Children at the Zaatari Refuge camp. Photo courtesy of Foreign Commonwealth Office/Flikr
The Truth Behind Jordan’s Helping Hand: One Doctor’s Reflection
Umar is a 6-year-old Syrian boy with a severe shrapnel injury to his right thigh. Several months ago, a military tank fired a shell through the wall of Umar’s room in Homs, Syria, killing his three other siblings. He was being treated in the hospital in Homs when it too, it was said, was destroyed by the military. His mom and he were transferred to the Zaataria camp outside Amman, Jordan. A Saudi Arabian humanitarian clinic there had no resources to properly treat Umar. His constant crying and the smell of the wound had finally pushed the paperwork through to transfer Umar to a proper hospital in the city for adequate medical treatment.
Umar was one of many Syrian refugees I was to see during a weeklong mission to Amman. By the time we met Umar, he had lost 10 percent of his body weight and the infection had taken all the skin off his right thigh and part of his lower leg. He screamed any time someone entered the room, fearful of another painful dressing change or examination. But the bureaucracy of treating Syrian patients in Jordan would impede our ability to swiftly treat Umar and other patients, and we found ourselves in a constant battle with hospital staff, Jordanian doctors and Jordanian laws that would prevent us from efficiently carrying out our work.
We arrived in Amman as part of a privately funded American humanitarian mission. A board-certified plastic surgeon and an Arabic speaking surgeon in training were with me, and all of us had years of overseas humanitarian work. For months prior to our arrival, we were in discussions with Syrian physicians in Amman, who kept us updated on the refugee patients we would treat once we landed and the equipment, staff and supplies that would be at our disposal. They were welcoming and cooperative during the planning stage.
The hospital we would work at was a private, for-profit hospital in Amman that had four stories, 40 beds and three operating rooms. But our work as overseas humanitarian doctors would primarily be on the third floor, which was leased by a Syrian doctor to provide health care for Syrian refugees in Jordan who could not find adequate care in clinics around the camps. Dr. Nauman was an established pediatric surgeon from Damascus who, like thousands of others, fled from Syria about a year ago and settled in Amman. As an increasing number of Syrian refugees entered the country without access to proper medical care, he decided to lease a floor of this hospital and “employ” other displaced Syrian health workers to help provide medical services. A smaller hospital in Amman also has a similar setup. Dr. Nauman told me it costs $40,000 monthly to maintain these two units and funding comes primarily from Syrians in England and the U.S.
In our planning discussions, we understood that our host Syrian physicians had access to operating rooms and were set up for in-patient work. We also had the impression that they kept a running log of the Syrian diaspora in Jordan to help us triage patients. Our goal was to provide specialty care for post-acute problems. The patients we were to see were those who survived war-related injuries, made it across the border and successfully had their paperwork sent through the makeshift health care systems of the refugee camps. As reconstructive surgeons, we were focused on treating patients with chronic open wounds, non-healing fractures and retained ballistic fragments. As a hand surgeon, I would also focus on tendon, bone, nerve and artery injuries of the hand. Unlike our other humanitarian missions, Amman was the first place we traveled to where we knew there was an existing, state-of-the-art medical care infrastructure. We were told to just bring our expertise.
When we arrived, we met our host, a team of physicians and non-physicians from all parts of Syria. Although Arab hospitality dictated the serving of tea, coffee and sweets, our team was eager to start operating immediately to maximize the number of patients we could care for while there. Except, we were told that we could not operate on anyone just yet. In fact, we were put in a holding pattern altogether by the Jordanian staff and physicians. We quickly learned that the Syrian physicians, and their demands for care and use of the operating room, were treated as secondary. Despite the entire floor being leased to Dr. Nauman for the purposes of treating Syrian patients, he faced limitations as a non-Jordanian doctor practicing in Jordan.
Syrian physicians do not have medical licenses to practice in Jordan despite the fact that Syrian medical education and training is on par with any Middle Eastern country. Even after years of war and an influx of refugees, Jordan has made no provision to allow these licensed physicians to care for their own people. Any patient treated by Dr. Nauman or his team would require a tacit Jordanian physician of record to sign off on it. These Jordanian physicians would often not be present or even interact with patients, and instead would profit off the work and service provided by Syrian physicians working almost entirely pro bono.
In addition, while the rent covers nursing, cleaning and support services, the Syrian physicians must pay for medications, intravenous fluids, dressings, bandages, laboratory testing and X-rays received from the hospital. The payments are made to the hospital owner (rumored to be a wealthy expatriate) and the Syrian physicians are often prevented from accepting donations or soliciting for donations from inside Jordan to pay for these necessary supplies. Dr. Nauman told us on several occasions that with all the money he was required to spend at the hospital — leasing the single floor and additional fees — he could have built his own hospital and operated it at a cheaper rate.
What we determined is that the Jordanian health system is either overwhelmed or uninterested in treating Syrian refugees and victims of war, and the problem is intensifying with a stream of refugees who continue to pour into Amman, many who need urgent and critical medical attention. Although Dr. Nauman and his well-trained and motivated Syrian medical team have established a possible solution to deal with this problem, the Jordanian system prevents them from working effectively.
We explained to the surgery staff that the best treatment for Umar was regular debridement of the infected tissue in the operating room, and he needed to be asleep so we could safely do this. And, because of his age, his surgery should be first thing in the morning so he wouldn’t have to go all day without food and water while waiting for surgery. We were told that everyone understood and agreed to the plan. The operating room was to be booked for Umar the following morning.
But the next morning, the Jordanian surgeons had bumped Umar’s surgery for their own cases. Umar was given something to eat and now he had to wait for the following day.
Day in and day out, we were uncertain about how effective we would be in treating the patients we came to see. The bureaucracy was overwhelming, and Umar and dozens of other patients who needed our care were left in limbo. Everyday, the Jordanian physicians would change the schedule and bump us from using the operating room.
By day five, and after much protest, we could finally operate on Umar. We successfully removed much of the infected tissue to make the bedside wound care much easier for him and to set the stage for a skin-graft surgery later by other surgeons. Since I’ve returned to America, Dr. Nauman has told me of the many setbacks to Umar’s recovery. I think of Umar often. But out of a feeling of helplessness for this boy, I stopped asking how he is doing. Not because I don’t care, but because I’m not sure I want to know the answer.