Corrections Canada.

 Corrections Canada.

   Following a modestly successful career in training young physicians in family Medicine in an era when superspecialization was the solution to all the world's problems, I was offered the Headship of the Department of Family Medicine at University Hospital in Saskatoon, the site of the College of Medicine at the University of Saskatchewan. Generalists In a territory the size of Texas, with a population of 1000000 were desperately needed. The opportunity was too good to turn down and eventually led to becoming the Chair of the Department of Family Medicine and a full Professorship. When I was forty I had taken an academic position as Assistant Professor of Family Medicine which involved teaching undergraduate and postgraduate students and developing a residency training program in the newly built teaching hospital, The Plains Health Centre. It was with mixed feelings that I left the community based partnership that I had enjoyed for fourteen years. My partners were of a caliber I don’t seem to encounter very often nowadays. Hardworking, caring and rugged individualists. We all took our own night calls, did our own deliveries and made house calls. All without whining about how hard we were working and what facilities we could access for burnout!! (What was that, anyway?) We kept our post-partum patients in hospital for five days, because we knew that new mothers needed the rest and weren’t likely to get it at home. When a patient pressed for early release we would reluctantly let her go home on the fourth day and feel we were exposing her to stress.

       In those days our heart attack patients stayed in hospital for several weeks and weren’t even allowed to get up to go to the bathroom for the first week. We would look after the elderly at home, making house calls as necessary to monitor their progress. Those were the days before the ‘Health Care Industry’, when being a physician was naively thought to be a noble profession.

 I had only been in my new position a few days when my nurse knocked on my office door,.

 “Dr. Smith, there are two Mounties here to see you, they say it’s personal,” she said apologetically.

 “Oh, they’ve finally caught up with me,” I said laughingly, “show them in.”

 Two young RCMP officers came into my office, looking a little uncomfortable.

 “We’ve come to pick up your RCMP special constable pass, doctor,” the shorter of the two said, awkwardly.

 “Oh, you mean you’re firing me?” I asked gravely.

 “Oh, nothing like that, sir. It’s just that our headquarters are in Regina. I’m sure that if we have any medical needs in Saskatoon you’d be the first person we’d be contacting.”

 I reluctantly handed over my RCMP Special Constable pass thinking of all the story-telling mileage I’d gotten out of it over the years. Little was I to know, however, that before long I was to be offered another position with the Justice System that would be more interesting, more lucrative and more dangerous than the one I had just given up.

 

 Soon after we had moved to Saskatoon where the Medical School was, I was approached by an old friend of mine from my Regina days. Dr David Williams was a graduate of Cambridge University, who had come to Canada, possibly to escape two ex wives and two sets of kids who’s maintenance kept him permanently impoverished, to the extent that he found it difficult to maintain the lifestyle he preferred. That included wining, dining, skiing and travel. Fortunately his current lady was also a physician, who was well able to support herself. He was a very competent and busy family physician whose itinerant lifestyle was prompted more by personal preference than by any professional shortcomings. In any event, he ended up in Saskatoon as the Medical Director of a maximum security Corrections Canada Psychiatric Institution. (Prison!)

             He sat in my office, “So how are you enjoying being the big boss at the Regional Psychiatric Centre?” I asked him.

 “The job is actually quite interesting and pays well too!” he responded.

 I interrupted, “How the heck did you get did you get a high level administrative job like that, you hadn’t had much administrative experience, had you?

 “No, not formally, at any rate. As you know, I did a term as President of the Provincial Medical Association and did interact quite a bit with Health Care Politicians and bureaucrats, regarding various issues. Being fluent in French didn’t hurt either.”

  “I wanted to talk to you about a couple of things, Stan. As you know, I’m the medical director of the Regional Psychiatric Centre. I’m quite enjoying the job but I have a couple of concerns. The first is that I don’t want to get so far out of medical practice that I can’t get back into it. I don’t want be an administrator for the rest of my life. I know that you have some community based physicians come in to the clinic and do some teaching, as well as farming out residents and students to community based practice. So, I’d like to offer my services to your department one day a week, doing anything that you feel would be useful in the department as long as it involves patient care. I have done some teaching in the past and had students do a month rotation in my office when i was in private practice. Actually, I got some pretty good evaluations from the students. So do you think there may be something I can contribute that will allow me to continue to have some exposure to patients on a weekly basis. Of course I don’t want any remuneration and any fees that I generate can go into the departmental slush fund or whatever.”

 “I have no doubt that you would be a valuable asset to the department. If you can firmly commit to coming on a Monday, which is our problem day to get teachers to come into the unit, I can definitely facilitate you. You say you had a couple of issues you wanted to discuss, what else do you want to talk about?”

 “We have a whole phalanx of psychiatrists at the Psych Centre, but we have as yet, no clear-cut mechanism for providing general medical care for the inmates. We wondered if the department of Family Medicine would provide that care.”

 “That’s going to provide a considerable time commitment, Dave. There’s no way we could do it on a fee for service basis.” I said.

       “We don’t expect you to do it on a fee for service basis.” He mentioned a figure that quickly removed any doubt in my mind as head of a university department with an unhealthy deficit. The Department needed the funds.

