Health and Medical Practice in Iran: Traditional Culture and Modern Medicine (Allopathy Goes Native) 9781780760445, 9781786732552

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Agnes G. Loeffler is Associate Professor at the Department of Pathology and Laboratory Medicine, University of Wisconsin School of Medicine and Public Health. She completed her PhD in Cultural Anthropology at the University of Illinois, Champaign-Urbana, and received her MD from the same institution. In addition to her contributions to anthropology, she publishes in the allopathic medical field, including the co-edited volume Introduction To Human Disease: Pathophysiology For Health Professionals.

Health and Medical Practice in Iran

‘A thorough, insightful portrayal ... this volume will appeal both to medical anthropologists and to people interested in Iranian culture in general, as well as in modernisation and globalisation in Iran and elsewhere.’ Mary Elaine Hegland, Anthropology of the Middle East

Traditional Culture and Modern Medicine

alth ddical ctice ran

Allopathy is often described as ‘western’ medicine, the antithesis of homeopathy, yet all medical systems are infused with culture-specific values, ideas and beliefs. Agnes Loeffler’s insightful and original book investigates how allopathic knowledge, theories and practice guidelines come to be understood and applied by practitioners in a non-western context. Based on research amongst doctors in Iran, Loeffler describes how the system of allopathic medicine has adapted to local explanations of health and disease and to the economic, social and religio-political realities framing contemporary Iranian life and culture. This approach simultaneously problematises the view of allopathic medicine as a ‘western’ entity exerting a hegemonic influence over non-western cultures, and provides a rare glimpse of the complexities of modern Iranian society – exploring the interfaces between culture, health and the experience of illness.

Heal and Medi Pract in Ira

Agnes G. Loeffler

Health and Medical Practice in Iran Traditional Culture and Modern Medicine Agnes G. Loeffler

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Agnes G. Loeffler is Associate Professor at the Department of Pathology and Laboratory Medicine, University of Wisconsin School of Medicine and Public Health. She completed her PhD in Cultural Anthropology at the University of Illinois, Champaign-Urbana, and received her MD from the same institution. In addition to her contributions to anthropology, she publishes in the allopathic medical field, including the co-edited volume Introduction To Human Disease: Pathophysiology For Health Professionals.

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Health and Medical Practice in Iran Traditional Culture and Modern Medicine Agnes G. Loeffler

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New paperback edition first published in 2017 by I.B.Tauris & Co. Ltd London ● New York www.ibtauris.com First published in hardback in 2007 by Tauris Academic Studies An imprint of I.B.Tauris & Co. Ltd Copyright © Agnes Loeffler, 2007 The right of Agnes Loeffler to be identified as the author of this work has been asserted by the author in accordance with the Copyright, Designs and Patents Act 1988. All rights reserved. Except for brief quotations in a review, this book, or any part thereof, may not be reproduced, stored in or introduced into a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of the publisher. ISBN: 978 1 78076 044 5 A full CIP record for this book is available from the British Library A full CIP record is available from the Library of Congress Library of Congress Catalog Card Number: available Printed and bound by CPI Group (UK) Ltd, Croydon, CR0 4YY

This book is dedicated to

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Erika Friedl Loeffler Diane Gottheil Aksi Qetrifi

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Contents

Note on Transliteration Acknowledgements

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Chapter 1 Introduction

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Chapter 2 The Contexts of Fieldwork

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PART ONE IRANIAN CONCEPTUALIZATIONS OF HEALTH AND DISEASE Chapter 3 Iranian Explanations for Ill Health

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Chapter 4 Key Concepts: Nature, Purity and Balance in Relation to Health

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Chapter 5 How Allopathic Knowledge and Practice are Interpreted in Distinctly Iranian Terms

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PART TWO THE CONTEXTS OF MEDICAL PRACTICE Chapter 6 The Economic Context of Allopathic Practice

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Chapter 7 Roots of Authority: Knowledge

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Chapter 8 The Relationship of `Elm to Medical Practice

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Chapter 9 Medical Knowledge and Islamic Ideals

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Chapter 10 Conclusion

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Endnotes Bibliography Index

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Note on Transliteration

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The Farsi words and phrases which appear in this text are transliterated according to the standard of the International Journal of Middle East Studies. It should be noted, however, that I have transliterated speech rather than writing: I make no distinction between the various signs for “s,” “z,” or “t,” nor does the orthography necessarily reflect that of written Farsi. Also, the transliteration of words common to Arabicinfluenced languages reflects local pronunciation rather than any conventions of transliteration.

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Acknowledgements

In Iran: I thank Dr. Faezipour, Director General of International Relations of the University of Tehran, Dr. Jenabzadeh, Director of the International Center for Persian Studies, and the staff of the Dehkhoda Institute for allowing me to participate in Farsi classes and benefit from the Institute's excellent instruction; I thank Dr. Razavi of the Foreign Student Affairs Office of Imam Khomeini International University in Tehran, Dr. Malek-Husseini, Chancellor of Shiraz University, and Dr. Talei, Dean of the Medical School, for granting me access to the instructional activities of Shiraz University Medical School. I thank especially Dr. Zahra Sarraf and Dr. Parvin Sadeqi, who facilitated my stay at Dehkhoda Institute and my research at the University of Shiraz. Their commitment to medical education and research is well exemplified by the extent to which they went out of their way to help and advise me, professionally and personally, during the course of my stay in Iran. Without their assistance and intervention, the research for this book would never have been accomplished. I thank the numerous physicians, residents and students who took the time to speak to me, clarify issues of culture and practice, and answer my ceaseless questions, despite the demands of their own hectic schedules. And I thank the many kind, knowledgable and generous people in Tehran, Shiraz and Deh Koh who provided me with a rich background on popular medicines. In the United States: I thank Dr. F. K. Lehman (U Chit Hlaing), Dr. Janet Keller and Dr. Clark Cunningham, all of the University of Illinois at Urbana-Champaign, and Dr. Mohammad Shahbazi, of Jackson State University, Mississippi, for their timely comments, constructive advice and, above all, their patient support during my protracted studies. I thank the Medical Scholars Program at the University of Illinois, for its financial and moral support during the dual-degree training process. The Pathology Department at Darmouth-Hitchcock Medical Center in Lebanon, New Hampshire, under the leadership of Dr. James

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AuBuchon, kindly tolerated an anthropologist in its midst and supported me during protracted revisions of the manuscript. Most of all, my thanks go to my parents, Dr. Erika Friedl and Dr. Reinhold Loeffler, who introduced me to Iran, supported my decision to pursue a dual degree, held my hand through my studies and research, and critically read every word I have written. I dedicate this work to Erika Friedl Loeffler, my mother, to Diane Gottheil, the acting director of the Medical Scholars Program for most of the time I was at the University of Illinois, and to Aksi Qetrifi, a pioneer in education and my hostess in Shiraz. Their assessment of my abilities encouraged me to embark on this project; their support held me through despair; their expectations were the only obstacles to failure. This book is theirs.

Chapter 1

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Introduction

When I set out to study how allopathic medicine was practiced in the Islamic Republic of Iran in the 1990s, I was prepared, as a cultural anthropologist, to see it reflect the worldview of the people who used it. I was less well prepared, however, for the degree to which that worldview influenced the manner in which physicians and their patients alike came to terms with the tenets promulgated in medical school. The process of how medical doctors in Iran make sense of their profession became a fascinating study. My research was complicated by a lack of models in the anthropological literature for studying non-Western allopathic medicine, and by logistical problems of doing ethnographic fieldwork in Iran. In the following, I will describe the theoretic background of my research, goals and assumptions, and present a short synopsis of my findings. Allopathic Medicine as a Cultural System Researchers in the field of medical anthropology are engaged with mapping out the interface between culture, health and the experience of illness. This interface comprises two inter-related domains. “Biocultural” medical anthropology focuses on the relationship between human biology, culture and the environment and explores how the evolution and distribution of diseases is impacted by cultural and socio-political forces. The “cultural” approach to medical anthropology, to which this study contributes, explores the manner in which culture mediates the identification of ill health and shapes people’s responses to illness. It shares with cultural anthropology in general the insight that human thought and behavior in all aspects of life reflect assumptions about people’s relations to the material and immaterial worlds. Medical systems, regardless of the biological basis of disease, are suffused with culture-specific values, ideas, beliefs, and themes that also inform other domains of culture. The cultural basis of medical systems is readily appreciated when one looks at “exotic” health-practices. Shamans, spirits, magic and witchcraft, 1

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flows of energy, cosmology, ancestors, the evil eye and violated taboos are integral to conceptualizations of disease etiologies the world over. For example, Ponapeans of the Caroline Islands attribute certain skin disorders to the violation of totemic food taboos (Fischer, Fischer, and Mahoney, 1959); Dobueans of New Guinea believe disease to be caused by violation of property protected by an incantation (Fortune, 1963); in Latin America, the disease susto is attributed to the flight of a person’s soul due to fright or shock (Rubel, 1964); in traditional Chinese medicine, disease is thought to be caused by derangements in the flow of energy through the body (McNamara and Ke, 1995.) The “exoticism” of these beliefs is due not to their cultural derivation, however, but to the fact that they are foreign to our own assumptions about health and disease. Indeed, our own assumptions, such as those embodied in allopathic medicine, are just as culturally derived and culturally specific as are the others. Before turning to the social scientific literature addressing the cultural basis of Western medicine, I need to say a few words about why I use “allopathy” rather than any of the other terms for this body of medical knowledge and practice popularly used in the literature. Each of the terms “biomedicine,” “Western,” “cosmopolitan,” and “scientific” is fraught with difficulties, and none uniquely describes what it intends to signify. Other “medicines,” from shamanism to herbalism, are practiced in the West and in cosmopolitan centers. Many, like the Ayurvedic and Unani medical systems, can claim a conceptual basis in human biology. At the same time, the medicine dominant in the West is practiced all over the world, not just the West, and its adherence to purely scientific principles has been seriously questioned not just by anthropologists but by its own practitioners. Most importantly, before the term “biomedicine” was even coined, this medical system has had a name of its own, viz., allopathy or allopathic medicine. The word “allopathy” is derived from the Greek allos, differing from the normal or usual, and pathos, suffering, and is defined as “a therapeutic system in which a disease is treated by producing a second condition that is incompatible with or antagonistic to the first” (Stedman, 1990). Thus, an infection is treated with an “antibiotic,” fever with an “antipyretic,” disorders of heartbeat with an “antiarrhythmic.” Its name draws attention to a basic, grounding concept or philosophy that distinguishes it from other Western biomedical systems such as homeopathy and osteopathy. The former is based on the principle “like cures like” (e.g., a fever will diminish when the body is exposed to an agent causing the temperature to rise), while osteopathy is based on the premise that, as long as its skeletal support is properly aligned, the body can heal itself.

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Already its name is a clue to allopathic medicine’s historical and cultural origins. In 19 century Europe and the United States, allopathy faced major competition for recognition, authority and ultimately clientele from other medical systems, such as homeopathy and osteopathy (Duffy, 1979; Starr, 1982). In the United States, allopathic medicine came to dominate the health-related arena to the extent that it no longer needed to be nominally distinguished; it became simply “medicine.” In part, this dominance can be traced to the enormous successes allopathic medicine had in curing, preventing and eradicating diseases which have caused endless suffering throughout human history. But just as important in establishing its dominance were historical social, political and economic forces (Baer, 1989; Starr, 1982). Allopathic medicine in the United States garnered the support of the capitalist establishment of the late 19 and early 20 centuries by molding itself into a “scientific” discipline. Osteopathic medicine was able to hang on to a modicum of respectability by imitating allopathy in its moves toward professionalization and by conforming to the American [Allopathic] Medical Association’s (AMA) demands of a medical training curriculum (Duffy, 1979; Starr, 1982). Homeopathy, unwilling or unable to bend, fell completely into disfavor. By the 1930s, all 22 of the homeopathic medical schools that had been operating at the turn of the century had been forced to shut down (Rogers, 1998). Thus, since its conception, allopathic medicine has existed in a social, political and cultural arena. This has been the subject matter of medical anthropologists, philosophers, historians and scholars of culture and the media for the past fifty years. Their studies have taken as entrance points the history of allopathic medicine, the doctor-patient relationship, health policy, medical ethics, medical education, patient narratives of health and disease, health management decision making, the relationship of allopathic medicine to political and economic systems, textbooks of allopathic medicine, and physicians’ self-reflections. From these studies is emerging an increasingly detailed description of allopathic medicine as an “ethnomedicine.” It is structured on the same principles upon which the dominant, modernist, Western vision of reality is based: on materialism, reductionism, objectivity, rationality and distinction between mind and body (Good, 1994; Kleinman, 1995; Lock and Scheper-Hughes, 1990; Martensen, 1995; Romanucci-Ross et al., 1997; Young, 1997). While allopathic medicine is ostensibly concerned with the “biology” of disease, every instance related to allopathic practice has individual, social, economic and political ramifications. Medicine is a social event, it posits people in th

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social relationships and engages them in social contexts. It is therefore necessarily culture bound, culturally constructed and culture-constructing. One of the insights gained by opening allopathy up to critical inquiry is that its disease nosology, contrary to allopathy’s claims, is not universally applicable. For example, it turns out to be notoriously difficult to establish a classification of psychiatric diseases which holds cross-culturally (Angel and Thoits, 1987; Lucas and Barrett, 1995). Some diseases, such as amok, susto, or latah, while causing very real suffering locally, find no specific correlates in allopathy’s Diagnostic and Statistical Manual of Psychiatric Disease (American Psychiatric Association, 2000; see, e.g., Chowdhury, 1996; Schieffelin, 1996). Other diseases meticulously and minutely described in the DSM, on the other hand, such as depression, anorexia and schizophrenia, are found elsewhere with a remarkably different symptomatology (Kleinman, 1998; Pliskin, 1987). Non-psychiatric diseases identified by allopathic medicine as biologic “givens” also show considerable cross-cultural variation. The experience of pain, for example, varies not so much with the biology of pain perception as with ethnicity and differences in sociocultural values (Bates and Edwards, 1998; Good et al., 1992; Zborowski, 1969). Menopause, identified by allopathic medicine as symptoms unavoidably linked to changes in sex hormone activity in middle-aged women and as a stressful life event, is such a non-issue among Japanese women (Lock, 1993) that it does not even have a name. And controversies within the allopathic field itself over the recognition of “pre-menstrual stress,” for example, or “fibromyalgia” or “post-traumatic stress,” as “real” diseases, attest to the ongoing redefinition of biology as allopathy’s methodologies and theories meet cultural prejudices (DeCherney and Pernoll, 1994; Groopman, 2000; Young, 1995). In other words, despite their presumably biological origin and universal nature, the manner in which symptoms are recognized, grouped and classified is culturally informed and culturally restricted. 7

The Meanings of Illness and Disease A second insight that has emerged from studies of the cultural basis of medicine is that the experience of being ill is a process of “making sense” of disease. In the anthropological literature, “disease” is defined as a set of symptoms and signs referable to a pathologic process, while “illness” is the patient’s response to feeling not-healthy (see e.g., Chrisman and Johnson, 1990; Eisenberg, 1977; Fabrega, 1971; Kleinman, 1980, 1988). Disease is a diagnosis, a hypothesis as to a pathophysiologic process and a guideline for its treatment; illness incorporates all the personal, social and existential

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implications of being afflicted with a disease. The meaning each individual patient gives to the experience of being ill, whether alone or with the help of his or her “therapeutic community” of therapists, doctors, relatives, nurses or friends, addresses practical, personal, existential and soteriological questions. Why am I sick? Why now? What effects will my illness have on my family? What should I do to get well? Is anything to be gained by my suffering? Through the process of being experienced as an illness, diseases are abrogated from the biologic and incorporated into cultures’ semantic realities. Their names are infused with symbolic meaning and values and in turn become metaphors for the prevailing social and moral orders. For example, in Western cultures, cancer is understood in terms of loss of control (Sontag, 1978) and its treatment modeled as a type of warfare (DiGiacomo, 1987). AIDS, and infections in general, are seen as incursions of foreign, unknown and physically and morally contaminated agents into the sanctuary of the self (Farmer, 1992; Martin, 1994; Sontag, 1989). In Iran, the diagnosis “high blood pressure” attests to stressful social relationships. Thus, through a culture’s semantic networks, the illness experience ties the healthy and the sick, “healers” and their patients together to a common philosophy of life, and at the same time turns disease into a commentary on conditions of life and stress. The culture-specific perceptions of ill health do not necessarily give prompt answers to the questions being ill raises but rather provide a broad frame within which the meanings of suffering from a disease are formulated. Allopathic medicine restricts its sense-making to the biological definition of disease and its implication for therapy. It recognizes the experience of being ill as located in culture, society and psychology, and therefore not properly part of the domain of medicine, or even really relevant to the natural history of diseases or the outcome of therapy. Allopathic medicine is not concerned with existential and symbolic meanings. Indeed, during my own training in (allopathic) medical school, the extra-biological aspect of being ill was addressed only to the extent that we were vaguely advised to incorporate into our practice an “awareness” of the disease/illness distinction, of the patient’s illness experience, and of social factors which have a bearing on disease distributions and outcomes. Medical Pluralism Despite allopathic medicine’s claim to universality, and, by extension, exclusivity, the meaning it contributes to being ill is very limited. Its limitations are highlighted in the setting of medically pluralistic societies. At

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least as soon as allopathic medical services are introduced to any society, more than one system of thought and behaviors pertaining to health and disease co-exist. Patients and their caretakers then sift through competing explanations and therapies in search not only of a cure but of the illness’ meanings and implications. Regardless of its alleged or even demonstrable superiority in treating disease, in medically pluralistic settings allopathic medicine becomes just another therapeutic strategy. Thus the use of therapeutic options must be understood in their cultural and social contexts. Studies of medically pluralistic societies have focused on patients’ or therapeutic communities’ decision-making strategies, on the factors that go into consideration of what should and can be done about particular illness episodes (see, e.g., Brodwin, 1992; Early, 1982; Fabrega, 1976; Janzen, 1978; Kleinman, 1980; Myntti, 1988; Romanucci-Ross, 1969). These include socio-economic variables such as education, the availability of healers and resources, and the value given to maintaining health as weighed against all implied costs. Thus, any kind of medicine, to be adopted and become effective, must be deemed worth its emotional, psychological, social and economic price. At the same time, the therapeutic strategies offered must “make sense” to the patient – they must contribute culturallyconsistent meaning to the illness experience. Indigenous cultural conceptions have posed and continue to pose considerable resistance to allopathic medicine’s interventions and recommendations. Examples illustrating this point are almost endless. The social meaning of communion and partnership in sharing needles among drug users in the United States hampers the acceptance of clean needles distributed at no cost (Connors, 1995). Surgery is only reluctantly accepted by traditional Navajo, who sanctify the integrity of the body (Alvord, 1999). Jehovah’s Witnesses’ belief that blood carries an individual’s life or soul leads them to prefer death over a transfusion of blood from another person (Filkins, 1998; Stotland, 1999). Antibiotics may be rejected by Iranians in case of an infection because of the popular idea that they potentiate a fever. To help overcome cultural barriers to acceptance of allopathic recommendations, medical anthropologists have been called on to elucidate cultural values, conceptions or themes which impact community health and patient compliance (Chrisman and Johnson, 1990; Coreil, 1990). Ideally, the local social concomitants and conceptual dimensions of illness, once identified, can be addressed in therapeutic and preventive measures (Carlson, 1996; Ingman and Thomas, 1975; Singer, 1998; Singer et al., 1998). Such insights have found recognition, for example, in clinics serving “ethnic” populations (Haviland, 1990; Lamberg, 2000; Willard and LaDue,

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1988); in the acceptance of terms such as “illness narratives” in medical schools (Brown, 1998; Eisenberg, 1988; Kleinman, 1988); in the application of concepts and methodologies derived from anthropology in psychiatric therapy (Rush, 1996); and in the incorporation of “social soundness analyses” in medical development projects (Allman, 1988; Wood, 1990). The Puzzle of the Native Practitioner of Allopathic Medicine In the context of medical pluralism, the position of “native” practitioners of allopathic medicine becomes a curious one, for native medical doctors can be placed on both sides of a great divide of understanding. On the one hand they are born and bred “natives,” acculturated to their own culture, socialized as local men and women. They receive primary education together with their own future patients, they are sick in their own culture, and they learn to negotiate the pluralistic medical system before they are accepted to allopathic medical school. On the other hand, they have systematically and rigorously learned allopathic medicine, i.e., acquired a body of knowledge based on non-indigenous principles, and are now offering this knowledge to members of their own culture. The puzzle of the native practitioner of allopathic medicine is how a physician reconciles allopathic and native cultural theory, knowledge and practice. Despite the universality of the dual identity of the native allopathic practitioner, the anthropological literature by and large ignores tensions inherent in this role. Indeed, the image of native medical doctors that emerges there tangentially is one-dimensional and simplistic. Both in critical political-economic discussions of “biomedicine” and in discussions of the “micro”- level of medical practice, native allopathic physicians are portrayed as allied with the dominant culture of the United States and therefore as distanced from their patients. Allopathic medicine is described as a Western export like blue jeans or Coca-Cola, a commodity imposed monolithically upon a vulnerable and clueless population, a hegemonic presence insensitive to local needs and cultural nuances and threatening to native medicines and native social orders alike. In the same vein native allopathic practitioners are invariably portrayed as removed from and condescending to those patients who hold on to native interpretations of disease, as unwilling to engage in discourse with their patients, as unwilling to offer their services to that segment of the population most in need of them, and as arrogant in their assumption that their patients’ health status is linked to socioeconomic and educational factors over which no one but the patients themselves have control.

