More than Miracles Needed:Breast Cancer Among Palestinian Women
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If you are a Palestinian woman with breast cancer, your chances of survival are poor. Breast cancer is the second most common cause of death among Palestinian women, even though the prevalence rate is much lower among Arab women than Western women. And the number is dramatically on the rise. Conservative estimates suggest seven out of ten Palestinian women with breast cancer will die.
The Palestinian Health Ministry reports that 60% of women diagnosed with breast cancer in the Gaza Strip were diagnosed after the disease had already spread to other parts of the body: 42.2% showed that cancer had spread to the lymph nodes at the time of diagnosis and in 17% of cases the cancer had reached other areas of the body.
The reasons for the low survival rates are difficult and complex. In Palestine, availability of mammography units is very low. In the Gaza Strip, for example, only three mammography units serve a population of around 1,300,000 people; two of these are in private centers. Private mammography costs as much as $30 for a test—a huge amount for the average Palestinian woman. One could say confidently that in general, a Palestinian woman does not have a mammography unless she already has a suspicious lump. [End Page 33]
In addition, a woman's motivation to be diagnosed is tremendously affected by the question of what can be done if she finds out something is wrong. This question—what treatments will be available—affects the success of any awareness and prevention program.
So indeed, what happens to a Palestinian woman when she finds out something is wrong? All Palestinian patients who need radiation therapy must get it in Egypt, Jordan or Israel: radiation therapy does not exist in the Occupied Territories. This is mainly due to Israel's objection to the import of radioactive materials into the area, but also to the lack of expertise in handling such equipment. This dependency on services provided outside of the Palestinian health system makes patients extremely vulnerable. Israel's policy of closure, and its total control over the Occupied Palestinian Territories, severely restricts women's ability to receive regular and prompt treatment after diagnosis.
The fact is, if you are a Palestinian being treated in Israel, you need a miracle to be able to complete a cycle of chemotherapy or radiotherapy. If you are from Gaza, even miracles may not be enough. The Israeli closure regime does not take into consideration its effects on the life and death of patients.
Being a woman does not necessarily make things easier. Following an attempted suicide attack by a young woman, Israeli authorities banned entry from Gaza to Israel to all women under thirty. This sweeping approach leaves little room for attention to the plight of individuals. So, if you are a mother accompanying your child to treatment, you are sent to find a substitute, and if you are a patient in the middle of treatment, you are asked to try again when the security situation is better.
Besides exposure to violence and infringement of basic human rights as part of an occupied society, women carry the burden of running a house and taking care of the children in a society under economic crisis. In the harshest circumstances, they give birth at checkpoints and are exposed to physical and verbal abuse. When they are members of a strictly religious society, their situation may be even harder. It is much more difficult to get an education, to postpone the age of marriage (or to choose not to marry), or to have control over the number of children, if any, they want to have.
In both Israeli and Palestinian societies, women's health issues not directly related to reproduction are given lower priority. Plans to increase the use of mammography in Israel— a country in which one in eight women will get breast cancer—have met with objection, often from women. This is partly due to the fact that women experience the test as humiliating and painful. There are hardly any educational programs amongst teenagers, and although it is a fatal disease, the national health insurance service providers have developed no clear response to the demand for a coherent policy for early detection. On the higher level of policy making, if one examines the Israeli health budget from a gender perspective, there are enormous gaps between women's needs and the funds allocated to this area.2
By contrast, both Israeli and Palestinian societies devote extensive efforts and funds to another aspect of women's health: reproduction. Israel's first prime minister and the first [End Page 34] Palestinian president had one thing in common. Both David Ben Gurion and Yasser Arafat agreed: the main weapon in the armed conflict is not bullets or bombs, but a secret one—the womb. Accordingly, both Israeli and Palestinian societies invest resources into making "their" women as fertile as possible, thus producing the next generation of soldiers.
Demography is a routine subject of discussion in Israel, among policy makers and the general public. The number of Jews and Palestinians—both in the Occupied Territories and in Israel—are constantly compared. In this sense, the Palestinian woman is the "enemy" for the Israelis and an "asset" for her own people.
