Earlier Thoughts

Monday, June 6, 2011

From the Daily Mail - 'From now, embarrassment will end': Saudi King bans men from selling lingerie

He's probably not the first person you would have on your mind as being the face of lingerie, but King Abdullah of Saudi Arabia has become something of a hero to women in his home country.  He has issued a decree banning all men from working in lingerie shops to end 'embarrassment' suffered by women who don't want to give men their measurements.

Saudi women working in the outlets got embroiled in a dispute three years ago with the labour ministry and the powerful religious authority, which issued a fatwa banning such jobs.  The decree from the king was part of a push to reduce the amount of female unemployment in the conservative kingdom, currently at around 30 per cent.  Saudi women say they have been uncomfortable buying lingerie from men and would prefer female sales assistants.

Fatima Garub, founder of a Facebook campaign called 'Enough Embarrassment', backed the king's decision saying it would create about 6,000 jobs for Saudi women.  'From now, embarrassment will end,' she said. 'We thank the king who felt our problem and took the decision that we have been waiting for a long time.'

In February last year, campaigners urged women to boycott lingerie shops with male staff for two week.  They said that women should not have to give their measurements to men they don't know because it contradicted Muslim law. Islamic scholars backed the boycott.
Religious leaders in the Wahhabi form of Islam - which makes up the majority of the country - require complete separation of members of the opposite sex who are not related.  The Saudi society continues to be incredibly traditional and the idea of women working is frowned upon.

Sunday, May 8, 2011

I told my psychiatrist...

“I told my psychiatrist that everyone hates me. He said I was being ridiculous - everyone hasn't met me yet.”

Rodney Dangerfield, 1921 - 2004

I remember seeing Rodney Dangerfield on the television in the 1960s and recall very clearly his signature line, “I don’t get no respect.”   His sense of timing and self-deprecating humor was clearly what made him enduring and damn funny.  But, it is his one-liners, always a bit on the dark side of humor, that ring true for me.  Today, about seven years after his death and still more years after his career peaked, Rodney is staring at me in the mirror and there is a crowd of expatriates staring back.
The Middle East has been in open unrest during the last four months.  Yemen, Syria, Jordan, Bahrain, Oman, Egypt, and Libya have witnessed the people revolting against their governments, demanding change.  Not all of these peoples have a clear view of what the desired end-state would look like at the end of the current revolt.  The violent actions of governments to suppress the people continue to cause injury and death.  The leaders in this part of the world are scared and willing to do anything to retain power.  A lot of promises have been made by the involved governments that hope to bribe their way out of the current situation.  It appears that most of these promises have yet to be fulfilled. Will the people wear out before meaningful change occurs? 
King Abdullah returned home to the Kingdom of Saudi Arabia earlier this year after a prolonged absence during which he received medical care for illness in the United States, and then took a bit of time to recover at his villa in Europe.  His return was received with celebration and expression of caring for this 87-year-old monarch.  People here seem to genuinely like and support King Abdullah.  Yet, the pressure to reform the Kingdom’s business and political practices are very real.  Religious differences between Shia Muslims in the northeast of Saudi and the rest of the country have resulted in visible though minor protests.  Press coverage here, which is subject to censorship, has carried the story of the Shia as a minor matter driven by a small number of radicals and even outsiders from Iran who may be here to disrupt the stability of Saudi Arabia.  Rightfully, the Kingdom’s leaders launched a number of initiatives to satisfy citizens and take energy out of public expressions of dissatisfaction:  Decrees have been issued to improve access to housing loans, raise wages, provide promotions for military personnel,  and institute new public social benefits, such as the first-ever payments for Saudis suffering from unemployment.  Still further, the Ministry of the Interior has committed to hiring 60,000 college-educated people into new jobs.  Over 350 billion Saudi Riyals ($1 = 3.75 Riyals) have been pledged to fund these 20 royal decrees. And the frosting on this sugar cookie is a bonus for all government and military employees equal to two months of “basic” salary.  Wow, a lot of money. 
At the food market, prices for most items were up by 20 to 30 percent.  The flood of money in these royal acts and a budget committing a new 135 billion Riyals to development work is putting tremendous inflationary pressure on the economy.  The government can certainly afford to spend these monies because oil is at or above $100/barrel, so a few extra days of pumping crude will pay off the latest stimulus.  But as oil prices are driving worldwide production costs up, oil-based products at correspondingly inflated prices are entering the local market.  The short-term joy over the salary bonuses has inflated prices that impact upon all people living here in Saudi Arabia.  So, why am I thinking that expats “don’t get no respect?”  Because the 4 million expats working for the military and government didn’t get the bonus payments and we too are being impacted upon by price increases.  Rodney was right when he said: “At 20, a man is full of fight and hope. He wants to reform the world. When he is seventy he still wants to reform the world, but he knows he can't.”

