Toward policy innovations from the field: a report from a Syrian refugee camp

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By Mitsuru Mukaigawara

“Between a high, solid wall and an egg that breaks against it, I will always stand on the side of the egg… Each of us is, more or less, an egg. Each of us is a unique, irreplaceable soul enclosed in a fragile shell. This is true of me, and it is true of each of you. And each of us, to a greater or lesser degree, is confronting a high, solid wall. The wall has a name: It is The System. The System is supposed to protect us, but sometimes it takes on a life of its own…”

Haruki Murakami, 2009

 

The Zaatari refugee camp in Jordan is home to 79,000 Syrian refugees [1]. In a clinic located in one corner of this sprawling camp, Dr. Muhammad attends to the refugees living in the camp every day. His office is small but neat and fully equipped with basic medical supplies.

A woman who appeared to be in her 50s visited his clinic, complaining of arthralgia. She had continued to take prednisolone and NSAIDs – both usually prescribed for rheumatoid arthritis – without official recommendations by her primary care physician. Her face looked puffy and skin translucent, both common adverse effects of prolonged steroid use.

Dr. Muhammad listened to her without interruptions, and went on to examine her carefully. He conducted joint examinations, looked into her mouth with tongue depressors, and performed abdominal examinations, since she had mentioned abdominal discomfort. He then ordered some laboratory tests, which would be performed the next day and wrote her prescriptions scrupulously.

“This was her first visit to my clinic. Both managing adverse effects and establishing rapport with her are essential. I decided to continue the medication,” he commented.

Dr. Muhammad is a medical doctor from Syria, working for the Arabian Medical Relief (AMR) [2], a Jordanian organization operating in the Zaatari camp. He takes care of more than seventy patients every day, whose diagnoses vary from hypertension to rheumatoid arthritis and Charcot-Marie-Tooth disease. Dr. Muhammad specializes in internal medicine, but sometimes works as a pediatrician and dermatologist when necessary. Back in Syria, Dr. Muhammad had been specialized in ultrasonography. Between busy patient encounters, he hosts laboratory technicians who visit his clinic to consult difficult cases in ultrasonography.

As I am now completing my residency in internal medicine, I know how difficult it is to work like Dr. Muhammad. In an era of specialization, the threshold for consulting other specialties is getting lower.

“Not all doctors can work as you do,” I said to him. During my visit to the camp, I met several people from Syria, who won popularity with their humility and shy smile. With a similar, hesitant look on his face, he replied, “To me, they are all my family. For the sake of my family member, I’d be happy to become a dermatologist, pediatrician, or medical technologist. Also, as a doctor I believe we need to change our roles as needed. That’s the core capacity to work as a doctor in this camp.”

Only by visiting and working in the field do we observe the unreported reality of people living in this crowded community. Otherwise, we find ourselves in the middle of the dichotomy: between realism and idealism, overmedicalization and oversimplification [3], or economics-driven approach and human rights-based approach. They are all black and white. But the reality on the ground is more diverse. It has every shade of grey. Such gradation is rarely reported because of its difficulty in conveying clear, simplified messages.

It’s easy to become a strong supporter or critic of this clinic. For example, the organization has become a huge medical center in the camp. It is highly equipped with radiology, primary care, OBGYN, and rehabilitation centers. The radiology center recently introduced the same digital imaging processing machines that we use in tertiary, referral hospitals in Japan. “We will introduce a new computed tomography soon,” one physician told me during the visit. The images taken in the camp are interpreted by specialists immediately. Healthcare professionals in the camp are all rigorously trained, and diligently working with the people in the camp. With such advanced medical technologies and diligent work, refugees in Zaatari camp have access to high quality medical care.

On the other hand, the unintended consequences of purposive social action [4] cannot be ignored. In the clinic, doctors can order laboratory tests, such as white cell counts, aspartate aminotransferase (AST, a liver function test), hemoglobin A1c (diabetes), prolactin, estradiol, or progesterone, but are unable to check electrolytes, creatinine kinase, or troponin (essential in making diagnosis of acute coronary syndromes). From primary care perspectives, this is a concerning issue. In this clinic, you can order highly specialized tests for gynecological disorders, but not for myocardial infarction or electrolyte abnormalities, which are more common and critical in primary care settings. This is partly due to the proliferation of earmarked funding for vertical public health approaches [5], i.e., financial support for treating specific medical conditions such as gynecological or pediatric infectious diseases. Such adverse effects of purposive action have been subject to criticism both at the local and global levels. [6]

However, black-and-white arguments do not solve the root cause of the problems the refugees face. I believe that we need to step back from such dichotomous, pendulum-like system and observe the gradient instead: every shade of grey that is rarely reported and hard to interpret. In so doing, we see the reality and the way forward. Dr. Muhammad and other staffs are expected to play multiple roles in the clinic to serve the community: physicians and laboratory technicians, dermatologists and pediatricians, and listeners and family members. After spending time with them and observing how they work, I identified the true needs in the field. Meeting such needs does not necessarily require significant changes in financing or decision-making structures. Rather, they are usually small ones: introducing venous blood gas test kits, or sparing a small amount of funding to securing seasonal influenza vaccination. Global policy innovation should start in the field, by carefully listening to the voice of the unheard.

Acknowledgement

I thank Ms. Aisha Almosali and Ms. Thawab A Amer, and all the staffs of the Arabian Medical Relief for their support during my visit to the Zaatari refugee camp. I also thank Dr Yoshihiro Takayama, Chief Physician, Division of Infectious Diseases, Okinawa Chubu Hospital, for his guidance and support.

References

  1. UNHCR. Syria regional refugee response: inter-agency information sharing portal. http://data.unhcr.org/syrianrefugees/settlement.php?id=176 (Last access: February 8, 2018)

  2. Arabian Medical Relief. https://amr.org.jo/english/ (Last access: February 8, 2018)

  3. Rosenbaum L. The less-is-more crusade — are we overmedicalizing or oversimplifying? New England Journal of Medicine 2017;377:2392-2397.

  4. Merton R. The unanticipated consequences of purposive social action. American Sociological Review 1936;1(6): 894-904.

  5. Cairncross S, Periès H, Cutts F. Vertical health programmes. Lancet 1997;349(suppl III):20-22.

  6. Atun RA, Bennett S, Duran A. (2008). When do vertical (stand-alone) programmes have a place in health systems? WHO European Ministerial Conference on Health Systems Policy Brief – June 2008. Copenhagen, WHO Regional Office for Europe.