Card Identifier, a Python library for credit/debit card identification, is now out! Card Identifier works on any payment card internationally, and takes out the busy work from simple card operations.

This utility offers anyone working with payment card numbers a framework to work with payment cards and classify them by type or issuer. This is especially important with the rising amount of credit card fraud and regulations surrounding online payments.

Caution: working with payment card numbers is subject to security regulations, and you should be incredibly careful about any code processing credit card numbers for security reasons.

Features

• Card number validation
• Card number reformatting
• Identify the card type (VISA, MasterCard, etc)
• Identify the card issuer (bank, financial institutions)

Card Identifier supports Python 2.7 and 3.4–3.6.

Installation

To install Card Identifier, use pip:

$ pip install card-identifier

Additional Information

The full documentation and usage instructions are available on GitHub. If you run into a problem, file an issue. Contributions welcome!

https://github.com/adelq/card_identifier

Card Identifier is completely open source under the MIT license. Enjoy!

What hardware do I use?

I currently do most of my work from a Thinkpad T420 laptop. It's got great Linux support but a nonexistent battery life. At work, I use an HP Z240 workstation, a beefy Xeon machine with lots of RAM and a big SSD. At home, I use a dual-monitor setup on a PC I built myself long ago, with an i3-2105 CPU and 12 GB of RAM.

I use a Google Pixel phone. Despite its shortcomings, it's by far the best phone I have ever owned.

And what software?

On my laptop, I use Xubuntu 16.04 with XFCE. I use Chromium as my daily browser, but I have been toying around with Firefox with the release of Firefox Quantum, which is actually fast. I do most of my coding in Emacs, but I also use vim, Atom, VS Code, Android Studio – whatever gets the job done.

On my workstation, I have a University of Michigan Windows 10 core image, which I do for most office tasks. It works well enough, but developing on Windows is still a major pain, even to SSH into the cluster I do most of my heavy compute tasks on. Therefore, I have Manjaro XFCE running in VMWare Workstation for any developer tasks. Unfortunately, working in a VM is still buggy, with annoyances around scrolling and general responsiveness.

On my desktop, I use Arch Linux with KDE, but otherwise similar software setup as my laptop. I also have the KDE/Qt equivalents for many core pieces of software, like Clementine and Krita.

I run stock Google Android on my phone.

What would be my dream setup?

On my desktops, I would like to have a dual monitor setup at work. Having a VM in one monitor and a responsive Windows desktop on the other would be a dream compared to having to switch between the host and guest OS so often.

My home laptop and desktop need to be upgraded to SSDs, but I keep slacking off on actually making the jump.

Another thing I always feel I'm lacking is a good camera. While the Pixel is leaps and bounds better than any other smartphone camera I've tried, it still (usually) cannot compare to a good DSLR.

Acknowledgements

This post was heavily inspired by the uses this interview series, which has some great interviews by other people working and struggling with their technology.

RxHistory has now been released! RxHistory is a Chrome extension that allows you to download the price histories for any pharmaceutical category on the popular medication price tracker, GoodRx.

This simple to use tool is designed for researchers to download pharmaceutical price data for analysis on pharmaceutical pricing. This is especially important with the ever-increasing price of healthcare, which in large part due to rising prices on existing medications and new, more expensive drugs that are being prescribed more often.

To get started, simply download the Chrome extension and navigate to any drug class page on GoodRx, for example the thyroxines page. Click on the RxHistory icon in the upper right when active (green), and a spreadsheet containing all the data will be downloaded immediately.

The spreadsheet contains all the data found on the original page, with the date and price of each data point. Each drug in the drug class has its own sheet: to view other drugs, simply click on the sheet name at the bottom.

RxHistory is also fully open source. Try it out today through the Chrome Web Store!

I was recently asked how technology can be used to help out refugees living in camps, and relived the experience of just how completely out of touch we are with refugee camps. This is a brief recollection of the medical technology used in the AMR clinic and how different universe refugees live in.

The Zaatari camp, despite its population of some 80,000 people, operates more like a hiking camp at the scale of a city. As mentioned in previous posts, there is running water, no sewage system, no organized road system, but of relevance to this post, no electricity, no phone towers, and no phone lines. This of course means that technology is basically nonexistent in the camp besides a few oases with gasoline or diesel powered generators, such as the clinic I worked at.

In the AMR clinic I worked at, the only electrical equipment used were:

• Blood pressure monitor
• EKG machine
• Otoscope
• Ophthalmology equipment (ophthalmoscope, slit lamp, phoropter, and autorefractor)
• Lab testing equipment

It is important for us to be mindful of the constraints refugees live in daily when aiming to help them. A huge part of modern medicine is highly dependent on our lifestyles, which are completely absent from the camp. By far, the most important amenities we take for granted are electricity for refrigeration and water sanitation. Each day in the clinic, at least half of the patients were directly or indirectly affected by these two factors, and many of the treatments prescribed by the doctors depend on them. Numerous medications are extremely susceptible to high temperatures that were common in the camp, and sanitary food and water was difficult to come by.

Luckily, things are changing in the camp for the better: now in 2017, the UNHCR and other authorities are placing much stronger emphasis on site planning and access to electricity. A recent update indicates that most households in the Zaatari camp will have electricity for about 8 hours per day during the evening, which is hopefully a sign of more to come.

This article was originally drafted in 2014, but has become much more relevant in our current political climate.

There are many ways one can rank a news agency's reputability, and simple to perform the statistical analysis. It is easy to make a ranking based on a statistical measure, and even easier to do it wrong.
Based on data from the Pew Research Center^[1] from October 2014, I will be walking through a proper statistical ranking of major news agencies.

The first and easiest way to rank them is by simply subtracting the "distrust" from the "trust" to obtain an overall "trust difference", a simple measure of how many more people trust the station than distrust it.

=B2-C2

The problem with this approach is that it's not weighted by the total number of reactions. For example, when comparing CNN to The Economist, our approach results in a reputability score of 35 for CNN and 30 for The Economist. However, CNN has a much higher distrust to trust ratio than The Economist but still has the higher score because it has far more votes overall (79 vs 42).

Let's fix this by dividing the original conceived score by the total number of votes, normalizing it to the number of votes received.

=B2/(SUM(B2:C2))

In most cases, this is close enough. But when comparing results with a different number of votes on each, one needs to be careful of unpopular results that are more prone to outliers. For example, if we add this very blog (blog.adelqalieh.com) to the list, with only 1 trust vote and no distrust votes, it would dominate the list at 100%. Hence, the final thing we need to account for is uncertainty for news agencies with fewer votes.

To account for this error, we will model the proportion of positive votes as a Bernoulli parameter, and estimate the lower bound of confidence interval with a 95% confidence level. Since we have a discrete number of votes, we will use the Wilson score. The result will be the minimum real proportion of positive ratings given the polled votes with a 95% chance. The Wilson score interval is a binomial proportion confidence interval, but using the Wilson score rather than a normal distribution. This is a much better estimator of a binomial proportion distribution because it does not assume a symmetric distribution and maintains the same bounds as a binomial (0 ≤ p ≤ 1). It also has many other nice properties like intervals for samples (news agencies) with only 1 Bernoulli parameter, which is not possible with a normal^[2].

