1. Romilly, Constancia MS, APRN, BC

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In 2002 I went to Israel and Palestine (the West Bank and Gaza Strip) to learn more about why we read, year after year, of intifada and occupation, of terrorism and the security wall, of checkpoints, closure, and curfews. What is it really like to live in the midst of these daily realities? How does it affect heath care and the work of nurses on either side? Perhaps the best way to illustrate the impact of these conditions is to describe two meetings. (Editor's note: the United Nations refers to the West Bank and Gaza Strip as the Occupied Palestinian Territories. The author of this article prefers to refer to these areas as Palestine.)

FIGURE. No caption a... - Click to enlarge in new windowFIGURE. No caption available.

As I met with Ora Shamay, MSc, RN, a pain specialist at Sheba Hospital Center in Tel Aviv, her cell phone rang. It was on the bottom of her large tote bag, and she continued talking to me as she searched for it. She'd missed the call by the time she located the phone, but she recognized the number as that of her child's kindergarten. She paled, her breath stopped. After returning the call and finding out it was a routine matter, she explained her reaction, "One can't help but fear the worst. Everywhere there is some gathering or crowd, we are afraid. We don't know when the bomb will come. We start living by the day and not make any far plans for the future. We have a lot of posttraumatic stress disorder. To see the parts of the body, it's horrifying."


A week later, I met with Suzanne Abu Tair, MPH, RN, a senior nurse at the Dheisheh Health Center, at the Dheisheh refugee camp in the West Bank. As we sat in the facility's community center discussing the state of health care, children ran in and out. The room was barren, but the atmosphere was lively. Suddenly, it became quiet. The radio had announced the news: curfew was being reimposed unexpectedly. Our conversation immediately came to an end as Abu Tair gathered up her coat, notebook, and pocketbook. She was clearly rattled as she rushed outside, apologizing, saying that she had to get home to her children before "the curfew shuts down all transportation."


As part of a fact-finding tour I organized, I had arranged to meet these women (with the help of the Israeli Pain Society, the National Association of Nurses in Israel, and the Middle East Children's Alliance). What I found on that visit-and again when I returned in 2004-is that nurses in the region have many of the same problems American nurses have: disparate educational levels, struggles for professional recognition and workplace representation. The nurses I met came into the profession for diverse reasons and are working in a remarkable variety of settings, carrying on in the face of political, professional, economic, military, and personal difficulties. Yet I was amazed at the things these nurses have in common with each other-and with us. As I listened to them describe their motivations and aspirations and watched them work, the seemingly impenetrable barrier created by the ongoing military and political conflict melted away.

FIGURE. Perhaps noth... - Click to enlarge in new windowFIGURE. Perhaps nothing symbolizes the state of Israeli-Palestinian relations better than the "security fence," a barrier that Israel is erecting around the West Bank. Begun in June 2002 to deter attacks on Israeli civilians and property, the completed barrier will be 622 kilometers long, running from Jenin in the north to Hebron in the south, and cost an estimated $3.4 billion. The complex of trenches, motes, electric fences, perimeter roads, razor wire, and concrete walls-some as tall as 9 m-is the largest and most expensive construction project in Israel's history.Approximately 15% of the planned barrier route follows the "Green Line," the border between Israel and the West Bank that was created in 1949; the rest of the barrier runs through Palestinian territory and cuts off approximately 157,800 acres (11.5%) of West Bank agricultural land. More than 93,000 Palestinians live in 63 villages and towns in this area. Of these, more than 16,000 live in closed areas between the Green Line and the barrier; approximately 77,000 live in 11 separate enclaves that are totally surrounded by the barrier. Many others living further to the east will also be cut off from their fields, pastures, workplaces, as well as their schools, health care facilities, and public services. Approximately 140,000 Israeli settlers, more than 60% of the West Bank settler population, also live between the Green Line and the barrier.

I was very lucky to meet these two women, one Israeli, one Palestinian, during my travels.

FIGURE. Ora Shamay a... - Click to enlarge in new windowFIGURE. Ora Shamay at work in the Chaim Sheba Medical Center in Tel Aviv, Israel, the largest hospital in the Middle East. "It's very hard to treat [victims of suicide bombings]," she says, recalling one blast that killed a mother and three children. "They left only a wounded father and one of the kids. How do you rehabilitate this part of the family?"


"I wanted to be a nurse since kindergarten," says Ora Shamay. "I'm hooked."


Shamay has worked at the Chaim Sheba Medical Center, the largest hospital in the Middle East with 1,100 beds, for nine years. She established the clinic for chronic pain at the facility. "At the same time I started the acute pain service in the medical center, and for the last five years I have been giving consultation in pain management."


