“Musculoskeletal care is often invisible in global health discourse, yet it is central to human function and dignity. My time in Jordan and Zaatari affirmed that orthopedic surgeons play a critical role, not only as technicians, but as advocates, thinkers, and partners in equity-driven care.”
by Fayez Ghazi, MED'26
During April 2025, I had the privilege of traveling to Jordan with the support of the Dartmouth Center for Global Health Equity to work alongside the Syrian American Medical Society (SAMS). Accompanied by my attending orthopedic surgeon, Dr. Rameez Qudsi, and Arabic–English medical student translators from the University of Jordan, our team provided direct orthopedic care to displaced Syrians while simultaneously assessing surgical capacity in humanitarian health facilities. This experience profoundly reshaped my understanding of what it means to practice medicine in conditions of scarcity and how physicians can respond with both humility and action.
Learning to Care Without Infrastructure
Our work began in Amman, Jordan, where we were assisted SAMS at a refugee clinic during an outreach day. The clinic was severely under-resourced, operating without advanced imaging, durable medical equipment, or surgical capabilities. Yet patient volume was overwhelming. Within the first hour, nearly forty individuals, many with chronic, untreated musculoskeletal conditions, were waiting to be seen.
Most patients were Syrian refugees who had endured years of delayed or fragmented care due to displacement, financial hardship, and limited access to specialist care. Treatment options were constrained to basic medications such as NSAIDs, topical diclofenac, and oral steroids. Without imaging or procedural support, clinical decision-making relied almost entirely on physical examination and careful history-taking. For me, this was both a challenge and a return to the fundamentals of medicine: diagnosis grounded in observation, touch, and listening.
Recognizing the mismatch between demand and capacity, Dr. Qudsi and I developed an improvised but effective workflow. I triaged and evaluated patients, formulating diagnostic impressions and treatment plans, which he then reviewed before moving on to the next case. This system allowed us to safely extend healthcare to more patients while maintaining appropriate supervision. It was the first time I truly appreciated how adaptability and trust within a care team can directly translate into increased access for patients.
One patient’s case has particularly stayed with me: a nine-year-old boy who had sustained a femoral fracture more than two years earlier. Flexible intramedullary nails had been placed at the time, but his family was unable to afford follow-up care for implant removal. Now, long overdue for extraction, he walked with a limp and visible discomfort. His case crystallized the human cost of interrupted surgical care in displaced populations. Working with SAMS coordinators, we were able to connect the family with a local surgeon willing to perform the procedure at no cost. It was a small success, but one that underscored how targeted advocacy can meaningfully alter a child’s well-being.
Understanding Systems in a Protracted Crisis
Later that week, we traveled north to the Zaatari Refugee Camp, one of the largest refugee camps in the world and home to approximately 80,000 displaced Syrians. Here, our work expanded beyond clinical care to include a formal assessment of orthopedic capacity across camp-based health facilities. Using a modified version of the validated PIPES surgical assessment tool, which evaluates Personnel, Infrastructure, Procedures, Equipment, and Supplies, we conducted structured surveys and semi-structured interviews with clinic managers, emergency department leadership, and orthopedic providers.
Each morning began at the SAMS clinic in the camp, where patients, hoping to secure an appointment, often arrived as early as 5:00 a.m. One of the first patients I evaluated presented with lower extremity swelling, which I initially thought was an orthopedic ailment. Through the patient’s medical history and our team’s physical exam, I recognized signs of heart failure exacerbation and volume overload, a common condition shared by many of the patients I helped treat during my clerkships. This encounter reinforced the importance of maintaining a broad differential diagnosis, particularly in settings where specialty boundaries blur and systemic disease often masquerades as musculoskeletal pathology.
Only two part-time orthopedic surgeons served the entire population, each visiting once weekly. Imaging capacity was extremely limited, as two basic X-ray machines served the entire camp, resulting in weeks-long delays in scanning. No facility had an operating room, anesthesia services, or orthopedic implants. Fracture care was largely limited to splinting, limiting our ability to perform reductions or definitive fixation. Elective orthopedic procedures, such as hardware removal, clubfoot correction, or joint reconstruction, were almost entirely unavailable.
A particularly striking realization was the role of policy in shaping care. The United Nations High Commissioner for Refugees (UNHCR) covers only life-saving interventions, effectively deprioritizing musculoskeletal conditions despite their potential to cause lifelong disability. As one clinic manager stated bluntly, “If it doesn’t kill you, it doesn’t get attention.” This philosophy, while born of necessity, carries profound implications for mobility, independence, and dignity, especially for children.
From Observation to Scholarship
Rather than viewing these constraints as insurmountable, our team sought to document them rigorously and responsibly. During this visit, we conducted three complementary research projects designed to translate clinical observation into evidence that could inform future policy, funding, and program design.
First, through semi-structured interviews with clinic managers, emergency department leadership, and orthopedic providers, our qualitative study captured the lived realities of delivering musculoskeletal care in a protracted refugee setting. Providers consistently described months-long wait times, severe workforce shortages, fragmented referral systems, and the moral distress of being unable to offer definitive treatment for conditions that cause lifelong disability. Importantly, they also articulated pragmatic, locally informed solutions, such as daily orthopedic coverage, strengthened triage capacity, and expanded basic imaging, highlighting that frontline clinicians are not passive recipients of systemic constraints, but active generators of solutions.
Second, our cross-sectional surgical capacity assessment using a modified PIPES framework quantitatively demonstrated the extent of these gaps. Across Zaatari’s health facilities, we found no operating theaters, anesthesia services, or orthopedic implants, with fracture care largely limited to immobilization. Even when aggregating resources across the entire camp, overall capacity remained insufficient to provide definitive operative care. These limitations expressed how structural deficits, rather than clinical decision-making, ultimately determine patient outcomes in humanitarian settings.
Finally, our clinical feasibility study of wide-awake local anesthesia hand procedures explored whether targeted innovation could safely expand access to care within existing constraints. By being resourceful, we demonstrated that selected minor hand procedures could be performed safely in an outpatient clinic without compromising patient acceptability and health outcomes comparable to hospital-based care. While not a replacement for comprehensive surgical services, this work demonstrated how context-appropriate adaptations can meaningfully reduce suffering when broader infrastructure is inaccessible.
Together, these studies expanded my understanding of global health research, teaching me that sustainable change requires more than short-term service. It demands partnership, longitudinal engagement, and scholarship that amplifies local voices.
Becoming the Physician I Hope to Be
This experience fundamentally reshaped my identity as a future healthcare provider. Clinically, it strengthened my diagnostic confidence and reinforced the value of foundational skills when technology is absent. Ethically, it forced me to confront the weight of decision-making in settings where every recommendation carries amplified consequences. Personally, it deepened my commitment to cultural humility, teamwork, and listening, recognizing that effective care begins with understanding patients’ social realities.
As I pursue a career in orthopedic surgery, I carry with me a renewed sense of responsibility. Musculoskeletal care is often invisible in global health discourse, yet it is central to human function and dignity. My time in Jordan and Zaatari affirmed that orthopedic surgeons play a critical role, not only as technicians, but as advocates, thinkers, and partners in equity-driven care.
I am deeply grateful to the Dartmouth Center for Global Health Equity for its support through this entire experience. This opportunity has enriched my clinical training, shaped my scholarly path, and clarified the kind of physician I aspire to become: one who bears witness to injustice, builds capacity where possible, and remains committed to the long work of improving care for the world’s most vulnerable populations.
