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The surgeon is depicted in theatre making an incision. The scene moves to her office where certificates adorn the walls. Her phone vibrates with a message: “Invitation to speak at a cardiac conference in London”, it reads.
She types a text while sitting at her desk: “Son, please grant me permission to travel.” At home on the couch playing a computer game, her son responds: “I don’t feel like it. I’m busy.”
Human Rights Watch (HRW) produced this animation arising from its investigation into Saudi Arabia’s male guardianship system, which imposes a range of legal and societal restrictions on women. Under Saudi law, women must obtain permission from a male guardian to travel abroad.
One wonders, though, if this really extends to a senior medical professional; a distinguished surgeon? “Yes, the travel restrictions are imposed on all women,” Dr Hala Aldosari, a Saudi women’s rights activist and social affairs expert, informs the Medical Independent (MI).
Women also cannot study abroad on a government scholarship without guardian approval and, while not always enforced, “officially require a male relative to accompany them throughout the course of their studies”, according to HRW’s in-depth investigative report into the male guardianship system, Boxed In, which was published in July.
The system includes measures not in law or regulation but tacitly permitted by government, such as guardian permission for women to work. There are no penalties for employers who impose this restriction, says HRW.
Saudi Arabia has made “a series of limited changes” over the last 10 years to ease restrictions on women, such as allowing them to participate in the country’s “limited political space”, states HRW. However, these reforms are “partial and incomplete”.
The country’s human rights record is disturbing: Minors are on death row; homosexuality is illegal; women are not legally permitted to drive. The most elementary freedoms are shorn bare.
“On the basic rights, expression, peaceful assembly, peaceful association, I mean, their record couldn’t possibly be worse,” Mr Adam Coogle, Middle East Researcher at HRW tells MI. “All dissidents pretty much get locked up; you are not really free to form associations; public demonstrations are banned and people are prosecuted for doing them. So, in terms of those basic rights, there is absolutely nothing on the horizon that would suggest that Saudi Arabia is changing its position.”
A harsh form of Sharia law is imposed in Saudi Arabia, where over 150 executions are reported to have taken place in 2015 including for nonviolent drug crimes. Beheadings are the most common form of execution. Allegations of a flawed justice system are recurrent.
Presently, a military coalition led by Saudi Arabia stands accused of unlawful and deadly airstrikes on markets, hospitals and schools in Yemen.
The travel advisory for Saudi Arabia on the website of the Irish Department of Foreign Affairs and Trade has a distinctly dystopian feel. “Under Saudi Arabia’s customs, in the event of a marriage to a Saudi national, the family has strong power over the individual. If a woman wants her right of movement or to work guaranteed, she must insist on a premarital settlement, stipulating this right,” is one of many jarring sections.
Nevertheless, Ireland and Saudi Arabia have diplomatic relations. Saudi Arabia is a “designated priority market for Ireland” under this country’s trade, tourism and investment strategy, Minister for Foreign Affairs Charlie Flanagan recently told the Dáil.
Irish medicine has set its sights on Saudi Arabia, too.
International linkages and partnerships are viewed as important by Western medical training colleges, notably for financial reasons.
Like counterparts elsewhere in Europe, and in North America, Irish postgraduate medical colleges continue to develop partnerships internationally, including in countries with dubious human rights records – such as Saudi Arabia.
The RCPI’s Strategic Plan 2015-2020 cites the development of a “global presence” as one of five strategic aims. The College’s 2015/6 annual report said that “strong relationships” were developing at “governmental and institutional level” in Malaysia, India, Saudi Arabia, Oman, Kuwait, Bahrain, and the United Arab Emirates.
It reported that a “high-level” Memorandum of Understanding (MoU) was signed between the RCPI and a Saudi governmental body called the Saudi Commission for Health Specialties to develop a “Joint Residency Training Programme”.
