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18 Nisan 2017 Salı

Bashar al-Assad trained as a doctor. How did he become a mass murderer? | Ranjana Srivastava

Preparing dinner, I bite my tongue as images of the latest atrocity in Syria flashes on the screen.


“Isn’t he a doctor too?” my daughter asks.


“Yes,” I cringe at the “too” and rededicate myself to the carrots.


But she knows that conversations about medicine are usually far more animated in our household and immediately sniffs out my reticence.


“I don’t get it. Aren’t doctors supposed to help people?”


Since it’s too late to switch channels, I say something benign. But the footage continues, leaving her to conclude, “I guess not all doctors save lives.”


The heart-wrenchingly succinct statement goes to the heart of my own dismay at the appalling crisis in Syria. More than 400,000 dead, most recently in a nerve gas attack. Six million citizens internally displaced. Five million refugees fled to neighbouring countries. An entire country in spasms. And to add to the unspeakable tragedy, at the hands of a president who used to be a doctor. Not just a theoretical doctor, not one of those who enrolled in medical school but never touched a patient. No, Bashar al-Assad was a proper doctor who by all accounts was personable and polite.


A doctor who studied first at the prestigious Damascus University, then committed to post-graduate training and finally went to London to gain further experience in ophthalmology, a niche medical specialty with many aspirants and limited places. A doctor whose boss recalled him as humble and whom nurses thought exemplary in reassuring anxious patients about to undergo anaesthetic.


To his medical class he was unassuming, seemingly unaffected by his status. Perhaps he had secured admission in the way of other entitled offspring, through power and privilege, but he seemed to be at ease with the responsibilities of being a doctor.


Some classmates kept their distance, wary of the dictator-father’s long reach. Some suspected he didn’t have it in him to be a leader, but then, the world needs good followers and it would have been quite normal for Assad to have settled in a leafy corner of London and practised his craft. Not necessarily groundbreaking stuff, but solid, dependable, everyday medicine that relieved the suffering of many. No one thought he would turn out a mass murderer.


Upon becoming president, he returned to London with his glamorous and accomplished wife, herself a cardiologist’s daughter, who presumably possessed insight into a doctor’s obligations. At his old eye hospital, he looked longingly at a slit-lamp and fondly recalled his medical training.


When he was recalled home, Syria was in the grips of a rebellion, Sunni fighting Shia against a backdrop of roiling tensions in the Middle East. Perhaps Assad, the urbane, London-educated ophthalmologist who spoke of Syria’s “own democratic experience”, would be the people’s advocate, the agent of change. But alas, the Damascus spring didn’t last and Assad the kindly doctor transformed into Assad the feared killer.


Revulsion at the horrific abuses perpetrated by the Nazi doctors – Josef Mengele most infamous among them – led to the development of the Nuremberg Code, which govern the ethics of human experimentation. Radovan Karadžić was a psychiatrist and a poet before being convicted of genocide in the former Yugoslavia. British doctor Harold Shipman injected lethal drugs into more than 200 patients, and American cardiologist Conrad Murray was convicted of homicide after injecting Michael Jackson with the anaesthetic agent, propofol.


History has witnessed other doctors turned rogue but Assad’s attack on his own people is staggering by any standard. He has gone from bombing civilians to destroying entire hospitals, and whatever and whoever lies in their wake. Nearly 800 medical personnel have been killed and many others detained and tortured. Four hundred medical facilities lie in ruins, their hapless occupants either dead or badly injured.




Doctors around the world regard Assad’s deeds with dismay and horror




Entire cities have been left without medical aid, turning treatable injuries into fatal wounds. The United Nations has pleaded that “even war has rules” but experts say that no previous war has witnessed such deliberate, systematic targeting of medical facilities and health professionals.


It defies belief, but in a way it makes sense, that a doctor who once felt the pulse of people, knows that the way to still that pulse is by aiming his strongest weapons at the hospitals that keep people alive and give them hope. It would take a doctor to predict the psychological devastation and desperate surrender of a people robbed of gauze for a bleeding wound, antibiotics for a festering sore, surgery for a lodged bullet.


There are interesting views on how someone who once pledged to save lives could so wantonly destroy them. Perhaps he is striving to prove himself to his dead father who had openly favoured his older son who died in a car accident while Assad was becoming an ophthalmologist. The younger Assad was teased for being interested in human blood rather than the blood of politics – this is the revenge of the bullied.


