JMAP 2022 - Targets: An Omnipresent Matter in Healthcare
“Finished? Come on! Quickly, let’s go! The bus is waiting for you outside” she exclaimed, rather hurriedly.
“Could I just quickly use the…” I muttered.
“No! We must go now!” She swiftly interrupted.
I rushed to grab my bag and as many of my stray items as I could - hat, sunglasses, pen, stethoscope - cradling them unstably in my arms as I was bundled into the bus, as though a VIP escaping a paparazzi mob. Of course, I forgot the lunch bag that was generously placed on my desk between my final two patients. But it was too late. Our antiquated bus - the sort that generates a nervous draw of breath between every gear change and leaves you wondering ‘is this the moment this thing breaks down?’ - had already screeched off, tyres spinning against the hot tarmac, back towards central Amman.
Hunger, heat and a full bladder, on a shaky bus ride, isn’t a combination I would recommend to anyone.
Talbieh Clinic.
An unassuming building.
Providing much needed support to residents.
A safety net.
The last two days at the Talbieh camp have been challenging, fun and frustrating all rolled into one. Talbieh is the smallest of the three camps provided for by Jordan Medical Aid for Palestinians (JMAP) with 25,000 residents, yet feels least like a refugee camp; rather some deprived urban sprawl on the outskirts of Amman. The Talbieh JMAP clinic is also the newest, having been established three years ago. Significant health inequalities, particularly leading to high rates of type 2 diabetes and hypertension, have kept the staff here very busy. Having encountered countless cases of these two notorious cardiovascular risk factors at the Hiteen/Schneller and Jerash/Gaza camps, I had anticipated the same would be the case at Talbieh. However, I didn’t expect that almost every patient I reviewed over the age of 40 - and I really mean almost every patient - suffered from either of these two diseases. So much so, JMAP have managed to partner up with a fledgling medical technology company, called Platinum, providing charitable support once a week by performing blood pressure and glucose readings on every single patient who enters the facility - regardless of which specialist they have come to see. There is also a dedicated diabetic retinopathy screening clinic. I am sure most of their workload in the last two days must have come from my referrals. Rates of obesity amongst women and smoking amongst men are also terrifyingly high. National targets here lack implementation and clarity, leaving it to smaller organisations and the voluntary sector to pick up the pieces in some cases.
A sense of desolation.
Talbieh neighbourhood.
Quiet streets.
Behind which are difficult circumstances.
Over the last two days I have been covering both rheumatology and internal medicine, much like I did at the Jerash/Gaza clinic. It seems my remit, originally planned to solely provide a rheumatology service, has changed to dual specialty provisions. On my first day at Talbieh, the waiting area was ominously bare as I walked through the entrance at 8am. I was invited up for a drink with the clinic manager, Thekrayat, a highly successful woman who had gained recognition from UNRWA for her contribution towards tackling the plight of displaced Palestinians. Thekrayat had an aura - commanding and calm - and an impressive ability to efficiently solve problems that came her way. In our 20-minute sit-down, before the start of my clinic, we were interrupted five times by colleagues asking her for input - each time she offered a sensible solution, without drama, boosting her team’s morale with a sense of enhanced confidence. She was also hands-on during the clinics, ensuring all the cogs in the wheel were moving slickly. She checked in with me twice during my clinic, once with Dr Zahira (JMAP Deputy Medical/Technical Director) - a pleasant surprise, to ensure I was settling in alright. Thekrayat is undoubtedly an instinctive leader.
Calm before the storm.
Clock hits 8:30am.
Cue ensuing hustle and bustle.
My clinic on the first day at Talbieh was relentless, to say the least. The schedule was 8:30am till 2pm and within an hour of starting, the notes of patients who had checked in to see me were stacked high - a grand total of 70 patients. A frankly impossible task lay ahead. Sister Hanadi, my assigned clinic nurse for the day, worked hard to keep me on track, much like Sister Rahaf from the Hiteen/Schneller clinic. “Faster! Faster!” she’d demand, sensing the growing impatience in the waiting area. At one point - to my surprise - patients were being brought into my room in pairs to speed things up. This felt rather unusual and certainly at odds with standard practice in the UK, however, the patients didn’t seem to mind - perhaps even appreciating the introductory preview prior to their assessment. I finished my clinic half-an-hour late having seen just 36 patients - that’s six per hour, most of whom were new to the clinic with various acute and chronic illness - with the remaining 34 patients moved to the following day. My tardiness lead to a delay in the departure of our bus much to the benign disgruntlement of my fellow colleagues who had gathered en masse outside my clinic room and nudged me onto the bus (despite my lethargic plea to use the bathroom!) the moment my final patient walked out of the room. I hastily waved goodbye to Sister Hanadi and I was driven off into the distance.
