Louay plays with a rubber nose given to him by a volunteer at the Italian Hospital. Photograph by Hiba Dlewati
Amman, Jordan -- Most of the doctors have started to go home, so we find an empty hospital staff room to sit down. Coffee or tea?
Dr. Mohammad* closes the door behind us. The 40-year-old orthopedic surgeon is one of many Syrian doctors working illegally in Jordan since the conflict next door erupted five years ago. He had just returned to Syria in 2011 to complete his mandatory military conscription when the uprising started.
"It was not bearable to stay with the regime," said Dr. Mohammad, recalling the time he witnessed a security officer shoot and kill a child after a protest. His hands tightened around his coffee mug. "I would see the killing with my own eyes."
In 2012, Dr. Mohammad defected from the Syrian military and fled to neighboring Jordan. Unable to find work legally within his profession, he began to work under what is called a "cover." That's when one or more Syrian doctors work underneath a Jordanian doctor's name. This entails working for more hours and less pay than a Jordanian physician would, and often paying the "cover" a fee. Although these Jordanian doctors are usually well-connected, there are no guarantees for the Syrian doctors' safety.
"If someone from the ministry comes and sees us working—even if there is a cover—it's still considered a violation," Dr. Mohammad said.
Syrian doctors caught working illegally face a number of dire consequences. Two Syrian doctors were arrested a few months ago while on a night shift, Dr. Mohammad told me, and are still awaiting their trial. Violations can amount to three-year jail sentences, and Syrian doctors can also be deported back into Syria, a threat "covers" sometimes leverage.
"A Jordanian doctor once told me: in one call I can have you sent to Zaatari (camp) or have you deported back to Syria," said Dr. Zeinab*, a Syrian ob-gyn also working illegally in Jordan. "I am working but I am not comfortable."
The threat was all too real for nine Syrian medical workers who were deported to Syria last December from the northern Jordanian city of Ramtha. They were a group of doctors, nurses, and activists working with the Syria War Wounded Liaison Office (which since then has closed) as facilitators between Syrian patients brought across the border and hospitals able to provide treatment in Jordan. According to this report by Human Rights Watch, the medical workers had been coordinating with Jordanian authorities for three years before they were suddenly and forcibly deported, which violates the customary international law principle of nonrefoulement.
"As far as I know, the deportation of those doctors occurred with no due process or consideration of the bar that would be faced by the doctors back in Syria, and therefore is a violation of Jordan's obligations under the Convention against Torture," said Christy Fujio, a human rights lawyer based in the U.S.
This state of instability that Syrian doctors must endure if they try to work in Jordan has driven many of them to leave, both Dr. Mohammad and Zeinab told me. While some have headed towards Turkey, others have taken the risky route across the Aegean Sea to European countries like Germany and Sweden.
"I'm not staying here," said Dr. Zeinab, pulling at the sleeves of her bright scrubs. "But I don't want to smuggle myself."
Vital Work
Despite the fact that Syrian doctors in Jordan work illegally, they leave a void in an already strained system when they leave. Syrian doctors are mostly privately funded, and thus do not take fees from their patients. Due to insufficiently funded UN agencies, the Jordanian government stopped providing free health care to Syrian refugees over a year ago. Even in public hospitals, Syrians must now pay a fee, and deal with extreme delays. An appointment for a CT scan can take up to three months.
"These hospitals were crowded in the first place, and now you have a million Syrians here," said Dr. Mohammad. "You do not get an appointment till a month or later, and there are delays with necessary medical procedures."
NGOS and medical aid groups have largely focused on war trauma patients, something Dr. Mohammad said was natural when the conflict first started. However, with the official number of Syrian refugees at 1.4 million, public health has become a real issue. Most funding for Syrian refugee medical aid is intermittent at best, and not sustainable or reliable. This manifests most clearly in maternal health care and patients with chronic illnesses.
"In the beginning we thought only of the wounded, but now we realize that regular patients are also a big burden," Dr. Mohammad said.
Photograph by Hiba Dlewati
Fatima Nahhas first realized something was wrong with her 18-month-old son, Louay, when he started grinding his teeth so hard they chipped. Then, he stopped urinating. She took him to the Caritas screening and diagnostics center in the Italian Hospital in Amman, where he was diagnosed with a tumor in his bladder, a cancer known as embryonal rhabdoymyosarcoma.
"I did not expect this," said a distraught Nahhas. "I felt I was going to lose my son."