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I will not argue that this characterization is entirely wrong; it is, however, shallow. No doubt identification with power, technology and the social status and material comforts that many medical doctors enjoy creates a distance between them and the traditional life ways of their patients. But this does not mean that they can forget their own culture when they practice medicine or that they will or ever could become either “acultural” or “Westernized,” or that one physician could stand in for another at any time or any place. Some anecdotal accounts address the “nativeness” of indigenous allopathic practitioners. A Navajo surgeon writes compellingly of the confusions that arise when living in two conceptual worlds at once and of how her practice improved when she began to integrate Navajo customs in her surgical practice on a Navajo reservation (Alvord, 1999). Janzen (1978) writes that, while African medical professionals behave in the clinic according to international standards of practice, at least at the time they themselves become ill, they “tend to act like their kinsmen” (p. 217). Finkler (1998, 2000) mentions that Mexican physicians incorporate folk understandings of disease causation, such as anger, nerves or fright, into their “allopathic” ones. Nunley (1996) describes how Indian psychiatrists base their practice on pharmaceutical drugs and electric shock therapy rather than on psychotherapy so as to identify psychiatry as a scientific/technological discipline, as well as to satisfy patients’ demands for polypharmacy, which is a criterion of “good” medicine in Ayurvedic herbalism. Payer (1988) describes how the practice of allopathy in European countries reflects defining cultural values or national themes. In Japan, allopathic physicians bring Japanese moral arguments to bear on the definition of brain death (Lock, 1995). In China, the concept “neurasthenia,” derived from 19 century allopathic medicine, has acquired legitimacy by acquiring a distinctive, culturally-consistent, local meaning (Lee and Wong, 1995). Feldman (1993) describes how French and American physicians’ use of different metaphors to conceptualize HIV and AIDS results in different treatment and research strategies and goals. These reports suggest that adoption of the allopathic medical system involves not simply an overlaying or supplanting of native conceptualizations by new ones but a process of amalgamation. As we have already seen, medical systems are not confinable just to disease nosologies and treatment strategies, and the feeling of being healthy or ill does not occur in a cultural vacuum. As applied medical anthropologists have shown us, the better the tenets of allopathic knowledge and practices can be made consistent with the philosophical, existential, ethical and socio-political tenets of local th

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patients, the more successful it will be. It stands to reason, then, that native allopathic practitioners must make sense of or come to a culturally consistent understanding of allopathic medicine before they can effectively apply it to patients’ concerns. Medical Systems as Cognitive Systems To talk about “understanding,” “giving meaning to,” “making sense of” or “integrating into existing conceptual structures” is to talk about cognitive processes. I therefore draw on insights, concepts and tools developed in the cognitive sciences, particularly schema theory, to explore the puzzle of the native medical practitioner. In doing so I posit culture squarely in the minds of people. Culture provides the cognitive tools by which to organize experience so that behavior can be generated. It is not simply a constellation of encyclopedic knowledge or a web of meanings stored somehow in the brain, but the source of rules or guidelines by which these semantic webs and knowledge can be used for generating purposeful, meaningful action. Cognitive anthropology has long been engaged in elucidating the manner in which knowledge is stored in the mind and the relationship of knowledge to behavior. One of these earliest contributions was the analysis of classificatory systems and their relative merits in modeling domains of meaning. “Ethnoscientific” works concentrated on how concepts (trees, firewood, illnesses) were semantically related. They laid out often quite complex classificatory trees to describe by what attributes objects in the world are distinguished from one another. It soon became apparent that classification schemes alone do not explain how people actually use concepts in real life (de Munck, 2000; Dougherty, 1975). For example, one early ethnoscientific project was to elicit linguistic color categories on the basis of the hue and saturation of colors (Berlin and Kay, 1969). But while a weaver in tribal Iran may not have a term for “purple” which distinguishes it from “brown” and “dark blue,” she will not confuse purple with brown or dark blue when she is weaving (Friedl, 1979b). Likewise, there may be multitudes of subdivisions of a category, such as “red” or “snow” or “infection,” which are meaningful only to those who use them (Kronenfeld, 1996). Thus the context in which objects are to be used and the motives with which individuals engage this context must be incorporated into models of mental representations (D'Andrade and Strauss, 1992; Keller and Keller, 1996).

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This realization has led to elaboration of the “schema” concept. A schema is a mental organizer of perceptions, thought and behavior. It is a shorthand form of thinking which allows essential information to be extracted from a flood of stimuli and to be used for generating behavior appropriate to a goal. Schemata obviate the need to scan one’s encyclopedic knowledge in order to find a “fit” between what one is experiencing, what one knows and what one ought to do. They select certain inputs from one’s internal and external environments as salient and assign meaning to them, and this interpretation in turn serves as a basis for action. Unlike the early classificatory systems, schemata are dependent on context, on experience and on motivation to become operational. At a basic level, a schema is like a script. Given a context and a motivation, a schema allows a person to determine “how to . . . ,” as in, how to order a meal at a restaurant (Shank and Abelson, 1977), how to design a house or a work space (Shore, 1996), how to make a success out of marriage (Quinn, 1982), how to tell stories of sickness (Garro, 1994), how to decide on a therapy. Textbooks and manuals, for example, are all about schemata: how to perform a physical exam, how to design an electrical circuit, how to play golf, how to bake a cake. While schemata may have to be cumbersomly learned, like the schemata of allopathic medicine (how to make a diagnosis and what therapy to recommend on the basis of it), with repetition, schemata allow behaviors to become automatic. They are like grooves that people get into in their thought and their behavior, simplifying the act of thinking and of living (Brewer 1999; Lehman, 2000). Schemata are related to one another by cultural premises or themes. These are basic theories about the world, about objects in the world and their relation to one another (Keller and Lehman, 1993). In fact, the extent to which schemata become organizers of perception, knowledge and action depends on the degree to which they have been linked to other domains of activity and of thought, i.e., the degree to which they have been experienced (Strauss, 1992). The “going to a restaurant” script, for example, is based on common cultural premises of social and economic exchange (Shank and Abelman, 1977); the process of dating in the United States is based on a view of romance as being something natural and innate (Holland, 1992b); the details of a physical examination are based on a mechanistic view of the human body (Martin, 1987). In this book I call such common cultural premises or themes “key concepts,” “first principles” or “basic modes of thought.” In essence, they allow judgment to be made on how “good” or “well-formed” a particular activity is: how morally sound a course of action,

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how fitting a verbal idiom, how correct and aesthetically pleasing a ritual, how purposeful and sensible a therapy (Lehman 2000). Key concepts are themselves schemata, though not of the “how to . . .” sort. They organize thought and provide both motivations and the means to achieve those goals in a culturally consistent, meaningful way. They can be used as a starting point to reason through a course of action in the case of ambiguous contexts or conflicting goals, when situations cannot be handled or resolved just by the rote execution of enscripted schemata. At an extreme, this is the stuff that ethical dilemmas are made of. A young Catholic Samoan man whose father has been murdered has to choose to act either out of the Catholic principle of “turning the other cheek” or according to the traditional Samoan one of “filial piety” which demands that he avenge his father’s death at any cost (Shore, 1996). A low-caste woman asked to visit a foreign ethnographer living in the top story of a high-caste family’s house is confronted with two schemata. One, accepting hospitality, requires that she enter the house; the other, based on her status in the caste system, prevents her from doing so (Holland, 1992a). Watching an old Inuit man walking off an ice flow to his death, an allopathic doctor would have to grapple with the dual implications of the allopathic principle of “do no harm” (Shah, 2000). Strauss has demonstrated (1992) that while working-class men identify two motivations for behavior, “success” and “bread-winning,” which schema will be enacted depends on the manner in which the day-to-day contingencies of life will be interpreted. Thus the schema concept ties the notion of “culture” to the psychology of individuals and their subjective and inter-subjective experiences as culture-bearers. Allopathic Schemata The preceding discussion of allopathic medicine can productively be reframed in a cognitive model. Allopathic medicine provides a classification of diseases and schemata for their recognition and treatment. These schemata guide physicians to salient characteristics of the disease’s presentation, i.e., those characteristics which allow it to be differentiated from others. The limited set of modifiers the physician considers in this algorithm allows him/her to generate a list of possible diseases the patient may have, or “differential diagnosis.” This is a working interpretation of the presenting symptoms, on the basis of which further action is structured: asking more questions, performing tests, or finally, determining the diagnosis. The identified disease, the diagnosis, is, again, both a theory about disease causation and a template for its treatment. Thus the “how to perform a patient history and physical examination” schema leads to the

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“how to rule out diseases in the differential diagnosis,” “how to make a diagnosis of X disease” and “how to treat X disease” schemata. The salient characteristics a physician considers in constructing a differential diagnosis concern the “nature” of the symptom in the context of the patient him/herself. Symptoms mean different things in different contexts. When confronted with a patient with “chest pain,” for example, the list of possible diagnoses a physician entertains varies considerably based just on the age, sex and race of the patient, regardless of the nature of the pain itself. The characteristics of the symptoms that are interesting to allopathic physicians include the time of day at which they occur and their duration, location and intensity. Patient characteristics a physician will consider include, besides demographic factors, the patient’s tobacco- and alcohol use, exposure to vocational hazards, sexual orientation, or a family history of genetically transmitted diseases. Notice that none of the limited characteristics the physician has focused on in the patient’s presentation addresses the “illness experience,” that which makes a generic disease personally meaningful. That is, in fact, not the purpose of allopathic medicine. The purpose is to delineate the “disease” and its biologic underpinnings with as limited a set of decision points as possible. According to this model, the practice of medicine is reducible to an informatics loop in which the interpretation of data, or assessment and reassessment of what one “knows,” guides action, be this the gathering of more information or the ultimate end point, administering treatment. The execution of the schemata requires an inordinate amount of knowledge, but is essentially clear, logical and straightforward. That is, within the confines of an allopathic medical school or between the covers of a textbook it is clear, logical and straightforward. The first practical lesson learned in clinics and hospital wards is that “patients don’t read textbooks.” In other words, the rote or robotic execution of schemata designed to identify diseases is complicated by the patients who embody them. The most obvious implication of the phrase “patients don’t read textbooks” is that patients often present with “atypical” symptoms or respond idiosyncratically to therapeutic measures, i.e., their diseases do not “behave” the way the textbook describes them. In these cases, schemata cannot simply be enacted, and the physician must go back to “first principles” to reason out what might be going on in the patient. At the most obvious level, these principles are the logics of anatomy, physiology, biochemistry, microbiology or any other allopathy-related medical science. These are themselves modeled on culturally derived themes and metaphors not uniquely allopathic or even necessarily scientific. Nevertheless, 12

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INTRODUCTION

“atypical” presentations are relatively easy to deal with, requiring simply reference to textbooks or discussion with colleagues. After all, this is the stuff the allopathic physician has been taught to think with. The phrase “patients don’t read textbooks” carries two additional meanings in the context of this discussion. One is that patients bring issues and concerns to the doctor’s office that are not written about in textbooks, i.e. do not directly pertain to allopathy. These are the things not asked about during the history and physical examination–the social, psychological, economic implications of the disease, the “illness experience.” The reasons these are not asked about are, firstly, that they are not considered to have a bearing on the disease, and, derivatively but more importantly, because allopathic medicine does not provide the physician with schemata with which to address them. These are, quite literally, not allopaths’ concern. This is an apologic statement for allopathic medicine, for it seems to absolve physicians from attending to the patient’s illness. It is not an excuse, however, for physicians are still human, still a participant in their patients’ culture, and still expected to (and capable of) responding at least with empathy to their patients. In addition, in the US at least, a host of paramedical organizations has developed to address some of these concerns. The “caring” physician can refer the patient to social workers to help sort out financial problems, to a nutritionist to help devise a healthful but tasty diet, to the chaplain for spiritual counseling, to a geneticist to discuss the implications of family diseases, or to “group therapy” for help in dealing with the stressors of chronic disease. The point is, though, that these issues cannot be dealt with by allopathy proper. They can at best be lateralized–at worst, they will be ignored. The other implication of the phrase “patients don’t read textbooks” is that a patient’s ideas about illness, disease and therapeutic measures, his/her “explanatory models” (Kleinman, 1988) are usually not derived from allopathic medical texts. On the one hand, patients’ understandings of disease causation and the workings of the body fall short of the knowledge contained in textbooks. On the other hand, their conceptualizations of health and disease extend beyond textbooks to encompass metaphors of personal failings and cultural and social ills. In other words, the interpretation of disease differs between allopath and patient, and therefore, the schemata enacted to redress the disease/illness will not necessarily be commensurable or compatible. These meanings of disease can be a source of resistance to therapeutic measures as well. This leads to patient non14

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compliance, therapeutic failure and frustration on the part of patient and physician alike. Based on this cognitive model of allopathic medicine, the following questions arise concerning the practice of allopathic medicine by “native” physicians: 1) Allopathic schemata may be based on the logics of allopathic sciences, but these are themselves influenced by cultural logics, themes, metaphors or “key concepts.” To what extent do native cultural logics provide interpretations of disease and therapeutic measures and to what extent do these change the practice of allopathic medicine in an allopathic setting? 2) Allopathic medicine does not provide schemata with which to address the social, economic and psychological aspects of illness. These must be addressed by schemata and “key concepts” coming from outside the domain of allopathic medicine proper. Do these social, economic and political contexts in turn impact the manner in which allopathic medicine is practiced? 3) The explanatory models that “native” patients have for their diseases are more at variance with the physician’s in a non-Western setting than in the United States. In fact, these discrepancies are the subject matter of applied medical anthropologists the world over. How well are native allopathic practitioners equipped to address them? In order to shed light on the questions the cognitive model of allopathic medicine raises, I looked at what happens to the key concepts and schemata of medical theories and practices in a setting where strong indigenous traditions and strong “Western” medical ones both impact the manner in which medicine is practiced. As I demonstrate with data on the practice of allopathic medicine in the Islamic Republic of Iran, allopathy comes to be understood in native terms and in turn provides rationalizations for native conceptualizations of health and disease and social, political and economic orders. The main conclusions of my research are: 1) that allopathic schemata provide medical doctors with interpretations of patients’ symptoms and with templates for action in a clearly allopathic context–the clinic, for example. At least outside the clinic, if not occasionally within it, allopaths may draw upon native conceptualizations of health to guide their actions. 2) Under certain conditions, allopathic schemata will be contested, such as, for example, when they do not offer a locally convincing explanation for a disease or an easy cure. In these cases, extra-allopathic key concepts will be applied to reason through medical issues. And 3) that medical doctors evaluate allopathic schemata critically and reflexively for “cultural soundness” and modify them as they adopt them into their conceptual

INTRODUCTION

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frameworks. Furthermore, they use the explanations in turn to rationalize “native” understandings of health and disease. In the first chapter I describe the context of my research in Iran, including why I decided to do the research there and the methodological difficulties I encountered. In the next two chapters I describe the four major medical traditions which account for medical pluralism in Iran, and show their connections to logical and philosophical principles or “key concepts” relating to the nature of health and disease. In Chapter 5 I argue that native conceptualizations of health and disease provide the default logic with which lay people as well as allopaths analyze and address health-related issues. While the physical context of practice superficially keeps the domains of traditional and allopathic medicine separate, the theories and practices of allopathic medicine are ultimately acceptable only if they make sense in terms of native knowledge. In the remaining chapters I elaborate on some of the extra-allopathic influences on the practice of allopathic medicine in Iran, such as the economic context, cultural definitions of authority, ethics or morality, and the religio-political context. Finally, I present a model of allopathic knowledge that makes sense of the multifarious ways in which allopathy is changed by native Iranian patterns of thought.

Chapter 2

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The Contexts of Fieldwork

The expectation that I should have been allowed to do the research I wanted to do demonstrates a great amount of hubris on my part. Since the Islamic Revolution in 1978, non-Iranian journalists and scholars have gained entry to the country only with great difficulty and for only weeks at a time, and their sojourns there were usually closely monitored by the government (which is not necessarily objectionable, as long as the resulting bias is recognized). Most foreign scholars the government has welcomed keep to arcana of academic scholarship--Mongol history, illuminated manuscripts, sparse remnants of nomadic lifeways--which have little relevance to issues of everyday concern to the Iranian government. There is some international cooperation on issues related to public health and medicine, such as studies of child nutrition or the epidemiology of esophageal cancer. But for a foreigner, a Westerner at that, to do research in Iran for one and a half years without official government supervision was unheard of when I proposed to do this research. I entered in the country in the fall of 1997, soon after the moderate cleric Mohammad Khatami was elected president of the country by a landslide victory over the candidate backed by the ruling conservative party, which had held that office since it was created. This victory gave Iranians a feeling of autonomy, of being able to resist the conservative forces which had dominated the political scene for two decades. It also gave them the hope that certain rights they had been deprived of would be granted, primarily, democracy, economic security and freedom of speech. The country had been unable to pull out of the economic crisis it had spiraled into during the war with Iraq, which ended in 1988 and left Iranians bereft of the comforts of first-world status they had enjoyed in the years immediately preceding it. At the same time, expressions of political dissatisfaction were officially discouraged: they could cost one no end of

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trouble, from interrogation to imprisonment, from heavy fines to a derailment of one’s professional career. One month after I came to Iran, the Iranian soccer team won the Asian Tournament, thereby qualifying for the World Cup in France in 1998. The celebration of this victory was spectacular. “There were more people on the street than on the day the Shah left the country,” I was told by jubilant Iranians who had witnessed both events. In Tehran, traffic came to a complete halt as people of all ages, sexes and social classes made merry in the streets. “The Islamic police danced side-by-side with young women whose veils were falling down,” I was told nostalgically by a teenager even months later. The event signified to Iranians much more than that their soccer team was good: it meant that Iran was participating, after a long hiatus, in an international, high-visibility event, that they were being seen and heard outside the country and that they were worthy of being paid attention to. It was in the same spirit that the people sat glued to the television to watch Khatami's address to the United Nations in January 1998. Their president’s physical presence in the United States was taken as an omen of improved relations and the lifting of barriers between the two countries. That spirit of hope and promise quickly faded. Iranians were pleased with what Khatami said before the United Nations but openly admitted their frustration with the president’s inability to achieve a rapprochement with the United States, and other campaign promises, in the face of the entrenchment of authority in the hands of the conservatives. It did not take long after the presidential election for the conservative party to undermine what little authority Khatami could have had. Although the situation was much better in 1999 than it had ever been since the Revolution, by the time I left Iran, people’s despair had grown to pathologic proportions. The lack of freedom from economic want, the lack of leisure time, the lack of freedom to be allowed to relax in mixed company, the need to be circumspect in all one said and did, the knowledge that some big, unassailable force was stymieing one’s actions and ideals, had led to widespread expressions of frustration and depression. Because of boycotts and sanctions which severely limit Iran’s ability to participate in the international scene, Iranians perceived themselves as being invisible and of no account to Western, first world nations, with whom Iran had intensely identified itself in the years before the Revolution. Official access to the khārej, to foreign, primarily Western, countries, was essentially blocked for Iranians on any front imaginable, both by their own government and by governments of foreign nations. Trade embargoes, low oil prices,

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exploitative fishing practices and restrictions on the export and import of Persian carpets significantly reduced Iran’s participation on the international market. Intellectually, the coming and going of foreign scholars and graduate and post-graduate training of Iranians abroad had practically come to a halt, for logistical and financial reasons. For the same reasons, tourism in non-Islamic countries was unfeasible except for a tiny minority, and problems with visa acquisition deterred any but the most determined foreign tourists from visiting Iran. Even sustaining contact with relatives living abroad was difficult. People said that fear of censorship reduced letters and telephone conversations to an exchange of pleasantries. Obtaining visas and permits to leave the country entailed a lengthy, costly hassle. Travelers were allowed to take with them only a small quota of carpet yardage or weight of pistachios and caviar, preferred gifts. Even the mailing of dry goods was curtailed. Frustration with difficult access to the khārej was aggravated by the often-voiced conviction that what Iran had to offer in terms of trade, academics, recreation, sports or leisure was on a par with what is available in the West. Iranians who have emigrated to the West have “all” become highly successful, Iranians said, they are doctors, lawyers, engineers, university professors, business entrepreneurs, thereby demonstrating equal if not superior Iranian brainpower. Iranians accused carpet factories in Pakistan, China and India of “stealing” Iranian designs, Russian fishermen of harvesting caviar in Iranian waters, and Californian farmers of growing pistachios from Iranian seedlings, thereby at once proving the desirability of these items on the international market and the unfairness of being barred from reaping the benefit from what is rightfully theirs. They accused foreign governments’ negative propaganda and Betty Mahmoody’s (Not Without My Daughter, 1987) vilifying report of Iran and Iranians of turning public sentiment against Iran and thereby stopping tourism. The role of their own government in putting up barriers to economic, intellectual and tourist exchange often was ignored or even denied. The point Iranians tried to make with these statements is that foreign countries, particularly nonIslamic, Western ones, are unfairly barring Iran from international visibility and progress. Access to the West may have been officially restricted, but the private influx and black-market circulation of Western goods proceeded at an astonishing rate. Though threatened by confiscation, satellite dishes mushroomed in gardens and rooftops, transmitting Western television newscasts and shows. Travelers brought with them the latest recorded pop music, videos, books, and the newest fashions in clothes and cosmetics.

