ayman is a very dignified man, a Urologist. As we walked he said to me, "Most of anything, I want to give my children hope and to tell them never to give up.  I keep telling them that we must not hate the Israelis.  Sometimes I feel so hopeless, but I want to give my children hope."

We can talk about shortages of essential goods, that it makes NO sense for a society that is this well educated and trained and "ready to go" to be so dependent on NGOs and relief agencies, that people live in a constant state of fear and hyper-arousal for when the next shelling or bomb will come, that the trauma is ongoing,  that the siege is absolutely brutal--imprisoning people and making it impossible to develop a viable economy.  It is a geo-political nightmare that is the root of all that is hard and wrong and traumatizing and dieing in Gaza. 

Yet there is the constant underlying reaching for hopefulness. This is not a population bent on destroying another population.  From what I've seen it is a people intensely set on being well educated, improving their lives, rightfully claiming land and place.  They want the freedom, as do we all, to get on with things--to re-build and develop and thrive.

I really believe that step one--as in, instantly, no delay--is that we must demand of Israel that the siege end.  People here refer to it as "the situation"--they are totally weary of saying "blockade or siege".  The blockade is immoral and is causing catastrophic hardships.  The larger political situation, of course, has to be addressed and cannot be ignored.  However, it is unconscionable that Israel has this land under blockade.  It serves no one (not Israel and certainly, not Gaza) and it is slowly destroying the environment and infrastructure here.  It negates freedom and human rights that are guaranteed under international law and it violates basic dignity for human beings.

The most important public health work we can do now, I believe,  is put all our efforts toward immediately ending the Israeli siege/blockade of Gaza.

Friday, April 20, 2012

Link to Gerri Haynes' blog

Please also read Gerri's blog and see the photos by Bob Haynes--they are quite wonderful!

Gaza day #3--Acts of defiance

Yesterday I went from the Palestine Trauma Center, where they provide mental health (which here is referred to as "psychosocial support") for children who have been traumatized by war and occupation, to the most exceptional garden I have ever seen in my life.  This is the clear example of the contrasts of Gaza, and of the resiliency of the Gazans. 

[I am writing this with the constant background thumping of the generator--our source of electricity for hours of the day.  We are grateful to the hotel for running it.]

Trauma is everywhere in Gaza.  I (all of us in the group) cannot understand how the world can choose to not see this and allow this to go on.  We each have gone through the moments of rage, heartbreak and total disbelief that this story is not being told.  Everybody (EVERYBODY)--doctors, nurses, teachers, psychologists, pharmacists--EVERYBODY  is under constant stress.  It does not go away at the of the workday (after caring for very difficult patients).  The stress level never quiets.  Everyone talks about how they feel like they are living in a prison.  One doctor asked, "What did we do to deserve this?  I cannot travel for professional classes.  I cannot get a medical book mailed to me.  My children cannot go on a vacation to see their relatives in the West Bank. We cannot build our houses or do anything without the Israelis' permission."  Over and over people tell of how the "situation" is so unjust and hopeless.  And yet, there is something much bigger than the despair--there is a sense of such determination like I have never seen.  Determination to build their country, to educate their children, to be creative (today we heard all about the one and only music school in Gaza and the excitement of all the young musicians), to plant gardens, to do good health care, to continue to learn.  It puts Maslow's hierarchy to a test.  How do a people who are living under the stress of war,  fear of attacks, shortages, hours of darkness, fuel lines still have the physical and psychological energy to tend to all the things that all of us, universally,  want in life?  I thought that as I saw a young mother cleaning off a strawberry that fell to the ground before giving it back to her young daughter--tending and mothering and loving as any one of us would do. 

The garden I mentioned is at the home of a family who traces their roots in Gaza back for many many generations.  Faten's garden.  Faten is a quiet,  beautiful, earthy woman who spends all her days cultivating this amazing place.  The street to their home looks like most in Gaza City--concrete buildings in various levels of non-completion, decay, rubbish strewn.  The house, like most, is surrounded by a plain high wall and the entrance is a metal door that is totally nondescript.  Open it up and walk inside along the paths of old Egyptian tiles inlaid into old cobblestones, lined with the most beautiful plants,  sculptures and relics from ancient Gaza and vicinity, a fountain, old stone walls and a stone cottage that is a library and study, and green houses filled w/ so many varieties of cacti.  We remarked that she chose cacti to grow in a lot of the parts of her garden--inside they hold water (a scarce resource here) and outside are protected by the spikes and thorns. 

