Friday, March 25, 2011

Embacing ambiguity....

I have heard about culture shock, and in fact, I was told I would experience when I made the decision to move.  I thought it was probably some psychobabble rhetoric that wouldn’t really affect me.  I have always considered myself pretty tough and determined enough to survive most anything.  Culture shock can be described in stages:  honeymoon phase, negotiation phase, adjustment phase, and mastery phase.  These phases can be described essentially just like you might think from the name of the phase. 
I arrived, obviously in the honeymoon phase.  Everything was magical, fascinating, different, and exciting.  In the negotiation phase the differences between the old and the new culture become more apparent and can create anxiety.  Language barriers, extreme differences in public hygiene, traffic safety, differences in types and availability of food all lead to a heightened sense of disconnection and ultimately a sense of frustration.
After much deliberation to include gnashing of teeth I decided I really need to have a car.  I have been very blessed by a couple that barely new me and loaned me their car for a month while they were back home in the States on holiday.  It has been wonderful having a sense of freedom even though I can only drive as far as the main gates of the compound.  Buying more than a handful of groceries or running home at lunch becomes very simple with a car. 
I carefully reviewed the classified ads on the company intranet page and ruled out all cars that were over 15 years old, had more than 285K kilometers, or cost over 15,000 SAR (approximately 5,000 USD).  I also had several people looking through word of mouth for me but I also ruled out large vans and makes of cars I knew to be unreliable.  This obviously meant that my choices were limited.  I found a relatively new car (2006) with low mileage (26,000 miles) in my price range and decided that was the one.  A nice Filipino man was selling the car and we agreed to meet so I could view and test drive it.  I decided it was perfect:  small, peppy, clean, well maintained and best of all BLUE!
This is where my story really begins.  You must remember that women are not allowed to drive in Saudi.  The company I work for is the ONLY company in the country that allows women to drive on the compound.  No other compounds allow women to drive and women are forbidden to driveoutside.  To buy the car, I would have to go with the Filipino man and his brother (who really owns the car) into Khobar to a used car dealer who would complete the paper work and make the title exchange.  I  already understood that I would be buying this car on faith – I didn’t have my husband here to give it a thorough once over, I couldn’t reach a mechanic that might check it over…I was assured that Filipinos take great pride in their cars and so this car had probably been very well maintained.  I would also have to go to a strange place in a car with a man I don’t know – something I would never even consider doing at home!!
Khobar is a fairly big city by Saudi standards.  There is a lot of traffic especially at night and we were headed into the beginning of the weekend as well.  Driving is Saudi is an experience unto its own.  Imagine being live in the game Grand Theft Auto.  Cars flying by you in all directions, speed is not a consideration, and traffic rules don’t exist!  I couldn’t watch – I was so terrified that we would be killed by another car I wasn’t even concerned that this stranger might harm me in some other way.  We were driving fast, tailgating, dodging in and out of lanes, slamming on breaks, and the crazy thing is that is normal.
We arrived at the car dealer in a terrible part of town, burned out buildings, rubble all around and I realized, I am somewhere very strange to me and I am not sure I like this.  The owner of the shop, a large Saudi man with a straggly beard, wearing a dingy white thobe and gutra greeted us by announcing “women are like snakes, they should all be killed!  I have had 2 or 3 wives and none of them were any good”.   I looked at the 3 other Saudi men behind the counter, they were not smiling, and I just laughed to myself.  I thought, “how crazy is this, I can’t believe he just said that!”.  Some paper shuffling, a little shouting, and a few hundred SAR(money) later I left with the two Filipino men having signed the car over to me.  Back into the crazy traffic for the ride “home”.
Morning came very early.  I was heading to the desert to see camels and have a picnic and after my night I really wanted to be headed to the airport.  I called my husband for a quick word of reassurance and burst into tears.  As I climbed aboard the bus that looks like a giant green and white caterpillar, the tour guide asked me, “Are you crying?” I said “no” and put my sunglasses on. 