=((G2 + I2*I2/(2*SUM(B2:C2)) - I2 * sqrt((G2*(1-G2)+I2*I2/(4*SUM(B2:C2)))/SUM(B2:C2)))/(1+I2*I2/SUM(B2:C2)))

Although relatively few news stations have dramatically changed in rating, a hypothetical placement of "Adel's Blog" now only receives a score of 21%, putting it just above the Glenn Beck Program near the bottom of the list :)

Based on examination of individual rankings and affected news agencies, this appears to be a fair evaluation that balances the proportion of trust with the confidence in that value.

Conclusions

Overall, the results are not too surprising. BuzzFeed barely qualifies as journalism, while more prestigious and respected stations like BBC and NPR take the top spots. Interestingly, the top two agencies are foreign, as The Economist and the BBC are based in the UK. The closing of Al Jazeera America in 2016 is not surprising in retrospect with the level of distrust found in this poll.

One thing to qualify as well is that reputability is orthogonal to the political spectrum, but the extremes are much less trustworthy than the centrist news stations that are less likely to be judged. The bottom half of the list is almost entirely occupied by news outlets that lean so far heavily to one side that it is almost completely dismissed by the other side. The proliferation of news on the extremes is both a cause and a symptom of the political divide in the US, and has no clear end in sight.

Caveats

The biggest caveat one needs to be aware of is the role of perception in this poll. This analysis is not at a judgement on the accuracy of the news itself: rather, a ranking of the news stations in the American psyche at large. This is especially crucial when considering the polarization of the media and, by extension, the American public.

The other caveat is that the poll was conducted in 2014, which was a completely different political climate than 2017, albeit a scary prelude. The logical follow-up is to repeat this analysis with a similar dataset for 2017, though I do not anticipate media polarization shrinking.

The medical situation in the Zaatari refugee camp is difficult to understand. At over 80,000 people, Zaatari is more like a slum than a camp, and providing adequate medical services with no infrastructure is an enormous challenge. It is also hard to find information about Zaatari due to restrictions on travel in and out of the camp, the limitations on photography, and the lack of electricity and internet.

Two years ago, I volunteered as an interpreter, scribe, and medical assistant at the Zaatari refugee camp to alleviate the severe shortage in medical staff. Here I will try to summarize the public health situation in Zaatari, though it has likely changed in the last 2 years.

At the time of writing, there are 2 hospitals and 9 medical centers in the Zaatari refugee camp, serving around 80,000 people. They are, in no particular order:

• Arabian Medical Relief Clinic
• Moroccan Hospital
• Italian Hospital
• KSA Hospital
• MSF Hospital
• JHAS Clinic
• Kuweiti Health Clinic
• Qatari Red Crescent
• MdM Clinics
• JHAS Maternity Clinic
• International Medical Corps Clinic

I worked in the Arabian Medical Relief Clinic, which was serving around 600 patients per day when I volunteered in June 2015. The following specialties had a location in the medical center, but were mostly unstaffed as they depended heavily on volunteers.

• Pediatrics
• Cardiovascular / Gastrointestinal
• Internal Medicine
• Surgery (defunct)
• ENT
• Neurology
• Ophthalmology
• Gynecology
• 2 × Dental
• 2 × ER (male, female)
• Lab
• Pharmacy
• Vaccinations
• Prosthetics
• Psychology
• X-ray / Anesthesiology

For instance, in the first few days of June, pediatrics had 2 wards, occupying both the cardiovascular ward. Internal medicine, neurology, ophthalmology, the dental clinic, both emergency rooms, the lab, and pharmacy were filled, as well as endocrinology. All other specialties were closed.

I urge anyone with an interest in public and/or global health to volunteer in the refugee crisis: the need is pressing and enormous.

Go is a new, open source programming language "that makes it easy to build simple, reliable, and efficient software" with excellent concurrency primitives. The same strengths that have made Go a Java/C++ replacement at Google make it an excellent choice for modern scientific programming.

To demonstrate how effective Go is at general-purpose scientific programming, we will be using a Python package called find_circ as a case study that I have adapted from Memczak et al. 2013, and is available under the GPL. I have been using this package to investigate the role of circular RNAs in plants and most recently in mutagenic cell lines, but frequently bumped into the limitations of Python in the scientific world, particularly for replication and speed. To start out, we will compare the entry point of the application: the command line interface.

Parsing Command Line Arguments

In Python, there are two packages in the standard library for parsing command line arguments: optparse and argparse. Although optparse has been deprecated, many Python utilities still use it for the CLI, including find_circ. These libraries are a huge step above manually parsing command line arguments. Go on the other hand provides the flag package in the standard library. Both programming languages have numerous 3rd party packages that offer command line parsing, but are used sparingly.

Adding CLI flags

The fundamental unit of passing arguments into a command line program is a flag or option. Nearly all CLI programs have a convention of having an explicit long-form of the option behind double-dashes (ex: --anchor), and sometimes offering a short, single character option behind a single dash (ex: -a). Short options can be combined, so -ab is equivalent to -a -b.

In our find_circ program, we need to have an option to get the anchor size desired, with a sane default of 20. In Python with optparse, we can do this by initializing a parser and adding an option to it with the add_option method.

from optparse import OptionParser

parser = OptionParser()
parser.add_option("-a", "--anchor", dest="asize", type=int,
                  default=20, help="anchor size (default=20)")

This is fairly simple and idiomatic, though as you can see there are some oddities that we'd like to avoid.

1. Although the default is defined as a keyword argument, we have to manually show the default in the usage string.
2. dest uses a string for the desired variable name rather than a symbol, so most syntax highlighting and IDE features will not apply here.

Let's see how Go compares in this case. Right off the bat, there's a huge difference: Go's flag package only supports long options, but are behind a single dash (ex: -anchor). This is extremely inconsistent with the conventions used in modern GNU/BSD systems, which may take some getting used to. The plus side is that using the CLI is more consistent and readable, which also makes it easier to understand. Now, to the code:

import "flag"

var anchor = flag.Int("anchor", 20, "anchor size")

That was easy! Notice that Go does not have keyword arguments, but the function arguments are provided in the documentation and any good text editor. There is much less duplication here: the result is saved to a variable anchor and the default is automatically appended to the usage string.

Customizing Usage

A huge issue that needs to be addressed in command-line programs is the user experience, or UX. Many CLI programs are difficult to use and understand, especially one-off scientific scripts that are undocumented.

Luckily, both optparse and flag provide us with a default help message that is output with the -h flag or when the validation fails. However, often this message needs to be customized further. First, let's start with the default Go usage message.

Usage of find_circ:
  -anchor int
    	anchor size (default 20)
  ...

