Contemporary Art in Health Care Environments

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Iraqi child holding a box of crayons

Image Credit: Claudia Lefko

Claudia Lefko, Founding Director, The Iraqi Children’s Art Exchange • www.iraqichildrensart.org

I coordinate a project with Dr. Mazin Al-Jadiry, a pediatric oncologist who lives and works in Baghdad. It's called Baghdad Resolve: An International Collaboration to Improve Cancer Care in Iraq. We were here in Boston in September for some meetings, and then I brought Mazin out to Western Massachusetts, where I live. I moderated a talk with him at the Art Gallery at Hampshire College, which had on exhibit Al-Muntabbi Street Starts Here, a collection of art books and broadsides in response to a bombing of that famous Baghdad street of booksellers and cafes in 2007. During the question and answer session, a librarian asked Mazin to comment on the role of libraries in Baghdad, reflecting on how important they can be, as they are free and open public spaces where people can get an education; where they can get away from their cares and access other worlds and ideas. He turned to me in all seriousness, this man with excellent English, and asked: "What is a library?” I was shocked. “You know,” I said, “a building with books.” He looked at me. I tried again, remembering that in the Middle East a stationary or a bookstore is called – in English – a library. It was a joke, he told me later, “and no one got it, not even you.” We didn't get it, so Mazin abandoned his clever response for a more standard one: he had no idea about people and libraries in Baghdad. Libraries seem like a luxury, he said, when you're struggling for your very existence. There is the problem of security, and then there's time. And even if there is time, who has the inclination to go to the library? He confessed he hadn’t read even one book since 2003. This is the condition we are in, he said. Mazin called it a joke, but we agreed later that it wasn’t really a joke. It was more like a line from one of the longest-playing dramas on the world stage: the War in Iraq.  An educated man living in that ancient land where stone tablets were collected and organized to make the very first libraries asks: “What is a library?”

I'm telling this story because this conference is about transcultural exchange and I think this anecdote demonstrates how difficult it is to actually exchange ideas and communicate across culture and language. Sometimes when we have opportunities we don't really even know what questions to ask or how to interpret the answers. It also highlights the extra, even greater challenge of communicating with people whose lives are lived in such categorically different circumstances, whose lives down to the tiniest detail are defined by the chaos of war. If Mazin and his colleague Dr. Salma were here, they might ask: “What is art?” Iraq is the Cradle of Civilization – ten thousand years ago, in the hunter-gatherer village of Nemrik, people took the time and developed the skills to create sculptures of the heads of birds. One individual in Nemrik valued this small sculpture so highly he died holding it in his hand when the roof of his burning house collapsed. Five thousand years ago, the people of Uruk, who understood that civilization needs structure, embedded that structure in the complex imagery of an alabaster cult vase. Today, descendants of these people might ask: “What is art?” Or they might ask: “What is a hospital?” Salma says she sometimes thinks of their hospital unit as a tent; a make-shift medical facility. Their hospital may have similar aspects to one in the West or Global North – it's not a tent; it's a building with doctors. (“What is a doctor?” they might ask.) Because an oncology doctor in Baghdad is different from a Boston oncologist; it’s a different job altogether. In Baghdad, the doctor and medical team are alone in caring for the patient. There is no multidisciplinary team; no Clinical Nurse Specialists, Occupational or Physical Therapists and no hospice care. There are no social workers, teachers, spiritual advisors or child life therapists; no one who might distract children with meaningful activities. There are only doctors and not enough nurses. And: “What is a nurse?” The majority of nurses in Baghdad have only a secondary school education and arrive with little if any medical training. So, the Baghdad hospital is a building with doctors, nurses, and beds with patients… but in reality it's a totally different beast, one that's difficult for us to comprehend. And yet it's important to try. So, like an archeologist who examines an artifact in the location in which it's discovered in order to understand it and its meaning, I will talk about the context in which I discovered art and people, medicine and the hospital in Baghdad.

I joined a humanitarian mission to Iraq in January 2001, when Saddam Hussein was still in power. I took three hundred drawings from children in my community and art supplies so Iraqi children could respond with art of their own. I had no idea what I would do with all of this. Our minder at the Al Rashid Hotel solved the problem, sending me to a pediatric oncology unit in Medical City. I had no idea how I would be received. The US had waged a damaging war against Iraq in 1991, and since then Iraqis had been living under very stringent UN economic sanctions, supported and to a large extent enforced by the United States. This was why I'd come; I felt responsible for my government's actions. I knew the war and the sanctions had taken a huge toll, especially on Iraqi children. I wanted to help repair the damage. My nationality seemed irrelevant to Dr. Salma and Dr. Mazin. “The children need this,” they said, “and so do we.” This is how our collaboration and the Iraqi Children’s Art Exchange began. Today, I can call it multi-faceted and multi-disciplinary. I can tell you it sits at an intersection of art and medicine, resilience, psychosocial intervention and children's rights. But this broader understanding has come after-the-fact, really. It began very simply in 2001 as a transcultural art exchange. I had no idea of the extent to which art and medicine could and would and SHOULD mix. People not involved in art and medicine might ask about the value of art and art supplies in a country where people need “everything”; where so much is damaged and broken and so much has been lost. Some mothers on the hospital unit glared at me and did ask. It’s a good question, and more difficult to answer in Baghdad, surrounded by sick and dying children. The art seemed like a great idea in the comfort of my home in Western Massachusetts.

