Refugees in Jordan: Staff Health

Mike is in Irbid, Jordan, where MSF / Doctors without Borders is providing medical care to thousands of Syrian refugees and vulnerable Jordanians. Part of his role is as the doctor for MSF staff working at the project. Today he blogs about what he's learnt for this unusual aspect of the job... 

Almost all of my role in Irbid is non-clinical, apart from having a role as the doctor on the project who is available for staff health issues. I’ll admit that some aspects of this role have irritated me.  Possibly understanding the local context has reduced the irritation and I’m also aware that being the staff health person has also meant that I’ve had insights into life that I might have missed out on without it.

If any member of staff takes even one day off for sickness they have to see a doctor and get a sick note. This seems to be a pattern throughout Jordan. My role is then to check that this has been appropriately stamped by a doctor and signed and that the length of the sickness is suitable for the condition. The doctor’s notes all tend to come in Arabic as this is easier for the doctors. Our staff are asked to get them in English … but this is not that effective. So one of the skills I learnt early (somehow I don’t remember this as part of my written or verbal induction) was how to scan things and store them in my PC so that I could then send them to my Arabic-speaking medical colleague in Amman for translation.

It reminded me of early in my career as a GP in UK when sick notes were necessary after only three days… and my relief when there was a national decision that the required interval would be after one week. I notice how much I’ve assumed that the UK story that doctors should not police minor illness is right.

I worry that by forcing people to see doctors  at such an early point in their illnesses, we are encouraging inappropriate prescribing, especially of antibiotics

Local culture here is that all illness should be reviewed by a doctor. Certainly people get seen by a doctor more rapidly, but I still wonder whether, given the numbers that need to be seen, it would be a better system if we enabled people here to manage their colds and fevers or other minor illness themselves and managed total sickness through a HR process.

Looking at the outcomes / letters I also worry that by forcing people to see doctors  at such an early point in their illnesses we are encouraging inappropriate prescribing, especially of antibiotics, which of course as well as being wasteful, is potentially damaging to patients/ our staff.

Image shows piles of paperwork

Photo: Mike Tomson / MSF.

I’ve yet to see the advantage to our staff, let alone to the doctors in our local hospitals who have to get through as many as 100 patients per day, of the approach we take; but I’m still looking for it, all systems are likely to have unexpected effects and maybe there are some here that I’m missing?

Because of my staff health role I also get occasional questions about how I would suggest that a particular problem should be managed. This is of course an interesting challenge, I’ve not yet listened to the full story, nor heard the concerns of the patient, and examining things in an open plan office with no couch is definitely beyond my role.  So what should I do when I’m told that the orthopaedic surgeon suggested that the best treatment for a new episode of low back pain is bed rest with a firm / hard mattress?  It is a challenge for me to keep my evidence-based medicine ideas relatively hidden, and to ensure that the trust in their chosen doctor is not undermined for my own benefit and that I don’t leave the colleague more confused in the long term about what to do… so I’m trying to get an appropriate balance of confusion (this is the easy bit!) and interest, and hinting that there might be other things I could say here if things don’t improve as expected or if requested. It is of course a good reminder of the difficult journey that many of my friends and colleagues in UK who are physios, breast-feeding counsellors or other specialists who are not doctors may have regularly when dealing with people who have been given a confident diagnosis and plan by a clinician who is less expert then they are in the area being discussed…

They have in general found it hard to talk about mental health issues and I am, I think, often the only health professional that they have talked to.

Even in Jordan not all issues that people have are physical and not all of my staff health role is paperwork and scanning letters to get them translated.  Some of the staff have many of the normal mental health issues that I’d see in UK. They have in general found it hard to talk about these issues and I am, I think, often the only health professional that they have talked to. Sharing a mental health issue here is still a sign of failure in many people’s eyes, it appears to me. Generally resources are pretty sparse for support with mental health issues and according to one of the agencies we collaborate with there are only 68 psychiatrists in Jordan for all the population. (I’ve not been able to verify this specific number, but note that the population (inclusive of refugees) of the country according to Google is 9.45 million). Our national staff all speak pretty good English, though of course (as with my Arabic) their written and spoken skills aren’t entirely at the same level. So some resources which are online can be suggested.

Photo shows a leaflet about depression, written in Arabic

Photo: Mike Tomson / MSF

Some of the mental health issues can easily spread into descriptions of the social organisation of life here and definitely into areas that I’ll never experience directly.  So I’m more aware than I was about the implications and limitations of the various permitted ways to meet a potential partner; whether arranged, pure love match or a subtle mixture of these. I’ve also heard about the challenging consequences of breaking these rather unwritten rules and the impact of local courts and judges when things get difficult.

 I’m a potential resource if people want to use me but I’m not here to change other people’s worlds

One of the recurring themes in MSF for our health educators is looking at the “stages of change”, or in simpler terms, looking to see whether the person you are talking to is ready to even consider change, or already thinking about change and might be helped by appropriate information and nudges. I’m careful to keep this and my staff health role in mind when I hear in passing about issues that might have excited me when I was a little younger, like extreme fast driving, alcohol or multiple partners… or the ubiquitous cigarettes. I’m a potential resource if people want to use me but I’m not here to change other people’s worlds?