Why Aleppo City? Not only because my city

It has been said that the natives of a place are the least who actually know about the same place they have been living in for almost all their lives. I have to say that I do believe this is, at least partially true. Our knowledge of Aleppo is mostly based on a collection of memories ad life experiences that will most likely reflect the true nature of the city. It get even worse for those who left Aleppo years ago and live outside and only visit from summer to summer only to stay for 2-3 weeks period…….

I will try in this post to shape a general description of the city –demographics point of view) - in the next post I will shed light on the current status of the health sector in Aleppo.

Aleppo governance has a population of a little more than 4 million, which is the largest in Syria (based on 2004 census). A little more than 50% are males, with a total number of families of 705000.

Aleppo consists of several “مناطق" -municipalities-” (FIGURE ONE)which include:

1. منطقة عين العرب

2. منطقة جرابلس

3. منطقة منبج

4. منطقة الباب

5. منطقة دير حافر

6. منطقة السفيرة

7. منطقة اعزاز

8. منطقة عفرين

9. منطقة اتارب

10. منطقة جبل سمعان

11. مدينة حلب


Aleppo city itself has a population of some 2.4 million (which means the rest 1.5 million live in the other municipalities). But as you all know, the total 4 million are frequent visitors of Aleppo City with good number of them depend on Aleppo Health System in case of sickness.


Important numbers to understand the composition of Aleppo City itself:

• Total number of families: 462000 families

• Percentage of population less than 15 years old: 40%

• Percentage of population between 15-65: 57%

• Percentage of population above 65: 3%

• Unemployment percentage: 7.43%

• Percentage of people with a regular paid job: 63.39%

• Percentage of people with a governmental job: 21.08%

• Median number of persons/family: 5.37

• Illiteracy percentage in people >15 years age: 17.29 %

(More than 20% of females >15 years old are illiterate)

• Percentage of population with higher education: 5.24 %

(College and University Education)

If you are really interested you can get more numbers on the official website of The Central Bureau of Statistical Tasks: http://www.cbssyr.org/


Looking at such numbers is important, especially if you are planning to start a “health sector project”. As we will see in the coming posts how to use such numbers in defining your brand values and the whole branding effort.

For me the most important conclusion from those numbers the huge need for medical services in Aleppo Area. You have around 2 million “baby boomers” if you want, within the next 5 10 years they will be flooding any health system providing services for adults. On the other hand, it has been reported that the annual population growth rate in Aleppo has recently dropped to 2.9% per year with projections for a further drop to 2.6% over the coming decade.

Other important aspect to look at is the current population density in Aleppo City, although I will cover this again when I discuss where to choose the place of your medical facility. Almost half of the 2.4 million people living in Aleppo are estimated to live in 22 informal settlements (IS) of different types and sizes. The city grew dramatically in the 1970s and early ’80s largely through migration from small towns and rural areas mostly in Eastern Syria. Those (IS) are in general highly dense areas and are usually under served areas when it comes to medical services. (Figure 2)  (GTZ website)




In my Next 2 posts I will discuss the current health system and available services in Aleppo.

Moving, Why Now and How

First, I have to apologize for the delay in this post, I have my parents visiting and It has been a little busy.

Second, I know that some of you following may be getting a little board with my personal story and want to get quickly in the relevant information; but as I said before; I have to mention this background in order to set the stage for what is coming next.
We have reached to where I am now, a Consultant Physician (Hematology-Medical Oncology-BMT) at a major referral center in Saudi Arabia. I consider myself successful in what I am doing but I do believe my personal growth potential will eventually slow down.

My options for now are either:

1. Why bother, continue doing what I am doing (what you better than what you don’t)

2. Consider moving to a different Hospital, but same setting

3. Consider Moving back to the US (I have been contacted several times by my original center in the US to consider coming back and working there), at least now my visa is less of a problem

4. Finally going back home

For option one, I presume you already know my take on that. But, If i was 10 years older and had to take the same decision I would probably opt to take this option. As we get older other factors start playing a more important role in our decisions (such as our kids, social stability, financial stability, our risk taking ability), and putting the whole picture together I think my situation would be ideal (given other options in the region). This is not only a personal analysis this more like an observation, I know several excellent Syrian Physicians in their 40s - 50s who although not 100% satisfied with their jobs in the Gulf Region but don’t want to take the risk of going to another situation which is a little more hazy. But for now I consider that if I do so I may end up with burn out syndrome earlier than I thought.

For option 2, that is not a bad idea. Moving from one place to the other in the Gulf region improves your chances of climbing up the ladder of Administrative Responsibilities (for example eventually finding yourself a head of a Department). But on the other hand, there are many downside of this. First, we are not talking about the US here, there are sometimes considerable differences in the quality between different hospitals, and the good ones are very well know but they are very few, so just being a "Department Head" is not that impressive if you were practicing in a bad place. Second, you local experience will never be taken with the same weight as someone coming fresh from the west (you will not be surprised that after 10-15 years of experience in the region there will be someone with less experience but just coming from the US would surpass you). Finally, moving in the same country is not always easy, there are some "restrictions" regarding switching employers and shortly, if your previous employer wants to complicate your move to the next one he can.

