Duty of care?

‘Metro’ visits the Medical Clinic for Refugees to learn what kind of impact a volunteer staff at a medical clinic has on the country’s poorest and most vulnerable people.

African refugees medical 521 (photo credit: CARL HOFFMAN)
African refugees medical 521
(photo credit: CARL HOFFMAN)
It is estimated that more than 30,000 African refugees and asylum seekers are living in this country, with 500 to 1,000 more coming every month. These people have either fled armed conflict and civil war or fear persecution in such countries as Eritrea, Sudan, Congo and Ivory Coast. Most have entered Israel by crossing the border from Egypt with nothing more than the clothes on their backs. Many have been victims of rape and other forms of physical abuse, trafficking, slavery, or war-related violence.
As “uninvited guests” of the country, these refugees and asylum seekers have few legal rights and virtually no accs on the lives of some of the ces and health care. While having to do without education and social support services is difficult enough, falling outside the umbrella of Israel’s national health insurance law poses problems that become particularly acute when these people – like any other people – become ill or seriously injured.
In 2008 the Israel Medical Association (IMA), in conjunction with the Health Ministry, responded to the growing crisis by opening a free medical clinic for refugees and asylum seekers in Tel Aviv’s Central Bus Station. The IMA took on the task of recruiting doctors to volunteer at the clinic, and the ministry pledged to provide a small operating budget, sufficient to rent the space and provide a nominal salary for the clinic’s manager. Both organizations have issued repeated calls for doctors and nurses to volunteer their services at the clinic one or two days a month. Magen David Adom joined the project in 2009, providing paramedic services, donating new equipment and refurbishing the clinic.
Today, the Medical Clinic for Refugees and a similar facility in Jaffa run by Physicians for Human Rights are the only two places in Israel where refugees and asylum seekers can receive medical treatment and medicines free of charge.
The clinic in he ministry pledged to provideugh Thursday from 4 to 8 p.m.
Patients are received until 7. Additional nursing and paramedic services are provided on Monday and Wednesday from 1 to 4 p.m. Anywhere from 60 to 100 people visit the clinic on an average night.
Metro recently visited the clinic on such a night to learn what kind of impact a volunteer staff at a bare-bones medical clinic operating on a shoestring budget could possibly have on the lives of some of the poorest and most vulnerable people in Israel.
We arrive at the clinic a minute or two after 4 p.m. to find the waiting room already full. Aside from one baby asleep in a carriage, all appear to be between the ages of 20 and 40, and men outnumber women by a rough ratio of three to one.
The crowd is quiet and orderly. Four young Israelis appear to be running the place. Three of them – two women in their 20s and a man of 19 – are volunteers, busily registering the visitors and trying to find patients who can act as interpreters for other patients, to talk to the volunteers now and to the doctor later.
Language is a problem. Some refugees have been here long enough to learn Hebrew. Others, like those from Nigeria, usually speak English to some degree.
Most of the Sudanese, however, speak only Arabic; the Ethiopians speak Amharic and the Eritreans speak Tigrinya.
The fourth Israeli looks particularly young, sporting a boyish smile, shoulder-length hair, faded jeans and a T-shirt that says “Good waves and cold beer make me happy.” He is Orel Ben- Ari, all of 28 years old, the manager of the clinic.
While the volunteers spend part of their time in a little reception office near the entrance, Ben-Ari seems to be virtually everywhere at once, and does not stop moving during the whole time the place is open. Formerly a volunteer, Ben-Ari became the clinic’s manager last May, driven, he says, by “a sincere concern” for these people, for what they have gone through, and for the difficulties they continue to face.“I grew [up] on values of volunteering and helping others,” he says.
“Although I’m still young, maybe I can compare it to a fatherly concern.”
We settle in with the physician on duty this night, Dr. Harvey Belik, a general practitioner. He has come here tonight from his practice in Ra’anana, a short distance compared with that traveled by several of the other 60 doctors who volunteer here, some coming from as far away as Haifa, Tiberias and Zichron Ya’acov. A nurse comes in regularly from Kfar Giladi, near the Lebanese border.
