By Maya de Vries and Laila Abed Rabho

Person typing on a hospital computer next to a stethoscope. Source: Unsplash

In the meetings that we held with women in Dar al-Hawa, we found that most of them were suffering from various health problems, the most common ones being high blood stress, diabetes, back, and leg pain. When going to one of the local public health clinics in Dar al-Hawa, clinics that are managed by local Palestinians as well as subsidised by the Israeli Ministry of Health, they are likely to get good quality treatment both in terms of their health problem as well as in terms of their own understanding of the process, as these clinics operate in Arabic.

However, the situation is much less convenient when they are required to visit one of the Israeli hospitals in Jerusalem to receive treatment – not because they will not be seen for their health problem or accepted as patients, but rather, in their own words, will not be able to understand large parts of what is being said to them by doctors, nurses and other staff. Sitting in a doctor’s office or treatment room is a stressful situation can be a stressful situation regardless of the health issue that is being investigated. When the issue of a language barrier between the patient and healthcare staff is added to the equation, the patient(s), in this case, older Palestinian women, can be made to feel even more uncomfortable as he/she is required to seek help with translation.

Hospitals are highly stressful places where many types of individuals (whether patients or staff) belonging to a variety of social groups intersect on a daily basis. These meetings can constitute points of friction or moments of acquaintance between groups of people who may ordinarily be fairly indifferent to each other. In al-Quds, Israeli hospitals, this tension between Jews and Arabs has existed for many years, as we found out from some of the women we spoke to in Dar al-Hawa. One expression of this tension is the absence of the Arabic language from the hospital space.

This situation makes the women of Dar al-Hawa more dependent, as patients, than they already are: presently, most of them have to rely on either their husband, their children, or their grandchildren to accompany them to the hospital, or on a translator provided by the hospital – usually, there is only one on the ward. There is also the possibility that an Arabic-speaking doctor or a nurse may be around to facilitate translation, but this is not certain. What does make the experience a bit easier is the fact that all signs at the hospital are usually written in Hebrew, English, and Arabic. However, our participants told us that this is not going far enough – something that even the women in our group who do speak Hebrew agree with.

Dina, 58, remembers her period of hospitalisation:

“I stayed in the hospital for some time, they used to give lectures in Hebrew, I hope they bring doctors that give lectures in Arabic, because there were Arab patients who had had an open heart surgery but did not show up to the lectures because they didn’t understand Hebrew, many Arabs don’t understand Hebrew, or they do, but not to the extent that that they are able to answer the nurses.”

Sireen, 42, adds that other than the language barrier, she does not have any complaints about the hospital:

”I usually don’t go to hospitals; I used to go the hospital just to give birth. Honestly, during the period that I was in hospital, I felt that the staff and the service in the hospital was very good, I didn’t face any problems except for the language.”

On the other hand, Nasreen, who is 76 and speaks good Hebrew, recalls seeing people her age struggling whilst in hospital:

“I understand, read and write Hebrew. Other people who come to the hospital and do not know Hebrew bring people with them to help them and translate for them, it’s hard that they don’t give information in Arabic.”

Mona, a 60-year-old research participant, described the language problem in a more nuanced way, stating:

“Since we are treated at Israeli hospitals and the language that is used is Hebrew, sometimes I can’t communicate with them [doctors] or understand what they are saying, if there is someone that can translate that can help…or if the information is written in Arabic, all the medication package inserts are written both in Arabic and Hebrew, but in the hospitals, not everything is written in Arabic.”

Taking into account the stories told to us by our participants, we think that the language gap points to a more fundamental, less spoken-about problem: that of racism. Even though the issue of racism is familiar to the Ministry of Health and there is an official protocol that aims to reduce racism against patients and healthcare staff within the hospital[i], the women we spoke to think this is still an issue. Rabab, 63, says:

“I want them to treat me like any other person, I don’t want them to underestimate me, we are exposed to racism in the Israeli hospitals. For me, Hebrew is an obstacle, when I visit the doctor, I take my sisters or my children with me so they can translate. I would prefer if everything will be in Arabic. Once, my husband felt pain in his eyes so we went to Shaare Zedek medical center, I heard the doctors speak, they said that there is no ‘use’ to his eyes , so I told him in Hebrew that I didn’t understand what he meant, he answered <<you don’t live in Iraq, you live in Israel, so you must learn Hebrew>>. I wrote a complaint and sent it to the hospital.”