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Even though many of these things were confiscated at the airport, enough got through to make an impact. Access to the Internet also contributed to increasing the visibility of the khārej in Iran exponentially, even if the reverse was not the case. Not only were people frustrated at not being able to participate in the larger world, they were frustrated at not being able to enjoy the kind of life they saw, or imagined, people in the khārej as having. The popular desire for communion with the West and national and international barriers to such communion framed my stay in Iran, colored each discussion I had with Iranians and were both the source and resolution of my difficulties in carrying out research. From the people, I felt nothing but welcome. I was welcome because I was a representative of the khārej, and my very presence, let alone the nature of my work, was taken as a sign that the khārej did care about Iran, that Iran did have something of value to offer. Iranians took every opportunity to show off to me their potential and their humanity: their intellectual prowess, their adherence to strict moral and ethical guidelines, their noble and admirable history and culture, their industry, their ability to produce world-class scholars and athletes, their beneficence towards those in need. They made a point of demonstrating to me that far from being the fanatic terrorists the world media had made them out to be, they were simply people, interested only in “living their lives,” going to work, learning a trade, raising their families, performing devotions in private, relaxing in the company of their families. Research Permission Though Iranians who learned about my work gave me unquestioning support and felt honored that a foreigner would dedicate a year of her life to report on the situation of medical education and practice in Iran, official approval for my research took a year to acquire. Part of the difficulty lay in the fact that, since no one had done such a thing before, no one could advise me on how to go about getting the approval. Just when I thought, in the spring of 1998, that all had been taken care of, I was summarily ordered to leave the country, ostensibly because I had not followed “proper channels” in petitioning for research permission. I do not wish to underestimate the difficulty I posed for the authorities. I was a foreigner. I was a single woman. I was a medical student but did not want to attend classes and clinics for educational credit. I was a student of anthropology proposing to do, for Iranians, an untraditional ethnographic study. I had my own apartment in Tehran but perversely went to a remote village for respite. I came to Tehran with a tourist visa to study Farsi and surfaced months later in Shiraz, asking for residency status. I was an Austrian citizen studying in

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the United States. I was an anomaly and fit none but suspicious, threatening categories. Vexatious as it was, it is little wonder that no official wanted to take responsibility for allowing me to stay in Iran. With the help of the Austrian embassy in Tehran I was able to procure another tourist visa in Vienna, and returned to Iran after just one month’s absence. My parents, Reinhold and Erika Friedl Loeffler, came to Iran that summer as well to continue their own ethnographic studies in the village of Deh Koh (a pseudonym) in southwest Iran. With my mother I made an allout assault on the petitioning process, and I believe we were successful just because we were together, on the spot, and insistent. No one could say “no” forever to our obstinate faces, and the very fact that I was with my mother reassured officials that there was someone responsible for me. We visited some fifteen offices in Shiraz and Tehran in four days. Finally, my sheaf of letters went for review to a committee overseeing international students in Iran. The committee took three weeks to convene, and the letter it issued authorizing the University of Shiraz to allow me access to classes and clinics was en route for six weeks. When my parents left the country at the end of the summer my research permission had still not come to Shiraz. Even after it did, the battle was not won. For with a tourist visa I was not allowed access to the medical school. Tourists were quite welcome in the gardens and mausoleums of Shiraz, but their visas did not allow them on to government properties such as the medical school. The various permissions and invitations I by now had in hand could not be honored without residency status, which had to be granted by the Foreign Ministry. My petition for residency status was sent from the local foreign police office to Tehran, and another wait ensued. It lasted so long that I sank into a depression. Despite assurances that a response from Tehran would come “next week” or “tomorrow,” the wait dragged on for another month, during which time I knew that I was under close surveillance and any step I even dared take onto university grounds would immediately be reported to authorities. I took to haunting the police station every morning, waiting for the mail to arrive from Tehran. The police officers got sick of seeing my woebegone face in the waiting room and of not being able to offer me anything but tea and sweets and assurances that everything would come out in my favor. Eventually they even laughed at my stubbornness and asked why I refused to go home and forget about Iran, why I was wasting my youth and life. When word finally did come from the Foreign Ministry, my depression even increased. For though the Ministry gave its approval that I be issued residency status for six months, the power to do so did not lie with the

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police officers themselves. The final decision to grant me the visa resided with the superiors of the nameless, drably-dressed, stubble-bearded, mumbling man who interviewed me numerous times in a locked back office of the police station. The interviews I had with him revolved around my intentions in Iran which, though I spelled them out again and again, continued to be suspicious to him and to the authority to which he reported. I continued to haunt the police station until one of the police officers took me aside to advise me not to bring so much pressure: “‘They’ will get a grudge against you; ‘they’ don’t like it." The issue was finally resolved in my favor, and, I was told by one of the police officers, the wait had all been my fault. For if I had said from the beginning that I intended to “write my thesis” rather than that I intended to “do research” for my thesis, no one’s suspicions would have been aroused. So was painfully brought home to me a vital distinction which I had known about but had, out of my own common-sensical understanding of what “writing a thesis” and “doing research” entailed, ignored. In Iran, someone doing social scientific “research,” tahqiqāt, is ipso facto a spy. Tahqiqāt has the connotation of gathering intelligence, and anthropological research means snooping around in the socio-political situation in Iran. Someone “writing a thesis” on the other hand, is safe, for thesis writers are not on their own. Medical students in Iran have to write a thesis to fulfill the requirements for the Medical Degree. They do this under the supervision of an advisor, who would not be a professor at the university if s/he were at all suspicious to the authorities. If the thesis involved the use of human subjects, permission to do the study had to be garnered from the Ministry of Health, so it came under yet another level of supervision. At every stage, the Secret Service closely monitored the questions asked and the data gathered. Thus, “writing a thesis” was a perfectly valid, respectable and valued undertaking while “doing research” was not. The entire ordeal brought home to me in a very real and personal way the extent to which the Secret Service was an omnipresent aspect of life in Iran and why Iranians found it necessary to be circumspect in their public speech and behavior. The Secret Service was involved in the promotion of individual’s careers based on their record of “Islamic” behavior. Female medical students complained to me of the necessity of constantly having to be on their guard lest their head-scarf slip to reveal a tuft of hair, lest they be seen speaking to a male colleague without other people present, lest they be overheard speaking with a man about anything other than medicine. Files were kept on whether or not they voted, and on their political opinion, on expressions of their dissatisfaction with lack of freedoms, even on the extent

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to which they had access to Western goods (e.g., videos) in the dormitory. These files were reviewed at every instance of promotion: access to medical school, progress through medical school, graduation, acceptance to residency positions, job with a government clinic or university. Even if people with files containing negative reports have never actually been denied their medical degrees at the end of their studies or acceptance to a residency position if the grades they made on nationalized, standardized tests were outstanding, the possible consequences of allegations made students beware of incautious speech or behavior. Iranians said they knew they were being watched, and this by members of their own social sets. At work or at home, anybody might be an informer, they said. When I tried to set up interviews at the women’s dormitory I was quietly but firmly advised by both the students and my advisors that this would not be a good idea. “Though neither you nor they have anything to hide, don’t attract ‘their’ attention,” I was told. The welcoming attitude of the Iranians I previously described was thus tempered by a great deal of circumspection when these same people became my research “subjects.” Research Methodologies The delay I experienced in getting permission to “write my thesis” and the circumspection of Iranians in their interactions with me necessarily affected the way I did my research. I used the time I had to wait for research permission to gather data on popular medical beliefs and the culture of sickness as described in newspapers, health manuals, popular literature, from the ways in which people talked about their own and others’ illness and their hierarchies of resort in addressing problems related to health. I started this while I was undergoing language training in Tehran and continued it over the summer of 1998 in Deh Koh, and then during the long wait in Shiraz. Much of these data were gathered in an unsystematic manner, but I also had the opportunity to observe the practice of a young physician employed in a rural clinic. This allowed me to observe doctorpatient interaction styles and solicit interviews with the two other physicians and several nurses and midwives employed at the clinic. Once I formally began my research I decided not to solicit interviews but let students demonstrate a willingness to talk to me themselves. Relying on self-identification, I felt I could trust that the students were aware of the risk they were taking when they spoke to me, a foreigner and therefore suspicious despite all my official letters and approvals, and could judge for themselves whether they could afford to take that risk. This tactic worked very well. In fact, in the one interview I did solicit, both I and the student

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were on edge, the fear of arousing suspicion never left my mind, and judging from the quality of the answers I received from the student, it affected her as well. Usually at the end of a lecture or towards the end of a clinic day, when work slowed, students and residents who were curious about my presence would approach me. I answered their questions (usually, in this order: what I was doing there, where I was from, whether I was married, and how they could get a green card for the United States) and then began to ask them to clarify some points of the lecture or of practice. From here the conversation easily turned to personal issues such as their own career choices, backgrounds, beliefs in alternate medical systems, their perception of the state of medicine in Iran and obstacles to effective health care delivery, and to a discussion of “scenarios,” hypothetical medical cases that would illustrate for me some point of doctor-patient communication, understanding of disease causation and treatment, or ethics. Our conversations continued on subsequent days, and often I would be asked to join the trainees in more casual settings, in the cafeteria for lunch or tea, in small, informal gatherings in their dormitory rooms, or in their private residences. Here I was able to observe them in social interaction with their friends, and test whether what they had told me in informal interviews held up in interaction with their peers. I was also introduced to more students and residents who were willing to speak to me. The strategy of allowing the trainees (students, interns and residents) to approach me rather than vice versa had the additional advantage that I could interview men as well as women. Men were as curious about me as their female colleagues were and quite as willing to answer my questions, provided we stayed in well-populated clinics for the duration of the conversation. I obviously did not receive invitations to join them in social settings but do not feel this had a deleterious effect on my data since the content of their answers did not differ significantly from those I received from women. What the trainees said to me in interviews I triangulated against the observation of actual medical practice in clinics and clinical conferences (morning reports and grand rounds) associated with the University of Shiraz Medical School, at which I clocked close to 200 hours of observation time. While activities in these clinical settings were obviously concerned with medical issues, my observations concentrated not so much on the medical content as on the cultural matrix in which medical issues were addressed, such as the distribution of people in classrooms according to gender and social rank, discussion of ethics, variations in the relationship between

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doctor and patient according to the level of training of the physician and social class of the patient, the spatial and temporal organization of patient visits, references to authority, whether English-language textbooks or God. These observations then served as a starting point for the interviews and discussions I subsequently had with professionals and trainees, they informed the basis of my understanding of what medical practice in Iran was all about. By having directly witnessed, e.g., that there was no such thing as “privacy” in the doctor-patient exchange, that patients’ questions were not entertained, that physicians often referred to God to allay patients’ fears, that men were circumspect in examining and treating female patients, I was in a position to not only ask directed questions about the rationales behind these practices, but also to challenge some of the idealistic assertions physicians made during interviews. Observation also served to test the extent to which verbal information reflected the ideals of medicine rather than accurately portraying practice. Through interviews and discussions I probed into contradictions in behavior and assertions to determine the logic or common-sense which made them consistent to the people I was speaking to and observing. The interviews I had with medical trainees and professionals were more conversations about aspects of medical practice than they were formal and structured. I did not use questionnaires and did not generate quantitative data. In discussions with my partners, I usually had a mental list of themes or topics that I wanted to address, or occasionally asked pointed, direct questions to clarify a particular point, but our discussions were generally open-ended. I allowed my partners to take the conversation wherever they wanted–except to political issues. Except where politics directly impacted medical practice (as with the tarh-e entebāq, discussed in Chapter 9), I did not allow conversations to turn political, for obvious reasons. By the same token, I allowed my partners to terminate a discussion whenever they wanted. For example, one woman I interviewed asked to be allowed not to give me her opinion on an ethical question because, being a member of a religious minority, her opinion diverged from that of her peers and, she feared, of the establishment. I did not press the issue. Whether or not it was because of the apolitical nature of the topics I was interested in, I was not bothered by the authorities again except for being called sporadically to “visit” a secretary or a professor who had “heard about my thesis” and was “interested in my progress.” After a polite discussion with him or her on hot and cold properties of foods and the quality of medical students’ English, I was free to go about my business again.

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I made notes of the conversations I had with medical trainees and professionals and of observations in the clinics and meetings I attended in the form of shorthand jottings in a notebook. These allowed me to reconstruct conversations and elaborate observations when I typed field notes into my laptop computer within hours of the time I made them. In these files, the identity of my interview partners was coded in order to preserve anonymity. Clinic patients were identified in my notes in a manner consistent with patient confidentiality in the United States: “A 40 year old woman with abnormal uterine bleeding . . . ;” “A male teenager with complaint of weakness.” Medical interviewees were identified by letters which coded their sex and level of training. Other than the date and location of the interview if it occurred in a clinic, identifying characteristics of the interview or the interviewee were suppressed in my records. For example, an interviewee referring to Deh Koh as the place in which he grew up would have been recorded as having said, “In the village where I grew up . . .” During the process of recording data from interviews and observations in the computer, I was analyzing this information, sorting it by searching for common categories of thought surfacing in the way physicians and trainees talked about and organized their practice. When I was done recording daily observations, I read through my notes to uncover patterns of thought and behavior which I then attempted to elaborate and test with questions and observations on subsequent days in the clinic and conferences. Every session on the computer therefore generated a list of further questions and problems to be addressed the next day. Keeping in mind the contributions the professor-clinicians, residents and students I observed have made to the medical field, their commitment to medical training and knowledge, and their generosity towards me, I apologize to them that I mention no names in this study. I see that this is unfair to the many students, professionals and lay people alike who spent large amounts of their time and energies explaining to me fine points of their practice and of their culture. They are proud of their accomplishments and of their culture, spoke to me of the honor of being allowed to demonstrate Iranians’ commitment to high standards of medical education and practice, and deserve mention as outstanding professors and teachers who taught me much about Iranian culture and medical practice in general. I have had sufficient experience in Iran, however, to know that however innocuous a statement I make appears to me, and no matter that I may just be repeating, even verbatim, something told me by an Iranian, it may be grounds for great consternation on the part of my Iranian audience, particularly of the secret service. Since I have no desire to weed out such

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statements even if I could identify them all, nor to subject the makers of such statements to harassment for having spoken to me or divulged some kind of information “the West” should not be privy to, I have chosen not to disclose the identities of the numerous Iranians who spoke to me and who are represented in the pages of this text. I did not tape-record or film any of the data on which this work is based, for a variety of reasons. For one, the hassle involved in trying to get official permission to record lectures and activities in clinics and conferences was more than I, after the long battle to gain research permission and residency status, was willing to undertake. For another, it would have been virtually impossible for me to make such recordings and concentrate on what was being said and done and what needed to be asked next at the same time, and my energy would have been focused on trying to make good video- and audio tapes rather than on the work at hand. And thirdly, I did not think I could allay my interviewees’ concerns about such recordings in the context in which I conducted the interviews. It would be stretching it to call my main fieldwork methodology a balanced participant observation. I had intended, when I first proposed the research, to be a medical student in Iran, to be assigned medical tasks and responsibilities on the basis of my own status as a medical student in the United States. But once I realistically assessed what this would entail, I decided against this. I knew from previous experience that it is impossible for me to be a student of medicine and its ethnographer at the same time, as neither gets done well. I did not want to be on call every third night. Modes of interaction with patients and superiors were so different in Iran from what I had been taught to consider was right, proper or ethical in the United States that I would have either had to compromise my own standards in these matters or violate Iranian sensibilities. Finally, my status as foreigner would have been an all too visible stigma, hampering communication with patients, colleagues, nurses and professors. It would have caused a contradiction in status which would have been difficult to reconcile, both for myself and for the people with whom I interacted: on the one hand I was a foreign scholar, to be awarded respect; on the other, I was a student, in need of supervision. Thus in clinics I didn’t even help carry supplies or shuffle charts or take patients to where they needed to go. This would have just drawn more unwanted attention to myself. I was puzzle and nuisance enough as it was.

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The Issue of Privacy One of the characteristics of observation and asking questions in the clinics that I quickly had to get used to was the absence of what I understood to be “privacy.” Even in “private” clinics, patients and staff crowd doctors’ offices, conversations can be overheard, physical examinations are conducted in spaces marked as extra-ordinary by curtains, walls, and small surface areas but which in fact only minimally restrict access for anybody. The only concession made to privacy is that the doctor-patient interview is conducted in a hurried whisper and bodies or hands are positioned so as to block others’ vision and hearing. Over a month of observation in a private OB/Gyn clinic, only twice did I see a concerted effort made to keep other patients unaware of the reason for a consultation: once in the case of a teenager who was embarrassed at the very small size of her breasts and the other time in the case of a woman whose hymen had accidentally ruptured. My having found out about the topics of these consultations, which were as “private” as possible, just goes to show how ineffective measures are for guarding patient information. “But that’s okay,” medical personnel assured me, “no one listens in, and even if they do overhear something, they won’t tell others, out of respect for the patient. Iranians are very respective of other’s privacy!” Just how standard and accepted the practice of the crowding of doctors’ offices is in the eyes of patients was illustrated in the practice of a psychiatrist at a university clinic. He allowed patients into his office only one at a time, that is, only one party at a time, since each patient was usually accompanied by one or even several attendants. At the end of the visit this physician personally escorted the patient and his/her entourage to the door, which he kept locked from the inside. Every time he opened the door he had to physically restrain masses of patients from pushing their way in, reassure them that he would see them all in due time and explain why he preferred to see patients in this manner, namely, that what they had to say was for his ears alone. The first time I visited his office I waited with the patients in the hall for the door to open. Squatting on the floor or leaning against the wall, many were engaged in discussing with one another their problems and diagnoses, and though they knew they would get to see the doctor eventually, complained about being locked out of his presence in the meantime. Iranians often told me that they trusted no one, that they wouldn’t even tell their own mothers or fathers their goals, ideals or intentions. Throughout my stay in Iran I was warned not to tell anyone of my “business.” Anyone who wanted to know what I was doing there was

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meddling and could throw a monkey wrench in all my plans, I was warned. By extension, what one did talk about, in even apparently “private” settings, was on the order of knowledge that was “safe” if it became public. How easily private conversations could be publicly appropriated was brought home to me on one of my first days in Iran when, opening the door to the telephone booth at one of the Telephone and Telegraph Offices in northern Tehran, I surprised a group of young women who had apparently had their ears pressed to a crack in the door. “We are learning English,” they informed me, “but now we are very discouraged because we couldn’t understand a word you were saying!” My informing them that this was because I was speaking German relieved them to no end, and my dismay that I had publicly been eavesdropped upon left them unimpressed. If I didn’t want others to know what I said, why speak where others could hear? Under such circumstances, where differences between “private” and “public” conversations are blurred, I figured that whatever anybody would tell me at all they would tell me in public as much as in private. Moreover, insisting on privacy or on being alone was in itself suspicious. To state one’s case openly indicated that one had nothing to hide, to do it privately required and indicated a disruption of the social order. In the clinic, it required rearrangement of the spatial and temporal organization of patient visits, vigilance over the fragile and temporary barriers to observation, and special time and effort on the part of the physician (when in fact one of the duties of the patient is to facilitate the physicians’ work). Even in the context of one’s own family, “wanting to be alone” is taken to indicate abnormality. Being “unsocial,” avoiding company, are said to be symptoms indicative of pathology; being alone could even lead to mental instability. Thus public opinion held that people preferred to be alone or insisted on privacy only if they were mentally unstable or if they had something to hide. I had no desire to arouse anybody’s suspicions on either of these counts, either as pertained to myself or to my interviewees, and so I asked questions and received answers in public, on the spot. Moreover, I wasn’t looking for anyone to spill secrets, I was interested in medicine, and that in itself is a public topic, concerned with public communication and public knowledge. The Issue of Language The language I preferred to conduct interviews in was Farsi. I had learned some Farsi and a dialect of it in previous travels to Iran, then studied Farsi as a graduate student, and finally spent the first several months I was in Iran,

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from October, 1997 to February, 1998, in intensive language training at the Dehkhoda Institute in Tehran. This institute, which is engaged in compiling an encyclopedia of Iranian language, history and culture, is affiliated with both the International University and University of Tehran. In addition to attending classes at the Dehkhoda Institute, I traded hours of instruction in English for practice of conversational Farsi with a woman in Tehran who subsequently became a good friend. She introduced me to her large social circle and my time in Tehran was soon taken up with social visits, movies, and, if I could spare the time, a few good books recommended to me along the way. By the end of the semester I had long ceased going to classes, and by the time I moved to Shiraz in the late winter of 1998 I was gratified to notice that even people who were fluent in English found it more comfortable to speak to me in Farsi than in English. It was necessary that I become fluent in Farsi because, their claims to the contrary, physicians and students trained or being trained at the University of Shiraz Medical School do not speak English well. Physicians who had received training in the United States or in England were more fluent than the new generation of physicians, but even with them, after the first exchange in English in which they invariably assured me I was wasting my time because the medicine practiced in Iran was exactly like that in the United States, they switched to Farsi to justify why certain practices I was observing deviated from what they had been taught abroad. They would then switch back to English in certain contexts: if they didn’t want a patient to know his or her diagnosis, if they found it easier not to translate knowledge they had acquired out of English-language texts, or in order to emphasize their commitment to medical knowledge. In Chapter 7, Roots of Authority, I discuss the use of English in the allopathic context at greater length. The translations I give of interviews or discussions I had with Iranians are my own. I indicate the instances in which my conversation partner spoke English exclusively or Farsi mingled with English phrases. Furthermore, these should not taken as verbatim representations or translations of what was said, but as my English paraphrasing of what I understood my conversation partner was saying in Farsi. My Medical Background By the time I conducted this study, I had finished all but a few weeks of medical training at the University of Illinois in Urbana-Champaign. My knowledge of medical practice in the United States, based on the training I had received in medical school, was a lens through which I saw medical

