As the panic surrounding the Coronavirus continues to grow, it is useful to look at where it would seem it would be most virulent.

The first point here is that health care, like almost every other aspect of life, it is culturally dependent.An excellent book as a primer on this is the Cultural Geography of Health Care by Wilbert Gesler.

As he writes “medical systems must be seen in the context of larger cultural and environmental systems. The context consists of many sub-systems: social relationships, political and economic systems, attitudes and beliefs, topography and climate. All of which determine how health care is delivered.”

First let’s look at some larger cultural attributes of the Islamic/ Middle Eastern world.

To begin with the Arab/Islamic world between the 8th and 12th century. The Middle East was far ahead of the rest of the world. Avicenna’s (Abu Ali Sina)  Qanun of Medicine  was the standard medical  book in Europe for centuries.

Avicenna

With the decline of the Islamic world so well told by Bernard Lewis, (What Went Wrong), many of the strengths of the Middle East mosaic which had made it more advanced than Europe eroded under corruption, sectarianism,  moribund Islamic induced cultural stagnation, and Western-introduced nationalism

The Turks, who were great soldiers, but not great inventors or agents of cultural advance, depended on their millet system of diverse religious and ethnic communities for many of the scientific achievements and managing everyday living institutions. For instance the Jewish millets furnished many of the financiers, and metal shop keepers, the Christians were the barbers, butchers, and medical providers. etc.  But with the coming of nationalism and militant Islam, most of these minorities have been expelled under the ethnic cleansing conducted by Middle Eastern governments – (nationalistic or Islamic) since WWII. So, the stark reality today is the unpreparedness of the Middle East to cope with any pandemic disease.

Ironically there are far more injunctions on cleanliness in Islamic tradition than the Christian, and Middle Easterners are just as personally ( or more) attuned to cleanliness as any other people.  In fact in Islam, cleanliness is considered to be part of the faith. Unfortunately the real world of the Middle East  there are many traits which militate against community efforts against coronavirus.

Some cultural traits adversely affecting  health care:

 The Lack Civic of Responsibility

Anyone who has lived in the Middle East knows well the lack of communal civic responsibility of people, especially in an urban area. Maids sweep apartments squeaky clean and throw the dirt in the street. Garbage is allowed to pile up on street corners,( hello SF and LA)  sewage after a heavy rainfall is always a problem  Smog produced by burning trash is endemic. Even in military headquarters, the VIPS are taken up in elevators because the stairwells are littered with trash. Officers walk outside their offices and throw food wrappers in the hallways.

In the cities, where neighbors are not of the same family or clan, this irresponsibility is most apparent.  On an international level the Middle Easterners do not seem at all embarrassed that the “hated West” supplies most of the medical help for the massive numbers of displaced families in the Middle East. (Exception is  Jordan which has done all that could be expected for about one million Syrian refugees in their country).

The “Potemkin village” aspects of the main westernized centers of the cities, with their gleaming shopping centers and upscale shops, often mislead visitors who do not see the areas of the cities where recent immigrants from the country side live in squalor.  On the other hand, rural villages have much more civic responsibility in that the people are mostly all related to one another and know they must depend on each other because no one else will,  particularly not the government.

Blood

In strict traditional Islam human detritus, e.g. blood, human skin, even hair is considered najis, (unclean) which is the main reason that in the Islamic empires, Christians normally performed the roles of butchers, nurses, barbers etc. Today as Christians have become rare in the Middle East, only low class Muslims will perform the role, and only with great reluctance, especially as nurses.  All of the Middle East countries are very short on nursing care. 80% of the nurses in Saudi Arabia are expats. Many stay only a short time, unable to cope with the environment and gender rules of the Wahhabi state. There are so many rules in Islam pertaining to cleanliness and personal hygiene one has to be an Islamic scholar to know them all, therefore the danger of running afoul of some proscription is very large indeed. Unfortunately, many of the rules are only peripherally cogent to personal hygiene. For instance a miscarried fetus is unclean.  a dead body, once it is cold, is unclean, Etc. More pertinently, traditional Islamic forbids postmortem dissection to ascertain case of death or more experimentation.

 Gender proscriptions

Our troops found during Operation Provide Comfort that treating women was a tough problem.   Generally speaking, the Kurds, who are usually less religiously oriented than many Arabs, would not allow male medics to treat women unless accompanied in the clinic with their husbands or senior male relative.

Among the women themselves, their mind set and indoctrination  often kept them from seeing a doctor until their illness was far advanced.  And women doctors are not plentiful in the Middle Eastern countries as there are many restrictions on what they may see and do during doctors training such as  looking at or touching forbidden parts of the body (Awrahs).

And of course, she should never treat men.  For that reason urology is absolutely forbidden to Muslim female doctors.  After going through all their proscriptions and prescriptions to be a doctor the incentive to be a female doctor are few indeed, especially in the more conservative Middle Eastern states.

