Gendered Struggles over the Medical Profession in the Modern Middle East and North Africa

Abstract

The present theme issue speaks to two bodies of scholarship: the history of medicine in the Middle East and the history of women in the medical profession. Historians of the professionalization of medicine in colonized societies have mostly focused on male practitioners and their place in the national middle class (e.g., Lo 2002; Patton 1996). The Middle East is no exception. Histories of the medical profession in the Middle East have addressed medical schools, study missions to Europe, and the production of male physicians. They have also studied these men’s employment in national or colonial public health systems, their unionization, and their intellectual production. University-trained medical professionals in the Middle East claimed authority over medical knowledge and struggled for professional mobility within colonial hierarchies and power relations (ʿAbabnah 2010; Blecher 2002; Bourmaud 2004, 2012; Chiffoleau 1997; Clark 2016a, 2016b; Dewachi 2017; Erdemir 1995, 1997; Gallagher 1983; Kozma and Furas 2020; Mahfuz 1935; al-Manawi 1999; Rafeq 2015; Sonbol 1991; Verdeil 2008). Graduates of medical schools in Istanbul, Beirut, Cairo, and several North American and European cities sought to replace earlier forms of healing with modern scientific methods. Medical faculties were established in the Middle East throughout the nineteenth century: in Cairo and Istanbul (1827); in Beirut—the Syrian Protestant College (1867; SPC, later renamed AUB) and St. Joseph University (1883)—and in Damascus (1903). With few exceptions these universities’ graduates were men, and their training further excluded women medical practitioners; male doctors gradually gained control over the domains of childbirth and healing, formerly populated by local midwives and women healers.

Whereas histories of biomedicine in the region concentrate mainly on male physicians, histories of women in the medical professions are mostly centered in Western societies. The latter start with the first women’s medical college, which opened in 1850 in Pennsylvania, and the first modern nursing training program, inaugurated by Florence Nightingale in 1860 (e.g., Conrad and Hardy 2001; Morantz-Sanchez 2000). Several historians examined European women doctors, nurses, and midwives in the colonies. They demonstrated, for example, that the colonies served as a medical career path often blocked in the metropole, and they studied these women’s interactions with colonial administrations, on the one hand, and local patients, on the other (e.g., Allender 2016; Hassan 2011; Sweet and Hawkins 2015). Others raised similar claims concerning the Middle East (Amster 2013; Fredj 2011, 2015). In addition, several scholars studied Jewish nurses and women doctors in late Ottoman and Mandatory Palestine, focusing almost exclusively on dynamics within the Jewish community (Bartal 2005; Shehory-Rubin 2014).

To the best of our knowledge, the current issue represents the most comprehensive examination to date of women medical practitioners in the Middle East. Contributions to this theme issue include case studies spanning the twentieth century from Algeria, Palestine, Israel, Iran, and Iraq. They reveal tensions within the medical sphere between men and women, foreign and local, colonizer and colonized.

This theme issue brings together nurses, doctors, and midwives to examine microlevel contact zones, in which women’s agency shaped and was shaped by colonial and postcolonial encounters, decolonization, and the formation of national professions. We question which professional opportunities impeded and which facilitated women’s medical practice in various political regimes and public health systems. All the articles read women medical professionals as active agents in the history of medicine. We show that in the Middle East and North Africa—though not only there (e.g., Reid 2012)—women’s reluctance toward and discouragement of treatment by male physicians enabled women practitioners to gain access to the medical professions. This helped them shape and define their professional role. Moreover, women’s reliance on women medical professionals for childbirth and medical treatment made room for midwives and women doctors, whose lived experience was inconsistent with the usual narrative of the displacement of midwives by male doctors. Midwives, nurses, and doctors, we argue, created and maintained spaces for medical practice by women in a changing colonial and postcolonial world.

