One resourceful Palestinian did his post-graduate training in Israel and has excellent references from there, but was unable to gain the full certificate because non-Israelis were barred from doing the final exams. It is staggering how many of our staff have either lived through, or are escaping from, areas of conflict. Syrians, Libyans, Lebanese and Iraqis are commonplace. They are survivors and life for them continues to be tenuous.
The interview results are ready but suddenly everyone is stalling. “We don’t know when the hospital will open so let’s keep quiet for the moment” is the message.
I am appalled, arguing that these people’s livelihoods are at stake and they should know where they stand, whether the news is good or bad. It should be added that those without posts in the new place are at serious risk of losing their jobs altogether since services are transferring en masse. However the managing director has promised to keep such people in employment here for two years, so they will have time to seek new work elsewhere and we might be able to keep some of them in managerial and administrative roles. Still the Arabs are stalling.
They are worried about the press. They are worried that rejected applicants might leave before the transfer of services (and why should they not?) but mainly it appears they don’t want to give bad news and they will do anything to defer a decision. We see this with patients too.
Doctors here are happy to talk to relatives, but balk at telling the patient herself that she has breast cancer. Conversations in committee rooms proceed in circuitous fashion with decisions carefully not being made. There is always someone higher up who can, or must, be consulted so decisions are deferred pending the minister’s opinion, for example. In this case, I pushed back hard and managed to persuade the committee that we must inform candidates of the results of the interviews.
Support comes from an unexpected source, namely a highly religious, dedicated senior doctor who agreed that the uncertainty and tensions among his staff are helping no one, least of all the patients. This particular doctor, Dr Hassan, is a small man with a long grey beard, flowing robes and twinkling eyes. He could be a benevolent gnome, but if encountered at Heathrow airport I suspect that he would not pass through security services easily. He is undoubtedly a good man, although I still find it disconcerting that he won’t shake my hand.
Dr Hassan and I are working together to review certain services. The genetics service is a case in point: diseases which result from the high degree of intermarriage are seldom seen in the west. The rate of consanguineous marriage is said to be of the order of seventy percent and is defined by marriage between second cousins or closer. In reality, first cousins often marry and stay within the tribe, so the gene pool becomes even more concentrated. He shows me a family tree where first cousins were married whose own parents were also first cousins in the same family. Tragically, of the five offspring of this latest marriage, four had serious rare genetic conditions. Dr Hassan and I discuss the issues with the consultant geneticist. It is now possible to screen in utero and I wonder if termination is allowed in Sharia law.
I hesitate to ask the question in case of giving offence, but the conversation is frank and humanitarian. Such terminations before a certain stage of pregnancy are permitted and encouraged and counselling is offered. Much research is being done and new conditions are being discovered along with the causative genes.
We discuss the coming holidays and Dr Hassan tells me that he is going to Mecca on a mini-pilgrimage, an Umrah (lesser pilgrimage). This is unlike the Hajj, which must be performed once in every Muslim’s life and takes place in a particular lunar month.
I know all this because Dr Hassan kindly gave me a leaflet on Islam, written especially for non-Muslims. What is fascinating is how so many of the tenets of this religion are similar to Christianity, although the conclusion that the Bible predicts the coming of the Prophet Mohammed through the gospel of St John is probably stretching a point.
Daily life for Muslims in this part of the world revolves around their religion, which also imposes standards of behaviour in daily living and recognises the importance of family and kinfolk. The sadness is that the fundamentalists have subverted it and we have threats of terrorism from extremists who bear no resemblance to the normal people living their lives in the Middle East.
17 The dark side
A consultant colleague came into my office last Thursday afternoon in order to ask for my help. He is an Arab but a non-Qatari. I had never met him before and he exuded a curious mix of agitation and resignation. He thrust a letter into my hand which was written by someone in the corporation, dismissing him from his post.
It was unambiguous but there was no explanation. I was shocked and asked him if he had received any warning.
“Nothing,” he said. “I am on a three year contract; I’ve done about twenty months.”
It occurred to me that perhaps he was failing in his clinical duties but he reassured me.
“No, my work is good. Ask anyone. Anyway, I will be OK. I’ve been offered a job back in the UK but I don’t want to disrupt my children’s schooling too much. They might let me stay till the end of the school term.”
“But,” I said, “this is appalling, frankly unbelievable. There must be some reason for your dismissal.”
I rang his boss who assured me that this was an excellent doctor, in a shortage specialty and he didn’t want to lose him.
“Well, perhaps my wife failed the CID scrutiny,” he said. “We used to work here in the past and she left to finish her training in England. Maybe that upset someone.”
I spoke to the Qatari Medical Director of his hospital who was more expansive.
“It is political and we will never know why,” said the director. “The decision will have come from the Ministry of the Interior and there is no point in trying to speak to them as they are all shits”.
This comment from a local.
