Nazareth Hospital EMMS 150 years on

BMJ 2013;347:f6994 doi: 10.1136/bmj.f6994 (Published 12 December 2013)

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FEATURE CHRISTMAS 2013: MEDICAL HISTORIES

From the Ottomans to the present day: 150 years of Scottish medical charity in the Holy Land Peter Turnpenny charts the extraordinary 150 year history of The Nazareth Hospital, which treats Jews and Arabs alike Peter D Turnpenny consultant clinical geneticist and honorary associate professor

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Royal Devon and Exeter Hospital, Exeter EX1 2ED, UK ; 2Exeter University Medical School, Exeter, UK

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During 2012 a year of celebrations took place in the Arab city of Nazareth, Israel, marking its main hospital’s 150 years of medical service to the town and surrounding Galilee.

The story begins with the Crimean war. A young English speaking Armenian, Pacradooni Kaloost Vartan (fig 1⇓), educated by American Presbyterian missionaries at Bebek Seminary near Constantinople (now Istanbul), was recruited as a translator for the British army (fig 2⇓). He may have met Florence Nightingale but certainly witnessed the horrors of war and ravages of infectious disease. Inspired to study medicine, he received financial support from an unknown Scottish woman in Constantinople. He was eventually accepted into the Edinburgh Medical School, under the auspices of the Edinburgh Medical Missionary Society (EMMS)—at that time less than 20 years old and starting to train and send medical missionaries around the world.

After graduation, he received a grant from the Syrian Asylum Committee and travelled to Beirut, where civil war raged.

Finding it difficult to be useful there, he journeyed to Nazareth—equidistant between Beirut, Damascus, and Jerusalem—where he opened a clinic with four beds in the town’s souk and began his life’s work, which continued until his death in 1908. In 1866 he returned to Scotland, where the EMMS agreed to sponsor him, and he set out again for Nazareth with his new bride, Mary Anne Stewart.

Dr Vartan’s work met opposition. The Ottoman authorities distrusted him because they thought he was a British spy, he read the Bible to his patients, and he was Armenian, but locals petitioned on his behalf and his medical work grew. At the time of his death he worked from a building in the town (fig 3⇓), but plans for a grander hospital were under way. Frederick Scrimgeour succeeded Vartan, and a large plot of land was purchased by the EMMS to build a hospital on the town’s southwest fringes. While the hospital was under construction, the first world war erupted, and the site was confiscated and

used for stables by the Turkish army. Two British nurses remained and treated all casualties, and when one died of natural causes in 1916 she was buried with full Turkish military honours at the Anglican church.

Dr Scrimgeour left in 1921 but building resumed until completion in 1924 (fig 4⇓). William Bathgate, a New Zealand veteran of the first world war, relieved him. Soon after Dr Bathgate’s arrival his wife developed a mental illness, was shipped to England, and spent the rest of her life in an asylum.

Their only child, a daughter, died from a stray Luftwaffe bomb dropped on Southend on Good Friday, 1941. Bathgate reacted by thanking God for his graciousness in taking her to eternal rest on a Good Friday. Devoted and committed to his calling, he ignored the directive from Edinburgh to close the hospital when the State of Israel was established, and the work continued.

Elsewhere, the EMMS Hospital in Damascus closed in the wake of Suez, and in 1959 the same fate befell the Church of Scotland hospital in Tiberias, by the Sea of Galilee 20 miles from Nazareth.

In 1952 John Tester, a new but mature London medical graduate, joined Bathgate. He first visited the hospital as a serviceman during the war, when Bathgate immediately asked him to help with an operation and told him, “You are on the staff now”—words that changed Tester’s life. Conditions were extraordinarily hard in the 1950s with Arab Nazareth under curfew (for many years). Resources were so scarce that any scrap of paper was used for prescriptions—to Dr Tester’s amazement this included Bathgate’s OBE certificate, which he one day discovered cut up for the purpose. Despite hardships, Tester built a team of expatriate medical and nursing staff.

Nurses were crucial to good patient care and maintained the training of local nurses to “practical” level through the school established in 1924, providing a rare opportunity for young Arab women to develop a career. A new X ray machine arrived,

Correspondence to: P D Turnpenny peter.turnpenny@nhs.net For personal use only: See rights and reprints http://www.bmj.com/permissions

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BMJ 2013;347:f6994 doi: 10.1136/bmj.f6994 (Published 12 December 2013)

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FEATURE

a laundry was built, and gradually the place began to resemble a 20th century hospital.

Hans Bernath, a Swiss surgeon who worked under the Red Cross with Palestinian refugees in 1949, joined the staff in 1956. A gifted carpenter and builder, he oversaw huge development projects—often paid for by money raised in Switzerland—that transformed patient facilities and gave the hospital its current appearance (fig 5⇓). He became a legend in his time and continued to supervise new building work long after his official retirement in 1988. By this time, just five superintendent doctors, men of outstanding and courageous Christian commitment, had seen the hospital through its first 126 years. Bob Martin, an American Mennonite who first worked at the hospital in the mid-1960s as an alternative to conscription for Vietnam (Mennonites, in general, are pacifists), returned to take over from Dr Bernath. This was a period of great change. During the 1980s, for the first time substantial numbers of Arabs from Nazareth and environs were emerging from higher education and postgraduate training, and Israel was less willing to license expatriates in professional roles. In addition, all nurses were required to be trained to “registered” level, so Dr Martin’s wife, Nancy, with a doctorate in nursing education, reinvented the hospital’s School of Nursing to meet this stipulation.

