ISRAEL BEYOND POLITICS: June 2004

Grace under pressure: Israeli medical students abroad

If you think treating leprosy, malaria, tuberculosis and making a solo dash through the jungle to deliver a baby in a remote Amazonian village sound like the stuff of historical fiction, guess again.  It's everyday fare for fourth year medical students enrolled in the Ben-Gurion University of the Negev MD Program in International Health and Medicine (IHM). 

In their last year of medical school, the nascent doctors spend two months in a supervised clerkship, program in a developing country. About a score of this year's 35 recently returned students presented oral reports at a Gala Presentation in Beersheva on April 29, and in the process, held an auditorium full of students, professors and other interested people spellbound.

They told of treating HIV patients in Kenya - two or three people to a single hospital bed.  They described reconstructive surgery for leprosy patients in India, of patients suffering from malnutrition, dysentery and exotic parasitic infestations in Ethiopia. Several told of unavoidable death, when nothing could beat back the filth, poverty, ignorance and complete lack of resources they encountered.

Yet a characteristic common to each of the about-to-be doctors stood out clearly: the warmth and respect for the patients and local medical practitioners they had come to know during their time in very foreign surroundings. In these times, when medical patients in "modern" countries are forced to adjust to the bean-counter approach to the practice of medicine, their warmth, compassion and sensitivity seems unique.

According to Professor Miki Karplus, Clerkship program coordinator, that's precisely the objective they hope to achieve."First of all, we select students who seem to have the qualities of kindness and compassion," he says. "But secondly, these students make great sacrifices of their own in leaving their home countries - America, India, Africa, Asia - to come to Israel. Over half have no previous experience with either Judaism or Israel. So yes, they learn to treat people of other cultures with great sensitivity, but they themselves are also vulnerable, immersed in a very different culture, here in Israel. It's a key part of the program."

International Program students receive a traditional four-year medical school education, a joint operation between Ben-Gurion University of the Negev and Columbia University Medical Center in New York. During their fourth and final year - after having been immersed in cross-cultural studies and practical situations during all three previous years, they are required to spend two months in a formal "clerkship" with a locally-accredited medical school in Kenya, India, Peru or Ethiopia, or in a supervised Israeli program within a distinctive community like the Bedouin, a haredi community in Jerusalem or the Arab community in Nazareth. 
 
That clerkship, working with real patients, mostly in less-than-ideal situations, is a part of the program most of the students seemed to appreciate most.
 
"I loved it," says Diana Wolfe, who spent her Clerkship in Peru.  "Working with the people I met in Iquitos is the kind of thing that keeps me alive." Wolfe, like several of her classmates, was a globetrotter even before she even got to Israel. Born in Pennsylvania, Wolfe spent two years in Mali, West Africa, in the Peace Corps and had a master's degree in public health from Berkeley when she saw a notice about the BGU-CU M.D. program on the Internet. 
 
"This program was made for me," she says. "I'm interested in rural health, working with people who live very different lives than I do.  The opportunity to study in Israel, improve my Hebrew, and then work in a developing country even before graduation was exactly what I was looking for. "The focus on intercultural relations, on sensitivity, on respecting other cultures, other ways of living - all of that was important to me."
 
Wolfe told of an experience she had as a third year student, treating a Bedouin woman. "The woman was suffering from several different medical problems," she noted. "She had an aortic aneurysm, but she also had diabetes, heart disease and very high blood pressure.  Neither of us spoke the other's language, but as she talked and explained, and I realized I understood what she was saying - not thorough words, but through her body language, her tone and the way she was saying thing. "What's unique about this program is that they teach us how to practice this kind of cultural communication, to understand on a different level, and to express ourselves with kindness and caring.  It's a completely different way to communicate."
 
Part of Wolfe's clerkship was spent on the Hope, a missionary boat that travels the Amazon River treating Peruvian villagers who live in the river's most remote spots. "We'd treat 400 people in four days," she says, noting that patients would travel two or three days through the jungle to get to the boat. "They came with diarrhea, dysentery, respiratory diseases," she says. "Their houses were built on stilts, over the river, and we said they had the kind of toilets that never got plugged - all sewage went directly into the river. But the river was also the source of drinking water - you can imagine the problems.
 
