Doctor’s dispatch: house calls in Aida refugee camp

David Scales – December 3, 2018
Rainstorms drape over the hills of Bethlehem, slowly tumbling over the wall separating Israel from the city.

The grey-blue deluge blurs the boundary between land and sky, occasionally highlighting a white stone minaret in the distance. Drinking coffee on the roof of the Refugee Center in Aida refugee camp, time is most clearly marked by afternoon calls to prayer reverberating off the billowing clouds or the church bells echoing in the distance, chiming the hours it takes for the storm to creep past. 

Badra Abu Akr, a refugee living in the camp, is too busy to keep track of time. Always putting the needs of others before her own, she thinks about little aside from her family and imprisoned sons. For Badra, time can never go quickly enough. “If you were coming in the fall,” Emily Dickinson once wrote, “I’d brush the summer by[… ]As housewives do a fly.”
Early in the summer, four of her sons were in prison. Two were released, one after the other, after the court-imposed fines were paid, the heaviest about $4,000. Already impoverished, the Abu Akr family scrimped for months for the prison fines, at the expense, unfortunately, of treatment for their complex medical problems.
Badra wasn’t seeing a doctor then, saying she couldn’t afford it. For even if a visit is free, the taxi fare there and back is too steep. Instead, she would take some of her husband’s medication whenever she felt a headache or strange symptoms like dizziness. Her haphazard self-treatments – a blood pressure pill here, a shot of insulin there – were dangerous but just enough to keep her going to put dinner on the table, go grocery shopping or visit her sons.
Maryam Darwish and Ashgan Ewise, two community health workers (CHWs) visiting the Abu Akrs since June, are working together to help Badra and her husband Mustafa focus on their health despite the tempest of life in the camp. As part of Health for Palestine, they’re building off of the Refugee Center’s prior success in improving water quality and building safe spaces for children to play.
Without a dedicated clinic to serve the 7,500 refugees living in Aida and Al Azza refugee camps with a population density three times that of Manhattan, refugees must find their own transport to the nearest ministry of health clinic about a mile away. Yet almost 50 percent of all deaths in the West Bank can be attributed to heart disease and strokes, both long-term consequences of chronic diseases like diabetes and hypertension. The nearest UNRWA clinic with specialized care to manage complex chronic diseases is about three miles away and uphill. For elderly refugees with limited ability to walk, expensive taxis are the only way to get there. Health for Palestine aims to change this by bringing care into refugees’ homes.
Through over thirty home visits, Maryam and Ashgan have been circuitously reorienting Badra’s focus to herself simply by showing up at her house. Since guests are sacred here, Badra feels obligated to take care of the CHWs whenever they visit. But by attending to her guests, the Maryam and Ashgan are able to attend to her – discussing how to make better food choices despite her financial constraints and her chaotic life while checking her blood pressure and blood sugar. Compared to five months ago, both are now much improved.
But diabetes and high blood pressure move on their own time scale, creeping slowly, surreptitiously, like a coming rainstorm. The steady rhythm of our beating hearts offering false reassurance while arteries silently harden and narrow, nerves and kidneys slowly malfunction. Unfortunately, our body only sounds thunderous alarms once the damage has become irreversible. 
For both Badra and Mustafa, the storm has already struck in the form of strokes. Mustafa remains paralyzed on his left side, frustrated that even his tongue remains stubbornly slow and clumsy when he tries to speak.
Badra was luckier, escaping without any lingering problems, but she is still struggling to take her medications. For a while Mustafa was too. When Maryam and Ashgan asked, both would defiantly insist they were taking their pills, but anyone would struggle to find all the right medications amidst the chaos of the plastic bag containing disintegrating medicine boxes and half-used blister packs of pills. The most plausible explanation for their wildly fluctuating blood pressure and blood sugars was that they were taking their pills intermittently.
So Maryam and Ashgan took them pill boxes, sitting down, organizing, and patiently explaining to both of them when and how to take their medications. It is now easier to remember, Mustafa admits, but his paralyzed hand makes opening the boxes challenging. He says it’s difficult, but he manages.
While her name in Arabic means “one who starts early,” Badra is still getting used to the rhythm of the rigid boxes, her priorities focused on her family’s meals, her sons in prison. So Maryam and Ashgan check in on them almost every day.
So far, Mustafa hasn’t missed a day. The pillbox seemed to be all he needed to get his blood pressure under control – as long as he remembers to take his morning medications. He still gets breathless on stairs, though, the consequence of a previous heart attack. His fear of a second one is his constant reminder to take his medications, which he can do now that they’re organized and right by his bed. But a pillbox hasn’t helped him stop smoking.
I’m a physician, helping lead the project. One recent Wednesday I went with Maryam and Ashgan to visit the Abu Akr’s apartment. The couple live on the second floor of a cramped, multi-story concrete building just steps the eight-meter high wall carved through the West Bank, their apartment lovingly decorated with photos of their imprisoned sons and a floor-to-ceiling mural of the Jerusalem’s al-Aqsa mosque.
We’re invited to the back bedroom where Mustafa sleeps and watches TV – behind the kitchen and beyond the room with the mural where they usually receive guests. Mustafa sits cross-legged on the bed, smoking with his good right hand. A dark circle of hair persists on the top of his head defiantly resistant to the passage of time despite the remainder of his crown engulfed by grey. Badra sat on an adjacent couch, making malfouf, a time-intensive dish of rice and meat baked in rolled in cabbage leaves.
Maryam peeked at Badra’s medication box. “Why aren’t you taking your cholesterol medication?” Maryam asked, in a gently chiding tone. In between rolling rice into cabbage leaves, holding her two-month-old granddaughter, and directing her daughter cooking in the kitchen, Badra parried our entreaties with laughter, saying she doesn’t like that medication. But it’s clear she didn’t like other medications either, the remaining pills in her pillbox revealing which high blood pressure and diabetes medications she sporadically avoided the past few days.
Maryam checked Badra blood pressure, which was borderline high. “Kteer kwayyis!” – really good – exclaimed Badra, taking heart that her blood pressure improved from the dangerously high levels she had over the summer. Close to 300, her blood sugar is less cause for celebration. Ten days after giving her the pillbox, Maryam and Ashgan’s almost daily visits have already revealed a trend: when Badra is taking her medications on time, her blood sugar and blood pressure are controlled. But consistency is elusive when the Abu Akrs are frequently sacrificing the present for the future with their imprisoned sons.
As we leave their apartment, we all chat. Maryam recognizes the struggle Badra is facing, saying her life is faudwi – chaotic realizing that pillboxes alone can’t resolve the chaos. But the Maryam and Ashgan are helping, even by their presence, keeping the Abu Akrs focused on the present, empowering them to either calm the storm or navigate within it.