Doctor's Review: Medicine on the Move

May 27, 2017
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Saudi German Hospital Group to Yemen

Many people have heard of the Queen of Sheba — either from the Old Testament reference of her meeting with King Solomon or from Handel’s oratorio, Solomon. But few realize that the word “Sheba” comes from the Arabic “Saba” and refers to the Sabaean kingdom in Southern Arabia, now known as Yemen.
    Yemen is one of the oldest centres of civilisation in the Middle East. Because of its fertile land and abundant rainfall, the Greek geographer Ptolemy dubbed the region “Happy Arabia.” During the Sabaean rule around 750 to 115 BCE, it was at the centre of the Incense Road which ran from the Eastern Mediterranean to India. The kingdom’s prosperity was based on the spice and aromatics trade — frankincense, myrrh, saffron, cumin and galbanum which made rich Yemeni merchants richer.
    Today, with a population of over 22 million, Yemen is the poorest country in the Middle East. The average annual income is US$380 per person and the unemployment rate is 35 percent.
    This past September, I had the opportunity to spend a week in this little-known and fascinating country, travelling from the inland capital south to the coast. I had been invited by Dr Jameel al-Ata, head of pediatric cardiology at the King Faisal Specialist Hospital and Research Centre in Jeddah in neighbouring Saudi Arabia.
    For most Yemenis, access to basic medical care is limited or non-existent. The infant mortality is 58.3 per 1000 (compared to just 4.6 per 1000 in Canada) and life expectancy is almost 18 years lower than ours, at 62.5 years. Expertise in pediatric cardiology is very limited and there are no pediatric cardiac surgery facilities.
    The trip was organized under the auspices of the Saudi German Hospitals Group, a private organization which operates eight facilities in the Arabian Peninsula and Egypt. The goal was to hold pediatric cardiology out-patient clinics and perform cardiac catheterisations at the group’s hospital in Sanaá, Yemen’s capital. The chief of pediatrics at their hospital in Jeddah, Dr Hesham Omar, accompanied me.     Arriving in Sanaá, a city of 2.2 million, we were met by Dr Nabil Bassouni Shehata, chief of pediatrics at the Saudi German Hospital. Opened in 2006, this modern facility is located north of the city near the airport. Yet access to the hospital is problematic for many, due to limited public transport.
    The next morning, I took my first trip into Sanaá’s bustling centre — quite an experience. The streets were filled with cars, minibuses, pedestrians, street vendors, goats and other four-legged animals all trying to reach their destination. The only traffic law seemed to be “whoever gets in first has the right of way.” There are no stop signs and certainly no white lines.
In spite of this, traffic moved at a surprisingly fast clip following a delicate choreography performed to the tune of constantly blowing horns. At some intersections, policemen perched on round pedestals managed to bring some order to the chaos. More than once, I thought we wouldn’t make it, but our chauffeur proved to be an exceptional driver who always knew when to go and when to give way.

KINGDOM COME
Ours was the first visit by a pediatric cardiology team. Local physicians had donated their time and the hospital reduced its fee to the minimum to give more patients access to care. In spite of having advertised our visit on the radio, TV and newspapers, the turnout was less than expected. But our presence did make a difference for most of those we saw in consultation. To our surprise, many parents told us that they were reluctant to accept the free medical care offered to their children.
    Later that day, we drove into the city and headed to Albeak Al-Shaibani restaurant for dinner. The menu consisted of traditional Yemeni dishes such as: aish mollaowah, a bread which looks like a large fluffy pizza crust; served warm, it’s addictive. There was also the national dish saltah, a meat broth with vegetables served with flat, flaky bread as well as other dishes of fish and beef liver and finally marsa, a ground-wheat bread mixed with bana­nas and honey: a pure delight! In Yemeni tradition, the dishes were put in the middle of the table and everyone helped themselves using their fingers.
    The next morning was spent seeing out-patients and performing echocardiograms. As in many hot countries, most businesses and services, including hospitals, close between 1pm and 4pm. During the break, Dr Saleem Al-Adroai, who was born and raised in Sanaá, took us around the Old City.
    According to legend, Sanaá was founded by Shem, Noah’s oldest son, at a spot chosen by a bird. The old fortified city dates back to the Sabaean dynasty 2500 years ago. This UNESCO World Heritage City is surrounded by six- to nine-metre-high clay walls and is home to over 100 mosques, among them the seventh-century al-Jami al-Kabir (the Great Mosque), one of the oldest in the Muslim world. There are also more than 6000 clay houses, most of which are decorated with elaborate friezes and stained-glass windows.
    During our tour, we were surprised by a sudden downpour and our guide took us into a century-old house which had been converted into an art gallery. After the rain subsided, we climbed the five stories to the flat rooftop for a panoramic view of the Old City. As we were leaving, I chatted in French with Mohammad who was studying French literature at the university and worked part-time at the art gallery.     On our way to the car, Dr Al-Adroai stopped in a bakery and came out with a few small, round whole-wheat buns called kodmas to hold us over until dinner, which was at least six hours away. We had to first return to the hospital for the evening out-patient clinic.