Women Medical Professionals in the Middle East

The first women to receive formal biomedical education in the region were the hakimas in Egypt. These medical doctors were trained by Mehmet Ali Pasha’s chief physician, Antoine Barthelemy Clot (known as Clot Bey), from the early 1830s on, to replace what he believed were superstitious and ignorant midwives. As he could not find other students willing to attend the school, the students were, at least initially, mostly orphans and manumitted slaves. The introduction of these medical professionals to the Egyptian medical system was motivated by the state’s choice to rely on women practitioners for childbirth and pre- and postnatal care, as well as the regulation of prostitution. The hakimas came to serve as trained midwives and doctors and also, from the 1850s, as forensic examiners in newly established police stations. Following the British occupation in 1882, the hakima school was closed and its graduates were demoted to nurses (Abugideiri 2010; Fahmy 1998; Hatem 1997; Kozma 2011). Later histories of female medical professions in the region demonstrate similar challenges. State concern with infant mortality and venereal disease led to an increased medicalization of women’s bodies. State authorities and the medical establishment considered apprentice-trained midwives unhygienic, even dangerous.

By the late nineteenth century only a few medical schools in the world were open to women—none of them in the Middle East. With female literacy extremely low—in Egypt, for example, it was about 0.2 percent by the end of the century—few women had access to higher education, and few also had the means to enter medical schools (Baron 1994). However, as more women acquired higher education during the twentieth century, more envisioned medicine or nursing as a career (e.g., Fleishman 2006; Greenberg 2010; Pursley 2020).

Because they were barred from entering the medical schools of Istanbul, Beirut, and Cairo, women from the region traveled to Europe and the United States for medical education. Nineteenth-century pioneers Sabat Islambouli (1867–1941) and Mary Eddy (1864–1923) had graduated from the Women’s Medical College of Pennsylvania in the 1890s (Rao 2014). Eddy, born in Sidon to American missionaries working in Syria, was the first woman doctor and surgeon to receive a license from the Ottoman authorities (Fleischmann 2009; Jessup 1910). Hilana Barudi and Anisa Saybaʿa (1865–1944) studied in London and Edinburgh, respectively, about a decade later.

The medical faculty of the University of Istanbul opened its doors to women in 1922, with the first women graduating in 1927 (Woodsmall [1936] 1975). However, after the collapse of the Ottoman Empire, it is safe to assume that Arab women had little incentive to travel there for their education. Fuʾad I University (later known as Cairo University) opened its medical faculty to women students in 1929 (ʿAbd al-Raʾuf 1933). Although the Royal Medical College in Iraq opened in 1927, women were not admitted until 1933 (Farhan in this issue). In 1935 three women were studying medicine at the University of Damascus (Woodsmall [1936] 1975).

Both the AUB and St. Joseph had their first women medical graduates in 1931. Their alumni records allow for a preliminary reconstruction of these women’s careers. Physicians include Edma Ilyas Abu Shadid (1909–92), who received her medical degree in 1931 from the AUB and later settled in Baghdad. Graduating in the same year from St. Joseph, Hélène D. Safi continued to work in the French Maternity Hospital in Beirut. Salwa Habib Khuri (born in Gaza in 1912) graduated from the AUB in 1936, returned to Palestine from Beirut, and was the only Arab woman employed at the British Mandate Department of Health (Alumni Association 1953; Bulletin annuel de la Faculté française 1947).

Several factors were responsible for the formation of the nursing profession in the Middle East. Early beginnings include individual missionary initiatives. Beth Baron (2020) describes, for example, the nursing training of manumitted women in the American Missionary Hospital in Tanta. Inger Marie Okkenhaug (2020) shows that Scandinavian and German missionary nurses trained Armenian orphans as nurses. Yet little is known about the extent of these missionary initiatives and of nurses’ training in the region. At the time that Ruth Woodsmall’s ([1936] 1975) book appeared, Iraq had no nursing school and only a few unqualified local nurses. By contrast, hospitals in Palestine were already training nurses in the late Ottoman years. Nurses were trained by the Red Cross/Red Crescent, by hospitals (through a program that combined classes and practical hospital work [Krik forthcoming]), or in university programs. Julia R. Shatz’s (2018) work on Palestinian nurses is a pioneering and rich social history of colonial medical encounters that also examines local women professionals. Shatz notes the difficulty of finding Muslim women willing to train as nurses in Mandatory Palestine. Because of this shortage, the British colonial authorities established a training center for nurses to work solely with women and children in the government hospital in Nablus. Conversely, the Hadassah school and hospitals trained Jewish nurses in Palestine from the early 1920s (Bartal 2005).

