15. A medieval fiefdom

Agnes, our maid, is a diminutive four foot six inches tall and weighs less than seven stone. Her skin is poor with frequent eruptions of acne, but she has a lovely open smile and lustrous long black hair. She works hard, cleaning thoroughly, pulling out sofas, chairs and even the cooker, so that the whole house is spotless. Her iPhone is plugged into her ears and she sings as she works. Her voice is beautiful and she belts out pop songs with a gusto that belies her size.

At Christmas, she and her fellow maids went out carolling and Agnes sang the solos. She confessed that Christmas is a sad time for her as her two children are in the Philippines and she only travels home once every two years. All her money goes back to her family there. She occasionally asks for medical advice and the latest was how to stop snoring. Apparently one of her room-mates snores loudly and on further enquiry, we discover that she shares a room with five other women.

We know little about this accommodation except that they are expected to be back by 10pm and there was trouble at Christmas when some of the girls stayed out late partying. Memos were delivered to the miscreants. We don’t know exactly what this means but to Agnes, it is a serious threat. The ultimate sanction for all ex-pat workers is to be sent home, but we think they all survived.

She would love to live and work solely for us. Our plans are different and when we converted the servants’ quarters into a gym, she was convinced that the new furniture was a bed for a new maid. Her delight when she discovered that it was a treadmill being delivered was palpable.

We ask her to stay late one evening in order to help with a supper party and we insist that she eats before we do. I cook a piece of fillet steak for her, which I serve with chips and salad and take to her while she perches on a stool watching television in the gym. When I then serve her some pudding she is quite overwhelmed that anyone would personally serve her and with such delicious food. We leave her happily watching musicals on the TV while we eat with our guests and when I go to ask for her help in between courses, I find her curled up on a couple of cushions, fast asleep. I haven’t the heart to wake her.

She is fiercely loyal and refers to “my madame and my sir”. Lionel threw out some of his hand-made Italian shirts because the cuffs were frayed and she retrieved them from the waste bin in the bedroom and proudly gave them to the driver who ferries all the maids to and from work. He was delighted, although we are not sure whether he has the cufflinks to go with the double cuffs.

The disparity in incomes is huge and she earns a pittance compared to us, yet still we pay significantly more to her company than many maids earn. Lionel slips her tips every so often and she seems very happy. She is certainly scrupulously honest and if we want her to work overtime she tries to insist that we don’t pay extra.

Along with her sunny nature she is extremely scatty. When we were away for a week we asked her to clean and to water the plants. Two days into our holiday, we had a phone call one evening, while settling down to a quiet dinner, to be told that there was water flooding out of our front gate. Because the property is surrounded by twelve-foot-high walls, no one could tell whether the water was emanating from the house or from the garden tap.

We phoned Agnes who went round in a taxi to find everything was fine. We subsequently discovered that one of next door’s staff had shimmied over the wall and switched off the tap which Agnes had left open causing the hose to burst and flood the garden ... except most of the plants are in pots and she had failed to water the two newest specimens. Luckily with some judicious drenching on our return, they survived. So Agnes managed to cause a flood while simultaneously dehydrating the plants, but it is difficult to stay cross with her for long. She just giggles while apologising.

She is resourceful too. When, in typical scatty fashion, she took the rubbish out and the door slammed behind her leaving her stranded outside in the road, she borrowed a ladder from next door, climbed onto the wall, straddled it, pulled the ladder over and climbed down our side.

One day she will go home to stay but like so many ex-pat workers, the money here is better and she has to support her family. We berate ourselves in the west for losing our family values, yet in many parts of the world, children are brought up by grandparents and the extended family so that parents earn the money to support them while living thousands of miles away from their young children.

The medical administrator, Dr Mahmod, is an Iraqi who left his home country after the fall of Saddam Hussein. Like many of his compatriots, he welcomed the fall of the dictator, but life in Baghdad became untenable in the aftermath. Bombings and kidnappings became commonplace. He has been here nearly ten years and runs the medical staffing office, which means that he knows everyone, knows how much they are paid, whether they have had complaints against them and of course he converses in Arabic. But as I later discover, all is not quite as it seems.