I looked impassively at Dave for a moment and wondered what all the wives and mistresses saw in him.

       “I’ll have to discuss this with members of the department, but we’ll certainly give it serious consideration. I could see that it could have some very valuable advantages from a teaching point of view,” I said. I didn’t add that it would also have some very valuable advantages from a financial view for a teaching department that was having difficulty maintaining its mission while functioning in the black. Let me talk to the department and think about it for a day or two and I’ll get back to you.”

       Experience had taught me never to say yes or no to any idea, no matter how good or bad it seemed at first blush, until one had a chance to think through all its implications.

My decision to follow such a policy had served me well over the years and avoided embarrassment on a number of occasions.

 It didn’t take me long to convince Staff and Residents that providing the general medical care for the Regional Psychiatric Centre would be a valuable teaching service as well as providing the financial means to provide some much needed improvements within the Department.

 And so it came to pass that Dave became a regular Monday afternoon teacher in the Department of Family Medicine and the Department of Family Medicine became the official care providers of the Regional Psychiatric Centre. We negotiated a start date a couple of months down the road and it took all of that time to get the necessary security clearance and complete the contract. Two of my departmental colleagues and I would alternate coming out to the centre on a weekly basis accompanied by a family medicine resident to hold a clinic and the physician or resident on call for the department would manage out of hours calls.

 On January the second nineteen eighty-eight, I showed up at the RPC Saskatoon, federal maximum security institution of Corrections Canada and walked up to the perimeter fence.. This place was for males only - the really dangerous guys. The entire complex was protected by a double ten foot high fence broken only by a single entry point that served as a check point for anyone or anything entering or exiting the centre. Sensors secured the area between the two fences which were sufficiently sensitive to be triggered on occasion by birds or small animals.

The entrance was protected by a checkpoint that was an office with an outer and inner door between which was a security desk and a scanner of the variety which we have all become familiar with at every airport. The security doors were glass in their upper part so that any prospective entrant who rang the bell to gain entry could be observed and questioned as to the nature of their business. Once admission was considered appropriate the visitor was questioned regarding the nature of his business and prior to gaining admission to the institution proper was required to turn out his pockets and empty any briefcase or other baggage to avoid the possibility of anything being smuggled in or out or of being stolen by the inmates. After passing through the metal detector the metallic clunk of the lock being released on the inner door, allowed the visitor to begin the long walk across the courtyard to the building.

 

 

 

The Holyland. Pt 3.

 Monday 29th Jan.

Met with Dr. Ben-Basud, head of the clinical decision making group at BG . A very interesting man who moved here from Jerusalem to head up the decision making group. We talked about changes in medical education, (he is about my age) and the change from traditional histo - pathologic based diagnosis and treatment, to 'evidence based medicine', which attempts to encourage professionals and decision-makers to pay more attention to statistic -based evidence to inform their decision making and to eliminate traditional or outdated practices. unless to some of the recent Russian emigrants who had been accepted into the FMR program. The Residency here is a four year program, the last of which is, more or less a social service year in which the resident practices independently for the most part, with some general supervision. This usually occurs in the various outlying clinics in the Negev. These immigrant physicians are faced with the task of trying to learn Hebrew and English at the same time- no easy job. Incidentally, they are among the best dressed people I have seen in Israel, where most of the physician are in jeans or cords and shirts. Afterwards I was driven back to the hospital by one of these residents, who was driving one of the nicest cars I've seen in Israel.
Irene has a bad cold so we didn't go out once I came home. I tried plugging in the modem, and though I didn't manage to make the connections I wanted, it didn't fry the modem. So I'l have to experiment a bit. Meanwhile, I will continue to use computers around the hospital.

