Ever since he was 18, when Omar Danoun started med school, they’ve called him “doctor.” Friends and family, cousins and neighbors — everyone in Rantis, the West Bank village he’s lived in his whole life. It’s a close-knit population of around 3,000, belonging to six clans and spread over a little more than 100 acres of arid, rocky hillside, dotted with olive trees that cut hard shadows in the ochre earth. The carved-stone ruins of Roman wells and cisterns abound, traces of a centuries-long history of human habitation. Donkeys graze at the outskirts of town, and nearby a small brown dog lopes after a chicken, yapping as he goes. A group of giggling children sends a soccer ball skidding across a concrete roadway in the last of the fading daylight.
To the west, just over the next ridge from Rantis, lies the Green Line, the border separating the West Bank and Israel. A wire fence and gravel track run along the ridge; on the other side, the Israeli military conducts training exercises, and occasionally the flat crack of automatic weapons fire echoes dully in the valley. From the village summit one can look over the ridge and the wall, to the far horizon and the rising skyline of Tel Aviv, and beyond it, the placid immensity of the Mediterranean Sea.
Omar has lived here his entire 26 years, and they call him doctor now because that is what he does. He ministers to the sick, helps to heal the afflicted: the work of doctors everywhere. Tall and slender, with dark, closely cropped hair and beard, he has a quiet intensity as he attends to his fellow villagers, farmers mostly, whether they need just a quick checkup or immediate attention, something that can’t wait for the 45-minute drive over dusty roads to Ramallah, the nearest city. Children, adults, everyone.
You could say he was raised to do this work. When Omar was born, his father, who once taught English literature and now manages student textbooks for the Ministry of Education, started an apiary in the valley west of Rantis. The family came to raise more and more bees, selling their honey to pay for Omar’s education. He graduated and opened his clinic, committing himself to the long hours of caring for his people. Today, he says, "I want to go back and repay them what they paid me. Because they spent a lot of money and effort on things for getting me education. So it’s a kind of payback."
Omar wants to pay back his parents not only by becoming the village doctor, but in another way, one almost completely foreign to Palestine. He’s among a group of students and researchers who’ve formed the Palestinian Neuroscience Initiative, hoping to kickstart sophisticated scientific research in an area with only the most basic medical infrastructure, and where specialization — in narrow but vital areas including pediatric cardiology, but also broader fields such as neurology and psychiatry — is almost completely absent.
Even among typically ambitious medical students, the idea of establishing a foundation for original neuroscience research in Palestine seemed daunting. The students were too busy or simply uninterested in clinical research; there were few qualified teachers; there was little equipment, or money to buy any. What there was in abundance was skepticism.
That was four years ago. Today the Initiative has more than 20 students doing original research, and partnerships with scientists from Rutgers University–Newark, Harvard University, Switzerland’s École Polytechnique Fédérale de Lausanne, and the International School for Advanced Studies in Italy. It has produced four published papers; four more are currently under review. Last September, it received a National Institutes of Health grant, considered among the most prestigious in the field, a marker of serious, professional work. It’s making the kind of steady progress necessary to build an institution.
But most importantly to Omar and his colleagues, it’s giving them an opportunity to help. To give back.Building a foundation
Building a foundation
On a sunny summer afternoon, Omar walks through a door with a computer-printed piece of paper taped to the outside. "Al-Quds Cognitive Neuroscience Lab," it reads, and the door opens into a rectangular, white-walled classroom dominated by a long wooden table. Just over a dozen students are seated around it. The women sit on the left, nearly all wearing hijabs, and the men sit on the right.
At the head of the table, umbilicalled to the wall by a long extension cord, sits a MacBook. On-screen, the slightly pixelated face of Mohammad Herzallah leads the day’s discussion, shifting black squares representing his curly hair. His voice, originating almost 6,000 miles away, in Newark, New Jersey, asks about the role of the hippocampus in treating depression. An extended answer follows about the workings of selective serotonin reuptake inhibitors, a popular class of antidepressant drugs that includes Prozac, Zoloft, and Paxil.
Or rather, "popular" in the United States. According to the World Health Organization, 19.2 percent of US adults surveyed experienced a major depressive episode in their lives; the Centers for Disease Control found that about one in every 10 Americans aged 12 and over takes antidepressants, including SSRIs. As both diagnoses of depression and use of antidepressants rose in the US, "Prozac" became a household name. More than just a drug, it has become a cultural signifier for debates about mental illness and its proffered cures.
