This subject is very close to my heart. This is not an academic dissertation but a talk based on my own observations, feelings and ethos.
Historical perspective - What was happening just over 90 years ago? Third battle of Gaza. Turkish and British each had ten divisions. The British had enlisted Arab help in driving the Turks from Palestine after General Allenby promised them independence!
In the Autumn of 1917 there were British and French cruisers shelling Gaza. This was one of the many battles being waged by the 'great' powers to carve out their empires; this was the driving force for WW1.
The commonest date of death on the gravestones of 3000 plus men in the Commonwealth War Grave to the north-east is the 2nd November 1917. On that same day, Arthur James Lord Balfour, Secretary of State at the Foreign and Commonwealth Office and a Christian Zionist addressed the 126 words of the Balfour declaration to Lord Rothschild. The future of your people was contained in these few words -
it being clearly understood that nothing shall be done which may prejudice the civil and religious rights of existing non-Jewish communities in Palestine,
You were trampled from the start. I learned from a recent talk given by Ilan Pappe that when the Zionist settlers planned a university they were supported by the British. When the native Palestinians asked for the same they were refused. In every possible way, the occupier has hampered the development of medical education and medical services in the land remaining to you.
Priorities in medical education -
Because you have to live with various degrees of chaos, standards of education and care are less than you would wish. To bring those standards up, it is obvious that every doctor should be trained to the best possible level of knowledge and competence.
He or she should have the broadest knowledge of the medical services and their deficiencies in the remnants of Palestine so cohesion is maximised.
The foundations should be anatomy, physiology with biochemistry, and pathology. I will return to pathology later.
So - excellence, the broadest of minds and the best technical base.
Priorities in clinical education -
I want to consider these by looking at what faces doctors in Palestine now. We can set a strategy only when we have a very clear idea as trainers and students what will make a good doctor for Palestine.
Medical care within a teeming prison - a Warsaw ghetto.
There are in fact great similarities between Palestine and the UK in regard to there being an increasingly intolerable amount of disease. The causes are largely different though.
The UK is fat but Palestine thin. 1 in 10 children in the UK is 'morbidly' obese and the intake of advertised high energy snacks is one factor. Diabetes is epidemic in both societies - but especially here.
Iron deficiency anaemia, which affects 30% of children and mothers - I do not know what the thresholds for diagnosis are - should be a rarity in 2007. It is a condition of the greatest importance - especially because it is said to inhibit cerebral development. What is being done to deal with this at present?
In my travels here I have also noted a good deal of inherited disease due to consanguinity which is the cause of considerable suffering in the affected children. I have in mind a family, of which three siblings out of seven have familial spastic paraplegia. The two eldest are girls and they are terribly disabled.
So there is a lot to get right before the profession tackles those more beguiling rareties.
Some basic rules I have taught to the young doctors
'Grasping the nettle' when the patient first presents himself to the doctor. And if you do not grasp it first time, then it is often never grasped. What I am saying is that the first shot at diagnosis is the best or indeed the only shot.
One needs time, quietness and no interruptions (no damnable cell phone as you talk with your patient) and of course the skill. Diagnosis is 75% the history, the art of history taking is the most essential art in the art of medicine.
Keep it simple. I have said this often to young surgeons. The human being is a complex organism - especially its psyche. Therefore, as often as possible, keep your management including your surgery as simple as possible. Sometimes a complicated solution is required, so save your skill and your brain for that.
Morbid anatomy and histology are probably taking a back seat now in the training of doctors in the UK. I do not know, but I know fewer autopsies are being done. Perhaps there is the same tendency here. I am assured that Islamic law allows for delay in burial when medical science/the law requires that an autopsy is performed. The teaching of pathology should be the greatest priority; the doctor who is so armed can look with Xray eyes into his patient, just as he can look into the eye with the opthalmoscope and see the vessels. So, first rate histopathology, morbid anatomy and forensic pathology departments are vital to the teaching of complete doctors. Justice in Palestine will be hamstrung until there is forensic pathology.
Rational as opposed to irrational medical practice. In the chaos which is occupation, siege and recurrent invasion which you have been subjected to, it is easy perhaps to slip into less scientific medical practice. At the more trivial end, I have seen a highly intelligent senior lecturer insisting that he swallow one of the pencillins for his common cold.
I will illustrate the irrational with this case. Beit Jalia. 3rd or 4th opinion on a 46 yr old lady.
