As Dr. Dhuha Ali stepped out of her dormitory, a glint of light on her chest caught her eye.
It was the tiny red dot of a laser sight. She looked straight ahead at the hospital doors and kept walking.
A loud explosion two feet above her head on the wall to her left shattered plaster all around her. She kept walking.
A second explosion hit closer to her head, and then a third, even closer. She kept walking.
She thought about all the physicians who had been kidnapped or assassinated – colleagues and professors – after the collapse of Saddam Hussein’s Baathist regime.
The wind from the sniper’s fourth bullet caressed her face as it flew past and exploded into the wall.
She stopped, torn between her commitment to the sick and injured patients in the hospital and her own life. But what good would she be to them dead?
She turned around slowly and walked back to the dormitory, determined to return to work another time.
Ali, who now works in research at St. Luke’s, is one of a group of refugee physicians who have made Boise and the Treasure Valley home.
These physicians from widely different global regions have found each other and formed a collaborative study group to further their common dream of becoming a licensed U.S. physician. Most of them say they escaped oppression and certain death in their home countries.
The murder of health care workers, especially physicians, in politically unstable countries is surprisingly common. It is a “force multiplier,” because fewer health care workers will result in fewer injured people receiving treatment. The end result is a higher death rate for adversaries. The red cross becomes a convenient crosshair.
The weaponization of health care
In March 2017 the British medical journal, Lancet, reported on a United Nations analysis of attacks on hospitals and medics in Syria, referred to as “the weaponization of health.” The NGO Physicians for Human Rights website reported a total of 553 attacks on medical facilities during the Syrian civil war, resulting in the death of nearly 700 physicians, according to a March 2017 report in The New Yorker. The website IraqiNews.com reported that more than 2,000 Iraqi doctors had been killed between the invasion of 2003 and 2015.
The secondary effect of this violence is to force the survivors ultimately to flee the country, often to neighboring countries, where they become political refugees. As refugees, these physicians often are relegated to the status of second-class citizens. The governments take advantage of their education and training.
“We made $200 per month working full-time in a clinic,” said Dr. Ziad Alsaifi, a physician from Iraq. He and his wife, Sally Naser, also a physician, lived in a tiny apartment in Damascus with their baby daughter, Sara, for five years. “But it was better than the $2.50 we were making per month during the period of Saddam,” he said with a smile.
Alsaifi and Naser live in Boise where Alsaifi works as a medical interpreter. They decided to leave Iraq when he narrowly escaped an assassination attempt. Aware that they were not Muslims but Mandaeans, a religious group that follows the teachings of John the Baptist, one of the homeless Muslim extremists who loitered outside his clinic ominously told Alsaifi, “Now everything will come back to the Muslim people.” Shortly after that, Alsaifi said his colleague was assassinated at his clinic in Baghdad.
“I was supposed to be working that day,” Alsaifi said. “The clinic had my name on it. They targeted me, not only because I am a physician, but because I am Mandaean. He filled in for me and was killed.” It was a case of mistaken identity that convinced Alsaifi and Naser to leave all of their possessions and flee to Syria with Sara.
In addition to Alsaifi and Naser, Idaho has welcomed several refugee physicians, including Ali, her husband, Dr. Salwan Swidan and his brother, Dr. Marwan Sweedan. Salwan was a cardiologist practicing in Baghdad while the younger Marwan was a trauma surgeon in Ramadi, a lawless city west of Baghdad. The brothers work in the two major hospital systems, Salwan at St. Luke’s and Marwan at Saint Alphonsus.
“The police were killing many people in our neighborhood,” Salwan said. “One day a friend told me he had seen the list of people to be killed that night and our names and pictures were on it.”
Salwan said he called his brother and told him that he needed to come to Baghdad that afternoon to settle some of their father’s business. The threat was all too real to Salwan because he said their father recently had been executed by Shia militia, but he didn’t want to alarm Marwan.
“I didn’t tell him the real reason why because I didn’t want him to behave in a way that could raise suspicions among the people who were watching him,” Salwan said. After Marwan arrived in Baghdad, he said his brother told him about the plot to kill them. They met a family member after the curfew to get forged passports. Later that night, the family joined thousands of physicians who have been forced by violence out of their home countries and fled to become refugees.
The challenges of a new country
Refugee physicians are not always welcome in the new country, however. They risk deportation back home where punishment or death may await them. Those who are able to stay temporarily may not find work and consider themselves lucky to find low-paying work as physicians like Ziad did. Citizenship is difficult in the new country, where they face discrimination. During this time, they become eligible to apply to the United Nations for refugee status, a process that can take five years before finding a new home country.
“We can’t help these doctors with their studying,” she said, “but we do provide support by connecting them with other doctors and services they can use to achieve their goals. For example, we connect them to resources for obtaining loans because they often come to this country with nothing, and no credit, so it is difficult for them to get a conventional loan to complete their studies.”
