SPECIAL SECTION

CHAIRMAN’S REFLECTIONS Part 11

Looking back at the first few years of working as a cardiologist at home in Qatar, is like watching an old movie. The scenes are clear, the events exciting, the struggles intense, and the heroes real. Some characters are still around; some are no longer with us.

                                                                                                              Hajar A. Hajar, MD*

Abroaditis

The first hospital that was built in Qatar was in 1945.
It was small with 30 beds and staffed by one doctor only.
 In 1954 more extensions were added and a few more general doctors were recruited. However, the lack of qualified specialists made the government send a few patients abroad through a medical committee. But at that time, most patients were sent abroad to Lebanon and Egypt. 
The opening of Rumaillah hospital in 1956 was a major achievement in the history of health care in Qatar.
 A few qualified specialists where recruited to take care of patients and their presence reassured Qataris that their health was in good hands for the first time. 
The trust of the people in the medical staff was at its zenith then, but unfortunately, that trust did not last long. By 1970 four agencies represented Qatar government abroad to assist Qatari patients in Lebanon, Egypt, Austria, and UK. The number of patients sent abroad were very limited until 1971 when their number started to skyrocket.
During the years 1964 – 1978, I was in the USA as a college student, medical student and then a postgraduate trainee.

 I was preoccupied with my studies and did not know much about the social and political changes in Qatar.
 My main source of information about what was happening at home was through my father's letters.
 My father wrote to me about family events; rarely did he write about political news. He had no interest in politics. He thought it was more important to inform me of a child born to my sister rather than a change of a head of state. 
Radio and TV news in the USA at that time were preoccupied with the Vietnam War. I never heard news about Qatar on American TV then.
 Most Americans had never heard of Qatar before the Gulf War.
 We did not even have the luxury of international telephone communication. 
We could not afford paying for over seas phone bills with our monthly allowance of $200 as students. In 1964, I had a very discouraging experience when I tried to make my first international call to Qatar from Texas.

 Direct international telephone dialing was not available then. 
The operator in Baytown Texas said that she had never heard of a country called Qatar. She asked a Houston operator to help her.
 The Houston operator looked at her codes and maps without luck. She asked me if I was sure that there was a country with that name. 
She requested me to respell the name of the country for her again because she could not believe that there is no "u" after the "Q".
 After more than twelve minutes of looking and asking colleagues, she gave up and connected me to a New York operator who had more experience with international calls than she.
 Even the New York operator was not able to find Qatar anywhere. She asked me if it was a part of Saudi Arabia. I said: "No. . . No". 
She called a London operator and asked:
"Honey. . . , have you ever heard of a country called Qatar?" "Yes of course" replied the London operator immediately. "Where is it?" Asked the American operator.
 "Just next to Bahrain Island", he answered.

I was not happy with the answer because Qatar is bigger in size than Bahrain and should be easierto see in maps. 
But I did not say anything. So, with the help of the London operator, I was able to make my first overseas call from the USA to Qatar.
 My mother thought it was a miracle. 
She never expected that I could call and talk to her from such a far away place. She asked me twice if it was really me! While I was writing this paragraph about my international telephone call from Texas in 1964, my son called me from Texas using his mobile telephone. He wanted me to check an e-mail he sent me. The distance between Texas and Qatar did not change in 37 years but almost everything else did! I learned about some of the changes in Qatar when I came for summer holidays. I used to come for summer vacation four weeks once every two to three years. Through friends and colleagues, I found out more detailed information about what was happening in Qatar when I returned home for good in 1978. In 1971 Qatar became an independent state after decades of British “protection.” Soon after, the independent State of Qatar with a population of 80,000 had a Minister Of Health.

 The new minister welcomed any patient who went to his office seeking help. He started to send almost all willing patients abroad for treatment, with or without medical board approval.
 The news spread in town like wild fire in dry grass. It was an excellent opportunity to go abroad with all expenses paid for by the government. 
The Minister Of Health became the most popular minister in the country. In the following few months and for many years, large numbers of citizens became "sick." Many diseases became "unresponsive" to drugs given in Qatar. 
Miraculous therapy and exaggerated treatment success stories by patients returning from abroad were the dominant theme in the country then. 
Some diseases vanished soon after the airplane landed in Europe. 
The blind gained 20/20 vision, the paralyzed walked, and the impotent became as potent as a teenager. Such magical therapy did not exist in Doha.
 Trust in the local medical staff was eroded. 
The new opportunity to travel abroad on the expense of the government, especially during the summer, was irresistible.

