My six day experience in the Middle East
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
I'd always meant to go to Israel but somehow had never got round to it. So I jumped at the chance when I was offered the opportunity to go on a press trip to Israel and the Palestine territories occupied by Israel with Médecins du Monde (MDM), a French medical organisation that has several projects dotted around the area. Admittedly I was nervous about going but convinced myself that if it were all that dangerous MDM wouldn't risk the lives of its staff—after all, many non-governmental organisations (NGOs) have withdrawn from Iraq. But what bothered me more was how I'd report what I see, and if people disagreed—and they're bound to—that I'd be dismissed as pro-Israeli and a Zionist or pro-Palestinian and a self hating Jew.
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Saturday 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.
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Jean Sebastién Dy, the [now former] 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."
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Sunday
We receive a security briefing and cream waistcoats displaying the MDM logo for our safety—it's standard NGO attire. I then make my first faux pas of the day, and what I presumed to be the first of many. For security purposes and ease of passage through checkpoints, we all were issued with MDM identity (ID) cards—it's far easier for NGOs and diplomats to negotiate their way around the West Bank. In the space labelled "Country of Mission" without thinking I wrote "Israel." My newness to linguistic diplomacy in the Middle East was met with wry chuckles by the MDM staff—someone's Israel is another person's Palestine. They reissued it, with "All countries" filling the gap.
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Map of the West Bank barrier adapted from map by Office for the Co-ordination of Humanitarian Affairs
Movement between the West Bank and Jerusalem is regulated by a system of ID cards. Palestinians living in the Jerusalem area have Israeli issued ID cards. They have access to health care, education, work, and national insurance benefits because they pay taxes in Israel. Palestinians living in the occupied territories carry a West Bank or Gaza ID card. They need a permit to cross checkpoints into Israel, Jerusalem, settlements, and industrial zones where they work.
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The "easy" way into Ramallah
As we head from Jerusalem to Ramallah, we arrive at our first checkpoint of the day. Cars channel into two queues—UN and diplomatic vehicles with their white licence plates, and "others." While we're waiting, the diplomats pull up and glide through effortlessly, and our MDM ID cards let us pass through with relative ease.
I didn't quite know what to expect from Ramallah. I'd only ever seen it on the television during chaotic and bloody flare-ups of the conflict or heaving under the strain of assembled masses grieving the death of Yasser Arafat. But it just seemed like a faceless, unkempt, hilly town. People roamed the streets, drove their cars, popped into a cafe for a coffee—nothing visibly untoward or unusual. It could have anywhere had it not been for the face of Yasser Arafat wearing his trademark kaffiyeh beaming down from adverts promoting mobile phones.
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We arrive at the headquarters of the Palestinian Red Crescent Society (PRCS), an observer member of the International Federation of the Red Cross and Red Crescent Societies. Reem Wadhan, public relations officer for the PRCS, takes us around the bustling building, explaining what each section does, and describes some of the problems facing the organisation. As I'm new to the region, Reem gives a quick summary of the travel restrictions in the West Bank.
Regional divisions and personal separations
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As a result of the Oslo Accords, the Palestinian Authority (PA) was established and the region divided into zones. Zone A is an autonomous Palestinian region, such as Ramallah, and many of the other West Bank towns. However, Israel controls the checkpoints between the towns and villages, determining who can leave and enter. She described zone B as the "ultimate grey area"—responsibility for the area is split between the Israeli and Palestinian authorities—and it forms most of the West Bank area that isn't already in zone A. Here civil responsibility falls to the PA but security is under Israeli control. Zone C is under complete Israeli control.
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Reem complains that for the Palestinians the situation on the ground has actually deteriorated. More roadblocks and checkpoints have sprung up, and East Jerusalem is now virtually closed off. This has made travelling around the West Bank a drawn out chore for Palestinians; passing from village to town is complicated by checkpoints.
"It's even harder to go from city to city," she says. "Our ID cards are all marked with our home towns, and soldiers won't let you pass through without specific permission, and even then, they may turn you away because you're from Ramallah. I haven't seen some members of my family for ages."
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She tells us tales of ambulances collecting women in labour to take them to the hospital delivery suites, only to be held up at a checkpoint where the women give birth. Quite often, ambulances aren't even able to reach sick people in the first place, she says. They are stopped from proceeding any further. When this occurs they contact the MDM team or the International Committee of the Red Cross, who liaise with the Israel Defense Forces (IDF) to negotiate their passage.
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Outside the PRCS, rows of ambulances stood waiting for action. Abdul Haleem, the director of the PRCS emergency centre in Ramallah, is keen to show us the layout inside one of the ambulances. "This one," he announces proudly, ushering Andy in its direction, "was made in Palestine." He then turns and points to an ambulance. The front is concertinaed and starting to rust. "It was crushed by an Israeli tank," he says. The ambulance station is its final rest home—a testimony to the difficulties the conflict creates.
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We meet the emergency medical technicians, who are hanging around, waiting for a call. Currently, the teams consist primarily of men, but they want to recruit more women. However, Reem says that women are often reluctant to travel as they are subjected to frequent searches by the checkpoint staff and are concerned about the attacks on staff.
From the 101 dispatch call room, Sobheyyeh Ahme, wearing a crisp white coat with a red crescent on the sleeve, fields all the emergency calls. Pinned on one of the walls is a poster of a smiling Yasser Arafat. Noticing our Médecins du Monde waistcoats, Sobheyyeh greets us warmly—she wants to extend her gratitude to our government for allowing her leader to die peacefully in our country. We point out we're not French, we're British. "Oh," she says, her smile fading ever so slightly.
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The hard way out
Apparently we've had the easy way into Ramallah, so Eid Mohammed, the MDM driver, decides to introduce us to the "hard way" out. The Qalandiya checkpoint bustles with activity; traders have set up stalls, selling everything from spices to birds in cages. Taxis ferry people to and from the checkpoint. Taxis are forbidden from crossing, so taxi ranks form either side of the checkpoint. The queue of traffic is long and chaotic, but after about half an hour we reach the front. Two girls are operating the checkpoint. They're no more than 19 years old, are heavily made up, and look like they're about to go to a military themed fancy dress party rather than a tough day operating security checks in the army. While they check our passes, they chat away to Eid.
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As we pass the 8 metre high concrete slabs forming the eastern part of the Qalandiya barrier, we see slogans daubed in black paint on the wall. One reads: "If Hitler were alive today, he'd say: `Damn, these Jews have exceeded my own expectations.' " Another says: "Palestine = one giant concentration camp." And another: "After WWII, you'd think the Jews would be the last people on earth to do to other people like what the Nazis did to them."
The West Bank barrier
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In June 2002, the Israeli government began the construction of a West Bank barrier, saying it was a security measure to protect its citizens from Palestinian suicide attacks that grew in number after the second intifada in 2000. Still under construction, the barrier consists of a system of 8-9 metre high concrete slab segments, fences, ditches, razor wire, groomed trace sand, electronic monitoring system, patrol roads, and a no go buffer zone. Israel's Ministry of Defence estimates that its total length will be 622 km when completed, costing some $4.7m (￡2.5m; 3.6m)/km.
