JMAP 2022 - Between a Rock and a Hard Place
Abject poverty.
Vantage point from the roof of the clinic.
Plight of the Jerash/Gaza refugees is inescapable.
More than just a catchment area.
Tawjihi! If you know, you know! A national day of celebration. Or a day of personal disappointment. Everyone here knows someone who’s done Tawjihi - victory or defeat feel like the only two outcomes. Sounds of revelry can be heard on the streets after midnight when the results are declared, akin to a new year celebration. For those who feel left out, it’s a few faint words with dejected parents, helpless relatives and commiserating friends. Tawjihi is the final stage of secondary education, much like Advanced Highers in Scotland or A-levels in England, and it’s a huge occasion here in Jordan. Last night Tawjihi results were released. Families rushed out in their cars into the early hours of the morning honking their horns in a cacophony of discordant notes, setting off fireworks and - sometimes - firing live rounds of ammunition into the night sky, revelling in the success of their children. The thing with Tawjihi is it has such a significant bearing on these hopeful teenagers, a stamp for life, shaping their futures for better or for worse. But 'Tawjihi-inflation’, as I like to call it, means that even if you score 95% - which by all accounts is outstanding - you do not get a place at medical school in Jordan, the most competitive of university courses. The person who gets the highest grade in the country will have their moment of glory by meeting a member of the Jordanian Royal Family. My father had this honour in the late 1960’s - we have a picture and a presentation Sultana watch as a memento - when he met King Hussein of Jordan; having scored one of the best grades in the land, a mere 88.4%. It seems inflation is everywhere.
Transportation.
Donation.
From Indonesia.
To JMAP.
As you may expect, I woke up with a headache. Suffering from yesterday’s baptism of fire and sleep interrupted by the sound of car horns - I knew that, while easing my trivial pains with a refreshingly cool shower, nothing would compare to the suffering I was sure to witness in the Jerash/Gaza refugee camp today. I arrived at the Jordan Medical Aid for Palestinians (JMAP) headquarters at 7am to be picked up by a friendly, young chap called Uday. I’ll get straight to the point - Uday is the ultimate stalwart. He’s been driving doctors, nurses and dentists to and from the Jerash/Gaza camp, over an hour each way, for the last five years. He’s never taken a sick day off work and could count on his hands and feet the number of days of annual leave he’s had during his time with JMAP. This 26-year-old trooper lives and breathes JMAP. The drive between Amman and Jerash is incredibly taxing - the roads, the obstacles, the other drivers, the detours and the congestion. I bet if we healthcare professionals in the UK were left to make this unforgiving journey - day-in, day-out - then the system would start to creak. Yet he does it with consummate ease and heartfelt cheer. I was the first to arrive at the bus and he swiftly shook my hand and made me feel like a friend. “Hop onto the front passenger seat, buddy!” he said brimming with positivity. We zipped through the north of Amman picking up colleagues on the way, including Dr Bassam - an extremely experienced general practitioner who quizzed me on everything rheumatological during the bus journey. His thirst for new knowledge was admirable.
Hands up if you enjoy having root canal treatment.
Dynamic dental team providing an essential service.
Tackling periodontal disease is crucial.
Thank you Canada Fund.
Invisalign not included.
We arrived at the Jerash/Gaza refugee camp shortly after 8am. I was introduced to many different people, including the cleaning lady who couldn’t have been more welcoming. She awaited my arrival with a cup of coffee - she must have heard about my day yesterday! I gratefully accepted the coffee on this occasion. After a brief multi-disciplinary meeting involving myself, the dentist, pharmacist and Dr Bassam, we got started with our clinics. I had two clinic nurses assigned to me - Sisters Maha and Doa’ - who were surprised to hear I wouldn’t be using the echocardiogram in the room to scan the patients hearts, asking me to explain; this never featured as part of my medical training, generally cardiologists and, sometimes, intensivists formally receive this sort of training in the UK, I told them. Sisters Maha and Doa’ informed me that my clinic would include both rheumatology and internal medicine cases, and that some of the other internists working with JMAP are proficient with echocardiography should I need their help. It seems that the level of skill and care the physicians bring here is second to none, a well-deserved feather in JMAP’s cap.