The SPC (later the AUB) opened its Nurses Training School in 1905. Its first three students graduated in 1908 and another two in 1910. This trickle of graduates gained impetus after World War I, with a total of 518 nurses and 59 midwives graduating from the AUB by 1952. From diverse ethnic backgrounds, these graduates included Arab, Jewish, Armenian, and Greek women. Similarly, 283 women were trained as midwives at St. Joseph University from 1922 to 1947. Still, no study has examined the history of these women or their training (Alumni Association 1953; Bulletin annuel de la Faculté française 1947).

The division of labor between existing medical traditions and university-trained practitioners was often complementary. Although colonial and state officials were eager to replace “ignorant” midwives with institutionally trained and licensed ones, most women still sought local midwives (dayas or qabla) to assist in deliveries. Consequently, the state endeavored to incorporate these midwives, offering them rudimentary training—mostly in hygiene, and registering them and relying on their services, for instance, in the administration of vaccinations (Bell 1998; Brownson 2017; Fahmy 1998; Fredj 2011, 2015).

The training of midwives varied between countries. Midwives had received professional training at a school of midwifery in Istanbul since the 1890s. In Egypt midwives trained at the Kitchener Hospital in Cairo, the Qasr al-ʿAyni Medical School, and missionary hospitals. Both the AUB and the Department of Health in Palestine offered midwifery training to graduates of nursing programs. We know of women who studied medicine at the AUB (seventeen graduates from 1931 to 1952) and St. Joseph (twelve from 1931 to 1947), but we have only partial data on other places (Alumni Association 1953; Bulletin annuel de la Faculté française 1947). In Palestine some training was offered to practicing dayas to improve hygiene (Brownson 2017; Krik forthcoming; Woodsmall [1936] 1975). Professional government-sanctioned complementary training for apprentice-trained midwives was available, according to Woodsmall ([1936] 1975), in Palestine but not in Syria or Iraq. Tensions between apprentice-trained local midwives and modern schooled nurses, midwives, and doctors are evident in recent scholarship (Brownson 2017; Okkenhaug 2020). Woodsmall ([1936] 1975) notes that nurses’ and midwives’ status differed between countries: midwives, for example, were considered no better than servants in Syria, but theirs was more prestigious employment than nursing in Egypt. The social status and prestige of nurses were generally low but gradually rose as improved training and higher pay attracted middle-class women to the profession. This process varied by region and deserves further study.

This overview attests to the gaps in existing studies of women doctors, nurses, and midwives, which this issue only begins to bridge. The issue, while contributing to existing bodies of scholarship, calls for more research. Such sources as medical schools’ alumni records and doctors’ published memoirs, as well as personal writings (e.g., Dulaymi 2000; al-Saʿdawi 1995; Zaki 2015), suggest that more can be known about women medical practitioners in the region (e.g., Maftsir forthcoming). Future research can examine their social origins, places of employment, social and geographic mobility, and intellectual production. Oral history interviews might shed light on women’s experiences in medical school, work experience, and career choices. In addition, more might be learned about foreign women medical practitioners in the region, including settlers, missionaries, and imperial employees. We have no research, for instance, on women dental surgeons, pharmacists, or veterinarians, although we do know that several women had already graduated from schools of dentistry and pharmacy in Beirut in the 1920s. Similarly, we know little about women in medical practitioners’ organizations and unions. Finally, and more intractably, we know very little about how ordinary individuals of different genders perceived their interactions with women medical practitioners.

Overview of Contributions

The articles in this issue draw on a wide range of sources. These include governmental, institutional, and missionary archives and publications as well as women health practitioners’ writings and oral narratives. These sources enable the contributors to reconstruct, at least partly, women practitioners’ voices and perspectives. Benny Nuriely and Liat Kozma, Sara Farhan, and Lydia Wytenbroek focus on professional training, while Dongxin Zou and Hagit Krik concentrate on professional practice. Both Farhan’s and Nuriely and Kozma’s articles analyze women’s admission to medical schools and highlight class and ethnic criteria that mediated their access to higher education. They also show how gender affected career paths and opportunities. Furthermore, they demonstrate that faculty heads viewed women’s admission as a waste of resources because, once married, graduates risked abandoning their professional duties.