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practice in Iran. This is not to say that it represented for me a standard or ideal. Rather, it was something I couldn’t help but compare Iranian medical practice to, especially at the outset of my research. I took divergences in practice style to reflect cultural influences and attempted to trace these. For example, one of the first medical cases brought to my attention in Iran concerned a woman who was diagnosed in a small town near the village in which she lived with peritoneal tuberculosis, a rare manifestation of this infectious disease. The diagnosis had been made and standard tripleantibiotic treatment begun on the basis of a pathological specimen taken from her abdominal cavity during surgery for a presumed ovarian cyst. This specimen showed “granulomatous lesions consistent with TB.” In American medical lingo, the phrase “consistent with” means that the lesion looks very much like TB to the pathologist reading the slide, that the possibility that it could be due to another disease process is slim, but that the pathologist won’t call it TB because only the microbiology lab culturing tubercle bacilli from the specimen can do so with absolute certainty. Trained as I was to practice medicine based on absolute certainty, on clinical and laboratory evidence documented in black ink in a patient’s chart, and not on the basis of clinical hunches, no matter how certain one can be of them, I was surprised that no effort had been made to culture the bacilli from the patient’s abdominal cavity, either to ensure the diagnosis before treatment was begun or at least for assurance that the treatment was appropriate soon after it had been begun. The bacilli are slow-growing, so it can take several weeks to get the results of a culture, time one would not want to waste not giving therapy. On the other hand, the drugs carry considerable side-effects, which one does not want to subject patients to if there is no “proof” that the bacilli are in fact the cause of the disease. I asked her treating physicians, the pathologist who read the slide, and the professors under which the latter had trained, for a justification for not following up the diagnosis with a culture and was told, by every one of the physicians, the same sentence, in English: “In the case of granulomatous lesions, assume the patient has TB until proven otherwise,” interpreted to mean, in this case, until there is no response to therapy, not until no bacilli grow from culture. The other diseases which could present a histological picture similar to that of TB are so rare that it is not cost-effective, they said, to make a laboratory diagnosis of TB. In addition, the logistics of getting the specimen from the town in which it had been taken during surgery to a laboratory in a city at which it could have been cultured were formidable. Thus this one case opened up issues of economics, of the spatial distribution of medical technologies, of the role of socioeconomic status

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and gender in efforts to procure diagnoses, and of the effects of gender, socioeconomic status and education in shaping the woman’s experience of diagnosis and treatment, which I have not mentioned in this brief description. Also, when I had the opportunity to compare this case with others, it allowed me to see even larger conceptual frameworks, such as a super-valuation of clinical experience over laboratory evidence, a pragmatic approach to diagnosis and treatment which is only partially based on economic necessity, the use of English as an indicator of authority, and paternalism in doctor-patient interactions. Basing an ethnography just on easily observable divergences in practice threatens to lead to an exoticization of the “other.” Had I restricted my endeavors just to recording how practice is different from what I had been taught, I would have nothing to offer but a journalistic account of “my experience in Iranian medical clinics.” In fact, after highlighting potentially interesting areas of inquiry, the differences themselves were not important to me, and I could not even rely in every instance on the difference I thought was there to be “real.” As merely a medical student, not a fully trained specialist, I did not have the knowledge to judge whether or not the actual treatment offered or diagnosis made was the one an American at the same level of training would have made. Thus I soon turned my attention from documenting differences to elucidating the logic behind what appeared at first glance to me to be strange: the economic, political, cultural, historical, social and common-sensical principles on which medical practice was structured. Certain practices that bothered me in their unfamiliarity, such as not giving patients detailed information about the medication prescribed them, or the absence of the regulation of the dispensing of drugs, may have been the first I went after, but once I began searching for the common-sense of practice, any case, any description, any assertion pertaining to medicine became another clue to the logic of Iranian allopathy. The Field of Obstetrics and Gynecology Most of my observation time in clinics and conferences was spent on the obstetrics and gynecology (OB/Gyn) service. Every specialty has its own characteristics which one must come to terms with personally and intellectually, whether one is practicing or observing practice. Of all the specialties I had spent time in during my own training, OB/Gyn appealed to me especially, and it was on the basis of this preference that I originally proposed to work as a medical student on the OB/Gyn service while gathering information for this study. Beyond this, certain issues that I

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thought would provide meaningful insights into the structure of Iranian medical thought and practice are of heightened salience in the field of OB/Gyn. For example, the issue of male practitioners seeing female patients comes to a head here, as do ethical issues pertaining to parentage. The need to define life is much more acute when dealing with an almostviable fetus in a brain-dead woman than when dealing with the woman alone. The distribution of authority is most easily traced when dealing with as weighty an issue as reproductive potential. This is not to say that I spent all my time on the OB/Gyn service, however. I triangulated data I gathered there with data from other services, from pediatrics to orthopedics. Despite all the letters of introduction I now carried everywhere with me I preferred to let one physician or resident introduce me to another and then ask to observe his or her practice. Personal introductions of this sort were much more effective at allaying suspicion and concerns than an independent approach. Though I was never denied the opportunity to observe physicians’ practices when I approached them through a mutual acquaintance, on occasion I felt I was no longer particularly welcome after the second or third day of observation. In these cases I did not insist on returning, since I had come really only to check on the generality of categories of behavior and interaction styles that I was detailing on the OB/Gyn service. The History of the University of Shiraz Medical School I chose to do this research at the University of Shiraz School of Medicine and Applied Health Sciences because of the reputation it enjoyed both before and since the Revolution and because of its strong historical ties to American medical training. It was founded in 1948 as “Pahlavi University” with funds from the Iranian Ministry of Education and from the United States International Cooperation Administration. The funds for the main hospital with which it is affiliated, Nemazee Hospital, were donated privately by a native of Shiraz. The university’s advisory board consisted of American physicians, and the university was administered by the Board of Directors of the Iran Foundation for the Advancement of Health and Education in Iran, headquartered in New York City (Halsted, 1960). Even today, students, professors, alumni and administrators tell proudly of the strong association the medical school of Pahlavi University had with that of the University of Pennsylvania, which recommended the curriculum and textbooks. Before the Revolution close to 90 percent of the staff of the university and of the hospitals with which it is affiliated were foreign, again primarily American. All instruction–lectures in the basic sciences as well as

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in clinical training–was in English, and it was said that graduates were fluent in English. Other medical schools established in Iran before 1978, most notably in Tehran and Ahwaz, were styled on other international models of medical education, such as the French or German. The education offered at all the Iranian medical schools was excellent, but the number of graduates they produced before the Revolution was insufficient to meet the needs of the population. This shortage was compounded by a “brain drain,” in that many physicians sought post-graduate training abroad and never returned. Even with the requirement that graduates serve two years in an underdeveloped area of the country before being granted their medical license, the Iranian Ministry of Health was hard-pressed to find staff for the rural clinics it had created, and found it necessary to import physicians, usually from Pakistan and India. It was also difficult to find well-qualified Iranian scientists and professionals to teach at the medical schools and to staff the hospitals. Even thirty years after the establishment of Pahlavi University, it was still dependent on an international faculty. Older professors remembering these years recount with horror having to be on guard against quacks from abroad whose fake credentials were not exposed until they were in the middle of a surgery or patient complaints were investigated. After the Revolution all universities were shut down. When they reopened after two years, they had undergone numerous changes beyond a change in name. The few foreign professors and staff who remained were under surveillance and were subjected to a constant threat of harassment. They felt restricted in their research and teaching activities and kept as low a profile as possible. Intellectual and trade embargoes and poor economic conditions restricted and continue to restrict the import of academic journals, pharmaceuticals and technologies. Economic shortages continue to prevent all but the most well-to-do and dedicated physicians from seeking specialty training abroad or even attending international conferences. The international presence and connections which characterized Pahlavi University have thus virtually disappeared from the University of Shiraz. Consistent with the goal of the Islamic revolution to make the country self-sufficient, medical school admissions were increased significantly. While Pahlavi University accepted 60 medical students for the academic year just prior to the Revolution, in 1998 the University of Shiraz accepted around 200 new students for the incoming class. In addition, since the Revolution new and subsidiary medical campuses have mushroomed, in effect tripling the number of medical schools operating in the country. The faculty at the larger medical schools, such as that of the University of Shiraz,

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were called upon to assume teaching responsibilities and clinical supervision at the smaller, newer campuses as well, which are at considerable distance from their home universities. Also consistent with the ideals of the Iranian Islamic society, criteria for faculty appointments at universities and admissions have expanded beyond academic merit alone. Political orientation and service in the military during the Iran-Iraq War affect admission and promotion through the university ranks. Iranians told me they feel that these changes had serious detrimental effects on the caliber of medical education and the quality of medical professionals in Iran. They claimed that professors may receive appointments based on political orientation more than on competence in their field and that in any case the most outstanding professors had left the country. They complained that with increased medical school admissions, students were accepted who did not have the intellectual prerequisites or even capacity to learn medicine; that there were not enough professors, so students did not have the benefit of one-to-one instruction as had been the case in the past; that there were not enough patients in the teaching hospitals, so residents and students had to compete with one another for the chance to practice physical exams and procedures; that medical school facilities and campus housing were substandard; that at the newer medical campuses, instruction in the basic sciences and clinical supervision were paltry. Although there was no longer a shortage of Iranian physicians to provide services in rural areas, they said, the quality of these physicians is not what it used to, or should, be. Iranians said that graduates of the Pahlavi University Medical School had no difficulty passing the American medical licensing board examinations, and that their performance in post-graduate training programs in America was at least on a par with that of American-trained physicians. Many people I spoke to could rattle off a list of names of graduates of Pahlavi University who had achieved positions of great distinction in the United States medical establishment: professors at Harvard, chiefs of hospitals in Los Angeles, writers of medical textbooks, and so forth. In popular accounts of the university’s history, Pahlavi University had an internationally known and respected name. One professor even asserted that the admission committee for post-graduate training at Harvard needed only to see the logo of Pahlavi University on letters of introduction to make the decision to accept an applicant. Interestingly, at the same time as Iranians lamented the decreased quality of the medical education available at the University of Shiraz, they asserted that its graduates were still equal to if not better than American-trained physicians. They cited cases of recent

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graduates who scored in the 90 percentile or better on the American medical licensing examinations, or who completed post-graduate training programs in the United States with honors to become chief resident, or who were offered a job in the US as soon as they were done with their training “because there is no one who can do the job as well.” A surgeon who received both his medical and post-graduate education at the University of Shiraz and who had recently seen a few months of sub-specialty practice in Canada assured me in halting English that while Canadian hospitals were better equipped technologically, he was a better surgeon than any Canadian ones he had observed. Whether these claims are founded or not is not for me to judge. The point is that this is how Iranians–in particular, the students, graduates and professors of Shiraz University–see themselves and their medical heritage. It was because of the strong historical influence of American medicine and the University of Shiraz and because Iranians themselves put so much stock in comparing their allopathic medical system to that of the United States that I felt it would make an interesting case study of allopathic practice in a nonWestern setting. It offered a context in which “all else is as equal as it can be”: students learn medicine from the same textbooks and follow a curriculum standard of United States medical schools; the allopathic medical system in Iran generally adopts United States standards of practice; historically the University was, from its economic to its academic structures, Americanized; and even today, twenty years after its ties to the United States have been virtually severed, students, graduates and professors of the University of Shiraz identify strongly with their United States counterparts. In such a context the question of how a native practitioner of allopathic medicine thinks about health and disease or, more broadly, of how culture influences allopathic practice, begged to be asked. A University Versus a Private Practice Setting One problem with choosing to do this research at a university is that allopathic practice in university clinics and hospitals is different in many important respects from that in private venues. Deriving generalizations about practice from observations in the university setting is therefore problematic. To begin with, university clinics and hospitals are referral centers for rare or difficult medical cases. The University of Shiraz serves in this capacity the entire southern portion of Iran, covering a population of about 15 million people. The concentration of unusual and difficult cases at the university is thus much higher than is seen in private practice. While this guarantees a thorough medical education, it distorts the reality of practice

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outside the university, which is concerned primarily with common afflictions–heart disease, high blood pressure, diabetes, aching limbs and back, runny noses and so forth. Another factor distinguishing the university from private practice is that professor-clinicians need not be concerned with finding clients. Professors at Pahlavi University were forbidden to open private practice so that all their time and energies would be devoted to teaching. They were recompensed for the income they would have gotten in private practice with a generous salary and the honor of being a “professor.” With worsening economic conditions since the war with Iraq, professors’ salaries no longer held pace with expectations and the professors successfully lobbied to be allowed to spend part of their time in private practice. Being affiliated with the university added to physicians’ credentials in the eyes of private patients, so professor-physicians do not face a shortage of patients. This is not the case for physicians in private practice. By 1998, generalists have had to go deeper and deeper into rural areas to find patients, and even so run the risk of sitting in their offices “counting flies,” as they say. Specialists as well are no longer guaranteed jobs and practices in the cities and need to work very hard to establish a reputation and patient base in towns and villages. The difficulty of establishing a practice is a real concern to graduates of medical school, who blame the excessive number of physicians in Iran for the inequitable distribution of patients. In clinics and hospitals associated with the medical school, primary responsibility for the care of patients is carried by students and residents. Decisions pertaining to patient care are made by them in conjunction with attending physicians, and they execute all the day-to-day work: physical exams, patient histories and progress notes, minor and major surgical procedures. In private hospitals, where patients pay to be treated by completely-trained physicians and specialists, this is of course not the case. Ironically, while universities are recognized as referral centers, patients expect to receive better care in private clinics and hospitals, which are administered with a concern for the patients’, i.e., the customers’, comfort in mind. With respect to these differences, a university setting was most suitable for the kind of study I proposed because this is the locus of transmission of ideals and standards of practice. In other words, I assumed that physicians model practice after what they learned during training at the university. What students learn at universities includes knowledge gleaned from textbooks, transmitted to them didactically in the form of lectures or anecdotally as professors recount their own experiences, as well as from

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observation of behaviors and attitudes of professors and students at higher levels of training. The content of the knowledge received in these manners includes medical facts–how to make diagnoses and treat diseases–as well as common-sense facts related to practical and ethical aspects of practice. How to structure practice to one’s economic advantage, whom to tell diagnoses, how and why to withhold the names of drugs from patients, what kind of diet to recommend to diabetic patients or to those with heart disease, the biochemical basis of the humoral system, how to address patients and how much to tell them about their diseases based on perceptions of their educational and economic backgrounds, what kind of information can be gotten out of textbooks and journals and of what use this is–these are all among the “knowledge” students are taught indirectly at the university. In this setting, the information one needs to have to practice medicine successfully is “in the air,” so to speak–it is verbalized, modeled, talked about, made an issue of, and therefore, from an anthropological viewpoint, much more easily studied than in independent practice. It is one thing to hear from a physician in private practice “in medical school we were told that . . .” and quite another to observe, in context, how knowledge forming the basis of practice is taught and learned. By observing practice in the context in which its guidelines were transmitted to trainees, I could get a feel for what was general to practice in Iran. By observing individual practitioners in their university or private clinics against the backdrop of university practice, I was able to tell what was idiosyncratic to them. In addition to observations made in training clinics and the clinics of professors, I observed and intensively interviewed four physicians who had just finished training and were engaged in fulfilling their medical obligations in rural clinics. Knowledge of the structure of their training and of the kinds of information they received in medical school allowed me to see more clearly the influences on and understand the rationales for their practice. My Familiarity with the Region I had been to Iran often since 1968, accompanying my parents to their research site, a village known in the anthropological literature by a pseudonym, Deh Koh. Shiraz is one of the nearest large towns, to which my parents sought recourse for medical help when the need arose. Since the 1960s, my parents have remained in contact with numerous friends and acquaintances in Shiraz, many of whom were very helpful in introducing me to the allopathic establishments and to family members or friends who were physicians. While I could probably have done this research without the

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help of this network of friends, their knowledge and help simplified the initial stages of research immensely. Also, it was comforting to know that Deh Koh, in a way my childhood home, was just a few hours away. The History of Medicine and Medical Research in Iran When I introduced to Iranians the topic of my study, they assured me they were honored to have the chance to demonstrate that medical practice in Iran was based on the same stringent standards as that in America. However, while proudly recounting the strong ties the University of Shiraz had with the system of medical education in the United States, they strongly asserted that allopathic medicine in Iran is not derived from the West but is actually of Iranian origin. “You are wrong,” a secret service agent told me flatly during one seemingly interminable interview when I asserted that allopathic medicine was a Western import. “Western medicine is based in Iran. The best physician ever was Ibn Sina [Avicenna]. He formulated the principles on which all medicine is based.” From here he launched into a lecture on the great medical school of Jundhi Shapur of the fifth century which attracted scholars from around the world and produced physicians for the Arab court, on Razes and al-Majusi, physicians of the ninth and tenth centuries whose original contributions to anatomy, surgery and pharmacy are of validity even today, on Avicenna’s Canon, which was the standard textbook of medicine in Europe through the Middle Ages, and on how the triad of teaching, research and practice which underlies allopathic medicine came into existence on Iranian soil. This lengthy and detailed exposition of Iran’s contribution to medicine, which in part or in toto was recounted for me by many other Iranians as well, professional and lay alike, can be found in any standard textbook on the history of medicine (e.g., Ackerknecht, 1982; Elgood, 1934; Porter, 1997). Whether the conclusion Iranians draw from this history–that Iranians contributions amount to allopathic medicine’s origin–is well-founded I leave for others to decide. In any case the advent of what is identifiably allopathic medicine in Iran dates to the 19 century, when military and diplomatic missions invited to Iran to help bring military technologies up to contemporary Western standards included allopathic doctors. European physicians were appointed to the royal court beginning in the early 19 century, and the Polytechnic University in Tehran, founded in 1851 by the Qajar Shah Nasr ul-Din’s reform-minded vizier, Mirza Taqi Khan Amir Kabir, included a school of medicine whose professors were European. Amir Kabir also established the first hospital in Iran, issued a decree for the compulsory inoculation of children against smallpox, and assigned th

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European doctors to serve in the provinces. These pushed for sanitary councils, quarantine measures during epidemics and for the reformation of local medicine, i.e., the purging of its Islamic and Galenic influences. The presence of physicians at the courts of the Qajar Shahs may not have been entirely altruistic, as their access to the court and the harem was consciously exploited by their home governments for “diplomatic” services (Mahdavi, 1997), nevertheless, their success at alleviating suffering from cataracts, gout and epidemics of smallpox or cholera to venereal disease endeared them and allopathic medicine to the Shah, his court and the populace. As in the United States in the 19 century, there was no effectual regulation of physicians in Iran at this time. A few European or Europeantrained physicians practiced alongside Galenic physicians and a vast number of so-called “quacks,” persons offering remedies for illness that were founded on anecdotal evidence or on fraudulent claims. The Iranian Medical Licensing Act was passed in 1910 in an effort to control the quality of physicians and the standards of practice. It was not until after the Second World War, however, that sufficient funds became available in Iran to allow a serious attempt to be made to meet the health needs of the population. By the time of the Islamic Revolution, this included founding of 13 medical schools throughout the country, establishing scholarships for graduates to seek specialty training abroad, opening rural health clinics and staffing them with physicians who earned generous salaries for their service there, training para-professionals to run well-mother and baby clinics and administer vaccinations, as well as establishing a large public health department. These efforts were subsumed under the “White Revolution,” a concerted effort made by the Pahlavi rulers to improve the educational and health status of the country. It deserves mention that the year the Medical Licensing Act was passed in Iran, 1910, was the year before Abraham Flexner produced his report on the dismal state of medical education in the United States. This report led, among other things, to revisions of medical school curricula and the enforcement of American medical licensing laws. Advances in scientific knowledge bearing directly on health and disease were made almost exclusively in Europe in the late nineteenth century and met with great resistance when brought across the Atlantic (Duffy, 1979). For example, twenty-five years after Louis Pasteur had elegantly demonstrated the falseness of the hypothesis of spontaneous generation, a medical student in New Orleans, with the approval of his professors, wrote a thesis suggesting spontaneous generation of yellow fever. It can be argued that science-based allopathic medicine is as much an import to the United States as it was to th

