A few highlights of the first months as an army doctor

Arriving to base for the first time

As my bus wound through desolate barren hills, past the occasional goat, rock rabbit, and dried-out skeleton of a bush, in the distance, I could see a large, developed army base – complete with an area for tanks, a formal reception and inspection area, and a nice stone wall with a sign reading ‘Welcome to the Regional HQ of 900 Battalion’. My bus pulled up, and as I descended, I confirmed with the driver that this was indeed my base. “No! You’re the next stop”.
So, we departed, and turned off the narrow winding road on to a narrow winding single-track. Some 5 minutes later, we arrived at a very much less impressive base. So as to prevent provocation of the extremists who try to kill us, most army bases in the West Bank, including mine, are intended to be temporary structures – every building is brought on the back of a lorry, and so the base is in effect a collection of static caravans, with pipes often running over the ground, electric cables overhead, poor drainage, and worse food (though still significantly better than on my previous base). The base is fairly cramped, and extremely hot. Nestled between hills on every side, there is virtually no wind, and in a desert below sea-level that means the night time temperature rarely drops below 30 degrees in the summer.

I quickly found the clinic, and wound my way through the crowds of new soldiers, all waiting to have their arrival checks. It was quickly clear that there would be a lot to improve in this clinic – the thick grime on the door handle to the treatment room gave the impression that no one had EVER cleaned it – by the looks of shock when I pointed it out to the staff some days later, I have come to the conclusion that the impression was correct.

My room is, of course, a caravan, but a relatively nice one – I share it with the Dentist and mental health officer (a very useful guy; thanks to his existence, I don’t need to see the depressions, suicidal ideations and psychoses, all of which would take up my entire working day and prevent me treating anyone else – the mental trauma of coming to the army means that a lot of people go through at least some level of emotional distress). As a result, the room is relatively clean, and has over the years been developed into a bachelor pad – dart board, TV, fridge, kettle... even real beds brought by my predecessors and then left behind.

The toilets are quite an experience – I’m blessed to be one of the elite few who can use the officers’ toilets... but that isn’t saying so much. I truly don’t understand how people manage to create such utter squalor in such a short time – from the sinks blocked with toilet paper, to the faeces in the showers, the tap snapped off the wall and so on. The kitchens are pretty good (with one exception... read on), but the dining rooms are appalling, with kitchen staff demonstrating a lack of a single synapse – they will put out a tray of food (sausages for example), carefully prepared in the army’s strict sanitary conditions, but will not think to put a serving implement in. Then, when a hundred soldiers come in from the field without washing their hands (because their commander is too lazy or stupid to point out to the lazy or stupid soldiers that it’s lazy and stupid not to wash hands when you’ve been crawling around in a field with wild animals), they pick up their food with their bare hands. Worse, they may fish around to find a better sausage, contaminating everyone else’s food simultaneously. But it doesn’t really matter – the swarms of flies who turn up for every meal time make sure to spread the diseases just as efficiently – and the kitchen staff are too lazy or stupid to request a spring be put on the door so it doesn’t remain open for the flies to come in.

The Health Inspector

There is one person appointed to look after all aspects of public health on the base – he does a daily inspection of the base, and needs to report hygiene issues before problems arise. Unfortunately, in my life I have never met a less adept person. In a base full of hundreds of pompous, overconfident soldiers and arrogant captains and commanders, an introverted Ukrainian immigrant of 20 years old, mentally incapable of functioning in any sort of emergency capacity was dumped into a role that some logistics manager somewhere else erroneously felt was unimportant enough that it wouldn't matter if he was incompetent. For months, the situation has been deteriorating on the base, the rates of disease rising, and no one doing anything about it. That is, until the new OCD doctor arrived...

Don’t have a cow, man!

One of the many little annoyances on the base are the wild cats and dogs who have made the base their home – with a plentiful supply of food from soldiers who throw food on the floor, or don’t bother to close bins, the base makes a nice little place to live. Unfortunately, conflicts regularly arise between soldiers and animals, and not necessarily through the usual Israeli mentality of treating the cats like vermin. Many soldiers have come to me with bites and scratches, either when trying to feed the animals (which is a punishable offence) or by random encounters – like opening a bin to find a petrified cat inside, or running around a corner to find that a dog is running in the opposite direction. Every single time, I need to refer to the soldier to the ministry of health for a rabies evaluation, and to complete forms on the exact circumstances of the incident. I decided to try and pre-empt this problem by requesting from the senior commander of the base that we get rid of them. The conversation went like this...

