Amman: Round Two

I’m headed back to Jordan this summer for thesis research, fieldwork, and (of course) weekend canyoneering. The original plan was Beirut – still angling to make it back & forth a few times. Here are a few things I’m going to work on while gallivanting about the Levant. All advice, criticism, and insight is more than welcome!

1. Gather some hard data on how immunization rates change during Ramadan.

I’ve been tracking patients that miss their immunizations for about seven months now. We started *just* before Ramadan last year, and noticed a pretty substantial increase in the number of missed appointments during that time. This is probably not surprising to anyone, but it’s also completely unstudied. Delaying immunization by a week or two isn’t a huge problem in an area with decent herd immunity, but waiting a full month before maybe forgetting about it, when migrants and streaming in and out from a warzone where hospitals are being bombed, when polio strains are blooming across the border, when we’ve seen unprecedented outbreaks of infectious disease along Syria’s border with Turkey? That’s not a good idea.

My hunch is that general fatigue and a mismatch between maternal waking hours and clinic hours might be the major inhibitors, but I’m open to other ideas (someone just told me some people view vaccination as breaking fast). No moms want to wait in line for hours in the early morning after preparing food all night. Nobody wants to do anything at 3 p.m. after nine hours without food or water. I barely drag myself to 8 am classes on normal days and definitely cannot without scary volumes of espresso, so I feel like these things aren’t unreasonable. One specific goal is to channel these findings into specific policy recommendations on clinic hours, which could be a good work-around.

2. Expand UNRWA’s mobile health capacity. We’ll be issuing immunization prompts to more clinics – hopefully some outside of Jordan, and some catering to Palestinian-Syrian double-refugees! – and gathering some hard data on effectiveness and patient satisfaction. Beyond that? The specifics are still up in the air. One promising suggestion from last summer involved sending reminders on basic aspects of diabetes management to adult patients. I’m not a huge fan of basic mobile health initiatives like this (engineers are technology snobs), but I do think they can be especially useful for patients with limited mobility. Gaza New Camp, in Jerash, provides a good (well, awful) example. The ’67 refugees who live in the camp were not afforded Jordanian citizenship, so they can’t obtain licenses or buy cars; if they bought motorcycles instead, however, they’d be short-changing the Jordanian economy by investing in a cheaper mode of transportation, so they’re also not allowed to buy motorcycles (cue eyeroll). So, if you live there, and your diabetes symptoms progress beyond anything you can manage, good luck getting to your regular dialysis treatments.

Of course, it’s not a problem if for Jordanians who reside in Abdoun mansions – take either of your Porsches down to King Hussein. But that kind of extreme disparity is what allows global health issues in the Middle East to fly under the radar: everything averages out to Middle Income Yellow (new Crayola shade?) and funding is directed elsewhere. Bigger rant on this later.

3. Health care as a bargaining chip. This is an iffy one, perhaps best illustrated by Hezbollah. They provide medical care that drastically undercuts the going rate on Lebanon’s private market, and care is FREE for Hezbollah party members. If you’re poor and sick and on the fence, is that opportunity enough to sway your political stance? There’s rumor of similar models being tested by different extremist groups in Mali, and I’m worried that this might be a growing phenomenon as AQIM spreads southward throughout and across the Sahel to sicker and more impoverished lands.

To be fair, one could argue that USAID does the same thing, “From the American People” emblems and all – maybe that would make a nice proxy study. I’m not sure exactly of how to pursue this line of investigation, but I think it’s really important and I’m surprised it isn’t getting more attention. Tentatively, I’d like to head up to Zaatari, where UNRWA is trying to deal with lots of pharmaceutical theft & redistribution, to see if there are any grander motivations aside from making a buck on the UN’s dime. Maybe I’ll gather up the gumption for more casual interviews in Beirut. More broadly, if there is any real political shift that comes from this discounted care, I’d like to see it incorporated as a very low-cost national security strategy. The US is good at fighting fire with bigger fires, but fighting knockoff pharmaceuticals and pandering with effective, strategic, and heartfelt health investments seems like a much better deal to me.

Amman: Round Two

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