Most of the international NGO's and humanitarian bodies active in Palestine, and there are many, fall into what could be called the "children trap." They put the majority of their women's health efforts and funds into pre-natal care, children's health, mother and child clinics, etc. A woman is in focus when trying to get pregnant, give birth or raise children. There is a tendency to neglect women as whole, separate human beings. In this sense, the attempt to recruit the woman's womb to the struggle stays unchallenged.
In parallel, efforts are made to turn Israeli women into the same type of "asset." Physicians for Human Rights-Israel (PHR-I)3 recently petitioned the High Court of Justice, asking that the State of Israel be obliged to pay for contraceptives such as pills. Today, most women in need of contraceptives have to pay the full cost from their own pockets.
At the same time, according to data presented by the Ministry of Finance at a meeting held in the Knesset, Israel is a fertilization superpower. For each million citizens, 3,400 IVFs (In Vitro Fertilization) are performed each year. This is almost four times more than in France and eleven times more than in England. In Palestinian society, financial means are more modest, but the intention is the same. In the Occupied Territories, the number of IVF centers grows steadily; there are presently two centers in the Gaza Strip and three in the West Bank. The Palestinian Authority pays for more than half of the treatments and the numbers during the intifada have risen.
In a publication prepared by the official Palestinian press center, an article describes how some prisoners' wives overcame the problem of getting pregnant while their husbands are jailed in Israel. This was done by having their eggs fertilized by their husbands' pre-stored sperm. One woman was quoted as saying, "My husband was over the moon when he knew that I underwent the operation. He and the prison inmates yelled loudly and jubilantly Allahu Akbar (God is Great)."4
The child that she bore was not only her husbands and hers: it belonged to the whole jail—a victory over Occupation. In that sense, her womb was nationalized to serve as a political tool. This example is not unique to Palestinian society. In Israel, a storm of protest met a recent proposal to limit the numbers of IVF cycles when a woman is attempting to become pregnant with her second child. In a debate in the Knesset on the issue, one female Knesset member claimed that two parents and one child could not be considered a family! [End Page 35] In the same debate, the chairperson of the Health Committee, MK Shaul Yahalom, bluntly expressed his dismay of the idea of limiting the numbers of IVF cycles for the second child, commenting openly that these babies will grow up to be soldiers.
It is not simple to have a critical point of view over the status of Palestinian women when you are a part of the occupying society. However, in PHR-I we believe we must address the reality where women of both societies are affected by the conflict. They are the victims not only of the violence inflicted by the outside enemy, but also of their own society, which remains dominated by a militaristic, patriarchal discourse.
In a situation of occupation, is there a chance for a change? In PHR-I we have some hope that joint work with our Palestinian partners, addressing the political as well as the professional health aspects, will create at least a motivation for change.
We recently started a pilot program, together with our Palestinian partners, the PMRS, more commonly known as the Medical Relief Committees.5 As part of this program, we hold a series of medical days for women only. The first joint clinic was held in Sebastia, a village in the Nablus vicinity. Israeli and Palestinian women doctors saw about 80 Palestinian women.
The goal of such medical days is to provide a safe and private setting in which women can receive medical services from a holistic approach that relates to body and soul. The outcome of the first day we held was striking. The Israeli medical team included three psychiatrists, two oncologists—one of them a breast oncologist—a chiropractor, three nurses and two gynecologists—one Israeli and one Palestinian. The medical day was organized in a clinic that belongs to the Medical Relief Committees, which is operated by a Palestinian woman gynecologist. The medical team was specifically made of women doctors so that the patients would feel as comfortable as possible to be examined.
The vast majority of women came with the intention of seeing gynecologists. The two participating doctors later described the nature of medical issues that arose: the majority of the women were seeking advice solely in regards to reproductive problems. Most problems were related either to getting pregnant or to maintaining a pregnancy. Some of these women came with their husbands. Nine women were seen by the psychiatrist. Most of them asked for consultation in regards to problems with their children, often related to behavioral problems. Only one of them asked for advice regarding herself.