SOUK IT TO ME
The next day we returned to the Old City, entering through the 1000-year-old Bab Al-Yaman (Yemen gate), the only one remaining of the six which once provided access to the city. The sidewalks were filled with vendors sitting on the ground surrounded beside their goods in a chaotic scene which defies description.
    The central souk is subdivided into dozens of specialized markets, where you can find everything from raisins and dates to the ever-present jambiya. In Arabic, jambiya means “dagger,” but the term most often refers to a curved blade worn on a belt. For most men over the age of 14, it’s an important accessory that denotes a man’s status. They wear it at all times, except in a hospital or a court of law. A jambiya can cost anywhere from YER$500 (about $2.50) to millions. The most expensive have a saifani hilt, made from rhinoceros horn which can cost up to $1500 per kilogram.
    At one of the souk’s stalls, Dr She­hata gave us a demonstration of the art of bargaining; although I could not follow the Arabic, the spectacle was fascinating.
    A few hundred metres inside the main gate was the Souk Bab Al-Salam where I met 12-year-old Ibrahim who had learned English speaking with tourists. With an irresistible smile, he told me that chewing qat was bad for one’s health and that he wanted to be an airline pilot or doctor when he grew up.
    The next morning at 7am, the driver we’d hired the night before was waiting in front of the hospital to take us to the city of Ibb. On our way south through the capital, we saw the city come alive: children walking to school, men sitting in the middle of roundabouts hoping to be hired for the day, rows of motorcycle-taxis waiting for customers and herds of goat crossing busy streets.
    South of the city, the road followed the plateau between the two mountain ridges that surround Sanaá. As we ascended to 3200 metres, we passed roadside vendors selling huge squash and qat.

THE CALL OF QAT
Qat-chewing is an integral part of society and distinguishes the Yemenis from other Arabs. The leaves of this plant contain three alcoholides which are mild stimulants; the WHO considers it to have amphetamine-like properties. It’s estimated that three quarters of the adult population chew qat every afternoon.
    The daily life of Yemeni men revolves around qat: in the morning, buying the leaves and deciding where to meet for the afternoon chew and spending most of the afternoon sitting in groups chewing the leaves. Women chew qat nearly as much but in separate quarters. It’s estimated that qat accounts for 30 percent of the country’s domestic economy. Yemenis spend as much as 30 percent of their income on qat. Even the least fortunate who have to choose between buying qat or food for their family, will buy qat.
    After the mountain pass, the road descended towards Dhamar, a very busy mid-size town halfway between Sanaá and Ibb, where we stopped for tea. After­­wards, the road ascended again, running along the mountain side, offering magnificent views of the valleys below with villages hanging off the cliffs or nestled on the top of small hills in what seem to be inaccessible locations. There were ubiquitous qat vendors, standing on the roadside in front of their little stone huts.
    At the entrance to Ibb we said goodbye to our driver; the fare for the 200-kilometre ride between Sanaá and Ibb was $45! We were met by Dr Al-Boraihy who was going to be our guide for the rest of the journey. This ENT specialist-turned-businessman owns two hospitals in Yemen, one in Taizz, the other in Aden. He took time off from his busy schedule to show us around both cities, while answering a near-incessant stream of incoming calls on his two cellphones.
    The Ibb Governorate sits at 2500 metres above sea level and has a population of two million spread over 20 districts. With an annual rainfall of 1500 millimetres, the area is renowned for its lush flora and has been dubbed the Green Governorate.