We stopped at a coffee shop to use the toilets and get coffee or tea or water.  I had to remember that the entrance for women is at the back of the shop and I could see from the door it wasn’t a place I would be ordering anything from.  It made my worst Waffle House experience seem like 5 star dining.  I decided I would just use the toilet instead.  To say it was a typical gas station bathroom is an understatement.  I didn’t see any way I could maneuver my abaya, slacks, personal garments and take care of business over an open trough.  But, as they say, “you gotta do what you gotta do”, so I did.
Our first stop was a camel market.  Camel reigns, camel saddles, camel blankets, camel bags and camel milk.  It was most interesting.  Here I was reminded of why I don’t run screaming back to the US.  The souks are filled with sights and smells never seen before.  The fully veiled women are warm and kind and inviting to talk with Western women.  I have learned about 20 Arabic words so far, enough to say hello, how much, thank you, I am new here, and good-bye.  I feel a connection and am reminded that these are women not so different from me.  They have families, husbands, children and they are all doing a honest day’s work to help support those they love.  They are very proud of their crafts and anxious to show anyone that will take a look.  The men speak more English and are enjoying the sight of Western women with their hair and faces exposed.  They want us to take their pictures and to tell them where we are from.  They are also selling such things as dates, spices, goats, etc.  The spice souks are filled with fragrant, sweet, exotic smells that remind me of the kitchen when I was growing up.  There are stalls filled with beautiful fabrics: silk, linen, cotton in vibrant colors of yellow, red, purple, orange, green and many shades of blue.  I use this as a chance to practice saying my colors in Arabic.
With our camel prods, camel bags, carpets, tea pots and other treasures stowed safely under the bus we head off to our next stop.  A quick stop at a restaurant in Nyria to pick up lunch and we arrive for what is supposed to be a brief 15 minute visit at a camel farm.  There are camels of all sizes and colors and camels are really interesting animals.  They are very curious and were not afraid at all to come close to be petted or photographed or fed. Some camels would be sold to be butchered and eaten and some would be sold to produce more camels.  They were priced as high as 150,000 SAR (approximately 40,000 USD)!  The Saudi farmer that owned the camels was proud to show us the father of the entire heard.  This camel had free reign to roam the area as he pleased.  The herd was surprisingly well maintained and appeared to be well fed.  And by now I was settling into a rhythm that yesterday seemed totally strange and in some ways frightening, but today is another day that is equally as strange in many ways.
Our trip concluded with lunch at some type of governor’s building.  I really wasn’t able to figure out what the place was but we had a place to wash our hands with soap and running water so I was happy!  The toilets were no better than the first stop but I had also learned to manage my personal needs by this time!
Shoes off, lunch in hand, I enter a big hall with Persian carpets on the floor and understand this is the table.  We all sit along the carpets and enjoy our lunch of hummus, muttabol, grape leaves, tandoori chicken and beef, and Arabic rice with flat bread.  After lunch we move to another hall for tea, coffee and dates.  Three young Saudis arrive with their falcon and the room is buzzing as we all get a chance to have a photo taken of us holding the falcon.  These birds are used for hunting and I enjoy learning about this using my new female Saudi friend to translate my questions and introduce me to new Arabic words.  A coke and a bottle of water mean another trip to the loo but by now I am resigned.  Sufficiently full of both food and culture, I climb back on the bus for the long ride to the compound.
It’s hard being somewhere new and strange where people don’t speak your language and nothing makes any sense.  Time has no meaning, what could be done at home in 30 minutes sometimes take hours here, and every day is filled with ambiguity.  My son reminded me that much of the world operates more like this than the US.  I chuckle and think about how uptight I can be when time and structure are not perfectly in place.  I feel this is a journey filled with ambiguity and I am learning to embrace it.

