2. Learning the ropes
We decide that we really should learn a few words or phrases of Arabic. At Lionel’s Heart Hospital, only four of the fifteen-hundred staff are Westerners, so he really is in a foreign land. We investigate the possibility of lessons and his secretary Noora, who has wasta, is on the case. Wasta simply means that you know how to influence and get things done around here. This may be because you are from a prominent family or may simply be that you know everyone.
It is a fine example of a mixture of tacit knowledge, nepotism and good old-fashioned charm, to the right people of course. Noora has all of this and proudly announces that she has found us a brilliant teacher, a professor of Arabic at the university and we are honoured because he doesn’t usually teach English to people like us.
“How did you manage it?” we demand.
“The professor is my father,” she says with a wry smile.
We’ve no choice but to follow her through the chaotic evening traffic to his house. The noise of the road has gone and we find ourselves outside a splendid villa with a lemon grove adjacent to it. There she leads us through a gate in a high wall, to a haven of peace beyond.
We’re ushered into the house by a bevy of Filipina maids and the professor’s wife. Coffee and cakes are served before the great man makes his entrance. Although we are not hungry it would be rude to refuse the fig roll cakes, which are filled with crushed rose petals, fragrant and delicious.
Lionel has already picked up a few words of Arabic from his drivers and is convinced we should not attempt to understand the writing but simply learn a few expressions with the correct pronunciation. So imagine our dismay when the professor sits between us at his dining table and proceeds to teach us to write the Arabic alphabet. At the same time he pronounces the letters and encourages us to speak. Unfortunately many of the letters sound the same, essentially a noise in the back of the throat that to the untutored ear sounds like someone attempting to be sick.
Well, we try. We make our dismal vomiting sounds, all of which are wrong, but at least we can copy the letters. Except that he isn’t happy with those either. We are, of course, writing from right to left and, because he is a classical Arabic scholar, he insists on showing us three different notations for each letter. I confess that I don’t understand but it is something about the name of the letter, its pronunciation and the way it is written within a word or sentence. He races through the letters and although Lionel is manfully keeping up, he loses me completely.
The experience is truly humiliating, akin to being a remedial child in kindergarten. Our next lesson is fixed and we dutifully do our homework, learning the letters as instructed and he tests us at the beginning of the session. We don’t do too badly but we still haven’t finished the alphabet so the first session’s process is repeated. We are both tired at the end of the day, the traffic has been dreadful on the journey there and although the professor is very kind, especially when he sees that I am close to tears with frustration, it is all too much.
We both realise that we were being overambitious so we manage to extricate ourselves from the arrangement without any loss of face on his part. In truth, we suspect he didn’t really want to teach us anyway and it is probably a relief to him also.
However, we did feel honoured to be allowed this fascinating glimpse into an Arab home. The rooms are large, with huge chandeliers, marble floors, heavy curtains and gold embellishments everywhere. I am reminded of extravagantly decorated baroque churches.
As we leave, his wife beckons to us.
“Come and see the garden,” she says.
We follow her into the warm night air where the scent from the lemon grove is intoxicating.
“The scent of those lemons is amazing,” I remark, whereupon she summons one of the maids.
“Pick a lemon for our guest,” she says, brusquely.
It’s an interesting culture where no one is expected to do anything for themselves if there is someone else available. During our lesson, Lionel had taken off his jacket so the professor assumed he was too hot and summoned a maid to turn up the air-conditioning. This onerous task involves pressing a button but would be far beneath the master of the household.
Things are no different in the hospital. Lionel has an Italian coffee machine in his office but an Arab guest looked up in horror, quite unable to cope when Lionel leapt out of his chair to make the coffee.
“Please, Dr Lionel,” he said, “sit and talk to me and get someone else to do that.”
When Arabic coffee is served, the ritual is to take a small half cup which is replenished by holding out the cup for more and when one has had enough then the cup is shaken from side to side. Incidentally, this Arab beverage does not taste of coffee but is delicious with a mix of spices, cardamom being the most prominent (unlike NHS coffee, which doesn’t taste of anything at all). Of course this ritual presumes that there is someone to stand in the corner of the room just in case anyone wants more coffee, while the conversation goes on around him.
