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RetroSaudi: Staying Alive

February 8, 2018

Sulaiman Habib Hospital, Riyadh

Wait outside any well-appointed private hospital in London, and you will find among the patients entering and leaving large numbers of men in western clothes who would look just as natural in the traditional thobe worn by Saudis and the citizens of other Gulf countries.

With them are women, covered from head to toe in black robes. Some have their faces covered, some don’t. Britain’s hospitals do a roaring trade treating the ailments of their wealthy Arab patients.

You might think that a lack of decent hospitals in their home countries leads them to seek help in London. This is not necessarily so. Although some go abroad for treatment of serious conditions because they believe that they can find the best-in-class care for that illness. For others a minor ailment or the perceived need for cosmetic surgery is an opportunity for a holiday outside the country, not just for the patient, but for family members. In other words, health tourism.

But back in Saudi Arabia, the majority of people can’t afford such travel. They are reliant on the services they find in the Kingdom, either from government hospitals or from the many private hospitals and clinics.

This latest piece in my RetroSaudi series is about healthcare in the Kingdom – as it was thirty years ago when I first wrote about it, and as it is today. My intention is not to provide a learned analysis of a big subject. As in 1987, I can offer observations and impressions, as well as a few oddities that made me laugh back then.

Since I started returning to Saudi Arabia in 2008, I’ve gained a deeper insight into the country’s health system through work I’ve done in a number of hospitals. Even in the 80s I was not entirely removed from the system, because my wife ran emergency rooms and outpatient clinics throughout our time there together.

Before I launch into my observations from 1987, I should say that Saudi Arabia is blessed with talented and dedicated doctors, nurses and health administrators, many of whom were trained abroad, and an increasing number through domestic universities . It’s always been a pleasure to meet and interact with them.

Healthcare may have been patchy in the past, and still is in some areas, but not for the lack of people who want to do their best for their patients.

Then (1987)

Saudi Arabia is a country whose citizens pay more deference to the medical profession than to any other group except the religious sheikhs and the royal family. Health, or rather illness, is such a preoccupation that the newspapers devote thousands of column inches to the subject every week.

Taking self-harm to extremes

Aleph ouch!

Typically, Tuesday’s copy of the Arab News devotes several features to medical breakthroughs. In a country where officially homosexuality and drug abuse are non-existent, the plight of the hapless blood recipient receives most attention, since this is the only explanation given for the spread of AIDS in the country.

Few countries – apart, perhaps from my own – pays so much attention to diet, with so little effect. The daily syndicated advice columns, “Harvey Frankenburger’s Diet Tips” and so on, are devoured by the pear-shaped masses, and then presumably ignored.

There is also a plethora of human (or inhuman) interest stories along the lies of: “Woman, 90, gives birth to monkey after 10-year pregnancy”. The weirdest stories seem to originate from the Middle East or the Indian subcontinent, which is hardly a surprise since many people in both regions are firm believers in magic. What is surprising is that so many papers report the stories as fact.

I never found out what the mermaid post-mortem revealed

Why this obsession with medicine? Some would say that the lack of external stimulation in a person’s life drives their attention towards the ailments, real or imagined, that blight their existence. The opposite of getting on with it, I suppose.

Certainly, in my experience, the appearance of a pimple or a bad bout of indigestion is often cause not only for a visit to the emergency room but for at least three days of sick leave. But then many Saudis have never really felt that they need sick leave. It’s enough to say “I’m tired”, for everybody to understand that the person suffers from an ailment that is as likely to originate in the mind as in the body, and is therefore definitely worth a couple of days off.

Despite their occasional bouts of hypochondria, Saudi men have a macho image of themselves. The older generation, who remember the days before hospitals and hand-outs, see themselves a strong as lions, contemptuous of physical comfort. The idols of the youth, on the other hand, are pop stars and footballers, not hunters and desert-dwellers. Sadly, the physical condition of city-dwellers leaves much to be desired. A reluctance to do physical work, brought about by the availability of foreigners to do the rough stuff for them, has taken its toll on the average citizen of Jeddah or Riyadh. Out of their glamorous sports cars step pitifully skinny guys you could knock down with a feather, or else alarmingly large ones you could never imagine being able to climb in, let alone out, of a Ferrari or a Porsche.

So what do the Saudis do to preserve the health of their pampered citizens? Quite a lot, actually.

Ten years ago the main public hospital in Jeddah was Bab Sherif, housed in a tenement-like building dating from the mid-50s. It was an institution in which, if you survived the surgeon’s knife you still had to contend with the eccentricities of the nursing staff, with raiding parties of cockroaches in the bedding, not to mention motheaten feral cats stealing your lunch.

That assumes, of course, that you managed to get there in the first place. First you had to make your way across potholes deep enough to stop a tank after D-Day, driven in an ambulance by an out-of-work racing driver who managed to avoid each obstruction, human or otherwise, by a hair’s breadth. By the time you got to the hospital there was a decent chance that you would be dead on arrival through fear. This perhaps explains why the patients of Bab Sherif viewed their lot so positively. They had already survived the worst.

The only occasion I visited the hospital was for the obligatory donation of blood in exchange for my driver’s licence. This involved sticking my arm into a hole in the wall. On the other side an unseen medical technician was waiting to insert the needle. I can only assume that the needle was clean, since I didn’t subsequently develop AIDS or hepatitis. But I did worry for a while.