When I asked Faten how she has been impacted by the blockade this was her answer.  "If you mean, how has my garden been impacted, it is an easy answer.  I cannot get the things I used to get--plants, garden materials like the special fertilizers I like to use, building materials for the paths and walls.  If you mean, how has the blockade impacted my life, those are bigger words.  It has taken away my heart and my soul." 

That Faten claims her right to her land, and (quoting May Sarton), "plants her dreaming deep", is an act of defiance.

The United Nations Relief Works Agency (UNRWA) provides massive relief for Gaza. Their programs include health centers, several hundred primary and secondary schools, housing, supplemental food programs and other relief work.  On this trip I have had the opportunity to visit four of the health clinics and one school. 

UNRWA's presence in Gaza is complicated and is controversial.  Were it not for Israel's aggression (read, war)/ occupation/siege/ blockade, Gaza would not be a place where a relief agency would be needed.  If UNRWA did not exist, would the fact that Gaza is being starved, suffocated and killed become more apparent and the world be more likely to respond and force Israeli policies to change? That is a possibility that must be considered.  But I am not going to write about that question, I want to write about the work of the UNRWA health care providers now because there can be no denial that they are heroes under the most intense distressed and overloaded situations that could be imagined.   I think that the amazing work they do, the ways they are truly looking at best-practices are examples, not just of great health care, but under these circumstances, are acts of defiance.

All of the UNRWA clinics are moving to a model called "Family Medical Teams".  It is exactly what we refer to when we talk about primary care providers, medical homes, "building better care"--models like that.  They realized that different members of the same family were getting somewhat fragmented care by different providers in different locations of the clinic and that they could coordinate care much better by having teams located in "pods" within the clinic so all members of the family would go to one team for care.  Each team consists of one or two doctors, a midwife, several nurses and a psychosocial care provider.  The only centralized parts of the clinic are the lab and pharmacy.  We met with the head nurse and the regional Medical Officer at each site and discussed the benefits as well as the challenges of transitioning to this model.  It is amazing how universal many of the observations and struggles are. I learned so much from them and hopefully, was able to share some ideas and thoughts that might be applicable to their situations.

At the UNRWA clinics, the medical doctors see up to 160 or more patients per day due to the need/demand. One concept they are very interested in is the idea of a role such as nurse practitioners.  This is something they were not familiar with.  One of the sites I visited was a return to a clinic I had visited on the last trip.  This discussion of training nurses to do some triage role was something they were interested in so I brought them a book of protocols for nursing triage.  Presently, at the UNRWA clinics, all patients are seen by the MDs (except low risk pregnancies, seen by midwives, and well babies for vaccines, seen by nurses).  We discussed that perhaps there could be a triage system, where some of the more routine, less acute visits could be triaged and managed by the nurses.  The discussion included what kinds of training needs there would be and how appropriate and safe protocols could be developed.  It was a stimulating discussion and the doctors and nurses talked of how they are starved for the contact with other professionals in developing their work.  They expressed feeling isolated--true the internet is access to resources, but they talked of feeling that Gaza has been surgically removed from the world and that they yearn for the ability to travel and learn from professionals outside Gaza.  Another act of beautiful defiance--Family Medical Teams as a model of coordinated health care in a country under siege.

The other truly innovative health care model they are working on is to integrate mental health care into the primary care setting.  Sound familiar to all you health care practitioners out there?  Yes, the same challenges and realizations that we all have.  Quality care means addressing the psychosocial issues that impact one's physical health.  The term "psychosocial care" is the one they have adopted as the term "mental health" holds a lot of stigma and is not widely accepted here.  There are psychosocial teams at each health center to work with patients who present with emotional issues and those with chronic disease (diabetes and hypertension are also common here).  There are health/psychosocial teams to evaluate children having school problems.  Teachers refer students about whom they have concerns for academic or behavioral problems to the specialized teams at the clinics.  The pediatrician and psychosocial counselor from these teams assess the child and then coordinate a plan for care with school counselors, optical and dental in providing care for these children with special needs. Health care with defiance!  99% immunizations rates--victory and defiance!!  (That despite the fact that MMR vaccine was held up at the single crossing from Israel for 3 months.  No, MMR cannot come in through the tunnels as they cannot give a guarantee of temperature control!!!)