"We had our own problems in treating them. Most of the equipment we had was donated, which meant that if it broke, it was almost impossible to get parts. It was all old or non-standard. There were times when we had no needles, no drugs and no supplies.  But this might be the only time for a year the patient would be able to visit the ship.  We had to make do, use our clinical skills - which was sometimes all we had.
 
Wolfe recalls delivering a baby one night. "The woman had been by earlier in the day," she says, "but it didn't seem as though she was due just yet. But toward evening, she came back in advanced labor. I didn't have anything - no antibiotics, not even latex gloves. But she had a fine, healthy baby boy, and she named him Scott after one of the male doctors. "They couldn't quite pronounce the name," Wolfe adds, "so they call the baby "S-Cott."
 
Another time she had to stand by while a patient died. "He was an older man suffering from advanced tuberculosis," she says, "a kind of meningitis. We couldn't treat him until his family arrived, but it took them several days, and by the time his daughter got there, he had died. She began sobbing and at the same time, singing this incredibly beautiful song. The song was the way they mourned. It was so beautiful. Moments like that I will remember for the rest of my life."
 
Danny Drew, a former self-proclaimed tennis bum from Los Angeles, came to the program in a different way. "My wife Rita and I are Christians," Drew says. "We felt we wanted to be involved in mission work of some kind, and I was looking for a medical school. When I saw the information on this program, it seemed too good to be true. I didn't think I'd ever get in, but we were committed. We decided if I did get in, then that would be God's message to us: This was where He wanted us."
 
Drew was accepted, and he, his wife and two children packed up and moved to Israel, living for the first year with almost no furniture. Their third child, a boy, was born here, and a fourth is due in July.  By special arrangement, Drew spent his clerkship on a Blackfoot Indian Reservation in Montana.
 
"It was a matter of expense," he said. "To move our family of five again, to Israel, back to the US, back to Israel again, was outrageously expensive. And if my family couldn't be with me, I wouldn't have been in the program - that's the way it was. So with the approval of the faculty, I spent my two months working on the Montana reservation. "It wasn't quite as primitive as what some of my classmates experienced," he says, "but the poverty, the ignorance, the lack of resources is still appalling."
 
Drew will spend next year, at least, doing his residency in a Spokane, Washington hospital. Will that seem tame, in comparison to the places he's been treating patients for the last four years? 
 
"Not really," says Drew. "In the US, wherever I go, I will still be treating immigrant populations.  My experience here, treating Ethiopians, Russian natives, the Bedouin, is invaluable. I've learned how to deal with language barriers, with cultural gaps, with a lack of supplies and equipment. I've learned how to relate to people who live very differently than anything I've ever seen, and to make do with a minimum of resources. That experience is likely to be worth quite a lot, wherever I end up living and working."
 
Savannah, Georgia native Daniel Urbine started his career as an electrical engineer, and then spent five years in the US Navy, serving on bases in California, Puerto Rico and South Korea. During a two-year stint at Camp David during President Clinton's administration, Urbine decided to take advantage of a local program to train as an emergency medical technician. "I was hooked", he says of the EMT training. "I loved it. By that time I knew I wasn't going to spend the rest of my life in the Navy, so I started to look at medical schools. This one, with the focus on international health, seemed perfect for me."
 
In making his presentation on his two months of clinical practice in Kenya, Urbine read an email he had written to his wife, who had remained behind in Beersheva. His story is typical:
 
"The past few days have been mentally and emotionally draining. I remember hearing a doctor compare the practice of medicine in a third world country to a grieving process.  She described how the physician new to this environment struggles through the traditional stages of denial/disbelief, then frustration/anger, followed by depression/mourning and finally acceptance. "At the time, I wasn't completely convinced. Now, having seen it myself, I think she was right on, absolutely correct."  
 
"Tuesday morning rounds started at 9 am as usual. The team consisted of two American residents, a Kenyan resident, Sarit (another IHM student) and myself. One of the patients was a 17-year-old street kid with pneumonia who was admitted with a huge head gash and possible skull fracture after being hit with a rock during a fight.  As we rounded on this kid, I noticed he was in shock (unmeasurable blood pressure, pulse 120, respiration 50, cool clammy skin). While all the patients on the ward are sick - and many guaranteed to die within the week this is the kind of patient who screams, 'I may die before you finish rounds unless you do something NOW.' 
 