This is quite handy: each flag is given with the desired type, as well as the default. However, most bioinformatics programs are intended to be used in a larger pipeline, find_circ included. Thus, a customized usage string is a huge boon to help new users learn how to actually use the program. In the original Python version of find_circ, the usage string is customized through the usage keyword argument of OptionParser, as you can see below.

usage = """

  bowtie2 anchors.qfa.gz | %prog > candidates.bed 2> candidates.reads

"""

parser = OptionParser(usage=usage)

Let's try to work this into our Go program. In Go, the flag package is never explicitly initialized, but it has a flag.Usage variable that can be customized in the init function, which is evaluated upon runtime after all the variable initalizations. Thus, we can emulate the exact behavior of the Python program through a few clever print statements as below:

flag.Usage = func() {
	fmt.Fprintln(os.Stderr, "Usage:")
	fmt.Fprintf(os.Stderr, "  bowtie2 anchors.qfa.gz | %s > candidates.bed 2> candidates.reads\n\n", os.Args[0])
	fmt.Fprintln(os.Stderr, "Options:")
	flag.PrintDefaults()
}

Now, the output of find_circ -h is our customized usage message.

Usage:
  bowtie2 anchors.qfa.gz | ./find_circ > candidates.bed 2> candidates.reads

Options:
  -anchor int
    	anchor size (default 20)

It is hard to decide which approach is preferred in this case: Python does the right thing with the input string, and is far easier to implement. However, the Go program is much more explicit and can be customized even further to add additional sections of documentation in the usage message.

Alternatives

In case the Go flag package is insufficient for your needs, there are countless Go packages that parse command line arguments (yes, each word is a link to a CLI package). I personally have never needed to use any CLI libraries so I cannot recommend one over the other, but this is especially useful if backward compatibility is needed.

Compiling

One advantage and disadvantage of Go in comparison with interpreted languages like R, Python, MATLAB, etc is that it is compiled. Luckily, the Go tool features a go run command that makes it easy to run .go source files easily without needing to compile each time, but the final project should be compiled using go build or go install to take advantage of all that the compiler offers.

The result of go build or go install is a statically linked binary that can be copied over to any machine with the same architecture and immediately run without installing Go or any other libraries - it is completely self-contained. Furthermore, building for other architectures (such as developing on a Windows machine for the Linux server cluster) is extremely simple with the go toolchain. This cross-compilation process is not needed in Python since it is interpreted, but one needs to install Python on the machines and maintain version compatibility across the board.

Conclusion

One misconception of compiled, statically typed languages such as Go is that they must be more verbose than Python, R, Perl, or Matlab, which are frequently used in bioinformatics. However, I have found that for most CLI programs, I am able to create concise programs in Go with similar levels of clarity as Python without any sacrifices to performance. This is the first of a series of articles on using Go as a data science programming language. For this first round, it is clear that Go is the winner: the syntax is cleaner and easier, and having the option of running in-place or compiling a static binary is a definite win over every other language compared.

The clinic opened its doors 5 years ago, in 2012. The whole medical center consisted of a single "caravan" - half was the "exam room" with a sponge mattress and the doctor, and the other half was the "pharmacy" which dispensed medications for the patients. The original team was Dr. Khaled, Dr. AbdulLatif, and Dr. Hussein, 3 Syrian refugees. They were simply volunteering to meet the health needs of people in the camp, nothing more.

A few months later, a Syrian expatriate living in Kuwait visited the camp, and found the clinic buried among the caravans. He was so impressed by their dedication that he donated a huge amount of pharmaceuticals. Each month, they would send a report to him of how many patients they treated and which medications they used.

In time, the medical center started to be well-known, which meant trouble for the founders. The UN, UNICEF, and several children's rights organizations came and complained and reported the medical center for operating illegally.

One day, a security guard came and delivered an official order to close from the Interior Ministry. At the time, they had 300-400 patients, no longer a small operation. The soldier asked them, "when do you close?" They responded, "we close at 2pm" He told them "Alright, then lock it up and bring me the keys at 4pm." And, they did exactly what they were told. For their offense, they would have to pay 5000 JD (approximately $7,000 USD), and a repeat offense would result in a fine of 50,000 JD (~$70,400).

The very next day, they went back to the "medical center", broke the window, retrieved all the medications, set up in a caravan immediately next to it, and opened up for the 300-400 patients coming in today.

"When an old man is begging for medication, you have to take any risk and stand up to any challenge to serve"

Every time someone passes by and visits the clinic, they cannot help but donate money or medications after being impressed by the number of visitors they have and the work ethic found only in this clinic.

"If you can get these drugs anywhere in the camp with a prescription, we'll close down tomorrow"

The taunting from security didn't stop. A plainclothes security officer from the Ministry of Defense came in once, and looked around. He then went up to an older man and asked him if they were selling the medications to him.

"What? They diagnose me, treat me, and offer me medication, all for free!"

Later, the security officer came in his uniform and informed the clinic that security checked whether they sold the medications, and found out the clinic does not. "However, you still have to follow the law," and gave them another order to close.

They closed up, and opened back the very next day.

Up to this point, the physicians and staff had been working independently, with no registered organization. Just an informal group coming together for a noble cause. But without an organization backing them, they knew sooner or later they wouldn't be so lucky with security.

They started searching for partners, and in time found the Arabian Medical Relief, an organization that primarily acted as a Jordanian Medical Association. At the time, they did not have any projects to their name, really no funding, just a name and registration. They discussed as a group that it would be best if they merged the groups, and had the clinic be officially registered under the AMR, but that would take a long approval process.

Not long after, they received an order to close the medical center from the Ministry of Health. They were worried, and were this close to closing down. The very same day, the AMR clinic got approved. They immediately got it via email, printed it, and took it to the Ministry of Health. Since then, the center has been legal in the eyes of the law.

But the bureaucratic struggle was not over yet. To maintain status as a subsidiary of the Arabian Medical Relief, they had to hire Jordanian doctors to join the clinic. They were incredibly desperate, but were able to find physicians to join. Dr. Malik, a Jordanian pharmacist, was hired in order to properly authorize the pharmacy and validate its legality. Another Jordanian doctor volunteered to put his name on the medical center's paperwork - he didn't do any work nor receive pay from the center. A final Jordanian doctor joined - a general physician, recent graduate, but he demanded more pay than any of the Syrian specialist doctors that were already there and his superiors - and he got it out of their desperation.

In fact, all the incomes at the AMR medical center are lower than its counterparts, both in- and outside the camp. Hence begs the question: why does anyone work at the AMR clinic? After surveying all the staff, there are uniting forces: upholding the honesty, dedication, and real clinical work the AMR clinic represents.

SAMS, the Syrian American Medical Society, funds the entirety of their budget. 15,000 JD goes to the pharmacy and 15,000 JD goes to salaries each month, each approximately $21,000. SAMS however is directed at supplying medical assistance to people within Syria, so the AMR clinic is not a priority for them, financially or organizationally.

