The coronavirus pandemic is highlighting glaring inequalities and the lack of resources for vulnerable communities worldwide. Joe Stork, in a prescient analysis from 1989, explains how health care is always mediated through politics and power. With vivid examples from across the Middle East, this ar
[This article was originally published in Middle East Report 161, November/December 1989.]
[su_dropcap style="simple" size="5"]H[/su_dropcap]ealth, along with food and shelter, is a fundamental element of every person's life. If we are in good health we may take it for granted, but when our health is bad -- when we are ill or injured -- it becomes central to our lives.
Medical specialists tend to talk about health in terms of its opposite -- disease and injury. The World Health Organization (WHO) defines health as a “state of complete physical, mental and social well-being, and not simply the absence of disease or infirmity." This formulation, though broad, has the virtue of situating health as essentially a social concept, the result of relationships between individuals and their physical, economic and social environment. And it is not too far removed from the terms that someone from a traditional, pre-industrial culture would probably use to characterize health -- as growth, strength and fertility. [1]
Who gets health care, and what kind of care, are political questions. The health care strategies of any society have a significant class dimension: Will resources be used primarily to improve nutrition, sanitation and workplace environments, and the health of the base of the population, or to acquire expensive technologies that will benefit mainly those holding economic power? Not surprisingly, given the rapid income growth of the 1970s and early ’80s, the Middle East region’s health profile shows some impressive improvements. Indeed, the Middle East has shown the most improvement of any region in raising its child survival rate, though it still has a poorer record than every other part of the world except sub- Saharan Africa. In a region with almost 50 million children below five years old, a 90 percent survival rate means five million childhood deaths and a level of suffering that cannot be quantified. Furthermore, the most populous countries are among the poorest in the region and most hard hit by the economic contraction of the past five years.
The influx of oil monies created a rapidly expanding market for sales of Western medical equipment and expertise, particularly in the wealthier countries. Between 1970 and 1985, Saudi Arabia opened 80 hospitals. By the end of this year, the kingdom expects to have more than 250 hospitals, ranging from small general facilities in rural areas to highly specialized units in the cities. The United Arab Emirates, with a million and a half citizens, has 31 hospitals. Iraq advertises in the Middle East Economic Digest for expatriate specialists to staff Ibn al-Bitar Hospital in Baghdad. The contraction in oil revenues over the past five years, though, is forcing even the richer countries to emphasize maintenance rather than expansion of sophisticated facilities.
The essential determinants of good health are the material conditions in which people live -- their access to food and shelter and clean water, first and foremost. In most Middle East countries, as elsewhere, such access is extremely skewed. The poor have less access to health care than the rich, those in the countryside less access than those in the cities. Gender can also be a factor. Rita Giacaman, in her study of three West Bank villages, found evidence that the nutritional status of young girls was consistently less than that of boys. Racial and national prejudice is another element. Israel’s child mortality statistics, for instance, suggest that Palestinian citizens of Israel do not have the same access as that country’s Jewish citizens to health care: They are 18 percent of the population and account for 26 percent of live births but 47 percent of still births, 38 percent of infant deaths and 39 percent of deaths under age 5. [2] Were the data available, one would likely find similar discrepancies in the health profiles of other national minorities in the region.
Even cities like Cairo and Amman boast physician-to-population ratios that rival those of major US cities but, just as in Washington, DC, poor neighborhoods have little access to basic clinic facilities.
The wealthy countries of the Gulf have, by and large, been able to offer access to medical care to almost all of their citizens, although the access of hundreds of thousands of “guest” workers is far less assured. Even cities like Cairo and Amman boast physician-to-population ratios that rival those of major US cities but, just as in Washington, DC, poor neighborhoods have little access to basic clinic facilities.
