JMAP 2022 - My Closing Thoughts
“I like football, so I want to become a footballer. But I also want to help people. So maybe I will become a doctor.”
- My response, aged 9, to an older cousin asking me about the future, shortly after Scotland were defeated by Morocco in the 1998 World Cup.
Almost one week ago, I returned to the UK following my 18-day trip to Jordan where I immersed myself in a longstanding wish to provide medical humanitarian support to Palestinian refugees. My experience with Jordan Medical Aid for Palestinians (JMAP) working across various refugee camps has been both deeply rewarding and exceptionally exhausting. Since touching down in London, there has been little opportunity to catch up on sleep. The wedding of two close friends in Stockport, England followed by a brief, and rather impromptu, trip up to Edinburgh (a city close to my heart having previously lived there more than 20 years) to visit a dear friend and his family, has kept me occupied and delayed my long-awaited hibernation! Yet, during moments of peaceful contemplation, gazing out of train windows, and through lively conversations with friends followed by an all-encompassing debrief with my father one night until the early hours of the morning, I delved deeper into my first experience with humanitarian work. Five key areas of contemplation emerged which I am happy to share by way of a final conclusion to my blog posts.
Unrelenting Deprivation
In the weeks leading up to my trip to Jordan, I had tried to imagine the environment and living conditions endured by refugees living within the camps. However, first-hand experience revealed that nothing could have prepared me for the task lying ahead. I was first struck by the vastness of the camps - particularly at Hiteen/Schneller and Jerash/Gaza. Over several decades, these refugee camps have grown from a cluster of fragmented tents to a cramped ecosystem defined by haphazardly assembled rough concrete block structures covered with zinc roofing, within which squaller and utter desolation prevailed. Children of all ages, in their droves, roamed the narrow dirt alleyways - all day and, I presume, until late at night - without supervision or a real sense of hope of being able to escape the harsh reality of their unrelenting deprivation. After all, they’d seen their grandparents and maybe even their parents grow old and perish within the shackles of the camp; so why should they believe that their own destinies would play out any differently?
To make matters worse, something I had pointed out in a previous blog post, a large number of refugees are not offered, for complex political reasons, the rights of citizenship which could afford them access to basic state-administered services in healthcare, education and employment - which, in effect, further compounds their abiding feelings of isolation and exclusion; the very reason why they ended up in refugee camps in the first place. One can only imagine that this situation would breed hopelessness and all the ills that follow from it, including the use of illicit drugs, involvement in crime and premature death. Breeding boredom and short-sighted decision making, hopelessness, at best, renders the individual unable to plot a path of deliverance out of their crippling reality. At a community level, without access to education and birth control, families continue to grow beyond their means, not heeding the fact that the socio-economic infrastructure of the camp is beyond breaking point. What keeps these families going, I think, is the hope that one of their children might, one day, succeed in the outside world and will, they forlornly hope, deliver them from the unrelenting deprivation that reigns over their lives. Without this, it is certain that their children’s lives will be a carbon copy of their own.
Witnessing all this was emotionally challenging for me. During each clinical consultation I made every effort to connect with my patients by referencing our shared heritage and common humanity which, on some level, was well received. However, beyond that, at times I felt depressingly detached from people with whom I thought I had a shared heritage, particularly when stepping outside the clinic to explore the camps. Our socioeconomic disparities were starkly obvious. I could sense I was being stared at and spoken about as an outsider. I was not perceived to belong. It was astonishing how similar this felt to my early experiences of having to convince others I was Scottish, as a young boy growing up in Scotland - the country in which I was born, raised and belonged.
Social Embedding of Health Beliefs
Challenging established health beliefs became a well-defined theme during my work with JMAP. Conditions such as type 2 diabetes and high blood pressure were not regarded by patients as illnesses or diseases, but just a natural progression of life: a formality of the ageing process. It took me a whole week to realise that asking patients open-ended questions about their pre-existing conditions or medications would almost never yield an answer about their prior diagnoses or treatment of type 2 diabetes or high blood pressure. Since these conditions were accepted as part of life’s journey, patients did not feel the need to disclose that information, despite being significant diseases requiring medications with potential for side effects and interactions with any new medications I might have needed to commence.