There is a constant stream of people popping into his office, sharing a pot of Arabic coffee or strong black sweet tea and enjoying a good gossip. He may not be a local but he certainly seems to have wasta. He is a large man with an expansive waistline, a droopy moustache and a lugubrious affect. Everything is gloomy in his world until he gets chatting, then he laughs. He is teased by one of the surgeons, who says that there are always bombs in Baghdad when Mahmod has been there to see his father and he must be a secret terrorist. This outrageous comment is treated with a smile and a shrug. It is a bit of black humour and no offence is taken.

Meanwhile he tells me that Qatar has been good to him. He was welcomed, given a job and has been able to educate his girls who are both now at university in Canada. He and his wife have a good life and he can travel freely back to Iraq to visit his aging father.

There are Palestinians here who have no passports, Libyans who are now contemplating going home after many years, Syrians who can no longer go home ... and all these ex-pats, unlike us, are endlessly peripatetic. The ex-pat doctors are well paid but have no pensions and for them there is no stability.

An episode that occurred after about eighteen months into the job brought this into sharp relief. A senior Lebanese consultant, Dr Hanadi, highly respected in the organisation with roles in research and management besides her clinical duties, was summarily suspended. There were allegations that her training in France was bogus and that she did not have the post-graduate qualifications that she claimed. There was a move to simply sack her and put her on a plane, but Dr Mahmod and the team insisted on an investigation. He made phone calls to various institutions in Paris, following which she was completely exonerated and returned to work.

She popped into my office, considerably shaken and wondering how this had happened. The Arabic speakers knew: there had been a whispering campaign instigated by a malicious member of her team. The gossip on Twitter was rife but we Brits heard nothing of this. We think that we are doing well, getting into the culture, but there are always undercurrents of which we have no notion.

Much later she dropped by again.

“I will miss you, Dr Penelope,” she said.

“Why? I’m not going anywhere.”

“But I am,” she responded. “My husband has work here and the lifestyle is good, but I’ve had enough. The children and I are going back to Paris.”

With her western dress and haircut, yet also perfect Arabic, she was a good link between East and West. I was sad to see her go.

On this same note of unexpected outcomes Lionel recently met with the local head of forensic medicine to discuss the lack of post mortem examinations. As one does in this society, initial discussion took them to their past medical lives and it transpired that the forensic physician had been a two-star general in the Iraqi Armed Forces heading their medical services while Lionel was the equivalent two-star in the British military heading medical operations for the opposing side. They are now good friends with many similar values. However, the Iraqi general cannot return home, having been a member of Saddam’s army; the British Admiral retains so much more inherent freedom - such meetings teach us so much about the privileges that our society enjoys.

Among these privileges are job security and fair treatment if allegations are made. Not so for poor Mahmod. He appears to have enormous wasta, knowing everyone, sharing a joke in Arabic and with fingers in many pies, yet what happens? He is sacked.

His title is Assistant Medical Director, which sounds very grand although his post is middle grade, far junior to me and junior to the consultants, though many hold him in awe. He runs the Medical Staff Office, which - it transpires - is responsible for just about everything including recruitment, annual appraisal, privileges for doctors undertaking operations, compensation, and reward. My role is to look after the professional development of medical staff, so that tallies nicely with the Medical Staff Office and I agree that I will take on Dr Mahmod and his team as part of my responsibilities. Mahmod declares himself very happy with this proposal.

Unfortunately nothing happens. Indecision rules and people are worried that a diminutive female westerner might not be able to manage him. In the event it becomes apparent that no one is managing him (so I couldn’t have done worse). Because there are no checks and balances, he does more than he should, making mistakes and ultimately condemning himself by a gross error of judgement. It is a salutary tale of a man promoted beyond his talents and allowed free rein to do things beyond the limits of his competence.

So what happened? I was away in Singapore on an official mission and return to work on a Sunday to be told that Dr Mahmod has been sacked. He received the letter on the Saturday and is never seen again. His office is a shambles and there are personal papers scattered over his desk. There seems to be no process for looking after this man who is now potentially a refugee with no home, no job and no income.

After his departure someone mentions to me, “Pity about Dr Mahmod - he was always good for a prescription,” even though Mahmod hadn’t practised medicine for over 10 years.

I never discover what happened officially but I subsequently hear from another Iraqi that he has been allowed to stay in his house for a while and someone has taken his possessions home for him. What was his crime? He gave his wife a job. She wasn’t exactly working for him and the issue is probably that he facilitated her employment. We will never know the truth but my impression is that his real crime was working in an Arab way in an Arab world that wants to be western and progressive, even though the reality is nearer to a medieval fiefdom.

