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Volume 25, Number 2March/April 1974

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Nursing in the Arab East

" We gathered round an old oil lamp, like the lamp used by Florence Nightingale, recited the nurses' oath and received our caps."

Written by Michael E. Jansen

In Saudi Arabia's Eastern Province a covey of abba-clad girls alight, one by one, from a bus, and skitter, laughing and chatting, up the steps of the Hofuf School of Nursing. Doffing their flowing cloaks, the 20 girls file into three classrooms and begin their day of study with a recitation from the Koran. In Cairo, 1,000 miles away, 400 Egyptian girls in kerchiefs, smocks and pantaloons gather in a practice ward at the 'Ain Shams University Nursing School. Outside Amman, at the Princess Muna College of Nursing, Jordanian Army nursing students in tall lace caps and brass-buttoned uniforms stand smartly at attention for their Matron-Colonel's briefing before beginning their rounds in the newly opened military hospital.

These girls, ranging between the ages of 14 and 20, with backgrounds varying from modern to medieval, are about to embark upon an exciting journey: the journey into nursing in the Middle East. The Saudi girls will go into midwifery, the Egyptians into general hospital nursing and public health and the Jordanian cadets into the technical byways of modern medicine. They will travel everywhere by every means: to new hospitals in bustling cities, to Bedouin tents in the shimmering desert, to mud houses along papyrus-clad rivers and to stone villages straggling up terraced mountainsides. Some will earn degrees from universities, some will become hard-working practical nurses and some will pass their years bringing forth infants, squalling and red-faced, whose childhood will be overseen by others who choose public health. But the goal of their long arduous journey will be the same: a healthy Middle Eastern society, healthy in spirit as well as in the flesh.

The growth of nursing in a particular society generally indicates that the status and education of its women are improving. Indeed it is possible to say that the levels which the nursing profession has attained in a country is a very good indicator of the level of overall development of that country. In the Middle East the levels vary considerably.

In the newly developing areas of the Middle East, particularly along the Arabian Gulf and in Saudi Arabia, nursing is a new idea. But it is an idea that is rapidly taking hold as the people of these countries propel themselves into the modern world. In Saudi Arabia, for example, there are some 50 government hospitals and 175 dispensaries now in operation. Admittedly, most of these facilities and similar facilities in the Gulf are still dependent on nurses imported from Asia, Egypt, Lebanon, Europe, the British Isles and the United States. But the countries have begun to establish modern nursing schools and are already turning out practical nurses able to staff at least some of the facilities. As early as 1950, for example, the Arabian American Oil Company founded a nurses' training school in Dhahran which provided the guidelines for what has become an extensive training program for practical nurses in such areas as Hofuf and Dammam. In Bahrain the government opened its first nursing school in 1959 and there is today under construction a modern 500-bed hospital with training facilities for 60 nurses a year. In Dubai last year, a British nurse from Zanzibar opened a nursing school affiliated with the new Rashid Hospital.

Along the Levantine coast, nursing has a much longer history. It goes back to 1847—seven years before Florence Nightingale landed at Scutari in Turkey during the Crimean War and founded the modern secular nursing profession. In that year, French Sisters of Charity established a hospital in Beirut, recruited local girls for training as nurses' aides and made Lebanon the medical center of the Middle East.

But even in Lebanon the levels differ. Within a 10-mile radius of Beirut, on any given day, can be found Miss Abla Bsat, Bachelor of Science graduate of the American University of Beirut, sitting before a heart monitor in the American Hospital's coronary care unit; Sitt Adele, a rural nurse with a diploma from a hospital in Tripoli, trudging through her mountain village on house calls; and Umm Fawzi, a traditional midwife with up-to-date training and equipment, delivering babies in the suburb of Bourj el-Barajneh. Each of these women, one a specialist, one a competent generalist, the third an experienced, though illiterate, expert, contributes in her own special way to the health and well-being of her people. From three different worlds, living within a few miles of one another but never likely to meet, all three equally represent the nursing profession in the Middle East. You will find their sisters—and a few brothers as well—in and around every Arab capital and town: technician, general practitioner and traditional midwife.

Miss Bsat is a specialist working in a world of specialists. Enrolled at the American University School of Pharmacy, she was, at the eleventh hour, persuaded by her family doctor to switch to nursing. In June 1971, she graduated from the university's new four-year Bachelor of Science nursing program and two weeks later joined the coronary care unit. Today she is the youngest head nurse in the hospital.

Miss Bsat—whose well-to-do parents backed her decision to become a nurse—also represents a break in the traditional conviction that nursing is an unsuitable profession for girls who can afford better. Once widespread, this conviction has begun to weaken everywhere. It is true that Arabia is by no means free of the conviction that nursing is an "improper" occupation for young women. Out of 1,279 nurses on government rolls in Saudi Arabia, for example, only 529 are women and of these only 47 are Saudi girls. But even in Saudi Arabia breakthroughs have been made. Samra Islam, one of three daughters in a wealthy Jiddah mercantile family, earned a Bachelor of Science degree in nursing and now works in Aramco's Maternal-Child Care Clinics in Dhahran. Moreover, one sister, Amira, is a pharmacist and the other, Sara, an opthalmologist.