For option 3, that is a difficult one to decide about. You when I think about it the most? This happens mainly when I go and attend a conference. In International conferences there are two types of attendees; the majority (people like me) are listeners who the drug companies want to talk out for dinner so we would prescribe their medications, and the other type (the minority) are the ones setting at the podium who are "the talkers" who most likely look at the listeners as a bunch of lazy physicians who care mostly about the dinner they are going to have after the lecture. I hate the feeling of being a "listener" and many times it comes to my mind that the only way to be a "lecturer" is to go back to the US. In the medical systems Gulf region there is "inferiority complex" for physicians coming from the west, we get many of those visiting professors who whatever they say is taken is a "holy script". Well, maybe I am exaggerating a little bet, but there is a part of the truth in that. I have to add though that on a regional level you would get the opportunity to be the "lecturer" if you work in a good place and have connections. So why cannot I go back? Simply, because I cannot. I cannot do (not physically but emotionally) I don’t have the enough guts to take this decision. I remember back when I was out of medical school coming to the US for specialization was a little difficult decision but it was like a "given". But now I find it difficult to "justify" the amount of pain I will cause for myself and people around us to take this decision. My parents, my kids, my wife and all the people who I feel are in need, I cannot......

So, we come to the last option.........this is the riskiest of all, it is the one that I am not really sure where start from. I am going to propose a theory; if you ask anyone about going returning to Aleppo to work, the statement will be most likely posed in "returning back"; I guess that is were part of the problem is. We think of this as a step "backwards"; is a "Regression" and a sacrifice we are doing. So most people believe they are giving up a better situation and downsizing for a lesser one because they have to do so for their "parents, kids, etc....). I believe that is wrong. The minute we start thinking it about i those terms that is the minute we will be heading for a failure. "EMOTIONAL DECISIONS" enigma last only for a short period of time and will never be a driving force on the long run. I will prose calling this return "moving forward to Aleppo"; let us think about it as a step forward, a move that will help in our personal and professional growth. The growth and success will not necessarily be "financial" or "academic" but it could be something else. We just have to study all aspects of possible growth opportunities and try to build a scenario of a successful move.


This is what I am personally trying to do, and the minute I started thinking about that way I start seeing things I was not seeking before and most important my level of anxiety has lessened. During this journey I will explain how I reached that point and what the things I found are.



Next post

"Why Aleppo, in general as a city not only my city"

My Saudi Arabia Experience

Now, and after spending more than 3 years working in Saudi Arabia (KSA) I guess I can summarize my experience in a way that can benefit others.




We have to agree though, that life experiences remain personal and unique and are totally "in the eyes of the beholder". For those of you know me also know that I have spent most of life in KSA. I came to KSA when I was 6 months old (obviously with my family) and stayed here until I finished my high school; after which I left only to come back again to work. Both of those experiences are different and I cannot it really make any connections between them. I will focus my observation on the most recent experience.



Also, another general rule when evaluating a life experience has to do with our tendency to fall in the trap of "comparison" rather than "objective Evaluation" and that is where confusion and contradiction start. Comparisons are a very bad way in evaluating anything in life in general, and it is even more when you want to evaluate complex structures such as a life experiences.



So for an "objective Evaluation" of this experience I will cover the following Domains:

1. Current Work Experience

2. Professional growth potential

3. Financial

Other Domains that have to be considered when moving to a new place include:

1. Social-Familial

2. Personal

3. Same factors in relation to spouse

Those are really personal and vary between a person and another and cannot be generalized



• Let us with my work experience.



I have to start with this because I can feel how important it is. The satisfaction that you get when you serve in a place when you are “needed” is immeasurable. When you see how a patient prays for you because he feels that you gave him/her something that he could not find at any other place……….this feeling – I can testify for that- is even greater when you are in Syria, it is the “NEED” factor.


As I have mentioned in my previous post, when I came to Saudi Arabia I did not even have my Hematology-Medical Oncology Boards with me. That meant I would not be eligible for a full consultant level (you should have a specialty Board and a 3 years experience beyond the Board). So I had to compromise, and that was a little tough in the beginning. In that position I had to accept to work “under” other physicians whom I considered at a “lower” level of competency. Although as soon as I passed my Board Exams I got promoted for a full Consultant Level for the reasons mentioned below.

With no other option in site I had to figure out how to solve this and fast. And the most efficient and time proven method is “working harder”. The nice aspect of working here is what I call “easy competition”. I remember my days back at the Cleveland clinic how it was a little challenging to compete with others who are already functioning at their extremes. Will, here it is different. Maintaining a step ahead of others is not hard. Don’t get me wrong, obviously it is not a piece of cake but not impossible.


