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
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
"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
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
"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
"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
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
"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
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.
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
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."