Virtual Refugees

There are a number of instances where we have challenging patients that need care from a specialist. Unfortunately, access to specialist services for Syrian patients in Jordan is somewhere between scarce and non-existent.

There was a teenager in Za’atari who had a foreign body lodged in his cornea. There are no ophthalmologists in the camp, so the physician gave him antibiotic eyedrops and sent him on his way. There was a two and a half year old with cerebral palsy, a condition he had since having extremely high fevers the month after birth. He was anemic because he could only eat his mother’s milk. He could not stand, and it was clear he could barely see. They came to us at the spinal cord injury center for physical therapy, but he clearly needed more. In addition to his neurological problems, he’d never had a single vaccination.

It was in this context I asked some colleagues in an NGO I volunteer with if we could post some occasional clinical questions to their network of experts. Their response resonated with me:

“Our policy is to keep our medical listservs focused on our patients in [our target country]“

To understand why it resonated, I’d like to invite you to be an honorary member of the Yale Med Class of 2010. It was a humid day at the end of May when Don Berwick, then Director of Medicare and Medicaid Services, gave his address. It was a surprising speech for a medical school graduation because Berwick spoke not of his patient, but of his patient’s wife, Mrs. Gruzenski.

Mrs. Gruzenski complained to the hospital after being asked to leave the ICU because visiting hours were over. Her husband spent 8 of the last 16 days of his life in the ICU where the staff restricted her visits to four hours a day. For a couple that had rarely been separated, Mrs. Gruzenski described these policies as “cruel”.

Berwick cautioned us that we will encounter the Gruzenskis repeatedly throughout our career. While we push papers around a desk, it might not seem that we are powerful, but he warned us that:

The choice is not in the hands of nameless power, not fated to control by deaf habit. Not “our policy,” “the rule.” Just you. Your choice. Your rule. Your power.

Berwick noted that these bureaucratic responses are rational, just like this one. This NGO may get innumerable requests for people to post on their expert listserv. Clearly, if they accepted all requests, their own patients’ cases would get drowned out.

But, as Berwick noted, it’s the ellipses, that which is left unsaid that is irrational. We must prioritize the people in our country over those from yours. What is the challenge of providing care to a refugee population if not this? As Berwick said, “This is the voice of power; and power does not always think the whole thing through.”

And for Syrians, differential treatment is one of the largest barriers to consultation and care in Jordan. Even in the hospitals that ostensibly focus on care for Syrian refugees, Syrian operating room cases get bumped to prioritize Jordanians. When that hospital only has capacity for four surgical cases per day, this sometimes means Syrian cases with a higher medical priority are dangerously postponed for nationality preferences.

Somewhat ironically, the organization I emailed is committed to global health equity. The organization provides free care to the rural poor in an unquestionably difficult environment. I know the founders well. I don’t doubt their commitment to their patients, their desire to provide the highest quality care, or their commitment to global health.

But the bureaucratese of phrases like “our policy” only marginalize the marginalized even further. It means refugees are second priority not only in their host country but virtually as well.

No more nights in the hospital

كلكم من آدم و آدم من تراب 
Kulkum min Adam wa Adam min turaab 
All of you are from Adam, and Adam is made of earth 

Yesterday there was a bombing in a mosque in Damascus. Sheikh Booti was killed after prayers by a suicide bomber who took around forty others with him. The head of the SCI house spat on the floor, cheering the death of this hated supporter of the regime. He's ecstatic and sees the fact that the bombing was in a mosque, or that it took forty others with him, as necessary evils for a greater good. For emphasis he added "Allah MA yrhamu" - may God NOT have mercy on him.

He tells us this as we're on our way to a funeral for Abu Hussein, the patient I took to the hospital one night a few weeks ago. A man who was shot on the outskirts of Damascus, paralyzed, and slowly deteriorated over two months until he passed away. Another casualty of this war. But Abu Hussein didn't die in a mosque, he died in a hospital, after multiple avoidable complications. Allah yrhamu.

Dr. B and I heard the news after a long day in Za'atari where a patient told me she was going back to Syria that afternoon. I asked about security and why she was going back. "Sooriya ahla" she said - Syria is more beautiful.

We stood on the main street watching kids throw rocks and kicked ourselves. We admitted Abu Hussein to the hospital and visited him once but figured, hey, he's in the hospital, they're taking care of him. What could go wrong.

We admitted him for his breathing, but he had been having diarrhea for weeks before arriving in Amman. While being treated for presumptive pneumonia his diarrhea resolved. But he was not on a bowel regimen, and paralyzed people can often have difficulty moving their bowels. I hear that he had eight days of constipation before he developed a small bowel obstruction. He was taken to surgery and did not do well. After two days in the ICU, he passed away.

We then stood in the cemetery, among the men who arrived in cars with Syrian plates, placing Abu Hussein in his concrete sarcophagus. Concrete slabs wedged over the box and sealed with mud clumps hurled with a thud.