At one point, SAMS was not able to afford to pay them, so the founders pulled together all the staff and told them, "Look. We're having some financial difficulties, and so we won't be able to give paychecks this month. We completely understand if you're unable to come into work." The next day, and the next, and the rest of the month, all of the employees kept coming in. That's not even mentioning all the times they had late pay, and we're not talking a few days.

Since they've established the center, the founders have always been around 2,000-5,000 JD in debt (approximately $3,000-$7,000).

Nowadays, the AMR medical center provides three services primarily. There's the day clinic, where I had been working for the last three weeks, and treats about 15,000 patients per month. In June when I visited, they treated over 13,000 patients. The next service is a mobile injury unit that travels around the camp to treat severe wounds or burns, especially for patients who cannot travel long distances to receive treatment. This unit treats between 100-200 patients per month. The last is CT/MRI/surgery referrals to other hospitals. They used to do surgeries in house, but surgery is "challenging here," a major understatement. Instead, now they partner with a hospital in Amman that has agreed to take their patients and do CT/MRI scans in exchange for the doctors working there for free as well. On my last day in Jordan, we gave them our goodbyes by taking them to Amman to work their shifts.

The passion and dedication found in the AMR clinic is out of this world - truly the heroes of our time. I feel incredibly fortunate to work alongside them and play a small part in their legendary efforts.

So far, I've been at the Zaatari refugee camp for 3 weeks, and yet I've never gone more than 100 feet away from the medical center, and have spent >95% of my time inside. Well, no longer. Today, I had a tour of the camp, and all I can do is weep.

The past few weeks, we've been parking outside a man's home, and over time we've gotten to know him. Abu Mi'taz is an older gentleman who's one of the of the first refugees at the camp, and has been extremely courteous and friendly our entire visit. Today, he invited us to get a tour of the camp to see what it's like, so I agreed to do it after noon. As the call to prayer sounded, I met with him right outside the medical center, and took 10 paces to reach his home, right behind the car. It consists of three 2 by 2 meter caravans and his home to his children and grandchildren, so about 28 people in this tight space that couldn't have amounted to larger than my dorm.

We enter his home, and I remove my shoes out of courtesy. The floor appears to be cement, unlike the rocky terrain everywhere else; it turns out, he had paved it himself. We start with the first room, and there are some large bags of bread and tiny loaves of bread - almost like samples. He explained that the small loaves of bread are the ones they get for free from the camp, but are woefully inadequate. Like most residents of the camp, he says, he smuggles the rest of the bread from outside the camp "from a real bakery".

Besides for that, the room is woefully empty. There's no furniture to speak of, and the room itself is just a desolate cube. There are some thin foam mattresses on the floor, about 0.5m x 1m each. The exposed foam mattresses were hand-outs, while the fabric coverings were purchased and sewn by Abu Mi'taz's wife. Not to mention, there aren't any personal belongings whatsoever.

In time, I found out that nearly the entire house is his own making. I looked around when we go back to the center, and it's 3 caravans surrounding an open space. The roof of the central area was fabricated from the metal making up the sides of the caravan. We go back into the second room, and the shelves inside were made out of the flooring of the caravan. Even the lighting in the caravans had to be outfitted by the refugees themselves. There's a single depressing window with metal bars in each caravan, some of which had been welded off for other uses.

As for other purchases: Each person in the family receives a pitiful 20 JD (~$28) voucher monthly to purchase things from the "UN Mall," which is reportedly extremely overpriced^[1]. Moreover, the allowance expires monthly, so refugees find themselves using the allowance for everyday use things and then saving up traditional currency. However, Syrians are prohibited from working in Jordan, so every purchase digs into whatever savings the family has, if any.

The kitchen and bathroom are just corners of the main hall; the kitchen is painfully bare. Originally, Abu Mi'taz says, the kitchens were communal just as the bathrooms were, but likewise were closed up when most families started making their own within their homes. The kitchen is really just some unfilled shelves and a small gas stove, which are used as little as possible due to the astronomic price of gas and the lack of a refrigerator to keep food from going bad. With the dirty water and scarcity of food, it's a wonder that anyone manages to survive here.

We walk out of his home into the blistering heat, and take a path along the side of the medical center. It seems that the entire camp has been built and planned rather haphazardly, because this path couldn't have been more than a meter wide and winded and turned among the houses. Reminds me a tiny bit of the small alleys of Old Aleppo, minus all the architecture and roads.

We pass by a daycare, and Abu Mi'taz discussed how the camp authorities have been providing daycare services within the camp, which is really good. They hold ordinary preschool and daycare activities like sing nursery rhymes, draw, learn simple things, but I never got a chance to go inside. That made me wonder about schooling here - what was it like, particularly for someone closer to my age who's going into college. It's a scary thought that had I been in Syria, college would no longer be a possibility for me.

We finally get to our destination, the main camp mosque. There's a large mosque built in the west of the camp. It's a large mosque for sure, but not nearly enough to accommodate anywhere near the population of the camp. There are some teenagers over at the podium, and a few men around the room are praying or reading Quran.

The mosque was fabricated out of Kuwaiti caravans by the refugees themselves. The Imams are local, meaning from the camp, and come an additional 2 hours during the day to give lessons. But it struck me that there is no space for women to pray in, nor is there a place to make wudu, the wash before prayer. Moreover, are no libraries whatsoever in the camp, not even in the schools or mosque.

Note: I was asked by the refugees to ask the international community for a generator for the mosque. If you were waiting for a wake-up call, this is it.

On the way back, I noticed a blue locked-up building a little bit further - that was one of the communal kitchens, roughly one per neighborhood; now, they're no longer used, but their footprint remains. What's left now is a decrepit structure with human waste all around.

As we got back to the medical center, I started talking with Abu Mi'taz about the history of the camp, and his own history. He told me how when he first came, everybody lived in miserable tents the first 4-5 months. Now, everyone is in caravans, about just as miserable. Though the tents are gone, the fabric from the tents is still being used to make roofs and siding for the caravans, as Abu Mi'taz has done. He still holds his dignity up high, and boasts that he's been on CNN and worked at the American Embassy at one point. Now that he's here though, he's uncertain about his future and even more wary about what the future holds for his children and grandchildren.

Reflection

Nothing can compare to actually walking around in the Zaatari camp. No amount of reading, Youtube videos, or UN reports will prepare you for the sights in the Zaatari camp. There's far more than I can ever hope to describe: there's absolutely nothing that can compare to visiting the camp and seeing for yourself.

There's hope, but unfortunately as the days pass, even that is dwindling.

By now, things have gotten relatively routine for me at the Zaatari refugee camp^[1]. The security guards at the camp's entrance now know us pretty well, as do basically all the employees at the AMR clinic. With only 3 days left in my trip, I'm frantically trying to squeeze in as much as I can before we leave. Today it's the 4th of Ramadan, and the number of patients is back to usual.

Today, I worked with Dr. Abdussalam, a pediatrician and a real character. Starting with the first patient, his methods proved to be very different than what I was used to, especially for pediatrics. Essentially, as soon as the patient comes into the room, he starts prompting the parent rapidly and assertively to quickly diagnose and triage patients. He wastes no time in getting the patient history, symptoms, and everything he needs as if his life counted on it.

