health refugees immigrants
While the country of Iraq
holds great oil wealth, the vast majority of Iraqis have benefited little
from this potential. When Saddam Hussein rose to power in 1979, the
country plunged into incessant war and internal strife. First came the disastrous
1980-88 Iran-Iraq war (a million killed at a cost of 100 billion dollars),
then the Anfal or campaign to destroy Kurdish culture, followed by the Gulf
War upon Saddam's invasion of Kuwait in 1990, and most recently the United
States-led war of 2003 (Central Intelligence Agency [CIA], 2003; Glover, 1999).
This chapter details historical and cultural factors for Iraqi refugees who
fled during the Gulf War and its aftermath, through 2002. From the outset
a distinction is made between Iraqi refugees and Kurdish refugees fleeing
from northern Iraq ("Iraqi Kurdistan"). For this discussion, then,
Iraqi refugees consist of two main groups:
- Iraqi political dissidents
and surrendering or deserting members of Saddam Hussein's national army.
- Shiite Muslims, some
of whom are the so-called "Marsh Arabs" from southern Iraq and
a small number of whom are of Iranian descent.
There is also a third,
smaller group of Iraqi "Turkomens" or Iraqis of Turkish descent.
Following the 1991 Gulf
War, Shiite Muslims rebelled against the Iraqi regime. With the collapse of
their rebellion in March of 1991, at least 100,000 Iraqi Shiites fled into
neighboring Iran, Saudi Arabia, and the U.S.-occupied zone along the Iraq-Kuwait
border. Fearful of retribution against these refugees on the withdrawal of
U.S. troops from the region, the U.S. brokered a deal with the Saudi government
for the establishment of a Saudi-maintained refugee camp near Rafha, and another
camp called Al Artawea. Many refugees report that conditions in the Al Artawea
camp were poor, especially for Arabs (as opposed to Kurds who also were housed
there). Eventually, Al Artawea was closed, and all the refugees were sent
to Rafha. Rafha camp was divided between the former members of the Iraqi army,
overwhelmingly comprised of single men, and the Iraqi families, most of whom
History of Immigration
In the mid-1990s, it had
became clear that Saddam Hussein's regime had not weakened, and repatriation
for the tens of thousands of Iraqi refugees in neighboring countries meant
certain retribution, especially for the former members of the Iraqi army and
dissidents in Saudi Arabia. With pressure from the Saudi government, the United
States agreed to resettle the Rafha group en masse, beginning in 1994. The
United States government's decision met with considerable opposition, especially
from veteran's groups, who argued that the resettled former members of the
Iraqi army had been potential adversaries to Allied troops during the war.
Furthermore, the existing resettled Kurdish populations also were distrustful
of these potential "agents of Saddam." Nonetheless, over 32,000
Iraqi refugees were resettled in the United States through 2002, adding to
the population of non-refugee Iraqi immigrants, for a total of about 90,000
foreign-born Iraqis (Grieco, 2003). The largest populations in the U.S. are
in Detroit, Chicago, and San Diego.
Culture and Social
Iraqi society on the whole
can be viewed as having three classes: the political elite, the military and
merchant class, and finally, peasants and laborers (Cultural Orientation,
2003). However, class differences aside, allegiance to the extended family
and tribe are stronger than allegiance to a central government. Throughout
the Arab world, loyalty to the family and tribe forms the basis of much of
culture, with nepotism in employment common and individual behavior frequently
tempered against the potential for shame to the larger family (Cultural Orientation,
It is not uncommon for
girls to be involved in arranged marriages at a young age, as young as twelve
or thirteen years, with preference given to first-cousin marriage. To Iraqis,
especially Shiites, the Islamic marriage is not only sacred, but also serves
as a bond between families. However, this tradition of early marriage has
flown in the face of United States law and there have been several widely-publicized
cases of arrests of men involved in unions with girls younger than sixteen.