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We visit the barrier in Abu Dis on the outskirts of Jerusalem. Inhabitants of Abu Dis typically consider themselves to be part of East Jerusalem—many of them have Jerusalem ID cards—yet they have been separated from it by an 8 metre high wall that runs down the "green line" (the border of Israel established by the 1949 armistice agreements, before Israel took control of the West Bank and Gaza in the six day war in 1967), which runs through the town. Two major Palestinian hospitals, Al-Maqassad and Augusta Victoria, lie on one side, and the main campus of Al-Quds University lies on the other. From Abu Dis, the spire of the Augusta Victoria is just about visible above the wall. To cross into East Jerusalem to access medical facilities, patients, doctors, and medical students must obtain permission.
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No access to East Jerusalem for Palestinians
As a result of the 1993 general closure that Israel has imposed on the occupied territories after a series of attacks, the Israeli government has denied Palestinians free access to East Jerusalem. Non-Jerusalemite Palestinians wishing to visit East Jerusalem must obtain a temporary permit granted by the civil administration. For a West Bank resident to access medical treatment in East Jerusalem, they must approach the civil administration for a permit; otherwise it is illegal to enter. Entry permits are automatically revoked after a "comprehensive closure" on the Palestinian territories, which is usually enforced to exact retribution for Palestinian attacks on Israeli citizens. When this happens, the West Bank resident must obtain a new permit.
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One section of the wall running through Abu Dis hasn't been fully completed and we clamber over brick walls and the rocky verge littered with barbed wire to the other side. The passageway is busy. People opt to travel this way—getting a taxi to one side of the verge and then taking another on the other side—as it's one of the only ways into Jerusalem. We don't encounter the army, but Kimberley Crunkleton, MDM's wall programme coordinator, says that security checks have been stepped up around this area since November 2004, when a teenager from Askar Refugee Camp near Nablus crossed over the verge and blew himself up in a Tel Aviv market.
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Kimberley says that before the wall it only took five minutes in an ambulance to reach the hospitals from Abu Dis and Aizaria, another village on the edge of East Jerusalem. However, people can now gain access only to Jerusalem hospitals, primarily to give birth and for scheduled surgery cases with a prearranged permit. The vast majority of people are transported to hospitals in Bethlehem, Jericho, Ramallah, Hebron, and Nablus. The average transport time by ambulance has increased to over one hour and 50 minutes, she says.
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Need for a broader perspective
My trip is taking a slightly one sided view—MDM's projects focus on the West Bank and the Gaza Strip, where they've identified a medical need. So I spend Sunday evening trying to arrange visits to the IDF, Hadassah hospital, and the Israeli branch of Physicians for Human Rights, who partner MDM on some of their projects. I have lots of offers of meetings—people have read Derek Summerfield's personal view in the BMJ1 and want to set the record straight. There's simply not enough time in the week to visit everyone, and most of my days are booked from seven in the morning until eleven at night.
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That night we go out for dinner in West Jerusalem. The restaurant is patrolled by a security guard carrying a gun. We're searched on our way in.
Monday
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.
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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.
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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.
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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.
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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.
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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.
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Tuesday
A day of extremes
Today I get the feeling I'm going to get a sample of Israeli political extremes. I've lined up meetings with Physicians for Human Rights (PHR) and the IDF in Tel Aviv. But, as one Israeli professor quipped to me: "This is a region where you have ten people and eleven different opinions." My first stop is PHR and a meeting with Hadas Ziv, the organisation's director for the occupied territories project. MDM is working with PHR and PRCS on an advocacy project, facilitating dialogue by working with both Israeli and Palestinian artists.
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Hadas is deeply impassioned about what PHR considers to be human rights abuses meted out by soldiers and politicians in the Palestinian territories. However, she acknowledges the right for Israel to protect itself, but thinks that the barrier should have been a last resort and questions its legality.
Travel restrictions cause health problems
She describes some of the health problems facing Palestinians in the West Bank, talking primarily about the travel restrictions. Ambulances are denied freedom of movement; women in labour are not allowed to pass through, giving birth on the road—she says she knows of at least 40 instances; the number of hospital deliveries has nearly halved since 2000; and in the past two years, the number of stillbirths in West Bank villages, she claims, are up 500%. Hadas also describes incidents when medical vehicles and staff have come under fire. "Medical staff and volunteers have been injured or killed while trying to carry out their medical duties," she says.
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But limitations on movement have not just hindered access to health care; they've placed an economic handicap on the Palestinian population. This has rendered an increasing number of people unable to pay for medical treatment and have contributed to a decline in general health and nutrition. Hospitals in the West Bank are also experiencing financial problems and are not equipped to cope with many medical emergencies.
I ask her whose responsibility it is to provide health care to the Palestinian population in the West Bank, given that most of the area falls under PA civil control. She replies categorically: "It's the responsibility of Israel. While Israel occupies the Palestinian territories, it has control of issues central to maintaining adequate health care. As there is no sovereign state taking control of the occupied territories, responsibility under international law rests with the state of Israel." Ultimately, she says, Israel is not willing to pay for the cost of occupation—donors pay for it.
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Having recruited hundreds of Israeli health workers, teams from PHR visit rural and urban areas in the occupied territories, providing free examinations, primary and secondary care, basic medicines, and baby formula. They also run expert and follow up clinics that accept patients who had previously been screened by Palestinian doctors and require further diagnosis and treatment. However, she says she's tired of being referred to as an example of "good Israelis."
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I leave and brace myself for the next interview, with an IDF spokesman, Captain Jacob Dallal. In Israel, the army service is a central part of Israeli public life. Enrolment is a rite of passage into adulthood, and service in an elite unit is a passport to the best jobs in the private sector, or a political career.
After some complex negotiations between the driver and Captain Dallal, we're taken to a building on a busy street. It's not the IDF headquarters but somewhere quite imperceptible. He arrives outside the anonymous building with a map tucked under his arm and escorts us to a bare atrium, where we sit on a sofa and chair. After several telephone conversations with him I'd inaccurately drawn a mental picture of a portentous middle aged man with a highly decorated chest to emphasise his military rank. He's not—he's surprisingly young and extremely chatty.
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One person's barrier is another person's fence
He chats away as he opens up the "antiterrorist fence" map, which details the route of the barrier, together with statistics and graphs showing how effective it is in reducing Israeli deaths. It also says that since September 2000, there have been 20 162 violent incidents, 137 suicide attacks, and 927 Israelis killed, 431 of whom where in suicide attacks.