Egypt offers a good example of the complex and multifaceted political aspects of health issues. [3] The National Charter of 1962 proclaimed that “the right of health welfare is foremost among the rights of every citizen,” and the government under Gamal Abdul Nasser established a health infrastructure that on paper represented one of the most integrated primary health systems in the Third World. It did reach large sections of the rural population, but the number of health units is still well below the target of 2500, and they have come to function more as outpatient clinics, providing inexpensive and poor quality curative care rather than preventive primary care. Endemic infectious diseases are still prevalent. Schistosomiasis, for instance, still afflicts many village children and contributes to the serious anemia affecting nearly 50 percent of the peasant population and 40 percent of those in cities.
Egypt's system of hospitals and clinics is immense and chaotic. They are modeled on Western institutions, dependent on expensive equipment which they are unable to maintain. The hospitals operated by the health ministry are at the very bottom in terms of resources and care. Hospitals funded by labor insurance cover workers but not their families. The private sector includes “investment hospitals” set up under Sadat, and recently there has been a dramatic expansion of clinics operated by political groups, of which the largest and best endowed are those operated by Islamist organizations.
The core problem is a pattern of corruption that links the private and public medical sectors. One reason is the great discrepancy between public sector and “market” salaries. Some physicians use public facilities for their private patients, and there is a high rate of absenteeism in public hospitals as the more qualified practitioners leave patients in the hands of new, inexperienced graduates. The government has responded by privatizing parts of the public health sector, setting up “economic” afternoon clinics in the hospitals parallel to the “free” (actually lower cost) morning services. The afternoon patients pay higher fees; the morning patients pay in terms of poor treatment which has the effect of encouraging them to use the more expensive afternoon clinics.
Israel also has an extensive health care system. The country's health profile, at least among its Jewish citizens, resembles that of industrialized countries, but shares some problems with its neighbors. Like Egypt, Israel has too many doctors and not enough nurses and other health care workers. It has state-of-the-art facilities in the largest cities, but the delivery system is in crisis. “We need more health care, not medical care,” one government health official says, adding that “in medicine, America is the leader for Israel.” [4]
There are government and private hospitals and clinics in Israel, but the largest component of the system is Kupat Holim, run by the Histadrut labor federation and financed mostly out of workers’ insurance fees. In addition to the private vs. public competition, there is competition between the Labor-controlled Kupat Holim and the Likud-controlled state sector. Kupat Holim doctors get higher salaries than those working for the government, which has prompted numerous strikes in the government sector, but Kupat Holim, reflecting the fiscal crisis of Israel's “socialist” sector, requires government subsidies. Under the Likud those subsidies have decreased substantially. The Histadrut, for its part, opposes any initiative to set up a national health system for fear that this would cause its membership to plummet.
We tend think of health care as coterminous with medical care, and to measure a society's health in terms of the number of physicians and hospital beds per capita. Indeed, hospitals, doctors and medical technologies often claim between 60 and 80 percent of the health budgets of many Third World countries, though they reach no more than 15 percent of the population. [5] In fact, the place of modern Western medical skills and equipment in producing healthy societies is decidedly less critical than the availability of nutritious food and decent shelter, sanitation and safe water. In the health sector itself, an emphasis on providing basic preventive health techniques to the widest sectors of the population is more critical than the replication of hospital and physician-centered services characteristic of the United States.
In fact, the place of modern Western medical skills and equipment in producing healthy societies is decidedly less critical than the availability of nutritious food and decent shelter, sanitation and safe water.
More than a decade ago, in 1978, the World Health Organization (WHO) met in the Soviet city of Alma Ata and set a goal of “health care for all by the year 2000.” Primary health care was declared the appropriate strategy to meet that goal. Primary health care emphasizes prevention rather than cure; small, mobile, rural clinics rather than town or city-based hospital centers; trained community health workers rather than physicians. It targets children and women as most vulnerable to preventable infectious diseases. Most Middle East governments endorsed this approach, ratified in the Alma Ata Declaration.
