MEDICINE AND PUBLIC HEALTH

an improving field based on a combination of traditional and modern practices.

The largest populations, comprising 52 percent of the Middle East, are in Egypt, Turkey, and Iran. About half of the Middle East population is urban. Because of public health advances, a Middle Eastern child born in 1990 can expect to live for seventy years, thirteen years longer than his or her parents. Death rates have fallen faster than birthrates, and at the current pace the population will double in twenty-nine years. Cultural traditions, including Islam, shape some curative options, but socioeconomic factors prevail. Local beliefs in breast feeding and birth spacing enhance maternal and child health. Access to health services, quality of environment, and labor opportunities remain uneven. Israel's comprehensive, Western-style healthcare system and developed economy exclude it from many generalizations here.

Typhoid fever, cholera (on the decrease because of better sanitation and improved water sources), typhus, leishmaniasis, trachoma, and gastroenteritis are characteristic of the area. Increased irrigation has raised the incidence of malaria and schistosomiasis. Smallpox was eliminated by the 1970s through systematic vaccination, but measles remains a problem in some countries. Tuberculosis, which replaced smallpox as the illness of crowded cities, decreased after a 1950s World Health Organization (WHO) and UNICEF immunization program but could resurge if AIDS expands. Ministries of health have combated AIDS, which is seen as the scourge of Western decadence, with frank public health campaigns.

Curative Options: Humoral, Prophetic, Local, and Cosmopolitan

Health care resonates with curative resources and one's life situation. Most people self-prescribe for mild symptoms, whether by taking vitamin C or consulting the local herbalist. Middle Easterners pick eclectically from a repertoire that includes humoral, prophetic, local-practice, and cosmopolitan (modern or Western) cures. Western medicine was introduced in the nineteenth century in medical schools in Cairo, Tunis, and Istanbul, and by the 1920s most governments required practitioners to be licensed.

Humoral medicine, predicated on the balance of the four humors, as in the allopathic, Galenic tradition, is important for herbal pharmacists (attarin) who provide such household remedies as ginger for sore throats.

Prophetic medicine (al-tibb al-nabawi) is based on sayings of the Prophet Muhammad, such as the Sahih by al-Bukhari (d. 870). The Sahih contains eighty paragraphs (2.3% of the entire collection) concerned with medical issues, including the ever-popular "God did not send down an illness without also sending down a cure."

In the twentieth century, prophetic medicine has assumed two forms: popular literature, which intermingles standard collections of prophetic sayings with local wisdom, including humoral principles of balanced, normal bodily functions; and formal medical practice, or Islamic medicine, advocated by such groups as the Islamic Medical Organization (IMO). Founded in Kuwait in the 1970s, the IMO administers a hospital that treats patients by the tenets of Islamic medicine and tests Prophetic cures under controlled, laboratory conditions. The experiments concentrate on symptoms ambiguous in etiology and cure, such as renal failure and eczema. The IMO ethical code critiques Western medicine's origin in a "spiritualess" civilization and adjures the Islamic physician to include the patient's therapy managers in the treatment. Other Middle Eastern physicians who consider themselves Islamic practice cosmopolitan medicine but within an Islamic-medicine moral context, such as Islamic benevolent association clinics.

Local and Cosmopolitan medicine frequently overlap. Local practitioners, a trusted first recourse, cooperate with cosmopolitan practitioners. For instance, the traditional birth attendant may encourage the mother through delivery but call the licensed midwife to cut the umbilical cord and provide post-natal care. Training by the ministries of health targets socially accepted but technically inadequate midwives, herbalists, and self-made nurses.

Such local practices as amulets against the evil eye or shrine visitation to enhance fertility, which is forbidden by official Islam, are part of a complex curative strategy. Caretakers calibrate symptom severity: They make a vow for a sickly child but rush a fevered child to the hospital. Western, cosmopolitan medicine may be construed in local terms. Traditional Egyptian physiology speaks of circulation of microbes that bombard a patient, much as black magic does, and are neutralized by the injection of a powerful agent, or exorciser. Western medicine may be well understood but not used. For instance, agriculturalists will return to snail-infested irrigation canals to cultivate, though they know doing so means reinfection with schistosomiasis.

Public Health: Child Survival and Maternal Health

Major public health problems among infants and children are dehydration from diarrhea; malaria and immunizable diseases; acute respiratory infections; and injuries from war. Among women, maternal mortality and morbidity from inadequate prenatal, delivery, and postpartum care are often problems. Infant mortality rates (deaths per one thousand live births) dropped in the period 1960–1995 from 214 to 109 in Yemen, 139 to 62 in Iraq, and 89 to 12 in Kuwait.

With oral rehydration solution widely available to parents, mortality from dehydration is no longer a major threat to infants. Nevertheless, early childhood acute diarrhea—exacerbated by nonpotable water, poor sanitation, and malnutrition—may cause more than fifty deaths per one thousand per year in pre-school children. Public health programs consider local perceptions of diarrhea and dehydration and teach mothers the warning signs of dehydration and home recipes for oral rehydration solutions in case mothers cannot obtain commercial packets. Given the synergy between malnutrition and diarrhea, these programs have promoted supplements based on such local dietary practices as Egypt's seven grains, which has been marketed as Supramin.

The percentage of children who are fully vaccinated ranges from 88 percent in Jordan and 85 percent in Morocco, to 45 percent in Yemen. Full-immunization rates have fallen in recent years, most notably in Iraq, after a decline in support from UN agencies previously leading this worldwide effort. While tuberculosis has subsided, acute respiratory infection remains a significant problem, in part because there is no vaccine to prevent it. In most Middle Eastern countries, it has replaced acute diarrhea as the number-one cause of infant mortality.