LIGHTS IN THE HILLS
We only caught a glimpse of Ibb before making our way after lunch towards Taizz. The 50-kilometre drive between the two cities offered more splendid scenery as the road descended towards the costal plain. Built on a number of hills, Taizz is a buzzing city with a population of 2.5 million. Our guide took us for delicious fresh lime juice at a small restaurant perched on a hill offering a panoramic view of the city. Our next stop was the Al-Qahirah castle, currently under renovation, which was part of the wall which encircled the city as recently as 50 years ago.
    We stopped at the Jabal Saber Hotel, where we found the terrace filled with young people of both sexes and families enjoying the early evening breeze and the view of the city below. The hotel recently re-opened as part of France’s Accor chain. Its rates are surprisingly low, given its location and its exceptional view of the city. After sunset, the lights in the houses perched on the nearby hills transformed it into a scene worthy of The Thousand and One Nights.
    It was past 9pm when, following a delicious and copious dinner at Dr Al-Boraihy’s home, we set off for the 150- kilometre drive to Aden. This two-and-a-half-hour drive was certainly the lowest point of our trip. In spite of the concerns of family and friends back home and despite the warning on the Canadian Foreign Affairs website, the only time during my stay that I felt my safety was at risk was during that late-night drive — and it wasn’t because I was worried about being kidnapped!

COASTAL EDEN
Aden is the southernmost city in Yemen. Because of its strategic location near the strait of Bab Al-Mandab which connects the Red Sea and the Arabian Sea, it was coveted and conquered by many: first by Muslim Arabs from the seventh to the 16th century, then by Ottomans from 1538 to 1839, at which point it was captured by the British.
    In 1937, it became a crown colony known as the Aden Protectorate. In 1967, the People’s Republic of Southern Yemen (South Yemen) was established and Aden became its capital. In December 1970, the country changed its name to the People’s Democratic Republic of Yemen and became the only communist state in the Arab world.
    In 1990, the People’s Democratic Republic of Yemen and the Yemen Arab Republic (North Yemen) were unified. Aden was designated as the economic capital of the new republic, and Sanaá became its political capital. Aden suffered significant damage during the civil war which shook the country in 1994. The city’s current population is slightly over half a million.
    Visiting Aden felt like travelling in a different country. Traffic was not only lighter but also much less chaotic and most areas of the city were cleaner and quieter than elsewhere in Yemen.
    The city is built on two peninsulas, Aden and Little Aden, which are linked by an isthmus. Most of the population lives in the Aden peninsula which is divided into districts. In the Crater district, where French poet Arthur Rimbaud lived in the 1880s, you can still see and feel the British influence. On the other side of town, in the small fishing village at the northwestern tip of Little Aden, you feel you’ve been thrown back in time 100 years.
    Before lunch, our guide took us to the Tanks. The origin of these huge reservoirs is still unknown. According to a plaque erected near, they were discovered in 1854 by a British lieutenant. Their purpose is to slow and canalize the large quantities of water that come down from the surrounding mountains during the rainy season. They cover a large area and look like a series of pools dug out in a stepwise arrangement so that the water can cascade down from one pool to the other.
    Our short visit to Aden ended at the fish market where, after more bargaining on the part of Dr Shehata, we bought a freshly caught grouper. We then took it a few hundred metres down the street to an open-air restaurant where the cook prepared it for us: some parts fried, others grilled. The flavour and the freshness of the fish more than made up for the shabby decor and the less than optimal cleanliness of the venue.
    An hour later, the bones and the eyes were all that was left of the five-kilogram grouper. After a short rest at the hotel and a visit to Dr Al-Boraihy’s hospital, it was time to fly back to Sanaá where the cool early evening air was a welcome relief from Aden’s hot and humid climate.

ROCK OF AGES
On our last day in Yemen, we drove a few minutes north of Sanaá to Wadi Dhar, a six-kilometre valley considered one of the finest in the country. The view from the top of the adjacent cliffs was spectacular.
    By chance, we came upon a wedding party and joined a circle of men watching two men perform a traditional wedding dance, barefoot with jambiyas drawn. We also met a falcon trainer who let me have my picture taken while holding his bird.
    Down in the valley was what we had come to see: the Dar Alhajr, the rock palace which is probably the most photographed building in all of Yemen. Built in the 18th century, this dramatic castle is built on top a high limestone formation. It was restored in 1930 and is now used by the government to host special events. It is open daily to the public and contains many artifacts depicting the life of its original inhabitants.
    For a visitor who has more time to spend in Yemen, the country has much more to offer: to the west, the narrow coastal plain of Tihamah, where houses and inhabitants resemble those of the African countries on the other side of the Red Sea; to the southeast, the fertile Wadi Hadhramaut; and for the truly adventurous traveller, to the northeast the Rub’ al Khali (the empty quarter), a desert area that merges with Saudi Arabia across an undefined border.
    If my wish comes true, I will have more tails to tell from these regions. Until then, besides the spectacular landscapes of the countryside and the architectural beauty of Old Sanaá, my fondest memories of this short visit to Yemen is the hospitality and joie de vivre of its people. This country still deserves the designation of Happy Arabia, but for a different reason.

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