Reem, a 50-year-old participant, talks about her experience in a maternity department in an Israeli hospital:

“We saw there were volunteers who came to help Jewish women and teach them how to breastfeed. We did not see anyone who spoke Arabic. There is a shortage of volunteers who do such work for Arabs, and even the Arabic language was not spoken. Only Hebrew.”

To conclude, our interviewees point to the importance of the language as an important parameter that should be taken into consideration in healthcare settings and when considering the quality of care, especially in al-Quds, where the public health system is fairly well-developed due to being part of the national Israeli health system. Treatment can and should be better when it comes to not just the medical treatment itself, but also the details of patients’ symptoms and the diagnosis. In order to get a comprehensive and accurate picture of a patient’s medical problem and decide on the best course of action in terms of care, it is very important to understand ‘the little details’, and for that to happen, understanding the spoken language of health at the point of care is a must.

Below, we show two examples of the home pages of two relevant, major hospitals in al-Quds, Hadassah Hospital and Sharee Zedek Hospital. Although both are available in Arabic, Hadassah’s home page only allows the user to select a different language if the user already speaks English – the different options for languages are written in English letters: ‘EN’, ‘AR’, ‘RU’. Sharee Zedek displays the different language options in the ‘mother tongue’ itself.

Pic 1: home page of Hadassah hospital. On the right side, visitors can choose between English, Hebrew, Arabic, or Russian – but the language menu itself is in English (written in English characters).

The home page of Sharee Zedek hospital: on the right-hand side, website visitors can choose their choose language, with the choices being English, Russian or Arabic. Although written in a small font size, the choices are given in the mother tongue itself (I.e. using the Arabic alphabet), which makes it more accessible to non-Hebrew readers.

[i] see for example this page published in the website of the MOH: https://www.health.gov.il/English/Topics/Equality_in_Health/racism/Pages/default.aspx) See also an important article about separation in maternity departments: https://www.haaretz.com/israel-news/.premium-though-illegal-jewish-arab-segregation-plagues-israel-s-hospitals-1.6725140

Fig 1: Screen showing Covid-19 prevention messages in a UN office in Ouagadougou. Photo credit: Charles Somé.

A few days ago, I came across a rather unusual document. It is a compilation of different technologies put together by the European Investment Bank, entitled Covid-19: Africa’s digital solutions[1]. It was published last year, with the support of the United Nations Development Programme (UNDP), and it sets out to identify the digital solutions currently on offer in the response to Covid in Africa. Several things strike me as I read this document: firstly, the breadth of these initiatives seems to reflect a faith in the ability of technology to respond to the health crisis. The inventory reports that about 100 digital solutions have already been ‘implemented’ or tested as of 20 June 2020. It also gives an estimate of the investment needed to implement such ‘high-impact’ solutions.

Then, there are different types of tools being promoted in different countries. There are collaborative tools such as Zoom and Skype, which have multiplied greatly, and use messaging apps such WhatsApp in professional contexts such as education, has also gone up. Traditional media, such as television, for example, has remained important due its ability to reach a great number of people during the crisis. Innovations also include tracking applications based on geographic information technology for epidemic surveillance purposes. On page 15 of the document, contact tracing apps are described as follows: “These applications, which often use geolocation data from telecommunications companies, help to identify contacts of people who have tested positive and help to locate areas where the virus is spreading.” We learn that applications have been developed and put to use in Kenya, Morocco and Rwanda among other countries. FabLab, an innovation hub in Kenya, has developed an application called Msafari, which can track public transport users.

