The Global Zeitenwende
How to Avoid a New Cold War in a Multipolar Era
Not far from Tahrir Square sprawls Sayyida Zeinab, an impoverished district named after the patron saint of Cairo. It’s a working-class neighborhood. Many of the residents are butchers who sell raw cuts of meat on open tables to passersby; goats amble through the narrow alleyways, red Xs on their hides marking them for future slaughter.
But behind the ancient mosques, apartments, and historic coffee shops is something new and unexpected: a children’s cancer hospital built on the old bones of a defunct slaughterhouse. The gleaming and modern hulk might have been rejected by the district’s conservative populace, especially since the Mubaraks had supported hospital fundraising efforts. But it wasn’t. During the unpredictable weeks before and after Mubarak was ousted, looters set fires, overturned cars, and broke windows in the streets of Sayyida Zeinab. But they drifted away from the hospital, as though its surrounding gardens were a hallowed ground. And one night, when a small crowd did rush the hospital, the butchers—those who had lived in the neighborhood for generations—gathered with their cutlery to protect the hospital gates.
One person who wasn’t there that night was Leslie Lehmann, an American doctor who spends weeks at a time each year at the pediatric hospital in Sayyida Zeinab. “I was in Rwanda when the revolution began in Egypt,” Lehmann, who, in her late 50s, is still as fiery and passionate about medicine as when she started her training decades ago, tells me. “I was standing in the sun, on this peaceful hillside, trying to imagine the tumult in Cairo.” Lehmann, clinical director of the Stem Cell Transplant Center at Dana-Farber/Boston Children's Cancer and Blood Disorders Center, is just back from a visit to Egypt. Many of her colleagues, reading the frightening reports in the newspapers about journalists illegally detained in jails, women groped in public squares, and roadside bombs that detonate in crowded streets, worried about her safety.
They were right to be. During any struggle, medical services attempt to operate as sanctuaries of neutrality. Just last year, the Western Galilee Medical Center in Israel treated countless wounded Syrians who fled across country lines. Médecins Sans Frontières has been in continuous operation since 1971 and has recently sent health-care workers into Afghanistan, Iraq, and Sudan. Even here, in Boston, doctors and nurses at the hospital where I work cared for the alleged Boston Marathon bomber with the same devotion they would show any patient. Medicine, at its best, allows people to forget their divisions.
But practically speaking, humanitarian efforts do not remain apolitical. The Syrian government has attacked medical workers in rebel-held areas; Médecins Sans Frontières has been forced to withdraw from conflict zones because of violence against medical staff; recently in Gaza, 24 medical facilities were struck by bombs, killing 21 medical staff and injuring 83. Since then, five hospitals have closed entirely.
Lehmann, though, hasn’t been deterred. She’s still a bit jet-lagged from her recent trip, but she offers me a little tour around her office, a quiet alcove on the third floor of Dana-Farber Cancer Institute. “That I got in Cairo,” Lehmann says, pointing out a little statue puffing on shisha beside her stack of oncology journals. A backlit painting of Mecca leans against a set of books. Displayed on a table is a tea set from Baghdad. It’s unlike any doctor’s office I’ve ever seen.
“This hasn’t been easy, really,” Lehmann says, setting down her coffee. “I don’t do this for academic promotions. But it’s in places like Egypt or Rwanda or the Middle East—that’s where we can create the most change.” She stands up and smoothes her white coat. Morning rounds in the cancer ward are about to begin.
The National Cancer Institute in Cairo opened in 1969, years before the children’s hospital in Sayyida Zeinab was constructed. Its very existence was radical for the time and place. Even today, the word for cancer in Arabic, saratan, is rarely used; people fear its utterance and refer to the illness euphemistically. “I have the bad disease,” an Egyptian woman might whisper to her husband. For years, Egyptian women with breast cancer were barred by their husbands and the medical community from seeking treatment until their tumors grew so disfiguring that the growths were apparent through their clothes. So when the NCI opened its doors, cancer patients finally had a place to go.
Unfortunately, the NCI has had terrible luck since then. Recently, during the 2011 revolution, protesters used its walls to set up ramparts and equipment; part of the hospital was bombed out during the violence. And before that, despite funding from the Mubaraks, the concrete walls of the NCI had cracked and the ceilings sprang daily leaks, dripping brackish water onto patients’ cots. Sherif Abou El Naga, an Egyptian pediatric oncologist at the NCI in the 1980s, would watch children with cancer dying in front of his eyes at unprecedented rates: nearly eight of every ten children admitted died. El Naga, believed the solution to fixing their hospital did not lie with the government, but rather with the people of Egypt and, perhaps, some American friends.