The only hospital equipped to provide the necessary treatment is the King Hussein Cancer Center, which demanded a 7000 JD deposit. For Nahhas, this is an unimaginable number. Fleeing war torn Aleppo three years ago, the mother of eight lives alone with her children in Amman, two of whom have dropped out of school to work and help scrape together enough for the family to survive.
Their father is stuck in Azraq Refugee Camp, having fled Aleppo a year later. He is not allowed to leave the camp since he lost his ID papers in the shelling, and unlike Zaatari Camp, there are no opportunities for work.
"What are we supposed to do," asked Nahhas, wiping away tears. "We can only pray."
Cases like Louay's are often faced with only two choices. The patient's family must seek a donor willing to pay for the necessary treatment, or the patient is left to die.
Vigilante Healthcare
Realizing that the gaping wounds in the Jordanian healthcare system have left refugees seeking medical attention reeling, some activists and medical workers have created a network to pick up the slack.
"We have a WhatsApp group," said Dr. Zeinab, referring to the mobile messaging app. "We post cases looking to match with donors or hospitals that can sponsor them."
Doctors in the group offer their services when they can, or look for hospitals willing to offer their facilities for a discount. Well-known activists share the cases on Facebook to crowdfund for cases like Louay's, hoping to make it in time. Dr. Zeinab's cousin was one such case who couldn't find a donor, and died from lymphoma at age 37 two years ago.
"It is not possible to keep depriving Syrians of their civil rights and not allowing them to work," said Naseem Samawi, the executive director of the Italian Hospital in Amman. "You either have to cover refugees completely: food, water, medicine, and housing. But by banning them from work, and not providing them will all the necessities, how are they supposed to live?"
Samawi told me that there needs to be a "realistic" long-term strategy for Syrians in Jordan, saying that the many waves of refugees to Jordan of Palestinians, Syrians, Iraqis, Libyans, Yemenis, and Somalis had all placed a burden on the infrastructure. He also pointed out that Jordan already struggles from not having enough doctors, with many specialized physicians and medical staff migrating in search of better opportunities. Earlier this year, the Jordanian Ministry of Health allowed doctors to work even after their retirement because of staff shortages.
"We have all these Syrian doctors who are qualified, and we could benefit from their expertise," said Samawi. "I think the government has the capacity to organize this."
Syrian doctors said that even if they do the necessary bureaucratic and often expensive procedures to obtain work permits and modify their medical degrees to the Jordanian system, they would still not be allowed to work without licensing from the Ministry of Health. However, foreign doctors requesting licenses in Jordan need to be members of the Jordanian Medical Association (JMA) and a crucial requirement to being accepted into the JMA is Jordanian citizenship. The Jordanian Medical Association was contacted for comment but could not be reached, and the Ministry of Health referred comment to the JMA.
"The Jordanian government could vastly improve the lives of Syrian refugees by allowing Syrian doctors and other health professionals to obtain work authorization," Fujio said. "Even a very circumscribed work permission, that for example, allowed doctors to treat fellow Syrians, would dramatically improve the health and well-being of Syrians living in Jordan."
Both Dr. Mohammad and Dr. Zeinab indicated that they did not want to treat Jordanian patients or compete with Jordanian doctors, but to just have legal authorization to work with Syrian patients in Jordan.
"We just want to have a nonprofit medical center for Syrians," said Dr. Mohamamd. "Where we could treat Syrian patients free-of-charge, and we would be paid salaries by the donor(s)."
A similar approach to this proposal has taken place in Turkey, where the World Health Organization and the Turkish Ministry of Health have started training Syrian medical staff to provide services to fellow refugees in camp and urban settings. In Germany, a Syrian doctor can obtain a temporary permit to work within a specific medical facility if he/she has command of the German language. After modifying their license and obtaining residency, a Syrian doctor in Germany can work anywhere in the country.
The remaining Syrian doctors in Jordan are busy, trying to steady a staggering system that continues to treat the refugee crisis as temporary, despite the conflict showing no signs of abating, and more than ten thousand additional refugees bottlenecked at the border awaiting entry. Patients refer each other by word of mouth since the doctors cannot advertise for fear of persecution. Dr. Mohammad sees at least 30 patients a day, taking only Friday off. He sees a systematic push to get Syrians to return to refugee camps, he said, what with the cuts to urban refugees' medical insurance and food vouchers.
"Personally, I won't leave Jordan. I want to go back from here to Syria," Dr. Mohammad said.
(*) These names were changed to protect the sources.
Hiba Dlewati is a Syrian American journalist and writer moving throughout Jordan, Turkey and Sweden to document and narrate the stories of the Syrian diaspora. Twitter: @Hiba_Dlewati