In short, there is no shortage of talent, stamina or determination here in Gaza.  On top of war and blockade, there is a huge shortage of funds to sufficiently run programs.  The symptoms of ongoing trauma are so enormous.  So too, are the rising rates of diabetes and hypertension.  We heard from the director of pharmacy services at the largest public hospital, Shefa, that all drugs are either not available or are only intermittently available.  

And finally, a great story.  Gaza, of course,  has a long coastline.  Until 2005 Israel had settlements in Gaza.  The settlements were huge complexes (towns) built along the coast on the most fertile and lush land.  Gaza was cut into two--divided north to south by the settlements claiming the best land along the sea.  Palestinians were forbidden to drive the coastal road and had to take a huge detour to the east to travel from the north to the south.  Just now, there is the plan to re-build the coastal road as a 2 lane in each direction highway.  And, best yet, along it will be a pedestrian pathway--paved, benches--all to encourage walking, jogging and family outings for exercise. 

Gaza is traumatized, but above all,  what shines through is determination, pride, and ingenuity.  I'd call that new coastal road with its parallel pedestrian pathway an act of healthy and beautiful defiance.

Wednesday, April 18, 2012

The Wall at Beit Hanoun

April 2012
Our PSR health delegation arrived in Gaza early yesterday afternoon. Feeling pretty much totally exhausted from travel and from the enormity of the situation, I am just now getting to try and summarize some of the events and feelings from the last 24+ hours.

Crossing into Gaza through the Erez crossing.  This is the Israeli controlled northern entry into Gaza.   Thinking about Erez in your mind, you should pretty much imagine the opposite of the word "welcoming".  This is the only crossing for people from Israel to Gaza.  (There is one overloaded and insufficient crossing from Israel to Gaza in the south for trucks to bring in a very limited amount supplies.)   Erez was once a busy passage with many day- laborers going back and forth from Gaza to Israel to work.  Then came the Israeli blockade on Gaza and nobody is allowed to cross.    Now it is truly a barren, empty and forbidding place.  From the Israeli side, only aid workers from the UN,NGOs, or occasionally groups like ours w/ hard to come by visas pass.  Going the other way, from Gaza- out are occasionally business people, but mostly the VERY ill who are fortunate to get permission for medical care in Israel or in Jerusalem.
Approaching Erez,  from the distance you see the large building where the process starts.  That fortress of a building  looks like an airplane hanger or a prison.  Actually the process doesn't start there.  It starts in the parking lot some distance away from the building.  There you get dropped off, unload your luggage, which in our case, was about 20 suitcases full of heavy supplies.  There is a little guard house where you must present your papers, and once cleared, a metal gate opens and you can pass through and walk the final distance to the building.  There begins the shuffle of luggage onto some broken down, rusted grocery store like carts and THEN you proceed to the airline hanger building.  Once inside you wait in the entry hall as one by one you can approach a small enclosed area to talk to the passport agent who is behind a glass window.  There are, of course, the scattering of soldiers standing around w/ big guns slung over their shoulders. Really, the total effect is one of total abandonment of place.  You feel like you are at some outpost that has been neglected, forgotten (except to be fortified in every human and electronic way possible),  and really not at all cared about.  Our group has the approval of the Israeli authorities as a humanitarian health delegation, so passing through was not a concern.

  And as you wind your way through the maze of a hallway with chain-linked fencing surrounding you, the landscape is dry dirt--totally barren except for rolls of barbed-wire scattered around and the occasional turrets for machine guns and surveillance.  At one point, as you turn the corner into a "blind" hallway, you have to talk to some remote security agent to get a door to open.
Like there is really any confusion about where you might be headed, every once in a while there is a small sign saying "Gaza" on the wall with an arrow pointing the way that the hallway goes (there is ONLY one way to go) ".  It's kind of silly because by the time you've gotten this far, it should be pretty clear that Gaza is your intention and that the single hallway leads you there.  But I guess the sign is a gesture of assistance--it feels like the only gesture of assistance offered.