May Haddad and Norbert Hirschhorn, in this issue, recount some Middle East success stories in the primary care area. Richard Reid, UNICEF's regional director for the Middle East, visited Iran and Iraq in early 1989, and reported that despite the toll of their eight-year war both countries have made great strides in primary health. Iraq’s campaign recruits “health motivators” from the General Federation of Iraqi Women to work in rural villages and urban neighborhoods. Iran has set up 8,000 man-woman teams of basvaran with two years’ paramedical training to work in villages, and plans to have a total of 10,000 to 13,000 teams. The Iranian system, Reid said, “seems as good a primary health care system as one can find anywhere in the world.” [6]
In many countries, though, the emphasis on primary health has led to decentralization but has not otherwise challenged the hospital-centered biomedical paradigm of what constitutes appropriate health care -- a paradigm that is promoted by drug and medical equipment manufacturers and medical establishments both local and international. Cynthia Myntti, in a discussion of health in rural Yemen, notes that the provision of modern medical care by a state bureaucracy “has begun, in effect, to diminish personal responsibility for health.” [7] Health has become something a person buys in the form of tablets and injections rather than an organic function of nutrition and hygiene.
Vicente Navarro, professor of health policy at the Johns Hopkins School of Public Health, sees Alma Ata as a response to the glaring failure of the prevailing Western biomedical approach to meet popular health needs, but also as an effort to cope with the surge of successful political revolutions in the Third World in the 1970s. An emblem of the health dimension of this revolutionary process was the Chinese “barefoot doctor.” WHO, looking for consensus, proposed technological solutions -- immunization campaigns, for instance -- to what are at heart political problems, relations of power. “Alma Ata said to the multinational drug companies and to Western governments: You don't have to alter the political framework. The WHO strategy can respond to the health dimension of crises that lead to political revolution and in the process expand your markets.” [8]
Navarro agrees that the Alma Ata goals are progressive. But, he argues, in countries like Brazil “infant mortality is declining while malnutrition is increasing. Death is prevented but the conditions of life deteriorate. Political, not technical, interventions are needed to address the root causes of the health crisis.” Even so, in the Reagan era Washington saw Alma Ata as a Red document, or at least as an impertinent critique of the multinational corporate health industries. The government campaign against the critics of Nestle’s infant formula sales was an example of official US hostility to any critique of those industries.
Many stereotypically Third World diseases, such as cholera, were common in Western societies in earlier eras. Biomedical remedies were only partly responsible for their elimination. Much more basic were the improved living conditions that came as a result of political struggles led by working class movements and unions for higher wages and social services.
The political dimension of health also stands out in any account of the “hearts and minds” campaigns that accompanied Western colonial expansion.
The political dimension of health also stands out in any account of the “hearts and minds” campaigns that accompanied Western colonial expansion. Medical missionaries played a leading role in colonial penetration of the Third World, including the Middle East, often making themselves indispensable to local rulers and elites. Physicians and paramedics have been part of virtually every colonial “pacification” campaign from Napoleon in Egypt to the US Green Berets in Indochina. Hubert Lyautey, the commanding officer of the first French invasion forces in Morocco in 1907, had pioneered the medical component of pacification during an earlier assignment in Madagascar. In 1901, at the height of the French campaign there, he is said to have wired his commanding general: “If you can send me four doctors, I will send you back four companies.” [9] At a medical conference in Brussels in 1926, Lyautey agreed that “colonial expansion has its harsh aspects,"” but he went on to argue that “if there is something that ennobles it and justifies it, it is the action of the doctor, understood as a mission and an apostleship.”
The direct and indirect colonial experience of most Middle East societies left its mark in many sectors, including the professional medical establishments of the post-independence era. Several articles in this issue note some consequences in terms of the emphasis on biomedical technology and training in most countries. Cynthia Myntti briefly recounts the development of modern medicine as a profession, a process more or less coterminous with the era of colonial expansion.