If you were to describe Dr. Abdussalam with one word, it would be boisterous. He's also humorous and even a little aggressive with patients, but only to the point of acting fatherly. It's hard to give a personality to a name, but you simply can't talk about Dr. Abdussalam without thinking of his passion and enthusiasm. Even while he's fervently quizzing parents in the exam room, his smile is overwhelming.

Dr. Abdussalam also works at the Emirati hospital in the camp Su-Th, and only comes here on Saturdays. A the Emirati hospital, they have a real triage system with nurses taking temperature, weight, etc ahead of the doctor's visit, whereas here he just takes patient's word for having a fever because there aren't any quick thermometers.

Differences in Medical Care

Dr. Abdussalam has a pretty different outlook to medicine than basically all physicians in the US, and part of it is having to work in a refugee camp. He prefaced many of his explanations with the phrase, "well, there's only so much you can do in a refugee camp," and it's hard to blame him. I've only spent 3 weeks here and I can already attest to the dire need of the patients that come here every day.

Dr. Abdussalam is extremely time conscious in his treatment. For example, he always uses a tongue depressor for his throat inspection, and the same was true with other Syrian doctor that I shadowed. The American pediatricians on the other hand always try asking the nice way, and only use the tongue depressor when needed - definitely much slower. When a patient has a chronic or repetitive illness, he repeats meds identically if they worked before for the patient and does a more cursory clinical exam.

Here in the camp, there are a lot of breathing related problems, mostly asthma due to the dust storms and smoking that are both rampant in the camp. Whenever a patient has wheezing in the lungs, the doctor always asks if there is smoking at home. When they answer with the affirmative, he tells them to quit or do it outside - forcefully. Not surprisingly, the doctor prescribes ventolin (albuterol) instead of the more commonly prescribed loratadine for asthmatic patients.

"You Americans do studies, here we operate on trust"

There was a patient with meningococcal meningitis. He came in Kernig sign extremely visible. I asked the doctor whether they gave meningitis vaccines, and he said they do, but appended it with the following:

Last, we saw an older infant with hydrocephalus today as well, which makes it the second case in a week. Based on my research, hydrocephalus is basically nonexistent in the US due to early preventative care, which is extremely difficult to obtain in the Zaatari.

Medications

One aspect that Dr. Abdussalam has a radically different attitude about is prescribing medications. On average, he prescribes 3-4 medications per patient even when they don't need it, and acknowledges that he's overprescribing to the patient. However, the majority of additional medications he prescribes are available over the counter (OTC) in the US, but are not available widely or cheaply in the camp, so there is hardly any risk there.

Other times, he prescribes medications to be safe rather than sorry, as in the case of a giardia infection. The clinic does not have any tests for it, so he prescribes flagyl when there are some symptoms that point to giardia but is not conclusive. For gastroenteritis, he always assumes it is a bacterial infection and writes the patient azithromycin most of the time. If there's any breeding ground for superbugs, it's here in the Zaatari camp.

"Scientifically, we shouldn't be doing this, but practically we should"

In fact, Dr. Abdussalam undermines the authority of other doctors who prescribe less, presumably to have the patients trust him. Many of the medications he gives are basically placebos and don't do much to address the patient's symptoms, like apisal for a URI. Other times, he writes prescriptions without an exam for relatively obvious syndromes like diaper rashes (panderm) or worm infections (vermox).

Near the end of the visit, the patients start asking the doctor exactly what medications they want, particularly when the doctor is writing the prescription. If it sounds reasonable, the doctor will throw it onto the prescription just for good measure - diametrically opposed to the American method of handing the patient their prescription with hardly any negotiation. The doctor explains that "even if there isn't anything relevant for them now, they should get some medications for it to be worth the visit - many of my patients walk 2 miles each way to see me."

Miscellanea

The doctor makes a lot of other miscellaneous medical decisions that I thought went contrary to what I'd been taught, and others made sense.

He prefers liquid medications to suppositories, which are very popular in the Middle East typically, because of possible diarrhea. He also starts using acetaminophen from day 1 for newborns, whereas the American doctor never gives it newborns before investigating what the underlying cause of the fever is.

A patient came in for treatment twice, for a bloody navel. The doctor prefers to treat the patient by rubbing iodine and keeping the umbilical cord dry than the silver nitrate treatment. Based on my research in a pediatrics textbook^[2], the preferred treatment is repeated silver nitrate application. In any case, the primary reason this patient needed care is because a Vitamin K injection was never given at birth.

One point that I've noticed is that the pediatrician takes into account cultural factors heavily in his treatment. For example, he adjusts medications to be as few times per day as much as possible, especially now with fasting during Ramadan, he limits does to 2 times per day. He also does this because patients are far more compliant the fewer doses there are.

Reflections

On the way back, the fact that I had only 1 more day at the clinic sunk in. There was so much lost potential here - so many patients that could be given better care if there was better equipment, and so many bad practices that could be avoided if there was better equipment, better tests, and better medications.

On the way out, I waved goodbye in case I was unable to come tomorrow.

Water is a hot topic in the Middle East, particularly the more inland you go. Jordan has a massive water scarcity problem^[1], and with more refugees coming from Syria every day, the problem has gotten substantially worse. However, this article is less about the geopolitical issues which surround the problem is water scarcity but rather how it affects ordinary life in Amman and especially in the Zaatari refugee camp, home to over 80,000 Syrian refugees.

Amman

In Amman, life is prosperous to a certain degree. A city that started out as a small trading town is now the largest city in Jordan with a population of over 4 million. Massive uncontrolled growth in the last century has resulted in an enormous increase in water needs, which is straining the water supply of Jordan as a whole.

For starters, the tap water is considered unsafe for drinking, so there is an expansive system of bottled water, much like other arid countries in the Middle East and North Africa. Running water is basically universal, though it appears that most houses have water storage tanks on the roof, possibly vestiges of water cut-offs like in Syria and neighboring countries.

In Amman, the most reliable indicator for a wealthy neighborhood is greenery outside, no doubt because of how expensive it is to water it. Neighborhoods like Abdoun and Sweifieh are full of landscaping and gardens, a testimony to their affluence. In general, bottled water is reasonably priced from my perspective (American visitor), generally 35 fils ($0.50) for a 2L of water, but may not be so affordable for a Jordanian citizen.

Zaatari Refugee Camp

In the Zaatari refugee camp, water needs are far more dire. From the first day I got on the camp, I was a little taken aback when everyone at the clinic, from the doctors to the nurses was drinking water out of little single-use foil-wrapped water containers. More surprising was when almost all patients would ask to drink from our water during the visit. A little odd, but not too surprising given the intense heat outside and the long walk to get here.

In time, I learned that the water being provided to everyday people here in the Zaatari camp was simply not suited for everyday use, let alone drinking. I've heard it be described as anywhere from mildly dirty to mud water. I haven't dared drinking it after looking at it for a few moments and knowing where it comes from. With this in mind, all the cases of gastroenteritis make perfect sense - you're going to have repeated GI infections with a dirty water source.

