Monday, July 9, 2007

Mobile Clinics

During my time with PMRS, I have had the amazing opportunity of getting to go with PMRS to some of their mobile clinics, in severely underserved areas of Palestine. On the first day that I went with the mobile clinic, it took a little over an hour to get to the two locations where the clinics were set up. (The mobile clinics seem to be located within religious buildings, old schools or community centers.) Just outside of Ramallah, we passed through a checkpoint that had a long line of cars waiting. It was strange how, in a way, I have gotten used to it. I don't know how other people feel about it, but the occurrence of checkpoints are the same story for the mobile clinic as well as for most Palestinians-having to pass through three jeeps and 8 or so soldiers with guns to get to work-and having no idea how long they will detain you or what they will require you produce to get through.

The first stop that day was to drop off the three staff for the women's mobile clinic-a doctor, a nurse and a lab tech. We got to our village around 9:15, and the staff unloaded the medications and got everything in order to see patients.

In the first hour, the two doctors, Community Health Worker, and nurse saw about ten patients-men, women and children. The clinic certainly hit a rush around mid-morning. That first day with the mobile clinic was amazing. People were so glad to get services, and were so kind to me as I sat in the waiting room taking it all in. Most of the cases were primary care-children getting vaccinations, older people checking their blood sugar and blood pressure, people following up with medications.

The second day I went with the women's clinic. It was very interesting because there was a woman from the village itself that was there for the whole clinic-and I saw that this was the regular practice. Someone right from the community who helped to coordinate patients and do basic services. (They also provided an awesome breakfast!)

Since this first week, I have gone with the mobile clinic more often, and am struck by the camaraderie, warmth and absolute dedication of the staff to each other and the project. It is obvious that they all really enjoy each other, their work, and the villages they serve.

Besides general impressions, I also conducted-what hopefully will be the first in a series of- interviews with the staff of PMRS on the topic of the occupation and health. Dr. Mohamad Iskafi, the Emergency and Mobile Clinic Program Director of PMRS, was kind enough to give me a lot of time on this topic-and to allow me to use his name in the write up.
Dr. Iskafi was trained in Russia as a General Practitioner. In 1988 he joined PMRS, first as a volunteer and then as staff. When asked why he joined PMRS, he replied: ''I wanted to help my people... I prefer to work in this field instead of at a hospital because I had previously worried so much about how to help my people.''

Following is more information about the history and evolution of the mobile clinic project from my interview with Dr. Iskafi.

The Emergency Response Program was largely born out of a need to take action to serve unarmed Palestinians who were victims of the violent actions by Israeli military and police though community based training in first aid. This training program resulted in 180,000 citizens trained in first aid just four years later, in 2000. During the Al Aqsa Intifada [uprising] for Independence in 2000, the Emergency Response Program quickly expanded to provide services to the victims of the increasingly violent and repressive response of the Israeli government and its army and police.

The ensuing reoccupation, which included more and more permanent checkpoints, closures and curfews, resulted in an increase in the isolation of Palestinians from one another and from medical services. These also resulted in the separation of medical personnel from their places of work. Naturally, these results of occupation further aggravated the health status of Palestinians, particularly in terms of diseases and conditions (such as diabetes, hypertension, pregnancy, and early childhood healthcare-including vaccinations) that require and benefit from primary care. In response, PMRS' work expanded to include emergency medical centers inside of towns. In 2001, its services also grew to include mobile medical teams. The goals of this project were to: ''Facilitate access of patients to health services in view of restricted mobility, alleviate the economic burdens by providing free-of-charge curative services, as well as prevent and minimize the development of medical complications." Mobile Clinics were an essential contribution to Palestinian health and health care provision, especially in light of data that indicates that by 2002, 260 governmental and non-governmental clinics had ceased working, leaving 73% of rural Palestinians without medical care.

Since 2001, the mobile clinics have grown. In 2003-2004, PMRS ran sixteen mobile clinics. However, because of lack of funding, they currently run nine. Each mobile clinic costs US$120-150,000 to run each year.
PMRS' mobile clinics are an example of how the grassroots sector of the Palestinian medical/health care system has adapted or grown to meet the needs of the people through the ever-increasing barriers to health and health care delivery.

Impacts of Occupation and the Role of PMRS' Mobile Clinics

When asked about the impacts of the occupation on the health status of Palestinians, Dr. Iskafi emphasized that the mobile clinics were indispensable because they served people in remote areas. For the increasingly isolated people of Palestine who suffer from chronic diseases, access to primary care through the Mobile Clinics is crucial in order to keep their situation from deteriorating into conditions that are more acute.

While the Mobile Clinics seriously aid Palestinians through provision of crucial primary care, Dr. Iskafi stressed that they are not sufficient in intervening with the detrimental impacts of the ongoing Israeli occupation. For example, he noted that the ability of the mobile clinics was limited in terms of solving the ongoing challenges due to continued isolation of villaes. For example, lack of sufficient follow up or medication (either because the medication is not available or because patients cannot afford to obtain it due to increasing unemployment and poverty) exacerbate the conditions of patients with chronic diseases like diabetes or hypertension. Dr. Iskafi also noted that the rates of late diagnosis of cancer are a direct result from the lack of access to primary care services due to the impacts of occupation.

Finally, and of particular interest to those concerned with mental health, Dr. Iskafi discussed the psychosocial problems of the occupation, especially among children. He maintained that a major problem is that symptoms of psychosocial problems, such as nightmares or bed-wetting, go largely unrecognized as such by parents. Dr. Iskafi noted that parents here tend to think of these things as normal. Unfortunately, the occurrence of PTSD among children is actually "normal", numerically speaking, in Palestine. For example, one study conducted in East Jerusalem and the West Bank found that 54.7% of children studied had experienced at least one lifetime trauma and PTSD was diagnosed in 34.1% of the children (N=1000). A study of the impacts of the new Apartheid Wall found that 40.8% of children studied had noctiphobia (fear of the night) on a permanent basis. It also found that children between age 6 to 12 have become increasingly aggressive, per parent reports (59% for males and 41% for females, compared to 9% and 6.7%, respectively (N= 945; 314 adults, 313 adolescents and 318 children in five villages in Qalqilya district) [].
Regarding mental health, Dr. Iskafi noted that a major task is to educate parents that these symptoms are not, in fact, "normal" within the trajectory of development. The growing mental health program of PMRS has in fact begun working to this end.

[A PMRS Children's Group]

~more on mobile clinics, health impacts of occupation and PMRS' mental health program to follow in the next weeks~

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