“It is proposed that this programme will be delivered partly in the Kingdom of Saudi Arabia and partly in Ireland. Participants take both the Saudi Board examinations and the MRCPI examinations and the programme will be recognised by both the Saudi Commission and RCPI,” stated the annual report.
Already, some overseas doctors including from Saudi Arabia are sponsored by their governments to train in Ireland under the auspices of RCPI and other postgraduate institutions through the International Medical Graduate (IMG) Training Initiative.
Many will be practising medicine in an altogether new environment.
The Saudi Commission for Health Specialties is responsible for supervising and evaluating training programmes in Saudi Arabia, as well as setting “controls and standards” for the practice of health professions in the country. Some stipulations in the Commission’s Professionalism and Ethics Handbook for Residents (2015) significantly conflict with guidance on medical ethics in Ireland.
According to the guide, the availability of safe and easily obtainable contraception “removes the fear of pregnancy and encourages sexual promiscuity and temporary sexual unions devoid of childbearing responsibilities”. The physician “must exercise due judgment before prescribing contraceptives to make sure that there are no immoral consequences”.
It continues: “Widespread use of contraception in the community has other undesirable consequences. Population imbalances by age and by gender may result. Widespread acceptance of contraception is a slippery slope that may make it easier for the community to accept genocide due to decreased respect for human life.”
A Medical Council spokesperson tells MI that doctors coming to work and train in Ireland under these programmes are registered in the Supervised Division and must meet “strict criteria”.
On the basic rights, expression, peaceful assembly, peaceful association, I mean, their record couldn’t possibly be worse
The Council has established guidelines for employers of doctors registered in the Supervised Division in supervised posts. According to these guidelines, there should be a programme of orientation and induction for doctors newly registered in the Supervised Division. The programme should include an introduction to the Council’s Guide to Professional Conduct and Ethics for Registered Medical Practitioners.
Writing recently in MI (‘Stand up and fight’, 16 November 2016), Consultant Gastroenterologist Dr Anthony O’Connor stated that “we again need to question why Irish medical training colleges, registered charities who by act of Government command the compulsory membership, subscription, and patronage of all Irish doctors, are engaging with governments in countries like Bahrain and Saudi Arabia”, due to their very poor human rights records and state interference with the practise of medicine.
“Quite where engaging with these regimes fits into their missions is beyond my understanding. The Colleges of Physicians and Surgeons have proven themselves in the domestic and international realms in recent years as being progressive, innovative and thoughtful institutions, taking on admirable public health work and developing their educational facilities to a standard unimaginable a short time ago….
“Regarding international engagement, if this is desirable then there are vast tracts of the developing world that would benefit from their expertise without plying the wares of Irish medical training in countries richer than we could ever hope to be.”
Dr O’Connor’s commentary was typically robust and composed. However, while there are many doctors who share his concerns, few wish to raise their heads above the parapet.
Dr Ronan Collins, Consultant in Geriatric and Stroke Medicine, is an exception. He feels strongly about the situation.
“A lot of the colleges have been struggling for funding, and seeking new funding opportunities, and some of those funding opportunities are about offering educational opportunities abroad to other governments,” he tells MI. “I suppose you could be very purist and say, what government would be acceptable? Should we deal with India, for example, that has a caste system; should we deal with China, which has its own problems with human rights?”
Given factors such as Saudi Arabia’s wealth, extremely poor human rights record, its conduct in Yemen and support for fundamentalist groups, he has “huge discomfiture” about the situation. His concern has nothing to do with the training of doctors who happen to be Saudi Arabian, but the nature of the governmental regime with which the RCPI is engaging, he explains.
“I would very firmly be not in favour of this, full stop. Well, actually, that is not true. If Saudi Arabia agrees to implement the UN charter of human rights fully, then I am fully in agreement with it. Until then, I am not.”
Dr Collins continues: “The problem is when I raised this with colleagues, most colleagues didn’t know. And I think there is a big disconnect between the business arm of the College and, if you like, the academic, medical arm of the College.”