El Naga found his American in Dallas, Texas. One day in the late 1990s, an architect named Jonathan Bailey was sitting in his office when he got a phone call. “It was from Egypt,” he told me. Bailey’s firm builds hospitals and consults for troubled health-care systems. “The call,” he went on, “was from the National Cancer Institute in downtown Cairo. They wanted us to come visit immediately. But it was a difficult time to travel to Egypt,” Bailey remembered thinking. Just a few months prior, 62 tourists who visited the Temple of Hatshepsut, one of Egypt’s main tourist attractions, had been massacred by an Islamic fundamentalist group that had sneaked onto the grounds armed with automatic weapons and butcher knives. Travel from the United States and Europe to Cairo stagnated. “They were surprised, I think, when we finally said yes, that we were coming,” Bailey said.
Bailey and his team arrived at the NCI in 1998. The crew stepped into the facilities and was immediately horrified. The rooms on the hospital ward had been designed to hold four beds; instead, there were at least eight to ten cots in each, with no space between them. The air conditioners had failed. The hot, dry desert heat rolled in through the open windows. Horseflies were everywhere. “I could only get to the fourth floor before I had to turn around,” Bailey said, sick to his stomach. “I saw a mother whose baby had died in her arms days ago and flies had gathered all over the baby’s body. The mother had begun wailing. The whole hospital was wailing with her. The sound was deafening.”
Bailey remembered walking into a room used to administer chemotherapy. “The room was probably about 11 square meters,” he said, “with a single light bulb on a cord dropping out of the concrete ceiling.” In that room, he saw a group of women sitting on the floor with packets of intravenous medications piled up like sandbags. They had no hair, and their skin was stone gray. These women were not patients—they were chemotherapy nurses who had fallen ill. Having no knowledge of how to deliver the drug, the nurses had inadvertently dosed themselves. Over the years, toxic levels of chemotherapy had accumulated in their blood. “What I saw hit my core,” Bailey said.
Bailey followed the pediatric oncologist who had called him, El Naga, back to his apartment on the 11th floor of a residential tower. They stood together and looked at the city splayed before them, the Four Seasons Hotel, the dense apartments and slums, and, beyond that, the glittering Nile. Here, El Naga laid out a vision for Bailey.
We want to build a new hospital, he told Bailey, pointing out the poor district of Sayyida Zeinab, the neighborhood full of slaughterhouses and butcher shops, where the NCI owned some additional land. We want to partner with you, El Naga told Bailey. We want a hospital that imports American principles of health care, but one that will remain distinctly Egyptian. And the hospital would be specifically for children, a pediatric oncology hospital larger than any other in the Middle East. Bailey looked out at the landscape again, thinking about El Naga’s description, the squalor of the NCI, the fractures between the United States and the Middle East. “You gotta be kidding,” Bailey remembered saying out loud.
WITH THE CURRENT
But he stayed. For an architect, designing a hospital in another country is a special challenge. “If this was going to happen, it couldn’t just be an American hospital,” Bailey said. He was right. Consider a recent case in Afghanistan: An architect at an American company received a grant to build hundreds of schools across the war-torn country. The buildings were constructed out of cement, the way they might have been built in a U.S. suburb. But when the schools were complete, no child would go inside. The buildings were simply too cold. In Afghan villages, buildings aren’t usually made of cement and concrete. They are made of adobe, which helps keep rooms warm enough in the winter and cool enough in the summer.
“It is possible to do it right,” says Bernard Amadei, a professor of civil engineering at the University of Colorado, who was recently appointed as a science envoy by U.S. President Barack Obama. “But you have to go slow. You have to get to know the local people, tap into their talent, and form relationships. This takes a great deal of time, often the kind of time that big companies don’t have.”
But Amadei isn’t a pessimist. He’s a pragmatist, who has faith that science and technology can bring people together. “If you give scientists and engineers a problem,” he says with a laugh, “they will fall in love with each other.” Between 2010 and 2011, Amadei received a grant from the Heinz Foundation to organize two meetings in Cyprus that brought together 40 people from Egypt, Israel, Lebanon, and Syria. “Okay guys,” Amadei remembers telling them. “We’re going to be stuck in this room for three days. You are all engineers and scientists. We are going to find a common problem and we’re going to solve it together.” Slowly, conversations began and ideas took root.