As physicians, and for many different reasons, our most valuable “merchandise” is our “clinical competency”. You can be a great “researcher” or a brilliant hospital administrator; but without a distinguished “clinical competency” you will not get the full benefits of being a physician. It is the most important tool to help our patients and for others to learn from us. Working to improve my clinical competency was feasible since our hospital is the major oncology referral center for the whole western KSA. The number of patients, complexity of cases and our resources are all advanced compared to other hospitals. I tried to establish myself as a reference in Lymphoma (not forgetting other diseases) since first I do like lymphoma and second I noticed it to be a common disease. Within relatively a short period of times I succeeded in achieving this. I was trusted in my hospital in that regards and I started being known on a national level in that regard as well. The nice thing about working in one of the major Governmental Hospitals in KSA (King Fisal Specialist Hospitals-Riyadh & Jeddah, National Guard-Riyadh & Jeddah, and King Fahad Medical City-Riyadh) is that you have the potential of being known on a National Level. You get to give lectures in National Conferences, Accept referrals from others, others calling you for your opinion, patients hearing about you and seeking to see you directly and drug companies seeking your satisfaction.


The other aspect which I liked about my current position is the opportunity to learn some medical administration stuff; and I am especially referring to Quality Improvement in Medicine. I had no prior knowledge in QI and I had to learn my way around. This is a unique opportunity since the QI field is a growing field in hospitals at the Middle East and there are not many people with QI qualifications around so many hospitals do give opportunities for their physicians to participate in this effort. The major hospitals I mentioned above are leading in the region with this effort and the ways I see the future is that many are going to follow. There are many sources and courses you can get over the internet; I specifically guide you to the Institute for Health care Improvement (www.IHI.org) which is the front runner in QI-medicine. They do offer many online courses (some for free) and for people living in the US, they do have many live courses. I encourage people to get some training in this and practice it if they can; it will be in very high demand in the Middle East in the short future. During the last 3 years I have foreseen several QI projects (some I designed by myself) including treatment guidelines, drug utilizations, improving medication safety and development of clinical pathways.

My hospital is a teaching hospital (medical students, residents, fellows) and interacting with them taught me that teaching others is a very nobel thing to do and it would be a major source of satisfaction on the long run.

Finally, I had the opportunity to explore and learn about the field of Health Informatics developing medical software, but this is a story by itself and I will devote a whole post for this story.


As you can see, what I mentioned above is “positives” or things I learned, but life is not all pink and I am sure you all have heard some “stories” that are negative. But as I have mentioned in my first post; I will try to lean toward positive thinking.


• Professional growth potential

This is an important thing to consider for physicians and in any setting. It is not only about what you are doing now nut where would you be 10 years from now. In my view’ this is the major weakness when it comes to working in the Gulf region in general. All the effort I have mentioned above may not necessarily translate into an objective professional growth. I guess if I remain in my Hospital 10 more years and put the same effort I will not be much different from where I am right know. I am not talking only about my salary but you know this factor that they use to weigh different scientific journals and they call it “Impact factor” I believe that each one also has an impact factor and your professional growth is measured with this impact factor. The individual impact factor grows by two ways; the growth of the institution in general and the personal effort. Well, here you will grow with the growth of the institution but not necessarily with your personal effort. I have to say the within the coming 10 years there will be significant growth in the health care institutions in general in the whole Gulf region and that fir sure will reflect on the people working for those institutions but that is a different talk by itself.

The problem is simply due to this thing called “this is an equal opportunity work place” which what makes the US different, well in the Gulf region it is the opposite. Many other factors are taken into account when it comes to promotions other than your achievements.



I would site this number one reason for wanting to move on for another setting



• Financial

I will not dwell much into this point, I am sure you all have an idea about that income range in the Gulf area. I just have to mention some points:

o Unlike the US, there are not that many differences between different sub-specialties when it comes to the salary.

o The average basic salary is around 10-11 K USD per month, tax free, and the differences between one place and the other is mainly in other benefits (i.e. paying the children school fees, how many tickets per day, do they have private business patients,)

o Life here has become gradually expensive, and although what you make is more than enough to live a very high quality life but to save something significant is something different.



As I said above, there are other domains to think about before you take a decision to move to the Gulf area, mainly the personal-social-familial aspects. Those are also complex to measure and think about and certainly you could not generalize any ones experience in that regard.



I only to have to mention one thing, being in Jeddah made us close to Makkah and, you could imagine, is something that surpasses everything else. You ability to ride your car and be in AL-HARAM within 35 minutes (exactly the time needed from me to reach to AL-HARAM from my place) is indescribable. It played a major factor in making me accept everything else, and I thank Allah for this blessing.

I am also eager to hear from others who have or had a working expereince as a physician in the Gulf Region

Next post will be about “why to move on now and how”