Through coordination with Global Talent, the Boise refugee physicians formed a study group that meets for three hours every Sunday to study for the U.S. Medical Licensing Examination that U.S. medical students take. These grueling all-day exams are divided into three steps taken sequentially and take a minimum of three years to complete. Refugee physicians must demonstrate mastery of the same knowledge that U.S. students must learn.
Dr. Scott Smith, a physician at the Boise VA Medical Center, has been working with and helping this group for several years.
“These people are extremely bright and motivated,” he said. “At the end of every Sunday study session, they take a mock exam under time pressure, just like the real USMLE. The average U.S. medical student scores around the 60th to 70th percentile. These guys are always well above the 90th percentile.”
Finding successes amid shortages
Smith and the group are doing something right. So far, all four physicians who applied for a residency have matched and have started the final phase of their training. Smith feels that the program’s 100% success rate is a testament to their high intelligence and strong determination.
The American Association of Medical Colleges predicts a physician shortage between 42,000 and 120,000 by 2030. Idaho now is ranked 49th in the U.S. of physicians per capita. Refugee physicians can help fill that void, but it is going to require great determination on their part.
Refugees do not need a visa, may apply for work immediately upon entry to the U.S. and may apply for a Green Card (Permanent Resident Card) after one year. They are referred by the U.N. High Commissioner for Refugees.
Those who make it through the lengthy UNHCR process to come to America still face an uphill battle. Since they do not possess a medical license, they must find employment in other fields. Several become medical interpreters, which helps them learn the American way of practicing medicine. They are unaccustomed to electronic medical records and medical jargon that may be unique to the U.S.
Between the purgatory as a refugee, time spent taking exams and then years of residency training, it can take up to 15 years before these physicians can practice medicine again, despite being some of the best and the brightest in their home countries.
“In Iraq, all high school students take an aptitude test,” Marwan said. “Those who score at the top go to medical school.”
Even non-refugee physicians face challenges
Sanda Karunathilake loves to help people and make them happy. As a 9-year old girl growing up in war-torn Sri Lanka, she was impressed when a heart surgeon saved her father’s life after a severe heart attack.
“He made my family so happy that I decided that I wanted to make people happy, too,” she said. “So I became a doctor.”
When she graduated from medical school in 2016, she was looking forward to helping the poor people in her country. However, her husband received a full engineering scholarship at the University of Iowa, so she came to the U.S. to be with him. He then was offered a job in Boise, so they moved again. Her husband is happy working as a bridge structural engineer for a Boise firm, but Karunathilake is frustrated with her situation.
“He has a F1 student visa, I have a F2 spouse visa, which prohibits me from working or even from volunteering,” Karunathilake said. Her husband is applying for an H-1B visa, which will then allow her to apply for a visa that will allow her to work or go to school.
“I may try to become a registered nurse or physician assistant while I am studying for the USMLE,” she said with a smile. “This will allow me to gain more clinical experience and sharpen my communication skills.”
Karunathilake says she hasn’t been tempted in the past three years to get a job or volunteer.
“I really like this country, and I want to play by the rules,” she said. “I don’t want to risk being deported.”
Despite challenges, there are success stories
Abdullahi Mohamed was born in Somalia in 1986. The government collapsed into anarchy in 1991 and Mogadishu became a violent city, the site of the infamous battle chronicled in the book and movie, “Black Hawk Down.” In this time of chaos, war and famine, Mohamed’s family constantly moved from one apartment to another. Warlords rose and fell in power, making the neighborhoods of Mogadishu their battlefields.
“It was not possible to go outside to play because even if you escaped robbery, rape and murder, the snipers high on khat shot anything and anyone that moved,” Mohamed said. Whenever violence suddenly erupted near their home, Mohamed and his brothers would frantically remove bars from the windows, allowing his siblings and his pregnant mother to jump down to the alley and run to a cousin’s or an uncle’s house far enough to be safe.
Despite having to constantly move their children from one small apartment to another, his parents stressed education and reading to the kids. They had been educated before the civil war and understood the value of knowledge. Although institutions and services such as schools, police, sanitation services and water supply had been destroyed, Mohamed’s parents managed to find books for their children to read.
Study paid off for Mohamed. At 17 he was accepted into medical school at the University of Jordan. At first his classmates poked fun at him because he spoke only an ancient dialect of Arabic used to study Islam. Lectures were in modern Arabic and textbooks were in English, so Mohamed had to learn medicine as well as new languages simultaneously.
He excelled and eventually graduated, which was somewhat bittersweet because his education made it impossible to return home.
Mohamed’s family came from a tribe of poor farmers. Other armed tribes and militias dominated his tribe, and part of that dominance was to deny them goods and services, including health care. Were Mohamed to return home, he could have been killed, he said. His mother told him it would be best for him and for the family to stay away.