As I fly in from Singapore I reflect on the insights gained from visiting two academic, high-achieving organisations. I have been discussing strategy and concocting bold plans and now in addition to my main role I am being asked to take over the running of an administrative department where chaos rules. In my former life in the NHS, I have been in charge of such departments, where my role was leadership, team building and strategy, alongside my clinical work. Other, highly competent, admin people ran the day-to-day business. I discover very quickly that such people do not exist with my new responsibility. There are rules but no one follows them or knows them ... but then they change all the time.

Maybe the rule is - there are no rules, yet I suddenly become the conduit for the rules and their interpretation. There are processes (probably) but no one knows them or rather they leak out piecemeal and everything is clothed in secrecy. Salaries are very variable even for people doing the same job and this causes immense unrest. Consequently individuals are always asking for salary revisions. I knew this and had been working with Dr Mahmod and others to simplify things and to be fair to him, he had been delighted as he’d been floundering. Only after he left did I fully realise the extent of the problem.

There is a backlog of salary review requests.

“What are we doing about it?” I ask Priyanka, the very beautiful but dippy Indian admin assistant.

“We tell them it is on hold until the next compensation committee meeting,” she says, smiling.

This sounds reasonable except that I have never heard of this committee.

“When is the next meeting planned?” I enquire.

“Oh, we don’t have one planned.”

“Do we have a committee?”

“Well not exactly, well no.”

“And how many requests are waiting?”

“Only about three hundred.” She beams.

So in a society where money is a huge motivator, we have systematically been lying to senior doctors, who as a result are making waves at high levels and suddenly I am being summoned to sort it out.

The ‘learned helplessness’ among the staff is endemic. They tell me they need an electronic filing system but they are incapable of articulating their needs; they want me to instruct them but they have no common processes; filing cabinets bulge with incomplete personal files and walking between desks is like stepping through a minefield with piles of files haphazardly distributed over the floor. Uneven piles of papers clutter every available space on every desk. I am notoriously untidy but even I am disquieted. I suggest putting some files away and this is greeted by gasps of horror and explanations about how each pile is crucial to some aspect of the work.

As a consequence of all this disarray, we are constantly bombarded with requests for information on the progress of various functions, such as the recruitment of a senior doctors. Dr Mahmod’s office was opposite mine and there was a constant stream of people visiting him. He was affable and there was plenty of laughter, but did they go away appeased? I am not sure. He worked like a vizier in the old Turkish Ottoman court.

All his immense organisational knowledge was in his head, but nothing was written down. His staff were incredibly loyal and as a consequence any rules or policies were kept secret. All the consultants in the organisation, though technically senior to him, were graced only with minimal snippets of information.

Hence they are amazed when I send them electronic copies of the promotion guidelines, as they were never allowed to know these except on a case-by-case basis. This is not unusual. We are currently undergoing what might be loosely described as a redundancy process: in truth, a mass sacking of loyal staff. When we asked the Human Resources department to produce a list of frequently asked questions with typical answers, this is refused.

Dr Mahmod was a product of his culture. He worked on the principle that knowledge is power and he became powerful beyond his limits. He thought that he could ingratiate himself by acquiescing to certain people’s demands, but when things went wrong no one could save him. Our western values of transparency, anti-corruption, consistency and fairness have never seemed so important to me as they do now.

It’s been a few weeks after the Singapore visit. I am beavering away with the door closed. The Arab way is to keep the door open, so people wander in, disrupting meetings and inappropriately listening to private conversations. Usually I keep to the Arab custom but there is a lot to do on salaries and promotions, trying to extricate us all from the mess left by Mahmod.

Suddenly the door opens and there is the MD smiling at me.

“I was just passing, Penny,” she smiled. “How are things?”

I am flabbergasted. She has never dropped by before. I gawp at her.

“The MSO needed a shake-up,” she says. “I’m pleased you’ve taken it on. And by the way, any more thoughts about the Singapore trip?”

We had a good chat and after she leaves I wander into a colleague’s office where I am late for an informal meeting. He knows exactly why, as do the rest of the corridor. They are buzzing with the news of the MD coming to see Dr Penelope. My street cred has become stratospheric.

