A Radiation Therapist’s Tale of Life in Saudi Arabia

Vol. 14 •Issue 6 • Page 33
A Radiation Therapist’s Tale of Life in Saudi Arabia

He left the U.S. five years ago wishing for adventure. He’s found that, and more.

By Gary A. Steffen, RT(R)(T)

The reasons most people come to work in Saudi Arabia can be divided into three categories: for the money, to escape and for the adventure.

The money is not as much an incentive today as it once was. Since the Gulf War and other world economic changes, Saudi Arabia is no longer awash in petrol dollars. However, it is still possible to make a good living here and pay off debits from home; depending on where you reside, living expenses can be very low, given the fact that housing accommodations are usually furnished.

If your motivation is to escape problems other than financial, then Saudi Arabia is not the place to be, as personal or emotional problems will follow you. As for the third category, the adventure and challenge of living in a foreign country amidst an alien culture is a great opportunity for personal growth in your chosen profession.

My personal reasons fall somewhat into this last category. I was looking for adventure and a change. I also had become disenchanted with the state of medical care in the United States, particularly in my field of radiation therapy. I felt that patient care had taken a back seat to the bottom line. I did not feel, and still do not, that it is possible to “do more with less.” Having worked in medicine for nearly 30 years, I have seen changes. While I do believe that fiscal responsibility is a necessity in medicine as in other disciplines, I believe that U.S. health care is going too far in that direction.

So it was in this frame of mind that I embarked five years ago on my new career as a radiation therapist in Saudi Arabia.

One-Year Contract

I signed a one-year contract to work at the Al Hada Military Hospital in Taif, Saudi Arabia. Taif is on the western side of the kingdom, due west and north from Jeddah, the main seaport for Saudi Arabia on the Red Sea. The drive from Jeddah takes about two hours and skirts the city of Mecca, the holiest city in the Islamic religion. Non-Muslims are not allowed to enter Mecca, so one detours by what is called the Christian Bypass Highway. The last 30 kilometers or so are on the “Escarpment” that winds its way up the Jabal Kabkab Mountains west of Mecca. This climb to the top takes you from sea level and the desert terrain of Jeddah up to around 5,000 feet and the “garden” of Saudi Arabia. The Taif area is known for its fruits and vegetables, which abound in the moderate climate. Its most famous product is an exotic rose oil, much prized throughout the Middle East.

The climate in Taif is similar to the high desert areas of New Mexico. The winters are mild and rainy with banks of clouds that roll over the hospital compound, blanketing it for hours at a time. The summers are not what one would expect of a desert country. They are mild, with the temperatures rarely approaching 90 degrees Fahrenheit. The air is dry with little humidity at any time of the year.

Al Hada Hospital sits on top of the mountain some 35 kilometers outside of Taif. The 250-bed facility is surrounded by living quarters for single and married personnel who work in and maintain the hospital and grounds. Since this is a strict Islamic country, housing is segregated between unmarried male and female workers. Dating is not allowed in the Western sense, nor are unmarried men and women allowed to visit one another in their apartments.

A mix of nationalities staffs the hospital. Prevalent for many years, the Western presence has declined over the five years I have been here. The radiology department remains staffed mainly with Filipino X-ray technologists. A mix of Americans, South Africans, Indians and Egyptians staff the subspecialties of CT, nuclear medicine and MRI. Only one other American besides me staffs radiation therapy, located on the main floor of the hospital. Our nursing staff in charge of administering chemotherapy is Filipino.

Before leaving for Saudi Arabia I was told that the hospital was in the process of enlarging and upgrading the radiation therapy department to accommodate a new linear accelerator. It was imperative that I and the rest of the new staff get there as soon as possible, as the new machine was expected shortly. Upon our arrival, however, we found that there was no linear accelerator ready to be installed, and the proposed expansion had not even begun. It would be three and a half years before any of this would come to fruition.

In the meantime we were not idle. Although we had a 15-year-old Siemens 4MV linear accelerator and a Siemens Accusim simulator, we had little else to constitute a modern progressive radiation therapy department. The department was lacking some of the basic tools needed for accurate patient treatment. Together with another American colleague, William H. Grush, RT(R)(T), CMD, I fabricated two breast boards, and redesigned the head-holder system to accommodate the AquaPlast system commonly used in the United States. We found this more efficient and less time-consuming than the British mold-and-cast system previously in use. All of the material used for these im- provements was scrounged from existing materials in the department and other parts of the hospital, mainly the carpentry shop. We purchased smaller items in the Taif Souk (markets). Items such as AquaPlast and A-F standard head holders were ordered through the hospital purchasing system. This was not easy, given hospi- tal budgetary constraints and the hospi-tal’s byzantine nature of purchasing. Each purchase required multiple signatures, as well as justifications for purchase, all of which needed to be translated into Arabic.

