JMAP 2023 - “Dignity is Priceless”
“Look who’s back! Welcome, welcome!” exclaimed Yaseen, as I opened the glass doors to his office, offering a warm embrace. Dr Mohammed rose from his chair, after placing his cup of piping hot black coffee on the table, shook my hand firmly, and with his characteristically cheeky grin remarked “the country is shining”, a translation of an Arabic turn of phrase oft used when welcoming someone from abroad. No sooner had I laid down my bag and sat down with the two of them than the cheerful housekeeping lady, who last year would venture out to the local market especially to source fresh mint leaves for me, emerged with – yes, you guessed it – a cup of fresh mint tea. Little did she know that I am now a self-confessed coffee addict, having previously managed to dodge the habit for two decades. I suppose that’s what almost one year as medical consultant does to you!
Hiteen-Schneller clinic timetable
A broad array of specialties
Spread across a six-day working week
The recent addition of a twice per week neurology service has been very popular
I had touched down in Amman’s Queen Alia Airport 24-hours earlier. The flight to Jordan’s capital city provided a rare moment of calm to revisit, with a touch of nostalgia, my memories from last year’s humanitarian work with Jordan Medical Aid for Palestinians (JMAP). I vividly recall the blend of excitement and anticipation, laced lightly with a sprinkle of apprehension, as I entered the unknown. Yet, despite being a journey into the unknown, it still somehow profoundly represented a long-term ambition – an ambition to provide medical humanitarian support to a people for whom I care dearly. Flashbacks of the abject poverty, the waiting rooms bursting at the seams, the clamour of desperation as refugees sought an antidote to their woes, the inspirational teams with whom I worked, the entertaining bus journeys with Uday to the Jerash-Gaza camp forty or so kilometers outside Amman, the inspiring story of Sister Sabreen, the comical moment when Sister Rahaf had to interject when I briefly forgot the Arabic word for bladder (instead describing it as a “p*** bag”, perilously close to an inappropriate game of linguistic charades!), the tales of treatment successes and the despondency of ravaging disease. There were highs and there were lows. My desire to return never wavered. When I received the call from Executive Director, Maha, and Deputy Medical/Technical Director, Dr Zahira, with a four-day programme working within the JMAP clinics across three refugee camps - Talbieh, Hiteen-Schneller and Jerash-Gaza – I felt truly honoured.
“Dignity is Priceless”
Inscribed on the wall of the UNRWA office at the edge of the Hiteen-Schneller camp
A pertinent message
A few things have developed in my career since I was last here twelve months ago. Inducted, welcomed and embedded within a fantastic team of rheumatologists and acute physicians, things are in full swing in my first consultant post at the Royal Free Hospital, London. My specialty training leading to that point was extensive and impactful, yet knowledge gains and professional development through clinical experience doesn’t stop once a consultant. As one mentor aptly imparted to me several years ago: “You’ll learn more in your first five years as a consultant than during the entirety of your medical training.” He continued, perhaps light-heartedly, “…and you’ll certainly have many more sleepless nights.” Never a truer word said in jest!
As I ventured towards Hiteen-Schneller by car, 14-km northwest of Amman, for my first day back at the camps, I felt a sense of confidence and preparedness – armed with consultant-level experience, a prior understanding of the health, welfare and psychosocial troubles of the refugees, and a familiarity with how the system works. However, nothing can prepare one for the emotional onslaught brought about by the expressions of hopelessness, desperation and, to an extent, expectations of patients sitting quietly, yet with anxious anticipation, in the waiting area outside my consultation room – having been informed of my visit weeks before. Yes, one may argue there are parallels with patients waiting many weeks, sometimes months, for their NHS outpatient appointment, perpetuated by the so-called “backlog”, hoping to receive life-changing treatment. Be that as it may, the fabric of destitution within the refugee camps – ‘homes’ characterised by zinc roofing and blankets for doors – does not compare. I was further prompted of the challenges which lay ahead when the clinic pharmacist informed me of a shortage of Depo-Medrone (an injectable steroid commonly used to treat rheumatic and inflammatory diseases) which would almost certainly hamper my approach to treatment for many of my patients. For context, there were only six vials of Depo-Medrone 40 milligrams available across all three camps, with no sign of upcoming deliveries. Rheumatologists reading this, aghast I’m sure, will know all too well of the hinderance and limitation this presents.