Within days, the team had narrowed in on the Kidron River, a foamy waterway that passes through territories controlled by Israel, the Palestinian Authority, and the civil administration in the West Bank. People in every area avoid going near the water’s edge. The channel, which begins in East Jerusalem, carries the sewage of almost 300,000 people underground and then in the open air, sickening those who live nearby. Now, an organization called Engineers Without Borders, which Amadei helped found about 15 years ago, has five chapters in Israel and three in Palestine. Ever since the meetings in Cyprus, the organization has been working together to clear the waterway.
Back in Egypt, Bailey planned to include in the new children’s hospital the latest in Western technology, such as HEPA filters to purify the air in the cancer wards of viruses and bacteria. However, the exterior of the hospital would take on the shape of the felucca, the traditional wooden ship that was carried by the breeze along the Nile. The hospital would be tuned into its location in other ways as well: reflective glass would keep down electricity costs, a mosque would operate alongside the wards, and the mission would appeal to Cairo’s diverse citizens—to treat and cure regardless of faith, race, or ability to pay. “It had to be a hybrid,” Bailey said.
As Bailey’s team began putting together an initial schematic for the hospital, the Egyptian teams began a public fundraising campaign. To collect donations, they opened a bank account that ended with the sequence 57357. Soon, those five numbers were everywhere. Teachers, policemen, firemen, and student unions stepped forward with donations, giving tiny slices of their paychecks for the new children’s hospital. Anyone could walk into a bank and donate a few cents for the cause. “Put it into 57357,” they said. Meanwhile, Suzanne Mubarak, Egypt’s first lady, helped organize lavish parties that pulled in the resources of the city’s elite.
Bailey’s time in Cairo was limited—he had his own company to run. By 1999, with initial schematics for the facility laid out, he handed the reins of the project over to the local team. “I was still in doubt,” Bailey said. At the time of his departure from Egypt, there was hardly anything in the coffers for a project that was estimated to cost over $290 million.
Aristotle taught that there are two kinds of friendships: personal friendships and civic friendships. In a personal friendship, two people care about each other mutually. Sometimes it’s hard to say how these friendships are born, but they usually revolve around something—a shared interest in sports, music, literature, a specific ideal, or a common memory. But in modern life, we don’t ordinarily deal with close personal friends. And this is where civic friendship comes in. William Rawlins, a professor of communication studies at Ohio University, has made the study of friendship his life’s work. Civic friendship, he said, is when two people, or two groups, who may not have anything to do with each other or who may not even like each other develop a concern for a common good. “They may share community or a peninsula.” Or the two groups may share a predicament: an epidemiological puzzle or a common disease.
About seven years after he left Egypt, Bailey got another call, this time from a colleague. It was one of his staff members from the Middle East, who had been passing through Cairo. “There’s a really wild building going up here,” the staff member said. “A really cool building.” A moment later, Bailey saw pictures coming through his fax. “I was flabbergasted,” Bailey said. “It was 57357, and from what I saw, it was almost completed.” Electrified, he got in touch with old contacts in Cairo and learned that Egyptian engineering and fundraising teams had managed to bring his design to life. But “they had no money left,” he said, “and they needed us to go out there and finish the job. They told us their mechanical systems were a wreck.” Bailey returned to Cairo. “I put people out there at no cost, and we finished the rest of the building.” A year later, his team helped with some of the interiors. “They had no MRI machine, the furniture had to be specified, the interiors had to be finished,” he said.
The hospital finally opened on July 7, 2007, with a capacity of 185 beds, expandable to 350, with operating rooms and intensive care units up and running. More than 90 percent of the funding had come from Egyptians. The architecture, design, and operations had been engineered through collaborations between Americans and Egyptians. Officially, the hospital was called the Children’s Cancer Hospital Egypt. But most of the city’s residents didn’t know it by this name; instead they remembered how their donations had led to the hospital’s construction. To this day, they tell cabdrivers, “Take me to 57357.”
One morning in Boston, Mark Kieran, the clinical director of the Brain Tumor center at Dana-Farber/Boston Children’s, discovered two people sitting in his office. The man introduced himself as El Naga. The nurse with him was Pat Pruden, a Canadian working in Egypt. Kieran, who had never been to Egypt and had never heard of Bailey, sat down and listened. We’re building this hospital, El Naga told Kieran. As our hospital goes up, could you help us design a medical oncology program in Egypt?
For a while, Kieran sat in disbelief. El Naga showed him photographs of the construction site. “At the time,” Kieran said, “it was just a big hole in the ground. It was hard to believe; I never thought they would get the hospital up.” But he agreed to stay in touch, answering El Naga’s questions to the best of his ability. Then, in 2007, Kieran was shocked to find an envelope containing prepaid plane tickets to Cairo. An onsite visit, it seemed, could be delayed no longer.