We make a similar observation when we wander into an upholstery shop in the souq, where an elderly toothless Arab is sitting on a large cushion, talking on his mobile phone while an Indian man is squatting on the floor, busily reupholstering a chair. He looks like a skilled craftsman but he is summoned to go and find fabric swatches for us while the Arab owner chats to us in completely unintelligible broken English. Needless to say, we decide against trading with him, partly because he has no suitable fabric but also because communication would be impossible.
Because we need to travel around independently, we each hire a car. Lionel is worried for my safety and I’ve promised to behave myself. Road rage is a universal phenomenon, especially here where the men drive their cars as if they were riding camels - hard, fast and randomly. Driving in my rented car, I am hooted at by someone on my tail in the middle lane. There is nowhere to go but when it is safe I pull over into the inner lane whereupon he proceeds to cut in front of me.
Shaking my head and laughing at this appalling driving, I then realise that my response has been noticed by the bad driver who gesticulates wildly at me before turning off right in front of me. Idiot, I think (and other less polite expressions) but I am still laughing at the absurdity when he does a quick U-turn and drives at me at great speed before swerving away at the last minute.
No points for guessing that he is an Arab in full robes and head-dress driving a huge four-wheel-drive Land Cruiser complete with go-faster stripes. Lionel suggests, “I should think being laughed at by a western woman in a poxy little car was an affront to his manhood.”
Later, when in traffic today, the driver of a car in front opens his door and spits onto the road - a good footballer’s gob - I suppress my expression of disgust. It would seem that a serene expression is safest. Maybe that’s really why the women veil - so they can express their emotions with impunity.
But what about the working environment? For me, one of the best things about being a doctor is the patients. They keep me grounded and remind me why I embarked on this profession. However, I also realise that without good clinical systems, we fail to do the best for our patients. For example, I might suspect that a breast lump in a patient is cancerous but if I cannot do an ultrasound, take a biopsy and get the result to her quickly, then her life will be dreadful for a few weeks, whatever the outcome. Patients always say to me, “The waiting is the worst bit”.
My job in the UK was a combination of hands-on doctor, clinical leader/manager and educator. I would have relished the opportunity to treat patients in the multi-cultural setting of Qatar, but I am appointed to run the show. People ask me if I would do some clinics, report some CT scans, do some biopsies; but I decline. Why? It’s such a wrench to give up seeing patients and yet it is the right thing. I reason that if I have to be called to a meeting at short notice I’ll be expected to attend. Fine, but if I have a clinic then for me the patients would always come first. Would this be a conflict and would my new Qatari masters understand my viewpoint? I elect to give up direct patient contact. It is the right move.
I have to adjust to my new role in an alien environment. I know that being a doctor gives me kudos but I feel the need to use that advantage carefully lest I am judged as a mere administrator. As ever, shwai, shwai, slowly, slowly is my tactic.
This is how I started: without a clinical role it would be difficult to understand the hospital, so I have taken to wandering around the corridors just to get a feel for the place. It is very multicultural with different nationalities, languages, dress and very few Westerners among this mix. Certain nationalities appear to be assigned to particular staff groups. For example, my secretary, the wonderfully named Honeylet, is from the Philippines as are many of the secretarial staff and I hear them talking in their local tongue.
One of the senior secretaries in my patch, Abdulrahman, is Sudanese and he is very supportive of me, taking me personally to meet various awkward people such as the transport manager. Male secretaries and male clerical staff are common out here. They are usually from one of the Asian nations, never from Qatar and only rarely from Arab nations such as Sudan. It was the transport manager who approved my (very beaten-up) temporary loan car and he likes to see prospective drivers personally. He made no secret of the fact that he dislikes foreigners and embarked on a conversation on the Holy Book, the Holy Month and why fasting is important, before launching into a long diatribe against colonialism.
He did manage to concede that as far as colonial masters went, the British were marginally better than the French, whereupon Abdulrahman replied staunchly that frankly his country wanted the British back to sort everything out. I was excluded from the conversation at this point until Tricky Transport Man turned to Abdulrahman and asked, referring to me, “So, can this doctor drive?”