As I attempt to ask Captain Dallal about the wall, he's quick to interject: "You mean, the fence," he says "95% is fence." I get the lingo wrong once again. Where the Israeli north-south highway, Route Six, passes close to the barrier, concrete slabs replace the fence to prevent sniper fire, he adds. In some areas, particularly in towns, there isn't enough room to construct a fence, which consists of barbed wire and a patrol road.
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On the IDF map, the barrier snakes several kilometres into the West Bank to link settlements with Israel and deviate away from the route of the green line. Captain Dallal stresses that although the green line formed the basis of the barrier, it made sense to incorporate the large settlements—some of which have up to 10 000 inhabitants—to bring them into the Israeli line of defence. Where Palestinians are cut off from their farmland, "agricultural gates" in the barrier provide access. He says that Israeli liaison officers have built up a rapport with Palestinian communities, helping to coordinate access to farming, and health care, among others. He cites the example of one family who were blocked off from their land by a gate that opens a few times a day. The liaison officer gave the family a key to enable them to attend their land whenever they wanted. "If the mayor of Jenin needs extra cement trucks to come in or electrical equipment or whatever, we arrange it on a local level," he says. "These things never make a newspaper article, but they're done."
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Soldiers are given training about how to handle the passage of an ambulance, and how to react to humanitarian and international organisations, Captain Dallal says. If an ambulance needs to come through to Jerusalem all the checkpoints en route are informed and they are stopped and searched for security reasons. However, when passing over the green line into East Jerusalem from the West Bank, the patient is usually transferred into an East Jerusalem ambulance and transported to hospital, he adds. It's a cumbersome process involving coordination between the Palestinian ambulance services, the checkpoint staff, liaison officers, and sometimes NGOs.
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Ambulances are checked
He tells me about one particular incident in 2002, when an explosive belt was found under a gurney transporting a sick child to hospital. The Red Crescent ambulance, containing the child's mother, brother, and sister, was stopped at a checkpoint in Ramallah, and the bomb was found and detonated. "Ambulances have been used as a method of transporting militants, weapons, and explosive devices," he says. Since that incident, ambulances are checked. He agrees that it's not acceptable that ambulances should wait at checkpoints. "At the end of the day, hundreds of ambulances travel around the West Bank daily. You're always going to hear about the one case out of ten thousand when something happens," he says. "The Qalandiya and Huwara checkpoints are the worst ones. Go to any other one, and they run smoothly."
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He also says that it was a culmination of events that led to the inspection of women at checkpoints. Suicide bombers were traditionally male, but an increasing number of women have been volunteering to blow themselves up in Israeli areas and, before routine searches were implemented, succeeding.
A similar fence has surrounded the Gaza Strip since 1996, and, with two exceptions, no suicide bombings have originated from Gaza inhabitants, Captain Dallal says. In 2003, two British passport holders passed through Gaza checkpoints armed with explosives—they'd used their UK citizenship to secure exit. One of them blew himself up in Mike's Place, a Tel Aviv bar, killing at least three Israelis and wounding many others. The other occurred in 2004, when two men from the Jabalya refugee camp in Gaza blew themselves up in the Israeli port of Ashdod. "I don't want to say how many lives have been saved or would have been lost had it not been for that fence," he says.
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Security issues
He also points out that where the barrier is operational in the northern West Bank no suicide bomb attacks have occurred in the north of Israel. Only one person, a women carrying a Jordanian passport, passed through a checkpoint into Haifa, killing 20 people on the eve of Yom Kippur. No women soldiers were operating the checkpoint that day, so she was able to pass through unsearched.
"This is something that's occurred over time. No one was doing anything about the suicide attacks. They kept on coming. Sure, the occasional person might still get through somehow. But if it prevents 95% of attacks, it's worth it," he says. He jumps up to go—he's in demand for other interviews. "It's a barrier. It doesn't physically harm anyone, it doesn't kill anyone. It actually prevents people from being killed."
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Later that evening Andy returns from his trip riding on the back of a PCRS ambulance. He shows me his photos; in one of them a soldier is checking a pregnant woman with a metal detector. He says that during the 15 minute wait, the documents of each person in the ambulance are checked. They're then passed through.
Wednesday
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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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"
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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.
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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.
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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.
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... 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.
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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"
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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.
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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.
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Thursday
Leaving Nablus, an ambulance is held up at the Huwara checkpoint. Cars in the queue of traffic don't pull over, leaving it trapped. When it finally reaches the front, soldiers climb on board to search it.
On reaching the checkpoint, we're asked for our ID cards and then, after answering a few questions about our activities, our passports. The soldiers examine them closely and spend a longer time focusing on mine. A mile further down the road, the army has set up a flying checkpoint, and we're forced to go through the same rigmarole again. While we're held up, an IDF bulldozer overtakes us. A little further down the road, we pass through yet another checkpoint—the third in a row.
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Specific health problems affecting women
MDM also run women and child health projects in the south of the West Bank, and we're off to visit Battir and Husan, villages just outside Bethlehem. They're pretty villages with olive groves and whitewashed houses, overlooking rolling hills in one direction and the start of a concrete wall and loops of barbed wire in another. There's a wave of concern spreading among the villagers. Under current plans, the barrier will jut into the West Bank and loop around the tomb of Rachel (a Jewish matriarch), which is located near the entrance to Bethlehem, to annex it to the rest of Israel. This will encircle the villages, cutting them off from Bethlehem. They're not sure how this is going to affect their everyday life.
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In Husan, I meet Vickie Ibrahim, the southern West Bank project coordinator for MDM, at the woman and baby clinic. Doctors and nurses are busy weighing, measuring, and giving postnatal and reproductive health advice. Not only does the clinic provide medical advice, but it acts as a counselling centre too, giving women time to talk about their psychological health.
Husan and Battir have their own specific set of health problems and needs. Vickie highlights early marriage as being one of the major problems for women's health. Although it's always been a feature of Palestinian life, particularly in Muslims, she says their records show the rate has increased since the second intifada. As Israeli security measures have intensified, so too have checkpoints and road blocks, making it harder for people to move freely between towns and villages. Not every village has secondary schools for girls, and if there is a block making travel difficult, families are reluctant to send their daughters. This has affected the number of girls accessing education. Attending university is more problematic—numerous checkpoints and road blocks line the route between villages and university campuses. Rather than fund an education that they might not be able to receive, some families, believing it's a waste of money, marry their daughters early.
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Vickie also accuses some of the checkpoint staff of transgressing Palestinian customs by asking girls to remove their hijab. Families, not wanting to see their daughters undergo what they consider to be humiliating behaviour, keep them in the village instead. "But they don't always want them at home, so they will marry them off instead," Vickie says. "The percentage of Palestinian women working is low, especially in the Hebron area, and as they're not economically independent, the families prefer to marry them rather than have to support them financially." As girls marry early—often at 15 years old—they tend to have more children. Vickie says the education ministry tries to incorporate lessons about early marriage and intermarriage into the school curriculum. The clinics also provide advice on contraception.