According to Islam, men may have up to four wives, but this not common among
Shiites. At marriage, women come to live with the husband's family and married
sons usually stay within the household. Children are to be the caretakers
of their parents when they are elderly.
Iraqi households are very
private and are sometimes segregated according to gender. Women in general
are subservient to male authority, although it should be noted that Iraqi
women on the whole enjoy more rights than other women from the Arabian peninsula
(Cultural Orientation, 2003). Especially among Iraqi Sunnis, there are many
educated and professional women. The husband controls the household finances,
but women exert considerable influence over the children, including grown
sons. Male relatives show concern over the treatment of their female kin after
Arabic is the universal
language of Iraq. While there are over fifteen dialects of spoken Arabic throughout
the world, defined by geographical and rural/urban differences (Cultural Orientation,
2003), Iraqi refugees appear to have little difficulty in comprehending any
Arabic speaker. However, literacy in Arabic is rather low in Iraq, at an estimated
58% (CIA, 2003). Even though Iraq experienced significant British political
influence earlier in this century, English language fluency is rare among
It is never acceptable for a man to shake the hand of a Shiite woman. Sunni
women, on the other hand, are less restricted. Touching, and even full embracing,
is quite common within (but not between) the sexes, especially when greeting.
When greeting, deference is always given first to males.
Most Iraqis are Shiite
Muslims, but the political elite, the military and merchant classes, and those
living around the capital area of Baghdad in general are Sunni. In general,
Shiites are more orthodox and strict in religious practices, food proscriptions,
and especially, treatment of women. Shiite Muslim women, especially older
women and widows, dress typically in black, in full "hijab" (purdah),
covering their bodies and faces. At all public events, and even within the
household, women are segregated from men.
Both Sunnis and Shiites
adhere to halal laws regarding food. Any meat consumed by a Muslim must come
from an animal slaughtered by another Muslim in a prescribed way, or it is
considered impure, haram. This ritual involves asking God for forgiveness
for taking the life of the animal. Furthermore, pork and alcohol are especially
haram and should never be consumed. Even in the West, most Iraqis do not buy
meat or chicken in a grocery store but prefer to go to farms to buy the meat
fresh, or from a few trusted halal markets. Islam is discussed in greater
detail in the section on religions.
Health Beliefs and
Islam and related cultural
practices are important influences on health beliefs and practices. Both women
and men are modest and either may resist or refuse examination or treatment
by a person of the opposite gender. Dietary proscriptions and fasting requirements
also influence health. During Ramadan, for example, more conservative Muslims
may refuse medications or medically-indicated foods during daylight hours.
The peoples of Iraq have a long tradition of complementary and alternative
medical practices, although there is much variation between tribes and across
geographical areas. The following discussion describes some of the more common,
but by no means universal, traditional medicine beliefs and practices:
- Fever is sometimes
treated with cumin and egg yolk heated in water and dipped onto a rag and
put over the forehead.
- Conjunctivitis may
be treated by laying a cloth boiled in tea over the eye.
- Dental pain may be
treated with ground cumin, ninia seed, and shabak seed, mixed together as
a powder and put on the gum.
- Tonsillitis is sometimes
treated by certain elderly women who insert their fingers into the mouth
of the child to manipulate the tonsils by pushing from side to side or squeezing
to relieve the inflammation.
- Respiratory distress
is sometimes treated with honey and lemon juice or lemon and orange juice
together (for cough). A sort of steam tent is made for upper respiratory
infections. Anise seed, boiled in water is used for sore throat or laryngitis.
- Gastrointestinal distress
may be treated in one of several ways. Abdominal pain may be treated with
cumin powder dissolved in water or with green tea. Karawya herb, boiled
in water, is also given for abdominal pain, diarrhea and constipation, especially
for children. Lemon juice and plain rice are also given for diarrhea. A
heated brick is sometimes used for diarrhea, where the brick is covered
with a cloth and sat upon.
