In 2002 I went to Israel and Palestine (the West Bank and Gaza Strip) to learn more about why we read, year after year, of intifada and occupation, of terrorism and the security wall, of checkpoints, closure, and curfews. What is it really like to live in the midst of these daily realities? How does it affect heath care and the work of nurses on either side? Perhaps the best way to illustrate the impact of these conditions is to describe two meetings. (Editor's note: the United Nations refers to the West Bank and Gaza Strip as the Occupied Palestinian Territories. The author of this article prefers to refer to these areas as Palestine.)

FIGURE. No caption available.

As I met with Ora Shamay, MSc, RN, a pain specialist at Sheba Hospital Center in Tel Aviv, her cell phone rang. It was on the bottom of her large tote bag, and she continued talking to me as she searched for it. She'd missed the call by the time she located the phone, but she recognized the number as that of her child's kindergarten. She paled, her breath stopped. After returning the call and finding out it was a routine matter, she explained her reaction, "One can't help but fear the worst. Everywhere there is some gathering or crowd, we are afraid. We don't know when the bomb will come. We start living by the day and not make any far plans for the future. We have a lot of posttraumatic stress disorder. To see the parts of the body, it's horrifying."

A week later, I met with Suzanne Abu Tair, MPH, RN, a senior nurse at the Dheisheh Health Center, at the Dheisheh refugee camp in the West Bank. As we sat in the facility's community center discussing the state of health care, children ran in and out. The room was barren, but the atmosphere was lively. Suddenly, it became quiet. The radio had announced the news: curfew was being reimposed unexpectedly. Our conversation immediately came to an end as Abu Tair gathered up her coat, notebook, and pocketbook. She was clearly rattled as she rushed outside, apologizing, saying that she had to get home to her children before "the curfew shuts down all transportation."

As part of a fact-finding tour I organized, I had arranged to meet these women (with the help of the Israeli Pain Society, the National Association of Nurses in Israel, and the Middle East Children's Alliance). What I found on that visit-and again when I returned in 2004-is that nurses in the region have many of the same problems American nurses have: disparate educational levels, struggles for professional recognition and workplace representation. The nurses I met came into the profession for diverse reasons and are working in a remarkable variety of settings, carrying on in the face of political, professional, economic, military, and personal difficulties. Yet I was amazed at the things these nurses have in common with each other-and with us. As I listened to them describe their motivations and aspirations and watched them work, the seemingly impenetrable barrier created by the ongoing military and political conflict melted away.

FIGURE. Perhaps nothing symbolizes the state of Israeli-Palestinian relations better than the "security fence," a barrier that Israel is erecting around the West Bank. Begun in June 2002 to deter attacks on Israeli civilians and property, the completed barrier will be 622 kilometers long, running from Jenin in the north to Hebron in the south, and cost an estimated $3.4 billion. The complex of trenches, motes, electric fences, perimeter roads, razor wire, and concrete walls-some as tall as 9 m-is the largest and most expensive construction project in Israel's history.Approximately 15% of the planned barrier route follows the "Green Line," the border between Israel and the West Bank that was created in 1949; the rest of the barrier runs through Palestinian territory and cuts off approximately 157,800 acres (11.5%) of West Bank agricultural land. More than 93,000 Palestinians live in 63 villages and towns in this area. Of these, more than 16,000 live in closed areas between the Green Line and the barrier; approximately 77,000 live in 11 separate enclaves that are totally surrounded by the barrier. Many others living further to the east will also be cut off from their fields, pastures, workplaces, as well as their schools, health care facilities, and public services. Approximately 140,000 Israeli settlers, more than 60% of the West Bank settler population, also live between the Green Line and the barrier.

I was very lucky to meet these two women, one Israeli, one Palestinian, during my travels.

FIGURE. Ora Shamay at work in the Chaim Sheba Medical Center in Tel Aviv, Israel, the largest hospital in the Middle East. "It's very hard to treat [victims of suicide bombings]," she says, recalling one blast that killed a mother and three children. "They left only a wounded father and one of the kids. How do you rehabilitate this part of the family?"

ORA SHAMAY: ISRAEL

"I wanted to be a nurse since kindergarten," says Ora Shamay. "I'm hooked."

Shamay has worked at the Chaim Sheba Medical Center, the largest hospital in the Middle East with 1,100 beds, for nine years. She established the clinic for chronic pain at the facility. "At the same time I started the acute pain service in the medical center, and for the last five years I have been giving consultation in pain management."

Like all women in Israel, Shamay was required to serve two years in the Israeli Defense Forces (IDF) when she reached 18 years old. (Men serve three years.) "I went into the army as a nurse, working as a guide, teaching paramedics, and working in the army clinic on a big army base. I didn't want to serve in a hospital; I wanted to experience something else."

