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Iraqis culture health refugees immigrants


Introduction

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 were Shiites.

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 Relations

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, 2003).

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 marriage.

Communication

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 resettled Iraqis.
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.

Religion

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 Practices

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 a tea.
  • Infertility is sometimes addressed by placing a placenta on the threshold of the infertile couple's house.
  • 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 area.

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 Screening

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, 2002) include:

  • Amebiasis
  • Anthrax
  • Boutonneuse fever
  • Brucellosis or undulant fever
  • Cholera
  • Crimean-Congo hemorrhagic fever
  • Cysticercosis (tapeworm)
  • Dracunculiasis (Guinea worm disease)
  • Familial Mediterranean fever (Mediterranean area, primarily among persons of Sephardic Jewish, Armenian, and Arab ancestry)
  • Giardia
  • Helminthiasis (ascariasis, echinococcosis/hydatid disease, schistosomiasis)
  • Hepatitis B (13% carriage rate)
  • Hookworm
  • Leishmaniasis
  • Malaria
  • Plague
  • Sickle cell disease or sickle cell hemoglobulinopathies (Occurs primarily in people of African lineage, but also to a lesser extent Arabs and others)
  • Thalassemias
  • Toxocariasis
  • Trachoma
  • Trematodes (liver-dwelling: clonorchiasis and opisthorchiasis; blood-dwelling: schistosomiasis or bilharzias; intestine-dwelling; and lung-dwelling: paragonimiasis)
  • Trichinosis (trichinella)
  • Tuberculosis
  • Typhus
  • Post-traumatic stress disorder
  • Nutritional deficits

For screening guidelines see Infectious Diseases, as well as the above.

Acknowledgements: Adil Abdullah and Mervat Moussa

References

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/

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