Friday, February 4, 2011

One Year Here

                                                         “The farther one goes
                                                           The less one knows”
                                                                                                   -          Lao Tsu, c. 550 BC

Living in Saudi Arabia has helped me to learn directly about the people, and political system of this country and the Middle East.  Today I watched television broadcasts showing the misery of Egypt as their people protested for freedom.  I visited Egypt a few weeks ago to stand in the very location at the Cairo Museum where rioting and destruction are happening now.  Here all is stable and calm.  Some rumors floated this week about minor protests in Jeddah about the unemployment situation and issues over flooding following a second year of heavy rainfall.  Life goes on without missing a beat in Riyadh.
I am now at the one-year mark as an expatriate.  It is strange to think of myself in this way, as someone who belongs in California and not here.  My enthusiasm to have an international work opportunity and to make a good impression among people of Saudi Arabia as an American importing valuable “western” hospital practice is a bit more realistic now. I had earlier underestimated the challenges of this endeavor.
I am an expat, but the meaning of this label isn’t clear.  When among westerners, expat means you are someone who is anxious do some work, to get something done, eager to demonstrate the “right” way.  Not all expats are equal. Those from impoverished or third-world countries don’t receive the privileges of North Americans, Europeans and Britons. Demographic information like expat headcounts by country or region of origin are dissected into groupings of professionals or laborers. All of the data sources are suspect. The numbers don’t true-up when compared against each other. I have accepted the idea that the Kingdom is populated by about 24 million people of which 4 million are expats with 1 million being professionals. Some think that professional expats are overpaid and have privileges that others don’t receive. 
Expat can be a derogatory term associated with our transient nature or a concern that we are overpaid.  Expat contracts are for time periods of between one to five years, and most have provisions that allow the employer (also known as the Sponsor of the work visa) to end employment at-will for breaking work rules, committing legal offenses, or becoming redundant.  This at-will employment contributes to the volatility of the expat work force.  As the Kingdom builds internal capability by educating its people, the Interior Ministry increasingly limits the number and types of visas issued to professional expats. This effort to train and employee Saudis makes sense.  The absence of sufficient number of on-the-job training slots for new technical and academic graduates to gain journey level skills is hindering this transition. (My recall of the literature is that a new graduate requires 10,000 hours -- five years -- of working time to be fully qualified.)  To the concern that we are overpaid, I don’t agree.  Tax benefits for all of the Western expats do afford a lift in our wages; our hourly rates are only equal to what we would have earned at home. At least this is true for me.  Adapting to a different culture, living thousands of miles away from family and friends, and becoming only an observer of life (not a new experience for my Canadian friends) isn’t entirely offset by salary gains.
Never in my wildest dreams did I imagine how difficult it would be to get my house fixed-up enough to have working Internet and television connections, or repairs made to provide hot water or air-conditioning.  It took almost nine months to settle my living arrangements.  Now it is finally possible to go home at the end of each day to prepare a meal and relax. 
It is still surprising to find myself tired and emotionally exhausted at the end of workday.  Every day is an ongoing challenge to get access to information and help from co-workers. Asking for assistance, to be greeted with an announcement that what I ask is difficult and requires invoking God's blessing before beginning worries me.  Most often my colleague takes action and progress occurs, but my worry sometimes turns into 4-in-the-morning awakenings and an early ride to the office.   
But what about my time at work?  One person told me in the first two weeks of working here that I didn’t bring anything meaningful to the hospital as all that I knew was available on the Internet.  Fortunately most staff is open to discussing ideas and incorporating new information into ways of doing things differently.  Work life, the committees and hallway conversations are much as they occur at home.
My enthusiasm for working here isn’t any less than it was a year ago, as the level of my involvement in the operations of the medical division is engaging.  I know you must think that the politics in America, with independently practicing physicians possibly losing control to business people (accountable care organizations and insurance companies), is at least as emotionally charged as anything in Saudi. Let me assure you that the differences are real. 
The experience is in me now and I am being shaped by it.  Insha’Allah tomorrow will go well. 