Tue 30th January.
This morning I went up the the shopping centre to have a haircut, while waiting for Irene to wake and see how the cold is and whether we would be able to make the trip to Jerusalem or not. Went into an Israeli salon where they didn't speak much English and I said I wanted it short. And boy, did I get it short, in a very military sort of style! At least I won't need another haircut for a long time! We still haven't become used to the manner in which Israelis invade your space, quite unlike Canada and the US. As I sat in the chair, one of the female stylists came over to talk to the young man who was cutting my hair. She leans over to talk to him, her bare midriff right in my face, totally oblivious to my presence.
We left for Jerusalem at about two p.m. and made our way across the countryside enjoying the rolling hills, the very green fields, this must be the greenest time of the year, the trees and the sights. Just coming out of Beer Sheva, the Bedouin Shanty towns, followed by nice new permanent Bedouin housing developments. Took some photos of both of these to illustrate the contrasts. Once onto the main Tel Aviv Jerusalem stretch, the traffic was horrendous, and we observed the Israeli phenomenon of turning a normal human into a lethal driving machine. As we get into Jerusalem and the traffic slows down before the ultimate gridlock, the other Israeli compulsion of honking the horn incessantly becomes evident. Israelis sound their horns insistently and incessantly, for reasons that are often not clear. Sometimes I think its just to let you know that they are there. They also pass on single lane highways in situations that most sane N.Americans wouldn't think of.
Jerusalem was far busier than when we were last here in 1989. As we were driving in we recognized the area where we were living then, and drove and walked around a little 'til we found 18 Mitudela where we had stayed, a big stone apartment block that was always cool - without air conditioning. It was so designed that the cool evening air blew gently through. We then drove downtown and after much hunting around managed to find a parking place. Ambled around King George street and Ben Yehuda St. and finally found a nice outside restaurant and had fish and chips. Thought it time to start heading back to Beer Sheva as I had no idea how to start back. Stopped at a gas station for some directions and they advised me to head the most direct way which was through Jericho. Now even we are not so poorly informed that we don't know that this is a dangerous place, and since the attendants at the gas station seemed a bit vague perhaps they were underestimating the dangers. Since we remembered that we came in on the Tel Aviv road we headed back out that way to look for the turn off to Beer Sheva, which we somehow seemed to miss. We soon found ourselves almost at Ben Gurion Airport, and I decided to turn into the airport for further direction. As we turned into the airport there was a sort of obstacle course, which quite obviously, was to stop any would- be car bomber from getting in to the airport. As I came through the path, three heavily armed soldiers, came out and. waved me down. I stopped the car immediately and jumped out. They had me pull the car out of the traffic lane, but quickly seemed to rule me out as a serious terrorist threat, despite my military haircut. They could speak hardly any English, and I just kept saying in my very few words of Hebrew "Where is Beer Sheva?" They told me in very simple Hebrew how to get back on the road, and sent us on our way. Later discussed our avoidance of the Jericho route with some of our local acquaintances. They assured me it was the right decision.

Wed 31 Jan 1996.
Went to Research meeting on Bedouin Health and their perceptions of their health care. Main coordinator of the research program is Maroud, a medical resident who speaks Hebrew, Arabic, Czech, English and Russian. He is carrying this project almost single-handedly, because acceptance of researchers of other ethnic origins would not be acceptable to the Bedouins. The research project calls for many meetings involving all the different communities and requires separate meetings for men and women, and Maroud attends almost all of the meetings. In addition he attends to his duties as a family medicine resident on his one year rotation of Internal Medicine. Many of the issues are similar to those of our Canadian Indians, to provide continuity and comprehensiveness of care in the rural areas. One of the differences is that the distances are so small in Israel, that even from the most remote areas it's at the most a couple of hours drive to a major centre. Anyway, after the meeting I had an interesting chat with Maroud, and he suggested I might like to go and visit some Bedouins and drink some coffee in the tent. I said I'd love to. He said he would arrange it.
Later I went to a meeting of the Family Medicine Dept, during which time all the peripheral teachers come in to have a department meeting and a continuing medical education presentation. When I came in to the meeting the Chairman asked me if I could follow the meeting in Hebrew. When I answered no, he said, "Dr Smith does not speak Hebrew, does anyone have any problem with changing the working language to English?"
Nobody had any trouble with that.



Thur 1 Feb.
Spent the morning in the Family Medicine Unit seeing patients with some of the staff physicians and residents. Some of the residents were experienced physicians who had emigrated to Israel and were working towards full licensure. Most, but not all had a working knowledge of English. Several were from South American countries including one from Cuba and several were from Russia. There were quite a few Americans and Canadians. Very few were fluent in Hebrew.
In afternoon went to old part of the city and sought out another well of Abraham. Seems to be several around here. This one was a tourist centre with information handouts and a women in the office who was delighted to have someone to talk to. This area had four wells and were not as old nor as impressive as the much narrower, deeper well at Tel Beer Sheva. This was in a part of the old city that we had not seen before, and had an interesting looking market and shops that would stand a little exploration.
In the evening we go with Mickey and Sid, the couple we rent the apartment from, to a social gathering a friend of theirs is hosting to present a lecture on the 'Alexander Method', a sort of alternative therapy ', aims to re-educate the mind and the body through a series of movements so the body uses muscles more efficiently'. The relationship between the head and spine is the key. The talk is given by an Israeli therapist, a fortyish, lean man who is the therapist of the aging hostess. He delivered the talk with some difficulty in English. It turns out to be another worthless, crack-pot theory but being the only physician there among the converted, I managed to keep my mouth shut and look thoughtful. Something I don't easily accomplish.

Sat. 3rd. Feb.
Got up at a respectable hour this morning and headed to Ein Gedi, a kibbutz on the Western sore of the Dead Sea. Ein Gedi was an ancient Oasis Settlement of great significance during the First Jewish Rebellion against Rome (66CE). The drive was incredible involving a drive through Arad and on to the Dead Sea, which goes through very picturesque sandstone mountains, up and down winding narrow roads, some overlooking dramatic precipices, the crazy Israeli drivers passing blindly on the dangerous curves. When the Dead Sea comes into view, 400 meters below, it does so as a glorious panorama of intense blue and white, overshadowed by the monumental Jordanian mountains. We drove on to Ein Geddi, where we stopped at the Spa, had some lunch, (an interesting salad bar, which included one of my favourites, egg-plant - known as hatzilim here.) walked on the beach, for a while and then went on to the En Geddi beach. Ein Geddi, has been an Oasis in the desert for thousands of years, across the Sea from which is the Moab mountains, where Moses was buried. Here is one of Israel's most important archaeological sites, which we did not go to see nor even know about. We will have to go there again.

