In 2005, just two years after the start of the Iraq war, I would attend the Pan Arab Rheumatology conference in Cairo and listen to a rheumatologist from Baghdad describe his cohort of RA patients. With a war raging around him, he continued to collect data on anti–cyclic citrullinated peptide positivity in his lab. Ultimately, he, too, left Iraq and lives in the safety of a neighboring Gulf country. There is a shortage of well-trained rheumatologists in the entire region. In the UAE, only 15 trained rheumatologists serve a population of 4.5 million. There are not many formal training programs, and often a person can be deemed a specialist by having worked in a rheumatology department for three to five years without having to go through an accreditation process.
Culture Brings Unique Challenges
During Ramadan, things are quiet and days feel languorous, waiting to awaken after sunset. At nights, the streets come alive with people who have broken their fasts, rushing to iftaar parties, buying food for the dawn meal, or having henna painted in their hands and having a leisurely smoke of shisha. Fasting from sunrise to sunset brings unique challenges. For instance, it is impossible to take Alendronate tablets first thing in the morning, wait thirty minutes, and complete the morning meal before 4:30 a.m. Similarly, it is not possible to do this in the evening. The fast is deemed broken if a fasting person bleeds, and many patients believe that they cannot have blood drawn for lab tests. They also believe they cannot receive intramuscular/subcutaneous injections. I go online to consult with religious authorities and can then reassure my patients that both blood draws and injections are, in fact, permitted. We need to take care to prescribe medications in a once daily or twice daily form.