The water comes every few days by truck to fill up all the water tanks lining the street. Of course, nobody can vouch for the cleanliness of the truck or the tank, but with a captive population there is not much they can do. The judicial system afforded to the refugees is a joke at best, so for now the refugees have forced themselves to live with it; there is no life without water.

The camp started out with only one or two water tanks for each neighborhood, but that was not nearly sufficient. Now, every house has one or two water tanks explains Abu Mi'taz, a local living across the street from the hospital. Absurdly, purchasing water tanks is illegal inside the camp, so most are bought just outside the camp and smuggled in.

When the camp was first constructed, the camp had public restrooms every block or so, shared between roughly 100 people. As the camp has become more permanent, people started building Arabic-style toilets in their homes due to the inconvenience of public bathrooms and the complete lack of sanitation^[2]. Now, nearly everyone has their own restroom, and the public restrooms are permanently closed. Sewage is still however a serious problem, since only those that can afford it are able to build makeshift bathrooms in their homes.

The foreign doctors have embarrassed themselves more than a handful of times by suggesting that the patient start drinking bottled water while they have GI - bottled water is too expensive for anyone living in the camp! Even temporarily, people simply can't afford to buy bottled water; after all, they are living on 20 JD / mo. Even the Syrian doctors living outside the camp make the mistake occasionally.

Moving Forward

With a similar but far less dire drought occurring in California, it's becoming increasingly imperative for us to worry about global water needs. At the same time, living near the Great Lakes, it's hard to imagine what life is like without plentiful water and rivers, lakes, and forests all around. During my 3 week trip, I never risked drinking tap water, let alone the muddy water in the camp. I simply cannot imagine how one can drink from this water on a daily basis for years. Even more absurd is why better filtration has not been brought into the camp when filters are so cheap and readily available these days.

The Zaatari refugee camp is suffering from a water shortage and water quality, and is simply not sustainable. Furthermore, the refugees really have no monetary or legal means to do anything about their present situation. As an international community, we need to move to get the Syrian refugees the most basic of necessities: water.

Medical education is huge in the refugee camp. With severed communication links to the rest of the world and lack of higher education, the camp had developed workarounds to deal with the knowledge shortage.

As a physician, one of the primary aims is to understand the patient concerns and convey a solution and plan that is workable and understood by the patient: in essence, communication. While this is true globally, this is at least an order of magnitude more necessary in the refugee camp. First, with no charts and a high illiteracy rate, it is as important as ever for the patient to totally understand their diagnosis and treatment, because almost all medical history is self-reported. Second, without a written action plan, phone to ask questions, or internet to search for answers, a patient must get all their information from the physician during the consult. This is compounded by the limited time each patient spends with the physician. Finally, the lack of general health education made it difficult for patients to understand the diagnoses or symptoms without baseline knowledge.

With that said, I had an unusually communicative day at the clinic with Dr. Hussein. Time to dive in.

Working with Dr. Hussein

I first met Dr. Hussein while working with Dr. John in pediatrics. He is funny, approachable, and always has a huge smile on his face. Even with all that is going on, he manages to get the patients and parents to laugh and smile. He also has a lot of wisdom about working in the camp having worked there the longest.

Educating parents is a primary job of medical workers, especially physicians. Dr. Hussein's style of communicating with patients was a unique surprise. Behind his happy demeanor, he was quite demanding of patients. Rather than offering suggestions, the doctor commanded them to do exactly as instructed. He says it's not his preferred style, but it is the best way to have the patients cooperate. He also has a sense of humor, even at the patient's expense. A patient once questioned his choice of medication, and he jokingly responded that "if you think I'm the expert, then follow what I say".

Another part of communication is getting the medical history, which is much harder without a real chart to go off. While I was with Dr. Hussein, he asked what medications the patient is taking multiple times. With a surprisingly high frequency, most parents changed their answer after the first time he asked. As prescriptions are not documented in the charts and are never noted by the other clinics, there is hardly ever a written record. Furthermore, the scarcity of pharmaceuticals in the camp means that often medications are borrowed from parents, siblings, or neighbors. The biggest cause is due to forgetfulness. The parents are usually preoccupied with much more urgent issues, so the prescription history does not come to mind easily unless reminded or prompted.

The physician preferred suppositories, because in his experience, patients follow the medication dosage and schedule more consistently. Patients also selected suppositories over liquid medications, the complete opposite of preferences in the US. Part of it was a cultural preference for suppositories, as most patients were already used to them in Syria, but another reason given was that they keep longer in the extreme heat.

Some less generalizable and less advisable lessons were learned today as well. I have not noticed any hand sanitizer use or hand washing whatsoever between patients, even with infectious diseases involved. With bacterial gastroenteritis a common occurrence, it's surprising that there are not more safeguards from preventing the spread of communicable illnesses in the clinic.

Patient Observations

Patients were generally surprised when they were not prescribed medications, and often insisted on receiving medications. Often, this was their way of justifying the long and time-consuming trip to the clinic, and most of the time it was their only source of pharmaceuticals. One downstream effect of this expectation is that patients who do not receive a prescription come back on another day to get another doctor who will write them a prescription. The local physicians tended to overprescribe just in case, as in the case of Dr. Abdussalam.

One issue facing newborn care was the lack of availability of baby bottles. Many patients complained about the lack of baby bottles. In fact, many action plans from physicians depended on baby bottles, from clean water to baby formula. It is incredibly sad that even something as basic as a baby bottled needs to be smuggled in from outside the camp. At the time of writing, there is no clear solution in sight.

A familiar concern was education about antibiotic use. Many parents quit using antibiotics early when their child improved, which is a huge issue with regards to antibiotic resistance. A related but new concern to me was increasing the frequency of antibiotics higher than the prescribed dosage to "speed up treatment". The concept had not occurred to me before, but it actually makes sense. More is better, right?

Final Thoughts

Long-distance communication without stable electricity, phone lines, cellular networks, or addresses is unthinkable to me. Even the clinic, which has a number of generators and backups, experiences several power outages during the day, which last anywhere from 5 seconds to 5 minutes.

The fact is, life in the refugee camp is somewhat like going back in time. Public health and city planning are nonexistent, so it harkens back to an era where bacterial infections that are basically a solved problem in the developed world spread like the plague and result in real-time healthcare crises. Only decisive action to address the causes, namely poor sanitation and food spoilage, can bring an end to this issue. The afflictions and prescriptions are merely a bandaid, however needed.

Today is my last day with the main mission, and I'm working with the ophthalmologist since it's his last day too. I feel like I'm starting to get the flow of things, so here's to a positive attitude.

We make our way to the camp on-time for the first time and go to the back hallway to find the ophthalmology clinic. Before we let in the first patient, the doctor gave me a quick intro to ophthalmology, the anatomy of the eye, and the equipment they have available in the camp. He explained that ophthalmology required a lot more equipment than we had here - an ophthalmoscope, a slit lamp, a tonometer, an autorefractor, and corrective lenses.

