Saying goodbye to Qalqilya

This morning we started to say goodbye.  It is a long process that starts with a visit to a bakery to get biscuits for the staff we have worked with.  I buy a tray for the midwives and nurses in the maternity department.  More biscuits and dates are bought for the rest of the hospital staff. A morning lecture is given on management of second stage labour.  One of the US doctors recounts the experience in his country, of the gradual acceptance of ‘passive descent’ and less aggressive coaching.  US obstetric practice is so foreign to me, and also to the Palestinians.  The epidural rate there is 90%, whereas here it is entirely unavailable in UNRWA and public hospitals.  Britain falls somewhere in the middle, much lower than in the US but still very common.  Talk of positions in for birth is interesting – anything other than supine or semi-recumbent is alien to both the Americans and Palestinians.  I’m on my own in advocating kneeling or all fours positions.

After the lecture we go to the municipality.  The mayor’s office have heard about our visit to the Governor the previous day, and now we cannot leave without also accepting the hospitality of the mayor.  We cram into the UN cars for the short journey across town.  Opposite the municipality building there is a cake shop.  “Popeye Cakes”.  What sort of cakes do they sell? asks one of our party.  The hospital director shrugs, straight-faced, “Spinach perhaps”.  And then we are all laughing again.  At the municipality building the mayor’s office has prepared a presentation of the effect of the wall on Qalqilya.  It reinforces and provides context for what we saw on our tour of the wall two days ago.

Then we rush back for the lecture on treatment of  Diabetic Coma, I find the chemistry challenging – not my area.  It is a very good presentation.  In an hour or so I will be on my way to Ramallah and then to a village near there.  I hope I will have some internet access when I’m there.

The Governor of Qalqilya recounts a story

Before we go to Nablus, we made a quick visit to the Governor of Qalqilya Governorate as he has said he would like to meet us.  He thanks us for visiting the hospital here, for our interest in his people. 

He retells the story of the Judgment of Solomon.  Two women claim to be the mother of a baby.  Solomon asks for his sword to be brought.  Divide the living child in two, and give half to one and half to the other.   And the woman who was the mother said do not divide the child, let him live.  And the woman who was not the mother said to divide the child, he shall not be either mine or yours.

Nablus is a trip: or, joy and hot cheese

Today I started with the midwives at 7am.  There is a woman booked for caesarean section who has been contracting overnight.  Another woman has been readmitted in the night with urinary retention, following an earlier postnatal admission with infected episiotomy.  Apart from that, the patients are known to me and many are fit for discharge.  I accompany the senior nurse-midwife and the doctor on the ward round.

There is a morning lecture on fetal monitoring by one of the American doctors.  He acknowledges the lack of evidence for routine continuous electronic fetal monitoring, and yet states categorically that it has become standard of care.  It is a ‘fact on the ground’.  Immovable.  I cannot help but think that a British midwife or obstetrician would have approached this issue differently.  After all, routine CTG was once a ‘fact on the ground’ in many of our hospitals, and now we monitor intermittently in normal labours.  How to effect change, this is the crucial question – in health care and in the rest of life.

After the lecture we are off to Nablus with the director of the hospital as our host and guide.  It is hard to describe how much fun, how mischevious this man is. We go first to the Old City.  The stones of this place are old, with roman carvings on stones reused in later times.  The market is wonderful and makes us hungry.  One of our party is gently chastised, teased one might say, for buying us all Kanafa (hot cheese sweets, hard to describe, delicious) – he will ruin our appetites for later.   When we get to the Turkish baths our guide says, completely straight-faced, that he will ask the owner if we can have the place for a mixed party.  Then cracks up. Of course, it is impossible and undesirable.  Absurd.  The very idea is hilarious.

Of course, the occupation is present here – there is no moment when one can completely forget it – but we are enjoying ourselves.  The director’s family were made refugees from Jaffa in 1948 and ended up in Balata Refugee camp adjacent to Nablus.  This is where he was born.  He takes us to his childhood home, which is still the home of his brother’s family, where we are treated to a fantastic meal of maklouba (chicken and rice) and many other traditional delicacies made by his sister-in-law.  As well as his brother’s family, we are also joined by his wife and two of his sons.  She is a gynaecologist and works in a woman’s health clinic for an NGO near Nablus. A good contact for me, though I cannot get to see her clinic on this visit.