Like all women in Israel, Shamay was required to serve two years in the Israeli Defense Forces (IDF) when she reached 18 years old. (Men serve three years.) "I went into the army as a nurse, working as a guide, teaching paramedics, and working in the army clinic on a big army base. I didn't want to serve in a hospital; I wanted to experience something else."


Shamay is a board member of the Israel Pain Association and chairwoman of the Nurse Special Interest Group. "As a pain practitioner and coordinator nurse, I gathered all the pain nurses into a forum," she explains. "Pain is important for them." She started with 120 nurses, and within four years there were more than 800 involved. She is also working on a project with the International Association for the Study of Pain to put together a program for 33 countries in Europe. However, she explains, it would not be possible for nurses from the West Bank or Gaza to participate in these programs. The border is closed to them.

FIGURE. Im no better... - Click to enlarge in new windowFIGURE. "I'm no better than people who were already shot and killed, innocent people," says Suzanne Abu Tair. "After so many long periods of curfews and hearing the news of many people being shot and killed, I'm so frustrated because you're not able to do anything to change it."

In Israel, nursing organizations operate easily. When nurses receive their licenses, they automatically join the Histadrut, the Israeli national labor union, which oversees the National Association of Nurses. Professional standards are set by the Ministry of Health.


However, staffing is a problem (each institution sets its own standards). "Everything is restricted by the budget," Shamay says. "We don't have a problem recruiting people to go into nursing, but we have a problem of retention. It's a funding issue, a decision of the minister of health. Canada and the United States are recruiting nurses from Israel. They prefer them because they are well trained."


"[Staffing] became an issue because of the situation here; it's another reason to go abroad."



"I love working with the community," says Suzanne Abu Tair. "It's a part of my personality to provide people with all the information they need and at the same time to learn from them, from their experiences."


In 2004 she earned a master of public health degree at Al Quds University. Abu Tair has formed partnerships with other public health professionals to open a nongovernmental organization to educate women on health care issues. (This is in addition to her responsibilities at the Dheisheh Health Center.) "The name of the organization is Da'a'em, " she says. "It means 'continuous, never stopping,' in Arabic." A grant from the United Nations Development Program has enabled the group to create an income-generating program for 30 women. "Each woman has her own project: raising goats; running a small sundries shop, a bakery, a tailor shop. Meanwhile, we had the chance to meet these women in our center and to discuss health-related issues."


Yet the frustrations of nursing can be extreme. A trained emergency responder, Abu Tair described the trauma of not being able to get to the wounded during the Israeli incursion in 2002, which took place very close to her home in Bethlehem. "If I moved [from my house]," she said, "I would be shot [by the IDF]. The dreadful part is I couldn't treat; I had to leave two people who were injured. They bled until they died. We say the oath and feel some kind of commitment. Even if one of the Israeli soldiers would be wounded, you can provide help. It's something human."

FIGURE. Jerusalems O... - Click to enlarge in new windowFIGURE. Jerusalem's Old City. In June Israeli Prime Minister Ariel Sharon announced a $60 million plan to revive Jerusalem. According to the June 20 issue of

Nor is professional development easy. "In 1994 elections were held to have a nursing union. We are all nurses from different districts: Hebron, Bethlehem, Nablus, Ramallah. So this union didn't work well [because] the majority of nurses were not able to attend the elections." Checkpoints and security zones are a major problem. "It's too difficult to get together to discuss professional issues," she says.


Nonetheless, nurses work together to do their best while living under occupation. "During the curfew, nurses with children take the morning duty so they can go back to their children. The ones who don't have children will stay the evening and night shifts." Because getting to and from work puts health care professionals in danger, transportation to and from home is provided, whenever possible, in public health department ambulances.



When I met Shamay in Tel Aviv, I felt I could be in any European country. Travel, commerce, shopping, health care, and education are maintained in spite of the "situation." In contrast, when I met Abu Tair I had entered a country under occupation, where the "denial of access to routine health care . . . and the destruction of infrastructure necessary for the provision of food, water, and electricity," are clearly evident. 1 Yet the two are bound together by geography, history, and the current political situation. Their courage in the face of adversity is a beacon: they are truly nurse exemplars.


Nearly a decade ago, the ANA promoted Nurses Week with the motto, "Nurses Have the Courage to Care." Those Palestinians who continue to provide health care under the most adverse conditions are surely demonstrating such courage-as are Israeli health care professionals who don't allow terrorism to prevent them from working (sometimes even across the barrier). American nurses must find the courage to help end the violence.



