Beyond On-Call

Country cousins unite

A group of rural docs takes their down-home know-how
to Kurdish Iraq. Unlearning helplessness

By Joan Eyolfson Cadham

"We have a phrase in rural health: learned helplessness," says Dr Dale Dewar. "That's what happens when we fail to apply the knowledge that we have to our practice, and bemoan the technical stuff we don't have." Dr Dewar, a family physician from Wynyard, Saskatchewan (population: 2,200), knows all about it. For the past year, she's been the driving force behind a three-doctor CME team called Care to Care who are currently planning their third tour of duty to Kurdish Iraq, where helplessness � learned or otherwise � is rife.

The Care to Care doctors deliver lectures, lead workshops and facilitate small group problem-solving sessions to help their Iraqi colleagues cope with the peculiar difficulties of rural practice. "We insist on rural teaching in rural areas there," says Dr Dewar. "We are going as rural doctors, as people who know what can be done, talking to people who have been told they can't do it."

Why are rural physicians so important? "We have a different way of practising," says Dr Dewar. "We know that rural areas in Canada suffer from lack of services, and we could imagine what was happening in rural Iraq."

PRAIRIES STORM THE DESERT
War, embargoes and occupation all help to breed an atmosphere where learned helplessness can run rampant. It doesn't exactly help, says Dr Dewar, that rural doctors in Iraq are taught by their professors that they can't make a diagnosis on head injuries without a CT scan � an absurd statement given the conditions of local hospitals. "They can spend a million dollars on a CT scan, or, for the same money, they can provide the population with clean water," she says. "Some of the people advising them may have vested interests in technological sales," she adds.

Meanwhile, since the post- Gulf War sanctions � which Canada supported � began in 1991, medical texts and periodicals, bandages, cleaning agents, disposable surgical gloves and blankets have been caught in the embargo net.

"I've always been opposed to military solutions," says Dr Dewar. "I wanted to be involved in the peace process in Iraq, but I thought it would be through writing letters to the Prime Minister."

QUAKERS OIL THE MACHINE
Meanwhile, the Toronto Meeting of the Religious Society of Friends were also looking for ways to help and approached Dr Dewar: "We've raised money for a project in Iraq and we don't have a project. Can you help us?" That's when Care to Care was born.

Dr Dewar, a founding member of the Society of Rural Physicians in Canada (SRPC) and Rural Division Coordinator and Associate Professor of Rural Family Medicine at the University of Saskatchewan, was joined by two other rural medicine veterans: Dr Len Kelly of Sioux Lookout, Ontario, a family doctor with advanced obstetrical skills and Associate Professor with McMaster, and Dr Karl Stobbe of Beamsville, Ontario, Rural Co-ordinator for the program at McMaster.

The group taught in self-governed Kurdish Iraq for two weeks in November 2003 and again in April 2004. Iraq is just two-thirds the size of Saskatchewan, but the team was 200 miles from major conflict. "However," says Dr Dewar, "land mines and unexploded ordinance injuries continue to challenge the emergency departments and the people are 'shell-shocked,' due to the emotional suffering following the losses of so many people over the 1980s and 1990s."

Dr Stobbe sent a postcard for the SRPC's newsletter which gives a pretty good idea of their experiences: "Wandering around the hospital... and talking to the physicians, it looks like there have been some improvements. The pharmacy at the hospital and clinics had shelves that were 3/4 full instead of nearly bare... [But] SSRIs are not available. Depression is treated with benzodiazepines. One of the physicians who was quite clearly depressed was taking Valium for it."

To describe the medical situation in Kurdish Iraq, says Dr Dewar, is to look at our medical system 25 years ago. It's good but out of date. For example, there are no technicians for the CT Scans, no discipline of family medicine and only one physiotherapist in the country. But it isn't hopeless. "They've managed to get professors in and out of the country. Children are going to school. We met bright, well-educated, English-speaking doctors, 50% of whom are women. They were able to hold their second annual Continuing Education Conference May 6-7, 2004 in Erbil."

The 250 Kurdish physicians who took part evaluated every session. The three most common responses were: "We need more of this;" "Please come back;" and "You give us hope."

Care to Care's next visit is planned for November. For more info visit www.srpc.ca