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Royal Treatment

Sept. 1, 2001
Hygienist offers an inside look at a Saudi Arabian palace where the patients are treated royally.

by Joanne Iannone Sheehan, RDH

Hygienist offers an inside look at a Saudi Arabian palace where the patients are treated royally.

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Ever wonder what it would be like to practice hygiene in another country? Need a little change of venue? After 13 years of practicing dental hygiene in Nova Scotia, Lisa Flowers, RDH, was presented with just such an opportunity ... and she grabbed it! An agent recruiting medical personnel to work in Saudi Arabia aroused Flowers' interest. Although the agent wasn't looking for dental personnel, she was impressed with Flowers during an interview. Flowers was hired on a one-year contract, becoming the agent's first dental hygienist.

The dental staffs in Jeddah were housed in a resort area, owned by the country's royal family.(two photos above)
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Flowers spent a month completing the ensuing paperwork. But she also used the time to research the area where she would be working. Understanding and getting used to the culture and religion in Saudi Arabia is of paramount importance. After three years of practicing hygiene there, Lisa is a fountain of information for any hygienist contemplating an Arabian excursion.

"In Saudi, the way the locals interact with others — daily routines, laws, and social mores — all stems from the Muslim religion. You need to spend some time understanding the new environment," Flowers said. "This will help you deal more effectively with the people and help you understand their behavioral differences."

The agency's one-year contract has a return ticket attached. There is a three-month period where, if things don't work out, either the hygienist can back out or her employer can terminate her. Lisa chose the King Faisal Hospital and Research Center in the Department of Dentistry in Riyadh. At that facility, tertiary-care patients who are medically compromised are treated on specific days and the royal family's relatives on other days.

Lisa Flowers
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"Ambassadors go through the Protocol Dental Clinic and then they are escorted though the huge doors to the hospital's Department of Dentistry," Flowers explained. "I've treated the royal relatives. They say there are more than 2,000 princes and princesses. But I treated all my patients with the same professionalism and respect, whether I was treating tertiary-care patients or the royals. They were my patients, and I cared for them all."

American hygienists in Saudi also represent their country. Flowers said a definite pecking order exists in Saudi society, and the way the natives treat you depends on gender and nationality. Americans, Canadians, and Swedes are held in much higher esteem, she said, than people from other countries. The seven hygienists in the Department of Dentistry were made up of Americans, Canadians, Swedes, and Saudis. The 32 dentists were comprised of Americans, Swedes, and Saudis.

"The Saudi women treat you like a woman and a therapist," Flowers said. "The Saudi males accept you as a therapist, but also see you as a woman who is a temptation. This is one aspect of their culture you need to understand."

Flowers explained, "In Saudi Arabian culture, the women have all the power, sexually. The men cannot suppress their sexual urges; therefore, it is always the woman's fault. Western women get stared at constantly by men in public places. You need to ignore it."

When asked about the level of dental hygiene care among Saudi patients, Flowers replied, "You need to be prepared to have a lot of patience as a hygienist.

The dental chair sits in the "outside" clinic at the palace in Jeddah.
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"The majority of the population in Saudi does not have a basic understanding of oral health. Most of the rural people have never seen a toothbrush, let alone dental floss. They are using a twig from a specific soft wood tree. They usually scrub anterior teeth only. This is their daily oral hygiene. "God Willing" is the guiding principle for all things and that includes good or bad health. Since it's in their God's hands, the final state does not depend on anything that they can do, so why do anything?

"This is where patience comes into play in a very large way. You have to help them understand that they are in charge of their dental health by repeating oral hygiene instructions with lots of positive reinforcement and encouragement."

She said she resisted the urge to trash the twig, since it's such an integral part of Saudi culture. She learned to integrate the use of it by mixing cultural rituals with good oral hygiene instructions.

"From my perspective, this is the only way you can be successful as a dental hygienist in Saudi Arabia," Flowers commented.

She also had some interesting observations about how she dealt with the religious and cultural differences.

"You need to know your rights and have some knowledge of the Saudi's beliefs," Flowers said. "According to their religion, they are not allowed to touch you. If they do, they will have committed a sin.

