Thanks to Donald Trump and Nikki Haley

I was forced to consider what cutting US funds to the UN agency for Palestinian Refugees (UNRWA—UN Reliefs and Works Agency) means?If you read my first post, you know that I am here to help grow family medicine in Palestine by helping faculty and teaching the residents while I wait for my Rhode Island license and insurance payer credentialing. (That takes three to four months!) We started our visit in Jordan to help our Palestinian colleagues and Ministry of Health officials travelling with us understand how family medicine is the foundation of health care delivery in Jordan. And how that might be possible in Palestine.

While family medicine started as a specialty in Palestine in 2010, it began in Jordan in the late 1990s. Hats off to US family physicians Cal Wilson (Colorado) and Cindy Haq (Wisconsin) who helped shepherd it along. Our first visit was to an UNRWA clinic in Amman. The articulate and personable director was impressive with his knowledge of clinic statistics and successes and discussed their challenges frankly. He quite professionally collected our email addresses and sent a follow up email thanking us for our visit and sharing photos.First a few words about UNRWA. The UN agency was created and began supporting Palestinian refugees when the British mandate created the state of Israel as its last action in 1948. With the creation of a state for Jews alongside a state for Arabs, many Jews now had a home and many Palestinians were pushed from land occupied by their families for centuries. Jews celebrate the creation of Israel having survived persecution for centuries prior to the horrors of Holocaust and World War II.

However, Palestinians refer to the 1948 event as al Nakba (the catastrophe). The UN responded to the refugee crisis by providing camps in Jordan, Lebanon, Syria and what is now called the West Bank and Gaza. In the beginning refugees lived in tents, and now, sixty some years later, we stared up at three and four story apartment buildings and walked along bustling streets. In addition to housing, UNRWA funds schools, vocational training centers, and health centers.Refugees live in the lower socio-economic strata. Streets are narrow, buildings show their age, cars are old, but sidewalk tables overflow with colorful fruits, vegetables and other wares. Bearded men, veiled women with children maneuver around the parked cars. Winter here brings gray and rainy days with temperatures in the 40s and 50s Fahrenheit, but I smiled at the locals dressed as if they were in freezing temperatures in Minnesota and Ohio. The mosque’s minaret was visible several blocks away and functions an important center of the community.

The sound of the call of prayers (Adan) caused me to pause. It can be heard five times a day.

The UNRWA clinic we visited serves a community of 100,000. Although it is 67 years old, it is very up-to-date and clean. The official UN blue trim and logo adorned the outside and were integrated into the local decor. Television monitors, posted in the waiting areas, showed patient numbers and room assignments. Electronic health records are used and parents can upload their child’s immunization records on their smart phones. Mental health is being integrated into primary care. The family health approach was introduced in 2012. Teams include a physician, nurse practitioner, midwife, pharmacist and nurses (practical and staff). Each team serves 10,000 patients. (At least triple of most US health care teams.). Because Jordan did not have enough family medicine specialists in 2012, a family physician teacher who organized our 3-day visit created a one week crash course on “family health” training for the GPs. A year-long diploma program (RILA) is also available through a UK group, although there is some controversy about the expense ($10,000 per physician) and currently no observation and feedback of trainees in the clinical setting. General Practice physicians (GPs) can enter practice after 6 years of medical school with little clinical experience. This includes what the US considers college. Some specialize in areas such as Internal Medicine, Surgery, Pediatrics, and Dermatology. Specialists are paid more than GPs. Jordan has graduated 400 family medicine specialists since the mid-1990s and fills the gap with diploma grads. 

Family physicians are in demand because they now serve as the gatekeeper to other specialty referrals. This has dramatically decreased costs and the automatic ordering of labs and imaging by other specialists. Patient satisfaction and trust in the physician and his/her team has improved as patients see one team who knows them well. Does this sound familiar? UNRWA aggressively addressed the initial rumors that family physicians provided poor care and our Palestinian colleagues were very interested in this because they face the same challenge. UNRWA launched community campaigns with other NGOS, partnered with the local mosques, and launched a social media campaign using Facebook. Good old community organizing and marketing!

The results are impressive if you believe them, and we had no reason not to.  High childhood immunization rates were achieved by following up no shows and making home visits. Decreased infant mortality with good prenatal and postnatal care, improving HGBA1cs with diabetes education, and decreasing the inappropriate use of antibiotics were some of the successes they shared. It was a report that I would be proud of in my own health care clinic.

So back to the Trump administration’s UN cuts. US contributions to the UN for Palestinian refugees include dollars to UNRWA. Budgets in the clinics have been held level for several years. Administrators respond by redistributing what they have to the most important areas. But as the old saying goes, you can’t squeeze blood out of a turnip, or perhaps more appropriately here—blood from a stone, or as Moses did, water from a rock. According to the news, other nations have stepped up as the US has pulled back, which is good, but not a sustainable solution.I would hate to see this terrific clinic and take steps backwards. In the US where we waste lots of money on health care and have poorer outcomes, it is humbling to see what can be accomplished with so little.