Gaza is harsh.  Roxanne, (a member of our group, a landscape designer, here to explore the development of a community project to build a therapeutic healing garden in Gaza) commented that it is not only the people who are traumatized by this situation, but it also the land and the environment.  That is so true.  Step across the Erez border and one is confronted with harshness.  It is truly hard to describe the environment.   Piles of garbage all over.  Today, as an afternoon wind blew up, the garbage took flight--pieces of plastic and paper in the air.  Bombed out buildings interspersed with the old and often neglected ones.  Store-fronts closed us, lines of cars and old trucks--whatever people drive lined up to get fuel. (Fuel, by the way, happens to be leaded gasoline).  Graffiti is all over.  Some just plain ugly,  some quite powerful, mostly political, and some even beautiful street art. 

But yet, what would not be fair is to start this too overwhelmingly pointing out one side of a picture of contrasts.  It doesn't feel fair to go on and on in the descriptions of a place abandoned, poor and broken.  I have to talk about the human spirit that one sees the second you start to talk to all the people we have met in Gaza.  There is a resiliency that is indescribable. The spirit of the people of Gaza shines.  Despite the hardships, not 5 minutes of a meeting goes by before we were brought a tray of coffee or tea, and in one place a plate of dates.  And at a school today, at the end of our meeting the home economics classes presented us w/ platters of cookies and cakes they had just baked.

Today on the first full day, I think I will just share some impressions instead of in-depth details.
  At every turn, one sees the resiliency of the people of Gaza.  Life is so totally hard and there is such ongoing trauma and injustice.  The political situation really feels hopeless.  And yet, the people of Gaza do not seem to let it stop the determination to learn, to be excellent health care providers, nurses, teachers, social service workers, etc. The level of education and ingenuity is unmatched and is totally inspiring.

We are welcomed and greeted so warmly by everyone.  Seeing the people from our last trip here felt like meeting up again w/ old friends.  For me the months in between visits have been a pretty steady last 6 months. For the people of Gaza, it has meant sustaining another series of bombings.  We were told of the bombs that hit so close to their homes that everything shook.  The re-kindling of the fears and nightmares from the war that we all refer to "Cast Lead".  They ask, "Why does it get called that, it was war."  Days of no electricity or water.  Raining sad days of winter cold.  And yet there is laughter and hope.  One friend who was an interpreter on the last trip got married.  She was beaming to tell me about how happy she is.  It is an amazing testimony to the strength of the human spirit.

Driving back from a UN clinic that we visited today, the lanes ahead of us in our direction were blocked-- lined up w/ stopped cars.  What did our driver do?  He, without missing a beat, drove over the central median island and continued driving in our direction in the right lane of the opposing traffic (it was a busy street)--tooting the horn every few seconds and flashing his lights.  Cars swerved, but it felt pretty safe.  Mostly it felt that he was showing his defiance. By the way, why were the cars stopped in both lanes for 2-3 blocks?  We saw as we got to the source of the stoppage that they were lined up waiting for gas.  And so goes the lines for fuel.

And one more thing--and I do hope someone from Israeli security or AIPAC is reading this.  What do you think the Gazans are doing 1 kilometer south of the Israeli border in Beit Hanoun Refugee Camp--in that land (which happens to be their land) and where the Israelis are so sure that terrorists are breeding like bunnies?  Well, let me tell you.  They have decorated a white cement wall w/ all kinds of beautiful graffiti and messaging about ways to stay healthy--exercise more, eat lots of fresh fruits and veggies; if you are diabetic, take care of your feet.

And go inside the clinic next to that cement wall and you learn that they are working on their new model for providing family centered care in their health center--a concept we call a "medical home", figuring out how to decrease the stigma of mental health care and incorporating mental health into primary care visits.  In short, they are moving ahead with very state of the art, fabulous and innovative health care. 

And... Beit Hanoun has seen some of the heaviest Israeli shellings and bombings on a regular basis.  They have high levels of mental health issues among their children from the trauma of war--bedwetting, nightmares, aggression and school failure.  There are a disproportionate number of orthopedic injuries in that area due to proximity to the Israeli border and the vulnerability that brings. 
We heard the school counselors talk about the 2000 students they care for to support their hopes and successes.  THAT IS WHAT IS HAPPENING IN BEIT HANOUN. 

 The counselors end their days of caring for the children at their clinics and go home to their own grief and ongoing trauma that is bought by our dollars. 

Another brilliant comment by Roxanne is that we need to send a bunch of photo journalists into Gaza to document this story. The pictures of what you would see are worth a thousand or maybe 1.7 million words.