I spoke to someone in Human Resources who said that in such cases they often could extend the notice period for the sake of the children’s schooling. Ten minutes later she rang back and said there was nothing they could do. I subsequently discovered that five senior doctors were being expelled from the country for no reason, except that they are all Shia Muslims from Iraq and the predominant group here are Sunni. We joke about being ‘put on a plane’ but it really does happen.
We rail against stringent health and safety rules in the west, but here such issues are a mere detail. Lionel is pleased to discover that his hospital had a valid Fire Certificate, just a pity that the emergency exits are locked and no one knows the evacuation procedures. He is reassured that he has nothing to worry about because there is an in-date certificate. Maybe that was the same reassurance given to the (British) Executive Director in charge of stores before he was thrown into jail.
His incarceration was despite the fact that he had complained to higher authorities about his organisation’s fire safety, but his pleas had been ignored. Regardless of his propriety, he was now being held personally responsible for the fire.
The fire was in a medical stores warehouse on a Thursday and someone had to be blamed. So the Director was arrested and imprisoned at a weekend with no recourse to lawyers, diplomatic aid or even a visit from the executive team in the corporation. He spent several days in prison before being released on bail.
The supply chain into the country is poor at the best of times and there is a certain degree of stockpiling. Unfortunately the stocks were cinders and we had to cancel theatre sessions and fly urgent medical items in from neighbouring Arab states, who currently are not always sympathetic to our plight. A recent pan-Arab international conference was boycotted by local GCC (Gulf Cooperation Council) countries as they are dismayed at our Qatari government’s stance on the Egyptian question. The Arab Spring in Egypt resulted in the overthrow of President Hosni Mubarak and brought the Muslim Brotherhood and the Islam
ist president Mohamed Morsi to power. Qatar supported Morsi but the other Gulf States were concerned that this meant Qatar was supporting terrorist movements such as so-called Islamic State. Who knows what is really going on? It is likely to be murky whatever the truth.
An Englishwoman was murdered outside a well-known hotel and her burnt body subsequently discovered in the desert. The perpetrators were caught as they returned to the scene to check their deed and the crime was widely reported in the international press. We do hear of such crimes going unreported and our colleagues in the Emergency Department see bodies brought in, but there is no investigation into the cause of death.
Back in the hospital a particular felony was almost certainly averted by the swift action of the CEO and medical director of one of the hospitals. The story is that a male nurse was found stroking the arm of a young female patient. The family discovered and were incensed; quite rightly so. Murder would seem to be an over-the-top response but the Qatari Medical Director, a deeply religious man, was convinced that if we didn’t get the hapless nurse out of the country, he would be whisked off into the desert, retribution would ensue and he would not live to tell the tale. The hospital smuggled him to the airport and managed to get him on a plane before the brothers turned up in a posse of Land Cruisers.
Throughout our time in Qatar, we constantly ask ourselves, “Can we live in this society?”
What is our problem? We like our Arab colleagues (in the main), we are well paid and we are constantly fascinated by this different society - but sometimes its values are so very different from ours that we feel morally compromised. There are times when we feel unable to do our jobs properly. Other ex-pats are more pragmatic, “Keep your head down, Lionel,” is one piece of advice. “Don’t rock the boat.”
My husband isn’t very good at keeping a low profile, particularly when he believes he is in the right. An example is the plan to decentralise the finance department. In theory this is an excellent idea. Each hospital in the country would have control over its own budget, hence using resources more wisely. Plans for this process are racing ahead but it isn’t going smoothly. No one likes change and the power of passive resistance should never be underestimated.
Lionel is in a top-level meeting where the managing director asks whether financial decentralisation is going well.
“Yes,” comes the group reply. “All the hospitals now have complete responsibility for their budgets.”
“Good,” she says, “because the Minister is uncomfortable with this decentralisation.”
Lionel, of course, speaks up. “He would be even more uncomfortable if he knew that finance had been devolved but without any financiers to advise within the hospitals.”
She glares at him down the table. He is obviously trouble. The others are glibly telling her what she wants to hear: Lionel is telling the truth. And his staff support him. At another meeting with the minister and the MD, he makes the same mistake of saying how it is. Later she reprimands him.
“I do apologise,” he says. “I am completely loyal to you. If you’d briefed me on your constraint then I would have kept quiet.”
The problem is a disconnection between the grandiose plans of the government and the reality on the ground. Beautiful new hospitals are being built but never finished, so the work goes on in underequipped shabby wards in old buildings. A world-ranking Academic Health System to rival Harvard or Cambridge is planned. Professors from around the world are recruited with promises of wonderful laboratories for blue skies research. They soon find their way to my office with their tales of woe. “But there is no lab,” or “There are no research staff,” or “Everyone is so busy that they have no time to even consider research” are comments I hear repeatedly.
There are some excellent doctors and nurses struggling to treat patients in an infrastructure more akin to the 1970s than the twenty-first century. In my working life in the NHS at home, I have witnessed and effected huge changes, over thirty years. In Qatar we are trying to do that in three years, in a society that is only just emerging from living as nomads in the desert.