“You reap what you sew.”
Josh Beckett, Major League Baseball right-handed starting pitcher for the Boston Red Sox.
In Batha, a local souk about the size of Dodger Stadium and its parking lots, stores sell sewing machines. Really big stores dedicated to the art and practice of making stuff out of cloth like curtains, shirts, and even tents.  The machines are bright sunburst yellow and candy apple red with names to match their Indian origins.  I like the big 220-volt Screaming Tiger and Red Bird models.  Of course, Singer machines are still available but now only using the name with little resemblance to the original brand.  It seems that sewing machine stores like these don’t really exist today in the West.
When I was about 3 years old and inside of a Singer Sewing Store, my first kleptomaniac act occurred.  Singer, then a very big brand of sewing machines, ran retail outlets catering to housewives by selling cloth, sewing machines, cutting patterns, and needles to make fashionable clothes for the whole family, why just like in Vogue Magazine. My mom sewed a lot of the dresses that she and my sister wore. The shop was busy with big women, perhaps even fat.  (It was Honolulu in the poor part of town where locals shopped and dined at noodle counters.  Starch diets satisfied hunger, were tasty and cheap, but led then and now to making eaters into large people.) 
I was a small child and didn’t know that taking something without paying for it was bad.  But, I think Mr. Singer bore a great deal of responsibility as he had installed a large rack with sewing needles and thread bobbins beginning at about my height and reaching well into the clouds in the middle of the store, just next to the register counter.  The colors and shapes were impressive. I suspect that stolen package of needles might have cost 10 or 15 cents, but it was to be a really great gift for my mom. She could use the needles to sew and we didn’t have much money. In fact, we were on state aid, getting a monthly check for food and a rundown apartment.  All of this thinking didn’t really enter into my head at that time but works well now to add “reason” to my criminal behavior.  The package was small and fit nicely into my pants pocket until we got home.
To say the very least, I was shocked and disappointed in my mother who did not thank me for the gift!  She yelled at me, made me put my shoes on, and took me directly to the store up to an old man who was the manager.  Then, she made me give him the needles and say that I was sorry.  I did say that I was sorry, which was not true.  I looked sorry with tears running down my face and having wet myself in the process, but I learned an important lesson that day: Never give women needles as gifts.  To this day, it isn’t clear to me why women don’t appreciate needling gifts.   

