Saturday, April 2, 2011

Case of the Month: The Gaza Strip

On one of my clinical days last month, I had a very unusual round. My first patient had a rare disease called PNH (paroxysmal nocturnal hemoglobinurea) which occurs in 1-2 per million people. The drug used for this disease is the most expensive medication in the world, its called Eculizumab with a price tag of around $410,000.00 a year. To make a long story short, this disease causes your red blood cells to pop at night, some theories say this is due to the more acidic nature of the blood which causes the defect to become more pronounced. This leads to red urine in the morning and chronic anemia.

The next case was a man with Gaucher's disease which causes your liver and spleen to become enlarged, as well as a lot of bone pain. The main issue with this disease is you can't break down certain sugars, which accumulate causing damage. The way to treat this disease is to replace the proteins that are missing that normally break down these sugars, and as it turns out, this is no cheap treatment either, it has a price tag of $200,000.00 per year. Again this is another relatively uncommon disease, and as a doctor, the chances of seeing this in the clinic are probably a couple times at most in an entire career.

The most interesting part of this day was the final patient we attended to. This Gazan was admitted to Israel because he had aplastic anemia. In other words, for whatever reason his bone marrow started to disappear which left untreated will almost certainly lead to death within 6 months. He was subsequently given a bone marrow transplant from an Israeli donor which saved his life. The only problem was that started developing graft versus host disease i.e. his bone marrow transplant gave him the immune system of anther person, which recognizes the recipient's body as foreign, leading to an attack on the entire body from the graft. By the time he was readmitted to the hospital, his kidneys and liver were failing, and he is being managed for this now.

This particular case was very interesting to me, because it was a window into what happens in the Gaza strip. As it turns out, most of the Gaza Strip patients come to Ichilov Hospital in Tel Aviv. Most used to go to Tel Ha Shomer however this hospital became progressively more expensive, which means that most of these patients are now forwarded to Ichilov for treatment. First of all most Gazans can speak fluent Hebrew, perhaps this is not a surprise to you, however I always imagined them just speaking Arabic. Secondly, I think most people assume that Gazans must be guarded the second they come into Israel, which is not true. They are not prisoners in the sense that they must be patrolled as soon as they gain permission to come to Israel for medical treatment. They are free to do as they please once they clear the red tape to get in, just like any free person in the country, they can move around with complete autonomy, which, at least for me was an interesting observation.

Finally and most interestingly was the conversation I had with this man. While your examining a Gazan, there's an elephant in the room. The fact that I am a Jew, and that this man, represents a constituent of a people that we are constantly at war with. Rather than ignore this, I decided to ask him what he thought of the situation between Israel and the Palestinians, and I was really surprised at his response. His reaction is similar to what I observed in the West Bank when I did clinical volunteering there (read my previous articles on this: first installment, second installment).

His main complaint was his dislike for the Hamas which is a point that a lot of the Palestinians of West Bank also agree on. This man was relatively moderate in his political outlook, and his general opinion was that he didn't like any organization that stifles the peace process. He said that his people are tired of war, and this is the last thing they want. He went on to say that its groups like Hamas spoil it for the rest of them. Recently if you have been keeping up with the news, the frequency of katusha rocket attacks by Hamas has increased and there has been a slight escalation in the political climate in the region. What ends up happening almost every time this occurs, is rockets are fired into Israel, and the response is an F-16 attack on military strongholds in the Gaza Strip. The unfortunate reality is that innocent people get caught in the crossfire, and this is what really frustrated the patient.

Imagine if you are just minding your own business, and someone dropped bombs right into your back yard. This is how this patient feels. In other words, perhaps the saddest thing about the conflict is the fact that most Gazans don't want to deal with this and their frustration translates to a dislike for groups such as Hamas which perpetrate these patterns. Most Gazans just like the Palestinians of the West Bank are moderate, reasonable people and again its a small powerful group such as the Hamas, that makes their lives more difficult. The stereotype that every person in the West Bank or Gaza is a terrorist is far from the truth, most of them just want this to be done with, so they can live their lives like any other unassuming person in the world.

One last point that I would like to restate from a previous post, is that Gazans who need access to healthcare, get it through the same nationalized health system that Israeli's do. Its harder for them in the sense that most people that come to Israel for treatment from the Palestinian territories have to go through a lot of red-tape and the conditions have to be serious enough that they can't be addressed by a local physician.

As for the humanitarian crisis that is perpetrated in the media, I can say that for the West Bank this is not wholly true.  Most of the West Bank looks like a rural version of Israel and is relatively nice. I made an analogy in my second installment of my clinical volunteering trip to the West Bank that the parts of this area that are in trouble (the refugee camps) are very similar to the favellas of Rio de Janeiro. Sure these areas aren't nice, and are very poor, but I do believe that there is a misconception out there that these people are in a situation much much worse that what I just described, and that's simply not true. Life isn't easy for the refugees in the same way that its not easy in a very poor ghetto, however it's not a humanitarian crisis like Sudan. As for the Gaza Stip, which has a lot more terrorist related activity and is much more unstable than the West Bank, I have never been so I am not going to make any claims about the humanitarian situation there, however what I can say is due to the more unstable nature of this area, its much more heavily controlled, which most likely translates to a poorer quality of life than those of the West Bank.

Perhaps the most interesting part about this experience, was the fact that even though there are so many differences between our cultures, at the end of the day, we were there to save his life, and he appreciated that. In this sense, medicine has no borders, and it brings people together even in the most extreme of situations.

--On a side note I just found this blog, which has a similar theme to mine. It's by a physician who lives in Gaza and talks about her experiences. I live in Tel Aviv and talk about my experiences from an Israeli perspective. Perhaps our political views aren't aligned, however I think it's just as important to hear the other side as well and again this isn't about politics this is about seeing what's going on in this region of the world with an unbiased eye. Check it out 

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