It is all very flattering. I seem to have broken through some invisible ceiling. In spite of the apparent brush-off early on, I am being noticed and appreciated.

The surgeon is tall and sweeps along the hospital corridors majestically, flicking his ghutra over his shoulders and twisting it back over his head. He sports an unshaven look with an almost beard, which is common in these parts. He is affable, diplomatic and once you get to know him, a wonderfully indiscreet gossip. Time management is not a skill that he possesses. The first time I met him, I was kept waiting in his secretary’s poky little office for twenty minutes. I was starting to feel irritated when he appeared and hustled me into his office where I was given Arabic coffee and made to feel like the only person in the world who mattered. Our meeting overran and subsequently colleagues told me that being kept waiting for only twenty minutes by Dr Mustafa, was an amazing privilege.

He was chatting in my office with me one day with Dr Mahmod.

“Dr Mahmod,” he said, “do you remember that surgeon who worked here, a few years back?”

“No, what was his name?”

“I don’t remember. He was a good friend and a nice guy but useless. We had to sack him.”

“No, sorry,” says Mahmod. “Don’t know who you mean.”

“Yes you do. What was his name? Got it - Mohammed.”

“Ah Mohammed, of course. Lovely man - useless surgeon. We had to sack him.”

And this conversation in the context of every other male person being called Mohammed.

Dr Mustafa was educated in the UK and Ireland like many of his medical compatriots and his English, though accented, is fluent and engaging. He chats about his fellow countrymen with a disarming candour. Discussing a tricky senior nurse, he explains that she has a good heart really and anyway, she is a product of the system ... so who can blame some of her dodgy decisions? Then he adds: “She is totally corrupt of course.”

He is referring to trips abroad for the purposes of recruiting new staff. Anyone sent on an Official Mission flies first class and receives a hefty daily allowance for their pains, plus an extra four days leave for travel purposes. Is this corrupt? Not really, since it is the rules. There are plenty of sanctimonious Brits who berate the locals for travelling abroad for medical treatment, or for accompanying their families for such treatment, yet the number of Official Missions undertaken by Dr Mustafa and British colleagues is legion. I knew I had made it in the system when I was eventually invited to go on one.

The Singapore trip was my first official mission and I was determined to enjoy my brief time there. We worked hard, visiting hospitals and meeting senior academics. Off stage I stayed in the glorious ex-colonial Raffles Hotel, where I enjoyed an original Singapore Sling cocktail. It was delicious and slipped down a treat, but one was enough if I was ever to stand up unaided. Dr Mustafa was also on the mission but like the other Arabs, was staying in a different unspecified hotel. Probably just as well. They would never have coped with the Singapore Slings.

There are many inconsistencies and anomalies in the system, which Dr Mustafa tries to explain. The problem is that just when you think you understand, something happens and you realise that so much culture is ingrained - as a westerner, you will never really grasp it all.

A typical episode which would never happen in the UK springs to mind. One of the extremely affable senior Arabs was passing my office yesterday. He waved a greeting then wandered in for a chat. He happened to be holding a piece of paper which was a report on a CT scan, which he wondered if I could interpret for him. The patient was the wife of a friend, the referring clinician was not from the appropriate specialty and I then realised that patient confidentiality has a completely different meaning out here. Dr Yousuf, who referred the patient, was probably just using his influence to get a head scan on a friend’s wife with headaches.

At home I would have asked judicious questions, but out here it seemed better simply to co-operate and then carry on chatting about growing lemons and mangoes. I have no doubt that the casual walk past my office was deliberate. Did we behave in a similar way years ago? Yes, probably. We certainly looked after each other as junior doctors and prescribing for ourselves and others was common when I was a houseman. These days the General Medical Council takes a dim view of such matters. Back in the UK I had to intervene when a good but naïve young doctor prescribed some antibiotics for a colleague, albeit quite appropriately.

Out here, Lionel was astonished to be regaled with a tale from the previous nightshift. A junior doctor on duty in his Emergency Department had an attack of renal colic, which is intensely acutely debilitating and described in textbooks as exquisitely painful. Certainly a sufferer would be unable to work. So, helpfully, a fellow junior gave the sufferer an injection of morphine and looked after his work for an hour or so, while the drug took effect, before the sufferer returned to his patients.