 The first well-trained surgeon to come to work in Qatar was Dr. Red Prendeville, an Australian. He arrived in Qatar in 1957 to work in Rumaillah Hospital, one year after it was opened.
 He was loved and very well-respected in Qatar. I knew him very well when I was in secondary school. 
He operated on several friends and relatives. He removed my tonsils in 1960.
 He retired in 1973 and went back to Australia. Dr. Prendeville visited us in Doha recently in May 2001.
 His memory was still very sharp. I asked him about treatment abroad during the early days. He told me that he was in Doha when Treatment Abroad suddenly jumped beyond control in 1971. 
The Treatment Abroad Committee was reformed and he was the chairman. The medical board committee would write: "Treatment abroad is not recommended," but the patient was sent abroad anyway. Dr. Prendeville recalled. "It became chaotic and the hospital was devastated. Patients came to us requesting referral abroad instead of treatment.
 Some patients wanted to go abroad for treatment for truly minor problems like a cyst on the back.

 All he needed was for his wife to squeeze it. When we refused to send a patient with a minor problem abroad, the minister overruled our decision." Dr. Prendeville happily performed first class surgery for four years in Qatar but suddenly found it difficult to convince patients to accept surgery or medical care in Doha. 
Medical and surgical care suffered. It was difficult for a professional surgeon to work in such an atmosphere. Dr. Prendeville told me:
 "It became so bad that in February 1972 I left the country, heading to the UK. While I was in Lebanon on my way to the UK, I was called and requested to go back to Doha with the news that there were some political changes in the country and treatment abroad would be controlled". Over the following decade, the major function of the ministry of health was sending patients abroad. 
Medical attaché posts were created in several Qatar embassies in Europe, Egypt and Lebanon.

 Rumaillah Hospital became overwhelmed with preparing patients to travel abroad. Some patients felt insulted if they were told to stay in the country for treatment. No VIP would accept to be treated in Doha.
 The local perception was that those who accepted treatment in Doha must be foreigners or citizens from lower and poor classes. In fact, well-connected foreigners, whether government employees or not, were sent abroad for treatment on the expense of the government with daily allowances for the patient and his or her companion. 
Later in this essay, I will narrate the case of a foreign young man who was sent abroad for treatment a few days after arrival in Qatar and probably before the ink of his residence permit dried. 
The following stories illustrate the difficulties andfrustrations faced by the local medical profession. The stories underline the magnitude of the “abroaditis” problem – a problem that evolved into a “disease” of epidemic proportions unique to our region.
 Qatar in particular had a severe case of that epidemic. 
In the summer of 1973, an old Qatari man went to the Minister of Health's office. He told the minister: "I pray that God prolongs your life. 

You send many people to London for treatment.
 I also want to go to London but I am not sick. Do I have to lie and claim that I am sick? If I were sick, I would rather stay home than go to London. Sick people cannot enjoy trips.
 Do I have to get sick to see London?" The minister laughed at the logic of the honest old man. 
He wrote an order for him to be sent to London for two months as a patient with two companions. 
The ministry paid for the tickets and daily allowances for the patient and his escorts. It is not surprising that illness in Qatar was statistically seasonal then. The number of “sick” patients increased proportionally with the increase in local temperature. 
During the summer, the country was almost deserted. Many people spent the summer months as “patients” on the government's expense in cooler countries in Europe. Every minister or politician who wanted to gain popularity in the country must help send patients abroad. Orders to send patients or groups of patients and relatives abroad for treatment came at that time from HH the Amir, HH the Crown Prince, the Minister Of Finance, the Minister Of Interior and of course the Minister Of Health.

 Those written instructions bypassed the medical board committee during those days. On joining the department of medicine in Rumaillah hospital in 1978, I heard a new local medical term: "abroaditis" i.e., patients eager or "itching" to be sent abroad. 
This term was frequently mentioned in the differential diagnosis in the presence of patients. Patients did not realize what it meant since it sounded like medical jargon. 
Most patients with abroaditis had no physical findings to support their complaints.
 In 1979 I met a senior cardiologist, Dr. Harris, in a hospital in London. He was a pleasant, helpful and well-respected cardiologist. I finalized a cooperation agreement with his department.
 The agreement was backed by his hospital in London and the ministry of health in Doha. He agreed to send his senior registrar to Doha to help me take care of patients in return for certain fees to his hospital. With that agreement I gained a young and well-trained cardiologist, Dr. Keith Woollard.

 He joined me in Qatar a few months later. He was a good cardiologist and very helpful. Even before Dr. Woollard joined me, I invited Dr. Harris to come to Doha as a visiting cardiologist for a week. 
An unplanned and spontaneous experiment took place during his visit. Some patients who had had a cardiac evaluation and therapy abroad requested me to send them to the same cardiologists for reevaluation annually in the summer. 
I refused because I could evaluate them in Qatar. They managed to travel, however, through orders from higher authorities as usual. In anticipation of Dr. Harris’ visit, I instructed my clerk to contact all of Dr. Harris’ patients in Doha for appointment to see him.
 We collected their names from Dr. Harris’ office and from the medical reports of patients in our files.
 Most patients refused and insisted to be referred to London to see Dr. Harris. They told the clerk that bringing Dr. Harris to Doha is a trick to deprive them of their right to get treated abroad. 