Friday, March 18, 2011

A day in life….

The hospital is not unlike any hospital in the United States.  Its original building consisted of a single story laid out something like a ranch house that extended approximately a city block.  The building housed some clinics, inpatient units and associated buildings.  Built in the early 1940s, it was very similar to the US hospitals built around that same time.  As times changed, technology evolved and the need for services expanded the original building expanded as well.  It has become as maze of hallways, crosswalks, and buildings built adjacent to and around the original Dhahran Health Center, now known as the Saudi Aramco Medical Services Organization or SAMSO.  The complex now covers approximately 2 square miles of the camp.
Every day the halls are filled with people in all shapes and sizes from all cultures dressed in everything from the traditional Saudi thobe and abaya to the orange jumpsuits of the Bangladeshi groundskeepers and the blue jumpsuits of the Sri Lankan or Filipino housekeepers.  The uniforms are culturally appropriate and supplied by the company.  This means that while nurses for the most part are dressed in white, it might be a white abaya with white nijab (scarf) and veil or it might be just plain with scrubs.  Some scrubs are long sleeved and the majority of the Muslim caregivers wear a head covering.  The physicians typically dress in western slacks/dress shirts but it would not be out of the question to see someone dressed in a thobe and gutra.  Although I haven’t become familiar enough with the different regions, you can tell the caregivers that are Saudi versus Egyptian or Lebanese by the way they wrap their scarf. 
Nursing units are much like the nursing units in the United States.  Since the entire company of Aramco is built on a US Military model, most everything looks and feels like the US.  Signage is in both English and Arabic and all signs are basically the same size, shape and color making finding your way around quite difficult.  Staffing on the units is a mixture of nurses from around the world.  You might see a floor staffed with nurses from Saudi, Eqypt, South Africa, the UK (England, Scotland or Ireland or all of these), Norway and the Philippines all working side by side together.   While that might seem idyllic, it really is quite challenging.  The language that is used throughout all of Aramco is English.  That too would seem idyllic until you begin to realize that English takes many forms!  The different accents, dialects, colloquialisms, and general understanding of the language make communicating very difficult.  For the most part the different cultures result to their native language to accomplish communication when possible and always for personal communications.  Each patient room is equipped with signage indicating the direction for prayer and prayer rugs.  Prayer is announced 5 times daily and patients, families and healthcare workers are permitted to participate.  There is a male and female mosque located in the hospital for payer as well.    Essential employees have to make arrangements to leave patients in the care of someone else if they go to pray and although prayer is announced the basic work of caring for patients does not stop to observe it.

Nurses are easily identified from other healthcare workers because each discipline has a dress code that by either style of dress or color makes them easy to identify.  However, the cultural expectations of what nurses do and what the practice of nursing is varies greatly, especially among the patients.  For example, many Saudi families have hired workers such as housekeepers, drivers, gardeners, etc.  When a Filipino nurse in a white uniform enters the room, a male Saudi patient perceives them to be the “housekeeper” and will often treat them accordingly.  There is also a cultural expectation by many of the different cultures that the nurses are there to do everything for them so patient participation in the care can be very challenging to say the least!  Adding to the complexity of care is the societal norm that men and women should be separated.  Men do not look at women, other than their wife, so when nurses try to teach male patients or even assess them, the man will most likely be looking at the wall or the ceiling.
Every Aramco employee is assigned an ID Badge number.  It is the first form of identification you receive and it could be considered equivalent to our Social Security number.  If you need maintenance done to your house you must first provide your badge number, if you want to make an appointment at the clinic you will need your badge number, if you come on camp in a taxi you will be asked to provide your badge number since the cab driver is your responsibility while he is on camp.  Additionally, all dependents of the employee use the badge number for identification.  In the US we have a requirement to identify patients using 2 identifiers before any care or treatment is provided.  The same is required here but the challenge is determining what 2 identifiers.  Saudis use the lunar or Hijri calendar for all important dates such as expiration dates of such things as your iqama (resident card), your passport, your birthday, etc.  It is common for the US to use the patient’s name and birthdate for the 2 identifiers.  Here, those are meaningless.  Islamic names are passed down from generation to generation, so it is not unusual for several people in the family to have the same or very similar first names.  Men are frequently named after the Prophet or associates of the Prophet.  And last names are formed by combining your mother’s maiden name and your father’s name – I don’t profess to really understand the exact nature of how this works but suffice it to say names can be very confusing and birthdates are not in a convention that relates to the Western calendar dates.  Women don’t drive, therefore have no driver’s license and since in the most extremely religious situations women are not allowed to have their face be seen, they also have no photo ID.  I think you can see where this is going, positive identification of patients is a challenge and a solution is very complex and cannot be based on a western model.
The cafeteria is a vibrant place that is perfect for people watching and experiencing the subtleties of all different cultures.  Food lines consist of lines for vegetarian food like stews or Indian dishes made without meat, traditional Arabic food such as rice, tandoori kabobs, and stews of lamb or chicken, traditional Western food such as beef wellington or roast chicken, a salad bar with all the trimmings to include hummus and a roasted eggplant spread that is similar to hummus and very tasty.  There is also a Joffery’s Coffee shop – the Arabic equivalent of Starbucks!  Coffee and tea are very important to the daily life here and coffee/tea kiosks can be found in every public area of the hospital.  Drinking coffee or tea and socializing is a popular pastime for men and women here in the Kingdom – just not men and women together!
As I close in on my first month in the Kingdom I am struck by one very important concept:  nothing is as it seems here.  Just when you think you have something figured out, there are 10 other reasons it doesn’t really work like you thought!  The people here are incredibly kind and generous.  Even though we all speak different languages, have different religious beliefs, wear different clothes and prefer different food, somehow it works.  It isn’t perfect, but people eat together, socialize together, look after each other and in general put their differences aside to make a difference for their patients.    