The chiropractor examined about ten women, all of whom suffered from knee and other joint pain. These problems are largely related to their size, a result of a diet rich in carbohydrates due to poverty and to numerous pregnancies. The average Palestinian woman gives birth to six children.
Only a small number of women sought the breast examination that was being offered. This was the first experience for almost all of the participating women in undergoing such an examination. The only exception was that of one woman who has had treatment for a pre-existing condition. None of the women had ever had a mammography. All in all, twenty-four women had breast examinations by the two oncologists. The doctors later reported that most of the women had heard about "breast cancer," and some were aware of the fact that there are tests to detect the disease. However, they showed little faith in the tests.
Fear of breast cancer was a shared feeling [End Page 36] by most of the women we saw that day. Though a third of the women who attended the medical day did take the breast examination, some of them had to be "encouraged" by the medical team to do so, especially the elderly women. One such woman told me she is not in need of such a test, because she has already been through menopause. After she was examined by the doctor and was told that everything was fine, she breathed a sigh of relief and told us of a neighbor who had passed away due to breast cancer. This story demonstrates that women know of the disease and fear it deeply—so much so they avoid being tested. Indeed when discussing it with the doctors, some of the women expressed great fear of the disease and most felt that this is a condition from which one usually dies.
One of the conclusions from this medical day was the need for some kind of screening for breast cancer that is not currently available, and just how great this need is. PHR-I is currently planning a series of medical days for the next few months, thanks to a gracious donation by an Israeli feminist Jewish woman. In these upcoming clinics, we intend to tackle the intense fear and lack of information about breast cancer.
However, more important than raising awareness of breast cancer, the existing medical procedure of diagnosis and treatment in the Palestinian Territories must be radically improved. If Palestinian women could trust that one might survive breast cancer, they might be encouraged to be regularly tested. Only by improving the two factors necessary for raising survival rates, diagnosis and treatment, will women see that survival is possible.
Maskit Bendel is the director of projects in the Occupied Territories for Physicians for Human Rights-Israel. She was born and raised in Jerusalem, and currently lives in Tel Aviv. She writes, "my father was a military man, and I grew up in a very Zionist family. I served in the Israel Defense Force and took the course of living of the average Israeli youth. My awareness to issues of gender and inequality rose at a very late stage in my life, while working for PHR. Through learning more about the Palestinian society, I opened my eyes to what is taking place inside my own society." Bendel has a degree in textile design and is completing a master's degree in cultural research at Tel Aviv university. She is also studying for a degree in law, intending to focus on human rights and international law.
1. Data taken from the Palestinian Authority, 2004.
3. PHR-Israel is a non-profit, non-partisan organization founded by Israeli and Palestinian physicians, with a view to protecting health and human rights of any and all individuals residing in Israel or in the territories under its control.
Their work is divided into five major projects revolving around five major populations: 1/ Palestinians in the Occupied Territories; 2/ Prisoners and Detainees; 3/ the Migrant Worker Community; 4/ Bedouin of Unrecognized Villages in the Negev; 5/ Residents and Citizens of Israel. The organization works on two distinct levels of action: it provides direct medical aid (given in the form of volunteer care and free medications) to people excluded from adequate care, and also works, in parallel, for long-term change in Israeli policies and norms by means of advocacy for individuals and for groups, legal action, public outreach and education, campaigning and lobbying. Over its 18 years of practice, PHR-Israel has effected some far-reaching [End Page 37] changes in Israeli society, both on the public and the legislative levels. You can learn more by visiting www.phr.org.il.
4. "Palestinians Defy Detention, Have Children." International Press Center. August 03, 2003.
5. The Union of Palestinian Medical Relief Committees is a grassroots, community-based Palestinian health organization. PMRC was founded in 1979 by a group of Palestinian doctors and health professionals seeking to supplement the decayed and inadequate health infrastructure caused by years of Israeli military occupation. It is non-profit, voluntary, and one of the largest health NGOs in Palestine. Find out more at www.upmrc.org. [End Page 38]