Collateral damage

There’s still one place uniting Israelis and Palestinians: cancer’s waiting room

July 24, 2014
July 24, 2014

TEL AVIV– The escalated Israeli-Palestinian conflict has entered its third week. Most often, coverage in the news has begun with updated casualty counts for each side or comparisons of rocket-launch numbers. Increasingly, however, the media seem concerned about tensions spilling over to venues previously deemed immune to ideological dissension. As an oncologist, I worry about safety in the waiting rooms of our hospital’s cancer treatment wards.

Waiting rooms, traditionally considered part of the backstory of the cancer experience, have begun to capture attention. After prostate cancer diagnosis in 2008, New York Times reporter Dana Jennings observed that there is a “muted sense of camaraderie” among diverse individuals in oncology waiting areas. Jennings reports that, in the American medical centers where he sat, anticipating his daily radiation treatment, “…no one spoke in a normal conversational voice except the employees.” In a blog post, Jennings sums up his opinion on waiting areas as, “the rowdier the better.”

Jennings might be encouraged to learn that, on most days in the Tel Aviv hospital where I practice, the camaraderie is by no means muted. Instead, our waiting areas tend to be what one of my patients has described as an “unvarnished blend of the boisterous, colorful middle-Eastern marketplace punctuated by a touchy-feely campfire setting.” Her meaning, I think, is that, in our waiting areas, polarized opposites—religious/secular, rich/poor, Ashkenazic/Sephardic, Arab/Jew, etc.—frequently find walls dissolving amid heated morning debates about channel settings for the big plasma TV, well-intentioned lunchtime disagreements about unconventional therapies, and afternoons culminating in warm-and-fuzzy multi-ethnic group singing sessions.

Still, in the midst of what Israeli officials label “Operation Protective Edge” and some Palestinian leaders call the “Third Intifada,” there is a mood swing in our waiting room. In a frequently quoted JAMA piece entitled “War and Children,” Professor Isaiah Wexler, a pediatrician at Hadassah University Hospital, points out that, during wartime, social inhibitions and cultural norms that characteristically bind societies tend to breakdown. In corroboration, the forces that, only a month ago, served to unify our waiting-room populations stand challenged now by metaphorical stress tests of missiles in flight over metropolitan Tel Aviv, as patients–Arab and Jew alike—scurry to reach bomb shelters within the 90 seconds of alleged safety following each new warning siren.

In peaceful times, our hospital held an exclusive contract to provide oncological services for the Palestinian Authority. But even with few Palestinian patients today, Israeli Arabs arrive from the adjacent town of Jaffa and remote northern villages lacking tertiary medical facilities necessary for delivery of sophisticated cancer treatments. As our Arab patients and their Jewish counterparts huddle together in protective shelters within and near our hospital, formerly supportive banter is replaced by uncomfortable reticence.

Their discomfort reminds me, an American expat, of the tensions I felt nearly two decades ago as a young physician practicing in the racially-charged city of Philadelphia. There, waiting-room denizens held their breaths as broadcasters in Los Angeles announced the verdict in O.J. Simpson’s murder trial. Here and now in Israel, the jury is still out as to whether we will be able to shed the troubling status of mutual pretense among Arab and Jewish patients who feign attitudes of business as usual. In reality, previously empathetic efforts to buoy fellow cancer patients fail while authentic thoughts and feelings are no longer exchanged or even exposed.

As a cancer doctor, I know that many deaths do not show up in the daily “box score.” I know also that, with recent fighting, numbers of no-shows have dramatically risen. Summer vacations aren’t to blame. Patients defer vacations to undergo life-prolonging treatment. Likewise, attendance hasn’t declined because of Ramadan observance. Last year also, the month-long Islamic fast occurred in July without reduction in our waiting-room populations. So I have to wonder: are some afraid to leave home with mortar shells flying? Or, are patients no longer drawn to wait without the company of warm hugs? Whatever the problem, oncologic consequences are certain to be grave. Delaying or prolonging cancer treatment is known to compromise survival for a variety of tumor types. Treatment “time outs” allow malignant cells opportunity to fortify themselves, often with fatal outcomes for cancer patients.

A colleague mentioned to me that her mother had died of an analogous type of secondary wartime consequence, a phenomenon known now in her family as “collateral damage.” At the start of 1942, just after Pearl Harbor had been bombed, Americans were scrambling to prepare for war at home while soldiers shipped out to fight in foreign territory. President Roosevelt instituted a rationing program requiring coupons for purchase of items ranging from meat and butter to typewriters and gasoline. Scarce medicines—including the recently discovered penicillin—were sent overseas to aid troops, leaving civilian hospitals with inadequate supplies.

After my colleague’s mother had come down with pneumonia, her local clinic’s triage panel declined to release antibiotic. They allowed the 38-year-old woman to die of a curable infection. A Google search doesn’t reveal how many people met with similar fate, but with frustration, I know that today, around our hospital, the same category of gratuitous death hovers.

In general, physicians have been mindful of maintaining a heightened level of professionalism that is not influenced by political leanings during the current war. At my hospital, a memo in fancy Hebrew reinforces the simple fact that people are people and must be cared for accordingly. Down the road in Ramat Gan, deputy director of the Sheba Medical Center, Professor Rafi Walden—also the leader of the local Physicians for Human Rights chapter, as well as son-in-law of Shimon Peres—states that his hospital admitted 50 Gazan patients yesterday and will continue to admit Gazans even if there is no reimbursement from the PA.

Although, by classic definition, oncology waiting rooms may not qualify as war-zone frontiers, behavior may say otherwise. Grounded in tenets of professionalism, doctors, so far, continue their medical ministries. However, one of the many tragedies of the current conflict is that patients have surrendered their boundless capacity to identify with the narratives of the neighbors they once loved.

We welcome your comments at ideas@qz.com.

 

 

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