The following factors are relevant to the communication problems that exist in this country: 1. Cultural aspects: The impression is that patients here cope better with terminal illness at home than do patients elsewhere. The extended family, with its strong ties, and the strong Islamic faith that encourages its members to provide for parents and children in case of need mean that any input by health professionals is magnified by the family in the care of the patient. At first, it was uncertain if foreign health professionals would be accepted into Saudi homes (which are intensely private and protected for the family) for the purpose of caring for patients. This has proved unfounded. Hospitality is a very important part of Saudi society; nurses and doctors are welcomed and respected. Much of this success is due to the use of Saudi men as drivers and translators. These people provide 24-hour service, act as social workers assessing the needs of the family, and are the link between the patient and family, the nurse, and the doctor. 2. 'Cure' or 'palliation': The emphasis for cancer patients in Saudi Arabia is still on 'curative treatment,' even after any realistic hope of a cure is gone. The problem this causes is compounded by many patients being excluded from the decision-making process. Decisions made by the family may not always reflect the patient's wishes. Greater communication is needed to guide treatment decisions. 3. Truth-telling: Denying information of the patient's illness is probably more a historical than a cultural phenomenon. Similar attitudes prevailed until very recently in practically all other countries. In this very conservative country people are committed to preserving Islamic culture in the face of Western technology. As medicine continues to demonstrate its effectiveness as well as its limitations, people will come to realize that the right of patients to know and understand their illness allows them to cope much better, and is compatible with the responsibility of the family to care for them. 4. Workforce: The government employs 14,500 doctors, but only 12% are Saudi nationals. Nearly all the 33,000 nursing work force are expatriates. There is a constant turnover of expatriate staff. The commitment to continuing care with proper communication that is required for the whole of medicine is Likely to be fully realized only when the majority of the workforce are Saudi nationals. 5. Primary, secondary, and tertiary care services: The Kingdom is well served by a system of 174 public hospitals and numerous private clinics. However, for a patient with a chronic or terminal illness, continuing care, even in the community, tends to be provided by the hospital service; whereas the polyclinics and health centers seem to provide mainly crisis management. The aim should be to develop community care for chronic illness as part of the primary health care system. The impact of Western medicine on Saudi society has been dramatic and sudden, as evidenced by the high growth rate of the population. There is now widespread interest in matching the culture to the technology. Much of the drive to change the attitudes of both patients and health professionals comes from young Western-trained Saudi doctors, who are in the best position to merge the strengths of both cultures in this sensitive area.