I must have somehow passed muster because I was taken to my car personally by Tricky Transport Man, whereupon we both examined the car for bumps and scratches before I drove it away. It is an accepted fact that the bodywork on most cars will be less than pristine.
There are flower and chocolate shops in the hospitals. These are set out as stalls in the large concourses and sell extravagant displays of flowers, particularly in the maternity wing, where huge gifts of chocolates are also sold. These may be several feet high, with elaborate mosaics of foil-covered chocolates, mounted among glorious flowers. It is all rather wonderful if completely over the top.
A western friend observes that her aesthetic has been somewhat altered since living here and she finds herself looking at objects and thinking, “That needs a little gold rim!”
The hospital corridors and public areas are busy with white-coated doctors sweeping along in ward rounds, nurses wearing surgical scrubs and workmen - usually Indian - in blue overalls. Last Thursday in the afternoon I suddenly encountered dozens of workers clad in grey uniforms embroidered with the legend Domestic Staff, the women wearing identical headscarves tied at the back of the head. The women were talking animatedly in a language that sounded a little like Chinese: they looked Asian but I couldn’t pin their nationality down further. The men were a different race and judging from my conversations with the hotel domestic staff, I think they were Bangladeshi. There were literally hundreds of these people all moving towards a destination at the back of the hospital.
As I turned corners, there were more of these grey-clad workers spilling out of every doorway. I still haven’t quite worked it all out, but possibly they were going to collect their wages at the end of the week before being bused home. I still don’t know where the women come from. These migrant workers, including many nursing staff, are very poorly paid and viewed with disdain by the locals.
Wages might be low yet are much better than those in their home countries. When I arrived at work on Sunday, I was told that Honeylet had gone back to the Philippines because of a family matter, but no one knew for how long. Relating this to a colleague, the immediate response was, “So she’s been deported”.
Who knows?
When I need to visit the hospital in the north, about an hour’s drive away, I am not keen to drive myself across the desert so, following guidance, I request a car. However, I’m informed that because I have been lent a car by the corporation, I must use it for this journey, though a driver will be provided. This is duly arranged, memos sent (the memo is an important bit of organisational currency) and on Sunday morning, Yasser (tea-boy, stationery dispenser and general gofer) takes me over to Transport. There are several men milling about outside the offices, which resemble a concrete cell block, and while Yasser negotiates in Arabic, I hang about outdoors as I am not invited in out of the sun and heat.
They claim to know nothing but eventually a driver is found for me and we go to my loan car, having assured them that it is full of petrol. My driver is straight out of Lawrence of Arabia with long flowing robes, head-dress with tassels down his back, worry beads, bad teeth and an aroma which is a mixture of male sweat and Arabian perfume. He speaks no English and off we go.
At this juncture, forget David Lean films with vistas of romantic sand dunes and dashing Arab princes riding their thoroughbred stallions over horizons. This landscape is completely flat, very dusty and there is the occasional dead bush. There is nothing else apart from the occasional building site, but at least the road is good and inevitably we drive very fast. Eventually we encounter some habitation and my driver turns to me gesticulating wildly, clearly asking me where to go. I have no idea and nor does he.
We turn into a small health centre and he stops the car, so I tell him to wait. I go in, where I find a man in a white coat with a label saying ‘Doctor’. He is charming, speaks English and happily responds to my request to speak to my driver in Arabic. It takes about five minutes of intensive voluble chat - plus gesticulations - to tell him to turn right, then straight on until we reach the hospital. Having arrived there, we stop somewhat randomly outside the Haemodialysis Unit, so once again, in I go and find a very helpful pharmacist and an Indian porter who offers to take me through the hospital to the office of the Medical Director.
This strikes me as a dangerous ploy since I may never see my car and driver again, so I herd porter and driver, who has by now appeared, and insist that the porter comes in the car with us to the main reception. Amazingly I am on time for my appointment and am treated like a queen. It is a good meeting, with coffee and a tour of the hospital, including an explanation of the isolation rooms designated for infectious diseases.
