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The pilgrim healers of Palestine

19 December 2014

St John Eye Hospital is an ancient institution providing up-to-date health care for Palestinians in East Jerusalem and Gaza. Jemima Thackray tells the story

st john eye hospital

Looking ahead: a boy is examined

Looking ahead: a boy is examined

THE St John of Jerusalem Eye Hospital Group is the only charitable provider of eye care in Gaza, the West Bank, and East Jerusalem. It treats about 115,000 patients a year, and provides hospital accommodation for those who need it. It seeks to provide care for all, without discrimination.

"There are private doctors around," the hospital's Director of Nursing, Ahmad Ma'ali, says, "but you have to pay, and they are expensive; so, for the poor, it's here or nowhere."

Ophthalmology may seem like a specialised, relatively small area of medicine from a Western perspec- tive, but the demand for eye care in the occupied Palestinian ter-ritories is staggering - the rate of blindness is ten times higher than in Europe.

"The reasons for such a high level of eye disease are varied and complex, but usually poverty-related," Mr Ma'ali says. "Poor nutrition, for example, leads to weaker immune systems. Then there is the factor of more intermarriage within families, which causes hereditary diseases like cataracts and glaucoma. We estimate that one child in every household in Palestine will have a form of congenital eye disease."

Not only is this devastating for the lives of individuals: it also has wider consequences for Palestinian society. A huge proportion of the population are children (almost a third are under ten years old); so the rate of eye disease in the young could lead to an entire generation who are unable to contribute to society because, owing to the stigma associated with blindness, they have been hidden at home, without receiving education or the confidence to lead independent lives.

THE hospital sees it, therefore, as a vital part of its work, in the knowledge that 80 per cent of all blindness is preventable, to reach these children before it is too late. The need for a proactive approach in reaching out to these children is essential, as not many poor families come to the hospital of their own volition.

In something of a reversal of history, the institution that once received pilgrims now spends a vast amount of effort journeying out to meet those who cannot travel, and therefore cannot gain access to health care, because of the remoteness of their village, or the poverty that renders them unable to afford the journey, or the restriction of movement caused by the myriad of Israeli checkpoints in the region.

It could be said that the staff at the hospital have become the pilgrims. One of the most important services is the outreach team, whereby doctors and nurses travel to remote villages and Bedouin camps to offer testing and treatment.

This function is overseen by the Head of Development, David Dahdal, who describes the carefully planned logistics of the service: "Each of our vans has to carry a team of healthcare professionals, plus all the screening machines, plus supplies of medicine. They also need to be able to bring patients with the most serious conditions back to the hospital."

Not only does this outreach initiative enable the hospital to reach many children with congenital eye problems, who are often marginalised in society: many women are now also using the service.

"It is still the case, especially in remote villages, that, for cultural reasons, women are not allowed to travel on their own or without permission from their husbands," Mr Ma'ali says.

"But, through our outreach programme, we are also starting to bring about much more equity in this area of health care."

THE investment in these outreach vans has also made it possible for the hospital to pioneer a new diabetes screening programme, the first of its kind in Palestine. It is estimated that almost 20 per cent of Palestinians are diabetic - three times more than in the West - and the condition leads to retinal damage, which is the third largest cause of blindness in the region.

Mr Dahdal also oversees this initiative. "We hope to screen approximately 40,000 people by the end of the three-year programme, as well as providing treatment and giving talks and distributing information leaflets. The educational element is important, as much of the problem is because of a lack of awareness."

For the patients who do manage to travel to seek treatment, the St John of Jerusalem Eye Hospital Group has also made every effort to make its journeying as straightforward as possible.

First, rather than invest only in the expansion of the main hospital in East Jerusalem, the group has made it a strategic priority to set up a second hospital in Hebron, as well as two satellite clinics in Gaza and Anabta, enabling maximum access in a region that is notoriously hard to move about in.

In fact, a current project is the construction of a permanent day-care centre in the Gaza Strip, in response to the growing need of a population of 1.5 million, 1.2 million of whom are refugees - a population that faces ever decreasing mobility.

The group's commitment to access for all has been enough motivation to overcome the frustration at the many challenges. "We have had a very complicated mechanism with the Israelis with restricted access to materials," Mr Dahdal says. "We have to buy them from Israel rather than Egypt or anywhere else that may be deemed as aiding terrorism.