Given the high prevalence of these two conditions amongst the refugee population, I adapted by asking every single patient who entered the room if they had diabetes or blood pressure or both, a neat ‘ruse’ I learned from one of my clinic nurses. The difficulty which followed was that most patients did not know which medications they were taking nor brought these to the consultation. This invariably led to a game of ‘guess the drug’! The colour of a pill or packet generally doesn’t shed light on the exact medication being taken - I was never going to win using this strategy. With time, however, I realised that most patients, for one reason or another, seemed to know the doses of their diabetes or blood pressure treatment, despite not knowing the name of their medications. So, questions like “Is your diabetes drug dose 500mg? How many times a day do you take this?” meant that I could, fairly reliably, establish what dose of metformin patients were taking. I adopted a similar strategy for blood pressure medications by using denominators for commonly used drugs.
Continuing with the theme of pills, I observed a rather interesting conundrum amongst many patients. One well established health belief is that every symptom or disease has a curative pill. So, I was frequently met with scepticism when I would explain there was no curative drug for osteoarthritis (a common degenerative joint disease which can cause pain and stiffness) and that the treatment was a combination of physiotherapy, pain killers and - in some cases - a joint replacement. For the patient, walking out of a clinic room without a prescription in hand was sometimes seen as a failure on the doctor’s part and an indictment of their competence. Indeed, my late grandmother would ruthlessly lambast any doctor who tried to explain that she did not require a prescription. Such was the extent of this attitude my uncle would strategically pre-warn the doctor that they ought to prepare an inert placebo (in the event that no pharmacologically active agent was required) or else they would have the living daylights scared out of them by my grandmother!
Yet, on some occasions patients would attend my clinic with a rattling bag of unused pills or an unused prescription signed by another doctor. I began to wonder why many of these patients would seek medications yet choose not to take them. Now, some of the medications issued to patients would have almost certainly not provided any benefit to them - perhaps these were indiscriminately dished out by a beleaguered medical professional looking to move the patient on and end the consultation at the expense of fostering a trusting patient-doctor relationship. Could it be that some patients would rightly sense this and, understandably, not embark upon taking the prescribed treatment? Be that as it may, much of the time the medications were important and, in some cases, necessary.
Delving deeper into the cultural dimension of these attitudes to medical care, I started to learn that a patient’s visit to the doctor was more than just to receive a diagnosis and treatment. It was also a journey of validation that their symptoms and suffering were indeed real. Perhaps they, themselves, were unconvinced by the meaning of their own symptoms or they were contending with a tricky family member who doubted the authenticity of their illness. The receipt of a prescription was viewed as the ultimate stamp of the veracity of their claim - regardless of whether medication concordance ensued. In fact, concordance was such a dilemma that it required much effort explaining to some patients that, for example, their oral diabetes medication, such a metformin, was not merely a “helper” (as they often described to me in Arabic) to just simply use whenever they, infrequently, checked their blood sugar readings. The widely held view was this: only when one required insulin would they consider themselves to be receiving treatment for type 2 diabetes.
Another interesting observation was the misconception held amongst my patients that most symptoms and diseases were hereditary in nature. Initially, I had wondered why some of my consultations involved reviewing two, three and sometimes four members of a family in one appointment, in many cases exhibiting remarkably similar symptoms. In the absence of an organic disease, which was usually the case in these sorts of scenarios, I surmised that there was a degree of ‘imprinting’ or ‘mirroring’ of symptoms; probably a gradual manifestation of the constant trauma and stress endured by these refugees. Some patients had insight into the matter, so an appointment with me was seen as an opportunity for a general ‘once-over’ and reassurance that there was no organ threatening or damaging disease process to explain their symptoms, nor any hereditary component. For others, I was simply another station in their carousel of health seeking behaviour.
Linguistic Challenges
My Arabic language skills were certainly tested. Conducting large volumes of clinical consultations solely in Arabic was a new experience for me and, unquestionably, a steep learning curve bridging the gap in linguistic proficiency of specialist medical terminology. Signs, paperwork and forms in all clinical settings were all in Arabic, although it was standard practice for doctors here to document their clinical notes in English. In the weeks leading up to the trip, I spent time familiarising myself with specific - particularly rheumatological - vocabulary I would likely need to utilise. Until recently, I hadn’t entirely appreciated that my medical training was more than simply learning the art of practicing medicine and honing clinical skills, but it was also - implicitly - the learning of a new language. Medical jargon, doctor lingo, medic chat; congregations of medics (although it only takes two!) almost always leads to discussions about medicine regardless of the occasion, often - and sometimes frustratingly - bamboozling so-called ‘non-medics’, as though they had suddenly been teleported, against their own will, to a foreign land, lost in the hullabaloo of unfamiliar noises, words and turns of phrase. To some extent, I can now empathise with my ‘non-medic’ friends and acquaintances. Having not learned medicine using the Arabic language, my mind was on overdrive trying to synthesise the chaotic flow of linguistic input during my clinics, all whilst adapting to a new clinical environment.