The first Gulf war of 1991, which saw the hospital prepare itself for SCUD missile attacks and the threat of chemical weapons, was a turning point—few new medical or nursing expatriates were employed afterwards. Over a few years, the hospital’s official language switched from English to Hebrew. With fully trained local doctors on staff, some departments could provide higher specialist training to consultant level, although the hospital remained a “private” one in the Israeli system. In 2009 a state of the art operating theatre suite was opened in the new wing, largely funded by an American government grant. Today the hospital has 144 beds and each year some 50 000 emergency department attendances, more than 2000 deliveries, and a £25m (€30m; $40.5m) turnover. However, ownership resides with the charity, now branded The Nazareth Trust (www.nazarethtrust. org/), which is still registered in Scotland and subject to scrutiny by the Office of the Scottish Charity Regulator.

All this, together with the charity trustees’ ongoing aspiration that the organisation continues to be visibly Christian in ethos and activity—not simply in name—is a heady mix, and challenges abound. The staff (around 560) reflect local demographics—70% are Muslim. But there are Jewish staff and patients too. A new Faculty of Medicine based at Safed (an extension of Bar-Ilan University) has opened, resulting in the hospital’s elevation to “university” status, and undergraduates now pass through various departments on clinical attachments.

In addition, there is a rapidly growing ambition to research and publish, with a steady flow of productivity. Foreign medical graduates have also received training there before sitting examinations to assess their suitability to practise in Israel.

The School of Nursing currently faces another major challenge because Israeli law now dictates that all nurses must be graduates. The students of the school, drawn from villages all over Galilee, besides Nazareth, have consistently achieved very

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high marks in national examinations. Currently, their nursing degree is awarded through a partnership with Haifa University, with the longer term solution still evolving.

The charity’s other key activities are the Nazareth Village and the “SERVE Nazareth” volunteer programme. In the early 1990s, a period of dry weather led to the discovery of evidence of 1st century occupation—a wine press, ritual bath, agricultural terracing, and a tomb (fig 4)—on unused hospital land. With the help of national archaeologists, village life of biblical Palestine has been reconstructed, including a synagogue authentic in every detail (www.nazarethvillage.com). This is a unique visitor attraction in Israel, which—had it been discovered a century or two earlier—would probably now be obliterated by an enormous church, perhaps claiming to be at a certain location in the account of Christ’s life. The SERVE programme, now in its fifth year, attracts paying volunteers worldwide.

Interns and volunteers have a genuinely unique opportunity to contribute practically in some way to the hospital or Nazareth Village, as well as integrating into the local community through one of the churches (www.nazarethtrust.org/SERVE). Medical students can combine an elective period with involvement in SERVE. The story of The Nazareth Hospital over 150 years is one of extraordinary survival through many stormy events, not least multiple wars (fig 6⇓). Some might regard its situation, ownership, and governance as an anachronism in the modern world. No one directly involved would deny its complexity, operating across cultures in a volatile part of the world, but for those involved it proves immensely stimulating and life changing. To conclude, these were the words of the chairman of the Knesset, Israel’s parliament, which in 2012 gave its annual award for a valued contribution to the nation to The Nazareth Hospital—the first time that the recipient has been a non-Jewish organisation.

“The Nazareth Hospital symbolizes, more than anything else, the common destiny, and the bridge between the inhabitants of this country, Jews and Arabs, new immigrants and seniors. The work of this old respected institution is based on the values of compassion and love for all people. This is a valuable and important institution, that has no barriers between humans, and treats everybody the same since they were created in the image of God, in sincerity and in professionalism.” (Reuben Rivlin, chairman of the Knesset, 4 December 2012.)

Competing interests: I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: I am a trustee of the Nazareth Trust and served at The Nazareth Hospital as a paediatrician and anaesthetist from 1983 to 1990.

Provenance and peer review: Not commissioned; not externally peer reviewed.

Cite this as: BMJ 2013;347:f6994 © BMJ Publishing Group Ltd 2013

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BMJ 2013;347:f6994 doi: 10.1136/bmj.f6994 (Published 12 December 2013)

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Bibliography Wilkinson J. The Coogate doctors. A history of the Edinburgh Medical Missionary Society, 1841-1991. Edinburgh Medical Missionary Society, 1991 Billings M. Vartan of Nazareth. Missionary and medical pioneer in the nineteenth-century Middle East. Paul Holberton Publishing, 2012

Figures

Fig 1 Pacradooni Kaloost Vartan (1835-1908), son of a carpet maker from Constantinople, who went on to found a hospital and dispensary in Nazareth, which continues today as The Nazareth Hospital.

Fig 2 Vartan’s Crimean war medal depicting Queen Victoria and service at Sebastopol, Inkermann, Balaklava, and Alma

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BMJ 2013;347:f6994 doi: 10.1136/bmj.f6994 (Published 12 December 2013)

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FEATURE

Fig 3 The “British hospital� in Nazareth town used by Dr Vartan and successors from 1904 to 1924

Fig 4 The new hospital nearing completion in the early 1920s, on the site purchased by the Edinburgh Medical Missionary Society some 15 years earlier, and the location of The Nazareth Hospital today

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BMJ 2013;347:f6994 doi: 10.1136/bmj.f6994 (Published 12 December 2013)

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FEATURE

Fig 5 The Nazareth Hospital today. The original building with the brown sloping roof can be discerned. The School of Nursing building is in the foreground to the left, and the reconstructed agricultural terracing of the Nazareth Village is seen in the foreground to the right

Fig 6 The Nazareth Hospital timeline. Many, past and present, have served and contributed greatly to The Nazareth Hospital, but a fuller historical account is not possible here. EMMS=Edinburgh Medical Missionary Society; WW1=first world war; WW2=second world war

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