If Adam is made of earth, he seemed angry today. A sunny morning turned into a dust storm that seemed intent on burying us all. The pale orange horizon consumed the mountains in the distance. The dust storm met the funeral procession as we walked into the wind.

Being buried in a strange land means no one knows you're the brother. It means you don't know where you need to be during certain times for certain rituals. But I recognized him by his hands. They're disproportionately large and today he struggled more than usual with where to put them. I love his Arabic. Long, drawn out vowels and his slow speech, like he's ordering a delicacy in a southern restaurant, make him simple to understand.

He recognized us and we hugged; his beard had grown longer but didn't hide his sadness or the clear disorientation. He was late to the line where everyone passes to shake hands. I wanted to ask how did things get so bad so that Abu Hussein passed so quickly. Ask why he didn't call us sooner. When I shook his hand all I could say was Allah yrhamu. He is a martyr now. Insha'allah he said, his eyes full of tears that the orange dust smeared and pasted down his nose.

A man from Abu Hussein's home town said that as the situation deteriorated he told Abu Hussein he was going to get Abu M and me. He died two hours later. He wanted us to know Abu Hussein died thinking we were on our way to see him.

The attendees disbursed with the wind. Abu M and Dr B recited the Sura Ya Sin over the mound marking Abu Hussein's body and we walked back to the car. On the way we passed by the next wave of graves, the cementery:

 

The FSA does not exist

In other news, this is a great post by Joshua Landis on the fact that there really is no Free Syrian Army in the context that we would know any army. Please keep this in mind when you read my posts as well.

My favorite line:

“According to photographic evidence seen by this reporter, it seems like ten guys from a tiny village outside Idleb have recently been lobbing mortar shells at a blurry target in the distance while shouting ’Allahu Akbar’.”

Reunion

The family I lived with in Damascus in 2004 was not your typical Muslim crew. The mother wears a hijab, but the daughters don't. In most places, even having men over to your house is haram - forbidden - but in this house there were multiple single, foreign men living with single, unhijabed women. We were the scandal of the neighborhood, but we also had a lot of laughs. This is where I met Andrew, now one of my good friends. Its where I took my first colloquial Arabic lessons (from one of the daughters) and also where I learned all of my Arabic curse words (from the matriarch, no less). I had recently finished one of my pediatric rotations, so the family liked to humor me, saying I was Adam's doctor, Adam having been born a month before I arrived. Adam is now 8, beat me at chess, and can handle himself in English, Arabic and Danish.

Last time I saw them, it was 2006 when my brother was in the Middle East. We took a service mini bus up Muhajireen and had a small dinner with the family. Since the war started I'd been afraid to contact them because I'd heard of people who were arrested being kept longer or worse just because of things written by their friends on Facebook.


Then I heard they were in Amman and reconnected. Andrew, who is spending most of his time in Turkey, happens to be in Amman this week, so we had a semi-family reunion.

The youngest was seven classes from finishing a degree in English, but things were too unsafe in Damascus to continue. They've come to Amman, but everything is more expensive - medicine, oil, transport - meaning that the fees one daughter charges for Arabic lessons are barely making ends meet. The matriarch has growing cataracts in both eyes, but surgery is very expensive and must be paid for out of pocket.

Sounds like stories I've heard from refugees in Amman, in Za'atari. But this one hits a bit closer to home.

White man's ice is colder

There is an old joke or fable among the African American community...It goes like this, in this small town, a black man was selling ice to the people of the town. He was making a good living from his ice selling business. A white man, seeing the profit in such a venture started a competitive ice selling business. The Blacks in the town began to buy their ice from the white man. When asked why the change, they answered "the white man's ice is colder".

"White man's ice is colder". I love how succinctly it shows the ridiculousness of internalized, institutional racism even better than the famous Clark doll experiment that paved the way for Brown v. Board of Education. Its a persistent problem in minority communities in the US, in post-colonial societies and its something I've witnessed in the medical community among doctors from Syria, Lebanon and Jordan.

When I was in Beirut, I was impressed with the level of care at the two hospitals I worked at. Residents there knew their stuff, worked their butts off and could handle anything that came in the door. One resident I knew had memorized every diagram in all 1500 pages of Harrison's.

To my surprise, there was a pervading expectation that you MUST train abroad. In one study 95% of Lebanese med students planned to do either residency or sub-specialty abroad. Of those, 3/4 planned to go to the US.

There are a number of factors in this decision, including increased competitiveness for jobs in Beirut (where there are actually too many doctors) as well as cultural norms of emigration.

But ironically, many Lebanese med students ended up in the US getting training of lower quality than they were getting in Lebanon (not to name hospitals). Yet having that "trained in the US" stamp was highly sought after regardless of the actual quality of training received.

This also manifested itself in how people interacted with me in Beirut, where pedigree was paramount. One resident once introduced me to a patient saying, "This is Yale." There was an assumption that whatever medical management we did in the US was the standard of care. Where the reality is that there is a high degree of variation in practice, protocols and quality between different hospitals in the US. To give one example, there is a lot of variation in antibiotic choice, duration and even what threshold to treat cases of ventilator associated pneumonia. In my own personal experience, I've seen vastly different practices from c-section rates to wound management.

