By Christian Coles, Barts and the London Medical School

During Summer 2016 I spent a month in Bethlehem, Palestine as part of a medical exchange coordinated with the IFMSA (International Federation of Medical Students Association). This moving experience was made possible in part thanks to the financial support I received from the QMUL Expedition fund and QMUL Annual Fund Overseas Project Scholarship. I am very thankful for this assistance otherwise my trip might not have been possible.

I was based at a Caritas Baby Hospital, in the West Bank of the Occupied Palestinian Territories. An NGO-run specialist Paediatric hospital. It dealt with the most challenging and difficult Paediatric cases of Palestine and therefore the patients included local Palestinians, Bedouins and also refugees from neighbouring conflict areas such as Gaza and other parts of the former British Mandate of Palestine (now Israel).

I shared an apartment with several other IFMSA students in downtown Bethlehem only a few minutes walk from Manger Square and the Church of Nativity; the supposed birthplace of Jesus Christ.

I was originally meant to be based at Al-Makassed Hospital in East Jerusalem, however unfortunately due to logistical issues, this was not possible. Although the hospital in Jerusalem was only 10 miles from my Bethlehem apartment; the daily commute would exceed over 4 hours each day due to Israeli checkpoints, “border” controls and an 8-metre-high wall that existed surrounding Jerusalem and the borders of Israel.

The illegal (according to the UN and international law) border and wall existed between Bethlehem and East Jerusalem preventing Palestinians from visiting and crossing into Jerusalem without a special permit. Even with possession of a special permit to enter Jerusalem, the buses which ran between Jerusalem and Bethlehem had to stop at the “border” with passengers of Palestinian heritage having to exit the bus and queue. They would then be questioned by two or more heavily armed soldiers and their belongings would be searched. Even as a Western tourist; showing any solidarity with the Palestinian people would subject you to similar treatment and a passport was essential at all times. Sometimes frail and elderly Palestinians would be refused entry for no apparent reason to what was their home until only recently.  As Al-Makassed Hospital in Jerusalem was the main hospital of Palestine; this quite literally was a barrier to healthcare.
Caritas Baby Hospital was a small modern hospital with 2 main paediatric wards as well as clinics, a neonatal unit and ICU. Medicine in Palestine was predominantly taught in English, so all morning handovers were communicated in English with the odd word of Arabic. This allowed me to generally understand each patient’s condition and also enabled me to pick up a couple words of Arabic especially when the doctors then spoke with the patients.

I would shadow the consultant and medical team (which included doctors, nurses, physiotherapists and social workers) each day rotating between the wards. One day I even went on an excursion which was part of an outreach program; where myself and some of the other healthcare professionals travelled to distant villages to take blood samples for genetic testing for rare genetic disorders, in this case: Epidermolysis Bullosa. Unfortunately, rare genetic conditions were more common in Palestine than the West due to consanguineous relationships. Consanguineous relationships existed in part due to religious beliefs and customs, but also due to the restricted mobility of families within the occupied Palestinian territories. These genetic outreach programmes aimed to identify the carriers of these rare conditions so that they could be appropriately educated and warned about future risk.

The most common conditions encountered in the hospital were cystic fibrosis and diabetes mellitus. However, I also saw 5 cases of traditionally rare conditions such as Kartagener syndrome, 2 cases of West Syndrome (infantile spasm) and many infants and children with global development delay and failure to thrive throughout my month stay. Despite the hospital’s modern appearance, it still relied on donations to operate and there was an obvious lack of general medical resources as well as vast health inequalities present. Families would get very little support from governmental programmes to purchase their medications which would result in those children with chronic conditions such as cystic fibrosis and diabetes mellitus to go undertreated resulting in rare characteristic signs; such as in the case of Cystic Fibrosis; severe nail clubbing. Life expectancies contrasted greatly too; whereas in the UK adults suffering from cystic fibrosis can expect to live to around 41, in Palestine this dropped to less than 25 years. It was deeply saddening to meet children knowing that the only thing which prevented them living longer lives was money and access to medical resources.

We are very lucky in the UK that socialised medicine and the NHS exists, which currently provides healthcare free at the point of use for all. This whole experience really helped me appreciate that. It also allowed me to appreciate how important freedom of movement is for Medicine. If one hospital in one area of England does not offer a certain diagnostic technique or treatment, then patients can be referred to other hospitals within the country or even other countries which do offer it. The wall, checkpoints and borders within the Occupied Palestinian Territories prevent this; and when patients did have special permission to cross they would be searched, interrogated, and lose any remaining dignity and left humiliated which was added to the already significant health anxieties that existed.

Paediatrics is a unique speciality in Medicine. Communication is not only between doctor and patient (the child) but also nearly always involves the parent or guardian as well.  The form and manner of communication also vary too; from basic communication with infants, to playfully examining children to trying to build rapport with troublesome teenagers. The challenge exists that the ideas, concerns and expectations of both child and parent(s) need to be addressed throughout the consultation as these can both differ greatly.

Despite the issue that I spoke very little Arabic I found that this was only a minor barrier to creating rapport between myself and the patient and their families. Simple gestures such as smiling, waving and generally having a friendly manner around them really helped to build trust.

Throughout the four weeks I built strong friendships with the other healthcare professionals as well as other hospital staff, I hope I can return in the future as a doctor. I had a fantastic memorable experience which really helped me appreciate the healthcare system and the freedom we have in the UK.

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