Children of Deir Alla

I woke up thinking of them. The kids in Deir Alla in the Jordanian river valley are the most concerning. They are living in the worst conditions. We were there near the end of March and the temperature was 89°F. I wonder what will the temperature be in the August. And how they will survive. Will the water be enough?

Their bathroom was a big hole in a tent. You can never approach without masking up. There were flies everywhere. The smell was unbearable. The place was filthy. It is very easy for a kid to fall and get lost in one of these holes.

They were finally able to engage the kids and set up a coloring competition. Papers of coloring books and crayons were on their laps or on the ground. There were no seats, no desks, and no clipboards. There were just kids with their papers and crayons without support on the ground.

Three kids won the reward for best coloring and got prizes. But even in their success there was sadness in their eyes. They have great potentials but some are not going to school, some probably by their parents’ choice. They want to play and they want to learn but who is going to help the parents earn? Who is going to help the single mother? Or the father who is crippled by his neuropathic pain related to his posttraumatic stress?

One or two kids are not happy that we came. They have the ulcer and they will get an injection. The endless screaming and the running away from the needle and the final succumb hurt ones heart. We are set to put a smile on each kids face. For those two, we are saving their smiles for the future when they look at their unscarred face in the mirror.

The problem of these children is beyond you and me. It is beyond a single mission or multiple missions. It cannot be solved by a Band-Aid. It can possibly be approached by organizations such as the United Nations if there was the will. You could set up sanitary living conditions, schools and clinics but that will only make their exile permanent. The disease has to be approached from the inside. The conflict has to end and they have to go back safely to their homes.

Children coloring for the competition 

Omar was one of the winner

Iman was another winner but she was too shy for a picture

The boy with leishmaniasis on his face was not happy

Goodbye Room 552

As I closed the door to the hotel room heading toward the hotel lobby to check out, a strange feeling came to me. I felt a knot in my chest, a flash back of the past few days with their ups and downs. There were moments of despair and others of triumph. The Syrian refugees are living a miserable life. We came to their life for few hours every day and then went back to the comfort of our hotel rooms and they went back to their daily misery. We will go back to our usual daily routine that steal us away from their plight but they will be there in the desert caravans, in the valley tents, and in the little molded rooms.

When I came here I was seeking three goals, as you know, but I did not know that one could accomplished way more in one week. I did get an update and some vision about the dialysis situation in Jordan, I certainly saw for myself the suffering of my country men and women and I hope that I helped as much as I can. Never in my life I functioned on this intensity with as little sleep as I did. In addition to that, I didn't know that I will be meeting so many great people from all over the world that will open my eyes to whole different worlds. Also, I didn't know that this week will be a mirror into my soul.

I met great humanitarians, wonderful attorneys, amazing pharmacists, and great physicians. They came from all over the world to help with the Syrian refugees. They came from Canada, Germany, the United Kingdom, Egypt, Turkey, Pakistan, India, Palestine and Jordan, and many from the USA. The newly graduate Jordanian doctors who volunteered with us were also truly amazing.

I will not deny that there were moments of doubts about the usefulness of all of this but my friends and colleagues words and encouragements made a huge uplifting impact to keep us going. There was the day that I was with Dr. Green in the poorly ventilated caravan in Zaatari camp seeing patients with such scarce resources. I was seeing cases that were either too simple to be even seen or too complicated that I don't have the resources to deal with or the chance to offer any continuity of care. I got frustrated and told him "I don't know if we are making a difference in these people's lives or medical issues!" Dr. Green with his reassuring voice answered without hesitation "Majd, think of us as the psychiatrists assistants! They are here and they are seeing these complicated PTSD cases and we are here to listen to these people too, and show them that we care". This simple conversation redirected my effort that day and kept me going, listening and helping with a smile and energy.

Mission Medicine is a unique spice of medicine. It intertwines the use of limited resources, and the scarcity of continuity of care, with cultural perception of medicine. One treats the patients with what one has at the time that one has it and within the framework of their cultural understanding of medicine. It is crucial that native physicians familiar with the culture and the language be an integral part of any medical mission but doctors from other nationalities are no less important. They are the ones that show the patients that the world is truly listening to them and standing by them.