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Iran, and its advent in Iran did not lag much behind that in the United States. In addition, as in the United States, allopathic knowledge was sought and generated by popular demand. Nasr al-Din established the University of Tehran because he recognized the need to keep up with the developments in science and engineering in the rest of the world. The university attracted bright young students from all over Iran, who went on for post-graduate training abroad. The fact that the system of allopathic medicine and advances in allopathic knowledge were brought to Iran practically as soon as they originated speaks to the great regard Iranians have and historically always have had for knowledge and practical technologies. The major difference between the American and Iranian histories of allopathic medicine is that while in the 20 century a strong economic and intellectual infrastructure allowed the United States to take over the reins of allopathic research, this infra-structure was never effectively established in Iran. Despite the sincere commitment of Iranian physician-scholars to the triad of teaching, research and clinical experience that their compatriot had established nine centuries previously, Iranian energies and resources were channeled to bringing knowledge to Iran from elsewhere. While students and residents are required to write a thesis based on original research before being granted their medical or specialty license (a requirement not made of medical students in the United States), academics and students alike told me that scientific contributions that would be of interest at least to Iranian physicians are only supported by a few professors who value intellectual challenges over economic gain. In fact, it was easy to observe how research responsibilities could be shirked. This is not to say that original contributions are not made by Iranian physician-scholars. Many are actively involved in research and publish in leading international journals. Numerous Farsi-language medical journals are published by the Ministry of Health and other organizations, containing both original articles and translations of articles in English-language medical journals. But medical professionals at all levels of training and of specialization claimed a scarcity of research opportunities, facilities, funds, sponsorship, and of post-graduate and sub-specialty training opportunities. Almost as a prerequisite for my research, Iranians expected from me assurances that their comparison of Iranian allopathic expertise, teaching and research to American standards was fair and accurate, and whether Iranian medicine was “good” or “bad.” In fact, when I was preparing to leave the country in 1999 I was asked to turn in a “thesis” on this topic as a condition for being allowed to leave the country. My remonstrances that

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anthropologists avoid evaluative pronouncements were not convincing to them. I was told that as a representative of the West with medical training, I had the obligation to give constructive advice on medical education and practice in Iran. In the end I obliged them with an applied anthropological report (Loeffler, 1999). Taking Leave While doing this research, some Iranian common-sense notions became part of mine. The traditional conceptualization of the “temperament” of the body and “hot” and “cold” foods affecting it, upon which all my hostesses in Iran offered or withheld food, still influences the food choices I make today; a blue bead against the Evil Eye hangs above my door, not just for decoration; and certain phrases or expressions surface in my mind in certain contexts, even if I refrain from uttering them (mashallah when praising a child’s beauty or intelligence, for example). At the same time, almost daily I encountered practice which required an effort to maintain a stance of cultural relativity. In these cases I found myself juggling two ethical principles: that which I accepted as correct based on my own training, background and beliefs, and that which I was beginning to understand on a logical and rational rather than intuitive level. The most distressing conflict came for me early in 1999 when I turned my back on a motor vehicle accident that occurred not fifteen yards away from me in a business district near the university. In the intersection I had just crossed, two cars, each carrying numerous passengers, had crashed into one another. One looked like a crumpled wad of paper, the other stood on its top. In the instant I stopped to look I saw hoards of men running from their shops to the site of the accident, pushing and jostling each other in attempts to break into the cars and pull the victims out. My American medical student persona welled to the fore, my mind urging me into the fray with full-body concentration: the ABCs of first response, stabilize the cervical spine, “call 911!,” caution, caution and take charge! Instead, I turned and walked away. That afternoon I had intended to visit a sonography clinic. Instead, I went home and for the rest of the day and through the night attempted to come to terms with my breach of the ethical code of medicine. Several days later, when I still had not been able to “intellectualize” my distress, I discussed it with my hostess. This elderly woman had all her life been a staunch advocate of women’s education in Iran. When I finished telling my tale, she said, without the slightest hesitation, “You did the right thing,” and detailed why: 1) I was a woman. A woman has no authority in the streets. It

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would have been a losing battle to attempt to convince the ever-growing crowds of men at the site of the accident not that I was a doctor but that they should do as I say. 2) I was a woman. A woman has no business making a spectacle of herself among the blood and broken bones, the death and disability, of an accident site. 3) I was a woman. My energy was to be spent on private affairs, on my family–and by extension on private patients who stand in line to pay money to see me–and not to be squandered on strangers who more likely than not won’t even give me thanks. And finally, I was a foreigner, and all the above points pertained again, with the addition that I was already “serving” Iran by conducting this study. What more did I need to do for this country in which men are so stupid that just because a street looks empty they tear along it at unsafe speeds with no concern for other cars that might be approaching the intersection? “No, you did the right thing,” she repeated. It was the only time she ever agreed with anything I had done. Whether or not I had turned my back on the accident because I had internalized Iranian schemata pertaining to gender and medicine in the course of my research, as my hostess spoke, I felt her logic had become part of mine: it made sense, it needed no further explanation, it was “obvious.” This realization was disturbing. My research subject had come too close for comfort, and I began to make preparations to leave.

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PART ONE

Iranian Conceptualizations of Health and Disease

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Chapter 3

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Iranian Explanations for Ill Health

Iranians use a variety of terms to describe deviations from the optimal state of health: nārāhat, marīz, bīmār, nākhosh, among others. Though they are all used in slightly different contexts and carry slightly different meanings, they are all also to some extent interchangeable. The explanations by which Iranians make sense of feeling not well or being ill, i.e., attribute a cause to it which in itself suggests a therapeutic option, can be grouped into five broad categories: the constitution, dirt, stress, supernatural forces and allopathic medicine. The following presentation of these explanations is not meant to be exhaustive (see Friedl, 1979a, Good, 1977, or Pliskin, 1987 for more detailed discussions of parts of Iranians modes of thought about health and disease). Rather, I intend to highlight those aspects of the explanatory models which have a direct implication for conceptualizations of health and disease. In the next chapter I will trace themes common to all these explanatory models to “key concepts” informing ideas about health and disease in Iran. The Unani System of Medicine The Unani (Yunani) or Galenic medical system is a circum-Mediterranean phenomenon. As the name implies, it is based on Galenic physiology, which identifies four humors produced by particular organs and circulating in the body. Personality is determined by whichever humor is normally preponderant in a particular person, and diseases are attributed to relative excesses or deficiencies of the humors. The Galenic system is the source of the most popular and the default way of thinking about health and disease in Iran, but only vestiges of the original intricate system remain current. Indeed, in books about “medicine” (teb’, from the Arabic), the system is described in greater detail, but general knowledge about the original system

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is scanty. Some of the four humors can be named by almost everyone (most commonly, blood) but very rarely all of them. Even if their names are remembered, they are no longer obviously associated with a particular organ, nor with personalities. What has taken the place of the importance of the humors per se is their qualities, primarily “hot” and “cold.” Other dichotomies complement this one: khoshk (dry or stiff) and martūb (moist) or narm (soft), qavīh or sangīn (strong, heavy) and sabok (light), but these are of much less importance in describing health and deviations from it. According to the Iranian version of Galenism, everybody’s body has a unique mixture of “hot,” “cold,” “dry,” “moist,” “stiff” and “soft” attributes. This is the body’s natural constitution, mezāj or tab’ (from tab’at, nature). Women’s tab’ tends to be more on the cold and moist side, men’s on the hot and dry side, and as they age all bodies become more cold, dry and stiff. A person is in good health as long as the tab’ ’s optimal, but precarious, position on the continua of these opposites is maintained. Any kind of food, the temperature and the weather, sex, bathing, hard work, fatigue, strong emotions and many other things can upset it. Ill health is consequently attributed to an imbalance of the dichotomous properties of the tab’. “Making cold” (sardī kardan) and “making hot” or “boiling” (garmī kardan or jūsh kardan) are some of the terms used in describing such imbalances. Nausea, fatigue and dizziness are some symptoms of “making cold,” and acne, high blood pressure, sweating, itching and rashes are symptoms of too much heat. In the original Galenic system, balance of the four humors could be achieved by ridding the body of the humor thought to be in excess through blood letting, purging, enemas and cupping or burning. Prior to the advent of allopathic medicine, when the Galenic medical system was the authoritative one in Iran (Elgood, 1934), these practices were still popular, and at least blood letting has survived as a potent therapy in popular thought. “In the olden days,” an elderly woman told me, “the best doctor in town was our neighbor. One day he was feeling ill and didn’t want to go to his office, but his secretary came and told him that patients were ramming down the doors: he had to come. He went, but when he saw the ocean of sick people in his office, his stamina failed him again and he said to them, ‘today . . . enemas for all of you!’ and he turned around and left.” The old woman was delighted at the physician’s cleverness in discharging his duty and sighed, “it is a pity

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doctors have let go of this knowledge, those remedies were so effective!”

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“I can’t wait to go have my laboratory tests done again,” a middleaged man said. “Every time after they take my blood for these tests I feel better, more energetic and healthier. I have the tests done twice a year.” Drastic measures such as blood letting for maintenance or restoration of balance of the humors have for the most part receded into the domain of nostalgia just as the importance of the humors in explanations of disease states has waned. What has taken their place is an elaborate focus on food as the primary means by which the condition of the tab’ can be adjusted. The other factors affecting the tab’–the weather, worries, work, for example–cannot easily be avoided or altered, but what one eats can be closely controlled. Knowledge about foodstuffs, their qualities and properties and their effects on the tab’ is consequently highly elaborated and detailed. The most important property of a particular food item considered in this context is whether it causes the tab’ to shift more to a “hot” or “cold” state, and it is classified as “hot” or “cold” accordingly. Particular foods are consistent in changing the temperature or energy (harārat) of the tab’, but just as every person’s constitution is different, so everyone will respond to foods slightly differently. The symptoms of “making cold” or “making hot” can be redressed by ingesting something of opposite value. For example, sugar crystals, inherently “hot,” dissolved in water can be ingested if feeling nauseated; high blood pressure can be lowered by drinking the juice of inherently “cold” unripe grapes. The properties “moist,” “dry,” “soft” and “stiff” are rarely invoked or considered in the classification of foods, but the relative “strength” or “weight” of the food in relation to the “strength” of the tab’ is. This appears to be judged by the ease with which the food is assimilated into the body, or digested. “Strong” or “heavy” (qavīh, sangīn) foods strengthen the system, but overly strong ones weaken it. “Mm, this soup is delicious,” I said of a hearty stew offered me as part of a ritual acknowledgment of the fulfillment of a vow, “I can imagine you give this to sick people to strengthen them, don’t you?” “Oh, no,” the women sitting around me answered, horrified. “It is much too strong for a person in a weak condition!”

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In addition to affecting the humoral properties of the tab’, foodstuffs are thought to affect the body’s function in idiosyncratic ways. The popular shops of attārī, herbal pharmacists, are filled with dried flowers and leaves, seeds, essences, extracts and faunal products which are used for everything from reversing baldness to improving sleep, from regulating menstrual cycles to treating headaches or a cold. Analysis of this herbal pharmacopeia would uncover its roots in a Galenic physiology: liver “builds blood,” pomegranate juice “strains” the blood of impurities, tea drives up one’s “pressure” (feshār), any product of a bitter-orange tree drives away “melancholy,” and so forth The effectiveness of foods qua “herbal medicines” is attributed popularly partially to their “hot” and “cold” properties, but more particularly, to their “vitamin and mineral” content. Vitamins and minerals are a handy explanation clearly adopted from allopathic science for why certain foods, especially fruits and vegetables, are beneficial. A Tehran newspaper daily described a food item’s intrinsic healthpromoting qualities. This is its entry on okra: “Okra is one of the strengthening and energy-producing vegetables. Okra contains water, protein, sugar, calcium, iron, fat and vitamins PP, A, B1 and B2. In addition to its usage as a food, when cooked in water, it has healing properties, namely: general fortification. Okra cooked in water does away with general weakness and in all cases in which the body has a need for vitamins A and B, it is suitably fortifying. Okra, because it contains iron and other mineral salts, is beneficial and effective in the treatment of anemia and disorders of the liver, digestion, and skin. “Iranians are healthier than people in the West,” I heard often, “because we Iranians eat so many fresh foods, especially greens [traditionally valued for their health-promoting properties]. These are full of vitamins and minerals. People in America don’t do this, which is why they are all fat and unhealthy.” A young man stopped at a fruit juice shop [as popular on the streets of Iranian cities as coffee shops in the US] every day on his way home from school to drink a glass of fresh carrot juice. “For the Vitamin A,” he said. “Because I study a lot, and Vitamin A is good for the eyes.”

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Food is not the only thing which can cause the tab’ to change, but it is the first line of recourse to return the tab’ to its optimal state. Hard work, for example, causes the tab’ to become “cold.” Under no circumstances should a “cold” food be eaten if one is fatigued. Milk, a “hot” food, should be avoided in the summertime, when the ambient temperature already drives the body’s harārat up. Sexual intercourse rids the body of too much “heat,” thus adolescent men’s acne is said to dissipate once they begin to have sex, but men who engage in it too much lose so much harārat they become fatigued, i.e., “make cold.”

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“Menstrual cramps are a cold condition,” a midwife in a public health clinic said. “When I feel my period coming, right away I dissolve crystal sugar in boiling water and drink it. Then I take a nap. When I wake up my cramps are gone.” Knowledge about the properties of foodstuffs is popular in the sense that everyone knows some of it: it is not proprietary or exclusionary. Those with a special interest in it may study it more intensively by apprenticeship to an attārī or by reading readily available books on the subject (e.g., Askari, 1993; Jazairi, 1997, 1998; Khosrowi, 1994; Sorur al-Din, 1998) or, in the case of those for whom these options are not a possibility, by experience and hear-say. Even for those with no special interest in it, talk about foodstuffs is ubiquitous: people in any setting, at weddings, at work, at informal visits, may converse on how a child’s dandruff, an aunt’s hemorrhoids, a father’s high blood pressure, a baby’s rash had been successfully cured by judicious use of a particular food item. Moreover, magazines and newspapers run columns discussing the properties of various food stuffs. Though knowledge about the inherent properties of foodstuffs may be written down on paper, none of it is written in stone. Just like a person’s tab’ responds uniquely to the “hot” and “cold” properties of food, so will it respond uniquely to the other properties inherent in foods. Lemon juice may be a good anti-hypertensive for one person while barberry juice is for another; tea usually has no effect on feshār (pressure) but causes that of a particular old woman to go through the roof; a middle-aged woman stays away from sunflower seeds because they cause her skin to become oily, while her husband can eat them by the handful with no such effect. It behooves one, then, to pay close attention to the effects foods, including pharmaceutical medications, have on one’s tab’ and to act accordingly. To remain in good health therefore requires both meticulous attention to one’s

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own tab’ and its responses to the environment and manipulation of the environment so as to keep the tab’ in its optimal state. “Many years ago, the doctor told me I had hemorrhoids,” an old woman said. “He said I needed to come to the hospital for an operation, but what could I do? It was wartime and my husband was sick at home. I could not afford to have the operation. I knew what to do. I knew myself, and I cured myself by eating eggplant.” “I stopped taking the thyroid hormone because I was feeling fine,” a university student said. “I had been taking it for six months and there was nothing wrong with me, I didn’t need to take the pills anymore.”

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In summary, the tab’ represents a theory of health and illness-causation which identifies symptoms as indicative of an imbalance of dichotomous forces in the body and suggests a means of rectifying that imbalance, primarily by means of diet. It provides the first hypothesis as to what may have skewed a body’s balance such that ill health occurred and the first line of recourse to remedy it. Dirt Dirt is not of itself an elaborate theory like the conceptualization of the tab’. Instead, it is identified as a powerful etiologic agent of disease, and great efforts are expended to minimize contact with it. In other words, healthrelated schemata pertaining to dirt encompass guidelines by which dirt can be avoided. Dirt is part of a much larger framework or theory which values goodness, beauty, purity, humility, modesty and balance in all personal characteristics and behaviors as well as in interpersonal relations. This framework will be discussed in greater detail in the following chapter, but because dirt is such a powerful etiologic agent of disease in Iranian popular medical thought, I will present some summary characteristics of how Iranians think about it separately here. Dirt (khāk, cherk, kesāfat) is commonly and frequently identified by Iranians as a cause of disease, and being “clean” (pāk) as an ideal state of physical and moral purity. Dirt is seen as a ubiquitous threat: it comes from the outside in the form of microscopic organisms, it is produced on the inside through normal physiologic processes, and it comes from moral weakness. To reduce the risk of becoming ill from encounters with dirt, one

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must therefore exercise constant vigilance over one’s contact with the environment and over one’s bodily functions and behavior, Iranians say. Mīkrūb, microscopic organisms in general, are for Iranians a characteristic of dirt and an obvious cause of disease. They were for the Prophet Mohammad as well, I was often told. He enjoined his Faithful to wash their tea glasses in such a way that water would not adhere to the sides but would run off in a, clear stream. Water adheres to glass that is dirty, “as we now know, covered with mīkrūb,” a retired schoolteacher said. Thorough washing of dishes prevents the ingestion of mīkrūb, and this was Mohammad’s intention when he issued his injunction, Iranians say. To keep oneself and one’s environment clean in the sense of free from dirt encroaching from the outside thus can be seen as a direct order from God. The insight that God’s intention in issuing this command through Mohammad was to prevent people from getting sick by contact with mīkrūb was conveniently offered by Western science. The two together, divine command bolstered by “proof” from the West, provide a powerful justification for Iranians’ almost obsessive attention to cleanliness. Putting one’s purse on the floor (which one might subsequently, inadvertently, put on a table), not changing one’s shoes when going to the bathroom, kissing one’s children or sharing eating utensils with them, flies, just going out on the street, all potentially can cause contamination by mīkrūb . “Ants are God’s favorite animal,” a devout, middle-aged man told me. “This was a puzzle for a long time: why would he love ants? But now we know why. They have shown scientifically that ants’ legs are covered with antibiotics, everywhere they walk, they kill mīkrūb!” “When I went grocery shopping once the shopkeeper blew into the plastic grocery bag to open it up,” an elderly widow told me. “I said to him, ‘You’re not going to put my groceries in there are you?” He was astonished and then saw that it was because he had blown into the bag. “With all respect, that bag is now full of mīkrūb,” I said. “It is not you I’m objecting to, it is the mīkrūb!” I said. Right away he apologized and thanked me for having pointed out his negligence: he didn’t want anyone to get sick, after all.” “Quit rubbing your hands on the table!” an old lady instructed her senile sister. “Don’t you know its covered with mīkrūb!” She instructed her servant to wipe down the already spotless table and

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HEALTH AND MEDICAL PRACTICE IN IRAN bring a hot washcloth to wash her sister’s hands before serving dinner.

Mīkrūb are just a detail of dirt in general. Dirt is bad because it carries mīkrūb, but even if these are not invoked, it is reprehensible, ugly (zesht). It is an obvious violation of God’s order. It is a sign of backwardness, of being uneducated, base, illiterate, uncouth, unprincipled, ignorant. It is to be avoided at all cost.

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A professor emeritus of public health said, “I used to teach medical students about behavior becoming to physicians when they go serve their obligatory duty in the villages. The most important thing I taught them was that no matter how tired they were or what they had done that day, at night before going to bed they should wash their socks. Having dirty, smelly socks is the worst thing: it undermines their status. A doctor is better than the people and should show this in his behavior and bearing and appearance.” The most important means of preventing contamination by dirt is washing anything that potentially will go into the mouth. The real reason God instructed his Faithful to perform ablutions before prayer, some people maintain, is that they will keep their hands, feet and faces clean and thereby protect their health. Water is a “gift of God,” it is the “liquid from heaven,” it is life (hayāt). Running water is cleansing and, by the instruction of Mohammad, clean. On a hike, a medical student encouraged his companions to drink from an irrigation channel. “It is running water, so it is safe to drink it,” he assured them. “The pollution will go away when the rains come,” is an oft-heard sentiment in Tehran. Or, “The snowfall made the air clean again.” “That is because the rain washes away all the dirt;” “The drainage canals fill up with running water and wash away all the mīkrūb”; “Don't you see all the dirt in the canals after the rain has come?” Dirt is ubiquitous in the environment, and it is produced on the inside through bodily processes and must be discharged periodically for health to be maintained. Without cleansing flow, impurities are thought to accumulate within the body. Defecation, urination, menstruation, discharge

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of mucous from the nose, sweating, crying and ejaculation are all means by which the body rids itself of impurities. Obstruction of these processes by constipation, abstinence from sex, or the cessation of monthly menses, for example, is a disease state in itself. Consequently, facilitation of the flow, by enemas, for example, or crying, is beneficial to one’s health. A saying goes, “flowing intestines are better than a kind mother” [shekem-e ravān bekhtar az mādar-e mehrabān], i.e., there is nothing better than open bowels or a regular stool.