Commander: Well, we’ve had a few gather-ups in the past, where we take them all out of the base; it’s fine for a while but we always get another load back eventually.

Adam: Well, how do they get back in?

Commander: Through holes in the fence!

Adam: Isn’t it a bit concerning that we have holes in the fence big enough for dogs to get through, when we’re 10km from Nablus (a hotbed for Palestinian Terrorists)

Commander: [Looking at Adam with confusion] I take it you haven’t seen the cows then...

(Note: I’m assured that the fence has been fixed before publishing this on the internet)

Building a more efficient leadership dynamic

I expect by now you’re getting a good picture of the nature of the base, and the army in general – there are many people who lack initiative, but more importantly, many more who have initiative but no chance to put it to any use. Only a truly motivated commander wants to have a busybody newcomer making suggestions for things which have no obvious immediate benefit, but that take time, effort, or money. Why fix a fence when no one’s tried to get through it in a long time? What does it matter to him if I have more forms to fill in because of animal scratches that are probably harmless? Why put soap by the sinks when it’ll only get used and then need to be replaced again?

The perfect example of this, to my sorrow, is the expulsion of one of my better medics – his platoon commanders (all aged around 21) felt he was taking too many people to see the doctor, and disrupting too much training by giving people exemptions while waiting to see me. From the medical point of view, if someone has a suspected stress fracture for example (something very common in the army), then it is vastly preferable to give them rest, see if the pain subsides, and assess them again, rather than irradiate them and find nothing. From the commanders’ point of view, they would much rather the soldiers trained until the last moment, and only when in agony, get checked out. The result is that most soldiers would be fine, but the small number with real stress fractures would then require such a long recovery period that they may not be able to complete their training. So, they deal with the problem in the way that bests suits them – remove the good medic and bring a more timid one, who won’t stand up to the commanders, and will request fewer appointments with the doctor. It also means less work for me, but a real chance that more soldiers will suffer more significant medical problems.

And so it suddenly becomes clear – people who are more incompetent, lazier, more obedient and less forward thinking have a better chance of staying in their position and ascending the ranks of the army.

There are, however, exceptions to every rule. Our new deputy commander is one of them.

The commanders of the base are actual adults, not hyped-up 21 year olds with big egos. In their 30s and above, they have in their 15 years or more of experience all served in wars, commanded combat units and battalions, before eventually rising to the level of the training base. As a rule, they have an air of authority and command respect. Each one will decide for himself how to conduct business with the senior staff – some remain ‘at distance’, meaning I call him commander, he calls me doctor, some will be on first name terms and call you in for a coffee and a chat. The deputy commander’s role is to basically do all the crap the commander doesn’t want to – logistics, maintenance, disciplinary issues etc.

As a fellow newcomer, I decided that the deputy might be a good person to approach to try and sort out the appalling lack of sanitation on the base, before the next epidemic. Straight-faced, permanently serious and quite abrupt, he struck me as someone who took his job very seriously. As we sat and I reeled off a list of the urgent repairs and basic requirements that were lacking on the base, his listened intently and wrote every single thing down. At the end, rather than negotiate with me what I felt was really important and what could wait, he immediately started to sort things out – the public health soldier who doesn’t seem to do anything was pulled in for a meeting with us both, an inspection of all the areas I’d mentioned was arranged, and deadlines were agreed for fixing the issues. I couldn’t believe it – someone in the army, in a senior position, expressed motivation, authority, intelligence, and most of all, genuine concern for his troops.

Unfortunately, his level of commitment to the rules and responsibilities stands on every single level; little perks that were acceptable with his predecessor are no longer okay – if I miss the bus home because of a sick patient, previous commanders would allow the ambulance to take me to another bus stop to get a different bus (rather than wait hours for the next one). This commander does not feel that is a good enough reason to dispatch the ambulance, even if it means I may not get home. On the one hand, he’s quite right – the ambulance isn’t a taxi. On the other hand, GIVE ME A BREAK! It’s a ten minute drive, and if they need the ambulance, then it’d already have a full staff.

Shabbat in the Army

Two weeks ago I experienced my first Shabbat in the army – that is, the first weekend I spent on base, on standby in case of war or major incident. The workload is very variable – it could be totally silent, looking after the relatively small number of soldiers remaining on the base that particular weekend, or it could be chaos, as the only ambulance ready and waiting in a large area.