He acknowledges that doctors under the College’s jurisdiction are “duty bound to read the annual report”, which references its agreement with the Saudi Commission for Health Specialties and other international initiatives. Nevertheless, he believes further information should be published by the RCPI.
“I would like to know, for example, how much money we have taken, and where has it come from [within the Saudi government]? I think that should be public knowledge.”
Women’s rights activist Dr Hala Aldosari
He acknowledges that there is no embargo with Saudi Arabia and the two countries have huge business ties in agriculture and the equine industry. “But medicine is different. I am very uncomfortable with the notion that the College would take funding from a government that would routinely stone women, and punish and execute people because they are gay.”
Medicine occupies “a different space” and “has to worry about human rights”.
MI understands that concerns have been raised internally by doctors within RCPI. This newspaper contacted for comment the three candidates for RCPI President – Prof Hilary Hoey, Prof Conor O’Keane, and Prof Mary Horgan- but none had responded by press time.
A motion carried at this year’s IMO AGM reflected the concern doctors feel about some of the partnerships their colleges are entering into.
The motion from the IMO Consultants Committee called on RCPI and RCSI to ensure that “funding received from overseas governments in support of postgraduate training of doctors does not legitimise regimes that actively support international terrorism, sectarianism, misogyny, homophobia or have laws enshrining such ideals”.
A spokesperson for RCPI told MI: “The College has a long involvement in providing medical training and education in Ireland and other countries including Malaysia, Oman, Zambia, Saudi Arabia and India. Many of our Members and Fellows will have worked and trained in many other countries around the world bringing that expertise back to benefit the Irish health system. RCPI’s focus overseas is to improve health care provision, through the delivery of training programmes and examinations. International Medical Graduates training with us are doing so in specialties in which there is a recognised deficit in their home country, and each doctor is contracted to return to their home country upon completion of training to develop and deliver services in their communities.
“It has been the position of the College over many years that where we believe that we can make a difference to the quality of care to the people of these countries, we will do so. We are not alone in this and many other Irish organisations have taken the same approach.
“Our overseas activities include the provision of examinations, training, training consultancy programmes and Continuing Professional Development activities.”
The Joint Residency Training Programme with Saudi Arabia is scheduled to commence in 2017. “The primary focus of the MoU is the structure of the training programme, curriculum, rotations, assessments and certification requirements. Participants will undertake their training on the same basis as all other national and international doctors currently in training in Ireland,” said RCPI’s spokesperson.
“Doctors in training in Ireland under the Joint Residency Training Programme will be provided with the same clinical training that is currently provided to all RCPI SHOs. All of these activities will lead to improved healthcare provision for the citizens of these countries.”
RCPI provided figures in respect of doctors enrolled in the International Clinical Fellowship Programme, which sits under the IMG Training Initiative. “We currently have 46 trainees on this Programme; 22 males and 24 females.”
Specific questions on the financial aspects of the training programmes, and whether the MoU with the Saudi Commission for Health Specialties included any human rights principles including access for women and employment opportunities for women during and post-training, were not answered. In addition, RCPI did not comment on whether other agencies of the Saudi government sponsored trainees.
Down the road from Kildare Street, on Stephen’s Green, the RCSI has been engaged in work in Saudi Arabia for a number of years. Most recently, its School of Nursing and Midwifery received a delegation from the King Abdullah Medical City (KAMC), Saudi Arabia.
During the visit in May, Prof Hannah Magee, Dean of the Faculty of Medicine and Health Sciences, signed a MoU on behalf of RCSI with regard to the provision of postgraduate education to KAMC’s 1,000-strong nursing workforce.
“The School will be providing MSc and Postgraduate Diploma programmes in areas such as wound care and tissue viability, respiratory nursing and a range of clinical specialities. Prof Zena Moore and her team will be commencing the provision of these programmes in the academic year 2016/17,” stated the RCSI website.
In 2014, RCSI Bahrain’s School of Nursing and Midwifery “successfully completed a BSc Bridging programme with Saudi Aramco and Johns Hopkins”.
