Review of Chief Complaint:
I have had the great pleasure of reading Chief Complaint by Hatim Kannaaneh MD (Just World Books, Alexandria, Virginia 2015 and available from Amazon).  It is with some trepidation that I discuss a book that touches on such sacred things. 

It is a collection of short stories, which is like saying a Mozart sonata is a collection of notes.  The stories are partly fictionalized, as the author points out, with most of the names being changed and some episodes that happened to different people being linked in one person.  The book is disarmingly simple in its organization, being the tales of people who came to Dr. Kannaaneh put together by chief complaint in the routine order of a systems review by a good clinician.

Beneath that inviting cover I found a narrative of different levels, which I shall try to describe. 

The easiest level for me is the political.  Let me quote the first two sentences from “The Gray Champion” by Nathanial Hawthorne.  “There was once a time when New England groaned under the actual pressure of heavier wrongs than those threatened ones that brought on the Revolution.  James II, the bigoted successor of Charles the Voluptuous, had annulled the charters of all of the colonies, and sent a harsh and unprincipled soldier to take away our liberties and endanger our religion.”  Chief Complaint makes clear that British rule was not improved by time, nor was the puppet government they installed.  As with Hawthorne, the doctor’s tale is one of the persecuted as seen by the persecuted – in flagrant defiance of the commonplace that history is written by the victors.  This is Palestine under Israeli rule, British Mandate rule and even Ottoman rule.  The protest is most clear.

The second level is still manageable for me.  That is the narrative style.  I graduated with high honors in English from Wesleyan University, so if this next paragraph is folly, at least it is by a fool with credentials.  There are multiple themes woven into the tale.  It is like spending days on a sailboat accompanied by an enormous pod of many-colored cetaceans.  Sometimes one passes submerged and the is only the hint of color gliding below the surface followed by another and another or more than one.  Then one of them breaches clear of the water and for a time all too brief shines resplendent in the sun.  And there are characters, many characters.  I think I have met more people of the village of Arrabeh than I can recall with such distinctness and understanding from my childhood plus present life.  We see them at their best and at their worst, their injuries and ailments, their deepest woes and their highest dreams, through the attentive eye of the clinician. 

At the third level I panic.  Long years among many different cultures have taught me that some things are fair game for conversation with anyone: family, weather, sports, ghosts, machinery and so forth.  One might not agree, but at least one knows the lie of the land.  But when one ventures into what is precious, sacred memory or dream, table manners and alcohol or tobacco, things immediately in touch with the physical body, one may all unintentionally offend.  The story is set with the constant presence of a wistful, mistful past when the people owned land, the land was bounteous and mouthwatering delicacies were available in their season.  It took hard work to wrest a living from the soil, from the goats and especially from the trappable wild things.  I have no doubt that these sweet memories are valid.  My own experience has been that the past is forgotten or seen through a distorting lens such that friends who seemed to be bounding with joy when they were with me recall later unfairness, squalor and privation I do not recall.  And yet the dream of this lost past summons problems; what would fix things?  Arrabeh is now a city of over twenty thousand.  It could never support itself on the produce of the land.  Nobody could possibly, any longer, be friends with every adult.  Natural increase has dimmed the dream.  Some things could be fixed, obviously, but all? 

The fourth level takes me where others might not choose to venture.  So if you have problems, let me say, “READ THIS BOOK.”  Now you can bolt any time you like.  The thing is that I see in this book not only the past but the future.  The rich countries of the world have an unsustainably low birth rate.  That is common coin.  My own work suggests that the middle class the world over will have a birth rate fall that will be extremely abrupt and profound.  But I do not see that in Arrabeh.  A large proportion of the Palestinians are highly educated and highly skilled.  They make money.  And they make babies.  Nobody else seems to be able to do both.  I imagine the reason is that there is such a close emotional attachment to the land, to the place, to the community, that they marry cousins frequently enough to keep the babies coming.  So the rest of us (I can’t even get a date, and that is really no new thing.) will not leave the world to the places that still have substantial growth: Yemen and Afghanistan I’m thinking, and sub-Saharan Africa.  Nice folk.  Love ‘em all.  Not so keen on the education thing.  But the Palestinians will endure.

And the fifth and final level is a voice that says, “Why wait?” Marrying cousins, specifically third and fourth cousins, maximizes your birth rate.  Tell them.  Ah, but high birth rate is already a problem; don’t blame global warming on the Palestinians, but just maintaining their society is difficult.  And I, after years of study, can’t tell you just what to do.  Go to my last summary of January 1, 2015 on and you can verify in the Iceland study that those third and fourth couple pairings are the most fertile, first cousins less so in the second generation and that distant ones, say ninth cousin or greater, even less so still.  Incidentally there is no difference between ninth cousin and somebody from the far side of the world.  Nature doesn’t care how distant your distant kinship is; what matters is how many generations it goes on.  (It doesn’t matter how far from the building you jump, it’s how long you fall.)  The Icelanders have looked at children and grandchildren, and it is the same story.  They have not seen fit to extend, as it seems they could, their study to great grandchildren.  I’ve written to encourage that.

Again on the web site I mentioned there is a Swedish study showing that rich people (who presumably leave forever their ancestral villages) have the same decrease in children and grand children and the decrease in great grandchildren is greater than the first two generations of outbreeding combined.

Ah but people keep track of such things in Arrabeh.  Do memories go back that far into the Ottoman regime?  Do the elders still chat?  Could they put together their own genealogies and see whether the rule holds, “Each generation of mating outside ninth cousin cuts fertility in half?”  That does not seem to be exactly the case, but something close to it.  Even so, it’s tricky.  The family trees will not be symmetrical at any level.  But we are talking about people intelligent and well educated who like to use their minds.  Maybe they can work it out.

But this summons another demon.  Now you know.  What do you do about it?

In the end, thank you, Dr. Kanaaneh, for this warm hearted, gripping and well woven book. 


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