Amman, Jordan - At least 60 people, most of them Syrian refugee women and children, squeezed anxiously into the makeshift waiting area. Some had not seen a doctor in years, but when a team of doctors came for one day to the northern Jordanian city of Ajloun, they had a rare chance to receive free medical care.
Inside the large general medical room, Frederic Hoffman, an American radiologist by training, and Khalid Abu Rumman, a Jordanian medical intern, brainstormed out loud. How could they take a urine sample from a 15-month-old, diaper-wearing boy? They determined fairly quickly that they had one option.
"Is his diaper wet?" Abu Rumman asked the boy's mother. She nodded and began removing it. Abu Rumman grimaced as he wrung out the diaper; he had caught a whiff of the foul-smelling urine the mother had warned him about.
A colour test strip showed that the boy had a urinary tract infection. Hoffman prescribed amoxicillin on an informal medical record, handing it back to the mother so she could take it to the makeshift pharmacy across the hall.
Meanwhile, other teams of doctors listened to patients' complaints and heartbeats, examined ears and skin rashes. They worked quickly with the resources they had: tongue depressors, various scopes, and a shared scale. Nearby, Rita Zawaideh, one of the leaders of the team, distributed milk formula and diapers. By day's end, Zawaideh would hand out 500 milk canisters and 2,800 diapers, while the doctors would see 388 patients.
It was the second day of a week-long medical-humanitarian mission under the auspices of the Salaam Cultural Museum (SCM), a non-profit organisation based in Seattle, Washington. The group included about 40 doctors and volunteers from Jordan, the United States, and Syria. Some provided urgent medical care to pockets of urban Syrian refugees that had slipped under the radar of other aid groups, while three surgeons operated on Syrians at a hospital in Amman and several psychiatrists held group therapy sessions for children.
As the doctors visited different refugee communities, they found a wealth of need. Chronic illnesses like diabetes and hypertension reigned among senior refugees, while children exchanged respiratory illnesses among themselves like new toys. Many women needed gynaecological care. Yet throughout these daily medical blitzes, a piecemeal healthcare system for refugees and a lack of resources raised tough questions about the doctors' long-term impact and their role in one of today's most complex humanitarian crises.
Refugees usually live in more cramped conditions. [In these kinds of situations] communicable disease will have the potential to spread faster.
From the hills above, the flat agricultural expanse north of the Dead Sea known as the Jordan Valley is comprised of two different colours: the off-white plastic of greenhouses, and the lush green of crops. Even from the ground, the dusty white tents of Syrian refugees interspersed between greenhouses and fields were difficult to discern.
"We are forgotten," said Fatima, a 19-year-old girl from Hama, Syria who lived in one of the three refugee communities that the mission visited in the area, known as Deir Ala. Like many of the refugees who had settled there, she had a background in agriculture and could earn 4-5 Jordanian dinars ($5.60-7) per day working on local farms.
But their living conditions were abysmal. "The water and sewage are the same," pointed out Eiad Sayed, a doctor and one of the team's leaders. Most of the refugees in Deir Ala lived in either UN-provided tents or in metal-framed structures covered with cloth.
"Refugees usually live in more cramped conditions" without immediate access to clean water or protection from extreme heat or cold, explained Dr Michel Gabaudan, the head of Refugees International (he is not affiliated with the medical mission). In these kinds of situations, "communicable disease will have the potential to spread faster", he said.
As the medical team arrived at the first site, a member of the Jordanian Women's Union (JWU) - the local organisation with which SCM coordinates - spoke with the refugees. One tent was quickly designated for general care and another for the women's clinic. Laila Midan, the group's pharmacist who proved adept at setting up a pharmacy anytime, anywhere, began unzipping and stacking suitcases in the back of a van.
Sayed's first patient was Amina, a 61-year-old woman who could not remember the last time she'd seen a doctor. She had diabetes and hypertension, and she showed Sayed the medicines she had been taking. "We have people with chronic diseases that we need to get them medicine for," Sayed said as he prescribed her something to make her more comfortable. Amina shuffled over to the women's clinic, where she confided in Maha Orabi, an obstetrician-gynaecologist, about other problems. Zawaideh, one of the team leaders, described her as "one of the most needed doctors", because women are frequently unwilling to share female-specific symptoms with male doctors.