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Intermarriage
However, contributing to more distinct group of health problems is the growing trend of marriage between close relatives or what Vickie calls intermarriage. Restrictions on movement have disabled the social network and prohibited Palestinians from mixing freely. With limitations on travel, family members fear that they will not be able to visit each other easily and marry people within the same locality. Although intermarriage has always occurred to some extent, Vickie says that it has become more common since the second intifada. This has brought with it an increase in associated genetic conditions. Four per cent of the population have thalassaemia. She also says that congenital conditions runs at about 12% in the villages, attributing this to both internal marriage and a lack of clinics providing ultrasound and pregnancy screening tests.
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Malnutrition
Dr Ghada Qandaleft, a Syrian women's health doctor, operates a clinic in Battir. Although she offers mainly health advice, she finds women in the village come to her to talk about their personal problems. She thinks there's more domestic violence, and now it's even directed towards the mothers, who are considered to be holy people. The levels of malnutrition in the community have risen, too. She advises people what to eat, but it's futile, she says. People simply can't afford to eat a balanced diet. She breaks down while were talking. Although she spends most of her time helping other women to cope with their difficulties, she's had her own share of personal stresses.
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A patient's experience
Back in Abu Dis, I've arranged to meet Ali-Khalil Afana. He's been receiving dialysis for the past year after he had renal failure and wants to share his experience. As we enter his house, we're immediately plied with tea and coffee by his wife, while his pretty little granddaughter charges in and out, showing off to the strange visitors. Ali-Khalil says he needs dialysis three times a week and attends Augusta Victoria hospital. It used to take him 10 minutes to get there, but the wall now blocks his route. His new journey takes him over the hills on the outskirts of Abu Dis and can take over an hour. He doesn't have a car, so travels by taxi or even walks. Sometimes the checkpoint closes and he finds a part of the barrier where he can climb over.
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As I leave I notice a picture on the wall. He tells me it's his son Bilal Afana, who was praying in the al-Aqsa mosque located on the Temple Mount, a site holy to both Muslims and Jews, when Ariel Sharon accompanied by members of his Likud party and a heavy guard entered the mosque compound. His son was killed in the resultant clashes between Israeli police and Palestinian protestors. His parents describe him to me as "the first martyr of the second intifada."
, 百拇医药 Marital separation—but not as we know it
Just as we're about to get into the car, Adeb El-Wahab, a volunteer for the newly formed Jerusalem Centre for Human Rights (JCHR) accosts us. Apparently, he wanted to speak to us and introduce us to two Palestinian doctors working at Augusta Victoria hospital, but we didn't get the message. He wants to talk to us about the JCHR and the problems he's facing. He's unable to live with his wife—they have different ID cards. She lives in East Jerusalem with her parents. If she leaves to live in the West Bank, her East Jerusalem ID will be invoked. But someone with a West Bank ID is not allowed to live in East Jerusalem, so Aded sees her twice a week only. He says that about 800 families are now forced to live separately.
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Later that afternoon, while travelling to meet Shmuel Shapira, the deputy director general of the reputed Hadassah Hospital in Jerusalem, the university's medical centre, I pass by Yad Vashem, the haunting Holocaust memorial.
Treating victims without discrimination
Before entering the hospital, I pass through a metal detector and guards search my bag. A beautiful stained glass window, donated by artist Mark Chagall, dominates the wall of the hospital overlooking the security process. The security measures have been stepped up since one of main campuses on Mount Scopus was attacked with Molotov cocktails, killing six people and injuring 79, and is the scene of regular attacks.
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Dr Shapira meets me in the atrium. The main waiting area is crowded—orthodox Jews are sitting next to Muslims.
As head of the "terror team," Dr Shapira has plenty of firsthand experience of the consequences of suicide bombs. The hospital treats up to 40% of terrorism victims in Israel, he says. "We treat victims without discrimination. We take them whether they are Israelis—Jews or Arabs anyone."
One of his colleagues, Dr Shmuel Gilles, was killed by Palestinian gunmen in a drive-by shooting in 2001 on his way back from treating patients at the Hadassah Hospital. His last noted patient was a Palestinian. And, he says, 28 of his other colleagues have lost first degree relatives in Palestinian attacks since the second intifada.
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"A sick person is a patient, no matter who he is"
He talks about some of the suspected terrorists he's treated and describes the hospital as "an island of sanity in a sea of insane violence." He says the hospital receives referrals from outside Jerusalem. A large proportion of his patients are Palestinian, and he produces a chart documenting the numbers of Israeli and Palestinian patients. Palestinian healthcare professionals work next to Israeli staff. "Everyone has their own political attitudes, but we all keep opinions out of the hospital. You come here to work as a doctor or nurse, and you get on with the job." Patients, he adds, are treated by medical need, not on religion or creed or whether you're a terrorist or victim. "Treating people is part of the Jewish tradition. Even orthodox rules say that you can break the Shabbat to treat a person," he says. "A sick person is a patient no matter who he is. In the IDF medical corps, someone can belong to the enemy, but the minute they are sick or are injured, they're your patient and not the enemy anymore."
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He talks about the unusual situation which the hospital is in. "Most often if a suicide bomber detonates, people are killed. But sometimes they're just wounded." On occasions, the attacker has lain on a bed next to a victim. It's created difficult management situations, he says.
Everyone knows someone who has been killed
He talks about the sense of dread and terror when you hear about a bomb. Doctors en route to the emergency department will make quick phone calls to their families to check that they're safe before taking to the floor. Phone lines are inaccessible as families and friends desperately try to contact each other. Everyone knows someone who has been killed. Children have seen their friends blown up whilst they waited for a school bus—many parents now won't let their children go on buses or to public places.
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Almost 1000 Israelis have been killed and 8000 injured in the past four years, and Israel has only a small population. "You extrapolate that for the United Kingdom," he says.
Dr Shapira shows me photos and x ray films taken at the scene. The floor of a cafe is a blood bath; the room is barely recognisable. Nails, ball bearings, and other metal items are lodged in the bodies of the victims, while others are strewn prostrate on the tiled floor. On one x ray film, the face surround of the suicide bomber's watch has become embedded into the neck of one victim by the force of the blast. In a sad irony, the watch is by Jewish fashion designer Calvin Klein.
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Trying to make sense of it all
I race off—I have another meeting, followed by a dinner date with an Israeli journalist. My feet have barely touched the floor and by the end of the day I'm close to hysteria through physical and mental fatigue. The intensity of emotion has finally overwhelmed me, and I'm tired of being asked if I'm pro-Israeli or pro-Palestinian. People from all different parts of the political spectrum have tried to convince me—who has suffered the most hardship. Layers of history have been peeled back to stake claims on the legitimacy of their cause and whose right it is to own the land, at times dating back thousands of years. Reading through my notes, I struggle to filter fact from rhetoric. Not even my usual panacea for brainache—a glass of red wine—seems to do the trick. But at least my French finally flows.
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Friday
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.