We cannot eat any more and then there is fruit.  One of the members of our party is giving a lecture about diabetic coma tomorrow.  We all start to complain about the stress on our pancreas’s, the pressure on our insulin function.  After the meal we waddle out to the cars and drive over to the best sweet shop in Nablus. More Kanafa!  There are several kinds, it is impossible to have just one.  Our guide buys us three different types each – I am told that he had to be talked down from getting us one of each type of sweet in the shop.  Kanafa is a kind of hot cheese desert with pastry, which can be smooth or shredded.  It is very sweet.  Hot syrup is then poured over.  It is delicious.  I feel I might die if I eat any more, but at least I will be in paradise.  Anyway, I am writing this, so you know I survived to tell the tale.  The best Kanafa comes from Nablus, and I have eaten the best Kanafa in Nablus, which means  I have eaten the best Kanafa in the world.

After that we go back to the director’s house for coffee.  More hilarity.  We are all a bit wired from caffeine and sugar rush and cannot stop laughing.  The journey back to Qalqilya passes quickly as we recount our hosts best jokes.

Maternal and Child Health Clinic visit

I had such a packed day yesterday that I forgot to mention a visit to the MCH clinic run by UNRWA here in Qalqilya.  I was able to spend some time sitting in on a midwives clinic.  Midwives here are not only involved in maternity care, but also offer contraceptive services, family planning advice and preconceptual care.  The handheld record for mother and child carried by the mother is excellent, combining concise but comprehensive notes and health education on child development, breastfeeding, nutrition, hygeine and many other issues.  My own hospital is trying to update its notes, and these may provide an inspiration.  I will try to upload some photographs later.

An evening in Qalqilya, speaking ethos to ethos

Yesterday, after the afternoon driving and walking near the wall that surrounds Qalqilya, a member of our group takes us to meet a man who runs a foodstore here.  It sells coffee, and roasted nuts and peas and many other delicious things.  They met by a crazy coincidence.  Our friend has Palestinian relatives from Ramallah and when they had come to meet him in Qalqilya they had bumped into this storeowner.  It turns they knew him from thirty years before.  Qalqilya was known for its citrus trees, and beekeepers from other parts of Palestine would move the hives to Qalqilya for a season. This is how the Ramallah relatives had, as children, got to know the now-storekeeper.

We are, of course, invited back to his apartment for coffee and hummus.  This man is more than a storekeeper, more like a professor.  He studied English literature in Beirut, and his discourse is filled with references to literary greats.  He is pessimistic.  Every ten years there has been war or warlike situation in this region.  He feels the Israelis would like to erradicate the Palestinians.  And that, in their hearts, the Palestinians can never accept a Jewish State.  His hope is for what he calls the ‘Lebanese formula’ – the idea being that all communities have a stake in the state.  It is this example, directly to the north, that Israel finds so threatening he says.  That is why there is so much outside interferrence.  Lebanon must not be allowed to succeed, precisely because the Lebanese formula is rejected by Israel, but not by Palestinians.  Palestinians, he says, would be happy to live Muslims, Christians and Jews alongside each other.  But to concede the moral high ground to those that come by force, to usurp others, never – it is not possible.  How can one honestly say that black is white, that the creation of a Jewish State through dispossession of the people living there is legitimate.  It is not possible.  His honesty is refreshing, and he asks us – like a professor – what each of us think on these matters.  It is illuminating to hear the views of my American companions.  The food is delicious too.

Happy International Women’s Day

Today is a holiday for women.  Not in the hospital of course (although the midwives joke about leaving the doctors, who are all men here, to handle everything).  The female teachers have a holiday.  A group of children from a local school arrived on the ward bringing flowers for us all.  Nice.  Cute.  I had forgotten, and it was nice to be reminded.