In February 2008, Mark Kieran visited the Children’s Cancer Hospital. The building stood before him, more beautiful than he had seen in the latest photographs. “This was like any modern American hospital, almost better,” he said, noting the CT and MRI scanners and the cyclotron (a machine that makes the radioactive isotopes necessary for PET scans). And sometimes, he remembered he was in another country. “Many women wore western dresses, working side by side with those in traditional scarves or abayas. Some men were in suites, others in the traditional Arab thawb,” he told me. “Some of the patients’ families were herders, who had come in from the desert, and were provided a new set of clothes to wear,” he said, since their traditional garb was often infested and could pose a risk to the patients. “Midway through a lecture, sometimes people would suddenly get up and go into the back of the auditorium, kneel down, and begin to pray. Learning to understand different cultures and customs is important, and this was part of my education.”
Kieran stepped into the hospital clinic, where the Egyptian oncologists had started caring for children with cancer. Immediately, he noted the absence of coordinated multidisciplinary care. “One of the first children I met was a four-year-old child who had a recent operation for a brain tumor,” he said. “After his surgery, the patient was expected to transfer the information needed to initiate radiation or chemotherapy” and had thus fallen through the cracks. That same day, Kieran’s team met with local faculty. Kieran brought all of the specialists together. “Neurosurgeons, radiologists, radiation therapists, and neuro-oncologists need to work together.”
Kieran also discovered that many physicians at the Children’s Cancer Hospital were using an outdated chemotherapy regimen to treat some kinds of tumors. Survival rates in Egyptian children with cancer were significantly below those of Western countries. So, “starting that day, the optimal therapy for each disease was selected from those already tested in either North America or Europe,” Kieran told me, explaining that he also instructed his staff start tracking outcomes. “If we saw they were inferior to [standard] rates, we knew they were doing something wrong.” Kieran told me that he “probably helped cure more kids with cancer in those few days I was in Cairo than in the rest of my life combined.”
Soon after, Kieran and his colleagues organized an international meeting, inviting specialists from Europe and North America to Cairo, to provide expertise in every area of pediatric cancer to learn from hospitals in other countries. The Children’s Cancer Hospital Egypt, it later struck Kieran, had become the largest freestanding pediatric cancer hospital in the world, by a factor of ten. It was much larger than his own Children’s Hospital back in Boston.
Kieran began to go back and forth between the two cities. “I started bringing my kids,” he said. “One Christmas Eve, the doctors at the hospital had put together a Christmas party for us. We had an Egyptian dinner and sat around a Christmas tree.” They even bought us Christmas presents to make us feel at home.” He told me that he kept thinking that it was an opportunity. “During those trips, we became equally committed toward learning about each other,” Kieran said. Standing in the hospital, watching his colleagues from Boston speaking with the staff in Egypt, he saw two different worlds coming together.
“I heard about the hospital from Mark,” Lehmann remembers. “And yes, I was worried,” she tells me, speaking of when Kieran asked her if she wanted to come with him on his next trip. “I was worried about my personal safety. I was worried about how I would be perceived as a woman, especially as an authoritarian American woman. Let’s face it”—she laughs—“I boss people around. I didn’t know how they would perceive me over there.” She pauses. “And Egypt. It’s a long ways away.”
But in November 2009, Lehmann boarded a plane to Cairo. She was traveling by herself. “What I remember first,” she says, “is the smell of the city, after we landed. It was like burning smoke, like burning trash. The memory of the smell stays with you. My heart constricted. I fell in love with Cairo in five seconds,” she says. Driving from the airport to the center of the city, she heard car horns all around her. “There’s always noise,” she says. “The only time the horns stopped,” she recalls, “was when Egypt lost in qualifying for the World Cup Finals.”
Soon after her arrival, Lehmann visited the bone marrow transplant unit at the Children’s Cancer Hospital for morning rounds. Back in Boston, she says, morning rounds are a very organized affair. An attending physician usually presents the case, and rounds are used as a forum to discuss how patients are being managed. Someone on the team may recommend changing to a new antibiotic, for instance.
But at morning rounds in Cairo, “everybody talks at once,” she recalls. “Someone presents a case, someone interrupts, half of it is in Arabic, half in English.” And yet—despite the chaos—she saw that the hospital was in many ways a sanctuary, a hybrid of Western and Egyptian sentiments. “I saw veiled female physicians shouting out, expressing their perspectives, their opinions. Later that day, these same women went back home to their husbands and their conservative identities, where they may not have been able to advocate for themselves.” Egyptian doctors approached Lehmann with thousands of questions. Lehmann was surprised: she had expected them to be less sophisticated with medical literature, less up-to-date. She found herself answering their questions. She taught them how to set up protocols, how to collect data.