The political importance of health care is apparent today in the spate of clinics sponsored by movements and parties. Some political groups use health services merely as a form of patronage, but in most instances the motive is to mobilize popular support by using health as an issue of popular empowerment. The work of the Eritrean People's Liberation Front and the Union of Palestinian Medical Relief Committees is emblematic of such efforts. In both cases, according to Palestinian and Eritrean public health activists, military occupation and conflict pose special medical needs but the key health problems stem from underlying social and economic conditions. In Lebanon some sectarian organizations set up clinics to recruit militants and supporters; other organizations, such as Secours Populaire, set up clinics with the purpose of overcoming sectarian divisions.
Then there is the “depolitical” agenda of the large, well-funded “Islamic” clinic adjacent to Cairo’s Mustafa Mahmud mosque. The founder of the mosque is himself a former physician who says the clinic’s purpose “is to embody and disclose the real Islam.” Mahmud's agenda supports the status quo. “We are showing that problems can be solved without this class struggle and so on,” he says. There is nothing “Islamic” about the services available. With more than a few donors from the Gulf, Mahmud's operation is equipped with a third-generation CAT scanner, laser eye surgery facilities and kidney dialysis equipment. [10] Egyptian anthropologist Suhair Morsy stresses the need to differentiate between the various Islamist tendencies, but for the most part she finds the clinics analogous to the “Islamic” banks and investment companies that have proliferated in the last 15 years. She characterizes the clinic phenomenon as “cultural elaboration of global hegemonic biomedicine” which in Egypt is geared to winning the mainstream Islamist parties a share of state power. [11]
Israel provided a good instance of the political propaganda possibilities of health care when it brought 61 earthquake victims from Soviet Armenia for therapy and artificial limbs. For Palestinians in the occupied territories, though, hospital days in Israeli hospitals were cut by 75 percent in 1988, from 16,768 to 4,612; protests by Israeli and Palestinian physicians managed to get the number back up, but only slightly, to 6,000. [12] Injuries inflicted by Israeli troops are much more likely to earn Palestinians time in prison than in a hospital.
In many instances, “development” has complicated rather than alleviated health problems. Malaria, for instance, is recurring in several areas, mainly owing to a new strain of mosquitos resistant to standard chemical eradication techniques. In Egypt, increased agricultural irrigation following construction of the Aswan High Dam brought wider exposure to water-borne infectious diseases such as schistosomiasis.
Many Middle Eastern societies today face a dual disease structure that includes “modern” industrial-era sicknesses alongside more familiar maladies. The incidence of cancer has increased with life expectancy, exposure to pollutants and increased tobacco smoking. The severe stress that invariably accompanies the high rate of social change in the region has led to rising incidence of heart disease and high blood pressure. A WHO report from 1980 noted that mental illness accounted for some 30 percent of the illnesses doctors see. [13] Drug addiction has become a serious problem, affecting both urban slums and royal palaces.
The access that wealth provides to medical technology can sometimes create new social problems. There are now five kidney transplant centers in the Gulf, but a shortage of cadaver kidneys. As a result, a kidney now fetches $13,600 on the “market,” half of which goes to the donor and half to the “broker” who arranges the transaction. Egypt has banned kidney transplants on foreigners not accompanied by relatives, in order to stop the local trade in organs. There seems to be no shortage of donors, though, since sale of a kidney will net an Indian worker the equivalent of six years’ wages. [14]
Urbanization has created new pathological profiles. Sanitation is frequently abysmal. In Morocco, for instance, only an estimated 70 percent of Casablanca’s garbage is picked up; the rest piles up or runs off. While many diseases related to the environment claim the poor as their major victims, some modern health problems are peculiarly middle class. Morocco’s rate of auto fatalities per hundred million kilometers driven is three times that of Europe. [15]
Occupational health hazards have become more important as urbanization and industrialization proceed, but workers are not able and governments and companies not willing to make health and safety a priority.
