Abu Mohammed, a bespectacled doctor, sits at a desk in a nondescript, rectangular room littered with hand-scribbled notes on sheets of lined paper. The 30-year-old is clad in a button-down shirt, jeans, and sneakers. A white coat is nowhere to be seen. Across from him is an ailing patient.
The doctor begins his evaluation with the basics: How is the patient feeling, and can he describe his pain? “I have fever and a headache,” complains the young man.
“For how long have you had these symptoms?” Abu Mohammed presses in neat but accented German. Several days, the young man replies.
“May I do a quick exam so we can find out what’s going on?” Abu Mohammed asks. The patient obliges.
Then, the two men swap roles.
Over three hours on an overcast November morning in central Germany, Abu Mohamed, an orthopedic surgeon, rattles off diagnostic questions to a handful of other “patients” — all of them immigrants enrolled in a medical-language class. Today their new vocabulary includes Verhütungsmittel (contraceptives), Röntgen (X-ray), and Ist es eher ein stechendes oder brennendes Gefühl? (Is it more of a stinging or burning sensation?). When he isn’t speaking, as doctor or as patient, Abu Mohammed is flipping through a textbook and worksheets that he keeps tucked inside a child’s Winnie-the-Pooh folder. The image on its glossy surface reminds him of his 9-month-old son, who lives more than 2,000 miles away.
“My son is growing up without me, and you don’t get another firstborn child,” he says. “It’s burning me.”
Abu Mohammed is from Syria, and like many of the war-torn country’s physicians, he has fled his homeland to seek work and safety abroad. (To protect his family, he asked that his real name not be used and that neither his exact location in Germany nor his hometown in Syria be identified.) Before the conflict, Syria had roughly 31,000 doctors, according to the country’s Ministry of Health. Today, Physicians for Human Rights (PHR) estimates that about half have left the country; hundreds more medical personnel have been detained or killed. While the vast majority of Syria’s 4.6 million refugees remain in the Middle East, many regional countries make it difficult for displaced doctors to practice medicine. And getting permission to live and practice in the United States, Britain, and other Western countries is onerous; it can take months, even years.
Germany is different. The country is welcoming Syrian doctors like Abu Mohammed by granting them short-term visas that allow them to avoid the crowded refugee process. (In 2015, some 430,000 Syrian asylum-seekers entered Germany.) According to the Bundesärztekammer (the German Medical Association), more than 1,500 Syrian physicians are now working in Germany, including 319 newly registered in 2014. “When Syrian doctors flee because of threats to their own life or the armed conflict in general,” says Maria Michalk, a parliamentarian who chairs the Bundestag’s committee on health, “it’s right to give them refuge in Germany and to integrate their medical skills.”
Taking in Syrians isn’t just a humanitarian gesture, however. Germany needs doctors. One in seven physicians plans to retire within the next five years. And thousands of practitioners leave the country annually to work abroad. According to the international research consultancy Roland Berger, German hospitals will lack 111,000 of the doctors needed to serve the country’s population by 2030.
To plug its medical holes, Germany has been hiring foreign physicians for several years, even recruiting them in eastern EU capitals — Bucharest, Sofia, Athens — where young professionals want to escape economic doldrums. Between 2010 and 2014, the number of international physicians in the country rose by 60 percent, according to the Bundesärztekammer. While Romania contributes the most physicians to Germany, Syrians escaping bloodshed are not far behind.
The tragic twist is the vacuum these individuals are leaving behind. “When it comes to Syria’s health care in the future, we should expect the worst,” says Karl Blanchet, a lecturer in health systems research at the London School of Hygiene & Tropical Medicine. “Syria will be left with lots of ruined hospitals. No doctor wants to work in a hospital where he can’t save people.”
Abu Mohammed, for one, is seizing the chance for a better life. “We doctors didn’t choose Germany,” he reflects after his language class, over chicken nuggets at a nearby McDonald’s. “Germany chose us.”