"But, having agreed to this, it then took us an entire year to get a permit to enable the materials to be transported into Gaza. And then, of course, we have to stop work whenever any violence flares up: for example, we stopped for 59 days during the recent war."

But the hospital has become well practised in the art of diplomacy in the cause of improving patient access, as staff members attempt to navigate the various travel restrictions around Jerusalem, on behalf of their patients.

PERMITS must be applied for, checkpoints must be negotiated, and many of the main direct roads to the hospital are closed to Palestinians entirely. "We have good relationships with Israeli military authorities, though," Mr Ma'ali says; "so we can help in the process of obtaining passes for our patients. We also have a liaison officer on the staff, who deals with difficult cases where access has been denied."

When the political tension is at its highest, however, there is an inevitable impact on the hospital's service: "As an organisation," Mr Ma'ali says, "we are completely apolitical; and yet in this part of the world everything is political, as our work is directly impacted by the situation. The number of patients we can treat in a week is dependent on the level of stability in the region. If there are problems, then people just won't travel for appointments.

"We also have a lot of European health-care professionals visit us for temporary periods, but, when the political situation is bad, the embassy calls them back, and they have to leave within 24 hours. We then have to change things around to make up the shortfall.

"But then that's how it is every day: every morning starts with problem-solving, as there are always staff who can't get in on time due to problems with checkpoints. But, fortunately, we train our staff to be very flexible: they can move from the theatre to the ward to the clinic without concern."

There has, indeed, been significant investment in effective staff training. The group has set up its own ophthalmic nursing school and doctors' residency programmes - the only ones in the region, enabling Palestinians to specialise and become experts in their field.

As well as this commitment to improving the infrastructure of the region through these education programmes, there is also a strong sense of obligation to every member of staff. "We're like a big family here," Mr Ma'ali says. "For example, despite funding issues, we make sure we pay our staff on time, as we're aware that most of them are supporting large extended families. That's how life is in Palestine."

Of all people, Mr Ma'ali is qualified to have the last word on the hospital's impact on "how life is" in this troubled part of the world: he has been on the staff for 24 years. He began as a student doctor in 1988, and, apart from a brief period in the UK studying at Cambridge University, he has lived and worked in Palestine, and witnessed many changes at the hospital.

"When I started, every single doctor here was an expat: all the senior nurses, except one, were British. But now the situation has reversed: every clinical post, except one, is held by a local person. I had opportunities to work in the UK, but I chose to come back.

"I was under no obligation, but I wanted to return, because I've been able to be part of such an obvious impact on this society. As a Palestinian, I am exceptionally proud of this hospital."



Impossible made possible

GEORGE and his family live in Bethlehem. Four of his five children have had compromised vision since they were small; all of them were diagnosed by the hospital's outreach team when it journeyed to their community. His 13-year-old son, David (above), was found to have retinis pigmentosa, an inherited disorder characterised by progressive peripheral vision-loss (leading in the end to blindness) and difficulty seeing at night. His brother Anton, who is 14, has high myopia and astigmatism, and his two sisters Sara and Maya also have astigmatism.

Although George works hard, his income barely meets the family's basic needs; so the economic burden of having four children requiring eye care has been carried by the hospital. "Without the outreach eye services, it would have been impossible for us to obtain the help our children needed, because this kind of medicine is too expensive for us," their mother, Dina, says.

Aton and his two sisters were referred to the hospital in Hebron, where they received free glasses for their astigmatisms, and their brother David has regular treatment for his retinis pigmentosa, which includes vitamin supplements, and retinal consultations every six months.

Independence returned

HABSA (above) is a 60-year-old housewife from Hebron. Like many older Palestinian women, she works hard to manage her household and look after her children and grandchildren, rarely travelling further than her local neighbourhood. For a while, she had been noticing that her vision was becoming blurry: "I couldn't carry out my daily activities. And I could hardly identify my grandchildren, except by touching them or hearing them talk," she said.

So, when the hospital's diabetes-screening programme came to her community, the staff were able to diagnose Habsa's diabetes, and also address the damage to her eyes (known as diabetic retinopathy), and stop the onset of preventable sight-loss. The same screening also showed that Habsa had a cataract. Surgery was quickly scheduled at the hospital in Hebron, and Habsa experienced rapid improvement to her sight, which has allowed her to return to normal life. "Now, I'm independent again. My children are back to work, as I can look after their children."

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