Occupational health hazards have become more important as urbanization and industrialization proceed, but as Aliza Marcus' story about Turkey in this issue illustrates, workers are not able and governments and companies not willing to make health and safety a priority. Cotton mills and phosphate mines produce numerous respiratory ailments. Weaving factories and steel mills generate noise as well as air pollution. Workers in refineries and petrochemical plants are exposed to many toxic substances. Handicraft factories and scrap metal smelters that crowd certain traditional urban quarters create health hazards that are no less dangerous for being long-standing. In both traditional and modern workplaces, especially those employing recent migrants from rural areas unfamiliar with machinery and toxic substances, exposure to disease and injury tends to be high.
Health is important to people in all societies as a measure of whether an economy and a sociopolitical system are providing for their basic needs. In many societies, the issue is not productive capacity but distribution and equitable access. The current fashion of proclaiming the “failure” of socialism, Vicente Navarro points out, ignores the credible job socialist countries have done to meet the broad health needs of their citizens, if one compares China to India, Cuba to the rest of Central America, Soviet Central Asia to the Middle East. The Soviet Republics with the worst infant mortality rates -- Uzbekistan, Tajikistan and Turkmenia range from 43 to 53 per thousand live births -- still compare quite favorably with most Middle East countries, including such paradigms of modernization as Turkey. Soviet Azerbaijan and Kazakhistan -- 26.5 and 29.2 respectively -- are equaled or bettered in the Middle East only by Bahrain, Kuwait, the United Arab Emirates and Israel. [16]
To date, no thorough and systematic critique of existing health care approaches that goes beyond the primary health care critique of Alma Ata has emerged in the Middle East. The Young Doctors organization in Cairo and the Union of Palestinian Medical Relief Committees in the occupied territories have encountered firsthand the difficulties of providing alternative models in societies where private practice, corporate ownership and professional privilege still prevail. The debt crisis that affects Jordan, Egypt and other North African states has opened those societies up to new pressures from the World Bank, the International Monetary Fund and the US Agency for International Development for further privatization in health care as well as other sectors.
Navarro observes that even revolutionaries often “think about health in a very conservative way,” equating it with “medicine better distributed.” In Cuba, even the most committed doctors maintain a clinical perspective and view themselves as the controlling element. [17] The stress on preventive primary care over curative hospital treatment is positive, but the critique and development of alternatives must go farther, to stress occupational and environmental interventions that can eliminate threats of disease and injury to whole sectors of the population. “Medicine is not a neutral set of institutions, knowledge and practice,” Navarro insists. “In conjunction with other sectors and relationships, it reproduces power. Revolutionary political forces must form alliances within the intelligentsia and technocracy, but this risks reproducing old power relations unless new mechanisms of accountability are devised. Distribution is likely to be only the first battle.”
[1] Cynthia Myntti, “Changing Attitudes Towards Health: Some Observations from the Hujariya,” in B.R. Pridham, ed., Economy, and Contemporary Culture in Society (Dover, NH: Croom Helm, Ltd., 1985), p. 169. [2] Data supplied by The Galilee Society for Health Research and Services. [3] This discussion is based on an unpublished manuscript by Alaa Shukrallah, an Egyptian physician. [4] Interview with an Israeli health ministry official. [5] UNICEF, Annual Report, 1989. [6] Middle East Health, February 1989. [7] Myntti, p. 169. [8] Interview, July 1989. [9] James A. Paul, “Medicine and Imperialism in Morocco,” MERIP Reports #60(September 1988). [10] New York Times, July 12, 1987. [11] Unpublished manuscript presented to the American Anthropological Association. [12] Association of Israeli and Palestinian Physicians. [13] Jan Simon, Middle East Health: The Outlook After 30 Years of WHO Assistance (Alexandria [Egypt], 1980). [14] Middle East Health, May 1989. [15] Jean-Francois Clement, “Maroc: Les Menaces et les Composantes Internes de la Securite,” French Institute for International Relations, 1988. [16] New York Times, August 14, 1989. [17] Vicente Navarro, “Historical Triumph: Capitalism or Socialsm?” Presentation to the Student-sponsored Seminar on Economic Development and International Health of The Johns Hopkins University, May 1989