Mosque at the edge of the camp.
A sense of solace.
The least they deserve.
Today’s clinic went smoothly. It was a shorter session - 8:30am til 1:30pm - and only 15 patients came to see me. However, each case was intriguing in its own way. From a medical perspective, I saw a patient with a recurrence of subglottic stenosis secondary to an aggressive form of granulomatosis with polyangiitis (GPA), an autoimmune disease causing blood vessel inflammation - vasculitis. I escalated her treatment and referred her to the JMAP Ear, Nose & Throat Consultant who will see her on Saturday. I also saw a patient with a large multinodular goitre, something I can only recall having seen in endocrinology clinics and practical exams during my medical training. Dr Bassam told me patients present with goitres on a frequent basis in his JMAP clinic, I suspect due to a nutritional deficiency of iodine in the camp. I also saw two patients with a first attack of naqras (yes you guessed it, that’s Arabic for gout - I was determined not to forget!). Also, 90% of women over the age of 60 who have come to my JMAP clinics thus far (including yesterday) have type 2 diabetes and hypertension, which in most cases were inadequately controlled. This is nothing short of a public health crisis.
Another case which captured my attention, less so for medical reasons, was a 38-year-old lady who, since the age of 16, had been suffering with psychogenic nonepileptic seizures (otherwise known as pseudoseizures) which are paroxysms of shaking that on initial observation may resemble epileptic seizures but are in fact stress-related. She had heard of a doctor who travelled from abroad, me, who might be able to cure her seizures. She and her sister, who was also in attendance, waited with bated breath for a verdict as I gathered my thoughts after a thorough general examination. The news I delivered - emphasising the need to focus on psychological therapies - felt to them like a shuddering blow. After all, the patient was carrying years of shame from having been engaged numerous times but not able to marry due to the impact of these seizures on her relationships. Her sense of cultural indignity, due entirely to misfortune, couldn’t but further compound her misery, as a refugee in abject poverty, without a partner to negotiate life’s unimaginable challenges.
The real deal.
Possibly the best falafel I’ve ever had.
A humble store in the town of Jerash.
Buoyant bus journey home.
Bonding over the sublime flavour.
Before I conclude this piece by raving about the quality of the falafel we had on the bus back to Amman - thanks to Uday, the perennial legend who treated us - I would like to touch upon one more serious point. The Jerash/Gaza camp is almost exclusively for refugees from the Gaza Strip. Displaced from their rightful homes in Gaza, which is nothing but a 140 square mile open air prison, and seeking refuge on the outskirts of Jerash, you wouldn’t be blamed for thinking that their lives would be less defined by oppression and hopelessness. However, to my dismay, I was told by various sources today that the camp residents are not granted the equivalent of a national number due to an archaic arrangement by Palestinian and Jordanian authorities, which makes it extremely difficult for these people to eke out a living on par with Jordanian citizens. Aside from the paucity of employment opportunities due to the lack of industry in the surrounding area, something that favours the Hiteen/Schneller and Talbieh camps, the ongoing enforcement of this regulation further ostracises an already marginalised community. I spent most of this afternoon trying to verify this information. After searching the depths of the web I stumbled across a document - Decades of Resiliance: Stateless Gazan Refugees in Jordan, published the Palestinian Return Centre - pages 10 and 11 allude to what I was told earlier. To encapsulate: “Most recently, in 2014 the Prime Minister granted certain privileges to Gazan children of Jordanian women instead of citizenship, claiming that citizenship ‘might affect the demographic balance in Jordan and might lead to empty Palestine from its people.’”. The author of this document rightly challenged this notion: “Such claims are entirely unfounded as [Jordanian] citizenship and the right of return [to Palestine] for refugees are not mutually exclusive.” I really hope the inspirational 17-year-old in the camp, the talk of the town who remarkably scored 99% in his Tawjihi, is able to escape the restrictions which surround his life and that he will be able to craft a new future for himself.
I promised I’d mention the falafel once more before I close. They were phenomenal. Uday, once again, brought the team together with an unshakable camaraderie, successfully facilitating what us medics seemingly struggle to do after facing adversity in the workplace - compartmentalise, defuse and recharge. Hats off to Uday, what a gentleman!