Today they’ve replaced Bab Sherif with a multitude of gleaming public hospitals and private clinics. Business is booming. Every day the newspapers shout out the latest achievements of Saudi healthcare: test-tube babies, kidney transplants and all. The Saudis are so proud of their healthcare system that descriptions of complex medical seminars appear on the front pages.

Imagine the Daily Mail or the Washington Post running a headline on its front page such as “Causes of dimuscular ventricalities of the pericardial sac discussed”. The prestigious private hospitals, of which there are many, import world-renowned doctors for well-publicised visits, and treat them like rock stars. You half expect them to be accompanied by minders with tee shirts over their beer guts bearing messages like “Magdi Yacoub and the Fibrillators, Middle East Tour 1987 – the Show That’s All Heart”.

Dr Bakhsh was a hospital beloved of expatriates

The private hospitals are hideously expensive. They give you a blood test and X-ray for any complaint. But at least they give you a modicum of choice about your treatment. They’re also not shy about announcing their acquisition of sexy new equipment.

One area of medicine that the Saudis haven’t come to terms with is primary healthcare. There are no neighbourhood clinics, health visitors or doctors who will come and visit you. Only hospitals. Often enough, unless you’re a road accident victim, you come to them, not them to you.

Now (2018)

Two things strike me when I revisit what I wrote in 1987. First, that I was writing with a somewhat supercilious expatriate consumer’s perspective. And second, there was almost nothing about women’s health. It’s all about the men.

Having spent several recent years running management and personal development workshops in the Saudi health sector, I know quite a lot more now. In those days I rarely met a Saudi woman, let alone had a lengthy conversation with one. But working with hospital staff – both male and female – has been a revelation. The women I’ve met are smart, enthusiastic and highly motivated, often more than the men.

Thirty years on, you would have expected the gaps to have been filled, and that with the huge sums the government has invested in healthcare, there would be a uniformly high standard of care, whether private or public.

Sadly that doesn’t seem to be the case. While there are a number of first-rate private hospitals, there are also some pretty awful ones. Medical negligence cases abound, and in one or two cases the government has had to step in and close the worst offenders.

In the government sector, again, the care is not uniform. The best hospitals are those operated by the military. They provide a high standard of care, and they train large numbers of Saudi doctors and nurses. Government hospitals in towns and villages are not, I’m told, of the same standard.

Healthcare for expatriates depends on what they can afford. Ten years ago the government decreed that every foreign worker should have private health insurance. But as with schemes elsewhere, there are different levels of coverage, and therefore of care.

That obligation has now been extended to Saudi citizens in the private sector. And for good reason, since the cost of treating lifestyle diseases – obesity, diabetes and heart disease – is, as we well know in the United Kingdom, cripplingly expensive.

Saudis have other health issues to contend with. For cultural reasons, consanguineous marriages – unions between close relatives – are still common. Although the government promotes screening for genetic conditions that might make close marriages inadvisable, they still take place on a regular basis, to preserve wealth, as well as family and tribal bloodlines.

As for women, two factors contribute heavily to health problems. First, Vitamin D deficiency resulting from the lack of sunlight among those who are required to cover up when venturing outside and don’t have the opportunity to catch the sun at home. And second, sports for women have been actively discouraged until recently. While women from wealthy families have always pushed back against this, and found their own ways to exercise in private, and those in rural areas still work in the fields, there are still many women in towns and cities whose only exercise is wandering around shopping malls.

Depression is another problem. Women who are aware either through experience of travelling or studying abroad, or through a regular diet of satellite TV, often feel trapped in their home lives, unable to live even moderately independent lives compared with their sisters in the West, or even their female neighbours in the Gulf. This is changing, as the government introduces a degree of social liberalisation, and encourages women into jobs. But often they are constrained not by wider society, but by their own families, whose conservative values do not allow them to contemplate their wives, daughters and sisters living lives beyond their control. This post from a female blogger living abroad powerfully describes the symptoms.

Saudi Arabia has other challenges that other countries do not have to face. The biggest is the potential for epidemics brought about by the massive influx of pilgrims during the Haj. It’s a melting pot for bugs imported from thirty countries. That there has been no outbreak of a serious infectious disease in living memory is a tribute to those who manage the whole process – doctors, civil servants and volunteers.

In recent years the Saudis have had to contend with MERS, a nasty and often lethal coronavirus that keeps popping up in clusters around the country. Again, however, they have managed to prevent a general outbreak.

Leaving aside the epidemics and the chronic ailments of the Saudi population, would I, if struck down on a visit to Riyadh by some critical condition, be confident that I would receive the best care in one of the Kingdom’s high-status institutions? The answer is yes, provided I was lucky enough to find my way to a National Guard hospital, or to the King Faisal Specialist Hospital in Riyadh. If you don’t believe me, ask Frank Gardner, the BBC journalist who in 2003 was shot down by Al-Qaeda operatives in Riyadh, and whose life was saved by the Faisal Hospital.

If I found myself in a car accident halfway between Jeddah and Riyadh, perhaps I wouldn’t be so lucky. But not for the lack of trying on the part of the helicopter rescue crews I met in Jeddah on a regular basis, should I have the fortune to be within their range.

The Saudi healthcare system is definitely getting there, but it’s a big country, and sadly there are times when you need to be at the right place at the right time. But I guess that’s the same just about anywhere. It’s only a question of degree.

Other pieces on Saudi healthcare:

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