The hardest case for a patient that we encountered was a 17 yr old girl with almost complete blindness but only a mild cataract. Other associated symptoms include completely uncontrolled diabetes, with blood sugar ranging from 35-700, which definitely plays a factor. After being unable to make any conclusions from the preliminary eye exams, the doctor dilated her pupils to get a better look. 30 minutes later, she was brought back in, but the doctor wasn't able to see anything conclusive now either. We ended up referring to a proper retinal scan, which was expected to take months at best. The doctor was not happy.

The most common complaint by far is dryness and eye irritation, presumably from the dry, arid climate and the dust storms that happen almost daily. Unfortunately, there aren't many good treatments besides staying indoors to avoid the dust and eye drops. Cataracts, or "white water" as they're called in Arabic, however were much more common than I expected, even in younger adults. All of those had to be transferred to a hospital outside the camp that could actually perform the operation.

In the room with me the entire time, the technician and medical scribe was learning how to use some of the more automated machines, for example to measure an eyeglasses prescription using the autorefractor. At the very end, the doctor gave him a brief introduction to the lenses, but it seemed like he zoned out.

The doctor asked, "So are you going to start using this equipment?" and he replied "Probably not anytime soon. We're out of glasses, doctor".

Something I found depressing was even after we were "done" with the patients for the day, there were 8 more waiting outside who were unregistered. The doctor and I decided to stay a little bit longer so we could see the patients, and to be honest they needed the care just as much as anyone else. More of the same: cataracts, itchy and dry eyes, and glasses prescriptions.

Reflections

As the day comes to an end, I start wishing I could stay with the mission longer. At the same time, the magnitude of the issues here is simply incredible: there's great need, and these doctors only come for 10 days every few months and they're still unable to treat the glut of patients that come daily. That's not even touching the public health issues of sanitation, nutrition, and immunizations which are largely handled by humanitarian organizations like the UNHCR but it's simply not enough.

All I could do on the way back was stare out the window and ponder.

Today's my second day at the camp, and this time I at least have some idea what to expect based on my experience yesterday. This time, though, I'm interpreting for an American pediatrician who has volunteered for the mission (Thanks Dr. John!).

As I mentioned last time, the Zaatari refugee camp is just enormous - I can't wrap my head around the scale of the camp as we approach it for the second time. I look into the distance and can't see the end of the camp, even though the terrain is completely flat.

We get to the clinic, and we make our way to the back hallway where all the physicians are, unlike the emergency room which faces right into the waiting room. However, it seems pediatrics works a little differently - with the mission bringing 2 pediatricians, and there is 1 local Syrian pediatrician today, there are 3 doctors and only 1 pediatrics room. So, the local Syrian doctor, the American doctor, and I all move over to the Internal Medicine room. As the doctor was unpacking, we briefly planned our approach to communication and working with patients.

Cases

The first patient we examined was a typical case of a urinary tract infection, or UTI. It was actually harder than I expected to translate between the patient and doctor, especially with lots of one-off phrases. At the end, the doctor told me he was going to demonstrate Murphy's punch^[1] for UTI, but the Syrian doctor beat him to it and gave a karate chop to the little girl's side. The doctor and I were a little taken aback and chuckled a little because it didn't seem like the girl was hurt, but it ruined the point of doing a Murphy's punch in the first place.

By far, the most common symptoms here are diarrhea, fever, and the common cold. The doctor suspects that they're from problems with the water and food supply, but doesn't bother to ask what the situation is from, so I've made a note to ask about it later when we get more time.

One of the big surprises is how common pinworms are in the camp. Roughly 15% of the patients today appeared to suffer from some sort of intestinal worms, and often ran within a family. The doctors disagreed over the proper dosage for Vermox (Mebendazole) to treat a worm infection - another note for later.

One patient that I won't forget is a little girl that came with 2 of her sisters but was incredibly shy. The doctor started with her first, and halfway through the visit, she started talking and helping the doctor examine her sisters. "Open your mouth wide," she tells her sister while the doctor examines her throat. For the next several hours, she would pop into the room and tell the other little girls waiting for their turn that it everything was OK.

A common concern among parents, regardless the primary complaint for the visit, is nocturnal enuresis. Mostly with young girls between 8-12, for whatever reason it seems they have a problem going to the restroom at night. I have my hypotheses, but I suspect that the restrooms here are unsanitary and the stresses of living here your whole life contribute to the problem.

There was a child that came in with obvious cerebral palsy. He had some clearly visible black stitches on his eye after a cornea replacement surgery, which was paid for by donations. However, the hospital completely neglected the follow-up and never removed the stitches which are already 6 months overdue.

Another patient in the same vein was an infant boy with Down syndrome, but the mother was unaware. It took several minutes for the doctor to explain the lifelong effects of Down syndrome, and several more for me to translate it all to the patient. In some ways, it seems like birth defects are so common and not well understood that there isn't much social stigma associated.

The biggest antipattern I've noticed so far is overdressing children, and especially infants when they have a fever. Today the temperature outside is almost 100F, and the babies with fevers are dressed with 3 layers of thick winter clothes and wrapped with another 3 or 4 layers of blankets and coverings. When discussing it with the parents, however, it makes sense because of the chills that are associated with fever.

There was a child who had an innocent heart murmur. It was actually somewhat surprising to me that I could hear it so clearly, and the child cooperating definitely helped.

Something I found uplifting was how caring some parents were for their children, especially in these conditions. One example was a parent who brought their child in for some sort of allergic reaction to insect bites which happened just an hour earlier when her child was playing outside.

Surprises

Actually, the doctor and I were very surprised how little malnutrition exists in the camp. We were actually expecting a lot of dehydration and malnutrition, especially in newborns. Even with the extreme prevalence of diarrhea, we didn't see any dehydration, which is even more odd.

Something noted by my translating colleague is the lack of signs of abuse in children. Even in the US you see relatively frequent cases of abuse popping up, but here it seemed like most parents were caring to their children, or at least hands-free. Parents are generally cooperative, interested in their child's care, and the children and parents are usually smiling. Some parents were even rather educated and came in knowing their child had tonsil inflammation and listed out the symptoms rather precisely. Others knew what medication they wanted and just asked for it straight out, probably from past experience or from the neighbors since disease is so common here. Just looking at their charts, on average it looks like the children visit the doctor every month or two.

Another surprise is just how little dehydration there is in the camp with the children, even when they have diarrhea. It seemed like that was a point of interest for the doctor as well, because he thoroughly covered how to look for dehydration in children, especially infants where it could be fatal.

Resources

Most things for the pediatric clinic are rather commonly used, so no shortages it seems like for 95% of the equipment and medications. There aren't enough stethoscopes or otoscopes to go around so it's best if you brought your own. Pediatric doses of tylenol, amoxicillin, azithromycin, and the like are readily available, though usually by Jordanian manufacturers and I doubt are as effective in the extreme heat.