The construction and installation of the new equipment finally began in the spring of 1999, with the installation of a new Varian linear accelerator C/D in February 2000.

While all of this may seem frustrating on the surface, it was a learning experience. We discovered very quickly that nothing moves at a very fast pace here and that in order to get things done in what we would consider a “timely manner,” the key is to plan ahead.

The treatment of patients at Al Hada when I arrived with two other therapists (one from Columbia, South America and the other fresh from radiation therapy school in Edmonton, Alberta, Canada) was very basic. It reminded me of what therapy was when I started in the mid-70s. We found it a challenge to bring continuity to the way patients were treated on a daily basis, given the limited means available. When we arrived the department had been without trained staff for nearly six months. They were relying mainly on Saudi Army in-house trained personnel. After an initial period to acquaint us with the patients and treatment plans of the oncologist, the Saudi techs were only too happy to turn over the daily treatment of patients and to just disappear into the coffee room. We were fortunate to have an Egyptian-born, British-trained and board-certified radiation oncologist.

Not only did we need to adjust to the culture and the hospital, we also had to gain the trust of the people with whom we worked. Over time that has happened. There is a built-in respect here for Western expertise and Western-trained personnel, something you notice almost from the day you arrive. I feel an obligation not to betray that trust and always to present myself as a caring professional.

Saudi Culture

Because Taif is not a large metropolitan area and not greatly influenced by Western modernity, I have had the unique opportunity to see Saudi society with its basic tenets still intact. Yes, the outward Western trappings are here–the cars, the Suburbans and, of course, the ubiquitous cell phones or “Jawals,” to use their Arabic name–but the basic core of family and religious values has not changed. Here the younger family members take care of the older ones, especially when it comes to illness. This can be difficult, and in some cases a hardship, for the working male members. Since women are not allowed to drive under Saudi law, the husband, father, brother or son must take his female relatives to whatever appointments they may have. In the case of radiation therapy it means taking them for treatment on a daily basis for up to six weeks. While in some cases this is an inconvenience, it is an accepted part of the culture and allowances are made. However, it is evident that changes to more Western ways are gradually occurring.

One of the most gratifying–albeit exasperating–examples of this is in the number of people who may accompany a patient who comes daily for treatment. Since Saudi families tend to be large, as many as five sons may bring their father in for treatment, and I don’t mean just to the department where you would nor-mally take over. I mean into the treat- ment room with you, helping you get the patient onto the table, waiting in the room while you set the patient up, even stand-ing and looking over your shoulder as you position the patient. They also would stay in the room while the treatment is being given if you didn’t firmly tell them that they must leave during this process. I have had family members insist that they re-main outside the door while the machine is on. This, as a therapist from the United States, took some getting used to, but I adjusted once I learned it was a cultural norm in this country.

One the most difficult cultural norms to accept is the treatment of women, who in Saudi Arabia have no rights as we think of them. Women here are totally “covered” or veiled, meaning that their faces are covered by a veil, some of which have a thin slit across the eyes. All Saudi women, as well as Western women, must wear an abaya, a long black robe that covers one from neck to toe. Western women are encouraged to cover their hair, just as all Muslim women are supposed to do.

A male family member must always accompany a Saudi woman. For radiation therapy this means that a woman will be escorted to the radiation therapy department by her husband, brother or son. A female relative also may accompany her. And this relative will stay with her all the while she is in the treatment room, except when the treatment is given. This does vary from family to family and with educational background. Once the patient gets used to the routine she may tell her family members to leave once she has been escorted into the room.

At this point women may uncover their faces if they feel comfortable in doing so, but it has not been unusual for me to treat a breast or pelvis patient for five weeks and have no idea of what my patient looks like. I have learned to recognize some patients by their shoes or handbags.

Warm Hospitality Evident

Hospitality and friendliness play a major role in Saudi society. I have found this to be true with the large Bedouin population that I serve more so than the more Westernized Saudi. Greetings here between men are very formalized, more so than in the West. Two men meeting will shake hands and kiss each other on each cheek while asking that God’s peace be upon him.

They also will ask after each other’s health, each in turn answering that they are well and praising Allah. On a less formal level, individuals who see each other every day will still shake hands and use the formal greeting.