We have written a healing word in the book of suffering of the Syrian refugees in Jordan but there are many chapters to write and I am hoping to be there to help writing them.

House calls

Ruseifeh-Huttein

Today our team was assigned a clinic in the Jordanian Woman Union branch in Ruseifeh. By now, I was comfortable seeing all kind of cases, familiar with the common conditions that will likely be seen and the type of resources available, just in time for the last day of the mission!

The morning was steady stream of patients. There was the girl that came with her mother in her school uniform. The old man that came to me with a smart phone that has a picture of his medications was also impressive. It was impressive not only because he has a picture of all his medication but also because he owned a smart phone. The fact that you need to know is that all the refugees that I saw carry a cell phone. My understanding is that UNHCR helped them get a primitive phone to track and get hold of them. Each refugee has a UNHCR number and a cell phone number.

I have arranged to spend the afternoon going to refugee houses with Dia. I had monetary donations that I wanted to make sure that 100% of it went to the needy families. We bought boxes of essential food supplies and went from house to house to deliver them. Dia is a young Syrian Jordanian. He came to Jordan when he was 3 year old. He speaks with a Jordanian accent but he has Syria and the Syrians in his heart. He has a list and records of many of the refugees and what was delivered to them and when.

The area was called Jabal Faisal (or the mountain of Faisal) and is made of random buildings separated by trashed dirt roads. We knocked on the first door. I was told that the husband is outside looking for work. A man opened the door and identified himself as the owner of this "rental property". Inside there were two women, the wife of the man who was looking for a job and her sister. One was in her full make up while the other appeared disturbed. There were two young kids running between the two rooms. The wife told me that her husband was outside looking for work because they didn't pay the rent for the past three months. I'm not sure if you know the tradition of the Middle East but it is not the norm for an unrelated man to be behind closed doors with women. I'm still disturbed by this visit and I asked Dia to have someone look into this family's situation further.

The common theme of all the visits was that many are crammed into small rooms. They all live on twin size sponge mattresses on the floor. Some of these mattresses don't even provide support. Many are living in water damaged, moldy rooms. There were kitchens combined with bathrooms, and a swing set made of rubber hose, yet many beautiful children everywhere.

She must be in her sixties, she opened the door to us into her tiny house comprised of two rooms. Her son's family lives in one room and she lives with some of the kids in the other. She was preparing potatoes. She has applied to the UNHCR nine months ago but they were still not providing her with any assistance. She complained without avail. Her room was obviously water damaged. She begged us to help and with each time she begged I felt a knife going into my heart.

Most of the registered families receive vouchers to get biweekly supplies from designated stores in Jordan. Most of it is not enough. I was told by some that the participating stores sell them the supplies at higher price so their vouchers don't take them far. Of course not all the refugees are living in the same conditions. Some are better than others. Few have couches and TV's but others have breadcrumbs and sheet-less mattresses.

The most encouraging thing from today was that most of the school-aged children that I saw were actually going to school. Some had missed a year of schooling but the majority outside Zaatari camp is going to school. These kids are the future of Syria. They need to be healthy and educated. They should never integrate in Jordan and forget their identity because we will all come back one day and rebuild.

Al-Zaatari Prison!

Oops, did I say prison in the title. That should have said camp. Al-Zaatari camp is located about 1-1.5 hours northeast of Amman depending on traffic. It is situated near the Syrian border east of a town called Al-Mafrak and a military base. It is a fenced area that started with few tents and now bustles with many caravans (POD storage units now used for human housing) and tents that provide a sanctuary to many Syrians. The number has been fluctuating. Some says that it houses +180,000 Syrian refugees. I have heard that it dropped recently to about 120,000 people.

The camp is the home of all of those refugees who cross the borders without a passport or illegally. The other fortunate ones who cross with a passport are allowed to live in other areas of Jordan. If a refugee ended up housed in here he or she cannot get out unless a Jordanian sponsor him or her. Few pay for that sponsor and few smuggle out. Through out this mission, I have seen few patients that were initially in Al-Zaatari and then were bailed out by a Jordanian relative.