Arij Mulhem (right), a 25-year-old from Damascus, arrived in Leipzig in March 2015. (Photograph by Toby Binder)
Syria’s health-care system was once the pride of the Middle East, featuring state-run hospitals as well as a network of private facilities. Over the second half of the 20th century, the government invested heavily in public health: Life expectancy increased from 56 years in 1970 to 73.1 years in 2009, according to the country’s Ministry of Health, while infant mortality plummeted from 132 per 1,000 live births to just 17.9. By 2010, 83 percent of children were being vaccinated for polio, up from 13 percent 30 years prior. “By and large, the system worked well,” says professor Fouad M. Fouad, a surgeon from Aleppo who now lives in Lebanon. “An ordinary citizen could get cancer treatment, cardiovascular treatment, and even small towns had primary-care clinics.”
Abu Mohammed, whose extended family includes several doctors, knew from childhood that he wanted to work in medicine. “I’ve always liked doing favors to people and helping them specifically when I expect nothing in return,” he says. “That brings a great feeling of satisfaction.” In 2011, however, just as Abu Mohammed was finishing his orthopedic training, war put a cruel end to his dreams — and to Syria’s medical achievements.
At first, Abu Mohammed wasn’t concerned by the street protests burgeoning across his country; he had watched Tunisia’s and Egypt’s dictators fall and assumed that President Bashar al-Assad would follow. “We had six months of people protesting peacefully with gel in their hair and wearing their best T-shirts,” he recalls. Things took an ugly turn, however, when police began firing on demonstrators. Before long, medical facilities became targets in an all-out civil war. Abu Mohammed remembers government soldiers arriving one day at the hospital where he worked. “[They] said, ‘You’re treating rebels,’” he says. “They ordered us out and put mortars on the roof.”
Hospitals and doctors are protected under the Geneva Conventions, but violent actors in Syria have blatantly disregarded these rules. PHR says government forces in particular use attacks on the health-care system as weapons of war. “When a doctor is killed, the loss is greater than one life,” explains Widney Brown, PHR’s director of programs. “It is also the lives of the people she or he may have saved.”
According to figures collected by the NGO, as of mid-January there had been 336 attacks on hospitals since the conflict began; 697 health-care workers had been killed. Three PHR investigators wrote in the New England Journal of Medicine last year, “Some personnel were killed in bombings of their hospitals or clinics; some were shot dead; at least 157 were executed or tortured to death.” In Aleppo specifically, more than two-thirds of hospitals have ceased functioning, and 95 percent of doctors are gone.
For a few years, Abu Mohammed was one of the lucky ones. He volunteered at hospitals and field clinics for rebel fighters, improvising to treat abdominal injuries, shattered bones, and other wounds with limited resources. It was risky work: With transportation disrupted, Abu Mohammed had to travel on foot, often carrying heavy bags with intravenous fluids and surgical equipment. Sometimes, supplies were moved through city sewers. All the while, government officials were grilling captured fighters to find out which doctors had assisted them.
One day in early 2014, Abu Mohammed was detained at a government checkpoint and taken to a police station where he was kept in an overcrowded cell for more than two weeks and interrogated. Officers attached electrical nodes to his hands, threatening to shock him if he didn’t confess to aiding rebels. Yet his luck held: He managed to convince his captors that he was innocent, and he was released with just a warning not to treat anti-regime fighters.
Certain that government eyes would be trained on him, Abu Mohammed decided to flee. He hired a driver who knew the checkpoints where soldiers could be bribed and sped toward one of Syria’s neighboring countries. (To protect the safety of others on the same route, he asked that the state not be identified.) The car made it across the border, but Abu Mohammed was still cautious. “I was so afraid that the driver would report me to the authorities, I didn’t dare to stay in the hotel he suggested,” he says. “I slept the first night sitting up.”
Abu Mohammed then sent for his wife, who is also a doctor, and they set out to find jobs. Yet they discovered that their medical degrees counted for little: Neither could get a work visa. The couple, by then expecting their first child, resolved that Abu Mohammed would try to secure work in Turkey, which they’d heard tolerated Syrian doctors plying their trade. His wife would return to her family in Syria to give birth.
