Tony Waterston on child health teaching in the occupied territories

Tony WaterstonArriving in Ramallah in December from a freezing UK, both the temperature and the welcome were very warm. The purpose was a regular visit to the students on the collaborative Royal College of Paediatrics and Child Health and Al Quds Medical school postgraduate teaching programme on child health, and to run an OSCE for the first group of graduates to upgrade them from Certificate to Palestinian Child Health Diploma.

The first day for we three RCPCH tutors was devoted to the exam for the six candidates including one nurse (the second nurse withdrew owing to illness). We ran six stations including two with role play, two clinical scenarios, a growth chart and a station to discuss their portfolios. The latter was a new introduction and was met with some resistance, as the concept is unfamiliar. We have found this with the second group too though they are learning fast. All passed the exam and will receive the Diploma from the RCPCH.

Later we travelled to Jericho, the lowest city on earth. It is like an oasis in the desert and many of the vegetables for the West Bank are grown there. This is a dry time and output is falling – the water table is being tapped higher up the Jordan valley for the use of the Israeli settlers who operate farms in the valley.

The next day we visited Makassed Hospital, the main teaching hospital in the West Bank. Here we have a group of ten residents training in paediatrics. The chief focus for the programme is primary care and we started this second group at the request of the paediatricians: it is valuable to use the same curriculum (which is holistic and comprehensive) for GPs and trainee paediatricians. They are an enthusiastic group including one woman from Gaza. She missed the beginning of the course owing to difficulty in obtaining a permit. Her portfolio is outstanding.

The teaching takes place next to the neonatal unit which we tour. Two small preterms are from Gaza. Their mothers have had to return to Gaza as they have no permit to remain in Jerusalem. It is possible that they will not be allowed to return to pick their baby up if they are aged under 35, and a relative may need to take the baby back. If an ill baby is transferred from Ramallah 10 miles away, the doctor may not be allowed to pass the check point and a doctor would need to be sent from Makassed to accompany the baby for the last five miles. Ambulances are frequently held up at checkpoints even if there is a severely ill patient inside.

The teaching session is on emotional health. The doctors are new to this but welcome the discussion which they relate to their own family. Some say this will change the way they see their children in future.

The second group in Ramallah is made up of 7 GPs and three nurses. Their feedback is very positive on the earlier modules of the 11 module course and the nurses had coped with the teaching on clinical skills and on acute and chronic illness. The students come from different parts of the West bank and are frequently held up owing to the checkpoints, so it is difficult for the sessions to run to time.

We met the 18 local tutors in the evening and their feedback is also positive. Should zinc be given for children with diarrhoeal disease, in a developed country? This query came up in relation to the acute module and will have to be followed up. The term ‘chronic illness’ will be replaced with ‘long term disorders’. Should the concept of the psycho social approach be introduced in advance of this module rather than on the first day? Are the jokes about Hebronites funnier than the ones about Nablus inhabitants?

Finally we had a long meeting with the Minister of Health to discuss the future of the programme and, we anticipate, the integration of the course into the training of all paediatricians and of all GPs and nurses. As a previous facilitator in the early days, he is an enthusiastic supporter of the RCPCH link. We do not discuss teaching in Gaza as there is a separate Minister in that region and we are unable to obtain permits to visit at the present. We are looking at using distance learning to develop the course there, as the need is huge and health professionals feel very isolated.

In the evening there were celebrations for the release of 200 prisoners from Israeli jails. A further 10,000 remain, so the happiness is muted. We ask if there is more hope as a result of the Obama election in the US. In general the response is no, since there have been many false dawns for the Palestinians in recent years. Yet their ingenuity, enthusiasm, hospitality and high standard of medical care is inspiring. As we pass through the towering wall the last time, we think of all the other walls that have eventually fallen and pray for this to be soon.

Tony Waterston is a paediatrician in Newcastle upon Tyne, working mainly mainly in the community with long term conditions, disability, child abuse and social and mental health concerns. His interests are in child public health, children’s rights and global child health and he leads the RCPCH teaching programme in the occupied Palestinian territories.