In late March and early April 2019 I traveled to Jordan and the West Bank (Palestine) with two colleagues, Sonia Dettman and S. Komarovsky, first to attend the Lancet Palestine Health Alliance conference in Amman and then to explore and better understand the lives of refugees and the workings of UNRWA, with a focus on the status of refugee health.
Even “ex-Gazans” have more trouble
We Uber over to the UN Headquarters again (Uber just bought Careem in the never ending cycle of capitalism). We are heading north to Jerash Camp (aka Gaza Camp), with Julia McCahey and several Japanese and German/Iraqi interns and analysts. In the van we learn that in Jordan, where 42% of Palestinian refugees live, there are ten official and three unofficial camps which accommodate less than 18% of the total refugee population. The aspirational UNRWA microfinancing program was largely cut in the latest financial crisis. There is a Department of Palestinian Affairs in Jordan; the UNRWA camps are owned by UNRWA or rented for about 1 Jordanian Dinar per year, either from the state or leased by the state from local landowners. The EU and the Saudis are providing funding to upgrade buildings which are often dilapidated and desperately in need of renovation and repair.
It seems that financial allotments to each clinic depend on need, plus local field officers approach donors and funds get earmarked for special projects like education. The 2018 and 2019 budgets for UNRWA were $1.2 billion per year. With the budget cuts, UNRWA launched the #Dignityispriceless campaign in 2018 to raise money for health and education. The reasons for the extreme disparities of resources and structures in the different camps still feel murky to me. I suspect it’s complicated. Jerash may give us a clue.
The weather is cold, rainy, and grey as we pass City Mall and Mecca Mall which feature swimming pools, cinemas, bowling alleys, and a wealth of international brands. In front of us is a truck with tens of bunches of bananas tied to its back, like a giant Big Bird. We travel through green rocky hills and the sun starts shining as we edge north towards Irbid. There are piles of pottery for sale, rows of olive trees, irregular terraces, solar panels on large structures, nurseries with stacks of plants, eucalyptus trees, and an increasing amount of garbage on the streets, junkyards, and goats wandering along the road. Our ears start popping from the hills.
As we head north, the scenery turns gorgeous with rolling hills that remind me of the West Bank along with increasing signs of poverty, markets piled with scallions and watermelons, villages of narrow winding streets. We are witnessing the economic extremes that are characteristic of the Jordanian economy. FYI, we are some 37 miles from Amman’s new downtown central business project, a $5 billion residential, entertainment, shopping, and business space in Al Abdali neighborhood with glamorous boulevards, shopping smalls, and tall glass and steel high rises.
But that is another world. Away from the hype of Amman, we chat with Julia who explains some of the challenges UNRWA faces. For instance, for unmarried pregnant women, UNRWA must provide care: this is a very rare situation but is very sensitive. The women’s IDs state whether they are married or unmarried, so the clerk in the clinic can see when an unmarried woman is registering for prenatal care. There is little privacy in the camps and a pregnant unmarried woman brings shame and danger to her entire family. This is a legal issue for the UN as a whole, both in Jordan and internationally. New technical instructions are being developed that ask women their preferences for the ID, collaborate with protective services, connect to counseling, and financial aid.
We arrive at the camp, five kilometers from the phenomenal Roman ruins of Jerash. Also another world, trust me, I explored them both. The camp was set up in 1968 to provide food aid, sanitation, health services, and education for 11,500 Gazans fleeing from the 1967 War (some displaced for a second time). It covers 0.75 square kilometers and is currently home for 30,000 “ex-Gazans.” There are a total of 158,000 Gazans living in Jordan, and the government has taken measures to limit the numbers. Jerash is the poorest of the Jordanian refugee camps for Palestinians, with over half of the population living below the national poverty line, 88% without any health insurance, and 97% without a social security number. The camp looks pretty bleak, densely crowded, mostly one-to-three story concrete structures, pot-holed streets, broken tarmac, crisscrossed with sagging electric wires, small markets with piles of strawberries and bananas, a rare straggly tree. The place is haunted by extreme poverty.
We are warmly welcomed by Dr. Maher Badr and Jumana Khader, the head nurse, and sit around a long wooden table with flowery curtains rippling in the breeze. Much of the conversation confirms what we learned yesterday. Once again I struggle with the concept of “ex-Gazans” who arrived in 1967 during the war and are not recognized as refugees by the Jordanian government, are granted temporary two-year Jordanian passports, but do not hold a national ID number. Because of the cost (200 JD), the refugees often cannot afford to renew and if the passport has expired for more than two years, it cannot be renewed without approval from the Ministry of Interior. These folks are often officially stateless and unable to access governmental services. Fortunately they have UNRWA. Fifty percent of the clinic’s employees are ex-Gazans.