"I was amazed at the stark contrast between this patient's extremely critical condition and the lack of urgency surrounding his care.

"Stage 1. Disbelief. Our team started an IV to pump him full of fluids and salvage his blood pressure - about all we could do.  If we'd been in Israel or the States, he'd have been given oxygen, drugs to increase the blood pressure, antibiotics, and transferred to the ICU. None of that was available here.
 
"I made sure he was getting fluids and the antibiotics that were available. His condition continued to fluctuate. As night approached, the resident and I made it clear to the incoming doctor that this kid was the sickest patient on our ward. I was absolutely convinced he would die in the next few hours if our extremely limited treatment was delayed even slightly.
 
"I returned to the hospital at about 10 pm to find the street kid in severe distress - pulse 140, respiration 70. I gave him more fluids, insisted he get oxygen. While I dreamed about ventilator support in the ICU, I realized that even oxygen isn't all that simple here.
 
"There are only two O2 (oxygen) machines, and only one worked, barely.  There was only one oxygen mask for 120 people. I made the tough decision to take the oxygen machine from a 15-year-old boy in congestive heart failure and use it on the street kid. If the younger boy started to show signs of distress, the plan was to put him back on the oxygen immediately. The younger kid went into a brief period of respiratory distress - and then the oxygen machine broke.
 
"Perfect. Really. Just perfect. Stage 2. Anger.  
  
"The younger boy ended up relaxing and doing okay; he was discharged the next day. But the street kid was still inches from death. After giving him more fluids, and feeling convinced I'd regained another inch or two from the grim Kenyan reaper, I decided to get some sleep. On my way out the door, another patient, from a different ward, called me, and asked for help. He said he was being discharged, but was having some chest pain.
 
"After three questions and two minutes, I realized we had another guy in almost the same condition as the street kid. I couldn't believe this! I was unfamiliar with this patient and felt even more helpless when I couldn't find his chart. I was convinced that again we had a major problem on our hands.  
 
"Despite our best efforts, the stories of my patients ended at 2:15 and 2:20 am. The following morning I came in to find their empty beds. Stage 3. Mourning.
   
"The most advanced point in the cycle is Stage 4, acceptance. And I'm not there yet. To be really effective, you have to operate in a state of acceptance. But I'm asking myself "What is it exactly that I'm supposed to accept?" 
 
"I think it's about limitations. Perhaps accepting the limitations of the situation.  Regardless of the situation - Soroka, New York Presbyterian or Kenya - there are limitations. It's just that in Kenya, the limitations are so much more pronounced. And acceptance, so much more difficult."
 
Sara Rose Haim, in making her presentation on her two months in India, appeared to sum up the opinion of most of her classmates: "Medical school is difficult," she said. "It's sometimes depressing and it can make students hard and cynical. But whatever medical school took away from me, the opportunity to work in India put it all back."
 
For further information on IHM, contact administrative director Stavi Baram, MD Program in International Health and Medicine, Health Faculty of Health Sciences, Ben-Gurion University of the Negev. Beersheva 84105 Israel. Email: stavi@bgu.ac.il

Faye Bittker
Department of Public Affairs
Ben-Gurion University of the Negev
fbittker@bgumail.bgu.ac.il

Haifa University archeologist uncovers world's oldest bedding
 
A team of botanists and archeologists led by a University of Haifa researcher have uncovered prehistoric floor coverings that constitute the oldest evidence of bedding for the sleeping and/or sitting area.

According to Dr. Dani Nadel, the Haifa archeologist in charge of the excavation, this is the first time that such bedding, along with a "modernly" organized hut floor, has been found.

Nadel and his team have been exploring Ohalo II, a 23,000-year-old fishermen-hunters-gatherers camp on the shores of the Sea of Galilee (Lake Kinneret).The site was uncovered several years ago after the lake had receded drastically because of years of little rainfall in the region.

The oval-shaped "mat" that was found is made of grass. Found in the largest of the six brush huts uncovered, the most ancient in the world, the floor covering measures 4.5 meters long. It was located close to the hut wall, around a central hearth.

The mat was meticulously crafted from bundles of grass. The charred stems and leaves were covered with a thin, closely pressed layer of clay. According to Nadel, this was apparently intended to preserve the structure and order of the sheaves.