"Once, when I was being driven in a cab to a dinner at the American ambassador's house, we were stopped by the police. I got into an altercation with them about my citizenship. I had a written dinner invitation in my hand. But because I am of Vietnamese ancestry, they didn't believe that I was a Canadian citizen. They said I was Filipino. Filipino women are treated shamefully in Saudi and their embassy does nothing to help them. A policeman touched my arm through the car window. He wanted to see what I was wearing under my abbayah or coat. I jumped out of the car and confronted him and the other policemen, shouting 'Harram! Harram!' This is their word for having committed a big sin. They were shocked and embarrassed that I knew the policeman had broken their religious laws. They told me to get back in the car and leave quickly."

According to Flowers, a woman must carry a marriage certificate with her if she goes out with a male companion. It is not allowed for women to have a male traveling companion without being married to him, although Flowers admitted that she got away with it a few times.

"They can legally have you put in jail if you don't have a marriage certificate, but they can't touch you during the process," Ms. Flowers said. "Because of this, women and men never develop friendships in the Saudi society as they do in western countries."

Flowers requested the agent to place her in a city, since there is more freedom there than in the rural sections of the country.

"In the rural areas, foreigners or expatriates have to keep their heads covered. One must wear an abbayah, or a sort of black, flowing robe to cover one's clothes. If a woman's ankles show below the coat, the Religious Police or Matawa will hit her ankles with a cane and may put her in jail. If a man is walking with his wife and her ankles are uncovered, they will hit her husband with a cane. No skin is allowed to show and no clothes that show your body form are permitted. But in Dahran, which is a distance from the capital and rural areas, you can wear a suit with a long skirt and a long-sleeved shirt for a brief period of time outside, covering your ankles somewhat. No abbayah is needed. As long as you don't make a day of it outside, you're OK."

She recalled when a Canadian nurse shared a cab with a man who was not her husband. She was caught and sent to jail. The administrators from the hospital bailed her out with a warning.

In the cities, the same designer clothes that are worn in the United States are sold. Unfortunately, since the Saudi government does not want Western influences diminishing or replacing their culture, if you buy fashionable clothing, you may only wear them indoors. Clothes are imported from Europe and America and are more affordable because there is no import tax.

Gold is very inexpensive. Eighteen-karat gold is imported from Italy and 22-karat gold is a product of Saudi.

Saudi culture is different. Another reason for the three-month trial period is the importance the royal family places on privacy. Flowers said one hygienist was suddenly sent home, although no one knew why. It was thought that she had violated the privacy of the royal family by gossiping about them on the phone.

How the culture affects hygiene
If a hygienist can limit herself to practicing dental hygiene, she'll be fine. She just has to get used to unusual sights such as guards at every door and bodyguards escorting the royals to and from the clinic. Flowers said they would switch her patients to another hygienist's schedule for one patient deemed more important. If the esteemed patient was late, she would just grab a cup of coffee and wait. She usually had one hour per patient. But for ambassadors and royal relatives, she could ask for more time.

Since most of the royal family speaks English, communication is not a problem. But the rule is not to get too personal with the patients.

"I always kept my distance as much as I could," Lisa said, "and made sure I was never left alone with them in a social setting. I was always in a group. This helped to avoid any misunderstandings or possible problems. If the hygienists were invited to any social or private get-together with the royals, their immediate supervisors cautioned them against it. They could go if they wanted, but they must act responsibly and within set limitations."

"In the clinic, being alone with these same people was a different story, Flowers said. "Every operatory had a door that closed and locked. When treating a women, I would be asked to close and lock the door so a man wouldn't walk in and see her face unveiled. One would have to knock and identify himself or herself before entering. It's OK for women to see each other's faces, but not the opposite sex. A male patient would sometimes have his bodyguard outside the door, but I would be alone with the patients while treating them."

The government supplied the hygienists' uniforms. Lisa wore only white — pants, short-sleeved top with a lab coat. Her equipment rated from top of the line to average. The facility was beautiful, she said. Flowers said she never saw any dilapidated dental chairs or outdated equipment. She was allowed to order any instruments she wanted and she took advantage of that freedom by ordering her favorites from dental companies. There were 10 instruments in each set, all brand new. The team of receptionists gave her a list of patients, but it was a flexible schedule.