Displays of friendship and emotion also are part of the culture. It is not un- common to see men cry openly without embarrassment over the plight of a family member brought to our department for treatment. It is also not uncommon to see two men holding hands while talking to one another, or while walking down the street.

This was at first disconcerting to me, coming from a culture where the boundaries of personal space and physical familiarity are clearly demarcated. I have observed since being here that the “personal touch” is much more prevalent in Eastern cultures, be it Saudi Arabian, Pakistani or Filipino.

An interesting aspect of Saudi culture from a Western perspective is the “intrusion” into one’s private life. Because families are large and so interconnected it is not unusual for members to make every person’s business their business. This stems from the religious concept in Islam that all Muslims are brothers and sisters, that it is one’s duty to take an interest in a family member’s private life if he or she feels that the individual in question is not meeting the criteria of what a good Muslim should be.

This has become a source of irritation and frustration to some Westerners who have converted to Islam. They find this an unwanted intrusion into an area of their lives that they feel is a private matter.

However, I feel that my friendship with Saudis is every bit as valuable as any close friendship would be in the West. Saudis themselves value friendships highly, perhaps in some respects more than we. A Saudi friend also can be a great asset in understanding the language, and as an entry into the culture.

National Unity Lacking

What Saudis could learn from us is a sense of duty and responsibility outside the family and tribal unit. Saudi Arabia as a nation is only 100 years old and in that time it has made great economic strides. What is lacking is a sense of personal responsibility for the country as a whole. Saudi Arabia still lacks the societal mindset necessary to use imported technology to its fullest potential. What has exacerbated this problem, in my opinion, is the continual use of expatriate service personnel, of which I am a part.

Another reason for this inability to move ahead more quickly is the cultural and religious influence. This is a difficult period of transformation for Saudi Arabia from what was a Bedouin sheep-and-goat-herding society, made up of desert clans, to one that can meet the challenges of the 21st century.

Saudi Arabia is now promoting “Sau-dization” of the work force. This will take time, as an educational infrastructure capable of training Saudi men and women for the future needs to be developed. A work ethic also must be instilled into the upcoming generation in order for Saudization to succeed.

Coming to Saudi Arabia can be a culture shock; how much of one depends on the person. It is probably easier for men than for women to adjust because of the restrictions. Your background and character will dictate a great deal about whether you will adapt successfully to the Saudi and Islamic culture, for they are one and the same. If you like the party scene with a wide variety of entertainments, movie theaters, concerts and nightclubs, there are none in Saudi Arabia. Alcohol and other drugs are also strictly forbidden. There are restaurants in abundance, but few have a “family section,” meaning an area where men and women can be seated together.

Stateside Luxuries Missed

On a personal level I miss the immediacy of things. When I came to Saudi Arabia and Al Hada there were two television channels. One was all in Arabic and the other in English–somewhat. Shortly thereafter the selection expanded to CNN, BBC and India MTV. In the past three years I have been able to add a satellite, so that now I can watch all of the network nightly news programs the following morning. Proba-bly the biggest improvement has been the arrival of the Internet to this part of the kingdom. It has been a great help with personal and family communication, as mail can be “iffy,” especially during Ramadan, the holiest month in the Islamic calendar.

The two things that I probably miss the most are a good bookstore and a Blockbuster Video store. Since there are no movie theaters here, you must rely on videos, and you buy, rather than rent. The videos available here in the kingdom are censored.

Any film that has any romantic scene, even a kiss, is removed from the copies for distribution. However, all films with gun battles, shootings and other explicit violence remain. The market for action films here is great, perhaps in part because of the low crime rate. The practice of public beheadings in front of the mosque on Fridays for capital offenses is perhaps the major deterrent.

The only major item that leaves me disgruntled all the time is the censorship of personal mail. Any packages received from abroad are opened and inspected. The main things checked for are drugs and pornography and, of course, any product that might contain alcohol. Personal letters may be inspected, particularly if they are bulky.

Yet, even with all these inconveniences and petty annoyances, I still enjoy my time here. The tax-free status is, of course, a major incentive, as is the chance to travel to even more exotic places in the world. I enjoy the culture here most of all because it is never boring.

Is there anything that would take me back to work in the U.S. health care system? In all honesty, no. I am nearing the end of my medical career, so in some ways the question is moot.

You may ask yourself if this might be something that you would like to do. The only answer to that question is to try it. You will lose nothing by doing so, and you will gain everything. n

Gary A. Steffen is a radiation therapist at Al Hada Hospital in Taif, Saudi Arabia.

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