JMAP 2022 - Meeting the Team
JMAP Headquarters.
Modest office space on the first floor.
Pleasant meeting with the Executive Team.
Work schedule finalised.
Challenges lie ahead.
After landing in Amman during the early hours of yesterday morning, I managed to have a day of rest and settle into this lively and endearingly chaotic city. Having visited Jordan more times than I can count, I generally know what to expect: the warm welcome of its people, the warm summer breeze and a gentle tug of war with the car rental firm to secure a car with both central locking and air conditioning. Suffice it to say I rather sheepishly (and somewhat predictably) realised that I had forgotten to manually lock the three passenger doors last night; however at least the air conditioning kept me nice and cool. Some things have changed since my last visit in 2018. They’ve embraced contactless payment, they’ve embraced an accelerated use of social media and they’ve embraced electric vehicles - a few Teslas, a smattering of Zoes and LEAFs, and a dash of Changans - an innovate Chinese car company.
Change very much felt like the theme of the day. On a personal level the most significant change, and the toughest for me to bear, is the absence of my late grandmother who sadly passed away last year at the age of 94 having battled for 40 days with Covid-19 infection and its complications. As my paternal grandmother, and having been my last remaining grandparent, she had become synonymous with my visits to the Middle East. She was my first ever memory of visiting Jordan and I had never truly imagined a visit without her being there. After all, until her last days (I vividly remember my final telephone conversation with her), she was vivacious, resilient, irrepressibly energetic, candid in her opinions and always wore her heart on her sleeve - oh, and she knew how to (force) feed me! She had become a symbol for being Palestinian in Jordan and, undoubtedly, she would have been so immensely proud of what I am about to embark upon.
Today I made my first visit to the Jordan Medical Aid for Palestinians (JMAP) headquarters in a fairly trendy part of Amman called Al-Swaifyeh. I met the Executive Director, Maha, and Deputy Medical/Technical Director, Dr Zahira - both of whom were wonderfully welcoming. The Honorary Chairman of JMAP is HRH Prince El Hassan Bin Talal (who I have not met!) but I have it on good authority that my CV was on his desk at one point! I had a productive discussion with Maha and Dr Zahira about the various facilities available to me at each of the three refugee camps; and the demographic, social and economic characteristics of each camp. These are all important factors which determine how I deliver medical care. These refugee camps have been around for many years and have essentially become towns in their own right. I was interested to hear that refugees residing within the Talbieh and Hiteen/Schneller camps are in a relatively better economic situation, compared to their counterparts in the Jerash/Gaza camp, due to the close proximity of manufacturing and manual labour jobs; bringing in income and generating local, small-scale commerce within the camps and their surrounding areas.
I was pleased to learn that I will have access to basic blood tests (such as full blood count, renal function, liver function, C-reactive protein and erythrocyte sedimentation rate) and some specialised immunology blood tests like rheumatoid factor and anti-nuclear antibody (the rheumatologists reading this will be wondering about cyclic citrullinated peptide - this would need to be sent to an external laboratory in Amman). I will also have access to plain x-rays. Prior to arriving in Jordan, I had corresponded with Maha and Dr Zahira about the types of medications to which I would need access in order to provide a necessary level of care. The World Health Organisation Model List of Essential Medicines acted as a useful reference point. Drugs like corticosteroids, non-steroidal anti-inflammatories, anti-gout therapies (namely allopurinol) and a small handful of disease modifying therapies (methotrexate, sulfasalazine and hydroxychloroquine) will be accessible to me through local pharmacies. Again, for the medics in the room, I can request treatments such a mycophenolate mofetil and azathioprine, depending on cost and availability; although biologic therapies and infusions - including rituximab - or chemotherapy with cyclophosphamide cannot be given at the camps therefore would require referrals to specialist hospitals or clinics to deliver these treatments, which I suspect entails a great deal of organisation. In spite of the limitations, it seems that JMAP aim towards providing a good standard of care. Tomorrow I will be starting work at the Hiteen/Schneller refugee camp located 10 kilometres northeast of Amman.
Rheumatology is interesting. Well, I would say that wouldn’t I?! Aside from the recent advances in treatment, the continual research into the causes of rheumatological conditions and the discovery of new diseases (VEXAS syndrome being one recent example); it is without doubt the relationships we build with our patients that make it most interesting. Many of our conditions require long-term, and sometimes life-long, treatment and follow-up. Many of our treatments require long-term monitoring, usually with blood or imaging tests, therefore I have become accustomed to the systems and safety nets we have in place in the UK to ensure this happens in a timely manner. Here in my work with JMAP, I foresee this being tricky. Indeed, in my last blog post - the preface - I touched upon two core challenges I anticipate facing in my practice here: remaining objective and dealing with long-standing, untreated disease. Adapting the way I practice rheumatology without being able to offer or guarantee the ‘gold standard’ follow-up and monitoring perhaps represents the third core challenge. I plan to build a continuity of care for my patients by establishing a working relationship and dialogue with the internists and general practitioners who provide regular humanitarian support across all three camps throughout the year.
Tomorrow I venture into a new experience where change will remain the theme of the day. While we may all agree change can be tough, I hope to bring about positive change for those with whom I cross paths; particularly the individuals who are most in need of our help - our patients - the reason why we love what we do.