- Flank pain may be treated
with handel, a type of bitter fruit, which is cut, boiled, and drunk as
- Infertility is sometimes
addressed by placing a placenta on the threshold of the infertile couple's
- Joint dislocation may
be treated with ninia and churned butter mixed together as a salve and applied
at the site of dislocation.
- Burns are sometimes
treated with barley mixed with butter, and applied as a poultice on the
burn for 48 hours.
- Cysts, splinters, and
pimples may be treated with a dough of flour and sugar applied to the affected
Henna dye is considered
to have magical healing properties, and is quite commonly seen, especially
on Iraqi women. For example, it can be used for treatment of migraine headaches,
where the hair is dyed. Henna can also be painted on the hands and feet, not
just for decoration but for pain relief and also for protection from evil
spirits and "evil eye." Tattoos can also serve the same purpose.
For example, Islamic holy words can be written on the hand, such as "Allah"
on the front, and "Ali" on the back. Circular tattoos over the temples
are common for treatment of migraine headaches.
Among the most conservative
Iraqi Muslims, typically the elderly, Western preventive health concepts may
conflict with the belief that God has determined one's lifespan from birth
which cannot (and should not) be altered by human intervention.
Pregnancy and Childbirth
In pregnancy, other female
household members relieve the pregnant woman from household tasks; and in
general, pregnant women receive more attention and care than usual. Some Iraqis
believe that sonograms to determine the sex of a developing fetus is against
God's will and should not be performed. In Iraq, midwives provide minimal
prenatal care and most deliveries are at home.
After delivery, the placenta
may be thrown in water, in a folk belief to encourage milk production. Circumcision
of boys usually occurs within the first few days, accompanied by a ceremony
and feast. Commonly, a barber performs the circumcision; crushed onions, sumaq
seed, and other acidic foods are placed over the circumcision and the umbilicus
for a few days to promote healing. During the circumcision, the person who
holds the child is perceived to establish a very significant bond with the
child. Females get their ears pierced at one week. Breastfeeding is the norm,
a least one year, for both sexes. Rice soup, potatoes, and bread are common
weaning foods, as is leban, a yogurt-based drink.
Birth control is virtually
non-existent in Iraq, as limiting births or interfering with conception in
any way is thought by many to be against the laws of Islam as life is considered
a gift from God. Likewise, abortion in any form is out of the question. In
the West, Iraqi women are beginning to use oral contraceptives, depo-provera,
IUDs, and even tubal ligation. Even among husbands support for birth control
is growing. There is an acceptance, or at least a rationalization, that limiting
births is a means for adaptation and economic sufficiency in the West.
Dying and Death
Expression of pain is
usually a private matter, except during labor and delivery (Geissler, 1998).
On hospitalization in the West, the family will stay with the patient and
often will bring food, not trusting the hospital diet to be halal. The eldest
male present will act as family spokesman and should be included in discussions
whenever possible. There are differences of opinion among Muslim clerics about
whether organ donations or autopsies are acceptable (Al-Mousawi, Hamed, &
Al-Matouk, 1997; Geissler, 1998). Life-support measures would be acceptable
to most Iraqis.
At death, the body is
taken to the mosque, where family, friends, and the Imam (clergy) take turns
reading from the Qur'an. White sheets are wrapped around the body, after ritualistic
washing, and burial takes place as soon as possible, usually the same day.
Traditionally the body is wrapped in cloth (not put in a casket) and carried
to the cemetery on a litter during a funeral procession. The ritualized recitation
from the Qur'an (sometimes a tape recording may be substituted) continues
until the following Friday evening prayers, asking God to forgive the deceased
for past sins. Black clothes are worn during mourning. A widowed wife may
remarry six months after the husband's death, sometimes to the husband's brother.
An exception is made in cases where a husband is missing in war, in which
case she may remarry only after seven years. Cremation is not permitted by
Islam (Geissler, 1998).