In the next Syrian community in Deir Ala, one boy had had diarrhoea for two years. Two American doctors, Naseem Paruk and Haidar Kabbani, asked for more details before trying to guess the cause - something in the local food? Amoebas? They decided on the latter and Paruk pulled up an application on his smartphone that had tables of proper dosages. Without a scale, though, the doctors were forced to guess the boy's weight.
Isolated or integrated?
In Jordan, 590,749 Syrian refugees are registered with the United Nations refugee agency, although the government states that Jordan is hosting at least 1.5 million, with the vast majority living in cities and villages. Three years since fighting in Syria began, the crisis response still consists mainly of emergency and month-to-month aid, like cash assistance and food vouchers. Jordan has made space in schools and hospitals for refugees, but as refugees are unable to legally work, they are heavily dependent on aid and government services, placing a significant burden on Jordan's infrastructure.
Jordan's minister of planning estimated that the country had spent $1.7bn on Syrian refugees as of October 2013, and from January through April 2013, the Ministry of Health estimated it had spent $53m on care for Syrian refugees alone.
Medical missions can be helpful if they meet specific needs that others cannot, noted Gabaudan, but such missions must also "leave some longer-term benefits to the government". He suggested that development aid "really reach out to the government to help them boost their own facilities".
"These missions tend to be far more expensive" than other options, Gabaudan added. Indeed, everyone in SCM's medical mission covered their own costs, and Paruk estimated that he spent $3,000 on flights, accommodations and food. Still, the short-term benefits of their visit were clear to him, since many common ailments could be treated fairly quickly and successfully. He was less certain about the long term. "I'm not sure if our referrals make it to the place they need to go," he said, suggesting that if more groups were involved, perhaps care could be more sustainable.
"The problem is follow-up," agreed Timothy Liveright, a US physician. Ending a visit with a patient gave him "a feeling that patients are leaving and going out into the wilderness". But at least patients are being cared for at that time, he added.
In that sense, JWU's "involvement is critical in terms of follow-up", Eiad Sayed said. "JWU gives us the opportunity to initiate a plan of care and create a medical record."
Regardless of the uncertainty of follow-up and long-term care, patients do benefit from the mission's visits. Samira, 53, was visiting the mission's clinic for the second time in Madaba, a city south of Amman. She had diabetes and hypertension, among other conditions, but was unable to get free care elsewhere because her UN papers identifying her as a refugee expired in mid-November.
"When I come here, it doesn't matter that it's expired," she said. She can get free medicine that would cost her hundreds of dinars otherwise. Still, she confided quietly as she lifted different parts of clothing to reveal various ailments, "I need more than one doctor."
Competing for space
At 8:30 am in a hospital in Amman, the team's three surgeons waited for an operating room. They were pleasantly surprised when one became available just before 9 am. Some days, they would arrive at the hospital at 8:30 am and wait until 2:30 pm for a room, said Benton Brown, a general surgeon.
"There are plenty of surgeons and plenty of patients, [but] there's a long line for operating rooms, and we're at the back of it," he added. None of the surgeons were licensed to operate in Jordan, but some hospitals will donate operating space and turn a blind eye to the technicalities as long as expenses are covered, according to Sayed.
That morning, Brown and Abeer Abdelnaby, a colorectal surgeon, would be operating on a patient who had been shot in the abdomen and needed a colostomy.
"We went back into his abdomen" and reconnected the colon "so that he go to the bathroom normally", Abdelnaby explained afterwards. After finishing, they continued to wait for an open room. Though frustrating, the process is ultimately worthwhile, Brown said. In one instance, a 14-year-old with gunshot wounds would have died had they not operated.
Because their work sometimes feels like a drop in the ocean, Brown said a lot of people assume that, "If I can't help everybody, why even try?"
Brown responded to the question: "That's no reason not to try."
For more information about the Salaam Cultural Museum, visit their website.
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