Friday, March 11, 2011

A city of contrasts....

I wander through the narrow, crowded streets of Khobar, filled with western women that have made a token gesture by throwing on an abaya over their shorts or jeans and t-shirts.  The streets are lined with suqs or open air shops that carry things such as kitchen and household appliances, fabric, watches, souvenirs, gold, rugs and other trinkets imported from places like India or Iran.  Freshly slaughtered goats with their heads still attached hang in the windows of the butcher.  The cars are everywhere and people drive manically, disregarding other cars or pedestrians or bicycles or anything else for that matter.  Open air cafes are dotted along the way and mostly men in their thobe and checkered ghutra sit outside drinking coffee in the soft morning breeze.  We stop in to a local bakery for breakfast, remembering to enter in the family section; an area dived by a wall that separates women and children from single men.  We place an order for fatir, a kind of flat bread spread with a thick yogurt called labneh and honey.
After breakfast we head off to the gold suqs to sell some old pieces and by new ones.  This is a common habit of most of the expats that have lived here for any length of time.  Collecting gold jewelry is more of a pastime than really thinking of it as anything of value to be treasured.  Gold of all shapes and sizes, fancy and plain, bracelets, bangles, necklaces, earrings, rings, beads, everything you could imagine is out on display.  Find what you like, it is simply weighed and priced at the going market price for gold per kilogram for that day.  Pieces are laid out for inspection without a care about it being stolen.  Shoplifting is highly unlikely since those convicted pay a stiff price by having their right hand chopped off!
The mall is very large, new, and very clean and shiny.  It has many US stores and restaurants.  There is a go cart track for the children and several places for them to play.  The smell of frankincense and myrrh waft out of shops that we pass.  We are watching the clock – timing is everything here because the prayer times dictate our schedule.  We need to finish our shopping and be seated in a restaurant before the call to prayer.  During prayer, shops close, workers leave, nothing happens like ordering food or checking out groceries until prayer ends.  We manage to just slip into our table before the exotic, rhythmic voice begins to chant.  There is a mosque in or near every public building.  There is a mosque at the hospital and for patients too sick to go to the mosque, every room has a diagram showing the direction for prayer and prayer rugs are found in every conference room, patient room and nurses’ station.  We enjoy our lemon juice with mint drinks and hummus as we wait to place our order.
The mosque is filled with men on hands and knees.  Sandals are parked like cars in a parking lot – all shapes, sizes and colors in a sort of order only they make sense of.  Again, women and men are separated.  The many families continue to filter through the mall waiting for normal shopping to resume.  Men carry the smaller children while the women follow behind, covered from head to toe in black abayas and hijabs, their eyes are often the only part of them you can see.   Prayer can last about 15 minutes or up to 30 minutes depending on the time of day.  In either case, the end of prayer is announced over the loud speaker and people resume their normal activity, including taking our food order.
Fellowship on the camp is held in a gym at a school.  Portable chairs, bleachers and a makeshift podium are there.  As I walk through the gates, a Muslim security guard greets me with a friendly smile “salam” or hello.  People are coming from all directions to join the worship.  There was a picnic yesterday to celebrate missions day so there is an extra sense of excitement in the air. The gym is filled with people from around the globe.  African women in the tribal dresses of bright green and orange, blue, and yellow – and their heads donned with pieces of matching fabric wound into tall hat like coverings.  Indian women in the elegant silk saris of rich purples and magentas and greens all trimmed in gold.  Western and European women dressed in all sorts of fashion ranging from blue jeans to sun dresses.  Men dressed in suits and ties, shirts and slacks, jeans and t-shirts.   Here there is no segregation.  We all sit together and worship as one.   There are Methodists, Baptists, Presbyterians – all there worshiping the L*rd – singing new praise and worship music and old hymns and music from their own country in their own language. 
The warm gentle breeze blows through the window, making the palm trees rustle outside my window as the morning doves begin to coo.  Birds of all sorts that I have never seen before begin their morning wake up call.  The sun is barely peeking over the horizon and I am hovering in the sweet place of not quite asleep yet not really awake.  Strains of the rhythmic chants float into the room and the call to prayer begins again.  I drift back to sleep to dream about my week – and wonder what surprises tomorrow will hold.

Thursday, March 3, 2011

Parties, clubs, shopping and more.....