Some explained to me that they refused to see him because he will not be as valuable to them in Doha without his equipment, his good nurses, and his highly qualified technicians in London, etc. The reader could make his conclusion from that unplanned experiment. 
I classified those as severe and very advanced cases of abroaditis. I do remember a few patients whom I sent abroad. One of them was a patient with aortic valve stenosis (AS). 
In 1980, I evaluated an old Qatari patient with AS. He looked over 75 years old, thin and malnourished. He was quiet with some loss of recent memory. Based on my clinical examination, EKG, CXR and M-mode echo, the AS was severe. Even though I had primitive cardiac catheterization then, as I had described in a previous article (The Blue Girl Heartviews 2000, 1 (9):375-377), I decided to send the patient to London without cardiac catheterization. I was sure he needed valve replacement. We had no cardiac surgeon in Qatar then. I informed the son the good news that I will refer his father to London for surgery. I thought he would be happy.

 The son said that his father was a VIP and not an ordinary person to be sent by the ministry of health! The son said that he could arrange for his father to be sent on expense of His Highness the Amir to London. 
This was the most arrogant response Ihad ever heard from a patient’s relative. 
I told the son that I do not care who sends his father, but he should take my medical report to the cardiologist in London and bring me postoperative report for my future follow up in Doha.
 I realized later that he took my report only to the Amir’s palace to justify his request for the trip abroad, but he did not take my report to London.
 I could not forget the arrogant response of the son for several days. I told my father the name of the patient and asked if he knew him.

 My father told me that he knew the old man.
 He was a very decent man. He had admirable speech. "He could sell you anything", my father added. He worked as a "dallal" i.e., he used to sell real estate to people and gets commission. The first time my father met him was in Dubai (UAE) 30 years earlier. 
Two months later the old man showed up in my clinic with a servant.
He looked very well for an old man with recent open-heart surgery. 
The servant handed me a report. It was written by a general physician in London. 
The report stated that the clinical history was obtained through an interpreter.
 When the patient was asked about his complaints, he said “constipation.” On physical examination the physician heard a cardiac murmur but he was distracted by the patient’s non-cardiac complaints and the objective finding of hard stool in the colon on palpation. The heart murmur was ignored. An immediate enema was arranged. 
The result was gratifying. Stool softener was prescribed for the old man and he was discharged from the clinic to return to Doha.

 The old man’s memory had deteriorated further. 
I told the servant to inform the son that I needed to talk to him about his father. 
I had to send him back to a cardiologist in London. 
I sent the son a note with my telephone number. Unfortunately, I never heard from the son. The old man died suddenly at home four months later. Another incident involved a young foreigner who was brought to work as a soldier for the Qatar army.
 On routine physical examination for employment a cardiac murmur was heard. He was referred to me to evaluate him for fitness. I found that he had tight AS. 
I wrote in my report that he was not fit. He needed valve replacement. 
Three months later, the same young man, a non-citizen, came to me to re-evaluate him for fitness again. The young man told me that he had a high-ranking relative in the army. 
His relative was able to get the government of Qatar to send him for valve replacement in London so he could be employed as a soldier. 
He was sent to London before he had a chance to see Qatar.

 He stayed over two months in London for surgery and post- operative follow up. 
His treatment bills, tickets and daily allowance were paid for by Qatar.
 An Arab general surgeon, Dr. A. Yashruti, who worked in Qatar from 1976 to 1982, told me that he had operated on a Qatari lady in the American University of Beirut hospital in Lebanon just before he moved to Qatar.
 He told her that he would remove her abdominal stitches in Doha. The lady came to his clinic in Doha asking him to do her a favor.
 He was shocked when she asked him to refer her to London for removal of the stitches. He refused and offered to remove them for her on the spot but she did not agree.
 Two weeks later he saw the patient in a shopping area. She told him: 
"Your stitches fell down by themselves." In the first year of establishing a cardiology clinic in Qatar in 1979, I referred 55 patients abroad. Of those 23 (41%) had cardiac surgery. 
The number of patients coming to cardiology clinic increased in the following years and so did the number of patients I referred for genuine cardiac problems that I could not solve in Doha. 
Those were mainly patients with congenital heart disease and patients requiring surgical procedures. In a report I wrote in 1980 to justify the need to have cardiac surgery in Doha, which was opposed strongly by my colleagues in the surgical department, I found some interesting statistics.