Also in 2014, RCSI’s Institute of Leadership announced that it had won a competitive tender to provide 46 training workshops over the following twelve months in Riyadh and Jeddah. “Over the past 18 months, the Institute has established a positive working relationship with the Central Board for Accreditation of Healthcare Institutions (CBAHI), a department of the Ministry of Health in Saudi Arabia that accredits all 5,000 healthcare organisations in the Kingdom. The Institute has also formed a successful partnership with Knowledge Source Centre (KSC), a healthcare training organisation, based in Riyadh,” according to the announcement on the RCSI’s website.
MI put a number of questions to RCSI on these initiatives.
For example, MI asked RCSI whether it insisted on any human rights principles in its MoU with KAMC, in respect of dress code, freedom of expression, access to further education/employment opportunities and indiscriminate treatment of patients irrespective of their gender, sexuality, and marital status.
The MoU is “ongoing” and the College does “not comment on the details of such MoUs or agreements”.
“Our primary responsibility is to contribute, by providing a high-quality education, based on internationally recognised ethical principles in a safe and supportive environment, allowing students and trainees in Ireland and internationally to reach their potential and maximise their opportunities,” stated RCSI’s spokesperson.
Meanwhile, as part of the IMG Training Initiative, there are 29 doctors undertaking training in Ireland in conjunction with RCSI. There are 23 male trainees and six female trainees; they come from Pakistan (24) and Saudi Arabia (five). “All are in Ireland with the support of relevant government agencies in their home country,” said RCSI.
Asked what government agencies were sponsoring the Saudi trainees and how many were female, RCSI’s spokesperson said it had “no further comment”.
RCSI’s most controversial foray internationally has been the establishment of its multi-million campus in Bahrain. Its medical school depends on clinical training sites that human rights activists allege discriminate against political activists, as well as patients and healthcare professionals from the Shia majority.
In 2011, the medical press reported that senior staff at the RCSI Bahrain “asked three medical students attending its college to swear an oath of loyalty to the Bahraini Royal Family and to sign a declaration that they would not participate in further protests” against the Bahraini government. Subsequently, RCSI issued an unreserved apology for this incident.
RCSI has always emphasised its role as a specialist health sciences institution and even maintained that it is employing ‘soft power’ or seeking to exert influence behind-the-scenes. But even some of those who believe RCSI was right to remain in Bahrain feel that there is more it could do – and say – publicly.
RCSI and RCPI also undertake Membership exams internationally, including in the Middle East. Both Colleges were keen to emphasise their philanthropic endeavours in developing world countries, of which there are many fine examples.
Dr Aldosari, the Saudi women’s rights advocate, tells MI that “meaningful engagement” in training health workforces “according to universal standards is rewarding more than refraining from interaction”.
Colleges must be mindful to ensure that issues such as gender-based discrimination, patients’ rights, and social determinants of women’s health are imparted to Saudi doctors during this training, she outlines. “This is crucial,” she says.
Dr Aldosari says Irish doctors and healthcare providers can influence the next generation of Saudi physicians and healthcare providers by showing them the potential of working in gender equal environments in practice.
The number of female doctors in Saudi Arabia is low, she says, and they usually practice in areas where most of their encounters are with paediatric or adult female patients, such as family medicine, paediatrics, and obstetrics and gynaecology.
While male guardian permission is not required to hire a woman, many employers enforce this. There is “no punitive action” for those who do so, says Dr Aldosari.
Female patients can face problems accessing various procedures without guardian permission, despite the fact that this is not required by law (with the exception of abortion), outlines Dr Aldosari.
There are “a plethora of western institutions that are happy to take Gulf money” to establish partnership programmes and “we see it in all the European countries and the US”, says Mr Coogle at HRW.
HRW don’t adopt a blanket position on whether these engagements are right or wrong. Mr Coogle says each programme needs to be examined individually.