You may recall from previous blog posts that I rather inconveniently forgot the Arabic word for ‘gout’ during one consultation and couldn’t recall the word for ‘bladder’ in another, forcing me - rather amusingly and inadvertently – to construct an unsavoury descriptive term, “p*** bag” for the latter, in the hope that the patient would identify the anatomical structure to which I was alluding. I was grateful to have had proactive clinic nurses, and sometimes even patients, who would step in if I was coming unstuck with any obscure words or phrases, ensuring the flow of the consultation was preserved. Nurturing trust with a patient not only relies upon the clinical acumen of the healthcare professional, but also their ability to communicate clearly and empathetically. Pertinently, this also extended to, what I call, ‘filler’ phrases which were crucial for creating a meaningful rapport with patients in my clinics.
Allow me to elaborate further. If you were to tune into and translate many Arabic conversations, you will notice a plethora of religious expressions (for example: “God bless you”, “may God protect you”, “by God’s will”) whose import extends beyond their literal meanings. I may explain to a patient their diagnosis and treatment plan which - backed by a strong evidence base - I expect to cure or treat their ailment. Yet it is commonplace for patients to respond by saying “it’s in God’s hands”, or phrases to that effect, which could be easily misconstrued as a hierarchical order whereby God’s will overrides the need for proven treatments, thus surrendering to an unduly complacent attitude to treatment and cure. The intended effect of these ‘filler’ phrases, in fact, is to bless the treatment with God’s Divine Will as well as to sew together the souls of those involved in the consultation, creating a quilt-like relationship between the patient, doctor and nurse in the clinic room, as well as fostering a bond among them that transcends the medical issue at hand. I gladly subscribed to this ethos; it undoubtedly enhanced the quality of my interactions with my patients.
JMAP: A Success Story
Jordan Medical Aid for Palestinians, a separate but not unrelated organisation to Medical Aid for Palestinians UK (MAP UK) based in London, serves a total of almost 190,000 refugees across three camps by attending to the medical needs of over 50,000 patients per year. Since being established in 1990, this relatively small charity whose patron is HRH Prince El Hassan Bin Talal of Jordan has consistently advocated for its people and has evolved, against all the odds, by leveraging donors - including large banks, an influential mobile telecommunications company and even McDonald’s - to deliver good medical care to those most in need for such care in Jordan. Deriving inspiration from MAP UK, JMAP has taken global models of charitable work and delivered locally, using local resources. It is this glocalising vision of thinking globally and acting locally which, in my view, has been a principal factor in its signal success at the strategic level. I was further impressed with how unwaveringly streamlined the delivery of this vision is: campaign hard to secure the necessary healthcare resources, then inject these directly where help is needed with minimal bureaucracy. The end result: spreading hope where despair would reign.
However, we must put things into context. In terms of size and financial might, JMAP is a drop in the ocean compared to the likes of Oxfam, UNICEF and Macmillan; let alone the upper echelons of charitable foundations such as the Novo Nordisk Foundation, the Bill & Melinda Gates Foundation and the Wellcome Trust. Yet for a small organisation, working within strict political and financial constraints, with a keen eye for legal compliance, JMAP is visible, accessible and resoundingly effective. If we use the analogy of driving a car on Jordan’s roads - chaotic and unforgiving as I had described in a previous blog post - to represent the environment in which JMAP operates, it is a true testament to this charity’s leadership and donors that it has not crashed, but continued to grow and thrive to what it has become today.