In Istanbul, Abu Mohammed supported himself at an NGO providing health care to refugees, but once he learned that the government would not license refugee doctors, he started looking further afield. (In January of this year, Turkey changed its rules to allow Syrian refugees, including doctors, to work.) A proficient English-speaker who once completed an internship at a hospital in Illinois, Abu Mohammed hoped the United States would accept him, but he discovered that he needed a formal job offer to even apply for a visa. (Moreover, says William Cocks, a U.S. State Department spokesman, a visa applicant must either be a graduate of a medical school accredited by the secretary of education or have passed the first two parts of the United States Medical Licensing Examination and be fluent in English to work as a medical doctor in the United States.) Abu Mohammed then considered going to Britain, but he got lost in a maze of requirements — exams to pass, certifications to acquire — in order to even obtain a visa.
Living in a hostel and separated from his family, Abu Mohammed was growing despondent. Then a surgeon friend from his hometown, who had also treated rebels and had later escaped Syria, called him from Germany. “He had managed to get a visa, an internship, and a job offer,” Abu Mohammed says of the friend, who requested anonymity for this article. “He told me, ‘You should definitely come to Germany.’” Other Syrian doctors in Turkey told Abu Mohammed they’d heard the same: They were going to try their luck with German visas.
“Mercedes, BMW, Bayern Munich, World War I, World War II, and the Berlin Wall” were all Abu Mohammed knew of Germany at the time. (He adds: “I’m not exactly sure why the Berlin Wall came down.”) He had never planned to build a life outside the Middle East. Yet he set off for the German Embassy in Ankara in February 2015, armed with his medical credentials. For once, they were all he needed.
Gerhard Scholz of St. Elisabeth hospital with Syrian physician Arij Mulhem. (Photograph by Toby Binder)
At first glance, all seems well in German health care. In 2013, the country had 4.1 doctors per 1,000 residents, the fifth-highest rate among OECD countries. The following year, the number of doctors in the country rose by 2.3 percent. These figures, however, belie wide disparities and worrying trends.
Germany’s population is aging rapidly: Over 20 percent of people are 65 or older, and at 46.5, the country has one of the world’s highest median ages. A growing number of senior citizens thus require medical care. Many doctors, however, will soon retire — an estimated 51,000 by 2021 — and the proportion of young physicians is shrinking. In 1993, nearly 27 percent of doctors were under 35. Today, that figure has dropped to 18.3 percent. Meanwhile, some 3,000 physicians emigrate each year for employment opportunities abroad.
Among those who stay, many gravitate toward cities, which tend to offer better medical facilities and higher salaries, among other benefits, than small towns do. A 2015 report by the nation’s labor agency showed that Germany’s three city-states — Berlin, Hamburg, and Bremen — are the only regions not already facing doctor shortages. Towns like Sonneberg, 60 miles from Germany’s border with the Czech Republic and home to 24,000 people, bear the consequences. “I’m leaving no stone unturned in trying to bring doctors here,” says politician Christine Zitzmann, Sonneberg’s district administrator. “I tell them that we have a perfect location, incredible transport links, excellent opportunities to build homes.” Yet area hospitals currently have 14 doctor vacancies, including two that have been advertised for more than six months.
Shortages aren’t helped by the fact that doctors are working less: In 2011, some 54,000 doctors worked part time, up from 31,000 a decade prior. In no small part, this is because female doctors limit their hours in order to raise families. “What the statistics don’t show is that the volume of work [physicians] perform is stagnant,” explains Hans-Jörg Freese, a spokesman for Germany’s main doctors’ association, the Marburger Bund. A particularly endangered species is the general practitioner, a role of decreasing prestige in comparison with specialists in fields like neurology. Only 11 percent of medical students say they plan to take up general medicine, according to the newspaper Die Welt, though 40 percent of doctors currently fill that niche. (Germany’s governing coalition recently launched a plan to make medical school more practice oriented and to increase the study of general medicine by 2020.)
Fearing a crisis, the Bundesärztekammer and Marburger Bund have demanded that the government, which funds medical schools and caps the number of students, increase enrollment of doctors-to-be by at least 10 percent. About 10,600 students embark on medical education each year, roughly the same figure as in West Germany before reunification.