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“I love to cry,” a middle-aged taxi driver said as we passed by a mosque filling up with mourners on the anniversary of the death of one of the descendants of the prophet. “It makes a person feel light; it is cleansing.” Certain foods can help cleanse the body of impurities. Pomegranate juice, for example, “filters the blood.” Fasting also is cleansing. The reasons given why God ordered people to fast for one month every year are multifarious, but heading the list is that fasting purges the body of impurities that have collected over the year. Western science has again provided the justification for this command: doctors and lay people alike told me that it has been “proven” that excess fat (cholesterol) and sugar are among the impurities excreted through fasting. Like His injunctions to wash one’s tea glasses well, to perform ablutions before prayer, and to abstain from worship in an unclean state, ritual fasting is also taken as an indication that in ordering people to supplicate Him He was actually looking out for their own welfare. Conversely, being unclean or standing in the way of cleanliness is a moral transgression: “I took a bath today for the first time in 14 days,” a very devout, frail, old servant told me, “it was high time: there was a lot of dirt!” Implicit in this statement was a criticism of her employers, who did not make necessary repairs to water pipes so there was not enough warm water in the house to make bathing less of an ordeal. Her inability to fulfill the religious injunction to keep clean was their fault. The concepts “clean” (pāk) and “ugly” (zesht) equate bodily cleanliness with spiritual purity. Pork is “unclean” because it carries parasites, causes

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defilation of the spirit and is a sign of alignment with the devil. Women who are menstruating not only dirty their clothes but are prohibited from worship. Defecation and sweating cleanse the body of tangible impurities; fasting cleanses both the body and the spirit; crying cleanses the spirit (rūh). Being in good health thus means being clean in body and in soul. Stress, Emotion and Reason In Iranian thought, a healthy mind is essential to being well. Worry, anxiety, unhappiness are all nārāhatī, literally “dis-ease,” “dis-comfort” or “distress.” Annoyance, aggravation, frustration are said to cause one’s nerves to become frayed (asāb-e khūrd), a common expression of ill-being. Strong emotions in general are said to be dangerous. For example, love causes people to go wild, to go off into the wilderness in a dazed state and subsist off roots out of craziness, to marry beneath their status and come to grief because of it, to give up all they have including their own kin, to irrationally attempt to move mountains. Grief is another emotion that can send one over the edge of sanity, Iranians say. If feelings other than a moderate kind of happiness are allowed to linger, if nothing is done to dispel them, feshār, pressure or stress, is said to build up and cause illness. Blood pressure (also feshār, though sometimes modified to feshār khūn, the pressure of the blood) is taken as a direct measure of stress. A retired schoolteacher whose household was in turmoil over several domestic and economic issues attributed his elevated blood pressure to his nerves, saying that they had become frayed because no one did as he knew best. The other family members preferred to attribute his hypertension to his own obstinacy in refusing to see things their way. A middle-aged woman said of her mother, “She was absolutely healthy, there was nothing wrong with her at all, until she went to the United States the last time and my youngest sister, who stayed behind in Iran, fell ill. Then the worry caused her to develop high blood pressure.” Stressors cannot be avoided. Children are pressured to do well in school. Youths are pressured to get into the university, to find a job, and to marry. Everyone makes cheshm be ham cheshm, that is, competes with one another for markers of status, including money, beauty, and sex.

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A university student was listening to a roommate extol the virtues of her sister’s suitor, including that he had a black belt in karate. “Oh come on,” she retorted. “Nowadays everybody’s suitor has a black belt in karate. What’s so special about it? I tell you what, though, I’m going to have a suitor whose black belt is blacker than anybody else’s!”

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A general practitioner reported that she had seen a university student that day in her office who was worried that something was wrong with him because he was physically incapable of having sex more than sixty times a week. His friends bragged to him of their own sexual prowess and he felt deficient because he could not keep up with them. Marriage is thought to be one of the greatest stressors, and a no-win situation. A husband must face the stress of having to provide for a wife and children who, so Iranians say, are never content with what they have in this time of severe economic shortage. A wife must face the stress of having to argue with her husband and children to provide more money, to study, to clean up after themselves, to keep themselves neat. Parents must worry about bringing their children safely to adulthood, healthy, educated and with their morals intact. Yet especially for a woman, not having a spouse or children is a pitiable state, both abnormal and predisposing to other abnormalities. A woman called in to a medical-advice radio show complaining of a rash all over her body which itched terribly except when she was in a social setting. When the physician found out she was single, he quickly diagnosed the rash as a somatization of loneliness and advised her to get married. A nurse in a public health clinic told about a suitor who had come for her sixteen-year old daughter. Her husband didn’t want to let his daughter get married yet because she was too young, but the nurse herself said, “She has to marry anyway.” Stress can manifest itself as symptoms other than elevated blood pressure. For backache, fatigue, depression, heart disease, musculoskeletal pains, weight gain or loss, stress heads the differential diagnosis. Moreover, the name with which allopathic physicians describe what is wrong, such as

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obesity, allergic dermatitis, osteomalacia patellae, slipped vertebral disc, coronary artery disease, stroke, diabetes, obsessive compulsive disorder, hypertension, etc., does not provide a readily understandable etiology for the feeling of “distress.” “Stress” does. A medical student in his last year of training said that the depression and anxiety disorder he was diagnosed with in his third year of medical school were due to the stress of living in the city. The “big environment” of the city had exerted so much pressure on him that his health broke down.

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An old man had spells of crippling chest pain and shortness of breath due to severe coronary artery disease which had been refractory to allopathic treatment. He attributed the pains and discomfort to the excessive economic and social demands his young wife put on him. By identifying stressors as the ultimate “cause” of disease, the remedy logically follows: to get rid of the stressor. The drugs given by allopaths, in this context, provide only symptomatic treatment. If depressed because the urban environment doesn’t agree with you, you should move back to your village. If hypertension is due to marital strife, it should be resolved. The diagnosis of “stress” thus assigns responsibility for illness and its cure to the patient him- or herself. True, stress cannot be avoided, Iranians acknowledge, but one should deal with it in ways that won’t make one sick. To become obsessive over certain thoughts, to worry, to let things get at you or nag you, to take injustices to heart, will make your nerves become frayed and cause you to become sick. In fact, dealing with stress, learning to cope with it or avoiding it altogether, is considered to be a more satisfactory and desirable treatment than the pharmaceutical remedies allopathic doctors recommend. A woman told me that she had suffered for many years from back pain, which was only minimally alleviated by pharmaceutical pain medications. At the same time, her marriage was deteriorating. A distant relative in whom she confided advised her to have her severely decayed teeth pulled and replaced with dentures. She did as advised. Her husband consequently took increasing interest in her, and her back pain resolved. Notice that the teeth were not pulled because of repeated bouts of infection and abscess but

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because of the “stress” they caused her marriage, which in turn caused the chronic backache. One way in which people try to get rid of worries and potentially upsetting thoughts is to trivialize them by, for example, saying “it doesn’t matter. What should I do, make my nerves frayed over this?”

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A middle-aged housewife complained bitterly over her husband’s refusal to let her pursue activities that would give her pleasure. She hadn’t been on a trip since she had gotten married fifteen years ago. He wouldn’t let her work though she held both beautician’s and caterer’s licenses. He wouldn’t invest any money to refurbish their decaying house. He reprimanded her for dancing at parties. He wouldn’t let her have more than their one child. He wouldn’t even install a heater in the bedroom. By the end of her long saga, tears were flowing down her cheeks. Suddenly she wiped them away, smiled broadly, said, “What do I want with any of those things anyway, it doesn’t matter!” and went to repair her make-up. In illustration of how one should deal with the world, an elderly woman said, “The world for a grain of barley, the barley for my vagina! [dūnyā be jou-ī, jou be kussom!].” She laughed riotously and explained: “After having sex with her husband a woman went to the public bath for her ritual ablution. As she sat there she realized she had forgotten to bring money with her to pay the attendant. So she splashed water between her legs and sang dūnyā be jou-ī, jou be kussom! What she meant was, nothing is important. The entire world is only worth a grain of barley, and if I had that it could go up my vagina for all I care.” Another way to get rid of worries is to lay the blame on someone else. This is especially true if the issue is too serious to dismiss lightly, such as the death of a son, a daughter’s choice of marriage partner, an intolerable work situation or a bad marital relationship. The old man’s heart pains would go away “if only” his wife would stop nagging him to sell his properties. The school-teacher’s high blood pressure would go away “if only” his children would plan their lives according to his wishes. An old lady mourning the death of her brother blamed her grief on her relatives’ jealousy. And the university student blamed the “big environment” of the city for his mental illness. While it is necessary to attempt to exercise control over one’s

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reaction to stressful things, inability to do so is not necessarily a sign of weakness. Rather, it is a sign of the unreasonableness of people in one’s environment. Being overcome by emotions and allowing oneself to express them, on the other hand, is a sign of weakness. Strong emotions can negatively impact various organs of the body, such as the qalb (heart, e.g., qalb-am shekast: my heart broke), jegar (liver-spleen-lung, e.g., jegar-am sūkht, my jegar was burned: I became angry, upset), or jūn (soul or spirit, e.g., jūn nadāram: I have no soul, i.e., I am weak). The organ primarily invoked when talking about emotions is the del, which is sensed to be in the solar plexus (Friedl, 1983; Good, 1977) but has no organic correlate. The del can become constricted, dislodged, overturned, wounded, burned, broken, torn to bits; it can turn cold; it can be filled with dirt (cherk) and blood due to excessive feelings of sorrow, loss, grief, fright, annoyance, helplessness, love, anxiety or nervousness. Both the del and jegar can harbor emotions. An old woman told me about the effort she had put into raising her five children alone after the death of her husband and the set-backs she had experienced at the hands of jealous and devious relatives. “All of these hurts are in a corner of my jegar [hame-ye īn dard-hā to gūshe-ye jegar-am].” A woman recounted how her relatives’ jealousy had killed her brother, and father, and mother, and grandmother, and then said, “In the bottom of my del I have the wish that God will visit upon them all the suffering they caused us!” If emotions are excessive or allowed to linger, they can impair the `aql or reason. Reason should be the basis of all the decisions one makes. People acting out of emotional impulse, out of grief, longing, passion, are “crazy”: they have lost their reason. The `aql should exercise control over emotions: a person without `aql is not fit for life, cannot be counted a reasonable adult. A collected, calm exterior is an indication of a wise, reasonable person. Women are generally considered to be weaker in `aql than are men. They are thought to be more easily swayed by emotions, more easily persuaded to do foolish things, less rational and less resolute. This makes them more prone to distress, to nārāhatī, as evidenced by their purportedly greater propensity to depression and the ease with which they cry.

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If a person is too weak to keep a lid on his/her emotions, it behooves him or her to express them in “reasonable” ways, for example by talking over their problems with someone or by crying (del khālī kardan, jegar rāhat kardan – to empty the del, to put the jegar at ease). Crying cleanses the body and the spirit of emotions like enemas cleanse the bowel, and, as we have seen in the previous discussion on dirt, it is said that God prefers people to be emotionally as well as physically clean. A devout man, in answer to a common sentiment that Shi’a Islam is all about crying, said, “It is the cleanest of the religions because crying cleans the spirit (rūh). God likes for us to cry.” “I have prayed (namāz khondam), I have supplicated Him (da’ā kardam), I have cried. Now God loves me,” an old lady told her infant grandson.

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Feeling well and being well thus depend on an `aql which “extends” (mīrasad) to an understanding of how to control one’s environment or at least how to adapt to it to reduce stress, and which is strong enough to manage the pathological, distressing effect of emotions. Supernatural Forces Friedl (1983) describes occult practices and beliefs from a village in southwest Iran, including love potions, ritual chants and sacrifices to ward off epidemics, and beads that can harm unborn and very young children. In the intervening years, these practices have been more and more relegated to the realm of superstition and discounted by the educated city people who I interviewed. Likewise, Djinn, people-equivalents living in a parallel world who can interfere in this one in usually harmful ways, such as by stealing children or eating the livers of pregnant women (Friedl, 1997), are no longer invoked as legitimate causes of illness. Djinn are mentioned in the Koran, so it is not easy for Iranians to refute their existence entirely, but the belief that they can cause disease is no longer popular. The supernatural causes that are still invoked as etiologic agents, though with reservations, are the Evil Eye, the descendants of the Prophet Mohammad (Imāms, Imāmzādehs and Sayyid), and God. Grouping these all together is problematic, for a “belief in God, with Mohammad as his Prophet,” which is the credo of the Islamic faith, is clearly not comparable to what Iranians themselves call “superstitions,” such as amulets or witchcraft or even, for some people, the Evil Eye. Yet I will discuss them all

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under one topic heading here because do they refer to “supernatural,” intangible but ritually addressable and manipulatable forces. Moreover, “hot” and “cold,” “stress” and “purity,” and allopathic explanations of disease do not address the existential questions being ill raises, while “supernatural” forces do. The Evil Eye is acknowledged as a source of misfortune throughout the circum-Mediterranean world. In Iran, it is called cheshm nazar and cheshm shūr; “cheshm-esh zad (s/he was struck by the Eye)” is said of one who has become a victim of it. The Evil Eye strikes an object of envy or even just of praise. Babies and children who are praised for their beauty are especially vulnerable to the Evil Eye, but in later life anything, any attribute, any activity that garners the praise of others can attract it. In the past, fear of the Evil Eye was great enough that mothers would purposefully leave their children unwashed and covered with flies so as not to attract its attention (Friedl, 1997). Such behavior is now considered backward and uncouth, especially among well-educated city dwellers, and worried mothers content themselves with attaching a small amulet, a blue bead or a verse of the Koran sewn into a little pouch to their children’s cradle or clothes to keep the Evil Eye from striking. A person does not strike others voluntarily with the Evil Eye. Apparently, praise or envy is a vehicle for the Evil Eye, regardless of the person doing the praising or envying. Anyone can therefore cause the Evil Eye to strike, though some do so unfailingly. In the latter instance, having the Evil Eye is an individual attribute or property which can be transmitted in a familial fashion. Even if the Evil Eye is not invoked, envy itself is malignant. People who envy what one has are enemies, even if they are close relatives. To prevent the Evil Eye from striking, expressions of praise should be followed with an invocation of God, such as Mashallah, “May God preserve you from the Evil Eye” or “What wonders God has wrought.” By omitting this expression, one is negligently making the object of one’s praise vulnerable to the Evil Eye. Certain amulets are thought to provide protection against the Evil Eye; other measures, such as burning wild rue, can be undertaken if one suspects the Evil Eye has struck in order to prevent it from doing further damage. That misfortune is caused by the Evil Eye is a diagnosis of hindsight. One cannot predict when it will strike or in what way it will manifest itself until the misfortune has occurred. The misfortune may be death, bereavement, or any kind of illness.

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A university student said about the death of a seven-year old nephew in a hit-and-run automobile accident, “He died because he was so beautiful,” i.e., his beauty attracted the jealousy of others, and therewith the Evil Eye.

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“My neighbor struck me with the Evil Eye,” a physician told me, outraged even years after the occurrence. “I was standing in the kitchen with my servant, quickly, quickly making meat patties. We were turning them out like in a factory. I was forming them and my servant was turning them in the frying pan, quickly, quickly. My neighbor who always was over at my house preventing me from getting my work done with all the prattling she did said, ‘Wow, you are working so quickly! How do you do it?’ The next day my back hurt so badly I could not walk; I could not even get out of bed. My mother had to come and take care of me and my three small children. For over a week I was bed-ridden, with what kind of pains!” A middle-aged widow attributes the loss of her son’s scalp and facial hair at the age of twenty-one to the Evil Eye. Everyone had complimented his full head of thick, wavy hair and nice eyebrows. The hair loss had been sudden, rapid and complete, and after four years of tramping across the country to visit one specialist after another, apparently permanent. “What else could it be? People were jealous . . .” A seven-year old girl who developed a stomach ache asked for wild rue to be burned to counter the effects of the Evil Eye after a shopkeeper had complimented her beauty earlier that day. The Imāms are descendants of the Prophet Mohammad via his son-inlaw, ‘Ali. Iranian Shi’a recognize twelve Imāms as the legitimate historical leaders of their community. In this capacity they were infallible and led their faithful fairly and judiciously in the true path of Islam. The last Imām, it is believed, went into hiding in AD 939, and will reappear on the day of judgment. The tombs of the other eleven Imāms, along with many of their close and distant relatives, are sites of pilgrimage. Of these the most important are the tombs of ‘Ali at Najaf and of Hussein at Karbala, both in Iraq, and the tomb of the eighth Imām, Imam Reza, in Mashhad. In addition to these there are literally thousands of tombs of descendants of

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the Imāms, or Imāmzādeh, scattered throughout Iran. There are almost 100 such tombs, eponymically called Imāmzādeh, in Shiraz alone (Betteridge, 1985). The Imāms and Imāmzādehs are thought to be able to intercede in this world on behalf of supplicants. Pilgrims bring gifts of money or make vows to give alms or host public dinners in return for help from the Imām or Imāmzādeh, be it safely returning a son from the war front, helping a child get through school, curing an obstinate illness such as infertility or procuring a green card for the United States. In terms of health and disease, Imāms and their relatives are not invoked as causative agents so much as curative ones. They can be supplicated for help in the face of any kind of hardship, from barrenness to blindness, from having given birth to too many daughters to poverty, for help on an examination to protection for one’s son in the army. Certain Imāmzādehs have a reputation for being especially helpful for certain conditions, such as ensuring a safe pregnancy (Betteridge, 1985), while others, especially Imam Reza in Mashhad and his brother Shah Cheraq in Shiraz, may be visited with no special request, just because it is beneficial to do so. Trinkets sold at shrines, such as little packets of soil “from the grave” wrapped in green cloth, or a religious picture with the Imāmzādeh’s special invocation printed on the reverse, are blessed and believed to carry protective powers. A general practitioner visited an acquaintance hospitalized for unstable angina. After discussing the woman’s condition with her physician and then visiting with the woman herself for a few minutes, she pulled a green ribbon with the invocation of Shah Cheraq, which she had purchased at his shrine the previous day, out of her purse and instructed the ill woman to put it under her pillow for the Imām’s help in her recovery. While Imāms and Imāmzādehs are generally thought to be paternalistic and charismatic figures who work beneficiently in interceding with God on behalf of their supplicants, it is said that they can punish broken promises: “Imām Hussein killed my husband,” an old, illiterate woman told me. “At his tomb in Karbala, my husband promised him that he would stop smoking opium. He did, too, for a few weeks after we returned from the pilgrimage he didn’t touch it. Then one day his old friends came by and offered him a smoke. ‘Don’t do it,’ I told him, ‘you promised Imām Hussein!’ But he did anyway and forty

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days later he was dead. Imām Hussein killed him for having broken his promise.”

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Seyyids are living descendants of the Prophet Mohammad, some of whom have charismatic powers. As with Imāms and Imāmzādehs, one can make a vow of money through these people in exchange for God’s help or protection. Seyyids do not intercede on one’s behalf with God as Imāmzādehs do. Instead, invocation of their names coupled with a monetary gift carries religious merit. A university professor recounted the following story: “There was a Seyyid who worked at the hospital. He was very poor, but every vow made in his name was fulfilled: it was of great merit to give him money. One day as I was driving to school, I saw a terrible traffic accident right ahead of me. All the people in the cars got out and walked away with not even a scratch on them. When I got to work, I called my husband and told him to give a certain amount of money to the Seyyid in thanks that nothing had happened in the accident. The same day, my oldest daughter found out that she had passed the examination for entrance to a residency program and she called her daddy to tell him to give the Seyyid some money she had vowed in his name in case she passed the test. And my youngest daughter woke up concerned because she had a bad dream in which the mother of a good friend died. When she got to medical school she found out that another friend had the same dream. Immediately she called her father and told him to give some money to the Seyyid to prevent the death they had foreseen. By this time my husband was getting angry. ‘Who is this Seyyid?’ he said, ‘I am a professor of pediatrics and don’t make that kind of money!’” Alms-giving in itself is protective and beneficial. The alms-collection box in the main lobby of Motahari Clinic, the University of Shiraz Physicians’ Clinic, is marked by a sign saying, “Giving alms keeps disaster and misfortune away,” with the double entendre that alms keep misfortune away from the giver and alleviate the misfortune of the needy. An old, illiterate woman told me about surgery she had needed several years previously. “Three times they had to open me up, for forty days I did not eat nor drink. The doctor who stood at my head when they put me under for the surgery had tears on his face. He

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HEALTH AND MEDICAL PRACTICE IN IRAN was sure I would not make it. He said it was a miracle that I recovered and put a coin under my pillow for me to sleep on. The next morning he took the coin and gave it to me and told me to put it in the alms collection box, even though it was only one Toman, because it was now blessed and would bring fortune to whoever received it.”

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A general practitioner listened with consternation to the story a bedraggled patient told her about a harrowing trip into Shiraz from a village four hours away. The driver of the car had driven at unsafe speeds, run over a chicken and narrowly missed hitting a child. The physician told the patient she would not examine her until after she put a contribution in the alms collection box in the lobby in thanks that no one got hurt. Ultimately, all diseases and all cures come from God. “We tell our patients, ‘we give medicines but the cure is from God (darmā az mā, shefā az khodā),’” a neurosurgeon and ophthalmologist husband-and-wife told me. “We do all we can for our patients, but if a brain tumor returns or a patient is in a coma and there is nothing more we can do, still in the back of our minds we have trust in God, that He will cure the patient if that is His will.” “When will I get better?” a concerned patient asked her psychiatrist. “Whenever God wills,” he answered. A general practitioner scolded a patient sternly for being frightened of hearing the results of laboratory tests: “Where is your faith?” She reprimanded the patient at length for not putting her trust in God and let her leave the office only after she had loudly and enthusiastically invoked the name of ‘Ali. “Will I get better?” a woman with prolonged and heavy uterine bleeding asked her gynecologist. “Don’t you believe in God?” the gynecologist answered. God is said to cause disease in two ways. He created the world, human bodies with their strengths and weaknesses, and diseases that run their own course and affect bodies according to the way in which He determined. Epidemics come and go, cancers grow, the Evil Eye strikes, bacteria cause

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infection, pomegranates make the tab’ “cold,” all in accordance with the way He designed the world. But God can also intervene in particular instances. He can send misfortune, death or a serious illness or deformity, either for no reason apparent to the afflicted, or as retribution for sins. The sinner may not be punished directly, but the punishment delivered on his or her descendants. A university student, whose family was embroiled in vicious arguments over the upcoming marriage of one of her sisters, sat weeping in her room. “I can’t help but be worried about what the effect all this fighting will have on my sister’s children. I keep seeing her sitting with a blind child on her lap.”

