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Since the war began in 2011, half of Syria's pre-war population of 22 million people has been displaced or killed. Most of those who escaped now live in camps in Jordan, Lebanon, Turkey or Greece.
More than 650,000 Syrian refugees fled to Jordan. About eight percent of those people, the ones with the greatest needs and the fewest resources, now live in refugee camps. Amnesty International has described their access to medical care as "grossly inadequate."
This sudden overwhelming influx, and the long wait for a solution, has taxed the country's health care resources. Clinics in Jordan were quickly overwhelmed; they no longer have the resources to provide free health care to refugees. Now various aid organizations have stepped in, providing Syrian patient-refugees with complex treatment for longer term problems, such as cardiovascular disease or respiratory ailments.
Interventional cardiologist Atman Shah, MD, an associate professor of medicine and co-director of the cardiac catheterization laboratory at the University of Chicago, just returned from working with a team organized by the Syrian American Medical Society (SAMS), the Jordanian government, and the United Nations High Commission for Refugees. The partners made arrangements with hospitals in Amman so that patients living in the camps who needed a higher level of care – complex surgeries, delicate cardiac interventions – could get the attention and specialized procedures they need, followed by postoperative care back in the camp clinics.
We spoke with Dr. Shah about this adventure. He spent eight long, exhausting yet rewarding days – from Friday, January 6, 2017, through Friday the 13th – diagnosing and mending broken heart valves and opening plugged arteries for people who had been without a home, or a homeland, often for years. The worst part, he said, was the 11-hour non-stop flights from Chicago to Jordan and back.
Atman Shah, MD: I was with about 65 people from the United States, the United Kingdom, Saudi Arabia, Jordan and others. The group included cardiologists, internal medicine doctors, pediatricians, ophthalmologists, dentists, nurses, translators and administrators.
In Amman, I was part of a smaller team: four interventional heart docs. We would alternate. One would go to the camp to evaluate patients, determine who most urgently needed help. Those patients, suffering from chest pain, for example, or a history of heart attack, peripheral arterial disease, structural heart disease, would be transported to the hospital. The other two team members would perform the procedures in the Amman's Gardens Hospital. We would do 15 or 20 procedures a day for the patients who came in.
It could get pretty intense. These were long days. We averaged about 15 procedures a day. That's about 25 percent more than a typical interventionalist's workload in a busy US hospital, such as UChicago. So, yes, this was a high-volume operation. But it went remarkably well. The hospitals there have been doing this on and off for a few years. SAMS and the cooperating hospitals run a well-oiled machine. They had everything worked out, from getting us through customs to supplying the hospitals and camps. The UN and the government of Jordan respect and appreciate this work.
We had all of the stents and the balloons and the guide catheters we needed. These were donated by companies such as Medtronic and Boston Scientific. For anything extra, the organization would reimburse the hospital for the equipment used.
Every patient had his or her own complex, heart-rending, often unresolved story. It has been a lengthy, devastating conflict.
One of my patients was a well-educated woman, a lawyer, until the war began. She had heart disease. In Damascus, she had the necessary medicines and access to care. Then, within the span of a few weeks, her house was bombed, her husband was killed, two of her sons disappeared. She had to flee in the middle of the night to save the rest of her family. Now she's in a camp with 8,000 other refugees.
It gets worse. In the camp, she had a heart attack. There was no way to get her the needed treatment until the mission came in. Once our team arrived, we were able to bring her in, reopen her LAD (left anterior descending coronary artery) and get her back to near normal.
Her story was so sad, but it wasn't at all unusual. All of the people we met had tragic tales. The war has been brutal for them. In the US, we commonly see patients, often obese, who have heart attacks in their 50s or 60s. But the Syrians, usually quite trim, have to cope with the unrelenting stress, plus a high smoking rate. They often seem to develop advanced cardiac disease in their mid-40s.
We did what we could for them. There was one 75-year-old gentleman who somehow escaped from Syria, even though his angina was so bad he couldn't walk. He couldn't get from his tent to the canteen to get his food rations. His angiogram depicted really severe disease. A bypass graft was no longer an option for him, so we put several stents in him – quite a few stents, a big number. We got him feeling good enough to walk. He was grateful. All the people we saw were just so grateful.