Depression in the West Bank is at 36 percent — nearly double that of the US
In Palestine, by contrast, television does not air commercials for antidepressants, nor do magazines feature full-page, pastel-colored ads suggesting you ask your doctor if a particular pill is right for you. Depression itself remains stigmatized. "People don’t want to speak about it, people don’t want to mention it, people don’t even want to speak about family members who have it," says Herzallah, co-founder and director of the Palestinian Neuroscience Initiative. Depressed patients often don’t seek medical attention; if they do, they often couch their ailment in physical terms, complaining about, for example, lower back pain. And they try hard not to be seen leaving a mental health clinic.
Beneath the collective reticence, Palestine has a problem. According to one published study, 25 percent of Palestinians will experience a major depressive episode in their lifetimes. Herzallah believes data gathered by the Initiative indicates that rate in the West Bank is closer to 36 percent — or nearly double that of the US. Yet, as Herzallah puts it, "We have about 20 psychiatrists and 14 neurologists to serve 2.8 million inhabitants of the West Bank in Palestine."
A high rate of depression, and not enough trained medical professionals to treat it. It was a serious problem, yes, but also a potential opportunity. And Mohammad Herzallah knew how to recognize an opportunity. He hadn't planned to be a doctor. Growing up in Jenin, in the northern West Bank, he wanted to be a physicist, either astro- or nuclear. His father, himself a professor, cautioned him that physics and Palestine don’t mix: if you want to do science and get support to go somewhere else to do it, he said, go for it. If not, consider something else. Always interested in biology, Herzallah chose medical school at Al-Quds University, a Palestinian school in Abu Dis, on the outskirts of Jerusalem. When he arrived, he focused on neuroscience, teaching himself.
He faced down a lot of skepticism in those early days. Neuroscience simply wasn’t being done at Al-Quds. "As an eager young medical student who wanted to become a researcher," he says, "there were no opportunities at all." No facilities, no resources, and, perhaps most crucially, no understanding that research mattered. And doctors lacking the basic tools to treat their patients weren’t likely to be swayed by Herzallah’s youthful enthusiasm; they’d tell him he was crazy to focus on such specialized research when people needed medical help now. Even his father told him he was crazy: he was on his own.
Until his fifth year, when he met Dr. Mark Gluck and Dr. Adel Misk. Brought together by previous collaborations on Parkinson’s research, the two neuroscientists sought to establish the infrastructure for neuroscience and mental health research in Palestine. It was a daunting goal: their two schools, Rutgers University–Newark for Gluck, Al-Quds University for Misk, had joined together, but as Gluck says, "It was very hard to find any student who would work for free on a project most of them thought would go nowhere." Comparing their resources — teachers, technology, and money — with the million-dollar labs at cutting-edge world institutions, he says, provoked not just skepticism, but despair.
Among those initial recruits, though, was Herzallah, who Gluck dubs "an absolute superstar." And soon enough the neuroscientists recognized the one problem they’d come together to address also provided an opportunity. In Palestine, there were many depressed patients to treat, and most of them had never taken any form of antidepressant. That enabled research on how antidepressants affect previously unmedicated brains — study difficult in, for example, the United States, where a much higher percentage of the population has taken such drugs.
Palestine has a relatively homogenous gene pool
Palestine had another advantage: a genetically homogenous population. Different people react differently to antidepressants; up to half of patients gain no benefits at all. Genetics play a role in how patients react, adding one more variable to any study. It’s especially difficult to control in a country like the United States, where centuries of immigration and intermarriage have diversified the gene pool. Palestine, by contrast, has a relatively homogenous gene pool thanks to a lack of immigration and a tradition of inter-familial marriage: relatives marrying one another.
Those marriages lead to genetic homogenization in the next generation, which can create serious health problems as negative traits get amplified. Rare genetic disorders such as juvenile-onset Parkinson's disease (in children as young as 14), familial schizophrenia, and early-onset Alzheimer's disease are more prevalent among Palestinians, says Herzallah, in part because of a lack of genetic diversity. That gives the budding neurogeneticists at the Initiative a tragic opportunity to study the links between genes and these rare diseases.
The students had one more unique opportunity. More than half of Palestine’s people are younger than 24. Rates of depression vary with age, and having so many young people offered an opportunity to study those differences.
From the beginning, the Initiative’s founders focused on turning problems into opportunities, and on building a foundation that would last, not just for the students involved, but for the whole community. "We train students to do research," Herzallah says, "but what we want to do is invest in people." In the long run, Herzallah and his colleagues believe, they’re helping to create not just researchers, but invested citizens who’ll fight the Palestinian "brain drain" by staying to help their homeland and people.