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Fear of such retribution may be a deterrent for sinning, and a belief that divine justice will be meted out even in this world may be a psychological defense to worldly injustice, but I personally did not hear of a single case of misfortune or disease, once it had occurred, attributed to the sins of the unfortunate’s ancestors. Allopathic Explanations Anyone who has studied allopathic medicine in Iran knows its pathophysiologic models of disease causation and of diagnosis-specific therapy, the allopathic schemata. Diabetes is a hormonal disorder affecting metabolic processes and can be treated by regulating the level of sugar in the blood; cancer is to be treated by eradicating the tumor cells which have lost their intrinsic growth-regulating mechanisms; gallstones are formed when the balance between cholesterol, bile and lecithin is skewed; and sinusitis, if caused by a bacterial infection, can be treated with antibiotics. When the “cause” of disease is asked of a medical student, his/her eyes glaze over and the standard textbook is quoted, often verbatim, in English. The same holds true for therapy: etiologies and treatments are memorized and called up mechanically when needed to impress an attending, answer an anthropologist’s questions or manage a patient’s illness in the clinic. Except when challenged to do so, allopathic knowledge need not be applied to daily life. During OB/Gyn grand rounds, the refrain, “This is exactly as it says in the book,” is commonly heard, followed by a quotation, in English. For example: “It says right in the book, [switch to English] ‘in the case of pre-eclampsia, vaginal delivery is preferable to

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A young physician, when asked her ailing grandmother’s health, said, “She is sick.” When pressed for more detail, she responded sadly, “I don’t know what is the matter with her. She’s just sick.” Allopathic knowledge and schemata are esoteric, however, and for those who have not studied allopathy, there is no reason to be concerned with it. Its terminology may be picked up from encounters with doctors or others’ stories of such encounters, but it is not expected that the etiologic and therapeutic processes are to be understood by everyone. In any case, they are not important in the daily management of an illness. For the majority of Iranians, allopathic diagnoses provide powerful words–“diks” (collapsed intervertebral disc), “sugar blood” (diabetes), “fat blood” (hypercholesterolemia), “thalassemia” or “ATN” (acute tubular necrosis). The word is a shorthand for all the knowledge the doctor has about the condition. It indicates that medical advice has been sought, the doctor has been able to identify the condition, it has been brought into the domain of the knowable and therefore potentially manageable. An understanding of the pathophysiology of the disorder, no matter how rudimentary, is not necessary for coming to grips with the disease. An old woman had to have her leg amputated. I asked her daughterin-law, who had lived in the US for thirty years and holds an MA degree from an American university, what had happened to the leg that it needed to be cut off. “She had pneumonia,” was the reply. When she noticed that I didn’t get the connection between pneumonia and an ischemic leg, she elaborated that the “pneumonia” had predisposed her to have a “stroke” which implicated the “vessels” in her leg. My host asked me to monitor his high blood pressure for a few days with my American blood pressure cuff and stethoscope. On a return visit I brought him an Iranian cuff and stethoscope and offered to show him how to use them. Calmly he sat while I explained the physiology of high blood pressure and how the cuff and stethoscope work. His smile grew more and more condescending and finally he

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interrupted me with, “You explain that very well, but it is not necessary. Just take my blood pressure with your cuff.” To my knowledge, he never used the cuff and stethoscope I brought him. Iranians can react to an allopathic disease diagnosis in a number of ways. They can submit blindly to the authority of the doctor and unquestioningly follow his or her orders. Such faith in the doctor is rare, however. More commonly, the disorder or its treatment are fit into categories of health with which the patient is already familiar, categories of the temperament (tab’), of hygiene (dirt vs. purity), or of psychosomatic illness (stress, emotions and reason) which generate their own treatments. For example, the belief that each person responds individually and differently to various foods, including drugs, leads patients to titrate prescriptions to their perception of their bodies’ states of balance. And thirdly, just as allopathy is recognized as inherently powerful because of its “Western” origin, engaging in activities which align the patient to the West itself contributes to the treatment regimen. Thus patients may visit numerous physicians, preferably ones trained in the West, for a single disorder, and they may go to endless lengths and expense to procure medications produced in the West, which they feel are “better” and “more powerful” than the Iranian counterparts. Just having one’s blood pressure checked by a European physician with an American cuff and stethoscope is a powerful “manipulation” of one’s high blood pressure. These measures may not obviate medication, but they put the problem in the hands of those people, knowledgeable, Western-oriented doctors, who presumably know what to do and will do it for you. An elderly woman with an obstinate allergic rash had a skin biopsy taken on the advice of her daughter, a general practitioner. The slide, after it was read locally by a pathologist trained in England, was sent to the woman’s son, a pathologist in California. As soon as the slide was sent away, she ceased complaining about the rash, and her son’s diagnosis of an allergic skin reaction, which came via phone call a few weeks later, left her coolly unimpressed. The diagnosis (with its implication for treatment by antihistamines) did nothing to change the way she talked about or treated (with herbal remedies) the condition. Just as patients themselves usually do not care to have detailed information about their disease, so doctors are loathe to divulge much

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information to them. To begin with, they are hesitant to give diagnoses to patients. If the diagnosis is fatal or frightening, for example, “cancer,” they argue that it is best for the patient not to know, or s/he would give up hope, without which there is no will to live. Instead, if anyone has to be told such a diagnosis, it will be a close family member who will henceforth be in charge of pursuing therapy.

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A recently graduated generalist working in a rural public health clinic said, “All the time when I am examining a patient I am thinking whom to tell, what to tell, how much to tell.” Another reason physicians do not divulge diagnoses is because they assume patients would not understand, anyway: they do not have the education to be able to make sense of information and they do not believe in the doctor’s knowledge and advice. An intern, when asked how he would tell a woman that she has severe coronary artery disease, replied, “I would tell her ‘Mother dear, your heart is weak. Don’t stress yourself out, don’t do any work, take it easy. Take a baby aspirin every day. Good bye.’ Then she will go home and take the baby aspirin for a few days and throw the rest away and continue to work like she always did.” He laughed at the futility of talking to patients. “Patients don’t know anything, they don’t even know enough to take the advice of the doctor.” Patients’ ignorance about allopathic principles makes them an easy butt for jokes. Friedl (1979a) reports that medical personnel at a hospital in a regional town took delight in teasing patients from villages by, for example, telling an illiterate woman who had a hysterectomy that all the birth control pills she had ever eaten had accumulated in her uterus as a solid white mass. Finally, medical students are instructed to withhold diagnoses from patients and to always write prescriptions in English so that patients will not take matters into their own hands the next time they are ill. A father who has paid lots of money to have his child seen by a doctor for an ear infection, the argument goes, will bypass the physician the next time the child has an earache and go straight to the pharmacy to demand ampicillin if he knows this is what the doctor prescribed last time. Medical students are warned that such behavior would lead to injudicious use of medications, harm to the patients and the development of antibiotic-resistant strains of bacteria. The economic incentive for such a strategy is readily apparent to them as well. Despite such negative images of allopathic medicine in Iran, Iranians are fully aware of the power of allopathic medicine. They know that it has

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reduced the threat of previously fatal childhood illnesses, that it can cure common and often serious bacterial and parasitic infections, that it can control family size and the pains of childbirth, that it has increased the life spans and quality of life of people suffering chronic diseases such as heart disease, kidney failure or diabetes, that it has helped to contribute to a better nutritional status for women and children, and in some instances it has even cured cancer. It is for this power that allopathic medical advice is sought, despite the above reservations and despite reluctance to follow physicians’ recommendations. In summary, in Iran allopathic knowledge is considered to be the rightful domain of allopathic doctors, to be used by them to procure a positive disease outcome on behalf of their patients. It is neither the patient’s responsibility nor his or her right to “know” allopathic disease processes and rationales for treatment, i.e., to concern themselves with allopathic schemata. Rather, the effective use of allopathy requires that patients believe allopathy to be powerful and to attribute to the doctor allopathic knowledge, which they themselves lay no claim to. Conclusions The etiologic agents presented in this chapter–the tab’, dirt, stress and emotions, supernatural powers, and allopathic pathophysiologic theories– are not exclusionary. In other words, none are contradictory to the others and all can be entertained simultaneously. Just because a person “believes” that his nārāhatī or distress is due to having ingested excess “cold,” for example, does not mean that he cannot go to an allopath for a penicillin (“hot”) injection, or that he doesn’t attribute the “cold” to fatigue from having worked hard in order to provide enough money to meet the demands of his wife and children. Most illnesses thus can have multiple “causes” and can subsequently be addressed by multiple means. A barren woman, for example, may supplicate an Imāmzādeh for a child by making a vow at his tomb, eat “warm” foods to optimize the tab’ for conception and pregnancy, wear an amulet to protect herself against the jealousy of others, ingest teas or take sitz-baths with herbs thought to facilitate conception, and consult an allopath for help in getting pregnant. None of these avenues are abandoned or taken to be ineffective if they fail at first to achieve the desired result. Success is due to determination and God’s will, regardless of the paths one attains it by. I have introduced here an outline of at first glance apparently unrelated factors Iranians identify as causative of ill health, distress or disease. Even at this level of description, there is overlap: concepts from allopathic medicine

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are taken to justify the native valuation of food stuffs and obsessive attention to cleanliness. In the following chapters I will present concepts by which these factors are in fact related to one another systematically. These concepts are criteria or values by which an explanation or course of action is judged to be consistent, meaningful and potentially productive.

Chapter 4

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Key Concepts: Nature, Purity and Balance in Relation to Health

The causes Iranians identify for ill health and the measures these suggest for maintenance and restoration of good health, as described in the previous chapter, range from environmental influences on individuals’ constitutions to dirt, stress and allopathic pathophysiologic derangements. Of course, it is not inconceivable that these often contradictory ideas can be entertained simultaneously in a given instance of disease, i.e., that Iranians do a kind of double-think in regard to causes of health and disease. For example, people are considered responsible for knowing their own tab’ and its responses to various dietary and environmental factors, yet when a person falls ill, the cause of the illness is frequently attributed to outside influences over which the person has no control, such as jealousy, the Evil Eye, social stressors or God. Or, while God is thought to be the ultimate cause of illness, to accept one’s “fate” without first attempting to find means to restore one’s health is not, to my knowledge, entertained as a reasonable course of action. Deeper exploration of these five explanatory models uncovers certain themes or “key concepts” which give them cohesion, tie them together into a system rather than leaving them hanging, unconnected, in separate corners of the mind. The explanations given for ill health and the strategies people employ to maintain and restore health in Iran are unified in their diversity, and even at sites of contradiction, by key concepts from which all healthrelated thought and behavior are ultimately generated. In other words, these key concepts at once inform explanatory narratives and health-maintenance strategies and provide criteria by which to evaluate explanations and strategies for their consistency, logic and potential productivity. In this chapter I will outline these concepts.

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Nature and Beauty Nature is thought to be a panacea for all ills. Anything “natural” (tabī’ī, as opposed to artificial, masnū’ī) is considered to be pure, good, restorative, rejuvenating, wholesome, curative in general. God made everything in nature for the benefit of humans, Iranians say, and if everything is used for its intended purpose, it is not harmful. Likewise God did not create a disease without also having provided a cure for it which can be found in nature. To begin with, Iranians find in the natural environment ārāmesh, peace and tranquility. To while away a few hours in a shady garden filled with flowers, listening to the birds in the trees and the burbling of flowing water, or to take a hike in the mountains in the springtime when they are green with new growth and colorful with wildflowers, is considered earthly paradise. In nature they can relax and make the del light of worries, retreat from the concerns and demands of daily life and allow stress to dissipate from the body, reverse frayed nerves (asāb-e khurd), decrease pressure (feshār), and breath fresh, clean air. Furthermore, such an environment, Iranians say, is conducive to contemplation of the meaning of life, the beauty of God’s creation, and through that, the existence of God Himself. Iranians liken enjoyment of nature to poetry and to prayer: through it they feel elevated to a position of enlightenment and happiness. A chemistry student went to spend an afternoon at the tomb of the poet Hafez in Shiraz, a garden full of flowers, shade trees and a few fountains surrounded by a tiled wall on which are written, in flowing calligraphy, some of the poet’s most famous verses. “I come here when I am feeling sad or need advice. Today I came here because someone I thought was a friend turned on me, and I was sad (delam gerefte būd, my del was caught). Sitting here reading Hafez has made me light. Now I feel relieved.” More particularly, gardens as symbols of nature are linked to one’s origins in God, in Eden, in childhood. They are symbols of a simple, pure, sinless state. “The alley is a garden greener than the dream of God,” a popular poem by Sohrab Sephari begins, and goes on to associate the garden with truth, maturity, sincerity, light and deep friendship. To visit a garden is to enter a state free from the lies and sins one must perpetrate to survive, free from worries and disease, from responsibilities and from “dirt.”

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An engineer educated in the United States withdrew from pursuing his career at the time of the Revolution and dedicates all his time, energy and money to his garden several miles outside of Shiraz. There he lives in a hut with a little fountain in front of it, surrounded by fruit trees. “I don’t participate in society anymore because I can’t stand the attitude of the people. For their own personal reasons everyone will stand in your way if you want to get anything done. Just for the simplest signature on a piece of paper they make a big fuss. You have to kiss ass all the time, tell lies and pretend to be something that you’re not. I didn’t want to do that anymore.”

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“It is important to have running water in your garden,” a retired preschool teacher said, “because it reminds you of your childhood. Once you have heard the sound of running water, if it is a fountain or a brook or the waves, you cannot forget it and you always yearn to return to it.” Iranians find ārāmesh in carefully planted and tended gardens and public parks, as well as in “the wilderness” (bīābūnī, literally, the place without water), the rugged, raw environment of mountains and deserts. The solace found in this setting is of a different scale than that found in the confines of a garden, however. While gardens are always enjoyable, the bīābūnī is a dangerous place. The lack of food and water and the alone-ness one experiences can lead to death or mental derangement. Nevertheless, in the wilderness one can find answers to existential questions. The Prophet Mohammad went into the wilderness for forty days and nights for contemplation and revelation, and it is existential questions that pull Iranians to the bīābūnī as well. In a television serial, a young man who is confused as to what path to take in life is asked, much against his will, to escort his maternal uncle on a trip to the desert. At the end of several days in the bīābūnī, experiencing the wind and the vastness of the desert, watching the sun rise and set, and engaged in thought-provoking conversations with his uncle, the young man has sorted through his difficulties and has found the strength to assert himself against the demands of his parents. During his vacations from medical school, a very devout student traveled fourteen hours to his grandparents’ village where he took to

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the mountains with nothing but the Koran, fasting during the day and returning to the village only for a simple meal and to sleep. “In the mountains I feel closer to God. There you can come to a closer understanding of Him,” he said. A second domain of meaning of “nature” includes the body and its tab’. The Arabic root consonants t b ’ signify nature, character or disposition. In a derivative, tabī’at, they signify “nature” in the abstract, as in the natural environment. Tab’ is used interchangeably in certain contexts with mezāj and with hāl or hālat. Mezāj is the physical constitution of the body, its temperament. The term appears primarily in formal speech and in writings about the indigenous medical system, but is not used in casual speech as generally as are tab’ and especially hāl. “Be mezāj-am sāzgār nīst [it does not agree with my constitution]” is a refined way of conveying the same message heard much more frequently as “hāl-am bad mīshe [my condition or health goes bad].” Like tab’ and mezāj, hāl and hālat also refer to the natural condition or predisposition of the body. Hāl can be loosely translated as health in general. It is used, for example, to inquire after someone’s health: hāl-et chetūr-e? (how are you, literally “how is your health?”) or hāl-am khūb nīst (I don’t feel good, literally, “my health is not good”). “I ate a bowl of yoghurt and hāl-am be ham khord, sardī kard-am (my health broke down, I made cold).” Hālat is a more general term for “condition” than hāl. It can be used to describe a variety of conditions, from political or economic ones to the state of affairs of one’s work environment or family relations. It is modified by badan, body, (hālat-e badan), when talking about health, for example, hālat-e badan-esh garm-e (the state of his/her body is “hot”). The tab’, mezāj, or hāl/hālat-e badan is “natural” because it functions in predictable ways, laid down in nature. For example, if the cleansing flow of waste products and dirt from the body is stopped, disease results; if one doesn’t take antibiotics for an infection, the infection will not go away; activities or foods that are “cold” or “hot” cause disease if the body is already “cold” or “hot,” respectively; stress frays the nerves; one illness predisposes to another. These processes Iranians consider to be tabī’ī, just like the changing of the seasons or the opening of flower blossoms. Likewise, “herbal medicine,” dārū-e gīāhī, subsuming both the “hot” or “cold” properties as well as the idiosyncratic effects of foodstuffs, is classified as tabī’ī. It is derived from natural products whose effects on the body and on disease are predictable. Because it is “natural,” Iranians say, dārū-e gīāhī, if used for its intended purpose, is not only curative but also

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devoid of negative side-effects. Even “dirty” things, whether physically or ritually impure, can be restorative if “natural” and used appropriately. A veterinary student recounted a story in which the famous Iranian physician Ibn Sina [Avicenna, A.D. 980-1037] cures a man of a wasting illness by making him swallow a lump of raw dog meat. The double impurity (from a dog, and raw) revolts the man and after a few hours he vomits the meat up again, only to see it covered by leeches which had been living in his insides and causing his illness.

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Because it is “natural,” Iranians argue, dārū-e gīāhī is better, safer and more effective than allopathic pharmaceuticals. Consequently, Iranians find it preferable to treat disease first with herbal medicines, and to seek recourse in allopathic medicine when the former does not yield a cure. Allopathic diagnoses themselves are often addressed with dārū-e gīāhī instead of, or simultaneously with, pharmaceutical medications. A menopausal patient was worried about taking estrogen replacement pills because she had a positive family history of breast cancer. She asked her gynecologist whether it would be okay to take an herbal extract instead. “Yes,” replied the doctor, “there is no harm in taking that,” and turning to me she explained, “This is a plant that contains estrogen. Because it is natural, it does not cause harm. Estrogen in the pills is not natural, it is derived from a chemical process in a laboratory.” An elderly lady suffered high blood pressure and very reluctantly took the antihypertensive medication brought her by her daughter, a physician. As soon as she heard that garlic was supposed to be good for high blood pressure from her neighbor, however, she sent her servant out for some and demonstratively ate a clove every morning with her breakfast. As much benefit as can be derived from nature in the form of ārāmesh and herbal remedies, in Iranian thought nature can also be dangerous and imperfect. The wilderness may provide revelation, but it is also filled with rapacious animals. More importantly, it is associated with mental and social instability. People who are crazy (divāne) go into the wilderness alone, Iranians say: people suffering unrequited love, or hermits who eschew social relations, or thieves, bandits and insurgents who pose a threat to both

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individuals and society. The very state of being alone is identified by Iranians as dangerous. They say the feeling of loneliness will drive people crazy, and that contact with other people is necessary to maintain mental health. Even gardens can be dangerous, as they can be associated with strong emotions, especially love or passion (‘ashq) and can weaken the ability of the ‘aql (reason) to make rational decisions. Likewise, while Iranians believe that natural products can be beneficial to their health, they enjoy these with reservation. The wilderness provides wild grasses, fruits, mushrooms, nuts and herbs which are wholesome and have medicinal properties, but having to depend to a large extent on these for one’s sustenance, like much of the poor, rural population did until recently, is a deplorable, risible, unmodern state. To follow herds of sheep and goats through summer and winter pastures, to live in tents close to the elements, to partake of simple meals of bread and yoghurt, may be a romantic ideal but practically neither comfortable nor desirable. Instead, Iranian commercial farmers use pesticides, herbicides and preservatives to improve crop yield and shelf life, dairies and poultry farms are mechanized, and animals are given antibiotics and commercial feed to improve herd health and productivity. The chemical manipulations of food production and preservation accomplish a maximization of what is already good–the ability to produce more milk, more eggs, more fruit, more wheat –but in the process compromise the natural “goodness” of these products. Eggs from free-range chickens are considered to be better than those from a poultry farm, which are even called, by some Iranians, “artificial” (masnū’ī). Meat from the animal of a village farmer is prized over that supplied to the butcher’s from a commercial enterprise. Milk delivered warm from a dairy farm is better than that which has been commercially homogenized and pasteurized. Moreover, agricultural products, while essentially “natural” and good, are considered to be “dirty” when first brought home from the market. Beyond its identification with the often excessive and injudicious use of herbicides, pesticides and preservatives, this “dirt” derives from three other contaminants: mikrūb, the food’s rural (uncouth) origins, and its effect on the body’s production of waste. Physical dirt containing mikrūb, which can make you ill if you eat it, is the off-the-cuff reason Iranians give for thoroughly washing and processing foods before they eat them. But washing and processing the food also civilizes it, rids it of its rural origin, which is associated with backwardness, ignorance and anti-social elements (thieves, scoundrels, rebels). And the processing of food helps the body get out of it what is good and get rid of the waste.

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An upper-class woman never purchased meat ground at the butcher’s because, she said, “You can never be sure that the grinder is clean.” The butcher and his apprentices, she claimed, are all “villagers” who don’t know enough not to let the grinder sit unwashed for a few hours, which would make all the meat processed through it go bad. A particular physician makes her butcher wash the grinder in front of her before allowing him to put her purchase through it. “Carrot juice is the best thing for Vitamin A,” a middle-aged man said. “The carrots themselves are okay, but the juice is better, it is more pure (khāles), because your body doesn’t have to work so hard to digest it.”

