The following manuscript was submitted to the February 2017 Social Medicine Themed Writing Contest.
I knew what was coming before it happened. She was looking up at the ring of white coats encircling her hospital bed, eyes darting from side to side to follow the sequence of their voices when suddenly, her lower lip began to quiver. And with her quivering lip, her breaths came faster and she sucked in deep gulps of air between her pleading questions. But soon the pack was headed on to the next patient on rounds. She was left alone, and the tears rolled freely.
Wael, one of the interns, and I hung back, offering the patient a few words of encouragement and a fistful of tissues. Wael explained to me (since I had missed much of the exchange due to my poor understanding of Arabic) that the woman had just delivered twins — prematurely — and that both babies were in the neonatal ICU requiring prolonged hospital stays. However, the woman herself was well and ready for discharge. The hospital needed her bed, but she was pleading to be able to stay, so she could be near her babies while they recuperated.
Prior to coming to Palestine, I might have assumed that this healthy new mother was worried that making the daily trips back and forth to the hospital would decrease the total amount of time she could be nearby her children. However, after being here for nearly a month, I realized that her fear of separation was far more complex.
Permission for Entry
The Al-Makassed Islamic Charitable Hospital, where I was doing an OB/GYN clinical rotation, is located in East Jerusalem, a primarily Arab section of the city that, since the Six-Day War ceasefire agreement of 1967, has lain within the demarcation lines of the Israeli state. However, as a referral hospital for Palestinians in the region, the majority of patients come from elsewhere; most are referred from the West Bank and some from Gaza. A smaller number of the patients live in Jerusalem itself, either as permanent residents of East Jerusalem or as Arab Israeli citizens.
Aside from the permanent residents and citizens of Israel, who are eligible for blue IDs also held by Jewish-Israeli citizens [footnote 1], the rest of Makassed’s patients are green and orange ID holders, from the West Bank and Gaza respectively, and by virtue of this status can only enter Jerusalem from the occupied territories if they have received a special permission from the Israeli government (Tawil-Souri, 2011). These permissions can be granted for certain specific reasons, such as medical referrals, and obtaining one can be a cumbersome process. Even if the hospital is aware of a clinical emergency and expedites the application, it can still take up to three hours to receive the needed permission. For non-emergent cases, it can take days. The situation is even worse for referrals from Gaza, where travel is most tightly controlled (World Health Organization, 2014).
The travel restrictions make it virtually impossible to achieve standard for care for Palestinians, especially for emergent conditions. For example, if someone presents to a West Bank hospital with a heart attack, under specific clinical scenarios this would require cardiac catheterization within 90 minutes. Makassed has the facilities to perform this procedure, however if a patient does not have a prior permission to enter Jerusalem, it can be very difficult to get that patient transferred in time.
For both emergent and non-emergent cases, additional political hurdles can get in the way of patients getting the care they need. For example, some patients requiring specialty care may be completely barred from entering East Jerusalem due to presumed ties with political groups or past accusations (either accurate or inaccurate) of subversive activity.
It is not only the patients in the hospital that have to contend with this process. Most of the hospital physicians, residents, and medical students at Makassed also reside in the West Bank. These colleagues all have to apply for and receive special permission to be able to commute into Jerusalem. And they are subject to the same political barriers. Mohammad, one of the medical students, tells me that some of his classmates at Al-Quds university are unable to do any of their rotations at Makassed, because they have brothers who were held as political prisoners many years ago. These young medical students are “guilty by association,” and are not allowed entry into East Jerusalem to complete their rotations.
Fear and Loathing at the Checkpoint
Once a West Bank dweller manages to receive permission to enter East Jerusalem for work or medical care, they still have to contend with the militarized checkpoints to get to the hospital and to their appointments. To get through the checkpoint, Palestinians and foreigners wait in a series of unpredictably long lines in front of full-height turnstiles that periodically turn on and off, letting a set number of people through at a time. Once through, all objects and bags are passed through a conveyor belt, and the individual passes through a metal detector. Then each person shows their ID to the Israeli solider behind a glass separation wall, and their admittance is either approved or denied. Although recently it was announced that there will be some loosening of the check point procedures for the doctors working in Jerusalem, for the vast majority of Palestinians passing through the checkpoints, they will still have to go through the same process (Friedson, 2015).
The daily grind of passing through the checkpoints is not only inconvenient (for example, it often takes someone from Ramallah more than three times as long to get to Jerusalem as it would if they rode there directly), it can sometime lead to outright harassment. My friend and co-medical student Marwa arrived at the hospital one day, frustrated and telling me that at the check point that morning, a button on her dress kept going off in the metal detector. The Israeli soldier asked her to take off her dress in front of all of the people, including men, who were also waiting at the checkpoint. For a Muslim woman, who is only expected to show her hands and face, this seemed outrageous, and Marwa was brave enough to resist and explain her religious preferences to them in English. Eventually, the soldier, who was female, relented and took Marwa into a private room to search her.
I was left wondering how that same encounter would have gone for a patient at Makassed who just received the permission to enter Jerusalem and may either be too nervous to speak up to the soldiers, or have too little English vocabulary to feel comfortable speaking to them. The Israeli soldiers usually speak a bit of English and little to no Arabic, so the Palestinians I met, the majority of whom don’t speak Hebrew, generally speak to them in English. Perhaps she would have been made to take off her dress in public and been thoroughly humiliated in the process.
