My patient’s father is tall and stooped, his face creased with worry. He wears the flowing white dishdasha, and on his dusty feet are cracked leather sandals. He clutches his battered briefcase and holds the door open for his daughter. She limps in, obviously in pain, and I notice even beneath the voluminous black abaya that she is thin—too thin. I hold my hand out and we shake hands. In truth, we just briefly touch hands. I take care not to squeeze her swollen joints and, keeping with local culture, do not offer to shake hands with the father. My patient and her father have driven six hours across dusty desert roads to get an opinion about this young girl’s arthritis. My clinic is located—quite incredibly for a musculoskeletal practice—on the 50th floor of one of Dubai’s many new and swanky high-rise buildings. This young girl and her family are initially somewhat intimidated by the designer-furnished clinic, but they are soon at ease, and I listen carefully to their story.
What I hear is becoming all too familiar in my short time in this country, the United Arab Emirates (UAE). The majority of the population who live here are expatriate, and it seems that healthcare providers are also expat, providing care in government hospitals and the private sector. Like many others I have seen, my patient has rheumatoid arthritis (RA), a devastating disease. She was not diagnosed correctly for ages, and then was inadequately treated. This young girl cannot study, work, or even go out shopping anymore. The father furtively wipes away tears from his red eyes. I pretend not to notice—men don’t cry, not in any culture. After I do the joint count and assess the damage, I say, “It is not too bad, she can be treated. She will be better, inshallah [God] willing.” I have to give hope before enumerating the destruction the raging forest fire has left.
This patient has had a long delay in diagnosis and treatment. Later, I would collect data on my first 100 RA patients seen at this clinic, where I have been practicing since moving here from Boston in the summer of 2005. I find that patients here have a delay in diagnosis of an average of 14 months and a further four months before disease-modifying drugs are started.1 We collaborated with Tuulikki Sokka’s QUEST RA group and reported that, despite being a nation with a high gross domestic product (GDP), the Disease Activity Score 28 remission rate was only 18%, compared with 36% in the U.S., and only 10% of RA patients here are on anti–tumor necrosis factor (TNF) therapies, which is much lower than the 25%–40% of other high GDP countries.2 The reasons for delay in treatment and the inadequate use of biologics are many, and include lack of awareness about arthritis, inadequate numbers of rheumatologists, lack of adequate medical insurance for the largely expatriate populations, and a cultural bias towards complementary and alternative forms of medicine.
A Different Portrait of RA
Mohamed, another patient I see in my clinic, is different. He is wealthy, American educated, born into privilege. He wears a Yankees cap with his spotless white dishdasha. “I have been to Germany, Singapore, and the U.K. for treatment. Next month, I am going to the Mayo Clinic because you know America has the best treatment.” He is 24, has just been diagnosed with RA, and is looking for a cure. In the process, he travels the world collecting rheumatology opinions, and when he ultimately ends up on a methotrexate–TNF combination, he goes promptly into sustained clinical remission. A year later, I attend the all-ladies party at his ornate wedding: a thousand nipped-and-tucked women crowd a massive ballroom, dripping diamonds and pearls, dressed in gowns worthy of the Oscars. Mohamed keeps his diagnosis a secret, feeling that there is a social stigma attached to arthritis.