Or more chillingly, all that medical training was just a show and behind the suave specialist lay a murderer who always had the measure of his power. Medical training necessarily inures doctors to pain and suffering: imagine how inefficient a doctor would be if he faltered at a patient’s every tear and cried over every wound. Part of becoming a good doctor is to learn to stand back enough to help, but most doctors experience a continual tightrope in maintaining a professional boundary while being empathetic. Perhaps Assad just dumped the empathy while fortifying the boundary.


Doctors around the world regard Assad’s deeds with dismay and horror. They know how many of their colleagues leave medicine for far, far smaller reasons than killing a patient. Most doctors can’t bear having a stain on their conscience for missing a diagnosis or misprescribing a drug, never mind that the patient wasn’t even hurt. Doctors take their own lives at the mere thought that they did something wrong. It beggars belief that someone who was once one of them could so systematically and remorselessly kill his own classmates and their patients.


History will diagnose Assad one day but in the meantime, when I see my Syrian patients I can’t help wondering whether to just treat their illness or acknowledge their deeper wounds. Their fragility is obvious as is their concern and shame.


Assad’s crimes against humanity seem distant until they are personalised in the form of a son, a mother, a neighbour. The easiest answer is to feel helpless and stay silent but it just doesn’t feel right. Another is to express solidarity with our fellow human beings even as they live unrecognisable lives in distant lands. This, too, can feel inadequate in the face of punitive government policies. A third is to support the courageous professionals and the organisations that are determined to stay put in Syria against the odds. Most of us won’t go to Syria because we are not skilled or capable of working in dangerous and impoverished settings. But we can be effective through donating to credible charities, such as the Red Cross, The White Helmets and Médecins Sans Frontières, who can channel our aid where it is needed.


Our gestures can seem insignificant in the face of so great a tragedy but I hope it says to the Syrian people that while their own doctor president has given up on them, the rest of the world has not.



Bashar al-Assad trained as a doctor. How did he become a mass murderer? | Ranjana Srivastava

23 Şubat 2017 Perşembe

Thousands of doctors trained in Europe "may quit UK after Brexit"

About 12,000 doctors trained in European countries could quit the UK because they feel less welcome following the Brexit vote, according to a survey of overseas medics.


About two in five doctors who qualified in European Economic Area countries are considering leaving the UK in light of the referendum result, research by the British Medical Association reveals.


The findings prompted alarm about an impending “disaster” in medical staffing and fears that an exodus of EEA doctors could exacerbate already significant personnel shortages in NHS hospitals.


The BMA’s findings are based on a survey it undertook of 1,193 EEA doctors working in the UK. When asked if they were thinking about leaving the UK following last year’s referendum vote, 500 (42%) said yes, 309 (26%) said no, 278 (23%) were unsure, while the other 106 did not answer.


“These are the people who staff our hospitals and GP surgeries, look after vulnerable patients in the community, and conduct vital medical research to help save lives. Many have dedicated years of service to healthcare in the UK, so it’s extremely concerning that so many are considering leaving,” said Dr Mark Porter, the BMA’s council chair.


“At a time when the NHS is already at breaking point and facing crippling staff shortages, this would be a disaster and threaten the delivery of high-quality patient care. But this isn’t just about numbers. The quality of patient care is improved where doctors have diverse experiences and expertise,” he added.


The EEA includes the 28 members of the European Union plus Norway, Iceland and Liechtenstein.


Figures from the General Medical Council, which regulates the medical profession, show that there are 280,932 doctors on the medical register. Of those, 177,912 (63%) were trained in the UK, 30,733 (11%) qualified in another EEA country and 72,287 (26%) are from elsewhere in the world.


“While thousands of overseas and EU doctors work across the UK to provide the best possible care for patients, many from the EU are left feeling unwelcome and uncertain about whether they and their families will have the right to live and work in the UK after Brexit,” said Porter.


European doctors feel significantly less appreciated by the UK government now than before the referendum. Their average rating on that score has fallen from seven out of ten before the vote to leave the EU to less than four out of ten now.


Similarly, they also feel a lot less committed to working in the UK since the Brexit vote. Their average rating on that question has fallen from nine out of ten before the referendum to six out of ten.


“Since the result of the EU referendum I feel increasingly uncertain about my future here, and am considering returning to Germany. It is unsettling that in a country that I have contributed to for 20 years and consider home, I am now seen as a foreigner and have to prove that I deserve to live and work here,” said Dr Birgit Woolley, a German-born GP who has worked in Britain for 20 years.


“I feel supported by my patients, with even those that voted leave telling me: ‘You can stay because you’re a doctor. We like you. We didn’t mean you.’ But the reality is that the government does not appreciate what EU nationals like me have contributed to the UK, and only sees us as bargaining chips.”


