Amira is explaining to some village women how to use herbal medicines that grow in their neighborhood. “I learned the skill from my grandmother when I used to help her harvest the wild plants,” she says. Amira describes the plants, carefully differentiating those for colds: babounij (chamomile), khatmiye (athea), na’na (peppermint), zatar (thyme); those for abdominal colics: yansoun (anise), krawya (caraway), shemra (fennel); and those for diuresis, shoushet dura (corn stigma), bakdounes (parsley), and bu‘atheran (millofia). She is also very precise with her instructions. “This mixture must not be boiled too long, otherwise it loses its volatile oils,” she explains. Amira is a respected middle-aged mother living in Bebnine, a small town in the Akkar area in north Lebanon.
In the isolated east Sudanese village of Mreibea, Madina, the daya al-habil (traditional birth attendant) faces a problem. The community has boycotted her services after her decision not to circumcise females any more. She made that choice after noticing the association of persistent urine leakage with circumcision. Although she is sure she has done the right thing, Madina is powerless to confront her critics alone.
Liyamna, a woman from the poor village of Wilad Hamouda in northwest Tunisia, is confused. Her sister, Khadija, is still suffering from severe menstrual pains and infertility, though they have spent hard-earned money to travel to the distant town of Makthar for treatment. The monthly injection of tetracycline, an antibiotic prescribed in a hurry by the town physician, has done no good.
During my work in rural Arab villages in Sudan, Tunisia, Egypt, Jordan and Lebanon, I have come to know many women like Amira, Madina and Liyamna who work to help other women in their communities. Their genuine concern for others makes change possible. But the resources they identify as helpful are sometimes no more appropriate than a prescription of antibiotics for menstrual pain. Many factors affect their judgement, well-being and health.
Poverty and urban/rural maldistribution of resources in these five countries are major determinants of health. What services exist are unevenly distributed between rural and urban areas. Two basic health indicators — the percentage of the population with access to safe drinking water and the percentage with access to health services — confirm this uneven distribution, which makes people in rural areas even more vulnerable to disease.
In times of economic recession, already tight health budgets are the first to be slashed, and plans for expanding health services abandoned. In almost all of these countries, health policy is still biased in favor of expensive curative and high-tech Western medical models that cannot be sustained. Limited budgets are spent on modern (“marble tower”) hospitals in urban areas that (when functioning) serve only a very small percentage of the population.
The entire Arab world suffers from an approach that defines health in terms of medicine and medical care, while clean water, adequate food and sanitation — basic requirements for health maintenance — are put aside. This “medicalization” is directly linked to the growth of pharmaceutical companies which have successfully recruited physicians as allies. Women, in the Middle East as elsewhere the major consumers of health services, are the prime victims.
“Gunshot” Prescriptions
Consider, for example, the prescription given to Nuzha on January 29,1987, in al-Minya, Egypt. Nuzha is a healthy, 22-year-old newlywed coming from a nearby village to see a doctor in al-Minya. Social norms in this area put strong pressure on young brides to become pregnant quickly or face the threat of divorce. After four months of marriage, Nuzha, not yet pregnant, seeks medical help. The doctor does not examine Nuzha, nor educate her about simple fertility rules. Instead, he gives her a “gunshot” prescription of five expensive medicines and injections that are not only useless in her case but actually endanger her health.
The medical hierarchy in Middle Eastern countries today reflects the sexual hierarchy of Arab societies: women, historically providers of health, have been marginalized, and men have taken over. Women’s skills in healing and health provision are devalued, and traditional midwives are often cast aside. The monopoly of expensive medicine continues as few question the reasons for medical management of childbirth, the increasing numbers of cesarean sections and hysterectomies, and overuse of medicines.
Other factors endanger women’s health and survival. The scarce data on maternal death points toward a drastic situation. Almost every villager I’ve encountered describes the burial of a woman who died in labor as a common scene. Do these women die from malnutrition and anemia, from insufficient obstetric care or lack of contraceptives, or from factors related to social and sexual hierarchy? Research on maternal death is minimal in societies where women occupy a low status. Laws fail to provide sufficient protection. Child marriage, chastity rules, repudiation, polygamy, segregation of women, demands for high fertility, unequal share in nutrition, circumcision (in Egypt and Sudan), household overwork, unpaid agricultural labor, preference for male children, unequal inheritance, minimal participation in leadership — all of these are factors often taken for granted.
The adoption of primary health care as a strategy over the past decade challenges the curative Western model and implies a variety of approaches, including promotive, preventive, curative and rehabilitative action. Primary health care also implies the need for health workers who live with the community, know their problems and work with them towards better health status. Organizations such as Save the Children have made a priority of recruiting women health workers to this cadre, and such women are being trained or are already at work in many countries. They are known variously as murshidat (Jordan, Egypt), raedat reefiat (Egypt), maenad sihiyat (Tunisia), or amilat sihiyat (Lebanon). Often traditional healers are being recognized as the basic providers of health services in many deprived areas.
Innovative educational methods are an important part of the primary health care approach. Nonformal adult education methods used to train health workers assume that adults have learned much from life which is applicable and that they apply lessons best when they discover things for themselves. Problem-posing approaches help people observe, listen, think, analyze, differentiate, discover and plan for appropriate action. A basic curriculum of 100 working hours costs from $100 to $200 per health worker. The course includes topics such as human relationships, women’s status and adult education in addition to nutrition, immunization, sanitation, and other more traditional health subjects.
Rural women health workers are usually in charge of about 50 homes in their own communities. They help mothers learn to use oral rehydration therapy, discover immunization defaulters, deal with breastfeeding problems, promote family spacing, act as a liaison to traditional birth attendants, refer those at risk, and perform many other tasks. In some areas they have established women’s groups and health committees, initiated home gardens and income-generating projects for women, and planned adult education sessions. They provide models of how communities can take charge of their health needs. Khadija from Wilad Hamouda in Tunisia, for example, visited an official from the Ministry of Health and complained that the immunization teams had not arrived on time.
As with many primary health care projects, questions of funding, sustainability and integration into ministry of health structures remain. But for the present, such projects have enabled women like Amira, Madina, Liyamna and Nuzha to regain their self-esteem and to find support in meeting the health needs of the women in their communities.