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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., 百拇医药(Deborah Cohen)
Introduction
I'd always meant to go to Israel but somehow had never got round to it. So I jumped at the chance when I was offered the opportunity to go on a press trip to Israel and the Palestine territories occupied by Israel with Médecins du Monde (MDM), a French medical organisation that has several projects dotted around the area. Admittedly I was nervous about going but convinced myself that if it were all that dangerous MDM wouldn't risk the lives of its staff—after all, many non-governmental organisations (NGOs) have withdrawn from Iraq. But what bothered me more was how I'd report what I see, and if people disagreed—and they're bound to—that I'd be dismissed as pro-Israeli and a Zionist or pro-Palestinian and a self hating Jew.
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Saturday 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.
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Jean Sebastién Dy, the [now former] 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."
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Sunday
We receive a security briefing and cream waistcoats displaying the MDM logo for our safety—it's standard NGO attire. I then make my first faux pas of the day, and what I presumed to be the first of many. For security purposes and ease of passage through checkpoints, we all were issued with MDM identity (ID) cards—it's far easier for NGOs and diplomats to negotiate their way around the West Bank. In the space labelled "Country of Mission" without thinking I wrote "Israel." My newness to linguistic diplomacy in the Middle East was met with wry chuckles by the MDM staff—someone's Israel is another person's Palestine. They reissued it, with "All countries" filling the gap.
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Map of the West Bank barrier adapted from map by Office for the Co-ordination of Humanitarian Affairs
Movement between the West Bank and Jerusalem is regulated by a system of ID cards. Palestinians living in the Jerusalem area have Israeli issued ID cards. They have access to health care, education, work, and national insurance benefits because they pay taxes in Israel. Palestinians living in the occupied territories carry a West Bank or Gaza ID card. They need a permit to cross checkpoints into Israel, Jerusalem, settlements, and industrial zones where they work.
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The "easy" way into Ramallah
As we head from Jerusalem to Ramallah, we arrive at our first checkpoint of the day. Cars channel into two queues—UN and diplomatic vehicles with their white licence plates, and "others." While we're waiting, the diplomats pull up and glide through effortlessly, and our MDM ID cards let us pass through with relative ease.
I didn't quite know what to expect from Ramallah. I'd only ever seen it on the television during chaotic and bloody flare-ups of the conflict or heaving under the strain of assembled masses grieving the death of Yasser Arafat. But it just seemed like a faceless, unkempt, hilly town. People roamed the streets, drove their cars, popped into a cafe for a coffee—nothing visibly untoward or unusual. It could have anywhere had it not been for the face of Yasser Arafat wearing his trademark kaffiyeh beaming down from adverts promoting mobile phones.
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We arrive at the headquarters of the Palestinian Red Crescent Society (PRCS), an observer member of the International Federation of the Red Cross and Red Crescent Societies. Reem Wadhan, public relations officer for the PRCS, takes us around the bustling building, explaining what each section does, and describes some of the problems facing the organisation. As I'm new to the region, Reem gives a quick summary of the travel restrictions in the West Bank.
Regional divisions and personal separations
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As a result of the Oslo Accords, the Palestinian Authority (PA) was established and the region divided into zones. Zone A is an autonomous Palestinian region, such as Ramallah, and many of the other West Bank towns. However, Israel controls the checkpoints between the towns and villages, determining who can leave and enter. She described zone B as the "ultimate grey area"—responsibility for the area is split between the Israeli and Palestinian authorities—and it forms most of the West Bank area that isn't already in zone A. Here civil responsibility falls to the PA but security is under Israeli control. Zone C is under complete Israeli control.
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Reem complains that for the Palestinians the situation on the ground has actually deteriorated. More roadblocks and checkpoints have sprung up, and East Jerusalem is now virtually closed off. This has made travelling around the West Bank a drawn out chore for Palestinians; passing from village to town is complicated by checkpoints.
"It's even harder to go from city to city," she says. "Our ID cards are all marked with our home towns, and soldiers won't let you pass through without specific permission, and even then, they may turn you away because you're from Ramallah. I haven't seen some members of my family for ages."
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She tells us tales of ambulances collecting women in labour to take them to the hospital delivery suites, only to be held up at a checkpoint where the women give birth. Quite often, ambulances aren't even able to reach sick people in the first place, she says. They are stopped from proceeding any further. When this occurs they contact the MDM team or the International Committee of the Red Cross, who liaise with the Israel Defense Forces (IDF) to negotiate their passage.
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Outside the PRCS, rows of ambulances stood waiting for action. Abdul Haleem, the director of the PRCS emergency centre in Ramallah, is keen to show us the layout inside one of the ambulances. "This one," he announces proudly, ushering Andy in its direction, "was made in Palestine." He then turns and points to an ambulance. The front is concertinaed and starting to rust. "It was crushed by an Israeli tank," he says. The ambulance station is its final rest home—a testimony to the difficulties the conflict creates.
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We meet the emergency medical technicians, who are hanging around, waiting for a call. Currently, the teams consist primarily of men, but they want to recruit more women. However, Reem says that women are often reluctant to travel as they are subjected to frequent searches by the checkpoint staff and are concerned about the attacks on staff.
From the 101 dispatch call room, Sobheyyeh Ahme, wearing a crisp white coat with a red crescent on the sleeve, fields all the emergency calls. Pinned on one of the walls is a poster of a smiling Yasser Arafat. Noticing our Médecins du Monde waistcoats, Sobheyyeh greets us warmly—she wants to extend her gratitude to our government for allowing her leader to die peacefully in our country. We point out we're not French, we're British. "Oh," she says, her smile fading ever so slightly.
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The hard way out
Apparently we've had the easy way into Ramallah, so Eid Mohammed, the MDM driver, decides to introduce us to the "hard way" out. The Qalandiya checkpoint bustles with activity; traders have set up stalls, selling everything from spices to birds in cages. Taxis ferry people to and from the checkpoint. Taxis are forbidden from crossing, so taxi ranks form either side of the checkpoint. The queue of traffic is long and chaotic, but after about half an hour we reach the front. Two girls are operating the checkpoint. They're no more than 19 years old, are heavily made up, and look like they're about to go to a military themed fancy dress party rather than a tough day operating security checks in the army. While they check our passes, they chat away to Eid.
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As we pass the 8 metre high concrete slabs forming the eastern part of the Qalandiya barrier, we see slogans daubed in black paint on the wall. One reads: "If Hitler were alive today, he'd say: `Damn, these Jews have exceeded my own expectations.' " Another says: "Palestine = one giant concentration camp." And another: "After WWII, you'd think the Jews would be the last people on earth to do to other people like what the Nazis did to them."
The West Bank barrier
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In June 2002, the Israeli government began the construction of a West Bank barrier, saying it was a security measure to protect its citizens from Palestinian suicide attacks that grew in number after the second intifada in 2000. Still under construction, the barrier consists of a system of 8-9 metre high concrete slab segments, fences, ditches, razor wire, groomed trace sand, electronic monitoring system, patrol roads, and a no go buffer zone. Israel's Ministry of Defence estimates that its total length will be 622 km when completed, costing some $4.7m (￡2.5m; 3.6m)/km.