One major missing resource is some kind of conversion between the American, European, and Arabic names for medications. The American doctor of course was more familiar with the American brand name and the generic name for a drug, but oftentimes that wasn't enough because even the scientific name for a drug is slightly different across the Atlantic. While most of the time the pharmacist was able to figure it out, the medical scribe had a lot of difficulty figuring out what medications to put down the medical records, which had to be in Arabic.

A key comparison Dr. John brought up is to the relief efforts in Haiti^[2], which he volunteered in 5 years ago. A common pattern is to report symptoms to receive treatment when they are subsyndromal - in Haiti, the most common complaint was headaches, and here in the Zaatari camp by far the most reported symptom is diarrhea. On a happier note, Dr. John noted that the parents here are less angry and more open to cooperating with the physician compared with the patients in Haiti.

Reflections

On the way back, Dr. John, the other student, and I started discussing the conditions in more detail. Although it's just one day, I don't feel nearly as traumatized or worn out, mostly because it feels like the cases are treatable in some way.

Today was my first day at the Zaatari refugee camp, and I'm speechless and breathless. Today, every possible line was blurred, all the way from the broken-down language barriers in the ER to the angry mob trying to get their prescriptions.

The Zaatari refugee camp is the 2nd largest refugee camp in the world, with estimates hovering around 80,000 people living there as of mid-2015^[1]. I went with SAMS, the Syrian American Medical Society, on a mission to improve the quality of medical care at a clinic in the camp. We had a short orientation session at the beginning with Dr. Zohaili and Dr. Hariri, the leaders of the mission, where they explained some rules and regulations that I found curious^[2].

1. No pictures
2. No offering money
3. No wandering in the camp

We left the hotel at the fine time of 9am and only arrived at the camp at nearly 11am, fashionably 2 hours late. We were let in with practically no inspection or even checking passports, and we were off to the races. As soon as we approached the camp, we were able to start making out what the camp actually is: thousands upon thousands of 2m x 2m x 2m cubes, lined up crudely into rows and streets. Many of them looked more like jail cells than they did living residences. Along the main road, there were many small shops, ranging from bike repair to wedding dresses - it almost felt like a city, but not quite.

After a turn into a narrow alley, we finally stop, but I look around and can't see the clinic - in fact, I don't even know what to look for anymore. I get out of the van, and follow the group to find the actual clinic, which I will describe in more vivid detail in a later post. Essentially, it's just a compound made up of several of the cubes with a sheet metal roof on top that doesn't properly fit.

Women's Emergency Room

So, after getting a quick look around the "clinic", I'm ushered into the Women's ER along with a female nurse from our mission, and my job was to translate and interpret for her between Arabic and her native language, English. The emergency room is small, roughly 8 square meters. There's a cart with some essential equipment the nurse regularly uses, like gauze, antibacterial ointment, antiseptics, and things of that sort. In the corner, there are shelves with additional supplies for the cart along with gloves, shots, syringes, and an assortment of additional medical supplies the head nurse doesn't use because she's not sure what they are. Normally, the room is staffed by the head nurse and the nurse's assistant, both of whom are living in the camp. For more difficult procedures, the general physician comes in to help out, but that rarely happens. Luckily, both of them are here today to show us how work is done around here.

Well, what are the cases like? Well, there's everything. A good number of cases here are a result of severe neglect. Deep cuts with infections that go untreated for days. First degree burns that go untreated for weeks. Severe deterioration of flesh in the heel that goes untreated for months. This - is what the Zaatari ER is like. Of course, you have your routine blood pressure measurements and EKG scans, which are done with reasonably modern equipment, and many patients are just getting their sutures removed or wounds cleaned. But none of that takes away from the shock of a patient losing large amounts of flesh and skin or panic attacks in the clinic. At the same time, all the support staff, including myself, remain calm, collected, and continue with the procedures.

As you may expect, translating with this type of pressure is far more intense. Soon, the head nurse started to use simple English words for convenience like 'left' and 'right', and the American nurse started putting together simple Arabic sentences, so my role at the clinic blurred further into more of an assistant role than a translator role. There's really no time to be wasted. I found out later that the nurse from our mission has been living in Amman for 6 months now to learn Arabic, and the head nurse has been taking English lessons for about 2 weeks.

Pharmacy

After going through the ER for about 5 hours, traffic slowed to a halt and I was recruited to help with the pharmacy, which had just received a large load of pharmaceuticals by truck. I'm told by the nurses that this is the only clinic within the camp which dispenses medications, which is crazy to me. In any case, it was clear within 5 seconds of walking into the pharmacy that it had a horrible organization problem. In short: chaos. I first started by helping the American pharmacist reorganize the inhalers as it appears they had been misclassified. Meanwhile, the local pharmacist continued dispensing medications at the window to the angry mob waiting outside to get their prescriptions filled.

After 10 minutes of going through the different medications and consulting with the local pharmacist between prescriptions, I finally understood the system - or what was intended of it. First and foremost, there is absolutely no inventory done whatsoever. It's close to impossible to determine if a medication is available or unavailable besides scouring all the shelves. The first set of shelves is reserved for "commonly dispensed medications", which are already packaged into little bags for commonly prescribed amounts. Next, we have the "expiring in 2015" shelves, which are organized by expiration date rather than by type of medication - so you have the June 2015 shelf, the July 2015 shelf, etc. Last, we have the largest set of shelves, which are all other medications organized roughly by purpose - vitamins, antibiotics, allergy drugs, painkillers, etc. However, the pharmacist doesn't know what all the drugs do, so he just leaves them in the first open spot he finds.

While this organization scheme is already bad enough as it is, it's no help at all that there is no system to maintain order. Our first task was to painstakingly check every medication in the large set of shelves to dispose of expired drugs and move drugs which expire in 2015 into those set of shelves. We actually found a surprising number of already expired drugs, and dozens more which the pharmacist incorrectly recalled were out of stock and so weren't being dispensed. The categorization system really broke down for multipurpose drugs, where often they were classified in both categories depending on how the pharmacist felt that day of the week. Other members of the mission were packaging drugs into little bags, which seemed tedious enough until I had the pleasure of doing it myself. Oh, and did I forget to mention there's no inventory system? Finally, possibly the biggest problem is that the local pharmacist is actually quite comfortable with the current system and didn't look too happy that we were organizing it for him. Meanwhile, the American pharmacist was visibly confused and frustrated at the state of things, and by the look on her face it looked like she was going to completely redo it.

Outside the pharmacy, there are around 30 people struggling to get their prescriptions filled, even though all the physicians have left already. Everyone is clustered around the pharmacy window with prescription in hand, pushing their way to the pharmacist's hand so they can get their prescription before the pharmacy closes for the day. After all, the main reason most people are here is to get pharmaceuticals for their sick.

Reflections

On the way back, I couldn't help but reflect on how fortunate I am and how in need the people I was working with are. To think that I could spend a few days sleeping in the camp to see what it's like instead of the hotel now sounded, well, ridiculous. I can't do it, and I can't imagine how the 200,000 people who live in the camp do it on a daily basis.