JMAP 2023 - A Trip Down Memory Lane

“Kayf al idrabat?!”

I couldn’t help but chuckle in response. This was typical of Dr Bassam. His inquisitiveness and insatiable thirst for understanding the world made him quiz me, within less than 30 seconds of greeting him, about the longstanding industrial action affecting the NHS. “How are the strikes?!” - I was certainly caught off guard by his question! Uday, to my left with one hand on the wheel, glanced over at me and smirked, as if to suggest I should be on my toes for the early Monday morning hour-long journey to the Jerash-Gaza Camp northwest of Amman. Reunited after a year, like not a day had passed us by, the three of us were once again absorbed in splendid repartee. Picking up other staff, we swept through the rolling hills towards our destination, often rattling along dusty gravel tracks in the hapless Jordan Medical Aid for Palestinians (JMAP) minibus.

As the other staff began to join us, the minibus started to spring into life buoyed by the enthusiasm of a dedicated team led by our senior figurehead Dr Bassam. The familiar hustle and bustle, to which I had grown accustomed during my maiden JMAP voyage in the summer of 2022, announced the start of a new day, but not for long. The irrepressible verve and vigour surging through the group suddenly changed to a hush before mutating to a stony silence. Momentarily disorientated by the abrupt change in mood, I quickly realised that we were getting there. Roads narrowing, ambience darkening, derelict buildings sprouting from a barren landscape. Humanity within inhumanity. It would only be a short distance before Uday would turn right past the graveyard, two streets from the local school, before parking up next to the clinic.

Pensively gathering my thoughts, I was surprised to be surprised by the reaction of the group. Surely, I thought to myself, these consummate professionals would, by now, have got accustomed to seeing the camp, making their encounter with it every morning a banal daily routine. I was surprised by how wrong I was. I wondered to myself, had I insouciantly forgotten this squalid leg of the journey to be rattled, yet again, in the way I had the first time I set my eyes on the camp? Had my subconscious, for its own mysterious reasons, stealthily erased memories I thought were graphically etched in my mind forever? How could I forget feeling that the sight of the Jerash-Gaza camp was so crushingly depressing that no human being would ever be able to inoculate themselves against its miserable appearance, let alone the catalogue of miseries that blight the lives of its wretched, but amazingly resilient and proud, inhabitants? Doesn’t the reaction of my colleagues testify to the enduring scars they silently suffer in offering care and assistance to those whose gaping wounds refuse to heal? And, who cares for the carers? Humbled by this, I stepped inside full of great anticipation.

The Jerash-Gaza landscape

 Rooftop view from the JMAP clinic

 Little has changed

A day earlier I had joined forces once again with Sister Sabreen. You may recall Sister Sabreen from one of my blogs of yesteryear. Born and raised in the Talbieh refugee camp, Sabreen is an inspirational nurse and the rock of her family. She cared for her husband after a major heart attack, all the while raising her young children, instilling in them the value of education and the freedoms it can bring. I arrived at her camp, 35-km south of Amman, towards the airport, full of excitement at the prospect of seeing ‘old friends’. Thekrayat, the Talbieh JMAP Clinic Director and resolute leader with – to my amazement – a profound curiosity about rheumatology, had prepared a list of interesting cases compiled over several months, many with active rheumatological disease requiring treatment, and others simply requiring reassurance that their symptoms did not represent an autoimmune rheumatic condition.

There was a deep sense of relief amongst those patients in the latter group. They obviously welcomed being unshackled from the burden of potential long-term ill health, easing their already deeply embedded anxiety. For those less lucky, there were usually mixed emotions. On one hand, the reprieve of finally receiving a diagnosis; on the other, despondency over yet another stroke of misfortune blighting their already challenging circumstances.

Optimism is not so difficult to impart to patients when practising medicine in my clinics back in London. Deploying the rapidly evolving therapeutic landscape in rheumatology, practitioners can successfully treat patients who, back when treatment options were limited, would have been ‘condemned’ to devastating joint and organ damage. Out in the camps, my therapeutic armamentarium is limited to what would be regarded as “first-line” treatments in the setting of an advanced healthcare system. In the prevailing circumstances of the camps this still reflects an effective approach.

Sadly, once that threshold is crossed, where my artillery is no longer fit for purpose – teleporting me back in time to what was once regarded as the frontier of treatment a quarter of a century ago – I have little choice but to remain sanguine, not least for the wellbeing of the refugees who pin so much hope on the outcome of their consultation. The term placebo effect has worked its way into popular daily phraseology, allowing me to exploit its potential to good effect during my JMAP clinics, as if clutching at straws.

I vividly recall one patient from last year, a woman in her thirties, with disabling and longstanding undertreated rheumatoid arthritis. The placebo effect option I tried last year with her as a stop-gap measure ran its full course. As expected, it failed to provide any semblance of control over her disease. Knowing this would be the case, I had recommended that treatment should be escalated to next-line options from major city hospitals on a compassionate basis owing to lack of resources at JMAP. I reviewed her case in absentia during my visit to Talbieh and was saddened to learn that she had failed to secure the treatment she so desperately needed. All too often refugees in Palestinian camps lack access routes to secondary and tertiary level healthcare either because of their status, as in the Jerash-Gaza camp, or the high cost of treatment in a health care system dominated by very expensive private provision. This young lady had decided not to attend her appointment to see me. She had lost all hope.

Alleyways of despair

Eeriness at ground level

 The conditions are almost uninhabitable

Returning to the Jerash-Gaza camp, Amal, the clinic manager, and Dr Bassam had been looking forward to showcasing their latest project. Dr Bassam, a supremely experienced GP, had always enjoyed practicing medicine at the sharper end of acuity. He thrived on both clinical complexity and the provision of urgent care. Working within a low resource setting for many years meant he had developed impressively sound clinical acumen which enabled him to reach sound diagnoses and to treat patients without the benefit of tests that I would regard as routine in my role as an acute physician in the UK.