On the journey back to Amman, I reflected upon the challenge of taking an accurate medication history from patients during my clinic. Except for four patients, nobody brought in or could tell me which medications they were taking. This made it extremely difficult to optimise chronic disease or be certain that any short-term medications I prescribed weren’t going to interact with any pre-existing treatments. In some cases, particularly those on immunosuppressive treatment, I had to ask patients to return home and come back with a list of their medications. At one point Sister Hanadi rather bluntly pointed out to a patient that I was a doctor not a magician! Admittedly, it was frustrating at times not being able to provide an ideal standard of care to those who really needed optimisation of their treatment, but I was careful not to display this frustration. Fostering trust with vulnerable individuals is imperative and I took the opportunity to discuss potential solutions to this matter with Thekrayat the following day.
Thankfully, the following day was more civilised. For one reason or another, only 20 of the 34 remaining patients showed up plus a handful of ‘walk-in’ patients. I was paired up with Sister Sabreen who was born and raised in the Talbieh refugee camp. She seemed to know everybody who walked into the clinic room, whether on a personal or professional level, and they all absolutely adored her. Every other patient offered her an invitation to lunch or dinner later in the day; she had an incredible connection with the local community.
Sister Sabreen’s story is quite remarkable. Growing up with nothing, she got married at the age of 16 and had the first of her three children by the age of 17. She then spent the best part of a decade raising her three girls, one of whom is registered blind, before her husband became critically unwell with a heart attack. He survived but not without lasting consequence. She dedicated the next three years fighting tooth and nail to ensure he received all the necessary medical care to help him improve. Finding reward and passion within this hardship, she decided to sit her Tawjihi (equivalent to A-level) exams at the age of 30 and go on to study nursing at university, achieving a distinction. Now she works alongside experienced physicians and surgeons in the JMAP clinic providing invaluable input towards patients care. Sister Sabreen is also a wonderful role model to her children, also born and raised in the Talbieh refugee camp, with her eldest about to enter her Tawjihi year and is on course for a top grade which will hopefully secure her a place in medical school. If you thought Sister Sabreen couldn’t be any more of an inspiration, think again. She spends countless hours in her spare time producing voice recordings of every page from every textbook belonging to her middle child, the one registered blind, to minimise the impact of her disability on her progress and opportunities in life. When she told me this, I was speechless!
Another spacious clinic room.
X-ray film viewer mounted on the wall.
Pleasing amount of clarity.
A change from the computer screen.
Thankful for the air conditioning.
Modern healthcare delivery is heavily target-driven. Whether it is blood pressure control, blood sugar monitoring or a ‘treat-to-target’ approach for treating autoimmune inflammatory diseases like rheumatoid arthritis, the goal is to drive improvements in individual and population health outcomes; in turn reducing the socio-economic burden on society. One case from my two days at Talbieh will stick with me forever. To contextualise, the management of rheumatoid arthritis, a disease which causes permanent joint damage if left inadequately treated, has advanced leaps and bounds in the last 20 years due to the advent of biologic therapies and adopting a ‘treat-to-target’ strategy - the target being disease quiescence. Gone are the days of waiting rooms full of individuals with advanced and disabling (‘burnt-out’) joint disease - the prevalence of this nature of rheumatoid arthritis is far less than it once was. Nowadays, in developed nations, newly diagnosed patients are treated rapidly and effectively to prevent the onset of irreparable joint disease, thus preventing joint deformity and any classical signs of rheumatoid arthritis.
Concerned that one of the Talbieh residents wasn’t receiving the treatment she needed, Thekrayat organised for a young lady from the camp, 31 years of age, to see me in the clinic. Ten years ago, this lady had been given a delayed diagnosis of rheumatoid arthritis, three years after her symptom onset, having already developed permanent joint damage to her hands, wrists, elbows, knees and ankles. Barely able to walk into my clinic room, I could instantly tell her rheumatoid arthritis was active. She had been started, and remained, on triple disease modifying treatment - methotrexate, sulfasalazine and hydroxychloroquine - for the past decade by a rheumatologist in a government hospital despite years of ongoing active joint inflammation. Almost all rheumatologists will know that she should be on an escalated form of treatment, a biologic drug, to gain control of her disease activity and prevent any further joint damage and disability. What really startled me was her perception of her own disease. She was convinced she was on maximal treatment and had accepted life with perpetually inflamed joints and an inevitable future of declining physical function. Her treatment target had fallen short, it seemed. One of the limitations of a charitable organisation like JMAP, understandably, is not being able to prescribe and provide higher cost medications such as biologic drugs. Dr Zahira, Thekrayat and I all agreed with the patient that we would liaise with her hospital rheumatology team with the aim of encouraging them to escalate her treatment. I was warned this might ruffle some feathers, creating a sense of provocation, but advocating for our patients is our duty and this poor lady desperately needs our help. Thekrayat promised to keep me posted on her progress once I return back to the UK. If she doesn’t, I will chase her up for updates!