Officials have found success in attracting foreign talent. Today, some 4,000 Romanian doctors, 3,000 Greek ones, 2,700 Austrians, and 2,000 Poles are practicing in Germany. (The nation recognizes medical degrees from EU countries.) Several hospitals use recruitment agencies and foreign trade fairs to fill vacancies. In the state of Saxony, the local physicians’ union has launched a project to train 20 doctors annually at Hungary’s University of Pecs; the students receive tuition money in exchange for the promise of working for at least five years as general practitioners in Saxony’s rural areas.
For Syrians, Germany’s doctor enthusiasm comes in the form of relatively low barriers for entering the country. It took Abu Mohammed 30 days to get a short-term travel visa pasted in his passport, which could be replaced by a student visa once he arrived. In March 2015, he boarded a flight to Frankfurt.
A German Foreign Office official, who spoke on background for this story, said Syrian doctors do not get special treatment in the immigration process. Yet other Syrian physicians report experiences similar to Abu Mohammed’s. Arij Mulhem, a vivacious 25-year-old from Damascus who received her German travel visa in Beirut, arrived in the city of Leipzig in March 2015 and completed her language training by the end of the year. Mulhem now insists on speaking German, which she does with skill. “Germany gives us doctors the opportunity to arrive in something other than a dinghy,” she says.
Support networks are forming. Mosab al-Shakaki, another old friend of Abu Mohammed, was studying for a doctorate — on top of his medical degree — in the German state of Saarland when Syria’s war erupted. After completing his studies and an internship, Shakaki began work as a cardiac surgeon at a hospital in the city of Kaiserslautern. He now considers himself something of an informal guide for his compatriots. “It’s not easy to know, ‘Where do I stay? How do I organize myself?’” he explains. “I say, ‘Send me your CV, and if I hear of vacancies I will forward it.’” It was Shakaki who helped Abu Mohammed, whom he’d known since medical school, sign up for his first language class when he arrived from Turkey.
Arij Mulhem now speaks fluent German. “Germany gives us doctors the opportunity to arrive in something other than a dinghy,” she says. (Photograph by Toby Binder)
It isn’t all smooth sailing for Syrian doctors. An obstacle course typical of German bureaucracy looms for new arrivals. “The hospitals give you the ball and essentially say, ‘Play with it,’” Shakaki says. “They decide whether you’re an asset. Germans won’t hire you just out of compassion.”
Abu Mohammed knows by heart which hurdles he must clear: earning five separate language certificates, obtaining a license to work for several months under the supervision of a fully qualified doctor, and then submitting to a registration process required for non-EU doctors to practice. Each phase introduces frustrations. A single language course can cost more than $1,000; registration can require months of preparation, and private outfits provide courses and trainings for a fee. One company, the VIA-Institut in Nuremberg, advertises on its website, “Good physicians are urgently needed in this country. We can show you the way.”
Mohammed Sheikho, a Kurdish internist from northwestern Syria, has already completed one internship and has sent off about 200 applications for additional provisional work. But he’s still waiting for his registration to be approved. Every day, he calls the government authority responsible for medical licensing. “They just tell me to wait,” he says. “But I can’t wait.”
Some facilities are assuming financial and other burdens to get Syrians in the door. The Zeisigwaldkliniken Bethanien hospital in Saxony offers language classes to foreign doctors, as well as mentoring programs, assistance in dealing with German authorities, and even temporary housing in one of its buildings. The hospital, which currently has three physician vacancies and already counts Czechs, Slovaks, and a Palestinian among its staff, brought in a Syrian urologist three years ago. Michael Veihelmann, co-manager of the facility, says he would gladly take on more Syrian doctors, so long as they agreed to stay on at his hospital after it helped them get state registration.
At St. Elisabeth, a Catholic teaching hospital in Leipzig, the approach is similar. “Nine months ago, our human resources manager called me and said, ‘We’ve had an application from a Syrian doctor. Do you need one?’” recalls Gerhard Scholz, chief physician of one of St. Elisabeth’s internal medicine departments. “I said, ‘Yes, I always need internists.’” The doctor hadn’t been registered, so Scholz took him on as an unpaid intern; he did the same shortly afterward when another Syrian asked for work.