No concern about the suitability of nursing troubled the widowed mother of Sitt Adele Jabbour when Sitt Adele determined, at the age of 15, to seek formal nurses' training. For her, Christian and needy, Sitt Adele's occupation was a financial necessity—as it was for the majority of Middle h Eastern women who went into nursing 25 or 30 years ago. Indeed, until about 10 years a ago, nursing was the major route to education and social betterment for girls from the Armenian, Maronite, Nestorian, Chaldean, Melkite, Protestant, Greek Orthodox and Coptic minority communities. And today their daughters and granddaughters have often gone several steps further. Mrs. Vathouhy Artinian, an attractive Armenian girl, serves as a specialist in the kidney unit at the American Hospital where her mother had been a practical nurse.

Nurses with Bachelor of Science degrees—like Abla Bsat and Samra Islam—are by no means common in the Middle East. And those who hold degrees are generally found in the modern hospitals in Arab capitals or teaching in schools of nursing. Indeed, until recently, when the American University of Beirut and the Jordanian University inaugurated their own B. S. programs, girls who wanted university degrees in nursing had to go abroad. The rest usually went into three-year diploma programs at various private and government nursing schools. As in the United States, Britain and Europe, the three-year diploma nurse becomes a Registered Nurse, or "R.N." In addition to the diploma course, most Middle Eastern hospitals also offer 18 to 24 months practical nurses' training to girls and boys who want to learn and work at the same time.

Outside the cities, furthermore, nursing has been generally restricted to the maternal care provided by dayas—the ancient sisterhood of midwives. Although they are the relics of a medieval society, dayas like Badr Iskandar, better known as Umm Fawzi, still deliver the majority of babies born in the region. Umm Fawzi has been a daya for more than 25 years and her grandmother and great-grandmother were dayas before her.

But even in this field there have been important changes. Arab governments, in cooperation with United Nations health experts, have begun to tap and harness this ancient and honorable profession, using the old to build the new. Rather than attempt to suppress the dayas—whose talents they cannot do without anyway—the governments have instituted "daya control" programs whereby dayas must learn the basic modern skills of midwifery to qualify for a license. Thus old hands are taught how to carry out pregnancy tests and to sterilize their equipment before a delivery. When Umm Fawzi sets out on her rounds in a Palestinian refugee camp outside Beirut she still wears her traditional long white dress and flowing scarf, but she also carries with her a kit developed by and regularly inspected by the United Nations: scissors, forceps, eye swabs, gauze, eye drops, cotton balls, antiseptic solutions, packets of sterile thread and bottles of medicine labeled with simple, clear pictorial signs. For although all dayas can expertly deliver babies, many cannot read.

The differing levels of nursing care in the Middle East reflect not only country-to-country differences in medical advancement and social development but also the training programs themselves. Within the area there are a multiplicity of training programs: those run by governments, by diverse foreign missionary societies and local charitable associations, by oil companies such as Aramco and by United Nations agencies. Each system promulgates its own theories. A girl studying in the French system, for instance, concentrates more on theory, while British and American schools stress practical experience.

There are also country-to-country, and hospital-to-hospital, differences in admission requirements. In Jordan and Lebanon, where the basic educational level is quite high, particularly for girls, prospective nurses must have completed high school. In Egypt and Syria, the requirement is one or two years of high school. In Saudi Arabia, where high school education for girls is relatively new, and where the conviction persists that educated girls must do better than nursing, requirements are necessarily more flexible.

Students in government nursing schools throughout the Middle East receive their room and board and a small allowance while they study. In return they usually must serve in field clinics, provincial hospitals or in other government capacities for two to three years.

In Egypt there are nurses' training courses in every provincial hospital. From these hospitals the new nurses are assigned to clinics in agricultural development centers throughout the countryside. Moreover, it has long been Egyptian Government policy to send a large number of trained nurses to Arab countries in need of hospital staff, particularly to Saudi Arabia and the Arabian Gulf.

Jordan is now making a special effort to train modern midwives to staff the 34 maternal-child health centers which constitute the basic units of its public health service. At present such centers depend on the traditional midwives like Umm Fawzi, but eventually the dayas will give way to the modern midwives: already young women are turning away from traditional daya training, preferring the new independence of midwifery college to apprenticeship, the smart modern nurse's uniform and crisp cap to a long dress and flowing scarf, government clinics to demanding private practice.

Although there are sharp differences in levels of care and regional peculiarities, nursing in the Middle East is still more similar than dissimilar to nursing elsewhere in the world. There are long hours. There is low pay—the average salary is $100 a month and the top $200. And there is dedication to the profession. The capping ceremony that is as familiar to a nurse in New York as it is to sisters in the Australian outback gave Sitt Adele, in Tripoli, Lebanon, one of her warmest memories: "We gathered round an old oil lamp, like the lamp used by Florence Nightingale, recited the nurses' oath and received our caps." This ceremony, carried out in English, French and Arabic throughout the Middle East, and the dedication it represents, unites in this magical moment one nurse to every other. It is the cement which brings nurses together in the face of family opposition, low pay and the fears and suspicions of their patients of modern medicine.