The NHS Friends and Family Test is a single-question survey, and an important metric for healthcare providers and commissioners, to better understand the degree of satisfaction and areas for improvement within a particular service. The question asks respondents how likely they are to recommend the service they received to friends and family if they needed similar care or treatment. From my limited experience with JMAP - looking after patients and working with colleagues - I would hazard a guess that, if such a survey existed there, most patients would answer “likely” or “extremely likely”. For those who have access to its services, JMAP really is worth its weight in gold. Its front-line staff, doctors, nurses, clinic managers, drivers, cleaners and executive team have every right to be proud of their roles in keeping JMAP as a flourishing organisation and beacon of hope for communities with little opportunity of escaping their unrelenting deprivation, bearing its effects with valiant stoicism and, in many cases, endearing good cheer.
Support Networks
The sense of being a part of, or surrounded by, a support network was ingrained into all aspects of my journey and experience in Jordan. I seamlessly became a part of the large and established support network for the refugees I set out to serve. Beyond the provision of medical care, JMAP forged alliances with local community services. During one of my clinics at the Talbieh camp, on the outskirts of Amman, I took a short break to explore the neighbouring community rehabilitation centre. Physiotherapy, audiology and psychotherapy were amongst the services available. Zikriat, the JMAP Talbieh clinic manager, suggested I observed part of the group psychotherapy session taking place later that day. It was an eye opener. Firstly, I recognised some of the participants: they were among my patients the day before at the camp clinic. The ‘opt-in’ nature of this psychotherapy session meant these individuals were, effectively, self-selecting, but I was still highly uplifted by their levels of engagement with, and commitment to, the objectives of the session. Almost all the participants were women, half of whom were illiterate, whose lives had been defined by motherhood and devoted service to members of their extended families. They had been deprived of the opportunity to focus on themselves, to seek avenues for personal development, to have an education and, not least, to just simply live their lives. I couldn’t quite put my finger on the essence of the atmosphere enveloping the room - fierce positivity or perhaps sheer defiance? Regardless, there was a real air of togetherness, a rich sense of community. The credit also goes to the psychologist leading the session who struck a delicate balance between being profoundly empathetic and powerfully motivational.
The second observation, you may have already established, was the lack of male presence at the session. In fact, there was only one male attendee. Ahmad - I shall call him - was a gentleman in his thirties with Down’s syndrome. Ahmad, like many of the women, was also illiterate but, my goodness, he was sharp and quick-witted. He was directly in my eye line throughout the session, so my attention was drawn towards him. My initial impression was he seemed reserved, quietly pouring all his attention into the session, all whilst holding a subtle wry smile throughout. I wondered if he was shy in the presence of the outspoken women surrounding him. Yet, something seemed to be building in his mind - I could just tell. Shortly, Ahmad had his moment to shine. A deep and perplexing question posed to the group by the psychotherapist, which certainly had me pondering, was met by a clever and scintillating response from Ahmad causing the whole room to erupt with laughter; followed by, rather unexpectedly, a lively chant created and sung by the women in appreciation for him. At this point I realised the true meaning of a support network. Yes, JMAP and the community centre were a support network for the refugees. But the real glue that bound these refugees together - the ultimate support network - was themselves. Regardless of their physical or psychological health needs, they all had each other’s backs. It was just saddening to see so few male participants, a group notoriously paralysed by the stigma of mental health, some of whom I am certain would have benefited from a session like that. Engaging with this neglected group in the community within the rigours of deprivation will be an almighty task.
And, finally, I’d like to extend my gratitude to my own support network - my family, relatives and friends who regularly offered words of encouragement and wisdom prior to and during my work in Jordan. Particularly my father who communicated with me, from the UK, on a daily basis, with characteristically piercing sharp comments, to debrief after each clinic; and my mother – a true inspiration as she has been throughout my life - who made the journey to Jordan in toe to continue that support. This was the first time in over a decade I had visited Jordan together with my mother, so it was a pleasure to be able to share my experiences with her. Aside from keeping me well fed and organising my social calendar with joyous visits to countless relatives, it was actually her insights that were most invaluable. What I hadn’t realised, until this trip, was how, over the years, she has - in her typical understated fashion - provided charitable support (in a non-medical capacity) to various refugee camps around Jordan when she was able to. Offering me perspective, contextual knowledge and pastoral care as I negotiated the unfamiliar challenges of providing humanitarian support to poverty-stricken communities, Shahla, my dear mother, was my JMAP in a place through which I moved as an intimate stranger. For her guidance and dedication throughout my time in Jordan, and a lot more, I will remain eternally grateful.