Other digital tools have been used for mass communication and self-assessment of risks and symptoms. In Sierra Leone, for example, an existing public platform using unstructured supplementary service data (USSD) has been expanded to allow citizens to self-assess their symptoms and get alerts on developments on the COVID-19 front in the country.

The use of drones has also been experimented with to deliver pharmaceutical products or to transport PCR tests from remote areas to laboratories in big cities like Abidjan in Côte d’Ivoire or Kigali in Rwanda.

But are all these innovations and techno-digital solutions going to make a difference in the medium or long term? Firstly, let us recall that there is a gap between the international presence and publicity around various technological innovations, some of which can even be award-winning, and what actually happens on the ground.  Throughout our 18 months of fieldwork in Yaoundé for the ASSA project, we noted this significant gap, which says something about the difficulty of digital applications and solutions when it comes to capturing the attention of users.

The profile of a young Snapchat user in Cameroon. The screen shows various COVID-19 messages superimposed onto a photo of the user. Photo sent to the author by research participant.

In most of these countries, although tracking applications were received with curiosity, they nevertheless worried public opinion because they raised problems of data use and privacy. Not only are they worrying, but they are not always seen as appropriate solutions for the local context. Interfaces such as the one in the picture above, where COVID-19 related messages fit into the user interface seamlessly, work well in the context because they fit into the social media landscape. Young people want to show concern about the virus and they might adopt features of a social media network that support COVID-19 messaging for a few hours occasionally during the outbreak. But for that, they also need to be reminded by other channels of support and communication that the crisis is still there. The resonance of this issue is strongly linked to the strategic orientations of African countries in terms of their politics, economic situation and sensitivity to innovations.

Another part of the current debate concerns the mistrust of not only technological solutions but also of vaccines against COVID-19. For example, medical anthropologist Alice Desclaux and a team of French researchers [2], who undertook an exploratory study among 215 people in four African countries this year, found that 2 out of 3 participants said they would refuse to be vaccinated against Covid-19. They say: “reasons for refusal included firstly fear of any side effects hidden by the pharmaceutical companies, and secondly the perception of the vaccine as a tool in a plot by Bill Gates to reduce the African population or by a coalition of the powerful (states, global institutions) to enslave populations and ensure a “new world order” using corrupt authorities in African countries (“coronabusiness”). The study also found there was a preference for endogenous solutions to control SARS-CoV2, such as traditional medicine or the protection provided by religion.” There is therefore an urgent need to study more seriously the sources of the constant doubt surrounding the surveillance of epidemics, which are reflected and accentuated at pivotal moments such as Ebola or recently, Covid-19.

The central hypothesis of this is that the operational responses of nation-states are aligned with a policy of systematically using surveillance (biometric) and the tracing of infected persons (mHealth) as the preferred institutional response to emerging epidemics. However, this response has underestimated the capacity for the circulation of alternative interpretations of epidemics favoured by an abundance of content conveyed via social networks and smartphones. The direct access of the public to this content reinforces a widespread suspicion of local governments that are seen as corrupt and that accept servile compromises with the leaders of large pharmaceutical groups to the detriment of ‘African solutions’. Therefore the solution for helping people accept technological and digital solutionism to the crisis is not just to blame them for pharmaceutical nationalism, or their non-openness to innovations, but rather like anthropology and the ASSA team’s approach, making an effort to understand and carefully analyse not only people’s perceptions of the vaccine and the Covid outbreak, but also the intertwining of the logics behind them.

References

[1] European Investment Bank (EIB): Africa’s digital solutions to tackle COVID-19, found at: https://www.eib.org/en/publications/african-digital-best-practice-to-tackle-covid-19

[2] Desclaux A, 2021, « Covid-19: En Afrique de l’Ouest, le vaccin n’est pas le nouveau « magic bullet », available at: https://vih.org/20210202/la-mondialisation-des-informations-et-la-fabrique-des-opinions-sur-les-traitements-du-covid-en-afrique/