But after graduation, Mohamed lost his student visa and entered refugee status in Jordan, which meant he had to find a home country. He worked as an intern and then as a general practitioner in a clinic while going through the arduous process of applying for refugee status. Eventually, the U.N. granted that status and asked which country he would like to go to.
“America,” he told them. “I had a dream to go to America because of the freedom and respect for each other that Americans have.”
Although he had no family or friends in Boise, he landed here in 2013 and immediately got busy making friends and trying to figure out the system.
“I thought I would maybe take an exam and then start practicing,” he said. “I did not know about the USMLE and the residency.” This was a time before the study group had formed, so Mohamed obtained study materials and went to work on his own. He scored high on Steps 1 and 2, which made him eligible to apply for a residency.
The hard work paid off in March when he received notification that he had matched in the Internal Medicine residency offered through the University of Washington at the Boise VA Medical Center, nabbing one of 12 slots out of 1,600 applicants.
“When I hear people on the news complain about certain things, I have to laugh,” Mohamed said. “Where I come from you are happy each day just to be alive.”
Dr. Ali Makki was working at a Baghdad hospital when the statue of Saddam came down.
“We wouldn’t let ourselves believe the Americans had finally toppled this brutal regime,” he said. “We were afraid it would be like 1991. No one would speak freely until Saddam was captured later that year.”
As part of his obligation to the state for his education, Makki began working in a rural province in the violent Diyala Province, northeast of Baghdad. By 2005 he spent a lot of his time taking care of trauma victims, working 24-hour shifts sometimes seven days a week. He occasionally traveled to Baghdad to see his wife, also a physician. They felt the same threats that other physicians were feeling.
“People were constantly asking if I was Sunni or Shia,” Makki said. “My name is ambiguous that way, so I would first assess who they were before answering. Physicians were kidnapped, ransomed and killed.”
“This was especially bad for professors because they were hunted down since, as educators, they could produce an entire new generation of doctors,” he said. Finally, Makki and his wife decided to take their son, leave the country and become refugees.
They found a sponsor who set them up in a rural practice in an undesirable area of Oman, but after two years they learned that Omani law required that they remain in that location unless they could find replacements for themselves. Ultimately, the family applied through the International Organization of Migration for re-location to the United States. It was helpful that Makki had lived in Alabama for the first three years of his life, although he was not born there. His father was accepted to a prosthodontics master’s program at the University of Alabama and his wife followed shortly after Makki’s birth.
Makki and his family finally arrived in Twin Falls in 2009, just after the economic downturn, which made it difficult to find any employment. He eventually found work as a medical interpreter and spent three months in Arizona taking a senior-level medical school rotation to gain experience with the American system.
Working full time and studying all night was not easy for him or his family (by then he had three sons), but it paid off when he passed the USMLE exams with high marks. Armed with that, and some strong recommendations, he was admitted to the Family Medicine Residency of Idaho in Boise, where he is in his second of three years.
Responsibilities weigh heavily on Makki.
“I came from a strong family name in Iraq,” he said. “My grandfather was in the military, eventually becoming Minister of Defense before the time of Saddam. We had an obligation to maintain and uphold the family honor, so my brother and I studied hard. My parents both were prominent dentists in Baghdad.” He also feels an obligation to the other physician refugees in Idaho.
“I feel a responsibility to my colleagues to do a good job as a resident to show the medical directors that refugee doctors are valuable and capable of doing good medicine,” he said.
Marwan feels responsibility as well and has been a powerful force in organizing the study group. He and his brother, Salwan, came from a prominent Iraqi family as his father had served as a general in the Air Force. At the time of the 2003 invasion he was working as a trauma surgeon in Ramadi. After spending five years as a refugee in Jordan and going through the UNHCR application process, Marwan came to the U.S. and joined the Army as a combat medic.
“I felt this would be the best way to learn the American culture,” he said. “Half of my uncles had received their education in America. It is the best country on Earth.”
“When the contractors came to Baghdad, we became familiar with them and realized how generous the American people are,” Salwan said. “I thought, America is where I want my son to grow up.”
Although, for the most part, these refugee physicians have felt welcome in Idaho, occasionally, they have faced disparaging remarks or behavior. Salwan feels this is just human nature, fear of “the other,” and tends to ignore it. However, he does admit to occasional frustration.
“Sometimes I get upset when I hear people complain about refugees,” he said. “When refugees come here, they are survivors, they are hard workers. The don’t come here by laziness. They don’t have high expectations. They work hard, they don’t mind starting from scratch. They appreciate this life, and they realize they have to work for everything they get. Refugees are what you want in this country.”
“There isn’t a problem big enough to cripple us, because we have been through the worst,” he said.
Dr. Timothy Floyd is a spine surgeon and a fellow of the American College of Surgeons and the American Academy of Orthopedic Surgeons. He practices in Boise.