Before coming here, Lionel and I had to provide a certificate stating that we had never had tuberculosis, yet there is a high incidence of TB in the migrant workers working in the industrial city in the north. They come mainly from the Indian sub-continent, without their families and are housed in dormitory-like accommodation.
They work in this industrial city that covers over thirty square kilometres and is a conglomeration of refinery, tanker port and pipelines. It abuts the huge natural gas field which projects out into the Gulf towards Iran. Unless I had looked it up on the internet I would have never known of its existence, yet it is the source of the country’s wealth. To be fair, I am new here so I do not presume any conspiracy or cover-up.
The episode with the enraged Arab driver made me realise that a decent car is a necessity. Given the state of the driving, traffic and roads, it is clearly important that we have our own cars which are well built, safe and with reliable acceleration in order to get out of trouble. I choose a good European make, a Volvo four-wheel drive and Lionel goes for an American tank, namely a 5.3 litre Chevrolet Tahoe.
I choose the lease-purchase option and he elects to take a personal bank loan (because only then would we be allowed, inexplicably, to take the car out of the country, should we feel the need to escape across the desert). It all sounds astoundingly simple - if only.
For the deposit on the car, which has to be in cash, I have to transfer some money from the UK. So, trotting off to the garage with my thirty thousand riyals (about five thousand pounds), I count it out and expect to drive the car away. Wrong. This is the first process in registering the car and so it goes on, with trips back and forth until eventually I can drive my new Volvo away ... except it isn’t exactly my car. I am still waiting for a resident’s permit, so the garage helpfully arrange for it to be in their name in the interim. It is all very simple.
“You just have to sign a paper in Arabic then you can have the car,” says my Egyptian car salesman.
Frankly by this stage I would have signed anything but Lionel is more cautious.
“Well, OK,” he responds, “But at least can we see my wife’s name at the top of the document?”
Carefully my salesman places his pen at the top right hand side of the document.
“But of course,” he says and, you’ve guessed it, writes something completely unintelligible in Arabic.
Well it all works out in the end, but not before I pledge the hire purchase payments, not with a direct debit but by writing twenty-two post-dated personal cheques, which I leave in the custody of the garage to cash at monthly intervals.
What about Lionel? His salesman is a pale, skinny Lebanese girl with fiercely plucked and painted eyebrows. Her hair is scraped back in a Croydon facelift and the answer to any question is, “Yes, of course,” delivered in the abrasive clipped tones worthy of any Bond villain.
“Can I drive my car away tomorrow?” Lionel asks.
And the answer is, “Yes, of course.”
This is pure fiction and he goes through similar convoluted procedures as I have, even though he has waited for his Residence Permit. There were some good things, such as the personal bank loan that was granted, no question, that very day. The money was simply transferred into his account. However when he suggests transferring it over to the garage’s account (same bank) this suggestion is met with astonishment.
No, cash is preferred. So off he goes across town with roughly forty thousand pounds in Qatari Riyals in a brown paper bag. On arrival at the garage they calmly put it through their on-site cash counter and all is well.
“Yes, of course,” is only one of several stock answers to any query. Others include, “No problem” and “In the next five minutes.”
In fact, any answer but “No” is given. How to judge the truth? Depending on the ethnicity of the person, there are often some non-verbal clues, the commonest being a barely perceptible head motion that manages to be simultaneously a nod and a shake, culminating in a subtle figure of eight. The more vigorous the movement, the more likely that he is talking complete bullshit. But most importantly, I learn to watch the eyes. Dodgy and evasive translates as “not a hope in hell,” despite the promise of “yes, sir, immediately!”
I fill up my new Volvo with petrol for the princely sum of thirty-two-and-a half-riyals, which is about six quid. The guide books recommend rounding up the bill in order to give the petrol pump attendant a tip, so I give him thirty-five riyals and with great largesse tell him to keep the change. He gives me a strange look and points out that the QR5 note is in fact a QR500 note - and I was priding myself on being able to read numbers written in Arabic script. Of course, had I turned the note over, it was all written in English anyway!