Luciana Berger, a Labour member of the Commons health select committee, said: “These extremely worrying BMA figures show the huge contribution made by doctors from the EU, and the severe risk that hundreds will leave the UK as a direct result of Brexit.”


A Department of Health spokesman said: “As the government has repeatedly made clear, overseas workers form a crucial part of our NHS and we value their contribution immensely.


“We want to see the outstanding work of doctors and nurses who are already trained overseas continue, but at the same time we have been very clear that we want to give more domestic students the chance to be doctors, given the enduring popularity of this as a career.”



Thousands of doctors trained in Europe "may quit UK after Brexit"

3 Şubat 2017 Cuma

Healthcare and Trump"s travel ban: data shows success of doctors trained abroad

American patients treated by internationally educated doctors have slightly better outcomes than those treated by their American-educated counterparts, a new study has found, as Donald Trump’s ban on travel from seven Muslim-majority countries is expected to stop some immigrant physicians from coming to the United States.


But that is not because American medical schools are falling short, the authors of the report in the British Medical Journal said.


“We’re not saying medical school in the US is not doing a good job, it’s only about selection,” said Yusuke Tsugawa, a research associate at Harvard University’s TH Chan School of Public Health and lead author of the study. Self-selection, to be more specific.


“They are highly motivated,” Tsugawa said of doctors educated outside the US. “They are not random doctors from their home country, they are the best doctors.”


Trump’s executive order banned people from entering the US from seven countries – Iran, Iraq, Libya, Somalia, Sudan, Syria, and Yemen – for 120 days following the order. The order also stopped the Syrian refugee resettlement program indefinitely.


Researchers looked at 1.2m hospital admissions of patients on Medicare, the American public health insurance program for the elderly, who were treated by more than 44,000 physicians. The rate at which patients died or were readmitted was used to measure patient “outcomes”.


Despite the study’s findings that internationally educated doctors were slightly more likely to treat a sicker population – people with more chronic diseases, as well as more likely to be from racial minorities and more likely to be low-income – outcomes were slightly better than among their American-educated peers. That held when comparing doctors in the same hospitals. Patients treated by both international and US graduates were about the same age on average, approximately 80 years old.


“Our findings indicate that current standards of selecting international medical graduates for practice in the US are functioning well for at least one important dimension: inpatient outcomes,” researchers wrote.


By the numbers, researchers found that when patients were treated by internationally educated doctors, they died at a rate of 11.2%, versus 11.6% for US-educated physicians, in comparisons of doctors working in the same hospitals.


Readmissions showed the same trend. Patients returned to the hospital within 30 days at a rate of 15.4% for internationally educated doctors, and 15.5% for US educated doctors, when comparing doctors in the same hospital.


Tsugawa said he and his colleagues undertook the study because other research showed there “was a bias against foreign medical graduates, both from colleagues and patients, so they are thinking quality of care might be worse than US medical graduates.


“Given that 25% of the doctors in the US – or in the UK as well – are foreign medical graduates, we want to make sure they are providingquality medical care,” he said. Tsugawa said he expected to focus on the race of doctors in his next study.


“To do the residency program in the US, the bar is really high; only 50% of the candidates can get the slot in the residency program,” said Tsugawa. “There are multiple ways they are highly selected, and highly motivated, and that is the reason they have better outcomes.


“Those who come to the US are the brightest and the best,” he said.


About one quarter of physicians working in the US were educated abroad, multiple studies show. But many workforce experts believe that even if the immigration status of hundreds weren’t suddenly in question, there still would not be enough doctors coming to the US to make up shortages faced by ageing and rural Americans.


For example, the largely rural Alaska already needs an additional 60 doctors per year, the Atlantic reports. And a 2015 New England Journal of Medicine article argued that programs that brought 8,000 doctors to the US each year would fall far short of the primary care needs of the country’s ageing population.


Research from 2013 showed that 299 doctors from Iran, Iraq, Libya, Sudan, or Syria applied to train in the US as residents that year, with an acceptance rate of just 40%, a New England Journal of Medicine article reported.


Syria is also one of the top exporters of physicians to the US in another program that places doctors in high-need rural and inner-city areas, the J-1 visa program. In 2014, 165 Syrian doctors moved to the US under the program, according to the same article. If the ban continues beyond 120 days the number of doctors – and therefore patients – affected could escalate very quickly.


“Physicians with J-1 waivers are filling clinical jobs in areas of need,” the NEJM authors wrote. “An executive order that has not taken into account the widespread ramifications may lead to further shortages of physicians in areas that are already in dire need.”



Healthcare and Trump"s travel ban: data shows success of doctors trained abroad