Large and with lax ligaments. Tripped - probable severe medial ligament tear. Groin to ankle plaster. Later another fall with likely dislocation of the knee and peroneal nerve palsy. Later poor mobility due to severe instability. Learned of a German surgeon who flew into Jordan fortnightly. Went there and was operated on straight away. An unconstrained TKR was implanted. Pain did not settle. She was repatriated by ambulance over the Allenby bridge. There was deep infection. Seen by a good surgeon at the Hadassa hospital. Advised excision with the hamburger treatment - a wadge of bone cement with antibiotic included.
I saw her. ESR had fallen. No sinus. Brace worn. Non-weightbearing. MRI scans before surgery showed normal articular cartilage. Advised to start weightbearing - to help her low morale partly. I strongly advised an arthrodesis.
I learned later that my words fell on deaf ears. Off to the US with the help of a relative over there. A free operation - but a constrained TKR. She is said to be fine but the long term outcome is likely to be different. She will have more surgery.
Grossly irrational primary surgery, and the opposite of simple.
Public Health is the priority
One cannot speak of the necessity of say, a cardio-thoracic unit in Gaza, until public ill-health - especially iron deficiency anaemia and diabetes, is dealt with. What logic or humanity is there in not dealing first with a deficiency affecting about 25% of the population.
Pure process, the reactive, the 'headless chicken' responses
There is an extraordinary amount of unnecessary and frankly unethical work being carried out.
Cosmetic surgery is commonplace in Britain and there is insufficient rigour in the selection of patients for operation. Instead, the targets set by politicians tend to drive action. I know as a surgeon how one needs to have the tightest indications for surgery. Just take varicose vein and hallux valgus - bunion surgery as good examples of what might not need a 'target', what might not need 'doing'.
At a guess, I would say that about one third of all hospital admissions are triggered by self - induced illness. Obesity leading to diabetes, liver disease from alcohol, athero-sclerosis - COAD - lung cancer from smoking and arterial disease from a diet high in animal fats are all unnatural diseases. Add to that western sexual mores, or the lack of them. Consider just how much medical effort is expended in dealing with the late effects of chlamydia.
So, one bears in mind these and other things I fail to mention in deciding what should be highlighted in the clinical training of a doctor for Palestine.
The foregoing are external factors of course. The internal factors - the facets of personality and the ethos of the emerging doctor will determine her or his competence, energy and future development. So, before I end, I will focus on those internal factors. I must first say the ethos, the typical spirit of the medical school, is valuable if it is good. Of course, each member of the school - teacher and pupil contributes to that ethos.
Elements of mind and personality
Humility - the most important quality
Fascination with the natural world and the human
A sense of mission - of calling. Doctoring is much more than a job
Self criticism - vital, always question
Scepticism - essential in a scientist, and at least as much in a doctor
Always learning, and yearning for the truth of things
One of many memories
When I was a registrar in general surgery I spent four months with a very good diagnostician and surgeon called Dendy-Moore. Thursday was his take day. We might operate most of 24 hours on emergency cases. A child would come in. We would leave theatre and enter a sleeping ward. With my master on one side of the bed, and myself, the apprentice on the other, we would hear the history and examine the child. A diagnosis would emerge and a plan of action decided upon.
There was quietness and there was humility. We were simply serving that child with all our will and with as much skill as we could muster. Thank you. 1660
1st February 2003 12.00 hrs
The Voyage of The Dove and The Dolphin
I have been asked many times why we are making this voyage to Ashdod and Gaza.
Firstly we know that many families there live in crushing poverty. The malnutrition rate in the children is reported to be 50% and rising. We are taking about 55 tons of essential foodstuffs. We are also of course taking ourselves and thus demonstrating our common humanity.
Secondly we are pointing the ship at a country which has been the centre of conflict and bitter dispute for 55 years. This demonstrates the bankruptcy of political institutions, both in this country and abroad. The priority should be to bring justice and peace to the Palestinian people and not to wreak yet more havoc in countries like Iraq.
Thirdly, we will sail a course which is almost the same as the warships being sent by the bombers Blair and Bush. Our little ship represents all that is opposite. We stand for justice and peace and against the irrational and the destructive.
In the weeks following 11-9-01 and when the high altitude bombing of the Afghan people was starting, there were bumper stickers on cars in Florida which read ‘Nuke them till they glow'. Millions of people in the UK are repulsed by such violence and hatred. Instead they would agree with the surgeon who says that ‘we should do our best to heal and not to harm'.
The Dove and Dolphin International Medical Centre.
Dr Khamis Elessi MD Dr David Halpin FRCS