A busy morning and the wall at Qalqilya

Today I spent the morning on the ward.  Again no labourers, but plenty of patients for surgery.  This morning’s theatre list included a woman with hydatiform mole (molar pregnancy), another with cervical polyps and a third needing a cervical suture.  Interspersed between following these cases are the lectures.  One is on episiotomy.  The task of the doctor is to explain the benefits of a policy of restricted episiotomy, whereas the practice here is for routine episiotomy for primagravid women.  The second lecture is on the ethics of caring, compassion fatigue and medicine.  There is a nice play on the word ‘disillusioned’, which means not to lose one’s hope or vision, but to be relieved of false images.  I do not yet have compassion fatigue nor am I disillusioned.  Maybe it is coming, but not yet.

After the shift the Americans and I go for a tour of the wall at Qalqilya.  We are taken by a Palestinian woman who works for one of the health NGOs here.  We are shown the checkpoint where Palestinians from across the West Bank queue from the early hours in the morning, to get to work at 7am.  Some of the group take photographs, until the disembodied voice from the watchtower dissuades them.  It is pointless, there are a million pictures of this horrendous place on the web.  Google Images “Qalqilya checkpoint” and you will see what we were prevented from photographing.

We followed the wall, and the bulldozed areas near it on the Palestinian side (the Israeli side is planted with trees to beautify it).  We go to fields, which were once planted with orange and lemon trees, but now are only permitted to grow small crops (did I mention that the Isaeli side is planted with trees).  We go to a place where the wall cuts farmers from their land.  They can get permits, but not sufficient in number to actually keep the land cultivated well.  If the land falls into disuse due to the diffculty of access, an old Ottoman law can be used to dispossess the farmers of their land.

There is nothing more to say.  It is a horror, this wall.  And it has been normalized.  The trees are growing up on the Israeli side.  Soon the invisability of the Palestinians will be complete.

From West Jerusalem to Qalqilya

My morning started early.  I need to get East Jerusalem so I can meet my host here who is driving me to Ramallah.  The earlier we leave the better, as we have to pass through Qalandia checkpoint.  You never know how long it is going to take.  She shows me where the recent settlement has been established near her house in East Jerusalem and points out the associated military presence.  Before the wall and Qalandia Checkpoint were finished, the checkpoint was located on the road at the end of her street.  Children are not issued ID cards here (her son – the one refused an ID -  has just turned sixteen). Instead Palestinian children have to carry their birth certificate around with them.  When the checkpoint was so close to her house the children were stopped constantly, going back and forth about their ordinary business.  Everywhere we have driven through East Jerusalem my host points out ‘pockets’ created by the barrier – Palestinian areas annexed by the path of the wall.

Qalandia Checkpoint and the wall is an incredible sight which I cannot risk photographing as we pass through.  The traffic from Jerusalem to Ramallah is bad enough, but in the other direction it is at a crawl.  A second wall has been built inside the wall at Qalandia and the suspicion is that ultimately the checkpoint will be moved further inside the West Bank, annexing another ‘pocket’ of Jerusalem.  We pass the refugee camp at Qalandia and then drive to Ramallah.  Physically it is close to Jerusalem, but conceputally feels another world.  The NGO of my host used to be located in East Jerusalem.  When the wall was built it ended up in a location that meant both Jerusalemites and West Bank residents ended up having to go through checkpoints to go to work.  They have since moved to Ramallah, so at least the West Bank staff do not have the inconvenience.  One of the effects of checkpoints is to powerfully disincentivise Palestinian presence in Jerusalem, in Israel.  The social, professional, commercial  relationships between Palestinians in Israel and the West Bank have been fractured.  This is to say nothing about Gaza, more thoroughly cut off from the rest of Palestinian society.

At the NGO office we talk about what I’ve seen in practice.  It feels great to debrief a bit and we try to explore the potential for future links and work. I will be back there next weekend, so there is no hurry to do make anything concrete now and I have to get a bus (actually a shared taxi) to Qalqilya, where I will be visiting the UNRWA hospital.  There is a group of US family doctors and medical students viiting at the same time as me.  US maternity care is so different from in the UK, and it will be interesting to get their perspective on care here.

At Qalqilya I meet the director of the hospital.  Qalqilya has a population of about 50,000 and the hospital has about 1,000 deliveries a year.  It used to have more, but there is a new public hospital which also provides maternity care and that has reduced the number of patients here.   I am given an orientation of the hospital, including the delivery rooms and then of the mixed obstetric/gynaecology inpatient ward.  There are no labourers at the moment so I hang out with midwives, following the care they give to the women on the ward.  There is a lecture given by one of the US doctors on the diagnostic use of transvaginal ultrasound, followed by a great lunch.