February 5, 1996
Meeting in morning re Inf Hepatitis Study. Pesach is very good at getting drug Co. money for acceptable research studies.
Went over to library to do a lit search on stroke incidence in Israel. Librarian from California. In the afternoon met with Vice Dean Carmi Margolis. Talked to him re computerized medical record. Very interesting. Need to spend more time with him re CPGs. He's from NY. He told me the story of how he and others developed an electronic medical record for Kupat Cholim, complete with all the bells and whistles, and that it needed updating and K.C. pulled their funding and decided to go with another system - that the clinics involved are now back to writing records manually. He referred me to someone else for further information. We talked for about an hour about emr. My diagnosis is they were shooting too high, and should have extemporized and tried to hang on to what they had, but there may be factors that I don't know about. We never did get on to talking about CPGs, and will have to schedule some further meeting to discuss this and other issues. Carmi's explanation for Israeli behaviour-Israelis got their country by fighting relentlessly, winning the war, and estalishing the state-and feel every issue has to be won in the same way, by fighting a war there is no such thing as resolution by compromise.

February 5, 1996
Today went to Ashkelon to the K.C. Clinic to spend the day working with David Tobin, a physician from Ottawa who has been in this area for about ten years. The clinic is very busy and David sees from 40 to seventy patients per day. This is a bit hard to understand in view of Israels very high ratio of physicians to patients. There seems to be some very real competition between family physicians and various specialists, and perhaps between the various managed care groups, of which there are four or five. A great cultural cross section of patients, varying from Ethiopians (very difficult to diagnose because of cultural differences and somatization), to new Russians, many of whom don't speak Hebrew. Patients tend to be pushy and tend to push into the Drs office without invitatiion, so Dr. Tobin locks the door between the examining room and the waiting room once he shows his patients in. Although part of Israel is extremely high tech in some ways, this clinic which could be very easily computerized at little expense, has an archaic record system. David seemed glad to have someone to confer with and I think must feel a bit isolated practicing alone. I saw a few interesting patients, David interpreting for me. I think I could pick up 'medical hebrew' pretty quickly. David stated he feels aware of the booming Israeli economy. His analogy of Israeli life is of the person getting on the bus getting trampled by the other passengers running over him, but when they see the poor fellow cannot get off the bus they carry him on their backs to the hospital.
Tonight we were invited to Noga Porter's for dinner and met her son, ready to go into the army, and her husband Basil, a pediatrician. He is very interested in CPGs and I think we shuld meet in the business setting to discuss this and other issues.
Basil is a S.African who immigrated to Israel years ago.

February 6, 1996
Met with Dr.Haim Belmaker, a transplanted American psychiatrist who is the head of Psychiatry here. An interesting fellow, who recently co-authored a paper entitled:
Dopamine D4 Receptor (D4DR) Exon III Polymorphism Associated with the Human Personality Trait of Novelty Seeking.
This made Time Magazine in January.
Of more mundane interest is that Dr. Belmaker holds the Chair of Ortho- Molecular Psychiatry, endowed by the Vikars family, brother-in-law of Abraham Hoffer. Dr.B. has been active in O-M research, recently publishing a paper entitled, "Double-Blind, Controlled Trial of Inositol Treatment of Depression," which was reported in a newspaper that came to the notice of Hoffer, who was not at all pleased that the research was not directly concerned with the use of vitamins in the treatment of schitzophrenia. He wrote quite a nasty letter to Dr. B. saying how displeased he was with the direction of B.s research, and that they would have done better to give the money to a Canadian or American University. He hasn't replied to this letter yet, and he states that he will show it to me before responding. Apparently the whole endowment brings into Psychiatry $3000/yr. I'll be iterested in the follow up. We have arranged a meeting between Dr. Elana Belmaker and myself for later, as she is some sort of a public health physician.
Walked round old BeerSheva and had a light supper at a side-walk cafe.
Rena phoned at one am, just after I had dropped into a nice deep sleep. She sounds great.

February 8, 1996
Met with Jeff Borkan this morning to talk about a possible low back pain project and made a few notes.
Also found an office that has word perfect, where I hope I will be able to print up some of the stuff I have written.

February 9, 1996
Dimona to meet with Dr.Alan Bitun, a graduate of BGU practicing in a Kupat Cholim Clinic. He lives at Sde Boker, Ben Gurion's clinic, and invited us to visit him at the Kibbutz, which I hope to do. I had a short but interesting takl with him, which covered the fierce competition between Israeli Family Physicians and other primary care specialists. Interestingly he very definately distinguished between 'specialists in Family Med, and other primary care physicians. Irene came withme and we went on to Mamshit, a city built by the Nabotheans two thousand years ago. A really impressive site and sight, of which i took many pictures.
Dimona is interesting apart from its Nuclear reactor. Noga told me that a large black commuity had come there to settle from Chicago years ago

The Holy Land. Pt2.