 In the first 9 months of 1980, I had referred abroad a total of 75 cardiac patients. Of those, 68 (90%) had cardiac surgery.
 Of the surgical patients 29 (43%) had valve surgery; 31 CABG (45.5%); Eight patients (11.6%) had congenital heart surgery.
 It is amazing to see those data now since we do not see that many patients requiring valve surgery these days. It took me three more years of struggle before we succeeded in establishing a cardiac surgery section.
 We succeeded only after I became the managing director of the new Hamad General Hospital (HGH). In those days, the official working hours for Rumaillah hospital was from 7 AM to 1 PM. By 1:00 PM, all the medical staff went home – only patients and nurses on duty were left in the hospital.
 Even those on call went home at that time and could only be contacted by phone or bleep. The working hours were too short for me to finish my work. I made my own working hours then. I used to bring cold sandwiches from home for lunch in my office.
I scheduled outpatients to come to my office in the afternoon. 
We had no cardiology clinic building then.

One afternoon I saw a female patient in my office. She was on an examination coach while her old semi blind husband was sitting in a chair next to the coach. 
She was about 45 years old with muscloskeletal pain. I reassured her that she had no cardiac problem. Her husband who was in his late sixties pleaded to me to send her to London to make sure that she had no heart disease.
 He wanted also to be seen by an ophthalmologist in London while escorting his wife. He said that he was afraid that his wife may fall dead at home.
I told the husband that there was no need for referral and she was in no danger.
 He got very upset and started to tell me how cruel I was refusing to help a poor patient. While he was shouting, he suddenly became speechless.
 He looked pale and his head dropped foreword. I had no nurse with me. I asked the wife to get up and help. We carried him and put him on the coach.
 His pulse and respiration were fine. His BP was moderately elevated. 
He obviously had a stroke during rage and anger brought on by my refusal to send them abroad. I called for help to transfer him to the CCU as there was no MICU in our hospital then. He recovered partially during the first week, but he was sent to London by the medical department later for stroke rehabilitation with his wife as escort.

 Of course, my medical colleagues in the department of medicine and I felt sorry for him. The referral was due to sympathy rather than necessity.
 He did benefit from physiotherapy that could have been done in Doha.
His wife was reassured that she had no heart disease.
 Referral abroad without the approval of the medical board continued over the years. Higher authorities continued to send patients all over the world. 
Some ministers of health restricted their own referral of patients and some abused it. 
One minister sent a child abroad because the mother complained to him that his hair was not straight.
 The same minister, while walking in London’s Hyde park during the summer vacation, converted some Qatari tourists who greeted him in the park to “patients” on government expense to help with their expenses. Interestingly, the local newspapers’ criticism of the government health care becomes exaggerated when the weather warms up and decreases remarkably during the winter when people do not like to travel. 

Over the last ten years we established several new medical services in HMC that were not available before, such as in vitro fertilization (IVF), Pediatric cardiac surgery, invasive radiology, and advanced neurosurgery, etc.
 In 1993, we opened the IVF unit in HMC and stopped referring patients abroad for that purpose. 
In 1992, the year before we opened our IVF unit we sent 233 patients to London with husbands for such therapy that cost us 5,299,372.14 Sterling pound (QRS 27,556,735) for that year. 
Nowadays we send relatively very few patients abroad. 
Those who are sent abroad require specialized care, which is not yet available in Qatar, such as radiotherapy and electrophysiology testing for arrhythmia. The reason for our recent success in this regard is not only due to the advancement in our medical services but also due to the great support from HH the Amir of the State of Qatar, Sheikh Hamad Bin Khalifa Al Thani. He is well aware of the abroaditis problem that we face.

 He is convinced that the abuse of referral abroad hinders the progress of medical care in Qatar and wastes the State’s resources.
 He gave orders to restrict referral abroad to the special medical committee in Hamad Medical Cooperation. His Highness himself sets a good example.
 He rarely orders sending patients for treatment abroad directly. 
In the summer of 1979 there were 16000 "patients" and relatives from Qatar in London alone. In 1981, one year before we opened our new hospital (HGH) we had 10,324 Qatari patients in London. That number is actually one third of the total since I did not add the escorts. 
Recently, in June 6, 2001, Al Sharq Al Awsat, an Arabic newspaper based in London, wrote that in 1996 Qatar sent 1900 patients to London and in the year 2000 that number dropped to 190. Abroaditis is responding well to local therapy. 
Hopefully, it will soon be eradicated for good. Ali Ibn Abi Talib, a cousin and disciple of the prophet Mohammed, peace be upon him, said: "Seek travel. . . you may gain five benefits: Amusement, revenue, knowledge, character building and good companionship." In the 7th century AD, the phenomenon of treatment abroad was unknown to be added to that list.