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We visit the barrier in Abu Dis on the outskirts of Jerusalem. Inhabitants of Abu Dis typically consider themselves to be part of East Jerusalem—many of them have Jerusalem ID cards—yet they have been separated from it by an 8 metre high wall that runs down the "green line" (the border of Israel established by the 1949 armistice agreements, before Israel took control of the West Bank and Gaza in the six day war in 1967), which runs through the town. Two major Palestinian hospitals, Al-Maqassad and Augusta Victoria, lie on one side, and the main campus of Al-Quds University lies on the other. From Abu Dis, the spire of the Augusta Victoria is just about visible above the wall. To cross into East Jerusalem to access medical facilities, patients, doctors, and medical students must obtain permission.
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No access to East Jerusalem for Palestinians
As a result of the 1993 general closure that Israel has imposed on the occupied territories after a series of attacks, the Israeli government has denied Palestinians free access to East Jerusalem. Non-Jerusalemite Palestinians wishing to visit East Jerusalem must obtain a temporary permit granted by the civil administration. For a West Bank resident to access medical treatment in East Jerusalem, they must approach the civil administration for a permit; otherwise it is illegal to enter. Entry permits are automatically revoked after a "comprehensive closure" on the Palestinian territories, which is usually enforced to exact retribution for Palestinian attacks on Israeli citizens. When this happens, the West Bank resident must obtain a new permit.
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One section of the wall running through Abu Dis hasn't been fully completed and we clamber over brick walls and the rocky verge littered with barbed wire to the other side. The passageway is busy. People opt to travel this way—getting a taxi to one side of the verge and then taking another on the other side—as it's one of the only ways into Jerusalem. We don't encounter the army, but Kimberley Crunkleton, MDM's wall programme coordinator, says that security checks have been stepped up around this area since November 2004, when a teenager from Askar Refugee Camp near Nablus crossed over the verge and blew himself up in a Tel Aviv market.
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Kimberley says that before the wall it only took five minutes in an ambulance to reach the hospitals from Abu Dis and Aizaria, another village on the edge of East Jerusalem. However, people can now gain access only to Jerusalem hospitals, primarily to give birth and for scheduled surgery cases with a prearranged permit. The vast majority of people are transported to hospitals in Bethlehem, Jericho, Ramallah, Hebron, and Nablus. The average transport time by ambulance has increased to over one hour and 50 minutes, she says.
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Need for a broader perspective
My trip is taking a slightly one sided view—MDM's projects focus on the West Bank and the Gaza Strip, where they've identified a medical need. So I spend Sunday evening trying to arrange visits to the IDF, Hadassah hospital, and the Israeli branch of Physicians for Human Rights, who partner MDM on some of their projects. I have lots of offers of meetings—people have read Derek Summerfield's personal view in the BMJ1 and want to set the record straight. There's simply not enough time in the week to visit everyone, and most of my days are booked from seven in the morning until eleven at night.
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That night we go out for dinner in West Jerusalem. The restaurant is patrolled by a security guard carrying a gun. We're searched on our way in.
Monday
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.
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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.
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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.
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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.
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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.
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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.
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Tuesday
A day of extremes
Today I get the feeling I'm going to get a sample of Israeli political extremes. I've lined up meetings with Physicians for Human Rights (PHR) and the IDF in Tel Aviv. But, as one Israeli professor quipped to me: "This is a region where you have ten people and eleven different opinions." My first stop is PHR and a meeting with Hadas Ziv, the organisation's director for the occupied territories project. MDM is working with PHR and PRCS on an advocacy project, facilitating dialogue by working with both Israeli and Palestinian artists.
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Hadas is deeply impassioned about what PHR considers to be human rights abuses meted out by soldiers and politicians in the Palestinian territories. However, she acknowledges the right for Israel to protect itself, but thinks that the barrier should have been a last resort and questions its legality.
Travel restrictions cause health problems
She describes some of the health problems facing Palestinians in the West Bank, talking primarily about the travel restrictions. Ambulances are denied freedom of movement; women in labour are not allowed to pass through, giving birth on the road—she says she knows of at least 40 instances; the number of hospital deliveries has nearly halved since 2000; and in the past two years, the number of stillbirths in West Bank villages, she claims, are up 500%. Hadas also describes incidents when medical vehicles and staff have come under fire. "Medical staff and volunteers have been injured or killed while trying to carry out their medical duties," she says.
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But limitations on movement have not just hindered access to health care; they've placed an economic handicap on the Palestinian population. This has rendered an increasing number of people unable to pay for medical treatment and have contributed to a decline in general health and nutrition. Hospitals in the West Bank are also experiencing financial problems and are not equipped to cope with many medical emergencies.
I ask her whose responsibility it is to provide health care to the Palestinian population in the West Bank, given that most of the area falls under PA civil control. She replies categorically: "It's the responsibility of Israel. While Israel occupies the Palestinian territories, it has control of issues central to maintaining adequate health care. As there is no sovereign state taking control of the occupied territories, responsibility under international law rests with the state of Israel." Ultimately, she says, Israel is not willing to pay for the cost of occupation—donors pay for it.
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Having recruited hundreds of Israeli health workers, teams from PHR visit rural and urban areas in the occupied territories, providing free examinations, primary and secondary care, basic medicines, and baby formula. They also run expert and follow up clinics that accept patients who had previously been screened by Palestinian doctors and require further diagnosis and treatment. However, she says she's tired of being referred to as an example of "good Israelis."
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I leave and brace myself for the next interview, with an IDF spokesman, Captain Jacob Dallal. In Israel, the army service is a central part of Israeli public life. Enrolment is a rite of passage into adulthood, and service in an elite unit is a passport to the best jobs in the private sector, or a political career.
After some complex negotiations between the driver and Captain Dallal, we're taken to a building on a busy street. It's not the IDF headquarters but somewhere quite imperceptible. He arrives outside the anonymous building with a map tucked under his arm and escorts us to a bare atrium, where we sit on a sofa and chair. After several telephone conversations with him I'd inaccurately drawn a mental picture of a portentous middle aged man with a highly decorated chest to emphasise his military rank. He's not—he's surprisingly young and extremely chatty.
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One person's barrier is another person's fence
He chats away as he opens up the "antiterrorist fence" map, which details the route of the barrier, together with statistics and graphs showing how effective it is in reducing Israeli deaths. It also says that since September 2000, there have been 20 162 violent incidents, 137 suicide attacks, and 927 Israelis killed, 431 of whom where in suicide attacks.
As I attempt to ask Captain Dallal about the wall, he's quick to interject: "You mean, the fence," he says "95% is fence." I get the lingo wrong once again. Where the Israeli north-south highway, Route Six, passes close to the barrier, concrete slabs replace the fence to prevent sniper fire, he adds. In some areas, particularly in towns, there isn't enough room to construct a fence, which consists of barbed wire and a patrol road.