Privacy and Proxemics

In the Middle East the idea of privacy is an abomination. Middle Easterners are congenial,  communicative,  and outside their homes or villas, very  public people.  Islam tends toward orthopraxy following the traditions of the Prophet. As  evidenced by the ostentatious use of public prayer on streets in European cities. Middle Easterners are a touchy feely people. As Edward T. Hall, the renown American anthropologist explains it, there is no personal space in the Middle East, particularly in the public sphere. This  is why  there  is seldom any such thing as  privacy in the Middle East.  In Arabic there  is no specific word for privacy, and as the Sapir -Whorf analysis showed, people think in words and if there is no word for it they can’t visualize it. Nor is there anything such as a cue , in that people push and shove in a manner that is considered very rude in the West.

My experience was that  people like to be able to smell the breath of the person they are talking to  (perhaps not literally and not mixed genders) but as a rule it is how close they want to be. In terms of privacy, the following scenario is typical.  When an American boards a bus he heads for a seat not only empty but some distance from the other passengers. If an Arab gets on a bus very likely if there is only one other guy on the bus he will go sit next to him.  If he does not the passenger will feel offended.  For these reasons it is it is extremely difficult to put a person in quarantine. A sick person expects to be inundated with visitors.

The Inshallah  factor

This is overworked factor  in the West when analyzing Arab/ Middle Eastern cultures but it still has validity. From my experience working with Arab soldiers their cavalier attitude handling weapons and driving vehicles is only a few examples. There is a strong belief in predestination as typified by a Jordanian taxi driver, observing me putting on my seat belt, saying “if God wanted you dead would that strap prevent it?”

Islamic  clerical  Misinformation and strong influence of reputation protection

Quite often people who may have the disease do not come forward, being ashamed and afraid of being shunned by relatives and friends.  Recently  an Iranian mullah told his flock that anyone who comes down with the disease is not a good Muslim. They sound ridiculous;lous but many believe that. Two examples from actual cases in Iraq:

An old woman in Iraq felt sick so her daughters and sons took her to the hospital, but deliberately withheld the information that she had been in Iran recently. When she died the children told the staff that she had just returned from Iran. They said – quite typically Arab and commendable – they did not want to leave their mom alone.  But the result is that  nurses and doctors were not quarantined in time.

Another example. An Iraqi tribesman went to the hospital saying he had the flu. When the doctor told him he had to be tested for corona virus. He replied that he would do so but if the test was negative he would sue the hospital and staff for demeaning his reputation. Moreover no one would believe that he tested  negative anyway.

treating corona virus in Iran

Doctors

Very often the medical credentials of the doctors in the Middle East are of doubtful credibility. Their training is suspect.  For instance the UAE, Qatar, and Saudi Arabia are reported to be  sending home hundreds of Pakistani doctors after they learned of the  inadequate professional qualifications they acquired in Pakistan.  Much more importantly, thousands of doctors have fled to the West to avoid the wars in Iraq and Syria, as well as the oppression of State controlled health care in  other Middle East countries.

A number of Middle Eastern countries financially support medical education with the proviso that the graduated doctors serve in rural areas for a specified time but few do because it is a characteristic of most Middle Easterners, that despite the fact the majority of their nations are desert, they  abhor  the desert and rural areas. Most find a way to depart before their specified terms are up.

Surgeons are a very respected profession in the Middle East, which seems to create a dichotomy considering their religious attitude toward blood as unclean.  But the  surgeon is considered an artist. He skillfully cuts and slices, leaving the clean up to the nurses.

Political Barriers

The primary reason for poor or inadequate medical care in the Middle East is the   incompetence and indifference of the ruling elites to their people, excepting those who are the pillars of the regime.  The difference between between military spending and health care is astronomical and the portion  which is allocated to health is siphoned off in corrupt deals. How this corruption and indifference plays out is in several forms;

When sanctions were applied against Iraq under Saddam, the Ba’athist elite did not suffer at all. Saddam continued building palaces and rearming his military, while the poor suffered from malnutrition, and the middle classes began selling family heirlooms just to keep body and soul together.

Uday’s “love Palace” Let them eat cake!

Looking at the statistics coming out of the Middle East, it would seem at present that with the exception of Iran, the Middle Eastern countries are better off than Italy and possibly Germany. ¹ But the governments  lie about almost everything and their data keeping is inadequate at best.  My view is that Middle East governments  have no real idea how many cases of Coronavirus they have within their borders, and if there are many, they simply lie about it. In fact lying has become a way of life for the regimes,  even if it is not  really their fault. A lack of potable water supplies, adequate power, sewage, and trash collection, and a host of other ills, over and above the constant bloodletting between regime rivals, have made the Middle East a prime area for an uncontrollable outbreak of the virus. But they are by no means alone in this disregard for taking care of their people. In certain parts of our country we have similar problems. Will we take heed?

1. As a footnote the low incidence of the Corona virus in the Middle East- so far- one may think about the fact that many middle easterners go through life  without having the plentiful availability of drugs, medical care, vitamins. etc that we do. In the Middle East I always advised newcomers to eat whatever, get sick and get it over with. Not being a doctor or even playing one on TV, somehow I think Middle Easterners to some degree, if they survive, become more immune to the diseases which lay us occidentals  low. Just a thought!