The Haifa University-led excavation at the site has also revealed the vegetarian diet of the camp inhabitants. Well-preserved seeds and even fruit have been discovered. Almost no other site dating to this period anywhere in the world has produced such finds.

According to Nadel, these finds are important for understanding the economic basis and types of seasonal food of humans at the height of the last Ice Age. Large quantities of charred material were found in the huts and near campfires at the site. Some 90,000 seeds and fruit from more than 100 species of trees and plants have been identified so far. Among the grains, wild wheat and barley stand out. These were among the first that humans cultivated at a much later period.

The finds, he continued, also testify to the fact that both food and incendiary material were brought to the camp from the Mediterranean groves, the lake shore, and the large salt flats that spread over the region.

Ohalo II, Nadel commented, is one of the best preserved sites of the period in the world, presenting one of the most detailed contributions to the reconstruction of everyday life in this period.

For background on the Ohalo II excavations, see http://ohalo.haifa.ac.il/

International Workshop on Auditing Democracies
1-3 June 2004
 
The Israel Democracy Institute (www.idi.org.il) is hosting an exciting workshop 1-3 June 2004, in conjunction with the National Endowment for Democracy. This three-day workshop is a follow-up to the 3rd Assembly of the World Movement for Democracy that was held in Durban, South Africa. Leading democrats from around the world will convene at the IDI in Jerusalem to discuss ways of auditing democracies.

Every year the IDI publishes the Israeli Democracy Index, which consists of two parts: a long-term and comparative study of some 31 indicators measuring Israeli democracy against that of 35 other democracies and a public opinion survey reflecting how Israelis view their democracy. The workshop will commence with the presentation of the 2004 Israeli Democracy Index to the President of the State of Israel, Moshe Katzav.  

During the three days, Prof. Asher Arian, senior research fellow and head of the Index team, will present the methodology and its findings. The program will also include plenary sessions, a discussion with students participating in our educational program "Kids in Search of Common Ground: The Education System Writes a Constitution," and participants will also be invited to present their own work and discuss challenges. We are hoping the workshop will result in concrete ideas and further cooperative projects.

The Israel Democracy Institute was founded in 1991, by Prof. Arye Carmon, with the generous support of Mr. Bernard Marcus and guidance of our Honorary Chairman, former U.S. Secretary of State Prof. George P. Shultz, as an independent, non-partisan think tank. In its mission to strengthen democracy in Israel, the IDI tackles issues such as accountability and transparency in government, reform of the judicial system, the relationship between the Israel Defense Forces and Israeli society at large, religion and state, business and democracy, and terror and democracy, just to name a few.

For more information:
e-mail: marne@idi.org.il 
tel: 972-2-530-0871
fax: 972-2-530-0870   

Israel Museum receives bequest of 20th century European paintings and drawings

The Israel Museum, Jerusalem, has received an important bequest of twenty paintings and drawings, including Amedeo Modigliani’s outstanding Portrait of Zborowski (1916), from the collection of Dr. Georg Guggenheim and his wife Josi Guggenheim-Strauss, founders and important early supporters of the Israel Museum. The bequest includes works by acclaimed artists including Picasso, Miro, Klee, Utrillo, Marcoussis, Steinlen, Friesz, and Poliakoff.
     
The portrait of Leopold Zborowski, which will be on view at the Israel Museum starting June 3, 2004, is the first of Modigliani’s six portraits of the young Polish poet, who was introduced to the artist in Paris. Succeeding Paul Guillaume as Modigliani’s dealer in 1916, Zborowski formed an intense personal and professional relationship with the artist, each depending on the other’s talent and success.

The portrait depicts Zborowski with folded arms, showing great self-assurance. The large capital letters of Zborowski’s name, inscribed above his head, further underscore his confidence in his identity. The delicate brushwork reflects the great care invested by Modigliani in this initial depiction of the man who would so faithfully and energetically champion his work. The Guggenheim bequest also includes two drawings by Modigliani. The Israel Museum’s collection is now exceptionally rich in examples of Modigliani’s portraiture, including also his “Portrait of Jeanne Hébuterne,” 1918; and “Portrait of Celso Lagar,” 1915.