The royal family owns the lodging for the dental and medical staffs, and they pay for the hospital and everyone's housing. While she did not elaborate on her salary, she did say that the hygienists are not paid as well as in most parts of the United States or Canada. But then there was no income tax, resident tax, no personal expenses, or rent.

The Al Yamamah Clinic is a satellite dental clinic that treats the immediate royal family at two locations — one at the King Fahad's Palace in Jeddha and the other at his palace in Riyadh. The palace consists of many buildings with several surrounding walls, resembling a walled-in city. It's so large that one has to drive to get around inside the palace.

The royal family's hygienist is on a rotating shift with two other hygienists. Only one is at the palace at a time. The Al Yamamah administrators request certain dentists and hygienists to work in the King's Clinics and prefer Americans or Canadians. Two clinics are inside the palace, although one is called the Outside Clinic and the other is termed the Inside Clinic. The Outside Clinic treats generals and people considered less important than those treated in the Inside Clinic, which is the king's immediate family. If a hygienist chooses or is selected to work for the royal family in one of the royal palaces, she will make double the salary with bonuses. All expenses are paid, including meals. The housing is much better, comparable to resort accommodations.

It is interesting to note that King Fahad has his own dental chair in his own clinic inside the royal palaces in Jeddah and Riyadh — for security reasons. Flowers said she was called to treat him once at 9 p.m., but by the time she could be driven there, the king's dentists had already treated him. He didn't want to wait. Two dentists attend to the king, rotating shifts as the hygienists do. The crowned prince resides at his palace in Al Rawdah. Unfortunately, he does not employ the expertise of a hygienist; two dentists care for the dental health of the prince.

Flowers said that, even with cultural and gender differences, she was respected by most because she was a clinician and because they invited her to come.

"For me, the experience was well worth any sacrifices I had to make," she said. "Don't let the differences in culture and religion discourage you. There is a very large network of expatriates living in Saudi that can guide you and help you with cultural issues. Working in Saudi Arabia is a challenge and will be one of the best experiences in your life."

Author's Note: Anyone interested in practicing on contract in Saudi Arabia can contact the recruiting agency of: Helen Ziegler & Assocates, Inc., 180 Dundas St.W., Suite 2403, Toronto, ONT., Canada M5G 1Z8. The phone numbers are (800) 387-4616, (416) 977-6941, or (416) 977-6128 (fax).

Joanne Iannone Sheehan, RDH, is a frequent contributor to RDH magazine, and she is based in Huntsville, Ala.

The 'common' patients
As a favor to the commoners, King Faisal allows patients who need advanced medical or dental treatment to use his hospital on specific days. Many of these patients in tertiary care were undergoing chemo or radiation therapy. Some had undergone heart or liver transplants, and some had developed severe ulcers from cancer therapy. Flowers had to be on the alert constantly, checking their charts for medications they were taking, such as Warfarin, a blood-thinner. The patients' medical conditions and treatments directly affected their oral health.

Flowers saw patients with xerostomia and other challenging conditions. It was hard work, she admits, and was sad when patients she had grown fond of didn't come back. She didn't always know what had happened to them. Patients in this clinic did not speak English, but a translator would appear at Lisa's request. When Saudi women came in for treatment, they frequently would be wearing a veil, expecting to see a male. Flowers would then ask the patient's husband to remove the veil, since it is their custom to address the husband. Through a translator, she would explain oral-health instructions.

Flowers commented that the approach to providing treatment depended on the patient.

"Your patients will range from poor rural folk to royal family members. Most royals speak good English and understand Western culture very well. The rural patients don't. You will have to individualize your treatment and approach depending on who is seated in your chair." Lisa explained.

The dental chair above sits in the "outside" clinic at the palace in Jeddah. Lisa Flowers (right) tries on a gift given to her on the first birthday she celebrated while employed in Saudi Arabia.

The dental staffs in Jeddah were housed in a resort area, owned by the country's royal family.