November 13, 2012

Jordan 2011 © J.B. Russell

Left to Right: Faces from MSF’s Amman project: Ali Abdel al-Kharim, a 13-year-old Iraqi from Baghdad, was severely burned on his face, arms, and legs when a car bomb exploded as he walked to school; Khanda Faraj Mohammed, 27, from Kirkuk, sustained severe burns on her neck, chest, stomach, arms, and hands when a car bomb exploded at the market where she shopped; Waleed Azziz Mohammed, 26, from Dahouk, was badly burned on his face and neck when he was hit by a rocket.

Patricia Kahn, MSF-USA’s medical editor, recently visited MSF’s surgical program in Amman, Jordan, which treats patients from throughout the Middle East.

Patients in the Amman program are civilians wounded by bombs, explosions, or gunshots in conflicts across the region. They have severe, complicated injuries that were not treated right away, or couldn’t be treated properly in their home country. Injuries such as bones that aren’t just broken, but shattered. Burns over much of the body. Many also have life-threatening bone infections, often with antibiotic-resistant bacteria.

This is a very neglected population, people who would otherwise never recover properly. Treating injuries like these often requires many surgeries over a long period of time, with intensive physiotherapy in between.

The program started in 2004 at the height of the violence in Iraq, when the security situation forced MSF and other NGO’s out of Iraq. Rather than leave the region, MSF looked towards Iraq’s neighbor, Jordan, which is politically stable and has an excellent medical infrastructure. We set up a special unit within the Red Crescent hospital in Amman, and it became a surgical referral hospital for Iraqi civilian victims of war. Patients were referred through a network of doctors in Iraq. Over time this network expanded, both inside Iraq and in surrounding countries. Patients have come from Yemen, Libya, Gaza, and now Syria. (Editor’s note: up to 50 Syrian patients were being admitted each month over the summer).

When these doctors see a patient who might benefit from treatment in Amman, they send a dossier—examination notes, medical records, X-rays, and, increasingly, video—to the Amman team, which meets weekly to screen prospective patients. The team is looking for people with very little mobility, or very little use of the injured area, and they choose those they think can regain basic functionality with the proper assistance. After suitable patients are identified, it can still take several months to get the visas and make the travel arrangements to bring the person to Amman.

The program does a lot of maxillofacial surgeries for people with severe injuries and disfigurement of the face (which is why there are dentists in the networks of referring doctors). For patients with injured arms or legs, the team focuses on reconstructing limbs whenever possible, trying to avoid amputation. Many patients have a very hard time accepting the idea of amputation, especially if they’ve already lived with their injury for a long time. Also, reconstruction can be better at restoring certain types of mobility that are part of daily life for many people here; for example, kneeling to pray is almost impossible with a prosthetic leg. So is using an Eastern-style squat toilet. Being able to do these things independently is a basic part of living an independent life.

The team does some amazing surgeries, including bone transplants, to try to preserve limbs and get people able to function. But before ruling out amputation, the team has to make sure they can effectively treat any serious infections. About half the patients arrive with a chronic bone infection. Often that’s because their injuries are months or years old and weren’t treated promptly or optimally. Some patients had multiple surgeries in local hospitals where strict sterility measures couldn’t be practiced. Some had inadequate antibiotic treatment. Many of these infections are already resistant to several antibiotics. Even if they haven’t spread too far, patients may still need months of intensive treatment with a combination of antibiotics. The resistance to antibiotics was the main focus of my trip, and our office in New York also hosts a specialist who is working on this complex situation as well.

Between surgeries, the patients stay in a hotel that’s part residence, part rehabilitation center. That’s where they get physiotherapy—a crucial part of recovery. So is psychosocial care, which is given both at the hospital bedside and the hotel. There are quite a few children among the patients as well, and there’s a small school at the hotel.

There are patients from all over the Middle East; the Amman program is a new kind of community for them. This is another unique element of this program, and something MSF is acutely aware of. People are far from home, so the program is more than just a hospital for them. For the duration of treatment, it’s their world. We’re aiming to help them return home eventually with the ability to function better in their world.  

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