The Patient’s Friends Society, Jerusalem (PFS), is a Palestinian non profit NGO established in 1980 by Palestinian academics and health professionals to promote health care services.¹⁸ The PFS is the only health related NGO that offers, amongst its other public health education and cancer support work, psychosocial support for women with cancer at the end of life. Since the early 1990s the focus of PFS-Jerusalem has been on women’s health and in particular supporting women with breast cancer in the West Bank and Gaza.¹⁹

Located in East Jerusalem at the Augusta Victoria Hospital, PFS offers a range of health education outreach services and literature to promote cancer prevention²⁰; a mammography screening service for early detection of breast cancer and bone density screening for osteoporosis.²¹ An important development since 2000 is the setting up of the ‘ Sunrise’ breast cancer survivors’ support group for Palestinian women. In 2002, women in the Sunrise group set up a Helpline for information and advice, which by 2005 has been shown to be very successful. They have a current membership of 50 cancer patients including survivors.²² There is a ‘Reach for Recovery’ programme, where trained volunteer survivors offer support to ‘breast cancer patients’. PFS also offer low cost wigs and prostheses to breast cancer patients.²³ Director Carol El Jabari explains that PFS can only offer limited support at the end of life: in this situation PFS volunteers will offer psychosocial support and sometimes may be able to help access oncologists to prescribe pain relief.²⁴

PFS is committed to training and professional development and research around cancer and women’s health, organising occasional short seminars for healthcare professionals; and self help workshops teaching first aid, Reiki healing and self care. Since 2002, PFS has regularly attended the conferences of UICC (International Union against Cancer). For example in 2002, PFS participated in a presentation of findings of the ‘Project COPE’²⁵ Israeli/Palestinian study, funded by MECC; ‘Coping with breast cancer among Palestinian and Israeli women’²⁶ at the 18 th conference of the UICC held in Oslo. In 2004, Carol El-Jabari, the director of the Society, presented at the UICC World Conference for Cancer Organisations in Dublin, Ireland with a workshop entitled "Cancer Patient Support Groups in Palestine and Jordan".²⁷ In 2005, PFS Director Carol El Jabari and Amy Avgar of the Israel Association for the Advancement of Women’s Health, sponsored by MECC, published an evaluation of the Project COPE study.²⁸ PFS also distributes a twice yearly newsletter to members, volunteers, and healthcare professionals.²⁹

Augusta Victoria Hospital, located in East Jerusalem, is a charitable hospital managed since 1950 by the Lutheran World Federation.³⁰ Its history and development is described as:

‘Built in 1907 as a pilgrims’ hospice by Kaiser Wilhelm II in honour of his wife the Empress Augusta Victoria, it was converted into a hospital for the British Army during WW2. In 1948, the International Committee of the Red Cross established it as a hospital for displaced Palestinian refugees. In 1950, the United Nations Relief and Works Administration (UNRWA) took over responsibility for Palestinian refugees. Today, 75% of the hospital’s referrals are made by UNRWA. Since 1993, Augusta Victoria has been providing services to the local and greater Palestinian community ... In co-operation with UNRWA, and through an assessment of the needs of West Bank communities, Augusta Victoria Hospital is developing the first radiation oncology centre available in all of the Palestinian territories, as part of the expansion of the hospital’s oncology department.’³¹

The Augusta Victoria is a general (medical and surgical) hospital with 100 beds. Facilities include a renal dialysis unit for children and a government funded oncology department run by the Medical Oncologist, Dr Fouad Sabatin, who treats around 100 cancer patients every year. He describes the current situation:

‘This number [of cancer patients] is supposed to, double or treble very soon because we are going to be the only radiation oncology department in the West Bank, so we are expecting that most, if not all the patients will be referred to us. They will still go to [oncology units in the West Bank] for chemotherapy, it’s just these places don’t have radiation therapy; they have to come to us for that. We have a medical department; we admit patients with medical conditions and oncology conditions to that department, and it’s really variable, so sometimes these beds are 100% occupied by oncology patients and other times 20%, so it’s variable. In the next one or two months [from May 2005], we [will] make a specific requirement for oncology patients.’

Dr Sabatin will provide palliation at the end of life in the hospital. He explains the difficulties of providing palliative support:

‘If they have severe pain we keep them and get their pain under control, but eventually they will be discharged. But one of the problems here that we don’t have hospice care, so there are a lot of patients who are candidates for that kind of care, but it’s not available. So I would say that towards the end of life, what happens is that these people, they tend to come frequently to the hospital because when they go home their pain’s no longer under control and because it’s unfortunate we cannot, 99% of our patients cannot afford to pay for the Fentanyl patches, for example. Sometimes they have side effects from the morphine and in that situation we are stuck. So these people come back into hospital because they don’t have a lot of choices. So that’s the main point - these people, instead of being in a good hospice program, they end up visiting the emergency room frequently.

I’m the only medical oncologist here at the Augusta Victoria Hospital, so it’s natural that I have to take care of, to palliate patients, not only give them chemotherapy but even after that, like during therapy if they have a pain, and after they’ve done the therapy, they can also have pain. Or even if they are not candidates for chemotherapy or aggressive therapies they still need to [have] palliative care. So it’s like [an] important part of my job here to do the palliative care for patients.’³²

There are considerable difficulties of access for staff to get to work at the hospital and for patients to get to services at the hospital if the checkpoints into East Jerusalem are closed. This is particularly serious if they are dialysis patients, as the hospital has the only dialysis centre for children in the West Bank. But access poses a tremendous problem for cancer patients, especially those at the end of life who are not living near an oncology unit:

‘People living in Ramallah are unlucky when it comes to having a diagnosis of cancer because there is no center in Ramallah with the facility to treat these patients; and typically, these patients need to be referred to Beit Jala hospital or to Nablus, and all of them are far away, and there are several checkpoints in between. So getting to the hospital is really difficult, and usually it takes several days for these patients to be sent in the right direction. Now, these patients have a choice to come to Augusta Victoria Hospital, but obviously not all of them will be sent to us because we’re not a government hospital. So most of the patients, I would say, will be sent to Beit Jala or to Nablus Hospital. And if you’re asking about how these patients will do and their management, if they have a pain crisis or something like that, it’s really very tough because, as I said, there is no place in Ramallah that’s really able to treat these patients. They end up being treated by general practitioners at government hospitals until they can be referred to another place. It’s a sad situation.’³³

The Middle East Cancer Consortium (MECC), of which the Palestinian Authority has been a member since 1996, provides support in several different areas; establishing standardised cancer registries in member countries; as well as sponsoring and supporting training and development in cancer registry and cancer services. In February 2004, MECC convened a two day conference in Larnaca, Cyprus, specifically to discuss the concept of palliative care and to initiate assessment of palliative care services and needs in the member countries.