Dr. Maher reviews UNRWA’s impressive achievements, the institution of an electronic medical record, the family health team approach to care, the preventive services, care for women (IUD inserts on Saturdays) and children, curative care, with a focus on noninfectious chronic diseases (NCDs). There is a pharmacy in the clinic as well as a laboratory, dental hygienist and two dentists, a pediatric clinic and a breast feeding room.
There are particular challenges with this population: Vitamin A is given as prevention for eye disease and measles complications every six months per WHO recommendations for refugee children. Mental health and psychosocial care will be embedded within primary health care, but this is rolling out soon; the needs are enormous. Health education is critical regarding marriage between close relatives and the increased risk of congenital problems. The incidence here is high. Some men have up to four wives, there are 1,200 women receiving family planning care, 700 receiving prenatal care, and 3,500 children ages newborn to five.
The sweet tea arrives perfumed with sage as Dr. Maher notes that the work loads are high, there are four doctors and two teams; each doctor sees 100 patients per day in six hours, two minutes per consultation, 25,000 patients in each doctor’s caseload. If one doctor is on leave, then his load is divided amongst the others. One midwife follows 700 pregnancies and sees 25 women per day. And today the electricity will be off from 9:30 am to 2 pm for repairs, although there are generators for the computers and the refrigerators.
Dr. Maher has worked at UNRWA for eleven years, the nurse for 20. He says he knows all his patients, he types into the electronic record, listens and examines the patient (in two minutes total remember). There are seven nurses who have five to seven minutes for taking a history, vital signs, labs, and education. The nurse says, “When you know that you deal for people who have no choice you will give everything, you will give the best,” and Dr. Maher adds, “I know all the family so it is very easy for me to see if this family has congenital malformation or noncommunicable disease so I will screen another from this family.”
With mental health issues, he can refer to a psychiatrist who has at least ten to fifteen minutes for consultation. Suddenly, a young man in a leather jacket, smoking a cigarette, calls at the open window. The doctor responds and closes the window. “Fuck you Israel,” the man yells in English. The doctor says the young man wants another psych drug, his current prescription is not enough. He appears at another window yelling, “Fuck you Americans,” and the doctor explains, “We have too many mental patients.” The electricity switches off. He says the patient wants psychosocial support. “Many of our patients are very poor, there are limitations with staff, drugs, many shortages. We do the best we can, for such cases we can speak with the patients, but we have a problem with the budget and the shortage with the drugs.” We sit in the dim room feeling the tension, the level of desperation and need.
Dr. Maher explains that IUDs and injectable contraception are popular and can be given without the husband’s approval, but persuading women to accept birth control can be a big challenge. If the woman wants contraception, the staff talk with the husband, but ultimately, they observe the woman’s privacy. “But the mother-in-law may monitor the door [of the family planning clinic] and rush in demanding to know.” Privacy in a refugee camp and the desire for large families is a tough dynamic.
Diabetes is common but people don’t want to use insulin. “It’s difficult to work with limitations, always an issue of shortage of drugs and staff members. Despite all, we work with love with every patient, what can we do?” The unemployment rate is high (he quotes 70% – but accurate numbers are hard to get and complicated by numerous variables. UNRWA cites lower numbers, but a wide range depending on many factors including gender, educational level, age, etc.). A 2014 UN report states most men work in agriculture, harvesting olives, on local farms. Girls are married between 15 and 18, and many have two babies by the time they turn 18. If they are not pregnant in a year, then they are diagnosed with infertility. UNRWA can offer lab analysis, a gynecological appointment, but the facilities are limited. Many go to a private doctor or the husbands take a second wife. “In our culture, always the problem is with the female, and the male may refuse any analysis.” UNRWA does not pay for infertility treatments.
The Caesarean section rate is 50%, in the private hospitals physicians are paid 300 JD for a normal vaginal delivery, 700 JD for a C-section. UNRWA covers 75%, up to 100 JD, the patient pays the difference (like 600 JD for the C-section). “This is a big problem.” He claims the women do not want C-Sections, but they are clearly preferred by the doctors. And then we are off for a tour of the clinic, symbolically done in the dark.
There are many educational posters about pregnancy, sexual exploitation and abuse, chronic disease, and a really creepy image of a heart with smoke pouring out of all its major vessels. The pharmacy is neat and orderly with piles of boxes of medications lining the shelves. We learn that a central UN pharmacy places the orders, each health center submits their quota, and the medications come from the World Health Organization’s list of essential medications, the Ministry of Health, and local and international donors. When they run out of anti-hypertensives, insulin, and antibiotics (yes this happens), then the patient has to buy it from private pharmacies, no prescription required except for narcotics, or go without. This is obviously a recipe for chaos. The laboratory has basic equipment for blood and urine tests.
