Friday, April 20, 2012

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.

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