When I began this journey, in 2001, it didn't seem that far-fetched to imagine art could offer some kind of temporary relief, or that it could help "make the case" for children suffering in Iraq. There was reason to believe sanctions might be lifted so that reconstruction and reconciliation would begin. But, it didn't play out that way: the 2003 invasion and war destroyed even more of the country and inflicted more social and emotional damage. In the years since then, things have been somewhat up-and-down, ranging maybe from not-so-bad to extremely bad. Some days, the notion of trying to implement a project and effect some change using art in a pediatric hospital unit located in a seriously dysfunctional hospital, in a city that is deemed one of the most dangerous in the world, in a country mired in ongoing violence and war seems completely insane. The institutional/governmental support one needs from OUTSIDE the unit is, for the most part, simply not available. And realistically, it won't be available in the foreseeable future. This is why we need the "other things” – art, music and human connection – to carry us through years and years of this. To give up is unthinkable for me and not a choice really for my Iraqi colleagues.

Their hospital unit in Baghdad is one of the largest cancer facilities in the Middle East, based on the number of patients they serve. Dr. Salma and Dr. Mazin are talented doctors. They KNOW what good medical care is and they know they need help providing it. They are not passive recipients of "help"; they are equal partners in many ongoing collaborations and very good at collaborating across language and culture. We're continuously co-constructing knowledge to inform our work together. So, when Mazin told me early on that he and the other doctors were suffering as much, if not more, than the children, I realized we had to broaden our approach. Caring for the caregivers – parents, doctors and nurses – was just as important, if not more important, than projects for the children. It was this statement – doctors are suffering too – that led us to pair art with medicine. "Help" for the doctors, nurses and patients meant, perhaps first and foremost, concrete medical help, but they needed psychosocial/moral help as well. They understood the value of art as a supplement to medical care; that it helped doctors and patients. But art had to be integrated into a bigger medical strategy.

I began a serious effort to engage cancer doctors/nurses, as well as global health practitioners and institutions, in our work in Baghdad. The art and documentation of photographs from our collection were helpful in telling the story because most people, including those just mentioned – doctors and nurses – have not and are not now thinking about a health crisis in Iraq; they are thinking about violence and sectarianism, about ISIS. The art and photographs are a non-threatening way to approach and educate people, to put a human face and provide a context.

In 2013 we created Baghdad Resolve in an effort to consolidate some long-standing international collaborations under one umbrella, to give ourselves a bigger profile.  Our goal is to improve the diagnosis, medical care and outcomes of pediatric cancer patients in Iraq and to create opportunities for international partners to work with Iraqi doctors, hospitals and civil society. We have made small inroads in the last three years, connecting with prestigious institutions and caring doctors. Some help has arrived, and there are promises for more help, but things move very very slowly. One can only imagine the difficulty of delivering traditional "medical help” – the kind you might offer to a poor but stable country in Eastern Europe or Africa, for instance. Very few people or institutions are signing on to "do training" or be in residence in Baghdad for a month; very few want to contend or be associated in any way with the corruption and bureaucracy involved in doing business in Baghdad. We have gone through long periods – sometimes years – when nothing seems possible, only impossible; when no one can offer concrete ways to deliver any desperately needed help. Personal connections sustain us, along with art. Art gives us a way to advocate for Iraqis, and it gives Iraqis a way to advocate for themselves. It's not just visual arts. Dr. Salma shocked me when we were in Baghdad in 2013. She turned on her cell-phone after an exhausting day with the visiting team and played Pavarotti. It struck me in the same way stories of the famous cellist of Sarajevo did: it was music in the face of exhaustion and frustration; in the face of destruction and desolation. Music when there was nothing left to say in response to war. Inspired, we put on two Bach to Baghdad concerts with Dr. Mazin and Dr. Salma – one in 2014, where they participated via Skype; and the second in 2015, where Mazin performed live.

I will conclude by saying I find the notions of “Art and Medicine” and “Medical Humanities” – this re-integration of the human with the science in caring for people – very exciting. For me, it seems like a movement toward a more holistic approach to the patient and their care. In this, the West and Global North may have something to learn from the East and the Global South, where the science and technology associated with medicine have not progressed to such a degree, and where life in general is different in so many significant ways both good and bad. From my experience, it is easy for those in low-middle-income countries to feel "behind" and inferior; to feel obliged to adopt ideas coming from nations in the "developed" world and strive to duplicate what those nations have achieved. I will give one example from a few years ago, when we were invited to write a chapter on palliative care in Iraq for a book being written on palliative care in the Middle East. I first asked the editor if he had ANY idea about medicine in Iraq. He did – he knew Mazin and Salma and felt Iraq needed to be included in this volume. So we began. The doctors knew something about palliative care from various journals and conferences, but there was no idea generally about palliative care in Iraq; not in the medical community and not in the general population. So, what can one write? That we don't have it; that we are behind in doing something the rest of the world is saying is very important for terminal patients? Instead, we re-framed the question as one of holistic and humanistic care for patients, so that the Iraqi doctors could write about their situation and how THEY care for patients in the best way they can with the resources available and in the cultural context of their country. In the end, rather than making them feel inferior, it was a testimony to the capacity of doctors in exhaustive settings. So, I think it is important to make this a two-way conversation.

I hope we keep the channel of communication open. I am grateful to have the opportunity to share my story of collaboration. Opening these important conversations across the huge global divides is critical if we are to improve care for all people, all around the globe.

Iraqi children painting a mural

Image Credit: Dr. Madin Al Jadiry