“It’s a two-way street,” she says. “While they were learning protocols from me, we were learning more about cancer from them. In Egypt, where resources are fewer, the practice of medicine is often leaner and more efficient. Their practice,” she says, “informs our practice.” Similarly, as Lehmann helped them set up data collection on their patients, she realized that the n for research studies in both the United States and Egypt would go up, increasing the potential for helping children everywhere. When the time came for her to leave, she had formed a friendship with a young Egyptian doctor, who would travel back to Dana-Farber for a year to learn how cancer was treated in the United States. “We ended up writing a paper together,” she says.
Lehmann went back to Cairo during Ramadan last year. “We drove through a Morsi camp and protesters were pounding on our car. They asked us to roll down our windows, and we did. They were Morsi backers, telling us to say no to the coup.” During that same trip, Lehmann, who had brought her daughter along, drove to an oasis near Marina. Even at the beach, they were instructed to dress conservatively, to cover their shoulders. “We were at this oasis where poor people go to play in the water. I don’t think many Americans had been there before.” It was a hot afternoon. Women waded into the river, their skin hidden beneath their wet clothes. A rickshaw parked in the middle of the stream had its door open and was playing music. “This little boy who was playing at the edge of the stream started giving me rocks to hold. His father, a Morsi supporter, was curious about us, why we were there. When I told him, he was amazed that Americans were working for an Egyptian hospital.” Lehmann was no longer afraid.
“My trips to Cairo have become an act of faith,” she says. “They care about me there, and I know they want to keep me safe.” She feels the ripples of goodwill following her, even when she leaves Egypt and returns to the United States. Last year on April 15, after two bombs went off in Copley Square at the finish line of the Boston Marathon, she received a flurry of e-mails and texts from her friends in Egypt, who were in the midst of their own, often violent, revolution. Many had written, in different ways: “Are you okay?”
Back in Boston, I walk with Lehmann through the double doors into the bone marrow transplant unit. It’s a far cry from the open-air souks, the wild goats, the rush and clamor of the crowds making their way through the streets of Egypt’s capital city. Here, there’s a hush, the sterile, soapy fragrance of hand foam, the snap of gloves and face masks, the muted rustle of gowns.
I walk with Lehmann into her patient’s room. The lights are still switched off. A young girl with sickle cell anemia, blinks at us in the dark, sliding up in bed from under the sheets. An intravenous pole drips antibiotics into her arm. Her lips have a couple of small ulcers, and her face is swollen from the fluids she has received continuously since she completed her marrow transplant ten days ago.
“Good morning,” Lehmann says quietly. She looks at the girl’s face, but in that darkened room, we might have been anywhere, and Lehmann and the girl might have been any doctor and patient. Physicians carry an unusual passport, granted to them not by any government, or regime, or political boundary. By the very nature of their profession, they are given entry into the universal kingdom of the sick, a place where all are united by a desire to palliate suffering.
“This is not Harvard helping some poor Third World country,” Lehmann says to me later. “We aren’t going over there and telling people what to do. This isn’t an academic exercise. We’re importing ideas and exporting others. We’re going to have failures. And we’ll have to keep going back to the drawing board, make corrections, change our plans, coordinate ideas between large groups of people. I’m talking about engaging in a continuous dialogue, the kind that you have between friends.”
And she is ready to have that dialogue in other countries. In the past two years, Lehmann, Kieran, and other doctors have gone to Iraq to try to replicate their experiment. On Lehmann’s most recent trip, she remembers passing through a checkpoint. “An Iraqi guard asked me why I was there. I told him, and he started crying. ‘It’s so good that people are coming,’ he said. ‘People are so afraid.’”
Fear is a powerful and persistent shepherd. But so is hope, and all the more so when people come together to focus their attention on a singular problem, one shared by groups of people who may otherwise want nothing to do with one another, whether they are Iraqi, Egyptian, or American.
Bone marrow transplantation, Lehmann once told me, “is an act of complete optimism. Initially, nobody thought it would work. But we’ve gotten to a point where it’s performed routinely. We’ve gotten here through trial and error, and things have been getting better. But I can’t say things always go right. There’s still so much uncertainty.” Lehmann touches her patient’s wrist, then puts a stethoscope on the girl’s chest, listening. She stands up. “I’m going to open the curtains,” she tells the young girl in the bed. The patient nods. The doctor goes to the window, and the early light fills nearly every part of the room.