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.