 Wanderings in the Negev.

Once on the road again we started heading towards Dimona, a modern Israeli town with a 'secret' nuclear reactor. I say secret in parentheses because absolutely everyone, Arab or Jew knew all about it, I knew all about it too but when I raised the issue they 'shushed' me.

"It's a secret, we don't talk about it!"
Somewhere in this area we pulled off the road again, for one of those pilgrimages to a Bedouin spontaneous settlement that was virtually invisible from the road, and only after a considerable journey over rocky, uneven terrain, they becomes identifiable when you are a few feet away.

Maraud showed us the Nissan hut that had been the medical clinic when he was on his remote rural rotation, which he said he had physically built himself. He described the difficulty in providing appropriate medical care to women, who were only allowed to come to the clinic if accompanied by the husband, who remained present during the history and the physical examination. The clinic had been discontinued when he left, and apparently was to be permanently closed down. The message being that the local people should go to Dimona, which is only a few miles away, where there was a modern well equipped well staffed clinic. My conviction was that after he had left it was impossible to find another physician to practice under those restricted circumstances when there was a modern clinic nearby. He agreed with this theory and he also pointed out that due to the terrain, which was subject to flash flooding, the ambulance would not leave the main road to pick someone up regardless of the severity of their condition.
We ended up at a traditional Bedouin goat skin tent where we were invited in for tea. We were seated around the in-tent fireplace where we were offered something to eat, which we politely declined, and were given the hot sweet tea that the Bedouin sit and talk and sip all evening, sometimes very strong bitter coffee was the alternative.. We sat talking for some time, the Sheik sitting reclining on comfortable woven mats that covered the floor of this communal tent, with their thick embroidered cushions. His traditional keffiyeh framed his dark mustached face, the gray Western style suit he was wearing forming a strange contrast. Shortly thereafter, the Imam or holy man came into the tent to join us, and was greeted with great respect - everyone stood up and shook hands. About eight or nine others sat around the fire, the older ones in traditional dress, the younger ones in jeans, but most wearing the traditional Arab headdress.

An Amusing Exchange.
As we had approached this settlement, I noted that the tents we were approaching were all black. I wondered about this, because, in the desert, where the sun beats down all day, surely the tents should have been white, to reflect the heat and the light of the sun. M. had introduced me as 'Professor Smith from Canada,' and of course all our conversation in both directions went through him.
As our conversations drew to a conclusion the Sheik inquired as to whether there were any other questions I would like to ask.
"Yes," I said, "I want to know why all the tents are black, when it would be much cooler to have white tents?"
All of the occupants of the tent, both old and young, broke out into hilarious laughter. It went on for quite a while.
"What's so funny?", I asked M.
"Well," he said, a smile on his face, " the Sheik said , tell the Professor , that the tents are black because the goats are black!"
After a while we took our leave, and after a long cross-country drive, over moon - like rocky terrain, we passed the Dimona power station and headed back to the road.

Sunday Jan 28th.
Meeting with the Dean scheduled for 11am. First I met witn Pesach, and when I noticed the time was a little past eleven and pointed this out, Pesach said, "oh, he'll wait for us" and carried right on chatting. A few minutes later the Dean's secretary came into his office looking for us. The dean was a very nice fellow, who chatted about the various problems that exist in primary care in Israel, particularly in the area of geriatrics, as this population has a high percentage of elderly people. They are talking about increasing the geriatrics in the program - at te moment there is one month of geriatrics in the FM program, and also of having some sort of a certificate of special competence ingeriatrics.
the dean then said, ( obviously he had read my CV carefully!)
"I hear you have a special interest in stroke prevention."
I agreed.
"I think I see a great need for that in Israel. Perhaps you could put forward some sort of a proposal in that regard while you are here. In fact," he continued casually, "I'd like to see something in place before you go."
"Certainly," I replied confidently. And so I've been commisioned!
After the meeting with the Dean, I came home, picked up Irene and went to Tel Beer Sheva. This is the archeological site of the ancient city of Beer Sheva, and is really very interesting. Particularly fascinating is the well, just outside the town site, which is the well of the biblical stiry of Abraham. The well is excavated to an amazing depth, and with the aid of some recently installed flood-lights one can see right down to the water - a long, long way below. Gives one quite queazy feeling in the stomach to look down there. Even though there is a robust grid over the top of the well to prevent one from falling down. We picked up a pamphlet which incudes a map of the general layout, and which will be a appendix to this journal, so I will not describe what others have done better. I took quite a few photos of the site and of the surrounding hills. The site closes at four , and we were a little late getting down to the exit area. A young bedouoin man told us it was timefor himto have a sleep and so it was time for us to go. (very politely). When we got to the exit the woman on the door said he had wanted to lock up the park, but she had seen our car on the parking lot and told him he was to find us first. Otherwise we would have been spending the night in the biblicalcity of Beeer Sheva. There is a view tower in the centre of the archeological site from which the 360 degree view is impressive.
Afterwards we drove around Beer Sheva a little and ended up in the old parrt of the city. Parked the car and found a seventy shekel parking ticket on it, when we got back. Lots of new Russians around town, and many of the stores had signs in Hebrew and Russian.
Monday 29th Jan.
Met with Dr. Ben-basud, head of the clinical decision making group . A very interesting man who moved here from Jerusalem to head up the decision making group. We talked about changes in medical education, (he is about my age) and the change from histo - pathologic based treament, which despite its rationality often just does't work, to evidence based medicine, which is so much in vogue and spearheaded by MacMaster.
Later I went to oneof the other Family Medicine Clinics in Beer Sheva, and after a drug company sponsored lunch, the topic was vertigo, the drug serc, spent some time talkig to some of the recent Russian emigrants who had been accepted into the FMR program. The Residency here is a four year program, the last of which is, more or less a social service year in which the resident practices independantly for the most part, with some general supervision. This usually occurs in the various outlying clinics in the Negev, as far as I can understand. These imigrant physicians are faced with the task of trying to learn Hebrew and English at the same time- no easy job. Incidentally, they are among the best dressed people I have seen in Israel, where most of the physician are in jeans or cords and shirts. Afterwards I was driven back to the hospital by one of these residents, who was driving one of the nicest cars I've seen in Israel.
Irene has a bad cold so we didn't go out once I came home. I tried plugging in the modem, and though I didn't manage to make the connections I wanted, it didn't fry the modem. So I'l have to experiment a bit. Meanwhile, I will continue to use computers around the hospital.

