Sunday, June 12, 2011

Mobile West Bank Neurologist

I had the wonderful opportunity to spend a few weeks working with Physicians for Human Rights (PHR) in Israel, and to participate in a "mobile clinic" that brought a group of physicians, nurses, medical students, and other volunteers to both cities and small towns in the West Bank. I want to use this blog post to take you through a typical day:

The group left from Taybeh, a small town northeast of Ramallah, and it was typically made up of volunteers from Tel Aviv and Jerusalem, and a handful from the West Bank itself. We met in the coffeeshop of a gas station outside the town, where Al Jazeera was typically playing on the television:

After the group assembled, we would stand outside in a large circle, and our leader (in the light blue shirt) would tell us about the town we were going to, and then we would go around the circle and introduce ourselves. I was typically the only American in the group, with mostly Israelis and Palestinians, and then various observers from European countries.

We would then load up the vans with boxes of medications, and then we were off. Most of the town we visited were in "Area B" of the Palestinian Authority, which is to say they are under Palestinian civilian authority and Israeli military authority, although we did go to Area A (Palestinian civilian and military authority) as well, such as Jenin. We passed through checkpoints at various places along the way, many of which were entirely empty, to my surprise:

I was kind of surprised at how rapidly something changed across the border--even the cell phone provider!

If we were in Area A, we were escorted by one or two Palestinian Authority security vans:

We would then arrive at our site, and we would typically use a small school, or less frequently an actual clinic. The visit from PHR would have been announced in the mosque for a few days prior to our coming, so we would arrive to a large group of people waiting outside, and there was always a warm welcome.

Dozens of people from the town were there to greet us, including the leadership (often the mayor himself) and scores of volunteers. We would first gather in a large room and the mayor of the town would address the group.

 I would them be led to my "clinic room" where a sign in Arabic reading "Neurologist" was placed above the door. A neurologists' coming would also have been expressly announced in the mosque, and there were typically 20-30 people waiting to see me. Many of them were local, but many had actually traveled from other West Bank town, likely taking hours to get there. This was my clinic room (aka classroom) in Jenin:

The chaos then began. Typically a volunteer was tasked with maintaining the order of the patients, and he or she would take one in to see me one at a time.  I was provided excellent interpreters, typically Palestinian nurses or medical students, and they would speak to the patient in Arabic and then to me in either Hebrew or English, whichever was easier for them. I had at least one Israel medical student with me, and usually one of the European observers. Here is a picture taken by a Swiss observer of one of my patient encounters. I am talking to the patient, who is looking at the interpreter. The medical student in scrubs is keeping up with the documentation. Behind the patient is her brother, who was my next patient (families always came as a group--I would often see three or four people from the same family, one after the other), and then by the door was the list-keeper.

So I would see about 20 patients per day, and I was always the last one seeing patients, keeping the entire delegation from their late lunch. In terms of the cases that I saw, they spanned the entire spectrum of neurological complaints and diseases. There was plenty of migraine, neck pain and back pain with and without radiculopathy, carpal tunnel syndrome, and painful distal sensory neuropathy. Despite my insistence that I was an adult neurologist, I was asked to see children as well, typically developmentally delayed kids, just as an umpteenth opinion as to whether anything was possible to improve the child's neurological function. I was told that there is relatively more consanguinity in this population,  accounting for the large number of developmentally abnormal children, but I have no idea if that's true, and how prenatal and perinatal care have been taken into account. This child is nearly three. His twin died during labor, and his family was told that he had suffered a hypoxic injury. He is non-verbal, and cannot walk, and just in the photograph his hypotonia is obvious with his drooped posture and the fact that this mother is holding his head up.

I saw a few fascinating cases, including what I think was a first presentation of Wilson's disease, severe B12 deficiency (the lemon-yellow skin doesn't really show up on the photo, but it was profound, as was the exquisite dissociation between absence of dorsal column mediated sensation and intact spinothalamically mediated modalities.

I saw a young man (25 years old) with profound Parkinsonism, and from the history I could not begin to figure out what the underlying diagnosis was. The picture is shadowy, but his stooped posture (although no worse than mine) and masked facial expression can almost be appreciated. We went through the protracted process of getting him admitted to Israel for an inpatient workup.

 After all of the patients were seen, the PHR group and all of the volunteers had a meal together ("lunch" that not typically eaten until 4PM when the work was done), with some time for casual conversation, and then a short talk about the history of the town and the specific difficulties it is facing these days.

The mayor of Jayus, a town whose farmlands have been divided by the "wall" told us about the town, looking out over the wall itself.

We would them pack up and head back to Taybeh, and then I would get a ride back to Tel Aviv.

It was a phenomenal experience. Anyone who read this and would like to hear more about it, or be put in touch with the PHR people I worked with, email me anytime at


  1. Working together with the Culicchia Neurological Clinic they are continuing to train future neurologists and neurosurgeons right here on the West Bank.

  2. Great introduction to a great post.Thanks for taking the time to share it.

  3. I am often to blogging and i really appreciate your content. thanks

  4. You made some good points there.I did a search on the topic and found most people will agree with your blog.Thanks.

  5. The content of this post is very well written.I like the visit on this site.

  6. Neurologists examine patients who have been referred to them by other physicians in both the inpatient and outpatient settings. A neurologist will begin their interaction with a patient by taking a comprehensive medical history, and then perform a physical examination focusing on evaluating the nervous system.

  7. This post very important .This post is very nice.