My new office is in the corporate headquarters, but I am more comfortable in the hospital, having worked in them all my adult life. It is an interesting observation that many patients and their relatives instinctively dislike and distrust hospitals whereas healthcare workers are completely at ease there, a fact worth remembering when patients and their families are anxious or even angry. They are simply scared stiff.
Throughout all the HMC hospitals are signs in English and Arabic and one of the most notable reproduced below, advises relatives how to behave when visiting patients.
Etiquette of visiting patient (published by the Religious guidance and Da’wa department.)
Imagine such exhortations in a British hospital! I did hear people volunteering to pray for patients when I was in America, but we British tend to be much more subtle regarding religious matters and even the chaplains do their praying discreetly. The sub-text of protecting the patient from unwelcome news is interesting and very much part of the culture here.
Relatives will go to great lengths to keep a diagnosis of cancer from the patient and I hear of one case where a daughter was proud that even on his deathbed, her father thought he was suffering from anaemia, not the prostate cancer that finally killed him. It would seem that openness is not embraced as a concept and questioning the doctor appears to be actively discouraged. Yet complaints are numerous and patients and their families are very demanding.
Expectations are high, but there are few attempts to manage them. An out-patient booking system has recently been installed, which is having some effect. Previously patients would simply turn up and demand to see the doctor of their choice, usually because they had seen that particular doctor before or because there was a family connection. If you are not from a local family then the Emergency Department is the only place, as there are very few GP surgeries.
Relatives from local Qatari families are unwilling to take their turn in the Emergency Department and stories abound of doctors being physically dragged away from treating a migrant worker in order to see a local patient first. This has resulted in a kind of local apartheid where Qataris are treated in separate bays, in order to diminish the acts of violence and aggression. And I thought the Emergency Department on a Saturday night in Portsmouth was bad.
Yet overall, people are generally warm and friendly. I make formal appointments to see prominent Arab doctors in order to discuss policy and strategy and am made very welcome. I’m given their delicious Arabic coffee, flavoured with cardamom and saffron and I’m offered sticky pastries with chopped pistachios or occasionally fresh dates, which look revolting yet taste sublime. There is much small talk and people are amazed when I say that we had a good laugh. I may not be getting the business done but at least we can share a joke and I suspect this relationship-building is crucial.
It is particularly important as a westerner to show that you have some understanding of these cultural mores. An abrasive let’s get straight down to business approach does not work in the Arab world.
Exactly how well I am doing is hard to judge. Lionel, needless to say, is flying in those terms but he needs to be. The prestigious new Heart Hospital has no governance, failing leadership and a need to meet external regulation. The place is in relationship meltdown with various warring factions, interventions by the Royal family and an expectation that Lionel will sort it out. Never frightened of confronting the issues, he asks directly whether a consultant attended his out-patient clinic and the reply is strongly affirmative, whereas the out-patient manager is perfectly clear that the consultant has seen no one in out-patients for months, but leaves it up to his junior staff.
Meanwhile there are votes of no confidence, disreputable memos signed by members of the same family discrediting other staff members, and only this week, Lionel has had several grown men and women in tears in his office.
Nevertheless the standard of clinical practice here can be high. I attend a Mortality and Morbidity meeting in the Heart Hospital where two cases are discussed in detail. The debate is scholarly and heated at times but there are some very wise voices among the assembled senior clinicians. I experience the same commitment to good medical practice at a Grand Round in the education centre. These usually take the format of a junior doctor presenting a recent interesting case followed by a discussion about the treatment plans, the outcomes and how this all fits with the recent academic literature. It is a good forum for the juniors to hone their public speaking skills and for the senior doctors to guide (and in some cases to show off) their knowledge. Everyone learns so ultimately the patients also benefit.
There is a pecking order among the staff. Lionel’s senior physician (and former minister of health) chairs the proceedings, asks the pithy questions and when he alone has decided that the meeting is over (regardless of any guidance on the timetable), he announces that the meeting is closed ... then sweeps out with a flamboyant swish of his robes. There is no question of a cosy chat afterwards.