Apart from the unauthorised use of opiates, goodness knows how the patients fared under the care of a spaced-out doctor with renal colic and opiates surging through his bloodstream. Luckily no one came to harm, but the fact that such an event was even contemplated, let alone executed, shows the huge gap in culture between here and home.

Mustafa works hard and thinks little of seeing patients at any time of the day or night. Scheduling work is a concept of which he has no notion. Operating lists routinely overrun and like many Arabs, he will work late into the evening before going to parties then going to bed long after midnight, only to be awoken by the call to prayer at 4.30am. We westerners wimp out long before that, but then we are bad at taking siestas - unlike the locals who often sleep in the afternoon.

There are examples of excellent medical care here, but even the enlightened ones have difficulty managing their diaries, partly because they don’t understand the idea of a diary and partly because plans change at short notice and urgent invitations appear which cannot be refused. I am often asked to meet visiting foreign dignitaries at twenty-four hours’ notice, yet I know that visitors from the United States, for example, will have planned their trip weeks in advance.

Relationships and trust are very important. I realise that I am trusted by Dr Mustafa when he is giving a fellow (junior) consultant surgeon some wise advice about how to deal with colleagues (in other words, a bollocking). I discreetly try to leave the room, but he makes me stay.

“She’s a good friend and she knows what I mean,” he says.

In the end the three of us drank some more coffee and all was well. I would never have imagined myself in such a situation –a Western woman sharing a joke with two traditionally dressed Arabs in a dark office (they are all decorated like the inside of Bedouin tents) while my other western colleagues are made to wait outside in the poky office of the secretary.

My admin assistant Aliya sashays along the corridor with killer heels peeping from below her long black abaya. Her hair is piled high underneath the long black veil which gives her a regal look and her eyes sparkle and flash with their heavily kohl-painted lids and carefully made-up lashes and eyebrows. We don’t see her face but her personality shines forth through her gestures, voice and expressive eyes. Her generosity is legendary and most days she brings in delicious home-made almond flavoured cakes or spicy samosas, which are distributed to all the offices along the corridor by the office boys.

She does no real work but literally pushes bits of paper around her desk and wanders around chatting to her friends and colleagues. Since she is local, her job is guaranteed and she argues that she does more than most, since she is always in on time and tends to stay till the end of the day.

She speaks very little English but is very warm to me, hugging me with a warm embrace and calling me her habibi while she compliments me on my clothes. The other day she came into my office and closed the door whereupon she whisked away the veil to reveal a heavily made-up but pretty face. She is in her mid-thirties and obviously keen on fashion. Her gleaming smile was spoiled by a lesion on one of her upper teeth. I was starting to commiserate with her when I realised that this was not incipient caries but a diamond that had been encrusted onto the tooth itself and of which she was inordinately proud.

She then raised her abaya to reveal tight leggings and figure-hugging T-shirt. Conversation is limited but she explained that she would dress like this outside of the country but here, the culture is clear. In her tribe she covers her face and seems perfectly content. Another colleague, highly educated, with her postgraduate education completed in London, also covers her face, but lifts her veil when I am in the room alone with her.

Aliya, who does no real work, earns a reasonable salary and extra benefits simply because she has a job. She and her husband drive large four-wheel-drive cars and were probably given land on which to build a house. There is no Arab Spring here. The Emir is generous with his people but the downside is the lack of motivation. Since the locals don’t really need to work, they lack drive and ambition yet in my organisation, the rules are skewed so that locals earn more than ex-pats and only locals can be promoted.

This ridiculous ruling causes tension and friction, particularly in admin and clerical grades where it is rigidly observed. Doctors fare better with promotion opportunities and their salaries are good (but with higher rates of pay for locals) - there are no pensions for ex-pats, whereas when locals decide to retire, they just stop coming to work and carry on being paid as before.

Meanwhile Aliya openly flirts with everyone, flashes her eyes and as she leaves on a Thursday afternoon, briefly lifts her veil and blows me a kiss, while wishing me a good weekend.

Lionel is particularly discomforted by the obvious flirting. One particular junior member of his staff is very blatant. We call her Fatima the Flirt - she openly describes how she feels about him, asks him about his wife and if I am out here and mentions that she herself is unmarried. She then flutters her eyelashes at him and proceeds to lift her skirts while asking him to examine her knee.

“You’re a doctor - will you look at my swollen knee?”

He has never even seen her face.