“Dr. Georg Guggenheim and his wife Josi were instrumental to the growth and success of the Israel Museum from the earliest years of its founding in 1965,” said James Snyder, Anne and Jerome Fisher Director of the Israel Museum, Jerusalem. “This final gift, including works by leading 20th century European artists and so important an addition to our holdings of Modigliani, is a fitting conclusion to the Guggenheims’ long history of commitment to our Modern Art department. The Guggenheim bequest was designated at the time of Dr. Guggenheim’s death in 1987 and honored upon Mrs. Guggenheim’s death at 99 in October, 2003.”

Among the other works included in the Guggenheim bequest are:

Henrijk Berlewi
Mechano Faktura (mechanically manufactured?), 1924
Oil on canvas, 52.5 x 52.5 cm

Othon Friesz
Composition, 1910-1912
Oil on canvas, 71 x 53 cm (double sided)

Paul Klee
Promenade, 1938
Aquarelle on cardboard, 23 x 32 cm

Lasker-Schüler
Yussuf Goes to God (Jussuf geht zu Gott)
Ink and blue chalk, 21.3 x 6 cm

Lasker-Schüler
Neapolitan
Pencil, colored chalk, and collage, 24 x 18 cm

Louis Marcoussis
Still Life
Oil on canvas, 33 x 22 cm

Joan Miró
Bird (Oiseau), 1960
Oil on cardboard, 105 X 75 cm
Plus two untitled prints: 1 page, 91 x 61.5 cm; 1 page, 26.5 x 18.5 cm

Amadeo Modigliani
Nude Woman (Frauenakt)
Pencil drawing, 42 x 26.5 cm

Amadeo Modigliani
Portrait of Zborowski, 1916
Oil on canvas, 63.5 x 41 cm

Amadeo Modigliani
Man with a Pipe, 1919
Pencil drawing, 43 x 27 cm

Meret Oppenheim
Unidentified Objects (Objets non identifiés), 1954
Oil on thin cardboard, 34 x 45 cm

Pablo Picasso
Woman Brushing her Hair (Femme se coiffant), 1952
Study for the cycle La Paix - Oil on linen, 64 x 50 cm

Serge Poliakoff
Untitled, ca. 1950
Gouache, 44 x 60 cm

Wladimir Segal
Georg Guggenheim, 1962
Pencil Drawing, 36 x 24 cm

Steinlen
Head of a Woman (Frauenkopf)
32.3 x 48 cm

Maurice Utrillo
Moulin Rouge
Aquarelle, 29 x 34.5

Maurice Utrillo
Snow Effect at Chatillon (Effet de neige à Chatillon), 1918
Oil on canvas, 85 x 80 cm

Jacques Yankel
Composition
Oil on canvas, 31 x 34 cm

Regional Cooperation

Jordan university looks to open Israel branch
Representatives of Jordan's Al-Ahliyya Amman University met with Education Minister Limor Livnat for talks on opening an extension of the institute of higher learning in Israel, Haaretz reported. The university's director and owner, Maher Hurani, told Livnat he was determined to establish ties with Israel despite threats and opposition voiced against the move by elements in the Arab world and Jordan. "I am happy about the request and see it as a boost to the spirit of peace and a national interest," Livnat said after the meeting.

The university will lease an existing building for three years, during which time the new university's campus will be built. While the university is expected to primarily serve the Arab sector, Hurani said he would also like to see Jewish students and Arab students from other countries in the region at the institute. Al-Ahliyya Amman University is Jordan's first private university and was established in 1990. The institute is owned by the Hurani family, which has business interests in Jordan, Lebanon and Dubai in the fields of industry and tourism. 
 
Iraqi doctor treated in Israel 
A doctor from Iraq is receiving treatment in an Israeli hospital for injuries suffered in a terrorist bombing, The Jerusalem Post reported. The doctor, whose eyesight was damaged in the explosion, is being treated at Hadassah Hospital in Ein Karem, Jerusalem, after ZAKA workers responded to a request by an international humanitarian organization to arrange for his stay. The organization turned to ZAKA with the request, because Hadassah is the sole hospital that could perform the surgery the doctor needed. Last week, the Interior and Foreign Ministries gave their okay and issued the permit for the doctor to stay in Israel for a month.