Wednesday, October 8, 2003
Nothing happens in rural Iraq unless one is willing to meet and be greeted by all the relevant elders and people of influence in the area.
Being in relationship with people of influence and stature is key to day-to-day survival for the average Iraqi and must be honored at almost any cost. Oh, and tea. It helps if you can drink a lot of tea. As a volunteer for Northwest Medical Teams, I had the privilege of encountering this cultural paradigm in northwestern Iraq.
Based out of Sinjar (near the border with Syria), a town about the size of my hometown, Hood River, my interpreter and I traveled daily to outlying villages to perform health assessments and conduct clinics. We would find the local health center (or if it had been looted, its burned out remains) and ask where the sheik lived so as to introduce ourselves and begin the process of gathering information and dispensing health care.
On this particular day, I arrived unannounced at the home of the sheik and was warmly greeted by him, his extended family and his friends. In the post-war nether-world that is Iraq, few of the men in these rural communities have gainful employment, so they sit, smoke, drink tea and wait. As per usual, I was soon discussing the current situation in the village, in this case Haardan, with about 100 men, all of us seated on cushions in a long, narrow meeting room. I was seated next to the village rulers flanked by my interpreter, Basil, as we discussed the many parameters of this community’s health.
Historically, Haardan had been relocated and “Arabized” like many of the villages in this district. Over a generation, the village had been moved away from a reliable source of water and re-settled by many people displaced from their native villages, ultimately forcing them to rely on the vagaries of the Ba’ath Party for survival. Or so the story usually went.
Unlike western cultures where we pride ourselves on relating the truth with precision (we call it integrity), sometimes at the the expense of relationship, my hosts took great pains to express themselves such that many parallel agendas were met. It soon became clear that, while there was no disaster, a crisis still existed.
Among the men in the room that day was a nurse who had been the sole, consistent medical presence in the village for 20 years. He knew everyone in the village and was regarded as one of its most treasured assets. Doctors had been assigned to Haardan over the years, but had never stayed longer than four months. This nurse was a native son and was now out of a job. The saga went something like this: the health administrator for the Sinjar district, my immediate supervisor, had asked a colleague to help in the administration of the district’s northern sector in which Haardan was located. Apparently this colleague was a member of the now banned Ba’ath Party and appointed a low-level party hack to be the nurse of Haardan. Now the currency of health care in this area of Iraq is medication. It wasn’t unusual for a patient to be given five medicines, at no cost, for a common respiratory infection. This nurse appointee allegedly removed the medication from the health center and was selling it out of his home. (I subsequently visited the center and noted that not all the medicine was removed. Remember: relationship over truth.) Would I please intervene, as an American doctor, and convince the medical establishment in Sinjar that the people of Haardan want their nurse back?
Thinking fast, I blurted, “How about an exercise in representative government?” Basil said he couldn’t translate. “Democracy,” I said. Basil blanched. It didn’t need translation. Immediately everyone started talking at once, and loudly. Basil seized the moment. As a retired colonel in the Iraqi Air Force, he could still project. He demanded silence as I proposed a first exercise in democracy, a petition. “The word of 100 men Haardan is worth more than the word of one bald American doctor,” I declared. Laughter, whew!
A sheet of paper was produced, a narrative was composed at the top, and the nurse nervously began to write the names of those present in the room. “It is better if you sign your name!” I shouted over the din. “Sir!” Basil leaned in. “If they don’t sign their names, then they can deny they ever agreed with the petition.” Deniability. These guys were farther along the political curve than I thought. “There is no risk in signing your name, and the petition will carry more weight if you do,” I shouted. Silence.
As this, the very first moment of realization that each man’s signature, his “vote,” was of equal value, I saw a lightness of being emerge. That giddy sense that comes when, out of the blue, life begins to work for no apparent reason. Men signed their name or made their mark with broad smiles and that silly laughter reserved for new-found love. They were free of the harsh consequences of self-initiation and felt empowered. It was intoxicating. “I can’t promise you that you will get the result you want. Democracy at its best is about compromise!” I actually said this. No matter, they sensed that, for the first time, no harm would come to them for simply expressing their opinion.
The next day I presented the petition to Dr. Kefa, my host and supervisor. Through misty eyes he contemplated what he was reading. Captain Bret Tecklenburg of the 101st Airborne Division, the Commanding Officer of Sinjar, also received the petition. He gave me a satisfied smile and assured me that he would discuss it with Kefa and share this small step towards empowerment with his platoon sergeants and the other members of Bravo Company. The result: party hack out, nurse back in. Better still, the colleague was informed that a new paradigm was in place and was not disciplined any further. It seems relationships cause one to be pragmatic.
The rest of my time in Iraq will be remembered for the cases of Duchenne muscular dystrophy (seems I make this diagnosis only on these assignments), Down’s Syndrome and other genetic disorders (some of the family trees are fairly vertical), the staggering slope of pathology there, and the delivery of a breech baby on the sidewalk in front of the hospital (another long story). But this particular mission will be remembered for the lesson in Civics 101 that I taught, and was taught, that day in Haardan.
I hope that we as a people have the energy, and our government the attention span, to continue these lessons so the Iraqis can experiment with representative governance, make some mistakes and ultimately succeed.
It will be a challenge for us to remember that this next phase can’t simply be about being right. Iraq will have a greater chance of success if we approach this as they would, through the covenant of relationship.
Dr. Michael Pendleton, who has a general practice in Hood River, spent a month in Iraq in the spring of 2003, approximately a year-and-a-half after a similar medical mission to Afghanistan.
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