There is an element of emperor’s new clothes. The courtiers happily applaud the superficial froth but there is nothing underneath. Some of the froth is quite good fun, however. The minister pays an unscheduled call to Lionel in his office. Lionel’s hospital is brand new, beautiful and well equipped but already too small.
“We need an extension and a more office space,” says Lionel.
“You are doing a good job. I hear excellent reports about you and I agree. I will sign off the building plans tomorrow,” responds the minister.
Within weeks, work is nearing completion on his new Emergency Department extension and a temporary Portakabin has been erected. But what a Portakabin! The staircases are marble and the office walls are panelled in the finest wood embellished with gold leaf. There is still no budget to raise the wages of the impoverished office workers, however. It is an extraordinary world.
We discuss our future while on annual leave, sailing in the Aegean. It is fascinating to reflect that when we first visited Turkey it was exotic and different. After two or more years in the Middle East, Turkey feels positively European. Drinking a glass of wine at a quayside restaurant while skimpily clad Turkish girls saunter past is very different to our Qatari experiences. The call to prayer still dominates but no one seems to take any notice, unlike Qatar where the mosques are full five times a day.
As our time passes, we are both becoming unsettled. We have achieved much and are well respected by our Arab colleagues, but we sense trouble ahead. Lionel has come to a natural break point in his role. There is a new ministry named the MOAD, the Ministry of Administrative Development, a name straight out of Yes Minister. Except these civil servants have an Arab mentality, not a Whitehall one.
Power struggles are in play between the MOAD and the Health ministries. There never has been a proper budget allocation and it is getting worse. Recruitment is nigh impossible: every newcomer to the country has to be vetted by the Ministry of Interior and this process takes months.
The rules are predictably opaque. We are told, unofficially, that certain nationalities will never get in. Sudanese and possibly Egyptians are on the blacklist, yet the country is full of such ex-patriots, well-educated and good workers. Where is the truth? I try to recruit an Englishman of Pakistani descent. His credentials are good and he is desperately needed in my department, but after a year of getting nowhere, I concede that he will never be let in, for whatever reason.
Meanwhile Andrea, my British assistant, has left. Her husband works in Dubai so she was going back to their apartment there every weekend, for which she needed an exit permit, signed by me, for every trip. We tried to circumvent the system by signing a pile in advance but when she was ill and couldn’t simply go home, it was all too much. She has resigned. I try to promote Joramae into her position but to no avail.
Understandably, the Qataris are keen to promote their own staff. There is a positive discrimination policy of ‘Qatarisation’, which means that all jobs should be offered to a Qatari first. Their country and their rules, we think, except that jobs are given to Qataris who have no experience of the job in hand and who then never turn up for work.
Non-Qataris are not allowed to be promoted except when a Qatari wishes to break the rules. Then a favoured ex-pat will be promoted internally. Such actions cause covert accusations of foul play and discontent among the other workers.
In many ways, Qatar is an ambitious state with a drive to modernise and improve. There is an awareness that the oil may dry up and something else will need to sustain the country. Dubai has settled for tourism, but Qatar has little natural beauty and its society is much more traditional, hence the suggestion of a knowledge economy as the way forward. So there is an Education City, a Medical City and a Science and Technology Park. Good work undoubtedly ensues but there is al
so much froth and misplaced energy.
For example, among our doctors we have multiple nationalities with diverse qualifications. Some are extremely good doctors, but have no specialist degrees to prove their credentials. Others are also-rans, who do the basic work to support the consultants. It’s an archaic system and not entirely fair as there is definite prejudice against some nationalities.
“We must change and modernise,” announces the minister. “If our hospitals are to be world ranking then we can only employ doctors with the best qualifications.”
He has a good point but the system cannot change overnight. As usual, passive resistance ensues and nothing happens.
I have some sympathy with the minister’s views. He wants the best for his country; the problem is that he doesn’t understand how medicine works and no one has the courage to challenge him. They just shout at me instead. Of course I would happily discuss matters with the minister but no one will allow that to happen. I feel frustrated with the system and angry on behalf of the doctors whose lives are about to be unfairly disrupted.
The minister discovers the inaction and put the pressure on our MD. She transmits his fury to my boss.
“Why has nothing happened?” she fumes. “The minister has discovered and he is furious! Sort it or I will dismiss these doctors who haven’t got full qualifications!”
It turns out that poor Dr Mahmod was partly to blame but then he’d had no direction. It falls to me and my new boss to sort out. As I start to delve into the issues I discover the tangled web and it certainly influences my decision that it’s time to leave.
Both Lionel and I feel we are being asked to do things that we find very uncomfortable. Hospital beds are much in demand, but Lionel is asked to provide one so that a Sheikha can have her own personal maid sleeping next to her. We signed up to the system but it is becoming clear that the conflict with our own values is too much to bear.
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