War exerts a heavy price on women and children, including death from military operations; starvation; orphaning; disruption of services that protect health, such as water, sewer, irrigation works, and health services; rape and sodomy; and separation of children from their families. For political reasons, there are no accurate data on children killed or maimed in Middle Eastern wars. Estimates are as high as two million killed and five million disabled.

The long conflict in Lebanon severely damaged the quantity and quality of drinking water. One 1990 study found that 66 percent of urban Lebanese water sources were contaminated and that one-third of urban communities were using cesspools for sewage disposal. It is more difficult to assess war's psychic trauma for children than its physical wounds. Civil strife in the Levant, West Bank, Gaza, and Israel has created a generation of children with dead parents and siblings, lost limbs, and nightmares of bombs and mines. Women and children pay much of the human price after several years of sanctions against Iraq. The food-rationing system provides less than 60 percent of the required daily calorie intake, and the water and sanitation systems are in a state of collapse. During the Gulf War, Iraq laid multitudes of mines; the allies also laid some one million land mines along the Iraq–Kuwait border. These pose serious threats to life and limb.

Countries are just beginning to recognize at the policy level the importance of maternal health to the health of a nation. Very few have as yet provided adequate resources. Reproductive morbidity—illness related to the reproductive process—remains relatively unstudied but critical. Over half of a sample of rural Egyptian women had such gynecological morbidities as reproductive-tract infections and anemia. Maternal mortality—fewer than 30 per 100,000 births in developed countries—remains high. Morocco averaged 332 in the late 1980s; an Egyptian province, 126 in the 1990s.

Poor maternal health and nutrition, too-short birth intervals, prematurity, and low birth weight underlie 40 to 60 percent of all infant and child deaths. In 1992, Egypt reported 26 percent of children from zero to thirty-five months with stunted growth, while Jordan and Tunisia reported 18 percent.

Public Health: The Politics of Population, Body, and Food

Women have always sought to control their fertility, first with folk remedies, such as aspirin vaginal suppositories, and now with largely safer, modern technology. Women obtain abortions in private clinics and also try such folk remedies as drinking boiled onion leaves. While birth-control pills, and more recently implants, have been widely used, IUDs (intrauterine device) have been popular in places such as Syria, Egypt, and Jordan. In 1994, 63 percent of Turkish, 47 percent of Egyptian, and 50 percent of Tunisian married women used contraceptives. Side effects or a pregnancy history with at least one infant death often prompt a woman to abandon the birth-control pill.

With population (as with all public health), local custom and socioeconomic context play a more critical role than what Islamic culture allows. For example, fertility rates have dropped in poor Islamic countries, such as Tunisia and Morocco, and remained higher in oil-rich Islamic countries where governments have until recently subsidized child rearing and de-emphasized female education, which is often associated with smaller families.

The Egyptian shaykh al-Azhar has in the past given fatwas (religious pronouncements) in support of family planning. The Qurʾan is silent on birth control, but jurisprudence texts record the use of azl (coitus interruptus). Muslim promotion of population control waxes and wanes for political and economic, more than religious, reasons. In Pahlavi Iran, the regime legalized abortion, but the Islamic revolution promptly condemned family planning as a Western imperialist plot. Population skyrocketed and threatened economic growth. In the mid-1980s, Friday sermons in Iran took a 180-degree turn and began to advocate family planning.

Child-survival and maternal-health programs are an integral part of family planning. While the population of the Middle East is growing at 2.7 percent a year, the labor force is growing at 3.3 percent. Jobs for forty-seven million new entrants to the labor force must be found by 2011. The Cairo conference on population in 1994 and the Beijing women's conference in 1995 hotly debated such issues as gender equity, employment and economic development, and a woman's right to control her body. Some Muslim ulama (theologians) united with Roman Catholics to oppose a platform seen as threatening family values.

Female excision—a non-Islamic custom practiced locally in Egypt, Sudan, and parts of Africa—is vehemently critiqued by Western feminists. In the Middle East, folk beliefs link excision and fertility; in traditional areas of Egypt, a recently excised girl who crosses before another woman is believed able to strike that woman with infertility. While Egypt outlawed female excision in the mid-1950s, the practice, referred to in the Western press as "female genital mutilation," continues in traditional areas. Middle Easterners criticize Western feminists for seeking to impose their standards cross-culturally.

The politics of medicine includes not only issues of population and cross-cultural judgments, but also such issues as access to food and health facilities. The Sudanese famine of the late 1980s was not a problem of food, because the harvests had been ample; rather, it was an issue of the logistics of food placement during civil strive. Finally a quick review of public health cannot cover specialized treatment and scientific advances in Middle Eastern hospitals and research centers in such fields as oncology and cardiology.

Bibliography

Burgel, J. Christoph. "Secular and Religious Features of Medieval Arabic Medicine." In Asian Medical Systems: A Comparative Study, edited by Charles Leslie. Berkeley: University of California Press, 1977.

Early, Evelyn A. "The Baladi Curative System of Cairo, Egypt." Culture, Medicine, and Psychiatry 12, no. 1 (1988): 65–85.

Kuhnke, Laverne. "Disease Ecologies of the Middle East and North Africa." In The Cambridge World History of Human Disease, edited by Kenneth F. Kiple. Cambridge, U.K., and New York: Cambridge University Press, 1993.

The State of the World's Children. UNICEF, 1996.

Claiming the Future: Choosing Prosperity in the Middle East and North Africa. World Bank, 1995.

evelyn a. early