There is a spiritual-healing
ceremony centered around the gravesite of a sheikh or very holy or powerful
person. People with mental problems or infertility (almost always assumed
to be the woman), are taken to the grave marker. An animal is sacrificed,
and food is given to the poor. Through prayer, as the participants hold hands
around the gravesite, the deceased person's spirit is called upon to ask God
to intervene on the sick person's behalf. Similarly, people can have a bad
spirit or jinn (jinn refers to any spirit) exorcised through this ceremony.
Commonly, a certain green material is hung around the gravesite, like a curtain.
Many Arabs, especially Shiites, cut scraps of the material and pin it to themselves
as a sort of charm for protection against evil spirits.
Health Problems and
As this is written, it
is unclear what changes, if any, in the health status of the Iraqi people
will occur after the 2003 war to overthrow the Saddam Hussein regime. Before
the war, Iraqis overall had healthy life expectancies (HALE) of 50.5 years
and overall life expectancies of 58 years (Population Reference Bureau, 2002;
World Health Organization [WHO], 2002). If the population were studied according
to ethnicity (Arabs vs. Kurds) and religion (Sunni vs. Shiite), a different
picture would likely emerge, with Arabs and non-Kurd Sunnis having greater
HALEs and overall life expectancies than Kurds or Shiites. Health risks in
refugees and immigrants from Iraq (Hawn & Jung, 2003; Kemp, 2002; WHO,
- Boutonneuse fever
- Brucellosis or undulant
- Crimean-Congo hemorrhagic
- Cysticercosis (tapeworm)
- Dracunculiasis (Guinea
- Familial Mediterranean
fever (Mediterranean area, primarily among persons of Sephardic Jewish,
Armenian, and Arab ancestry)
- Helminthiasis (ascariasis,
echinococcosis/hydatid disease, schistosomiasis)
- Hepatitis B (13% carriage
- Sickle cell disease
or sickle cell hemoglobulinopathies (Occurs primarily in people of African
lineage, but also to a lesser extent Arabs and others)
- Trematodes (liver-dwelling:
clonorchiasis and opisthorchiasis; blood-dwelling: schistosomiasis or bilharzias;
intestine-dwelling; and lung-dwelling: paragonimiasis)
- Trichinosis (trichinella)
- Post-traumatic stress
- Nutritional deficits
For screening guidelines
see Infectious Diseases, as well as the
Abdullah and Mervat Moussa
Al-Mousawi, M., Hamed,
T. & Al-Matouk, H. (1997). Views of Muslim scholars on organ donation
and brain death. Transplantation Proceedings. 29(8), 3217.
Central Intelligence Agency
(2003). World factbook 2002: Iraq. Retrieved April 10, 2003) from www.cia.gov/cia/publications/factbook
Note that the 2002 Factbook has been updated in 2003.
Cultural Orientation (2003).
Iraqis: Their history and culture. Retrieved April 10, 2003 from http://www.culturalorientation.net.
Geissler, E.M. (1998).
Cultural Assessment, 2nd edition. Mosby: St. Louis, pp.129-131.
Glover, J. (1999). Humanity:
A moral history of the twentieth century. New Haven: Yale University Press.
Griece, E. (2003). Iraqi
immigrants in the United States. Migration Information Source. Retrieved April
10, 2003 from http://www.migrationinformation.org
Hawn, T.R. & Jung,
E.C. (2003). Health screening in immigrants, refugees, and internationally
adopted orphans. In E.C. Jong & R. McMullen (Eds.) The travel and tropical
medicine manual (3rd ed.) (pp. 255-265). Philadelphia: Saunders.
Kemp, C.E. (2002). Infectious
diseases. Retrieved April 12, 2003 from http://www3.baylor.edu/~Charles_Kemp/Infectious_Disease.htm
Population Reference Bureau.
(2002). 2002 world population data sheet. Retrieved May 12, 2003 from http://www.prb.org/pdf/WorldPopulationDS02_Eng.pdf
World Health Organization
(2002a). World health report. Retrieved June 5, 2003 from http://www.who.int/whr/2002/en/