Another week – it went by so quickly!  Time seems to go really fast here….I’m not sure why exactly.  It could be because I am not waiting all week for Saturday – since Saturday is another workday here….I get Thursday and Friday off as my weekend and since I am still not used to the days I never really know what day it is : )   I have the time down and I am over my jet lag though.  It took really almost a week to stop waking up at 3 am and wanting to go to sleep at 4 pm!!
I still haven’t really started work.  This week was spent with some consultants from Joint Commission International – doing a mock Joint Commission Survey.   For my non-healthcare friends, the Joint Commission is sort of like the Good Housekeeping Seal of Approval for hospitals.  It really doesn’t mean a whole lot but most hospitals have the accreditation and wouldn’t think of not having it.  It involves a survey team coming to the hospital every three years and looking stem to stern to be sure their standards are met and everything in the hospital seems in order.  The big difference is the International Standards book is about an inch thick and the Standards book used in the states is about 4 inches thick.  For my healthcare friends, I can say all the additional standards really make no difference and the issues in the states are the issues here….unsecured medications, the occasional expired something, lack of communication between healthcare team members, care plans that aren’t individualized, etc…..
Surprisingly, the hospital looked pretty good to me overall.  It is probably the cleanest place I have ever seen – every bathroom, corner, closet, floor is spotless!  It is also pretty well maintained and has all of the state of the art equipment – in fact, they have things they probably don’t need - like a panoramic x-ray machine in the ER!  Everyone I have met is exceptionally nice, including the doctors.  The nurses are from everywhere but a lot are from the Philippines.  They seem pretty knowledgeable but language is definitely a barrier.
Last week, I met some new friends from the states, a married couple from San Diego.  They both work for Aramco, she is a nurse and he works for the “Core” (meaning the oil side) in finance.  They have a lovely home on camp and they were leaving for a month for what is called “repat” leave.  Every year within 3 months of your anniversary date you have to take at least 14 days leave out of the country.  If you add up the travel days and other things is really comes closer to 3 weeks.  So, since they were going to be gone a month they loaned me their car.  That has been a real treat!!!  I was worried about a driver’s license, only to learn that since women can’t legally drive in Saudi we are all driving illegally so a driver’s license isn’t needed.  Also, in case of an accident, the cars are insured and the owner of the car will be issued points that affect their annual safety award!!  This camp is really bigger than I thought and getting around by bus isn’t as easy as they made it sound in the orientation so I am enjoying my freedom (sort of!).
The camp is beautiful and the weather has been fantastic!  It has been sunny and warm during the day and cool with a lovely breeze at night.  Just perfect for sleeping with the door walls open.  There are flowers, palm trees, green grass and parks everywhere!  I just live about 50 feet from the golf course so I have been enjoying my evening walks on the trail that goes around it. 
My co-worker, Valerie, has been good to show me around and introduce me to people.  I have decided to join the Scuba diving club and look forward to getting certified.  Diving in the Red Sea is very popular and the fish are beautiful!  There are also some islands in the south on the Gulf that have lovely diving and the fish there are really interesting too.  The dive club meets once a month and someone gives a little presentation on one of the dives.  This week was about whale sharks – and that was spectacular!!  These are huge fish, they don’t bite and they are relatively rare.   I also went to a birthday party for a guy I met at the dive club.  He and his wife have been here, left, and just come back.  They have a sweet little baby girl.  The party was fun – just like a party at home complete with ***!!  They also had a “Shwarma dude”  -  that is what they call the chicken or lamb that is grilled on a spit kind of thing and then sliced off and rolled in a flat bread with tomatoes, garlic sauce and pickles.  It is really good!!  So think of a catered party with a **** -  just like home!!
I’ve missed everybody this week.  It has also been a little frustrating trying to figure out where I want to go, how to go there, how to do the things I need to do….in some ways like anytime you move, it’s all new.  But here, it’s all different too!!  Nothing really works like it did at home – there isn’t a WalMart and I can’t just jump in my car when I want to go to the mall because I am bored or lonely : )  I have to remember my abeya if I go into town (a long black robe thing the women have to wear) and I can only go in the “family doors” and “family sections” – the other are reserved for men.  But I think I am going to like this place – I am going to learn to balance work with the rest of my life and I am going to have a chance to learn some new things.  I can already hear some of you saying “ yeah, sure, you have only been there 2 weeks” but, there is a vibe here that is different.  I can’t explain it yet but I am confident I will be able to one day…..they call it the “Magic Kingdom”!!!