Not surprisingly, as this is one of only two clinics offering free medical services to refugees and asylum seekers, patients come from all over Israel as well, and in numbers that often strain the clinic’s very limited resources. The clinic effectively runs on donations, yet struggles to provide an ever-wider array of services and medical specialties, depending on money and volunteer manpower.
THE FIRST patient enters the examination room. He is 31 years old, from Eritrea. He sits nervously while Ben-Ari and the volunteers scurry around the waiting room, looking for someone who speaks either English or Hebrew and Tigrinya. Such a man, also from Eritrea, is quickly found and pressed into service. He sits next to the patient and begins to interpret.
“He’s got pain in his back and hip,” he tells the doctor.
Belik examines the patient and asks in his quiet voice, “Did he fall? Was he shot? Did he get hit? Did something happen?” “No, nothing happened,” says the interpreter. “It’s from lifting big heavy sacks of maize. The pain is already two months [old].”
“Two months? Before that, there was no problem?” “No, no problem,” says the interpreter. He is also a patient, waiting to see the doctor for a frequent, jagging cough. Belik diagnoses the first patient’s problem as severe osteoarthritis. He says, “In the real world, a patient with this problem would probably have hip replacement surgery. I’ll see if I can arrange an X-ray for him. Also, we do have orthopedic specialists that come here to volunteer. In the meantime, I’ll give him something to relieve the pain.”
Belik crosses the room and opens a tall metal cabinet, filled with different medicines. Not finding what he is looking for, he checks a list of medicines that SuperPharm drugstores provide free of charge with a prescription from this clinic. He writes a prescription for Voltaren, hands it to the patient, and tells him through the interpreter to go downstairs to the SuperPharm on the first floor of the bus station. He also tells him to go back to the reception office to make an appointment with an orthopedist who is scheduled to volunteer here one night next week.
Aside from the orthopedist, the clinic has volunteer specialists in ENT, ophthalmology, urology, gastroenterology, psychiatry, gynecology, pediatrics, dermatology and surgery, as well as a pharmacist.
Lastly, Belik writes up a referral for X-rays and tells us, “When we send someone for a test, the tests cost money. Unless we think they have TB or a sexually transmitted disease, in which case there is a free service, everything else they have to pay for. So we have to think hard about whether we really need to send someone for a test.”
The clinic has an arrangement with the laboratory at Wolfson Medical Center for various tests at 20 percent discount, up to a ceiling of a certain amount per year, but this falls far short of the amount needed. During one of his many high-speed fly-bys, Ben-Ari tells us of his hopes to set up a basic blood lab right here in the clinic this year, pending donations of money and equipment.
The next patient is a woman from Eritrea, somewhere in her 20s. She has a rather nasty-looking open wound on her foot, which she says is from having dropped a glass bottle on it.
She is here with a male companion, possibly her husband, who is doing most of the talking. Volunteer Ben Wallach, 19, brings over a light so Belik can see better. Belik says the woman needs an X-ray and writes up a referral slip for her to bring to the hospital.
A young Eritrean man then comes in complaining of pain in the groin. Belik sends him over to the examination table and has a look. The patient says that he has had the problem for three days.
“He’s got an abscess at the back of the scrotum,” Belik informs us. “He might need surgery.”
He says to the patient, “You’ve got an infection. Do you know what that means?” The patient says that he does.
“Okay, then. We’ll give you some antibiotics. If it’s not better in a week, come back.”
The interpreter explains all this to the patient. The patient gets a prescription for an antibiotic from SuperPharm’s free-of-charge list.
“God bless SuperPharm,” Belik says as the patient thanks him and turns to go.
The next patient is a man in his 30s from Sudan.
“Feeling in my heart no good. And my eyes too,” says the patient, in English.
“Tell me more,” Belik says.
“At night, heart shaking at night.
Feeling like too hot. Sometimes my eyelids shaking. I’m feeling ache up here,” he says, pointing to his forehead.
The doctor asks, “How long have you been in Israel?” “Three months,” the patient replies.
“It must have been difficult for you coming here.”
When the patient says, “Yes, very difficult,” Belik tells us that the problem is likely post-traumatic stress disorder, a common problem among the refugee patients. To the patient, he says, “Coming from Sudan to Israel must have been very hard. That’s why when you go to bed at night you feel your heart shaking, and your eyes shaking, because you had a very difficult time.