Tue 30th January.
This morning I went up the the shopping centre to have a haircut, while waiting for Irene to wake and see how the cold is and whether we would be able to make the trip to Jerusalem or not. Went into an Israeli salon where they didn't speak much
english and I said I wanted it short. And boy, did I get it short, in a very military sort of style! At least I won't need another haircut for a long time! I still haven't become used to the manner in which Israelis invade your space, quite unlike Canada and the US. As I sat in the chair, one of the female stylists came over to talk o the young man who was cutting my hair. She leans over to talk to him, her bare midriff right in my face, totally oblivious to my presence.
We left for Jerusalem at about two p.m. and made our way across the countryside enjoying the rolling hills, the very green fields, this must be the greenist time of the year, the trees and the sights. Just coming out of Beer sheva, the Bedouin Shanty towns, followed by nice new permanent Bedouin housing developments. Took some photos of both of these to illustrate the contrasts. Once onto the main Tel Aviv Jerusalem stretch, the traffic was horrendous, and the Israeli phenomenon of turning a normal human into a lethal driving machine. As we get into Jerusalem and the traffic slows down before the ultimate gridlock, the other Israeli compulsion of honking the horn incessently becomes evident. Israelis sound their horns insistantly and incessently, for reasons that are often not clear. Sometimes I think its just to let yo know that they are there. They also pass on single lane highways in situations that most sane N.Americans wouldn't think of.
Jerusalem was far busier than when we were last here in 1989. As we were driving in we recognized the area where we were
living then, and drove and walked around a little 'til we found 18 Mitudela where we had stayed in then. We then drove downtown and after much hunting around managed to find a parking place. Ambled around King George street and Ben Yehuda St. and finally found a nice outside restaurant and had fish and chips. Thought it time to start heading back to Beer Sheva as I had no idea how to start back. Stopped at a gas station for some directions and they advised me to head the most direct way which was through Jericho. Now even we are not so poorly informed that we don't know that this is a dangerous place, and since the attendents at the gas station seemed to me to be Arab, perhaps they were underestimating the dangers. Since we remembered that we came in on the Tel Aviv road we headed back out that way to look for the turn off to Beer Sheva, which we somehow seemed to miss. We soon found ourselves almost at Ben Gurion Airport, and I decided to turn into the airport for further direction. As we turned into the airport there ws a sort of obstacle course, which quite obviously, in retrospect, is to stop any would- be car bomber from geting in to the airport. As I came through the path, three heavily armed soldiers, came out and waved me down. I stopped the car immediately and jumped out. They had me pull the car out of the traffic lane, but quickly seemed to rule me out as a serious terrorist threat, despite my military haircut. They could speak hardly any English, and I just kept saying in my very few words of Hebrew "Where is Beer Sheva?" They told me in very simple Hebrew how to get back on the road, and sent us on our way. Later discussed our avoidance of the Jericho route with some of our local acquaintances. They assured me it was the right decision.

Wed 31 Jan 1996.
Went to Research meeting on Bedouin Health and their perceptions of their health care. Main coordinator of the research program is Maroud, a Bedouin resident, who speaks Hebrew, Arabic, Czech, English and Russian. A tall, handsome, dark-skinned man in his early thirties, he is carrying this project almost single-handedly, because acceptance of researchers of other ethnic origins would not be acceptable to the Bedouins. The research project calls for many meetings involving all the different communities and requires separate meetings for men and women, and Maroud attends almost all of the meetings. In addition he attends to his duties as a family medicine resident on his one year rotation of Internal Medicine. Many of the issues are identical to those of our Canadian Indians, and to providing continuity and comprehensiveness of care in the rural areas. One of the differences is that the distances are so small in Israel, that even from the most remote areas its at the most a couple of hours drive to a major centre. Anyway, after the meeting I had an interesting chat with Maroud, and he suggested I might like to go and visit some Bedouins and drink some coffee in the tent. I said I'd love to and he is going to give me a call sometime.
Later I went to a meeting of the Family Medicine Dept, during which time all the peripheral teachers come in to have a dept. meeting and a cme presentation.