The weekend started with a briefing Thursday night where each division (medicine, logistics, catering etc) presented their plans for the weekend – naturally, 80% of the meeting revolved around food. The main issue was due to the fact that the majority of soldiers present belong to Netzach Yehuda (I’m going to write a whole section on them in time – although they deserve a book for the amount of chaos they create) – a strictly religious platoon for soldiers who have taken on themselves the highest level of orthodoxy; as a result, they have a super-kosher dining room, prayer-time built into the timetable three times a day, compulsory fasting on fast days (where everyone else has free choice), and a total absence of women in every aspect of their army service – they require a male doctor for example (although I know of no place in Judaism where modesty overrides preservation of health). The blind decision was made by the kitchen staff that  for Shabbat all food would be prepared and served in the Netzach compound (they have their own fence to ensure a full separation), and the regular soldiers would go there to eat. A small level of insight would have ensured they would therefore check that there would be no women on the base, who would as a result have nowhere to eat... but of course that was not the case, my medic was a female soldier, as were several other staff that Shabbat. The commanders of Netzach would not even agree to allow the women in to collect takeaway food (which I would have vetoed regardless – the idea of isolating a few soldiers from everyone else on Shabbat, a time when everyone eats and relaxes together, was physically repulsive and in my opinion a disgrace). Eventually, a compromise was made – two dining rooms would open, one for the super-religious, and one for everyone else.

Alongside the driver, the medic and a major incident coordinator, I had fun making the most of the potential free time; the plan was to spend the Friday having a drive around the region as a ‘getting to know the region’ tour: as our standby could require driving to anywhere, including Nablus (where we treat Palestinians after traffic accidents etc), the local settlements and Bedouin tent villages, and all the roads in-between, it makes sense that I should know the names and locations of key sites and flashpoints. The fact that a nearby settlement had a beautiful outdoor swimming pool that was free for soldiers was beside the point entirely and absolutely not the reason we wanted to get out of the arid, feculent base. Honestly. Ahem. In the absence of the clinic commander, the deputy commander of the entire base was the only person who could authorise the trip – and once again his dedication to the mission threatened to throw a spanner in the works – calling us in for a meeting, we had to present not only the reason for the trip, but a full specific itinerary of precisely where we would go, where we would turn around, how long the trip was expected to last, and agree to make no stops, to enter no other army bases, nor to enter any settlements. The purpose of these rules is still beyond me, given that the result of the trip was a ready ambulance, full of staff patrolling the exact area it was serving, rather than having a staff dispersed across the base, and an ambulance unattended.

Somehow, despite not leaving our ambulance during the trip at any point, we returned happy, relaxed, and all an unusual shade of sunshine glow.

Friday night is the highlight of Shabbat for many people – tired from a week of intense work, returning home to sit down, eat, talk and rest is a really special moment, and I was very curious to see how that atmosphere would transfer over to the army. Entering the usually revolting dining room, I was amazed at how the Shabbat atmosphere permeates everything – the tables were all set, salads and drinks on the tables, challah (Shabbat bread) ready on the table. Around 100 soldiers were eating with us, most of whom weren’t religious (the very religious ones having been isolated). Nonetheless, the respect for Shabbat was profound – no one started to eat – everyone waited without being told until the last people had arrived – I was ‘voted’ by way of shouting ‘The Doctor!’ by the soldiers to make Kiddush and hamotzi (the blessings over wine and bread), which was quite a privilege in the presence several far more senior commanders, and a good number of soldiers far more religious than me. Arrogant and pretentious as it sounds, it was nice to feel that my work is appreciated by the soldiers I treat, even though they often seem so irritated that I didn’t send them home or discharge them from the army. Thankfully, the deputy commander sitting directly opposite didn’t seem to notice our red glowing poolside faces.

The rest of Shabbat passed smoothly, and uneventfully – meaning that I was almost ready to enter the next week of insanely busy work, despite having only had 12 hours to see my lovely wife.

Deborah's bit

Meanwhile, back at home Deborah’s concerns about the competition building at work between Israel and Manila proved to be well founded – she’s now in her last few days of work on the projects and feels deflated and disappointed. Personally, I think the timing is wonderful. The job came along at a perfect moment in Deborah’s life, where she needed to adjust to life in Israel, while simultaneously losing her husband to the army. It gave her freedom to work as she wanted, while being available to sort out our mortgage, and to adapt to the new lifestyle. And the job has continued up to just a few weeks before she takes her first steps as a hospital pharmacist in Israel, after some freedom to refresh her knowledge and get ready for the next big step. It’s never easy losing a job, but if it has to happen, the timing couldn’t be much better. And she made sure to get her complimentary Rosh Hashanah present from the office before she leaves. That’s the most important thing.