The inner voice
"The quality of life here is... I mean, it’s bad, it’s not the best. Finances are bad. So everything is against people coming back here," says Ibrahim Mughrabi, a postdoctoral researcher with the Palestinian Neuroscience Initiative. The unemployment rate in Palestine is over 20 percent, with a poverty rate nearly as high. Over half the labor force works in the service industry, and economic growth is driven almost entirely by donor aid and government spending, with very little private development. With the import and export of goods and labor controlled by Israeli security policies, Palestine has difficulty utilizing local resources. Smart people can see more opportunities elsewhere, and seize them where they can.
But Mughrabi, like his colleagues, chose to stay. He helped establish the neurogenetics program, with studies examining genetic markers that confer risk for psychiatric disorders. He also examines how genotype affects responses to therapy, studying how genetic differences determine whether antidepressants help a patient. He describes the Initiative as taking the first steps toward a Palestinian Neuroscience Institute that would support researchers, educate clinicians and students, and inform the public about mental health issues. Like many of his colleagues, he believes "research lies at the heart of medicine, and healthcare should be concerned with providing service, but with finding answers as well." Palestine needs doctors and clinicians, and it needs the medical infrastructure to support them. But it also needs researchers willing to remain and address their people's unique problems.
Many in the Initiative echo Mughrabi’s sentiment. Sundus Shalabi, a fifth year medical student, says, "I believe that you can do much more good for the whole community than just being a doctor. If you’re a researcher, you can help so many people out there who are suffering." She’s worked on genetic research with the lab for two years; she’s grateful to be doing the kind of work she believes in. "I think as a doctor, as a medical student, and as a researcher, you have to make some sacrifices if you want to do some good for this country. I’m willing to make these sacrifices because I think it’s a very good thing to do for the people. We have very much to offer for our people and for the country, but this energy is wasted, so we need to collect it."
Collecting energy, harvesting brainpower and putting it to productive, local use. That’s what the Initiative’s all about. It’s a long-term endeavor, as everyone acknowledges. "We’re starting a new generation of not only good medical students," Shalabi says, "but also motivated young researchers who are willing to do something good for this country other than just prescribing medicine." And for some students that means sacrifice: giving up potentially lucrative jobs elsewhere, declining the clear path to becoming "just" a doctor, and dedicating themselves to a project the provokes skepticism in even their fellow medical students.
"I think as a doctor, as a medical student, and as a researcher, you have to make some sacrifices if you want to do some good for this country."
"You have to have faith to do this. Without hearing anybody, you have to go with your inner voice to do things, especially in Palestine," says Aya Imam, a sixth year medical student from East Jerusalem. She was among the first to join the lab in 2010; she saw it as an opportunity to study abroad, and later spent two months as an intern in Switzerland. During that time, she says, "All I was thinking about was going back home. Because whatever you do outside, okay, you're benefiting, but you don't feel like you're giving." She wasn’t giving until she was back home, doing her part for the people around her. Currently she’s working on antidepressant research, looking for impairments in cognitive function among patients taking SSRIs.
"‘You want to do what in Palestine? You know, we don’t have roads,’" laughs Mousa Hamad, describing the skepticism he often still encounters when talking about the Initiative. He works alongside Mohammad Herzallah at Rutgers–Newark, doing research and helping to publicize their work. It can sound crazy to outsiders. Even Herzallah’s father still thinks he’s crazy — if maybe a little less so than before. Maybe you have to have that inner voice. For his part, Herzallah says, "I'm not against the idea of being crazy, because everyone who achieved something important in history was crazy."
Looking to the future
Of course, not everyone thinks he’s crazy. Herzallah can point with pride to the partnerships with prestigious universities worldwide; he can talk about the 35 students trained on cognitive neuroscience research methodologies, about the 14 working with partner institutions such as Columbia and NYU; he can offer the four published research papers and the other four under review. He can talk about the NIH grant and about being on campus at 7:30AM every Monday to Skype with his students, seven hours ahead of him in Abu Dis. Call him crazy if you want, but for him there’s no reason to think neuroscience can’t come to Palestine. "We don't lack the brains," he says, "We don't lack the ambition. We don't lack the availability of smart people." And the Initiative continues to grow, with more students applying every year.
With that success comes hope that as Ibrahim Mughrabi puts it, they "will inspire our colleagues to start their own initiatives and maybe help channel and train future graduates into the much-needed specialties in Palestine." The crazy idea just might spread.
Meanwhile, Omar Danoun is leaving his small village, Rantis. But not forever. He’s leaving to learn more, heading to the University of Detroit Mercy to study. (His relatives can’t resist making jokes about sending him off to Detroit with a bulletproof vest.) He will go there to learn, and then he will come back, bringing with him the knowledge he’s gained. Back to his culture, to his family, and to the people who call him doctor.