This mission was different from previous trips. I've been on missions to India, Indonesia, Guatemala, countries where profound poverty was rampant and education opportunities were limited. But Syria wasn't like that. Many of the Syrians who got out were used to good medical care, well-staffed hospitals with modern technology. Before the war, Syria had good health care. Now, most of these patients in the camps have nothing: no home, no job, no savings. They have no safety net. They are completely reliant on humanitarian groups, like SAMS. Were it not for this organization, the UN and other charitable groups, they would be in even bigger trouble, or worse.
Our mission was supported primarily by individual donors who gave to the Syrian American Medical Society. That's where the bulk of the donations came from. Certain medical device companies donated devices, products, medications. There were, for the most part, no big grants, just a lot of individual donors.
That's hard to know. The refugee camps are huge. The concern right now is whether or not there will be more refugees. Even if people can stop fleeing Syria, that doesn't solve the problem.
There are now several million refugees in camps in Jordan and other destination countries. Where on earth are they going to go? Europe has accepted a lot but some countries may not accept many more. The political situation in United States has changed, so the US may or may not take any more refugees. Jordan is a small country with limited resources. Turkey has its own issues and Greece has significant financial trouble. It's unclear what options are left, where people with serious health issues can go.
The patients, and their doctors, rely on help from these benevolent organizations. The refugees need everything. At the least, we can help in simple inexpensive ways, well-child visits, immunizations, dental care. Groups like ours can help take care of their cardiac issues the best we can. I don't know what the end point is.
The important thing to keep in mind is that this is still actually going on, it's happening, day after day. And don't be overconfident; it could happen to us. It's real. It's not all that far away.
It makes us realize how blessed we are here in the US. We, most of us, have access to health care and extraordinary technology. We perform procedures with the refugees using a fraction of the resources we might use in the US. In Jordan we don't always have all the guide catheters we want, or the models we prefer. We don't have the same variety of stents. We don't have the wires we need. But we make do and we do OK. Even with limited resources, you do the best you possibly can.
The one thing we lack is time. It's a lot or pressure to get the cases done. If I take two or three hours for one procedure, that means a couple other patients have to go back to the camp and come back another day.
Ha! Am I faster now? I don't think so. I've done a lot of cases. I think I was pretty fast already. But maybe an experience like this makes you quicker on the tough decisions. This is a high-volume urgent situation. In the US for a patient with two damaged arteries and one that was partially closed, we would fix all three. But in this setting, with patients waiting and out time here limited, sometimes it makes sense to open the two tightest vessels and delay the third one until a better opportunity arises.
The resources here, although impressive, are not always available. Sometime the hospital doesn't have all the tools and devices, the toys and safety mechanisms we are used to. So we have to treat some patients who are critically ill without the usual fallbacks, the safety networks we are accustomed to. We have to balance it.
I sort of expected to, but, no, we didn't, not really. Even in Chicago we have the opportunity to see and take care of a lot of unexpected cardiac issues, cases where intervention was delayed. We have some of the same issues, but not on the same scale.
I tell my colleagues to consider doing this, or at least to donate so that others can do it. At home we worry about goofy things, the Super Bowl, what Kim Kardashian is wearing. Meanwhile, millions of refugees live in rags. They face real, prolonged suffering. It doesn't have to be 1,000 miles away. It could be a few blocks away. It's important to stay tuned in to that. Each of us could in some way make the world a slightly better place. Take a moment to realize how lucky we are, that we could help other people with just a little bit of effort. We could all do that.
It was incredible, indescribably rewarding. These patients have been through so much and suffered in ways that, I desperately hope, my family will never know. The refugees we worked with would not have been helped if we had not come. They knew that and were so grateful, so understanding.
The people we worked with also were fantastic. They came for the same reason, to help people with profound problems feel a little better, sometimes a lot better. This organization has their act together. My time was never wasted. My colleagues and I have volunteered for many projects and sometime our skills are sub-optimally used, but there was no downtime or distractions for our team in Jordan.
The hours were long, usually 7 am to 10 pm. Things were stressful. But it was uplifting, life changing. I met so many great people from around the world. I think I'm a better physician because of it, and, I hope, a better person. Plus, except for the agonizing long flights, yes, it was a lot of fun.
After getting short-of-breath, Michael finally went to UChicago Medicine Ingalls Memorial and soon cardiologist Abed Dehnee, MD, diagnosed him with congestive heart failure and identified a blood clot in his lung.