When I, the great Canadian Professor, came into the meeting the Chair asked me if I could follow the meeting in Hebrew.  When I answered in the negative he said, "Professor Smith cannot follow the meeting in Hebrew, is there anyone who would object if we change the language to English?"  Not a person objected!

The Holy Land. Pt.1.

 Wanderings in the Negev Desert.

It was in 1996 when I took a year of sabbatical after having been the chair of the Department of Family Medicine at the University of Saskatchewan for ten years. I spent half my sabbatical at Duke University in Durham, North Carolina, working with their renowned stroke prevention unit, with Dr. David Macher and his colleagues at Duke University. I had been involved with a similar unit at the University of Saskatchewan that was focused on stroke prevention as applied to primary care.

The second half of my sabbatical, starting in January, 1996, was spent in Israel as a visiting professor at Ben Gurion University in Beer Sheva, the gateway to the Negev Desert. Historically an intriguing area, the odds are that when you stub your toe, the object you hit dates from long before the Christian Era (you can read your bible if you want to know more!). It was regarded as a bit of a backwoods then, apart from its outstanding Ben Gurion University. Extensive building was going on everywhere and still is and friends who have visited since tell me I wouldn't recognize it. I was working as a visiting professor in the Department of Family Medicine and since the provision of health care in remote northern areas of Saskatchewan was provided under the aegis of my department, one of my interests was in outreach medical care in remote areas. Because of my experience in this area, the Dean of. Medicine at BGU requested that I review and comment upon outreach medical services in the Negev Desert and make any recommendations that I thought appropriate.

It was after a presentation to faculty when we were discussing issues of providing medical care in remote areas, that I was approached by Dr. Mahmoud Maroud , a senior resident in the department of family medicine at BGU. His resident project was a study of medical care to patients living in remote places in the Negev. He had heard my presentation regarding the role the department of family medicine played in developing medical care to people in Northern Saskatchewan.

Saskatchewan's 651,036 square kilometres of land area, (population about a million) is larger than all but two states Alaska, which is almost three times the size, and Texas, with a population of less than 20,000,000 at that time. The Negev, on the other hand, is an area of 13,000 km squared, with about half a million population, about 25% of which are Bedouin. Dr. Maroud, a Bedouin, observed that many of the issues in delivering health care to the native population in remote parts of Saskatchewan were similar to the issues of delivering health care to the remote desert Bedouin, despite the great difference in area served, and of course the climate. Half of the Negev Bedouin lived in unrecognized villages in traditional Bedouin nomadic tent communities and half of them lived in towns built for them by the Israeli government between 1960 and 1980. Dr. Maroud, invited me to accompany him on his tour to visit and comment on Bedouin communities and their health care issues. I enthusiastically accepted his offer, ecstatic at the prospect of having a guide who spoke Arabic, Hebrew and English fluently and who, as an insider, would provide access to people and places I would otherwise have little chance of meeting. He informed me that he would contact me for his next foray into the desert. I informed him that my wife and companion was interested in coming along and he responded by pointing out that this would be fine in most but not all of the places that we were to visit, emphasizing the dress code and a number of other issues with which my wife and I were well familiar, that would make an accompanying woman's presence tolerable in the Bedouin culture. Several days later, he phoned.

Here my journal notes start and I share them with only small corrections:

On January 16th 1996, at 3.10pm the phone rang at the apt. It was Dr. Maroud, and he arranged to pick us up later that same afternoon to visit a fairly near-by Bedouin settlement and introduce us to the Bedouin way of life. He was a tall, dark, man with a strong face who looked to be in his mid thirties, dressed in modern style and spoke accentless English. I introduced him to Irene, and we both climbed into his small car to begin what was to be an eventful and unusual day. We drove out onto the road from the small modern town of Omer on the periphery of Beer Sheva where we had rented an apartment. The setting was more reminiscent of California than Israel and we drove towards Shoket Junction while Dr.Maroud gave us a short history of the Bedouin and of himself.

He told us his uncle was a member of the communist party and he himself had gone to medical school in Czechoslovakia and then came back to Israel for his postgraduate training.

His off the top of his head population figures, and remember this was 1996 were as follows. There were approximately one hundred and ten thousand Bedouin in the Negev, and another hundred and ten thousand in the north of Israel. There were approximately two and a half million in total, mostly in the surrounding Arab countries, but extending as far as Cuba. We could not imagine how they came to migrate there, but as the story unfolded we were later able to gain some insight as to why that happened.