You get to the camp by turning right just before the Syrian border, south of ‘Jaber’. The road takes you east of Al-Mafrak and then you take another right toward the area. I am not sure if the road before you get to the camp is meant to be a dirt road or is currently undergoing construction. The camp itself can be seen in the horizon but when you get near by it is hidden behind recently planted trees. There are two checkpoints to enter the camp and many soldiers.

There is an armored vehicle on the main entrance and photography is not allowed near or inside the camp. The tiny road filled with people and kids walking in and out takes you to another check point were you see another set of soldiers (some hiding in civilian clothing) who check your approval papers again. You will need a permit and a valid passport to enter. After we got in, we rearranged our vans so that the psychiatry team went in one van and the medical and optometry team went in another.

We travelled on a dirt road around the camp and then entered what seems to be Al-Zaatari main road. There are multiple shops on both sides, shops of all kinds: clothing, shoes, food, mobile technology, and even bridal shops. People were everywhere and kids were everywhere. They jumped on vans back bumper to get free rides or may be they were just having fun. There are areas of the camp that look like a sea of tents but others that are now made of caravans. I am not sure what determine where people live or if it is a matter of short term versus long term stay.

The alley that took us to the clinic has caravans on each side. Each group of caravans is blessed with a water tank that gets filled on a regular basis. Our clinic area was spread across the two sides of the alley. There is a pharmacy with very limited resources and two clinic areas. We set up quickly the Optometry clinic in one room and the Family Medicine in another and the Internal Medicine in a third. We paired up each non-Arabic speaking physician with an Arabic-speaking physician (in addition to their interpreters).

The room I shared with Dr. Green, the great Cardiologist from Seattle, was a 15x25 rectangle with no ventilation. It has one paper-shaded window on each side. There was an exam table at the end and one desk. Dr. Green took the exam table and I took the desk. Which meant that he will write without support and that my exam table is a wooden bench. There was an air conditioner in the pharmacy and after an hour they brought us a fan. I don't know what was better; survive the clinic without ventilation or trying to catch all the flying papers the fan blew away.

Dr. Green coined the term 'the physician's lounge' describing a room that has a toilet hole in the ground, a primitive shower and a stove to boil water for tea or coffee. The couch was made of a rear car seat. Needless to say, we avoided eating or drinking anything there that day but I am sure if you keep going to that clinic every day you will become numb. We learned that this clinic houses an Ob/Gyn clinic and a neurosurgery clinic during the week. The ladies who were triaging for us were Syrian nurses who are themselves refugees.

It didn't take long to realize that the cases are either too simple to even be seen by a physician or too complicated for our very limited resources. We did what we needed to do to see patients. I saw kids, checked blood pressures, measured weights and calculated doses. By four o'clock our clinic was done but the optometry clinic had about sixty patients waiting. We went in to see what we can do to help and soon enough a cardiologist, a nephrologist and an attorney were prescribing reading glasses. Seeing a smile on the face of a grandma after she was reading clearer with her new frame was the most rewarding event to me that day.

There are other clinics in Zaatari. There is the Moroccan, the Saudi, and the Emirates clinics and probably others. Each clinic has different resources and I have no doubt that patients are shopping around. They all try to tell you that they were stable on the medications they were taking in Syria but in the camp they get whatever are available that day. I am sure that there are many resources provided to the camp by several agencies, governments and individuals but the lack of coordination, and the chaotic nature of the process is only creating a fractionated health care system for these poor people.

There was a silver lining though because one patient came to me with a health care passport book that was issued by the UNHCR and should contain her medical history. It took about three years for this idea to come about and hopefully, if the various organizations are unable to keep records of the patients, the patients themselves will. This is an issue that needs reinforcing.

I have heard about two other refugee camps in Jordan. One is Al-Rajehi camp on the Syrian border for the defectors from the Syrian army and the other is called Cyber City. Cyber City is supposed to house Syrian Refugees of Palestinian origin such as those who used to live in Al-Yarmouk camp in Damascus. Though I did not see it, I was told that it was more prison-like than Al-Zaatari with enhanced security and snipers on multiple observation towers.

There are some who believe that the Syrian revolution was a revolution to reclaim the dignity of the Syrians. The things that I saw today and through out this week make me doubt that this is what the Syrians accomplished so far.