Occupational health

For the past 20 years, teams of Arab and Jewish doctors have defied Israeli blockades and bureaucracy to deliver essential medical care to isolated Palestinian communities. Rachel Shabi reports on the work of Physicians for Human Rights-Israel Dr Danni is examining 10-year-old Mohammed, whose eye keeps twitching. "Does it happen at night?" asks the doctor, one of a team at a mobile clinic in the West Bank village of Nahalin. No, Mohammed's father answers for his son, the twitching occurs only during the daytime, although Mohammed does have tics in other parts of his body, sometimes his legs and arms.

Dr Danni continues his examination of the boy and, having eliminated the possibility of epilepsy, says he thinks Mohammed has a nervous disorder. "You know you can learn to control it," he tells the quiet, shy boy. "And I'm prescribing B12 vitamin tablets, because nervous tics are often a symptom of deficiencies in this vitamin." Dr Danni is one of a team of Jewish and Arab doctors from the organisation Physicians for Human Rights-Israel. For the past 20 years, this organisation has sent doctors out to treat Palestinians who have poor and patchy access to health services.

"We work on the issue of the right to health," says mobile clinic director, Dr Salah Haj Yahya. "This is our flagship project, a mobile clinic that goes into the occupied territories each Saturday, a large team of Jews and Arabs as one." The clinics visit villages where access to medical facilities is often curtailed by checkpoints and closures. "The main idea here is our solidarity with the Palestinian people - in their fight against the occupation, for freedom. The political issue is the most important."

Nahalin is typical of the villages visited by the PHR-Israel clinics. Located 12km south of Bethlehem, the village, which has a population of about 6,000, struggles to obtain regular access to a family doctor; the Palestinian Authority health services send one approximately once a week. Too poor to visit a private clinic and with Bethlehem a long, bumpy ride away, many of these Palestinian villagers suffer the sort of illnesses that could easily be treated, or prevented. On the day the PHR-Israel clinic comes to the village, scores of people queue for hours in the baking sun, waiting to see one of the five doctors who have set up a makeshift practice.

A stream of parents bring sick children in to see the Israeli Dr Danni, a paediatrician. One of those is seven-year-old Dina, who comes in with her mother and is suffering chest pains, a fever and has trouble swallowing. After examiningher, the doctor prescribes antibiotics, which he tells her mother to administer only if the girl's condition worsens. "You're OK, you're fine," he tells Dina, and she breaks into a smile.

"We don't have a local doctor," Dina's mother says. "I am very happy that these Israeli doctors come to help us. I respect them all." There's a PHR-Israel pharmacy at the entrance to Nahalin's medical relief centre, where the doctors have set up for the day. For many Palestinians, the clinics are a chance to obtain medicines that might otherwise not be available, says Dr Yahya, who is manning the pharmacy. "Painkillers are what we run out of first, at all the clinics," he says. "Otherwise, the medicines most requested are to treat blood pressure, cholesterol and diabetes."

As well as paediatric doctors and a family practitioner, there's usually a specialist on site at the clinics. Orthopaedic specialists are in high demand but today at Nahalin, it's the turn of Dr Idit Schwartz, who normally works at Tel Aviv's main hospital and is a specialist in internal medicine. "I've been doing this more intensively for the past five or six years," she says of her work with the mobile clinics, though she has been involved for a lot longer with the clinics that PHR-Israel runs for migrant workers and refugees within the Jewish state. "Usually, the kind of medical care we administer is like fire-fighting."

All the doctors who work in the mobile clinics are frustrated with this style of one-off care-giving, but stress that the practice is not just about the medicine. "The primary concern is to give treatment, of course," says Dr Schwartz. "But the smile, the touch - that does something, too, something beyond the prescription and the antibiotics." That's in evidence when Dr Schwartz sees a woman in her 70s, who comes in complaining of pains in her stomach, along with other symptoms. The doctor is quick to help the patient, who is struggling with her clothes and to climb on to the bed. The male translator has left the room, but somehow these two women, so many worlds apart, manage to communicate through gestures, humour and a string of basic Arabic words for various parts of the body. By the time the woman leaves the room, she has a diagnosis - and she looks as though she feels better somehow.

Dr Schwartz believes that Palestinians living in the West Bank pay the high health cost of the occupation, with bad healthcare conditions compounded by poor finances. "A very important aspect of medicine is prevention and I get the feeling there is not enough knowledge or prevention in terms of appropriate diet, eating habits, and so on," she says. "Occupation and bad access to water, to nutritious food, to health care, it all goes together. There is a large economic burden on people, and without money the diets are usually poor and unhealthy, and then on top of that are limitations to the quality of care-giving that they receive."