Tuesday, January 4, 2011

Middle East Healthcare Congress of December 2010

“Nothing is more fatal to health than an overcare of it.”
- Benjamin Franklin
This entry was to have been about the Transportation Safety Administration’s (TSA) program to improve aircraft fuel efficiency by asking passengers to fly nude, thereby reducing cargo weight.  But that rant will wait, as I found discussions at a recent meeting of hospital managers, technology salesman, government officials, and care providers at least as stimulating, if not more provocative than TSA. 
I just returned from a week-long meeting in Abu Dhabi called, The World Health Care Congress – Middle East.  Trust me when I tell you that Abu Dhabi is growing.  While the city boasts a few spectacular sites like the Emirates Hotel and Grand Mosque, the noise and disruption from construction-gone-wild disappointed.  The Beach Rotana Hotel hosted the meeting where I stayed, set along a water inlet from the sea and facing the shore of a building site nested with 15 construction cranes busily hoisting materials and workers up 30 and 40 floors of skyscrapers.  If on the hotel-installed beach, a modest expanse of grass, palm trees, and sand, you enjoy all of the noise attending building sites anywhere in the world.  So, while you drink a beer or soda, you also listen to a cachophony of hammers, trucks, and heavy machinery.  (Yes, Abu Dhabi serves alcoholic beverages and pork.  The hotel hosts a rather wonderful German restaurant with more good things.) If you are planning a vacation to this part of the world, visit Turkey, Oman, or Jordon for the entertainment, history and culture.
At the World Health Care Congress, (I thought that we had all agreed to the accepted usage of healthcare vs. health care, but not with the folks who run this for-profit meeting mill.)  I observed a lot of really smart folks talking about how they and their countries and companies were developing care delivery in the region.  Some of the publicly spoken comments are highlighted here for you to digest:
1.       “We are beginning the development of a cost efficient healthcare system by building hospitals…” spoken by the leader of a large for-profit hospital company based in India. 
2.       “…America’s healthcare system is broken,” announced the president of a USA consultant firm.
3.        “We found that providing a network of family care doctors decreased hospital utilization and improved the quality of care…” said a physician working in the Health Authority -Abu Dhabi (HAAD). 
4.       “Doctors are looking for energetic and active nurses instead…” according to a management consultant based in the region.
Is your stomach aching a little?  I know that my public health education and work experience doesn’t support the idea that bricks and sticks investment yields significant gains in health status.  In fact, putting real treasure into building hospital beds makes sense only if you run a hospital and are focused on disease treatment.  Hospitals don’t have much to do with prolonging life or improving the overall health of people.  (More on what does impact health and was visible at this meeting later.)  In fact, isn’t one of the reasons why the USA. health care system takes 17% of the GDP related to the infrastructure costs inherent in buildings and technologies – implants, pharmaceuticals, and diagnostics -- associated with hospitals? 
Given that America’s cost for disease treatment is running wild doesn’t lead to the conclusion that the system is broken.  The use of money in the American system isn’t ideal and likely to not be sustainable. And, the system “fixes” installed by Mr. Obama and Congress contributes to the problems by mostly financing hospitals, technology companies, and doctors.  Politics is playing out on a grand scale to support the disease treatment industry.  The system does a good job of treating illness while not improving the overall health status of Americans and this isn’t likely to get better.  
But, broken?  Let’s limit this assessment to the politics of financing care.  Financing the disease burden is the distinct issue not solved by just moving the cash around.  Supporting the milieu for long, high quality of life requires a community, not institutional, focus.  I do applaud the efforts (and new monies) for community organizations that provide primary health care at lower cost than traditional private practice models or hospitals.  What America does in treating acute disease is good.  What America does in promoting health and managing chronic illness can be improved.   To this point of early and appropriate health relationships, I applaud the young and female Arab doctor’s comment above Abu Dhabi’s success.  What the Middle East learns from the West about disease management and systems is solid.  The challenge is to not replicate the sticks and bricks mania in care delivery such that disease management costs prevent us from funding for adequate food and water, accessible housing, reliable transportation, safe working conditions, and access to education.  All of these things impact quality of life and improve health status.
To the earlier comment by the local expert in manpower development and staffing models,  I don’t think he recognized the ageism or sexism in his statement, but he also didn’t acknowledge this problem when I called it to his attention.  Did it strike you that some men want young and energetic women for all sorts of things, including work?  But the doctors who I know want partners in providing care who, like them, are seasoned professionals with years of experience and thoughtful practice. 
While my stomach hurts a little from the meeting dialogue, soothing relief came not from the lectures or panel discussions hosted at the Congress, but from the poster session in the conference lobby.
About 20 posters were hung in one corner of the large conference center.  These posters were about health promotion, disease avoidance, and early intervention.  I even witnessed a few conference attendees glance at the offerings here.  This small and neglected area offered hope about how the health status of people can truly be improved.  I am truly amazed at the ingenuity of the offerings which included incubators for newborns from used car parts to low-cost applications for disease screening.   Take a look at a few of the innovators at work:
1.       Smart phone ultrasound scanning – www.mobisante.com
2.       Solar powered hearing aids – www.solarear.com.br
4.       Diagnostics-for-all – www.dfa.org
5.       Safe drinking water – www.safewater.org
6.       Point-of-care testing – www.path.org
7.       Diabetes care – www.amcaremobile.com
 I’d like to see conferences that educate professionals about improving the health status of communities by deploying local efforts and low-cost strategies.  Transitioning local innovations into commercial applications without adversely impacting that part of the invention related to its being low-cost will be tricky.
Next time, let’s talk about Saudi Arabian healthcare priorities.

Wednesday, October 27, 2010


“A man who views the world the same at fifty as he did at twenty has wasted thirty years of his life.” Muhammad Ali
People talk about culture shock as the trauma experienced by moving to a new place or into a new culture.  It is certainly easy to understand the feelings of discomfort, or outright revulsion at the different standards of cleanliness when traveling outside of the western world.  Yet, emotions are really heightened when communications become difficult or impossible.  Making requests or providing direction may result in others responding in an unanticipated fashion, or not at all.  The lack of understanding between people not because of language differences alone, but because of customs and values creates the challenge for the traveler. 
I recall reading an Indian story about blind men who, when confronting an elephant, were asked to describe its essence.  Using only their sense of touch, each man reached out and touched a part of the pachyderm to determine the nature of the animal.  It was not much of a surprise to find that each man had independently drawn different conclusions about elephant architecture.  All of the men were correct in their assessment and must have felt conflicted as their experience was shared with the others. Each had had a unique experience.  The lack of a shared vision as told in this story might lead to open conflict, maybe anger, and even a fight.  It is only but for the participation of someone with vision that each of the men can integrate the information to work together.  The essence here is that differences should be welcomed and integrated to make for a richer experience. 

Over the last few months, I have been leaning how to perform an elephant examination. (And, no it isn’t necessary to wear rubber gloves for this effort.) This education has occurred in committee meetings, private discussions, and even in the local cafeteria.  Time and time again, I have listed to the conversations and wondered privately, “how can they all be correct and wrong at the same time?” 