We watch patients register and get a number and a time, (a big improvement from the past when everyone arrived and just sat much of the day waiting for a turn). The patient population is much darker-skinned by and large than at Nuzha Camp (a reflection of the Gazan Afro-Palestinian population). A brief bit of a long history: Folks from Senegal, Niger, Sudan and Chad arrived in the Holy Land as far back as the seventh century, often after making pilgrimages to Mecca. There are pockets of Afro-Palestinians in Jerusalem, Jericho, the Negev, and Gaza. And now the “ex-Gazans” in Jerash.
Many of the women are totally covered with niqabs and sometimes a full burka (with veil covering their eyes), often attending to a collection of young children.
We peek into the pediatric clinic with four scales, one in each side of the room, and lots of kids. A child squirms as he gets a vaccine. We greet a tired looking internist sitting at his desk, with a computer screen, a sphygmomanometer (for measuring blood pressure), a small pile of papers, and an exam table, scale, and the smoking heart poster behind him. There are lots of mostly women and children sitting in the darkened waiting areas, just waiting. We really don’t want to bother the clinicians who are busy doing the two minute visits, so we leave, thanking the staff and apologizing for the interruption.
If you want to fly with eagles, don’t swim with ducks
We walk over to the UNRWA school just as the morning and afternoon shifts change. The grey-white building with blue on the metal trim crisscrossing the windows is old and the concrete wall along the perimeter is peeling with white paint and graffiti. There are waves of children, all the girls wearing white hijabs. Suddenly a group of boys starts throwing stones at us and hitting our legs with sticks, yelling, “Fuck you! Fuck you!” After the initial shock, all I can imagine is, what they see is another parade of white people dropping in, clutching notebooks and cameras, for what? They have a right to be enraged.
The school principal is apologetic and appalled. She explains this behavior is highly unusual. We try to explain, no harm done, they are understandably angry. In Jerash there are four double shift schools and one single shift school for grades one to ten (which means the number of hours of classroom time has been reduced). There are girls’ and boys’ schools in the camp and one boys’ school outside the camp. After tenth grade, students go to government schools. The approximately 5,000 students in Jerash Camp are very well prepared for governmental schools and score higher on the Tawjihi, the General Secondary Education Certificate Examination, than the general population. That is something to be proud of. To put that in perspective, however, according to UNICEF, educational outcomes in Jordan are low in both basic and secondary education and students do poorly on international standardized tests, including mathematics and science. So this is both good and bad news for the ex-Gazan students.
Each school shift has its own hierarchy of principals, administrators, teachers, etc. Most students are “ex-Gazans,” and the principal explains, they can get a temporary national passport but no ID and no health insurance. They are not considered refugees but are called displaced persons per Jordanian law. Sometimes they can get a visa to travel. She says the main challenges are poverty, unemployment, and lack of resources. There are eight UN branches for microfinance, three in Irbid, mostly used for things like personal loans, minimarkets, and crafts.
The principle explains that 1,462 girls are attending this shift and there is a big focus on education among their families. At university they are charged as foreigners and sometimes can get scholarships from the Palestinian embassy and businesses. After graduation, unfortunately it is very hard to get employment because the majority don’t have a national ID. They can’t even get a driver’s license, or own a taxi. While men mostly work in agriculture and raising animals, there is still a strong societal motivation to get advanced degrees. Most of the teachers at the school are ex-Gazans.
We visit classes, still in the dark, and smile at rows of girls in a variety of styles of white hijabs. The girls are very engaged, sparkly, eager to ask questions. We see classes studying financial education and the renaissance. The school reminds me of a big, loud urban school in a poor neighborhood somewhere in the US. The level of disrepair, we are told, is a reflection of the lack of upkeep for two years due to budget cuts.
The walls are decorated with colorful displays done by the children, packed with lots of thoughtful advice.
When people throw you stones, it’s because you are a good tree full of fruits. They see a lot of harvest in you. Don’t go down to their level by throwing stones, but throw them your fruits so the seeds of yourself may inspire them to change their ways.
If you want to fly with eagles, don’t swim with ducks.
Keep your thoughts positive because your thoughts become your words. Keep your words positive because your words become your behavior. Keep your behavior positive because your behavior becomes your habits. Keep your habits positive because your habits become your values. Keep your values positive because your values become your destiny.
We walk through the crumbling streets, back to the van. There is no green space and piles of litter gather along the walls of buildings. Thanks to Trump’s budget cuts, the 43 workers collecting garbage have now been reduced to ten. I ponder Trump’s comment that Palestinians are not grateful and respectful enough. We see crowds of lively children lugging backpacks, with no place to play, living in a place where 52.7 percent of the people live below the poverty line, surviving on a dollar a day. At 6:15 pm I discover that Israeli forces are bombing Gaza and it is snowing in Petra. The world feels upside down.
We end up at a lovely restaurant in Amman, sipping white wine and the local beer. In the bathroom over the toilet is a sign: “Do not flush toilet paper, phone bills, goldfish, or your hopes and dreams down the toilet.” Strangely, that feels like solid advice.