Political Lines
Perhaps most striking about the experience at the checkpoint is how dispiriting and demoralizing the entire mechanized ritual feels. In many ways, it is an ongoing reminder to Palestinians that they are under occupation and subject to constant scrutiny.
Prior to 1948, the year of al-Nakba (“The Catastrophe” in Arabic), when 700,000 Palestinians were forced out of their lands and the state of Israel was declared, Palestinians moved freely in and out of all of Jerusalem and the current Israeli territories. They visited friends and family in towns throughout the region, enjoyed the natural wonders of the land, and worshiped in their various holy sites. Between 1948 and 1967, the West Bank and East Jerusalem fell under the control of Jordan. During this time, in 1964, construction began on Makassed Hospital. By the time the hospital was inaugurated in 1968, it was just one year after the hospital had fallen within Israeli territory and the challenges of Palestinian access to the hospital heightened.
Throughout this time, the enforcement regime of ID cards as a means of controlling and restricting movement was becoming more and more entrenched, although many Palestinians were able to travel in and out of East Jerusalem without special permissions (Tawil-Souri, 2011). In 1993, policies were put in place to prohibit entry without the special permission, however these were loosely enforced (OCHA Closure Update, 2008). Then in 2002, following the second Intifada, travel restrictions in the region were tightened significantly and additional mechanisms of control, such as curfews, were instituted.
These travel restrictions extend to travel outside of Palestine as well. Since 1995, West Bank and Gaza dwellers are eligible for the Palestinian Authority (PA) passport. However, obtaining visas for international travel can still be an expensive, time-consuming, and unpredictable process (Atallah, 2013). East Jerusalem residents are not eligible for the PA passport or an Israeli passport and must obtain a travel document from Israel every time they travel internationally (Atallah, 2013). And again, anyone who has gotten onto the “bad list” with Israel can be restricted from all movement, and end up stuck in either the West Bank or East Jerusalem. People living in Gaza are the most restricted due to periodic travel bans.
According to the Israeli government, these travel restrictions are necessary in order to ensure the security of Israel and its settlements (OCHA Closure Update, 2008). However, human rights organizations point out that Palestinians have disproportionately suffered the impacts of the conflict; between 2000 and 2007, more than four Palestinians have been killed for every one Israeli (OCHA Special Focus, 2007). Furthermore, the travel restrictions themselves, along with other aspects of economic and resource control, are contributing to overwhelming health disparities and other human rights violations against the Palestinian people (B’tselem, 2014). For example, the average life expectancy for Palestinians residing in Occupied Territories is 10 years lower than the average life expectancy in Israel (Efrat, 2015).
The Pain of Separation
Now, with the new mother of twins sitting in front of me, I think about all the variables that will impact her ability to see her twins on a daily basis. Firstly, she will need to have permission to come in to visit the twins. Secondly, she lives in Jericho, which is only 17 miles away from Jerusalem by map coordinates, however in practice, with the checkpoints and public transportation, it will likely take her between four to five hours round trip to travel each day from Jericho city, even more if she is coming from a village around Jericho. As a green ID holder, she might be prohibited from staying overnight in Jerusalem, since it is forbidden for West Bank dwellers to relocate to East Jerusalem. Even if she did try to stay overnight, without a family member or friend to offer her a room, this would be a very costly, likely unrealistic proposition, especially given the huge differentials in cost and wealth between Israel and the occupied territories. Finally, no matter her situation, she would be at risk of getting her permission taken away at any moment, and losing complete contact with her twins as they recuperate.
As the tears stream down her cheeks and she lets out a low sob, I feel frozen in the vastness of her struggle, in the beauty of her strength as a woman and mother. I notice own throat tighten and my tongue twist on itself, trying to remember the shape of the new sounds I am learning to form Arabic words.
But I know I can offer no support, no words of encouragement. What I really want to say is simply, “I’m sorry.” I’m sorry for all the times I’ve turned away, too distracted or uncomfortable to stare the reality of Palestine in its face. I’m sorry for whenever I’ve paused, hesitated to speak up when political interests seem to win over human interests in the Middle East. I’m sorry I went so many years without questioning, without pushing back against the lies the media tells … I’m sorry that I haven’t done more.
I hand her a tissue and she mutters thanks, turning her eyes up to meet mine. I squeeze her hand and will my eyes to communicate my message to her … but she looks away quickly, gives a weak smile, and turns her whimpering towards her hands.
Wael stands at the foot of the bed. “Yalla, Juliana,” he says softly, “let’s go.” And we move on to rejoin rounds and listen to the story of the next patient.
Footnote 1: Tawil-Souri (2011) explains that even among the blue ID cards, there are many different “hues” (73). All ID cards include a line that says “nationality,” which is defined as Jewish, Arab, Bedouin, etc.; Arab citizens have freedom of movement but can be seen as less “authentic” than their Jewish counterparts. For permanent residents, while the cards’ exterior is identical to those of citizens, on the inside the line next to “citizenship” is left blank. These residents are only permitted to reside in East Jerusalem and travel outside of the city with an Israeli-issued travel permit.
Image credit: Ras ‘Atiya by Paolo Cuttitta licensed under CC BY 2.0.
Resident Physician Contributing Writer
University of California San Francisco
Juliana is a PGY-2 resident in Family and Community Medicine at the University of California San Francisco (UCSF).