Published August 15, 2012
Dicle University Hospital is a massive complex of concrete and green glass buildings sprawled across a hillside in Diyarbakir, the de facto capital of Turkey's Kurdish southeast. It is lunchtime, and in the blistering June heat medical students eat outside, seated on low stools beneath dry trees. Nearby families picnic in the parking lot, waiting for news or hoping for an appointment. The hospital is crowded but not overrun, worn but functioning, aging but well. And contrary to the dominant narrative here, it is where the alienated Kurdish population lives amid a violent resistance; where that resistance can result in death or prison; where jobs are scarce and education interrupted; where the Turkish state is the oppressor and its army the enemy; and where the prosperity of other Kurds, just across the border in Iraq, is at once a consolation, a beneficence, and an insult. In most instances, it is Turkey's Kurds who must seek solace and aid from their wealthier neighbors, but when it comes to health care that relationship is reversed. At Dicle University Hospital, it is the Turkish Kurds who have it good and the Iraqi Kurds who must travel outside of their country and pay a lot of money to get better.
Health care in Iraqi Kurdistan is still stuck in the ruin masterminded by the regime of Saddam Hussein. But the lack of hospitals doesn't stop the population from growing—as Iraqi Kurds move back and foreigners swoop in. A population booms, and oil wealth looms, but the cities and their hospitals falter.
"We are a learning country," Interior Minister Karim SinjarI told me. Our large armchairs are angled toward one another in his office's well-appointed meeting hall and just behind us both the Iraqi and the Kurdish flags stand tall in gold posts. Sinjari continues, "Building roads is a problem. There is water in some places, but not in others. There is a problem with the medical care." Above our heads, chandeliers hang in the still air and a government photographer takes a few, efficient shots of the meeting. The office reflects the hopeful attitude of the Iraqi Kurdistan government; it's fit for a rich country. But the story the room tells goes beyond the trappings of a growing economy and the new government that oversees it; like many of the structures in Erbil, Sinjari's office is defined by the terrible history it was built to conceal.
"In 2007 a car bomb destroyed all of this," Sinjari says, gesturing to the wall behind us, the flags, our armchairs. A number of employees were killed and now staggered concrete barriers keep vehicles from approaching the rebuilt office. Sinjari uses the attack to illustrate his government's priorities: safety first. In the meantime, Iraqi Kurds can go to hospitals in Turkey.
On that hot June day there are three Iraqi Kurds checked into Dicle University Hospital. They are there because of the better treatment, and because hospitals in southeastern Turkey are relatively close to Iraqi Kurdistan and staffed by Kurdish-speakers. Fifty-year-old Abdullah Temo has traveled from his home in Dohuk to Diyarbakir to take advantage of what university public relations tells me is the finest transplant team in the Middle East ("Maybe forty years ago," the hospital accountant jokes). Temo had undergone two procedures in his native Iraq—one in Erbil and one in Dohuk—to repair his first surgery, a kidney transplant, also preformed in Dohuk, that had become dangerously infected. His frame is reduced to bones, dwarfed by a large green diaper, his only article of clothing. "I was going to die before I came here," he says. "In Iraq the doctors give us lots of medicine, but the medicine isn't good. Here it's cleaner, and the doctors are better. Only the money's worse."
Temo tells me he is paying $10,000 for his four-month stay at Dicle University Hospital, and while that is less than what he would pay at a private Turkish hospital (at least twice that, the hospital press liaison tells me) it is far more than back home, where he paid nothing, and more than a Turkish patient with the same ailment would pay. Patients like Temo give public and private hospitals in Turkey, where Turkish citizens have access to free or significantly cheaper services, a chance to make a substantial profit. The hospitals are mostly leaping at this opportunity, setting up recruitment offices in Erbil where they advertise special deals like a travel agency—cut rates at five star hotels and discounted airfare if you choose to have your heart operation in Turkey.
The staff at Dicle University Hospital is excited about opening their own Erbil office in a few months, and not just because of the money. Iraqi Kurds crossing the border for Turkey's superior hospitals makes Diyarbakir's residents—whose reputation for political unrest normally exceeds their reputation for successful transplant surgeries—proud. Their doctors are heroes in a cross-border relationship in which aid usually flows in the opposite direction. As one doctor says, standing in the hallway flanked by eager medical students, "Our doctors could teach their doctors."
But this system is a dangerous one, excluding poor Iraqi Kurds and, less directly, poor Turkish Kurds as well. Not all doctors in southeastern Turkey consider this growing market to be a good thing. Cengiz Guney, a doctor at Diyarbakir's Memorial Hospital, is having a busy day when I visit him. Memorial Hospital is private, and its halls and rooms fancier and more spacious than at Dicle University. The public hospital is sterile and handsome, but Memorial is made-up with flowers, cushiony armchairs, and bright tiles. All this makes Dr. Guney unhappy, and between patients he runs into the office—where I'm sitting with my interpreter—to complain.
"They don't care about being good," he says. "They only care about getting people from northern Iraq who have money." Most of them pay in cash, Guney says, and it's not just the hospital that profits; along the way, recruiters, drivers, referrers, and anyone involved with making sure that patient chooses Memorial Hospital gets a fee. Like most things in Turkey, health care is political and hotly debated. Guney's objections identify him as left-leaning, opposed to the AKP government and the increasing privatization of Turkey's health care system. The ushering of only the wealthy to his operating table violates Guney's notion that health care should be "equal, free, and accessible." The doctors he knows, he says, are "mostly against them coming. We are against the idea that we can save the lives of whoever has money and those who don't have money will die."
Guney expresses a solidarity with other Kurdish doctors in the region and has attended a number of conferences with the purpose of devising a way to collaborate beyond the profit-based system—to use Turkish expertise and resources to establish sustainable health care in Erbil, rather than exploiting the area's floundering infrastructure. "Right now, we have a colonialist approach to the health care system," he says. "The hospital paid money to establish an office in Erbil to recruit patients and Iraqis think Diyarbakir hospitals are good because they are famous. This is an ambush."
Erbil's malls and clinics are full of pamphlets advertising medical services in Turkey, from transplants to nose jobs. In a small clinic off a main street in Erbil, a doctor sits behind a rickety gray desk, beleaguered by paperwork. The small waiting room has neither the wealthy sheen of Memorial nor the promising antiseptic appearance of Dicle University. It feels hidden from the city, and indeed the outside is camouflaged beside identical apartment buildings and shops. If the perception in Turkey is that all patients from Iraqi Kurdistan can and do pay for better care across the border, that is certainly not the reality here. Neither is the belief in the infallibility of the government's "safety first" rationale—here such policies are viewed as a way for officials to shirk their responsibility to all of their citizens, even those unable to afford better care in Turkey.
The doctor is busy treating patients too poor to travel and sometimes, he says, the medicine is expired or impossible to get and sometimes the local hospitals can't provide treatment. He's considered taking a job in a hospital in southeastern Turkey. It would certainly be an easier life, with less pressure and more success, but his determination to work in Erbil is a hopeful counterpoint to the magnetism of Turkish medicine. Like many residents in Erbil, the doctor lived abroad when Saddam was in power, but joyfully returned when he fell, unable to resist the promise of a free, prosperous Kurdistan. Like the scores of other returning professionals, he didn't come home to a city he loved, or one that resembled itself, but to a city he wanted to be great. In his ragged Erbil office the doctor is like a squatter living on barren land, dutifully stacking a few bricks around him with the assurance that one day he is sure to wake up in real house.