For timelines of events in the region, go to,12575,1122113,00.html


For more information, go to


U.S. Department of State: Middle East Peace


Israel Ministry of Foreign Affairs


Palestinian National Authority


To learn more about what you can do to help, go to


Physicians for Human Rights-Israel


The Union of Health Work Committees


The Union of Palestinian Medical Relief Committees


Middle East Children's Alliance




1. Failure to address the health toll of the Middle East crisis. Lance t 2002;359(9314):1261. [Context Link]

A Fact-Finding Mission in the Palestinian Territories

Aid agencies take advantage of turning point in the Israeli-Palestinian conflict.


It's a critical moment in the decades-long, seemingly intractable conflict between Israelis and Palestinians. Some recent events point toward progress. After the death of Palestinian leader Yasir Arafat last November, Mahmoud Abbas-also known as Abu Mazen-was elected president of the Palestinian Authority. Abbas met with President Bush at the White House in May, and Bush promised $50 million in aid for housing in the Gaza Strip, to be built after the planned withdrawal of Israeli settlers this month.


But the current cease-fire is fragile. There are sporadic outbreaks of violence. Palestinian parliamentary elections scheduled for July have been postponed. Abbas's ruling Fatah movement is being challenged by Hamas, the radical Islamic organization that the U.S. government considers a terrorist organization. And even as the Israelis prepare to withdraw from the Gaza Strip and several settlements in the northern West Bank, prime minister Ariel Sharon is permitting the expansion of other West Bank settlements and continuing the construction of the "security fence," a huge barrier that cuts through Palestinian land (see photograph, page 51), two policies that the Bush administration opposes.


Gerald Martone, MS, RN, director of emergency response for the International Rescue Committee (IRC), traveled to the Palestinian territories in January and February. "The Palestinian refugees are the oldest and largest refugee population in the world," Martone said. "All of the recent changes in the situation provide an opportunity to take fresh approaches to assistance, protection, and advocacy. What better moment to become involved?" Martone was part of a fact-finding team of the International Refugee Support Network (IRSN), a consortium of four international relief organizations, including the IRC.


Martone noted that despite the many international organizations operating in the Palestinian territories, there are gaps in services that leave the needs of displaced populations unmet. The team recommended that the IRSN conduct health surveillance and implement psychosocial interventions in addition to economic, protection, and advocacy programs for the displaced.


A few items from Martone's report on the fact-finding mission give some idea of the scope of the problems these refugees face.


The number of registered Palestinian refugees has grown from approximately 914,000 in 1950 to 4.1 million today, scattered throughout the Middle East, but primarily residing in the West Bank, the Gaza Strip, Jordan, Lebanon, and Syria. 1


According to the World Bank, the current recession in the Palestinian territories is worse than the Great Depression of the 1930s in the United States and the recent economic collapse in Argentina. Nearly half of Palestinians, more than 2 million people, live on an income equivalent to about $2 per day; more than 600,000 (16% of the population) "cannot afford even the basic necessities for subsistence." 2, 3 The United States Agency for International Development reported that the per capita income of Palestinians has fallen 40% since the beginning of the second intifada (uprising) in September 2000; by mid-2004, the unemployment rate had reached 29%, almost three times the rate before the intifada. 4


Security restrictions or "closures" that hamper the movement of Palestinian goods and workers across borders and within the Palestinian territories have contributed significantly to the economic crisis. 2, 3 Aid workers are also severely restricted by the byzantine system of barriers, control gates, checkpoints, and travel regulations.


The closures and the economic crisis have also had significant impacts on the health care system, food security, and nutrition, according to the World Bank. 2 Their report cites a 2003 nutritional survey conducted by the Johns Hopkins and Al Quds Universities, which found that the quality of children's diets had declined sharply between 2002 and 2003, although the rates of acute and chronic malnutrition in children younger than five had improved in the Gaza Strip and remained fairly low (roughly 9%) in the West Bank during the same period.


One study found that almost half of the Palestinian children interviewed had witnessed at least one incident of house demolition; shooting and shelling; or the imprisonment, injury, or killing of parents, siblings, or friends. One out of six (18%) reported having been physically injured in the previous two years of the intifada. Ninety percent of Palestinian parents report trauma-related symptoms in their children. 5


According to Martone, "The future of the Palestinian people depends on the possibility of hope for its youths. That's the challenge for aid workers now: not merely satisfying survival needs but helping to instill that sense of hope."-James M. Stubenrauch, senior editor



1. United Nations Relief and Works Agency (UNRWA). Who is a Palestine refugee? [Context Link]


2. World Bank. Four years-intifada, closures and Palestinian economic crisis: an assessment. 2004. [Context Link]


3. World Bank. Disengagement: the Palestinian economy and the settlements. 2004.$File/. [Context Link]


4. United States Agency for International Development West Bank and Gaza (USAID WB/G). Expanded private sector economic opportunities. 2005. [Context Link]


5. Arafat C, Boothby N. A psychosocial assessment of Palestinian children. United States Agency for International Development. 2003. [Context Link]