With her medical specialism, this doctor sees the consequences of such a situation. As well as the regular cases of hypertension, high cholesterol and diabetes, Dr Schwartz says: "I see so many patients who walk in with gastric complaints, heartburn, dyspepsia, ulcers and kidney stones." Today, she also saw a young woman with suspected appendicitis, who was rushed off to the nearest hospital, in Bethlehem, for a full examination.

PHR-Israel was founded in 1988, during the first months of the first Palestinian intifada, as a reaction to the sight of Palestinians being killed and injured on a daily basis, and the belief that access to healthcare was being used as a means of controlling the Palestinian population. By 2002, a few years into the second intifada and a time of deadly Israeli raids, attacks and curfews in the Palestinian West Bank, the organisation's founder, Dr Ruchama Marton, told a British newspaper: "People are dying at home for nothing, for things they could easily be treated for in hospital." Today, the group has more than 1,000 members and holds several awards for its humanitarian work and constant challenging of human rights abuses.

It has now branched out to set up clinics and medical care within Israel for migrant workers and refugees, as well as for the unrecognised Bedouin villages of the south. PHR-Israel works in tandem with the Palestinian Medical Relief Society to co-ordinate visits to the villages of the West Bank, where Israeli doctors have also been running monthly women's clinics for the past few years. These medics are also engaged in the often bureaucracy-riddled task of getting Palestinian patients referred to Israeli hospitals, in cases where local facilities are not equipped to give proper care. During Israel's four-week assault on Gaza earlier this year, PHR-Israel was trying to get critically injured patients out of the strip and into emergency care in Israel - a process that the organisation accused the Israeli army of constantly thwarting. It was only after the war on Gaza had ended that PHR-Israel was able to evacuate some of the most critically injured of that assault. And in March the organisation published a report claiming that the Israeli army "repeatedly violated Medical Ethics Codes during its Gaza Offensive". The report called for an independent investigation of events.

Back in the West Bank, the mobile clinics visit villages across Areas B and C - the Oslo designations for part of the West Bank that are under complete or partial Israeli security control. The Israeli doctors are prohibited from entering Palestinian-controlled area A, but they never ask permission from the Israeli authorities to gain access to any area. "We believe that a doctor has a right to see a patient and the patient has the right to medical treatment," says Dr Yahya. "It's forbidden for checkpoints to prevent medical access and that's what we fight over. Whenever access has been denied, we've insisted for hours and hours until we succeed and arrive at the village."

Their persistence usually pays off, says Dr Yahya. On the day the clinic arrives in Nahalin, there's an especially long queue outside the examining room set up by Dr Aaron Karni, a family practitioner. "We don't normally get the chance to see a doctor of this quality," says one man, who has been waiting for several hours. "These doctors have more knowledge and more time. They check you properly and give you the right treatment."

The assumption that Israeli doctors are in some way superior is one that Dr Karni is quick to dispel. Examining one patient with lower back problems, Dr Karni says: "I know she has heard this diagnosis before and wants to know what the Israeli doctor thinks. But I think the same as the Palestinian doctor." Later he points out that the practice of "doctor shopping" is common all over the world. Dr Karni, who usually practises at clinics on the outskirts of Jerusalem, is seeing a lot of patients with back, hip, shoulder and leg pains in Nahalin.

"There were a lot of painful joints, some 10 to 15 joints that I injected [with painkillers]and that will relieve the pain for three to four months," he says. "That is simple. I advised several patients today that they need to lose weight, but it is difficult because I can't follow it up with these patients." He believes that this village is not one of the hardest hit, in terms of access to healthcare. "I think it is on a higher socio-economic scale than those in other areas, for instance in the south of Hebron." In the villages of southern Hebron, says the doctor, Palestinians are dealing not just with poverty but with constant harassment from the Jewish settlers who surround them. "When the settlers there burn fields, attack shepherds and don't allow movement, the [Palestinian] villagers are engaged in a struggle of surviving, of keeping the family together. So they can't send the old man of the family to repair a hip or treat a cataract."

Dr Karni is the last of the doctors to close his clinic for the day at Nahalin; so many people wait to see him and he doesn't turn anyone away. With everything packed up, the doctors eat a fast, light lunch on their feet, before boarding the transit van that takes them back, along snaking village roads to the smoother roads on the Israeli side. At the checkpoint straddling the two worlds, an Israeli soldier is about to insist everyone gets off the van to be individually inspected.

But the Palestinian-Israeli driver swiftly puts a stop to that idea. "There's no need, really," he tells the soldier. "They're all Jewish."