When we reached S.Junction we turned left and headed to Leguia, and pulled off the highway onto a dirt road. The dirt road appeared to have no distinguishing features. We seemed to be driving across oceans of sand with no identifying landmarks and the idea did cross my mind that we could perish in the desert if the car broke down or worse. (No mobile phones in those days!)

"How do you know you turned off the highway in the right place?" I asked. This was in the days before GPS. "It all looks the same to me."

"We should see a water pump in about another five minutes and then turn right," he said.

"And what if we don't?" I asked.

He laughed."then we'll just have to stop and ask someone!. You think that there's no one to ask, don't you?"

He was quite right, we hadn't seen anything or anyone since we had left the road.

"Now, I'll just point out some things as we drive along. Oh, and there's the pump just popping its head over the sand dune almost straight ahead."

M. pointed out to us the galvanized iron huts and tents on the one side of the road, so well blended in with their background we would never have noticed them if they were not pointed out to us by someone who knew where to look. On the other side of the road were some new houses built by the Israeli government. He commented that though the new houses looked lovely from the outside that the inside was not correspondingly furnished, and usually contained the furnishings typical of the interior of the tent. The new houses, known as planned settlements, had electricity and running water, while the old shanties had no such provisions, although many of them had small generators.

The car climbed up a small hill. We got out to look around.From the top of a hill we were standing on, Mahmoud pointed out a fine, affluent home that would have looked quite in place in California and informed us that it was being built by one of the wealthy members of the tribe and it needed to be large because he had three wives. He commented that many of the young men were reverting to having two or three wives if they could afford it. I asked him jokingly if that was what he had in mind. He laughed back,

"I don't think my wife would let me -she's a Czech!"

I asked why some of the Bedouin have new homes in settlements (the so-called planned settlements), while others stay on in tents - the old settlements. Apparently, the issue is one of giving up land in exchange for resettlement homes, and according to M. there is some pressure on the Bedouin to resettle. The reason for this is ascribed to 'security reasons'. We then headed east toward Ksifr and turned south across land where no life could be seen, unless trained eyes were there to point them out. M. pointed out more Bedouin tents that were almost invisible against the background of the rolling hills of sand and some green. The green, I was later to find out is wheat, somehow shlept out of this sandy, stony terrain and looking pathetic when compared to the lush prairie wheat fields where some of the farms were nearly as big as Israel. We continued up a meandering stony path, which I wondered if the car could negotiate, Finally we arrived at the high point, overlooking several Bedouin tents. Out of nowhere a white car appeared, a menacing man behind the wheel. M indicated to me that I should lower my window, and started talking to the driver of the other car in Arabic. Once he identified himself as a fellow Bedu, the animosity vanished instantly, and the man came around and shook his hand, ignoring me. M. showed us some olive trees, explaining to us that the Bedouin don't usually grow trees but the land ownership act stipulates that if there are trees growing on the land it implies ownership. He also explained to us that the Bedouin build permanent structures inside the tents, another sign of land ownership.

We continued driving over this harsh, pitted, rutted, uneven terrain, over mounds of rocky sandy earth that I was sure the car could not negotiate. I could picture the undercarriage hung up on some huge sandy knoll. M. however seemed to have no such worries, seemed to know every inch of the terrain and traversed it with complete confidence, everywhere pointing out with pleasure Bedouin tents invisible to the casual eye. Back onto a road where we drove to another resettlement road, beyond the new dwellings, some of which looked very nice, There was a magnificent timpressive looking mosque. We stopped to look at it, and I asked M. if I could take a photograph.

"Of course!" he answered. I pulled out my camera and took a photograph. I was just getting back into the car when a rather aggressive young Arab man came over to ask what we wanted. Again M. responded in the Bedouin dialect, introducing himself. The man asked in Arabic some questions.. (I confirmed this with M. later). "Are you Bedouin?"

M answered in the affirmative, entering into a short discussion. The young man was obviously dealing with a person of some status. After which much shaking of hands (including mine!) and friendly farewells. I don't think I would have felt very comfortable stumbling into this by myself. I asked M. what would have happened if he wasn't there, he answered that we would have just been told to move on.

He looked at the magnificent mosque I had been photographing.

" Where do you think the money came from for this mosque," he asked me.

"Where?" I asked, not wanting to offend him with my opinion.

"From fundamentalist countries like Iran and Iraq. They are trying to foster fundamentalism among young Bedouin. The Bedouin are traditionally non political, but there is some fundamentalism arising among the young people, who feel their needs are not being met and they are in danger of losing their land."

We pulled out towards the road again.

"See how far the school is from the village?" he asked, "why do you think that is?"

"I don't know," I answered.

"It's because the teachers don't feel safe with the school being right in the village," he said, "in the case of any trouble the school could become a fortress. "There is the Kupat Cholim clinic, also quite far from the village, for the same reasons." He pointed out the medical clinic to me. It looked nice and modern and clean, but there was nothing going on in it. Certainly no doctors or patients visible. How was that?

He explained to me that women could not come to the clinic unaccompanied by a relative - usually male. He pointed out that many preferred ritual healers and avoided modern medicine if they thought they could.

More next week.

medicalmanes.com

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