“So, for example, if the Saudi doctors are going over and being taught in Ireland that it is absolutely wrong to require anyone to approve a medical procedure for a person, if that person has the legal ability to make the (decision) for themselves – if they are teaching that, then that is good, right? The idea that women’s healthcare should be a private matter between them and their doctors, that is good….”
However, in the absence of more detailed information from Colleges surrounding their engagements with countries like Saudi Arabia, questions will abound in medical circles.
More widely, the area of business and human rights is coming under greater focus internationally.
Business and human rights
According to Dr Shane Darcy, lecturer at the Irish Centre for Human Rights in NUI Galway, there has been greater attention at the UN recently around business and human rights.
“The UN Human Rights Council has adopted what are called the guiding principles on business and human rights. The idea is that when it comes to business activities, states have to make sure that companies respect human rights, and companies themselves also have a responsibility to respect human rights throughout their operation…. Each country is encouraged to adopt a national action plan that puts this into practice.”
Ireland has signalled support for these guiding principles but has dragged its heels on the action plan. It is anticipated that the plan will be published in the first quarter of next year.
“The idea is that your human rights obligations should follow you irrespective of where you operate. There is a big push for that now internationally and nationally, but governments are not overly enthusiastic… they give it lip service but they don’t really oblige companies.”
At the UN, some countries are pushing for a binding treaty on business and human rights whereby states would have clear obligations. “Ireland is opposed to that treaty, the EU is not a big fan of that treaty, it is being led by poorer countries, developing world countries, Ecuador and South Africa in particular are pushing it, because they and countries like them come out of the wrong end of globalisation.”
On universities, Dr Darcy acknowledges that many look at opportunities abroad due to restricted funding at home. But when such institutions say they are “building bridges and engaging on these issues overseas, that is not the purpose of having a campus overseas, it is sort of effectively a business arm. If they made human rights a part of it that would be a separate issue.”
ICGP ‘not currently deriving income’ from MVI
The ICGP has said it “currently derives no income” from its involvement in Medical Validation Ireland (MVI), an RCSI-led consortium of Irish postgraduate medical and dental training bodies that undertakes consultancy work abroad. The College has been involved in a medical revalidation project in Qatar through MVI.
The ICGP did not answer questions on whether its members were consulted about its decision to join MVI, which offers a “range of bespoke assessment, accreditation and consultancy services”.
MVI was not explicitly referenced in the ICGP’s most recent annual reports. However, the annual report for 2013 states: “The College, along with the other Irish Post Graduate Medical Training Bodies (PGTB), embarked on a medical revalidation project in Qatar. This project is very innovative and allows all the PGTBs to collaborate and gain experience in the area of medical revalidation. It is certainly something that is on the horizon for Irish doctors.”
A College spokesperson told MI: “ICGP became involved in MVI following an approach from the RCSI in 2013. ICGP currently derives no income from its involvement in this organisation and has no involvement in the day-to-day running of MVI. Queries relating to MVI should be directed to RCSI or MVI.
“ICGP was involved in an MVI led project (the Assessment and Revalidation Programme, Qatar) for a period of two years, along with a number of other Postgraduate Training Bodies. This project involved the revalidation of Family Physicians in Qatar through MVI. This project is now concluded.”
MI understands that the exercise was on behalf of Hamad Medical Corporation, which describes itself as “the main provider of secondary and tertiary healthcare in Qatar and one of the leading hospital providers in the Middle East”.
The ICGP did not respond to questions on how it approaches the differing sociocultural/religious norms in respect of general practice delivery in Ireland and in other countries when undertaking this work. It also did not make any comment on whether it had plans to hold MICGP exams or undertake any ventures in the Middle East or develop overseas chapters akin to other training bodies.
In the UK, the RCGP has an international strategy which it adopted in 2011.
It has a MoU with the Health and Family Planning Commission, Zhejiang province, China. This agreement has seen RCGP provide training to doctors from the province, and it is also active in India.
RCGP offers an international Fellowship and runs international Membership exams.