Such fears and suspicions are now waning, but until recently were widespread in the Middle East. In Jordan nurses found that dealings with reluctant tribesmen could be particularly trying. If the tribesmen knew that a mobile clinic was to be at their camp on a certain date, they simply moved away. If referred to a hospital, time and time again a Bedouin patient would refuse to budge, preferring to stay among family and friends even if a stay in hospital would mean recovery. One Bedouin woman insisted that a visiting nurse deal on the spot with a finger nearly severed in a harvesting accident rather than making her leave home to see a doctor.

Yet the nurses are turning the tide. With persistence and ingenuity they have gradually convinced both villagers and nomads that they do good, not harm. Today clinics throughout the region are busy, their halls crowded with patients, young and old, who would never have seen a doctor or a nurse a few years ago. In Jordan, a group of Irish Franciscan nursing sisters carry out sophisticated tests and analyses from a mobile pathology laboratory and in the outskirts of Amman operate a "rehydration" clinic where fluids are restored to babies seriously dehydrated by various intestinal illnesses endemic to the Middle East.

"The Bedouin no longer try to escape us," asserts Andaleeb Arida of the Save the Children Fund, "because they have seen the results of our visits—healthier babies. We do preventive care, teach the mothers what to feed their babies and how to prepare nourishing food, give inoculations and refer cases for treatment to government clinics. So now they wait for us to come; our visit has become a social event, the mothers of one clan gathering in a tent to have their children inspected and drink a glass of tea." Nurses in the Arab world are not stiff in their starched white uniforms; they have too much to do besides what can be called "nursing" in the strict sense of the word.

The shining new hospitals a building in and around Arab cities are also making converts. Now when referred to the splendid Amman Civil Hospital, Bedouin patients need no coercion: they seek admittance and feel quite at home in the bright, airy wards with their plate-glass views of the stony hills round the hill-top building. It has taken time to win their confidence, but since the breakthrough was made, there has been an unending stream of sick and undernourished to hospitals and clinics. Aramco alone treats more than 500,000 people a year in its outpatient operations in the Arabian Peninsula, making it one of the largest outpatient clinics in the world.

Behind this change is a series of hard-won medical victories; successful cures are naturally the best advertisement for a nurse, a doctor or a clinic. Umm Fawzi, for example, says she has never lost a patient. "I make them laugh and they deliver quickly," she chuckled. "And I always call a doctor when there are complications."

Sister Damien of the Indian Missionaries of Charity brought a whole tribe to a clinic when she operated successfully on the Bedouin woman who nearly lost her finger. "The finger was nearly detached," said Sister Damien, "so I had to either replace it or amputate it. I chose to stitch it back on and fortunately I have a great deal of experience in stitching. I had several years in a leper colony."

To most nurses in the Middle East, such unexpected challenges are commonplace. In Lebanon Sitt Adele once had to give five injections a day for seven days—to a cow. "It was my most difficult case," smiled Sitt Adele. "I was terrified of that cow. The veterinarian taught me how to do the injections. You put the needle in first and then attach the glass tube with the medication, for cows have very tough hides. But, what to do? I couldn't refuse; that cow was very valuable." Sitt Adele saved the cow and received four quarts of milk in payment.

Some of the most striking changes have been wrought in the nurses themselves. An Egyptian village girl studying at 'Ain Shams University might arrive in a long peasant dress but she soon saves enough pocket money to buy a miniskirt and blouse to wear in her free time. She learns Ping-Pong, decorates her room with pop-star posters, dresses up to go out. Fine feathers do not, of course, make fine birds, nor do miniskirts make modern women, but new clothes and new ways do indicate new attitudes and ideas.

Behind this new confidence is the nurses' awareness that they are at the top of their profession since, so far, men have generally gone in for practical nursing and work as nurses' aides. Thus, as wage earners, women nurses have better positions in their families and communities, particularly vis-a-vis their husbands. Today, in fact, a nursing career improves a girl's eligibility as a wife. Although many nurses once tended to marry unskilled workers, they now, according to Mrs. Fayez Tell Haidar head of nursing at the Amman Civil Hospital, do much better. "Many of our young Arab doctors now marry Arab nurses they meet on the job. These doctors used to marry foreign girls, often nurses whom they met while they were specializing abroad. Today they can find their own countrywomen working beside them."

It is easy to see, nevertheless, that a Middle Eastern girl who goes in for a nursing career is made of stern stuff. A nurse in the Middle East today must be all things to all people. The challenge is enormous and the material reward small. But, then, there is the greater satisfaction of presenting the world with a healthy baby and watching him grow into a tall, straight youth, of achieving cleanliness where there was dirt, of bringing forth light where before there was darkness, health where there was sickness, confidence where there was only fear.

Michael Elin Jansen contributes regularly to Aramco World Magazine.

This article appeared on pages 14-23 of the March/April 1974 print edition of Saudi Aramco World.


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