For all his expertise, Dr Bassam was incensed when several months ago he encountered a medical emergency (an exceedingly rare occurrence in the JMAP clinics) and found himself without the necessary equipment to provide life-saving treatment. Dr Bassam attached great value to human life, above and beyond the cost of the statistically near negligible day-to-day risk of the occurrence of an emergency of the above type happening again any time soon. He felt a real sense of duty and a compelling desire to drive continual improvement in the service JMAP provides. For this purpose, he argued for the setting up of a one-bed emergency area with a defibrillator and a well-stocked emergency trolley to be deployed in the clinic. Knowing that space was an issue, and that care of the best kind ought to be provided no matter what, he insisted that the emergency station be set up in his clinic room, to be directly under his supervision. Always the consummate professional, and never failing to put his patients at the forefront of his concerns, Dr Bassam succeeded in achieving his aim despite the limited out-stretched resources of JMAP. Well done Dr Bassam and well done JMAP! I take my hat off – or should I say keffiyeh – to you!

The Emergency Room (ER)

 Dr Bassam’s Emergency Room

It was then Uday’s turn to showcase his inbred ability to delight. Before we left the clinic, I had asked him if we could swing by the delicious falafel stall on the outskirts of Jerash, to which he replied “no, we need to take a different route home today”, offering no further explanation. I didn’t wish to pry. As I wondered down towards the exit, Amal emerged from her office, also ready to board the minibus, when she then spilt the beans! Uday wanted to take the scenic route home via the Dibbeen Forest Reserve.

And, my word, it lived up to the hype. Lush greenery lining the floor of the pine-oak forest, on a vast and rugged hilly backdrop, such contrasting scenery seeming to symbolise my day which happened to swing between joy and melancholy. The intensity of the work, the inexorable emotional and cognitive load swirling amongst us all, was wonderfully balanced by Uday’s usual savvy tricks. An enchanting detour back to Amman.  

Steadfast and tuned in, Uday knew exactly how to help us unwind. Last year it was falafel and banter. This year it was nature and the warm summer breeze. His empathy and acumen surpassed the norm in a culture where generosity is second nature. Uday didn’t do a medical degree with hours upon hours of bespoke communication skills training. And he didn’t need to climb the greasy pole to become the CEO of a multinational corporation. He just had an innate and culturally attuned sixth sense. Uday had, once again, managed, single-handedly and without fuss, to ignite joy within the group like no other person could.

Detour from the Jerash-Gaza camp back to Amman

From left to right

Uday, Dr Bassam, me

Coach Hannah put me through my paces once again

 New surroundings – KABS Underground Gym 

Revisiting some CrossFit workouts

 In the words of Adam Kay: “This Is Going To Hurt”

It certainly did!

Quick as a flash, my trip was over. Graced by Amman’s clear blue morning sky, I boarded the plane heading back to London. I had ample time to ponder during my flight, my mind – once again – nudging me back to memories of twelve months ago: my first humanitarian endeavour with the JMAP team. I remember this being a time of great change, and indeed unfamiliarity, in my career – on the verge of embarking upon my consultant role at the Royal Free Hospital, preceded by a voyage into a greater unknown in the camps.

My three-week stint with JMAP last summer was the ultimate whirlwind experience. Fresh surroundings, new people, different ways of practising medicine and adapting to conducting medical consultations in Arabic. It was clear to me that there was a real weight of expectation, to which I was largely oblivious at the time, as patients and colleagues awaited their first rheumatologist on site since the inception of the organisation in 1990. Reviewing countless patients, sometimes up to sixty patients in a session, my clinics were a melting pot of challenging physical and psychosocial ailments. At times, the waiting room was spilling into my consultation room. And, you wouldn’t have guessed it, I would be assessing patients in full view of others who were waiting patiently in the corner of my room for their turn.

My clinic became a revolving door to which I had no control. It was a peculiar experience. And yet, I stoically persevered, relishing the chaos, mindful of the blessing bestowed upon me to help others desperately in need. Those who know me well can testify that those three weeks left me immeasurably more exhausted than the previous decade-and-a-half of medical training.  

Well equipped with those experiences and cognisant of the challenges ahead, as well as almost a year of working as an NHS consultant, there was an unusual sense of calmness and serenity on this, my second stint, with JMAP. The moment my first patient walked in, I instinctively dialled into auto-pilot mode, as opposed to rabbit-in-headlight mode! My clinical acumen more refined, my linguistic skills – as Sister Rahaf remarked – smoother, and rapport with patients easier to achieve, I could truly savour things in real time. This time, I could harness trust with patients on a deeper level, enabling a stronger collaborative relationship with patients requiring immunosuppressant treatments – such treatments heavily relying upon them ‘buying-in’ to the favourable risk-benefit balance and strict monitoring requirements.

However, the opportunity cost, if it could be described as such, to fostering richer and more meaningful interactions with my patients provided insights into their relentless quotidian toil, nourished by their hunger to survive in the face of injustice and inequality. Sentiments of grief and the palpable wounds of untreated, damaging disease – epitomising many of my consultations – were only a glimpse into their unmistakable anguish. If empathy had a downside, this would be it.

Yet, there were touching moments that will forever remain carved in my mind. To the handful of patients who popped in, unannounced, simply to say, “thanks to you, I am now better”, and to all my colleagues who welcomed me with open arms, I say – thank you for making every moment at JMAP worth it.

Until next time.

Can you spot Venice?

Barely a cloud in the sky for the entire flight back to London

Treated to unique bird’s-eye views from 37,000 feet of western Asia and Europe