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On the IDF map, the barrier snakes several kilometres into the West Bank to link settlements with Israel and deviate away from the route of the green line. Captain Dallal stresses that although the green line formed the basis of the barrier, it made sense to incorporate the large settlements—some of which have up to 10 000 inhabitants—to bring them into the Israeli line of defence. Where Palestinians are cut off from their farmland, "agricultural gates" in the barrier provide access. He says that Israeli liaison officers have built up a rapport with Palestinian communities, helping to coordinate access to farming, and health care, among others. He cites the example of one family who were blocked off from their land by a gate that opens a few times a day. The liaison officer gave the family a key to enable them to attend their land whenever they wanted. "If the mayor of Jenin needs extra cement trucks to come in or electrical equipment or whatever, we arrange it on a local level," he says. "These things never make a newspaper article, but they're done."
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Soldiers are given training about how to handle the passage of an ambulance, and how to react to humanitarian and international organisations, Captain Dallal says. If an ambulance needs to come through to Jerusalem all the checkpoints en route are informed and they are stopped and searched for security reasons. However, when passing over the green line into East Jerusalem from the West Bank, the patient is usually transferred into an East Jerusalem ambulance and transported to hospital, he adds. It's a cumbersome process involving coordination between the Palestinian ambulance services, the checkpoint staff, liaison officers, and sometimes NGOs.
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Ambulances are checked
He tells me about one particular incident in 2002, when an explosive belt was found under a gurney transporting a sick child to hospital. The Red Crescent ambulance, containing the child's mother, brother, and sister, was stopped at a checkpoint in Ramallah, and the bomb was found and detonated. "Ambulances have been used as a method of transporting militants, weapons, and explosive devices," he says. Since that incident, ambulances are checked. He agrees that it's not acceptable that ambulances should wait at checkpoints. "At the end of the day, hundreds of ambulances travel around the West Bank daily. You're always going to hear about the one case out of ten thousand when something happens," he says. "The Qalandiya and Huwara checkpoints are the worst ones. Go to any other one, and they run smoothly."
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He also says that it was a culmination of events that led to the inspection of women at checkpoints. Suicide bombers were traditionally male, but an increasing number of women have been volunteering to blow themselves up in Israeli areas and, before routine searches were implemented, succeeding.
A similar fence has surrounded the Gaza Strip since 1996, and, with two exceptions, no suicide bombings have originated from Gaza inhabitants, Captain Dallal says. In 2003, two British passport holders passed through Gaza checkpoints armed with explosives—they'd used their UK citizenship to secure exit. One of them blew himself up in Mike's Place, a Tel Aviv bar, killing at least three Israelis and wounding many others. The other occurred in 2004, when two men from the Jabalya refugee camp in Gaza blew themselves up in the Israeli port of Ashdod. "I don't want to say how many lives have been saved or would have been lost had it not been for that fence," he says.
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Security issues
He also points out that where the barrier is operational in the northern West Bank no suicide bomb attacks have occurred in the north of Israel. Only one person, a women carrying a Jordanian passport, passed through a checkpoint into Haifa, killing 20 people on the eve of Yom Kippur. No women soldiers were operating the checkpoint that day, so she was able to pass through unsearched.
"This is something that's occurred over time. No one was doing anything about the suicide attacks. They kept on coming. Sure, the occasional person might still get through somehow. But if it prevents 95% of attacks, it's worth it," he says. He jumps up to go—he's in demand for other interviews. "It's a barrier. It doesn't physically harm anyone, it doesn't kill anyone. It actually prevents people from being killed."
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Later that evening Andy returns from his trip riding on the back of a PCRS ambulance. He shows me his photos; in one of them a soldier is checking a pregnant woman with a metal detector. He says that during the 15 minute wait, the documents of each person in the ambulance are checked. They're then passed through.
Wednesday
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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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"
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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.
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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.
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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.
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... 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.
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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"
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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.
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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.
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Thursday
Leaving Nablus, an ambulance is held up at the Huwara checkpoint. Cars in the queue of traffic don't pull over, leaving it trapped. When it finally reaches the front, soldiers climb on board to search it.
On reaching the checkpoint, we're asked for our ID cards and then, after answering a few questions about our activities, our passports. The soldiers examine them closely and spend a longer time focusing on mine. A mile further down the road, the army has set up a flying checkpoint, and we're forced to go through the same rigmarole again. While we're held up, an IDF bulldozer overtakes us. A little further down the road, we pass through yet another checkpoint—the third in a row.
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Specific health problems affecting women
MDM also run women and child health projects in the south of the West Bank, and we're off to visit Battir and Husan, villages just outside Bethlehem. They're pretty villages with olive groves and whitewashed houses, overlooking rolling hills in one direction and the start of a concrete wall and loops of barbed wire in another. There's a wave of concern spreading among the villagers. Under current plans, the barrier will jut into the West Bank and loop around the tomb of Rachel (a Jewish matriarch), which is located near the entrance to Bethlehem, to annex it to the rest of Israel. This will encircle the villages, cutting them off from Bethlehem. They're not sure how this is going to affect their everyday life.
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In Husan, I meet Vickie Ibrahim, the southern West Bank project coordinator for MDM, at the woman and baby clinic. Doctors and nurses are busy weighing, measuring, and giving postnatal and reproductive health advice. Not only does the clinic provide medical advice, but it acts as a counselling centre too, giving women time to talk about their psychological health.
Husan and Battir have their own specific set of health problems and needs. Vickie highlights early marriage as being one of the major problems for women's health. Although it's always been a feature of Palestinian life, particularly in Muslims, she says their records show the rate has increased since the second intifada. As Israeli security measures have intensified, so too have checkpoints and road blocks, making it harder for people to move freely between towns and villages. Not every village has secondary schools for girls, and if there is a block making travel difficult, families are reluctant to send their daughters. This has affected the number of girls accessing education. Attending university is more problematic—numerous checkpoints and road blocks line the route between villages and university campuses. Rather than fund an education that they might not be able to receive, some families, believing it's a waste of money, marry their daughters early.
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Vickie also accuses some of the checkpoint staff of transgressing Palestinian customs by asking girls to remove their hijab. Families, not wanting to see their daughters undergo what they consider to be humiliating behaviour, keep them in the village instead. "But they don't always want them at home, so they will marry them off instead," Vickie says. "The percentage of Palestinian women working is low, especially in the Hebron area, and as they're not economically independent, the families prefer to marry them rather than have to support them financially." As girls marry early—often at 15 years old—they tend to have more children. Vickie says the education ministry tries to incorporate lessons about early marriage and intermarriage into the school curriculum. The clinics also provide advice on contraception.