In one committee that I attend on a weekly basis, we have spent more than five hours talking about the definition of a Full Time Equivalent or FTE.  The definition of this personnel metric in the West is based on a equation of the number of hours paid or worked by an employee without overtime compensation.  Typically, we allow 40 hours per week multiplied by 52 weeks in a year to reach a total of 2080 hours in a year, or one FTE.  This idea sounds simple enough.  This measure then can be useful to determine how many full-time employees would have been needed to perform a job even when part-time workers are used to produce the same output.  (Are you following this?)  So, you’d think any hospital might adopt this definition and you’d be mistaken.  Imagine for a moment that the stability of the 12 month, 365-day Gregorian calendar were replaced with the Hijrah calendar.  The Hijrah or Muslim calendar is based on lunar cycles, which makes it difficult to correspond with traditional Gregorian calendars. The date for the beginning of the first month of the year changes annually.  The Hijrah calendar is 12 months long with 354 or 355 days.  Add to these differences that salary is paid for all days of the year, including weekends – which are Thursday and Friday in Saudi Arabia – and that the month of Ramadan may start early or late, depending on the sighting of the moon, and the FTE is just another word for elephant.

OK, gloves on, let’s talk about paid versus “worked” FTEs!

Monday, October 4, 2010


“Man is the only one to whom the torture and death of his fellow creatures is amusing in itself.” 
                                                                                                                           James A. Froude
                                                                                                       English historian (1818 - 1894) 

At about eight-years-of-age, rheumatic fever following a bout of measles kept me out of school and in bed for a year.  My weekly visit to the local family doctor for an exam and shot of penicillin, along with toxic daily doses of aspirin was the treatment regime prescribed and administered by mom.  Although I missed a full year of school, the teacher who visited me at home dutifully “placed” me in the next grade when I turned nine.  The earlier absence from school and poor test results put me into a “special” group of children who were then called “retarded.”  I rode the “small yellow bus” for a while.  I didn’t learn to read or do basic math until the summer prior to entry into junior high school.  The summer before beginning the 7th   grade, I learned to read by attending an intensive remedial program and developing an interest in science fiction. (I have read every book written by Robert Heinlein and published before his death in 1988.)  Yes, I was really a nerd in every aspect of dress and behavior. The earlier primary school experience didn’t leave me feeling very good about me.  I had no confidence, was shy and withdrawn.  

I met Mrs. Phyllis Stroud in the 8th grade. (I tried unsuccessfully a few years ago to locate her to offer my sincere thanks.  I know she is now dead as she is listed as deceased on the website for the Redlands Footlighters Theatre. She had to have been already 60 when she taught me.)  Somehow my class schedule included an assignment in her speech class. She was the best teacher in my life. I failed to thank her for her competent teaching skills, honest and inspiring interest in me, and forward-looking expression to me about what was possible in my life.  With her support, my speaking skills and stage skills developed enough to allow me to win awards in speech and debate throughout my high school years; more importantly to build a sense of confidence and self-esteem.

This wonderful woman, a teacher of 13-, 14-, and 15-year-old children, demonstrated traits of leadership.  I know now that she led children to become better people.  (If you are so inclined, read Kouzes and Posner’s research into leadership in the book The Leadership Challenge, which discusses these foundational leader skills.)  She was a leader. 

I have worked for a lot of people with different titles during the last three decades.  Almost all of these folks have been managers, not leaders.  Some of these people have gone to school to learn about management and business.  Their academic programs awarded degrees in leadership.  Leadership may be a substantial field of academia, but its theories are still conjectural and, so far, irreproducible.  Schools claiming to educate leaders miss the point: Anyone can learn skills to manage, but leaders are not made.  

It brings me to my premise: Few of us are leaders, capable of inspiring others. We can employ behaviors to maximize results; to get the job done through others.  We get our teams to work well together by integrating our actions with our values, being open to ideas, dealing justly with others, thinking creatively, recognizing that all members of the team are equal, and having a sense of humor.  I think these are all important and necessary managerial traits.  Good managers can motivate others to do their jobs.  A good a manager may become a better manager. 

But there is something more that defines a leader.  Integrity -- that subtle blend of humility, wisdom, enthusiasm and devotion -- is what attracts a follower.  When my teacher “walked the talk,” spent her time, attention and patience on me, she became someone I wanted to follow, irrespective of her age or official position.  I wanted to please Mrs. Stroud and be like her.

Leaders are devoted and tireless in their efforts to bring out the best among their followers.  I am still working on my repertoire of skills, after so many years, and am hopeful that my management skills are improving.