Word seems to have spread, because applications from Syrians have been flooding in. Scholz now has two Syrians working for him as interns. Among them is Mulhem. “I got tears in my eyes when Professor Scholz told me I had a space in his department,” she says. Scholz, who won’t require the interns to stay at St. Elisabeth after they get their licenses, says simply, “It gives me joy to train doctors.”
For ad hoc programs to be scaled up — that is, for an even larger number of Syrian doctors to make their way, and quickly, into Germany’s medical system — Mulhem thinks the government should create a training program specifically for Syrians. Albrecht Adelmann, CEO of St. Elisabeth, agrees that the scope of support needs to widen: “Syrian doctors should get quick access to internships and longer training at larger hospitals.” He adds, “The question is, if they are to earn an income while doing the training, who will pay them?” In October, Health Minister Hermann Gröhe told the newspaper Passauer Neue Presse that the government wants to expedite putting Syrian doctors into medical practice, but he offered no details on how that might happen.
Nonetheless, windows of opportunity continue to open. On Oct. 24, the Bundestag passed a law that allows immigrant doctors without a German license to work alongside certified physicians in the refugee centers housing some 1.1 million asylum-seekers. “I’d love to do such work,” says Sheikho, even though it isn’t formal practice. “The main thing is that it’s work related to medicine.”
In the eastern city of Chemnitz, Veihelmann of Bethanien hospital interviewed a doctor in Damascus over Skype in the fall of 2015. “Of course it’s bad when there are crises in other countries,” he acknowledges. “But if doctors have to flee their home countries, them coming to Germany is a win-win for them and for us.”
Yet as much as Germany may need physicians, Syria needs them infinitely more. Even the Islamic State, intent on wiping out all vestiges of modern influence in the Middle East, has acknowledged the toll that the mass exodus of doctors is taking. In 2015, the extremist group launched a video propaganda campaign to discourage skilled workers from leaving Syria, and it announced in May that any health professionals who had fled Raqqa, the self-declared caliphate’s capital, and who did not return within 30 days would have their houses confiscated.
One doctor in Aleppo told PHR in 2015, “If the [barrel bombs] stop, doctors will come back. We just need to stop the barrels.” Syrian physicians in Germany, however, say it’s hard to imagine returning. “I was planning to go back as a professor to help make young Syrian doctors better,” says Shakaki — but no longer. Fouad, the surgeon in Lebanon, thinks a reverse migration of physicians is unlikely. “It will be very difficult to replace these doctors,” he speculates. “We have to start training a new generation now in order to have a fighting chance to build up a health-care system in Syria when the conflict ends” — a feat that, given the country’s gutted state, is likely impossible.
Abu Mohammed is planning to stay put. “Germans are friendlier than Arabs,” he says, an opinion that hasn’t changed since the uptick in anti-refugee sentiment that reportedly followed the Cologne street attacks. In December, he completed the medical-language course, leaving him with just one German certificate to complete. He is currently volunteering at a pharmacy while living off his savings, and Shakaki has promised to help him look for jobs when he’s qualified. “I hope that my guilt will bring me back one day,” Abu Mohammed says. “But we can’t count on a lot of Syrian doctors going back out of a sense of guilt.”
In the small dorm room where he lives, Abu Mohammed Skypes with his wife and son whenever they can get a reliable Internet connection. Recently, he saw the boy pull himself up to stand for the first time; the father’s eyes grew misty at the sight. But Abu Mohammed won’t have to wait much longer to see his family: As early as this June, his wife and son will fly to be with him. His son will be 17 months old by then and walking. His wife will begin her own transition to practicing medicine in Europe.
Germany, in other words, will be gaining another doctor — while Syria loses yet one more.
A version of this article originally appeared in the March/April 2016 issue of FP under the title “Side Effects.“
(Top image: Ulrich Baumgarten | Getty Images)
Elisabeth Braw is an adjunct fellow at the Center for European Policy Analysis.
(@elisabethbraw)