There is lots to explain about Qalqilya, but I will save it for another post, but this is where the wall started.  It is a place encircled.  More later.

‘Coexistence’ in a segregated society

Yesterday I visited a Jewish Israeli friend in Jerusalem. We go to pick up her kids from their school.  It is mixed Jewish and Palestinian and is bilingual, teaching equally in Hebrew and Arabic.  It is the only school of its kind in Jerusalem, and one of only a handful in the country.  On the way she explains how segregated Jerusalem is and that even a self-conscious ‘coexistence’ project like the school her children go to doesn’t really break down the barriers.  Maybe between the children, but not between the parents.  Perhaps it is different in Haifa, but here in Jerusalem the separation is almost total she feels.  The status of Palestinians is different here as well.  There are Palestinians who have Israeli citizenship, of course, but also many in Jerusalem who have a different status – Israeli residency.  They are in a legal limbo, neither ‘citizenship’ of the Palestinian Authority (although how you can be a citizen of a non-state, I don’t know) nor Israeli citizenship.

We pass the residential neighbourhood from which most of the Palestinian children at the school are drawn.  She would have no reason to go there.  She explains that part of the problem in forming relationships is that the motives of the Jewish and Palestinian parents are very different.  The Jewish parents are motivated by a coexistence ethos, liberal values.  Perhaps they sacrifice something to send their children here, certainly they have to drive from all over Jerusalem rather than send their child to a neighbourhood school.   The Palestinian parents are mostly from one neighbourhood and just want to send their children to a good school, to get some articulation with Israeli society to improve their social position.  There is an edge of disapproval about the ‘base’ motives of the Palestinian parents.  Of course, when you are in the stronger position you have the luxury of noble motives, especially if they do not fundamentally challenge your privilege.

We talk a bit about how segregated the ultra-orthodox are from secular Israeli society.  How visibly religious her neighbourhood is becoming.  That Israel is not just separated between Jews and Palestinians, but between religious and secular Jews.  I say it reminds me of something Walid had said at the HRC in Old Hebron – that most secular Israelis would prefer to live next to Palestinians than the extremist religious settlers.  My friend’s daughter has misunderstood me:  "The settlers do not want to live next to Palestinians, they want to live instead of Palestinians" she tells me, disapproving.  I applaud her accurate description of the situation.

I am reminded of my Palestinian host, the woman who has arranged everything – the one with the Jerusalem ID who cannot live with her husband who has a West Bank ID.  This policy of separating families puts pressure on Palestinians to move out of Jerusalem.  It is not just in the West Bank that Israelis are wanting to live ‘instead of Palestinians’ but right here in Jerusalem too.  In East Jerusalem neighbourhoods like Sheikh Jarrah.

Later today I will go to East Jerusalem to meet with my host and we will travel together to Ramallah, from where I can get transport to Qalqilya.

Taking my leave of Hebron

I’m in transit again. Before I left Hebron I took a tray of biscuits and cakes to the staff in the Obstetric department at the hospital. And then I met with the director of the hospital. He has been incredibly generous with his time and attention to detail, arranging for me to go to a smaller hospital, coming to see me on the ward. I do not have a way to repay the kindness. Somewhat ceremonially, I am given a ceramic clock, painted in the colours of the Palestinian flag – black, green and red, and with the logo of the hospital in the centre. I will have to post it home. I would not want to take it out through Ben Gurion airport. Maybe I will give it pride of place in our new kitchen extension at home (whenever that materializes), I also have a friend with a passion for unusual decorative clocks so perhaps that is the ultimate destination.

The journey to Jerusalem, via Bethlehem is uneventful, involving getting out of the bus just once to have my passport checked. The bus from Bethlehem to Jerusalem is too fast to get good pictures of the scenery, settlements, the barrier. I am writing this in a comfortable airy flat in West Jerusalem, where I’m staying with an Israeli friend who used to live in England. Tomorrow I am to Ramallah and then Qalqilya. I will try to post a bunch of photos today, but no more writing. Today is a day off for me.