Corrugated zinc and rusted asbestos sheets
A typical roof
Legal stipulations prohibit the building of safe, secure and humane roofing in the camps
Being reunited with Yaseen, Dr Mohammed and Sister Rahaf at the Hiteen-Schneller camp, felt as though I had never left. Yaseen, a multi-talented former chef and restaurant owner turned clinic manager; Dr Mohammed, a knowledgeable and exuberant young general practitioner; and Sister Rahaf – how could I forget the way she saved me from sinking during our infamous first clinic together last year! With memories still firmly etched in my mind, I slowly paced into my consultation room, while soaking in the enduring – almost holographic – atmosphere. Sister Rahaf was sitting exactly where I last recall her, waiting, but this time loading up the new computer system equipped with electronic patient records, as opposed to organising reams of note paper on the desk. Sensing my footsteps: “Welcome back, Hakeem”.
The word “Hakeem”, which directly translates to ‘wise’, is a traditional term for ‘doctor’ used in the Levant, giving an indication of Sister Rahaf’s origins and, perhaps, family upbringing. Sister Rahaf outlined the plan of action over the next two days. Rather than a pure first-come-first-serve policy adopted for my clinics last year, Yaseen and Dr Mohammed compiled a list of patients over the last few months, primarily inviting new rheumatological cases, comprising the majority of my two clinic lists at Hiteen-Schneller.
Follow up appointments were also arranged for some cases I reviewed last year, with some capacity created for urgent on-the-day walk-in appointments. Over the course of those two days, I saw close to sixty patients. There were a variety of cases ranging from rheumatoid arthritis, lupus and vasculitis, through to osteoarthritis and gout.
Neurophysiology
Introduced as part of the recent provision of neurology care at Hiteen-Schneller
Electromyography and nerve conduction studies can be performed on the day
Expanding diagnostic services has led to significant improvements in patient outcomes
The most memorable case was of a young man, aged 20, who had been diagnosed in childhood with a rare condition called juvenile dermatomyositis (JDM), often characterised by muscle weakness and inflammatory skin manifestations. Having previously encountered just one such case of JDM in my career, one which really did stick in my mind, during a 6-month rotation in paediatric and adolescent rheumatology at the Nuffield Orthopaedic Hospital in Oxford, my interest was piqued by this young man’s extensive calcinosis and disabling muscle contractures perpetuated by longstanding active and aggressive disease. He had received a short period of treatment as a child. However, this was not continued through into important developmental years, particularly during adolescence, drastically impacting his physical, social and educational progress. He attended my clinic with three relatives; he clearly had a loving and caring family who were deeply concerned. His mobility had worsened and his mood plummeting as a result. His sense of self-esteem had been quashed. After a thorough assessment and a frank discussion about treatment goals, he agreed to commence immunosuppressive treatment aiming to stabilise the disease, with a multidisciplinary approach involving physiotherapy and psychology input, led by Dr Mohammed – who joined me partway through the consultation – offering continuity of care by directing this treatment strategy in my absence.
He will be in good hands under Dr Mohammed; I am optimistic things should begin to improve and that I will see a stronger and happier young gentleman next time.
Mixed grill and shish tawook
Yaseen ensured I was well fed after the clinics
Specially requested from his friend’s restaurant
An opportunity to decompress and bond with one another
Utterly sumptuous!
Finding some time to unwind after two intense days at the Hiteen-Schneller JMAP clinic, I took the chance to pause and reflect. Once again, fortunate to have the company of my mother who had travelled out to Jordan a couple of weeks beforehand, we spent much of our spare time catching up with beloved relatives – conversing, laughing and, of course, eating plenty!
The invaluable blessing of being able to visit family freely, embracing strong ties, while having the means to remain in good health and in positive spirits was emphatically amplified by witnessing the living conditions, health disparities and social injustices marring the lives of those refugees I had met and treated. Their beleaguered lives, blighted by many indignity-inducing calamities, made me reflect on what dignity means. At what point does dignity meet indignity? Does dignity mean the same thing to all people regardless of their fortunes in life? Do I take my own dignity for granted?
A flicker of clarity shone through. Attempting to self-ascribe a meaning to “dignity”, I realised that anything with the potential to be taken for granted – health, family, friendship, financial and social security – is precious and represents a foundation, among others, for living with dignity. I pray that one day the generations of refugees I have had the honour of meeting, and all those close to them, will experience the freedom and privilege of being able to take the basic necessities of life, the truly priceless things, for granted.
“Dignity is Priceless”.