You could need to check your eyes. We have a doctor here who will check your eyes. Not now, but here. I will write something. You go back to the office, and they’ll arrange a time for the doctor to check your eyes.”
He goes, and another patient from the Sudan comes in, speaking only Arabic.
In a flash, Belik is out in the waiting room, calling for someone who speaks both Arabic and Hebrew. Another Sudanese comes in, converses with the Arabic speaker, and then explains the problem to the doctor in Hebrew. Based on the symptoms he is hearing, Belik suspects a urinary tract infection and calls for a sample to be analyzed here at the clinic tonight.
“It’s a simple urine test,” he says. “We can get an idea. We can see if there’s a stone or blood in his urine. He’s probably got an infection that we can treat.”
While Belik is arranging the test, we leave the examination room and wander over to the reception office to watch the patients being registered and triaged. We meet a female volunteer who tells us that this is her first night of volunteering at the clinic, and that she does not want to be interviewed.
She does, however, tell us that every patient who visits the clinic for the first time receives a greenBelik suspects a urinary tracte clinic’s name and telephone number, as well as his or her patient file number. We are also informed that some 5,500 patients visit the clinic regularly, of whom 3,482 are males, 1,668 are females and about 350 refugees’ babies and children born in Israel.
At this point, all men, including Ben-Ari the manager, are ordered out of the room so that another female volunteer can deal privately with a female patient.
Leaving the office, we catch sight of a middle-aged Israeli woman darting into what looks like a storage room. We follow and find her unpacking bags and boxes of medicines and arranging them in metal cabinets. She is Yael Polat, a pharmacist who says that she volunteers here “once a week, sometimes more.”
Asked where all of the medicines come from, she replies, “From all kinds of sources. From donations. Some are medicines that people don’t need any more. Some come from doctors, from patients, from medical visitors. Some of the medicines come from people who have died and their medicines are collected and brought here. Some are from organizations like Magen David Adom. Sometimes I don’t know where the medicines come from.”
Do you need more donations, we ask? “Always,” she states simply.We return to the examination room to find the doctor deep in consultation with a young man from Darfur speaking a very rudimentary level of English. Belik tells us, “He’s got something in his leg and needs to do a bone scan. It’s painful. He’s had prior tests. He asks the patient whether he understands what his problem might be. The patient replies that the pain is the result of a fall, but Belik begins to explain to him that he needs to get an operative biopsy to determine whether or not he has cancer.
At this point, volunteer Ben Wallach comes in with the she replies, “From all kinds of sources. From Sudan. Belik tells us, “It might be a stone, but because this is not a definitive test, the guy is getting an antibiotic. It could be an infection, so we’ll treat it as an infection.”
He then returns to the leg pain patient to explain what a biopsy is.his leg and needs to do a bone scan. It’s painful. He’s had prior tests. He asks the patient whether he understands what his problem might be. The patient replies that the pain is the result of a fall, but Belik begins to explain to him that he needs to get an operative biopsy ns and leaves, the urinary infection patient returns. Belik offers him a free antibiotic from the metal cabinet. He also informs him that there is another, somewhat better antibiotic that soothes the infection in addition to curing it, but that one is more expensive and must be purchased by the patient.
The patient then says, “I want that one. I’ll pay. No problem, no problem.”
As the hours tick by, Belik sees a young Eritrean with metal sutures in his head that need to be removed, two Nigerians with bad colds and severe coughs, an Eritrean woman with an itchy rash, a Sudanese with a fever who needs to be tested for malaria, an Eritrean man with an injury from falling off his bicycle, and a 65-year-old Nigerian woman complaining of pain in one eye, among others we may have missed while wandering around the clinic.
Eight o’clock arrives with an almost jarring abruptness, and the clinic begins to close for the night. Belik, in training for a series of marathon runs on behalf of a foundation that deals with eye cancer in children, prepares to run home to Ra’anana. Ben-Ari and the three young volunteers turn off the lights, close the doors and shut the clinic down until it opens again tomorrow, promptly at 4 p.m.