Wytenbroek, Zou, and Krik each analyze intercultural encounters in the medical and nursing professions. Their work examines unequal power relations between foreign women medical professionals and their local students, patients, and colleagues. Krik explores the complex power relations in which British nurses in Palestine were embedded, as the only British employees subordinated to both British and Palestinian officers, even as they had responsibility for the training and work of both British and Palestinian women nurses. Her article analyzes tensions between their self-perception as racially superior and their status within the British colonial hierarchy as inferior. In contrast, Zou describes tensions between Chinese women doctors working in Algeria and Morocco and their local patients and nurses. These tensions are related to the conflicting childbearing ideologies between the Chinese one-child policy and Algerian and Moroccan pronatalism.

Wytenbroek describes a hierarchical relationship between American missionary instructors and their students in schools as well as in hospital work settings. These American missionary nursing schools, unlike the settings Krik explores, were independent of men’s supervision. Wytenbroek depicts the first nursing schools established and run by American missionaries in Iran between 1916 and 1936. American missionaries sought in Iran, as they did elsewhere (Makdisi 2009), to “civilize” the local society. Their trainees were among the first institutionally taught nurses in Iran at a time when few professions were available to women. Their educational programs set international and modern standards of nursing that served as a unifying factor among different ethnic and religious sectors of Iranian society. Showing how these schools forged both nurses’ professionalism and an Iranian nationalism, Wytenbroek argues that their work also challenged class differences. These missionaries, she argues, saw women’s education not merely as nursing training but also as a goal in its own right.

Krik’s article explores the ambivalent position of British nurses employed by the Overseas Nursing Association within the British imperial hierarchy in Mandatory Palestine. Drawing on biographical data of more than one hundred nurses who served in Palestine, along with a microhistory of their daily life and work, Krik examines the diversity of nurses’ experiences and frustrations: nurses who had hoped for an adventure and found themselves tending to British patients; nurses who felt lonely as the only Britons stationed in a rural post; and nurses working under conditions they deemed unsuitable for a British nurse in a colonial setting. As colonial women, they were both subservient (to male colonizers) and in a dominant position (vis-à-vis the colonized) within the British Mandate system.

Farhan’s article in this issue is the first to explore the history of twentieth-century Arab women medical doctors. She discusses women doctors working in modern Iraq but roots the profession in the history of medicine from Ottoman times. Her discussion of women graduates of the Royal Medical College of Baghdad is unique in that it pays special attention to class and ethnicity and shows how daughters of dignitaries pushed their way into the medical faculty. These doctors were subsequently marginalized in the medical profession yet were able to challenge these gendered structures.

Nuriely and Kozma examine women students at the Hebrew University Medical School, founded in Jerusalem in 1949, during its first two decades. They argue that the school’s gender quota reduced the ratio of women in the Israeli medical profession. They then examine the experience of women admitted to the school and show that sexist slights continually reminded them of their inferior status as both students and future professionals. To counter these attitudes, some students emphasized their professionalism and commitment to a rigorous, “masculine” work routine, while others kept challenging those attitudes.

While some of the articles grapple with the colonial or North-South encounter, Zou’s looks uniquely at South-South encounters, specifically the mobility of medical professionals from China to rural Algeria and Morocco during the last four decades. These women were sent by their government to strengthen Chinese relationships with developing countries. Zou argues that these women doctors understood local reproductive practices through a Chinese gender rhetoric. She unpacks Chinese doctors’ narratives to uncover cultural biases and preconceptions stemming from the gap between the Chinese one-child policy and North African pronatalism. Overworked and performing in difficult conditions, these Chinese women ob-gyns expressed their frustration with what they saw as local midwives’ neglect and local patients’ indifference to their own health and well-being.

Acknowledgments

Research for this article has received funding from the European Research Council under the European Union’s Horizon 2020 research and innovation program (grant agreement no. 723718).

References