It manifests in how those around me are treated. Dr. B, who is a second year resident and whom I have high respect for as a clinician, is often dismissed when he raises medical points with some of the patients we've seen. Yet when I speak, people seem to listen. So we've tried to use this to our advantage - like when one patient was hypotensive and needed fluid (quickly!). Dr. B's requests were ignored when we could see that running one small-bore IV with 0.5L at a time wasn't going to cut it. We only got a second IV when I went directly to the doctor to ask for it.

Granted, there are clear differences in the capacity of different medical services here. Troponins are binary in many hospitals here, meaning that they're either positive or negative. In the US we use these lab values to track not only whether someone had a heart attack (i.e. positive troponins) but how high the troponins go tells us about how bad the heart attack was. And even worse, when kidney function is reduced, these numbers are even harder to interpret. (Troponins are released when there's injury to heart muscle and cleared by the kidney. But if the kidney isn't functioning well, it messes up our ability to tell both if someone had a heart attack and how bad that attack might have been.)

And sometimes there's just poor care, like how it took 30 minutes to even get vitals on Abu Hussein when we took him to ER. Unfortunately, poor care occasionally happens both in the US and here in Jordan. While individual physicians and nurses in both places can be excellent, infrastructure, hierarchy and budget constraints negatively impact care in both places.

Healthcare in the US and here are not equal. In a middle income country, resource and infrastructure constraints have a more palpable impact on the system of care here than in the US. But I've been extremely impressed by many of the physicians I've worked with - from Syria, Lebanon or Jordan. Internalized racism does not subside easily, yet I hope the fallacy that one "must" be trained in the US to be a good doctor can be put to rest sometime soon.

Its funny cause its true

Somehow The Onion gets it right:

Report: Syria Running Dangerously Low On Civilians To Oppress

Scientists Say U.S. May Have Discovered Previously Unknown Level Of Not Caring About Syria

Having Gone This Far Without Caring About Syria, Nation To Finish What It Started

Alien World To Help Out Syria Since This One Refuses To

Less funny, more scathing:

The 6 Best Dresses at The Golden Globes

Match Day

Celebrating the two-year anniversary of the start of the Syrian revolution yesterday, a few hundred peopled gathered in protest in front of the Syrian embassy in Amman. Across the street, the embassy is passive, surrounded by the Jordanian army. In front blares Quranic chants to drown out the chants of the protesters. It doesn't work.

"Takbir!" he yelled.

The crowd bellowed back "Allahu akbar!"

Again he yelled "Takbiiiiir!"

Louder this time, "Allahu akbar!"

Coming from the US, such freedom of expression shouldn't surprise me. I've been to protests and marched on Washington. But when I was in Syria, the ubiquitous photo of Bashar Assad and his father was what passed for political expression. Talking about anything else was dangerous - for Syrians not for me. So no one in Syria expressed dissent or displeasure except once, an elderly taxi driver who had woken up at 3am to drive a friend and me to the airport for $10 spoke about how bad things were under Assad. And I'm sure he only spoke because he knew we were leaving the country.

But yesterday's protest surprised me. Syrians, protesting. I'd never felt that before. Sure, I'd seen the protests on YouTube, of oceans of people in squares I had visited, chanting and singing. I knew, cognitively, there had been protests with hundreds of thousands of people. But yesterday for the first time I felt the pulse.

I saw how eagerly women yelled various popular chants:

Yalla irhal ya Bashar! (Hurry up and leave, Bashar!)

Wahad, wahad, wahad, asshaab assoori wahad! (One, one, one, Syrians are all one)

I saw how elderly men who couldn't stand inched their chairs closer and closer. I saw young men, including some of the injured from apartments I've visited, dancing and singing. And the protesters were diverse. There were rich and poor Syrians, men and women of all ages. Christians and Muslims. I thought of the guys in the SCI house, how they would have wanted to be there.

Protests aren't democracy. There's no way to distinguish a vocal minority from the majority. But coming from a Syria where protests are violently suppressed, it takes courage to stand in front of their estranged embassy. Courage, because they know they're being filmed. Courage, because they're already refugees, because they do not know when they'll be able to return to a safe, stable Syria. If they returned now they'll risk being arrested, not to mention the situation is still so unsafe in the big cities that returning would be unwise.

An hour later I get an email saying I matched at Cambridge Health Alliance in Internal Medicine. I'll return to home to Boston in April, knowing where I'll be for the next three years.

Cotton anniversary

Its the two-year anniversary of the start of the Syrian revolution. Since I'm not on the ground in Syria, I'll leave it to the experts to describe the war two years on:

This is what the Syrian war looks like. Every man with a gun is an authority, and for some the enemy—who was once their neighbor—is no longer a person. How can a man who has inflicted such harm, and become used to that sort of power, let it go and step back—especially if others do not?