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Intermarriage
However, contributing to more distinct group of health problems is the growing trend of marriage between close relatives or what Vickie calls intermarriage. Restrictions on movement have disabled the social network and prohibited Palestinians from mixing freely. With limitations on travel, family members fear that they will not be able to visit each other easily and marry people within the same locality. Although intermarriage has always occurred to some extent, Vickie says that it has become more common since the second intifada. This has brought with it an increase in associated genetic conditions. Four per cent of the population have thalassaemia. She also says that congenital conditions runs at about 12% in the villages, attributing this to both internal marriage and a lack of clinics providing ultrasound and pregnancy screening tests.
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Malnutrition
Dr Ghada Qandaleft, a Syrian women's health doctor, operates a clinic in Battir. Although she offers mainly health advice, she finds women in the village come to her to talk about their personal problems. She thinks there's more domestic violence, and now it's even directed towards the mothers, who are considered to be holy people. The levels of malnutrition in the community have risen, too. She advises people what to eat, but it's futile, she says. People simply can't afford to eat a balanced diet. She breaks down while were talking. Although she spends most of her time helping other women to cope with their difficulties, she's had her own share of personal stresses.
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A patient's experience
Back in Abu Dis, I've arranged to meet Ali-Khalil Afana. He's been receiving dialysis for the past year after he had renal failure and wants to share his experience. As we enter his house, we're immediately plied with tea and coffee by his wife, while his pretty little granddaughter charges in and out, showing off to the strange visitors. Ali-Khalil says he needs dialysis three times a week and attends Augusta Victoria hospital. It used to take him 10 minutes to get there, but the wall now blocks his route. His new journey takes him over the hills on the outskirts of Abu Dis and can take over an hour. He doesn't have a car, so travels by taxi or even walks. Sometimes the checkpoint closes and he finds a part of the barrier where he can climb over.
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As I leave I notice a picture on the wall. He tells me it's his son Bilal Afana, who was praying in the al-Aqsa mosque located on the Temple Mount, a site holy to both Muslims and Jews, when Ariel Sharon accompanied by members of his Likud party and a heavy guard entered the mosque compound. His son was killed in the resultant clashes between Israeli police and Palestinian protestors. His parents describe him to me as "the first martyr of the second intifada."
, 百拇医药 Marital separation—but not as we know it
Just as we're about to get into the car, Adeb El-Wahab, a volunteer for the newly formed Jerusalem Centre for Human Rights (JCHR) accosts us. Apparently, he wanted to speak to us and introduce us to two Palestinian doctors working at Augusta Victoria hospital, but we didn't get the message. He wants to talk to us about the JCHR and the problems he's facing. He's unable to live with his wife—they have different ID cards. She lives in East Jerusalem with her parents. If she leaves to live in the West Bank, her East Jerusalem ID will be invoked. But someone with a West Bank ID is not allowed to live in East Jerusalem, so Aded sees her twice a week only. He says that about 800 families are now forced to live separately.
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Later that afternoon, while travelling to meet Shmuel Shapira, the deputy director general of the reputed Hadassah Hospital in Jerusalem, the university's medical centre, I pass by Yad Vashem, the haunting Holocaust memorial.
Treating victims without discrimination
Before entering the hospital, I pass through a metal detector and guards search my bag. A beautiful stained glass window, donated by artist Mark Chagall, dominates the wall of the hospital overlooking the security process. The security measures have been stepped up since one of main campuses on Mount Scopus was attacked with Molotov cocktails, killing six people and injuring 79, and is the scene of regular attacks.
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Dr Shapira meets me in the atrium. The main waiting area is crowded—orthodox Jews are sitting next to Muslims.
As head of the "terror team," Dr Shapira has plenty of firsthand experience of the consequences of suicide bombs. The hospital treats up to 40% of terrorism victims in Israel, he says. "We treat victims without discrimination. We take them whether they are Israelis—Jews or Arabs anyone."
One of his colleagues, Dr Shmuel Gilles, was killed by Palestinian gunmen in a drive-by shooting in 2001 on his way back from treating patients at the Hadassah Hospital. His last noted patient was a Palestinian. And, he says, 28 of his other colleagues have lost first degree relatives in Palestinian attacks since the second intifada.
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"A sick person is a patient, no matter who he is"
He talks about some of the suspected terrorists he's treated and describes the hospital as "an island of sanity in a sea of insane violence." He says the hospital receives referrals from outside Jerusalem. A large proportion of his patients are Palestinian, and he produces a chart documenting the numbers of Israeli and Palestinian patients. Palestinian healthcare professionals work next to Israeli staff. "Everyone has their own political attitudes, but we all keep opinions out of the hospital. You come here to work as a doctor or nurse, and you get on with the job." Patients, he adds, are treated by medical need, not on religion or creed or whether you're a terrorist or victim. "Treating people is part of the Jewish tradition. Even orthodox rules say that you can break the Shabbat to treat a person," he says. "A sick person is a patient no matter who he is. In the IDF medical corps, someone can belong to the enemy, but the minute they are sick or are injured, they're your patient and not the enemy anymore."
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He talks about the unusual situation which the hospital is in. "Most often if a suicide bomber detonates, people are killed. But sometimes they're just wounded." On occasions, the attacker has lain on a bed next to a victim. It's created difficult management situations, he says.
Everyone knows someone who has been killed
He talks about the sense of dread and terror when you hear about a bomb. Doctors en route to the emergency department will make quick phone calls to their families to check that they're safe before taking to the floor. Phone lines are inaccessible as families and friends desperately try to contact each other. Everyone knows someone who has been killed. Children have seen their friends blown up whilst they waited for a school bus—many parents now won't let their children go on buses or to public places.
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Almost 1000 Israelis have been killed and 8000 injured in the past four years, and Israel has only a small population. "You extrapolate that for the United Kingdom," he says.
Dr Shapira shows me photos and x ray films taken at the scene. The floor of a cafe is a blood bath; the room is barely recognisable. Nails, ball bearings, and other metal items are lodged in the bodies of the victims, while others are strewn prostrate on the tiled floor. On one x ray film, the face surround of the suicide bomber's watch has become embedded into the neck of one victim by the force of the blast. In a sad irony, the watch is by Jewish fashion designer Calvin Klein.
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Trying to make sense of it all
I race off—I have another meeting, followed by a dinner date with an Israeli journalist. My feet have barely touched the floor and by the end of the day I'm close to hysteria through physical and mental fatigue. The intensity of emotion has finally overwhelmed me, and I'm tired of being asked if I'm pro-Israeli or pro-Palestinian. People from all different parts of the political spectrum have tried to convince me—who has suffered the most hardship. Layers of history have been peeled back to stake claims on the legitimacy of their cause and whose right it is to own the land, at times dating back thousands of years. Reading through my notes, I struggle to filter fact from rhetoric. Not even my usual panacea for brainache—a glass of red wine—seems to do the trick. But at least my French finally flows.
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Friday
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.
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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., 百拇医药(Deborah Cohen)