Shamay is a board member of the Israel Pain Association and chairwoman of the Nurse Special Interest Group. "As a pain practitioner and coordinator nurse, I gathered all the pain nurses into a forum," she explains. "Pain is important for them." She started with 120 nurses, and within four years there were more than 800 involved. She is also working on a project with the International Association for the Study of Pain to put together a program for 33 countries in Europe. However, she explains, it would not be possible for nurses from the West Bank or Gaza to participate in these programs. The border is closed to them.

FIGURE. "I'm no better than people who were already shot and killed, innocent people," says Suzanne Abu Tair. "After so many long periods of curfews and hearing the news of many people being shot and killed, I'm so frustrated because you're not able to do anything to change it."

In Israel, nursing organizations operate easily. When nurses receive their licenses, they automatically join the Histadrut, the Israeli national labor union, which oversees the National Association of Nurses. Professional standards are set by the Ministry of Health.

However, staffing is a problem (each institution sets its own standards). "Everything is restricted by the budget," Shamay says. "We don't have a problem recruiting people to go into nursing, but we have a problem of retention. It's a funding issue, a decision of the minister of health. Canada and the United States are recruiting nurses from Israel. They prefer them because they are well trained."

"[Staffing] became an issue because of the situation here; it's another reason to go abroad."

SUZANNE ABU TAIR: PALESTINE

"I love working with the community," says Suzanne Abu Tair. "It's a part of my personality to provide people with all the information they need and at the same time to learn from them, from their experiences."

In 2004 she earned a master of public health degree at Al Quds University. Abu Tair has formed partnerships with other public health professionals to open a nongovernmental organization to educate women on health care issues. (This is in addition to her responsibilities at the Dheisheh Health Center.) "The name of the organization is Da'a'em, " she says. "It means 'continuous, never stopping,' in Arabic." A grant from the United Nations Development Program has enabled the group to create an income-generating program for 30 women. "Each woman has her own project: raising goats; running a small sundries shop, a bakery, a tailor shop. Meanwhile, we had the chance to meet these women in our center and to discuss health-related issues."

Yet the frustrations of nursing can be extreme. A trained emergency responder, Abu Tair described the trauma of not being able to get to the wounded during the Israeli incursion in 2002, which took place very close to her home in Bethlehem. "If I moved [from my house]," she said, "I would be shot [by the IDF]. The dreadful part is I couldn't treat; I had to leave two people who were injured. They bled until they died. We say the oath and feel some kind of commitment. Even if one of the Israeli soldiers would be wounded, you can provide help. It's something human."

FIGURE. Jerusalem's Old City. In June Israeli Prime Minister Ariel Sharon announced a $60 million plan to revive Jerusalem. According to the June 20 issue of

Nor is professional development easy. "In 1994 elections were held to have a nursing union. We are all nurses from different districts: Hebron, Bethlehem, Nablus, Ramallah. So this union didn't work well [because] the majority of nurses were not able to attend the elections." Checkpoints and security zones are a major problem. "It's too difficult to get together to discuss professional issues," she says.

Nonetheless, nurses work together to do their best while living under occupation. "During the curfew, nurses with children take the morning duty so they can go back to their children. The ones who don't have children will stay the evening and night shifts." Because getting to and from work puts health care professionals in danger, transportation to and from home is provided, whenever possible, in public health department ambulances.

DEMONSTRATING COURAGE

When I met Shamay in Tel Aviv, I felt I could be in any European country. Travel, commerce, shopping, health care, and education are maintained in spite of the "situation." In contrast, when I met Abu Tair I had entered a country under occupation, where the "denial of access to routine health care . . . and the destruction of infrastructure necessary for the provision of food, water, and electricity," are clearly evident. 1 Yet the two are bound together by geography, history, and the current political situation. Their courage in the face of adversity is a beacon: they are truly nurse exemplars.

Nearly a decade ago, the ANA promoted Nurses Week with the motto, "Nurses Have the Courage to Care." Those Palestinians who continue to provide health care under the most adverse conditions are surely demonstrating such courage-as are Israeli health care professionals who don't allow terrorism to prevent them from working (sometimes even across the barrier). American nurses must find the courage to help end the violence.

Resources

For timelines of events in the region, go tohttp://www.guardian.co.uk/israel/page/0,12575,1122113,00.html

For more information, go to

U.S. Department of State: Middle East Peace http://www.state.gov/p/nea/rt/c2829.htm

Israel Ministry of Foreign Affairs http://www.mfa.gov.il/mfa

Palestinian National Authority http://www.pna.gov.ps

To learn more about what you can do to help, go to

Physicians for Human Rights-Israel http://www.phr.org.il/phr

The Union of Health Work Committees http://www.gaza-health.org/english/index.php

The Union of Palestinian Medical Relief Committees http://www.upmrc.org

Middle East Children's Alliance http://www.mecaforpeace.org

REFERENCE