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“Natural,” as Iranians think it, does not therefore mean untouched by human hands. Humans can make natural products better–bigger, more nutritious, more wholesome, pure and clean–by their interventions. Even the “natural” process of conception can be made “better” by appropriate manipulation: A nurse in a family planning clinic informs women who ask whether there is anything they can do to determine the sex of their child that an Austrian study has shown that in order to have a boy, the man should eat “hot” foods for three months before intercourse in order to weaken all the sperm containing the X chromosome, that intercourse should take place on the day of ovulation so that the egg is “fresh” (tāzeh), and that after intercourse the woman should take a “hot” vaginal douche [sodium bicarbonate] and eat “hot” foods throughout her pregnancy so the boy will become healthy and strong. Should a girl be desired, the man should eat “cold” foods, intercourse should take place a day after ovulation when the egg is no longer “fresh” (tāzeh nīst), and the woman should take a “cold” vaginal douche [vinegar] after intercourse. The idea that what is “natural” can be improved through the practical application of knowledge is seen particularly with regard to the appearance of the body, primarily the face and hands. Big noses, thick eyebrows, wrinkles, gray hair, dark skin, chapped lips, freckles and calloused hands may be natural, but that does not make them appealing to Iranian eyes. A face devoid of these blemishes is considered to be clean (tamīz), beautiful

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(qashang or zībā) or good (khūb). Such a face reflects not only good health but also good character: an unblemished face and hands belong to a person who is a cut above the rest. Beauty, qashangī, therefore implies social status, as, e.g., freedom from having to perform manual labor in the sun, economic status, since the creams, facials, make-up, perfumes, hairdresser and cosmetic surgeon all cost money, and strength (zerengī ) or success, because only with strength can you possess something of beauty. A young woman from a village, who was just beginning her clinical training in medical school, had her large nose surgically reduced on the grounds that it interfered with her breathing. “Bah!” said her aunt. “She had it done because doctors don’t have noses like that.”

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“I was exceedingly beautiful when I was young,” a middle-aged man said unabashedly, “so beautiful that I would have had no problem becoming a movie star in Hollywood. One day after school my religion teacher stopped me as I was about to get into my car and said, ‘You are a beautiful young man, you know that. Don’t sully your beauty with evil deeds.” I saw the truth of what he said and have led an exemplary [pāk, clean] life.” A man said of his friend, “He may have studied law in the United States, but he wouldn’t ever have amounted to anything here if I hadn’t taken him in hand. I made him get a nose job, I made him have his eyes surgically corrected so he wouldn’t have to wear heavy glasses or contacts that made him squint, I took him to the best tailors in Tehran, and I introduced him to his wife–you saw what a beautiful woman she is. He would never have gotten her if he hadn’t been beautiful himself. Beauty is an investment. His business hadn’t gotten off the ground when he met her, but because he paid attention to himself, she knew he would succeed.” Just as the absence of physical dirt or of waste products naturally produced by the body is desirable to God, so is a clean (tamīz, pāk, qashang) face, Iranians say. In the context of religious belief, however, cleanliness can be defined in two different ways. Make-up, creams, hair-dyes can be identified as “dirt,” since they would come off during the act of ablution, and therefore offensive to God. Moreover, any alteration of the natural face by make-up or surgery, depilation, tattooing of the eyebrows or other means can be taken as an indication of dissatisfaction with what God

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has given, a clearly, to Iranians, sacriligous sentiment. While most Iranian men and women would desire to undo the effects of aging on their body in some way, even if only by applying henna to their hair to mask the grey, others, as a matter of principle and testament of their faith, ostentatiously do not do so. These people are considered to be “beautiful” in a spiritual sense–they are spiritually pure and good. On the other hand, God is thought to cherish beauty and to favor beautiful people. A person who maintains or improves his or her looks is therefore doing something pleasing to God, Iranians say. God gave everyone his or her looks, just like He gave them their health and their children, and He also gave them the ability, some even say the duty, to take care of them, to keep them qashang. A successful OB/Gyn at the University of Shiraz was telling me about the popularity of plastic surgery in Iran. “The plastic surgeons don’t need to worry about their income. To even get an appointment with the best one here in town you have to wait six months. Most popular are noses, because you know, Iranians have big noses. Mine, too. Often I think about having it done. Because it would be more beautiful, and God likes for us to be beautiful and happy.” The literal translation of “beauty” is qashangī, but the semantic fields of qashangī and tamīzī, cleanliness, overlap to a great extent. Anything beautiful is clean–a dirty beautiful thing is oxymoronic–and anything clean is automatically beautiful. The overlap between the concepts of cleanliness and beauty allows for the notion of the beautiful to figure significantly in Iranian conceptions of health and illness. Via cleanliness but also on its own, beauty is a necessary ingredient to good health. In The Message of Health, a pamphlet about health, safety and hygiene distributed in schools, middle-school children are instructed over several pages about the importance of washing their hands, keeping their fingernails short, brushing their teeth, keeping the space between their toes clean, brushing their hair well, not playing in the dirt, not sharing towels, toothbrushes, silverware, hats, or drinking glasses with others, changing their clothes at least once a week and washing their socks every day. A neat, tidy, clean appearance is clearly linked to good health (Edāre-ye kol-e taqzīye va behdāsht-e madāres, 1997).

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HEALTH AND MEDICAL PRACTICE IN IRAN A gynecologist spends a good portion of her lightning-quick historytaking time addressing her patients’ appearances: “What have you done to become so beautiful since the last time I saw you?” “You were much more beautiful while you were in the hospital. What is going on that you are not taking care of yourself?” “Tell me your secret for beauty.”

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In summary, what is “natural” is an idealistic state of absence of all the things that make one sick: absence of dirt, and absence of stress. Nature, and thereby good health, implies physical purity (breathing fresh air, clean hands, face and feet), social order (trouble-free marital relationships, freedom from contact with “undesirable” social elements) and moral uprightness (feeling close to God, taking care of one’s beauty). What is “natural” is both health-promoting and a symbol of health. At the same time, the “natural” defines the body’s responses to fluctuations in the environment, which are best countered by “natural” means. Thus the definition of what is “natural” underlies all the etiologies of “dis-ease” discussed in the previous chapters. It is a powerful and productive concept with which the logical soundness of explanatory models can be judged, and which ties the tab’ , dirt, stress and supernatural forces to one another. Balance, Moderation and Humility Good health depends on the balance of various internal and external factors. For example, the constitution or tab’ must be kept at a point of balance between “hot” and “cold,” by eating foods which, by their inherent “hot” or “cold” properties, shift the tab’ in one direction or another. “Hot” and “cold” are just two of many attributes of food which can be manipulated to maintain the body in a state of optimum health. Others include foods’ “weight” and “strength” and their chemical composition. Derivatively, disease is thought of as a disturbance in the body’s equilibrium by an excess or deficiency of any of these factors. Many allopathic diagnoses lend themselves to interpretation as “excess” or “deficiency” states as well. For example, anemia is said to be due to a deficiency of iron in the diet, obesity to an excess of fat and sugar, polycythemia to an excess of rich food in general, diabetes to excessive ingestion of sweets. Moreover, the uniqueness of everybody's tab’ offers an explanation for individual variation in the propensity to these diseases. A husband and wife, personally known to an internist, came to her for their yearly physical exam. He was skinny as a rake and had

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blood sugars in the normal range, she was rotund and had elevated ones. The doctor chastised the woman for eating sweets that cause her blood sugars to rise. Her husband laughed: “Mrs. Doctor, you have got it wrong! She doesn’t go near them because they make her fat and I eat them hand over fist!” The physician could not call her acquaintances liars, though she clearly did not believe them. So she explained the discrepancy with differences in their bodies’ responses to sugar. In a subsequent discussion with me, the doctor stripped all the intricacies of energy production and insulin secretion in the pathogenesis of diabetes to an essential of “excessive sugar in the diet.”

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A young physician proposed an explanation for depression which hinges on an imbalance between “acid” and “base” in the body, to be corrected by neutralizing the pH of the body through dietary management. “Excess” and “deficiency” of factors that are conducive to dietary manipulation are preferred etiologic agents for many disorders for which the pathophysiology is not understood, either because it is too complicated to bother with (e.g., diabetes) or because it is mentioned only as “idiopathic” (unknown) in the textbooks (e.g., depression). But “excess” and “deficiency” can extend to social and psychological factors as well. For example, medical students refer to the Koran when attributing psychiatric disease to “deficiency of love” (mohabbat, also “kindness”). It often surfaced in conversations I had with medical students that they “knew,” regardless of the textbooks’ claim that it is not known exactly what sets off the sequence of hormonal events underlying high blood pressure, that hypertension is ultimately caused by excessive pressure on the nerves. The feeling of good health, Iranians say, depends on a balance not just of properties derived from food but of many factors in one’s life, including the state of one’s social relations and the activities one engages in for work and for relaxation. Generally, excesses and deficiencies, be they of sex, socializing, exercise, food or particular types of food, studying, work, extremes of temperature or of emotions, have negative consequences for one’s health. “Backache” in women is a symptom of not being sexually fulfilled, a middle-aged housewife said.

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A patient had re-clogged coronary arteries six months after a triplebypass operation. Her neighbor, a physician, explained to me, “That is because she works too excessively. She won’t leave off working. Her husband, her children, her neighbors and friends, they all tell her ‘Don’t do this, we will do it for you,’ but she does it anyway. She lives on the third floor and all day long she runs up and down, going shopping, coming and going and doing for others. Did you see-three days out of the hospital and she has already sent āsh-e reshte [a hearty stew] she made herself. Of course her heart suffers.” To avoid excesses and deficiencies means to enjoy and consume things in moderation. A story attributed to the Prophet Mohammad has it that upon learning that the people of a certain village claimed that the secret to their exceptionally long lives was that they ate just until their hunger was stilled and no more, he instructed his Faithful to do the same. Moreover, they are to give what remains on their table after they have eaten to those in need. To eat moderate amounts of food thus has both worldly and spiritual significance. On the one hand, by not engaging in gluttony, people can preserve their health and ensure a long life. On the other, gluttony is framed as a vice which is displeasing to God, while its opposite, sharing, is taken to be an act of piety. An elderly denture-maker told the following story: “A rich man had two beautiful daughters. A poor man who was hungry, tired and cold knocked at the door of the rich man’s house to beg. No one was home. So he opened the door and went inside. He saw the table laid for dinner. He sat down and ate one portion of everything, just so the edge was taken off his hunger. Then he went into the bedroom, opened the closet and saw two men’s suits. He took the old suit and left the new one hanging in the closet. When he put his hand in the coat pocket of the suit he found 60 Toman. He put 30 back and the rest he put in the pocket of the new suit. Then he went to take a nap. He took one blanket and one pillow off the pile of bedclothes and lay down in a corner. Then the family came home. The rich man saw what had happened and was so pleased that the poor man had taken only what he needed that he woke the man and gave him one of his daughters for a wife.” An old woman who had been listening attentively commented, “That just goes to show how much God rewards people who know their place and are not greedy.”

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Thus moderation implies much more than just finding the balance between “hot” and “cold” or eating a sufficient amount of vitamins or exercising ten minutes a day. Rather, it embraces the concept of humility and with that, active participation in the faith, or continuous remembrance of God. Sharing resources with those in need, or “serving people” (khedmat be mardom or khedmat be jām’e), by, for example, giving food to the hungry, raising one’s children properly, building a new mosque or school, or even just performing one’s job conscientiously, is a form of alms-giving, which is one of the principles by which a good Muslim is to live, by order of God, Iranians say. For Iranians, a life lived in humility and submission to the will of God is truly “good” (khūb), “clean” (pāk), and by implication, “healthy” (sālem).

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“This man who died,” an elderly, retired schoolteacher told me, “he was 100 years old. Such a good man! I asked him what his secret to such a long life was and he said he drank a cup of tea and ate a hand-sized piece of bread with two little pieces of cheese and an apple before sun-up, dedicated his day to study and didn’t eat again until sun-down, and then only a few spoons of rice and stew.” Medical knowledge attributed to the prophet Mohammad includes: - the stomach is the home of every sickness and abstinence the source of all cures - wean your body of everything you have accustomed it to - don’t subject your stomach to excessive food because that is like giving a field too much water–its ability to be cultivated and bear crops diminishes - for a long life, eat breakfast early, dinner late, sleep with women infrequently and decrease your debts (Askari, 1993). Contact with society should also be sought judiciously, in moderation. While social contact is necessary for one’s mental health, Iranians say, excessive contact is polluting and thereby harmful. Iranians claim that while conducting any kind of personal, business or professional transactions they need to exercise constant vigilance so as not to be taken advantage of, and often even need to be dishonest themselves. This causes stress, which in turn raises pressure and frays nerves. Moreover, the poor, the illiterate and the indigent are considered to be base and unclean, so contact with them is in itself a potential source of ill health. Even just witnessing all the injustice in the world causes stress, Iranians say.

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HEALTH AND MEDICAL PRACTICE IN IRAN “My children tell me to stop smoking,” a chain-smoking physician said. “They are worried that it is bad for my health. But what I am supposed to do when there is so much injustice in the world? Just listening to the news, all the bad things that go on–the unrest in Algeria, war in Afghanistan, the twenty teenagers who were killed when their bus turned over as they were on their way to the Science Olympics–all these things weigh so heavily on my heart. And in my clinic, the young people, the university students come, and they are all depressed because of the situation. There is so much suffering, and I feel it all. Then how am I supposed to stop smoking?”

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“My daughter stopped going to the university because her health broke down,” an upper-class woman said. “To get to classes every day she had to go through the poor part of town. She saw the children standing there, dirty, selling tomatoes, in all the squalor of the streets. It was too much for her health.” Participation in society, even if it is restricted to keeping up with the news, is clearly potentially harmful to one’s health. It causes one to come in contact with all kinds of things that can disrupt the precarious equilibrium of good physical and mental health. One is exposed to dirty elements: the poor people of the city, villagers, the unclean and illiterate, people who want to take advantage of one or stand in the way of one’s success, mikrūb, havoc, disorder, deceit, disruption. Trying to maintain one’s integrity while dealing with these elements causes pressure to go up and nerves to become frayed; it forces people to engage in unhealthy practices, such as not exercising, not relaxing, not eating healthfully, smoking, and doing drugs; quite generally, it ruins the health. At the very least, Iranians say, one could get some thanks for serving society, but doesn’t. This in itself poses a psychological burden. An OB/Gyn resident rotating through a public health clinic in the south of Shiraz which provides services to poor women sneered at the waiting room full of patients as she said, “It was a mistake to study medicine. Look at all this: dirty, uneducated, stupid people; this is who I have to spend my time with, to whom I have to provide services. For what? They say I am being trained in a desirable profession, but when I’m done with my training, there will be no job for me. No money, my youth gone, no prospect for social advancement, and nothing but dirt all around.”

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A gynecologist, a devout Muslim and acknowledged by her colleagues and patients to be an excellent physician and scholar, occasionally forfeits her salary because she is too busy with her work in the hospital and clinic to insist on reimbursement. She confessed that she was tired of this state of affairs. “My colleagues, many of them did not go overseas for sub-specialty training because they would have had to pay for it themselves. They do not do research. They see only private patients and even refer the patients they see at the university clinic to their private office for surgery. And yet look at them: they have big houses, rental property, big cars, vacations in Europe. They are far ahead of me in procuring a good life, and then they laugh at me because I do not have these things. I have been offered a green card for the US three times and have not taken it, because I felt the people of my country needed me. But I should have gone. There is no reward for staying here.” These comments reflect a deep bitterness on the part of many Iranian physicians who dedicate their lives idealistically to the improvement of social conditions only to be rewarded, after many years of hard work, with ill health, indifference, resentment, even scorn and ridicule from the people they have attempted to serve and their own peers and colleagues. They feel as though they have been taken advantage of, that they have been losers (sādeh or sādeh del), that they are or will be stuck at the end of life with nothing to show for their services– no investments, no easy life, not even the benefit of knowing that their sacrifice had been appreciated, and that rather than helping society all they did was work themselves into ill health and old age. Leading a pāk (clean) and qashang (beautiful) life is therefore not only not an easy feat but a virtual impossibility. The only way it can really be accomplished is by withdrawing from society entirely, like the engineer who moved to his garden outside Shiraz and now lives in poverty but ārāmesh (peace, tranquility). But to completely pull away from society and the lies, deceit and ugly deeds that must be perpetrated and witnessed to participate in it is not a realistic option for most Iranians, who need to put dinner on the table, nor does it allow one to fulfill one’s religious duty to serve society. It is not an option at all for women, on whom the primary responsibility for raising children falls. The concept of moderation, encompassing the balance of factors affecting the tab’ and humility, cuts across all the etiologic factors of disease presented in Chapter 2. It informs food choices, through which the state of

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the tab’ can be tempered. It frames contact with “dirty” social elements and “stressful” social relationships. And it ties the notion of health to supernatural forces via the concept of humility. “Moderation” is thus, like “nature,” a powerful theory of relationships between one’s self and one’s environment, from which explanations of disease causation can be extrapolated and by which a suggested mode of recourse can be judged to be potentially efficacious. Allopathic explanations and treatment recommendations are not exempt from being passed through the calculus of logical soundness. If “backache” is due to not being sexually fulfilled, exercises and pain medications will be of limited value. If depression is due to “lack of kindness,” the site of treatment should be family relations, and pharmaceutical drugs can at best treat the symptoms. If coronary arteries clog up because of “too much work,” a triple bypass operation is bound to fail unless the patient gives up his/her work drive. The ideas of allopathic medicine are not always contradictory or illogical to “native” Iranian ways of thought, however. In the following chapter I will focus on the manner in which allopathic medicine is integrated into Iranian conceptualizations of health and disease by its interpretation in terms of the native concepts described in the previous chapters.

Chapter 5

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How Allopathic Knowledge and Practice are Interpreted in Distinctly Iranian Terms

In the examples I gave to illustrate points made in the previous chapters, I allowed allopathic professionals to speak alongside lay people in order to demonstrate that the causes of ill health identified by Iranians, and the larger framework in which health and deviations from health are conceptualized, are common to Iranians and do not evaporate from the thought of those who have received allopathic training. Native conceptualizations of health and disease appear to provide the default logic with which lay people as well as allopathic professionals analyze and address health-related issues. The manner in which these default conceptualizations inform allopathic practice and the complex relationship between allopathic and traditional approaches to health and disease are the topics of this chapter. Contextual Separation It is without question that in Iran, allopathic and traditional medicines are thought of as distinct and separate entities. The former, concerned with understanding pathophysiologic processes so as to be able to manipulate them for a positive disease outcome, is associated with a university education, with the West and with sophisticated technologies; it is practiced by an elite class of doctors and enveloped in formalities and technicalities. The latter is an informal, personal, generally available set of knowledges and practices which provides ultimate explanations and symptomatic treatments. It is generally acknowledged that traditional medicine does not provide reliably effective modes of treatment for many allopathic diseases; moreover, it is not within the domain of traditional medicine to even make

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the diagnosis of these. Diabetes, congestive heart failure, pelvic inflammatory disease, sinusitis, detached retinas, endometriosis, thalassemia, renal failure and cervical cancer, for example, are allopathic diagnoses which, after they have been made by allopathic technologies, are demonstrably treatable by allopathic interventions. Conversely, it is not in the domain of allopathic medicine to counter the effects of the Evil Eye or to mediate a miracle cure or to give advice on the “hot” and “cold” properties of foods. To a large extent, then, allopathic and native ideas about health and disease and treatment options are kept separate just because they address different issues. Moreover, the context of practice keeps the domains separate. Allopathic schemata make most sense, that is, are called upon to explain medical findings and to suggest a course of action, in a clearly allopathic setting, in clinics and hospitals. I was assured by allopaths and lay people alike that by the time patients go to see the allopathic doctor they have already tried to alleviate their illness by traditional means, by dārū-e gīāhī (herbal remedies) and dietary manipulations, for example. These not having yielded a satisfactory result, the patients turn to allopaths for strictly allopathic advice. While some allopathic doctors may study traditional medicines out of their own interest, it is their job in the allopathic clinic to make allopathic diagnoses and dispense allopathic advice. Thus in the allopathic setting, thinking in terms of allopathic principles is facilitated by allopathic practice being set against a background in which traditional medicines and therapeutic strategies are taken for granted, and therefore can be ignored. That traditional medical conceptualizations do not really belong in allopathic settings was furthermore demonstrated to me every time I asked doctors, nurses or trainees about traditional medical systems in such a setting. While we may have been having a fluent conversation about an allopathically related topic, such as a patient or about economic influences on the practice of medicine, when I asked about the concepts of “hot” and “cold” or about herbal medicines, my interviewee would first distance himor herself from the allopathic setting before beginning to answer the question. An intern took a stethoscope from her pocket, put it on the table in front of her, pushed her chair away from the table and assumed a relaxed posture; a recent medical school graduate working in a government clinic carefully closed an allopathic textbook and clinic chart in front of him and pushed them away; a nurse asked me to come to the family planning clinic across the hallway where we could be more “comfortable” (rāhat) discussing this topic; several students made an obvious break in the conversation by

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offering me tea or telling a joke. In a clearly allopathic setting, to talk about traditional medicines after having been engaged in the practice of or in a conversation about allopathic medicine required a physical and mental readjustment. Once this had been accomplished and the “allopathic-ness” of the setting broken, very few people had difficulty discussing the topic with me in great detail. The contextualization of allopathic knowledge extended not just to the physical setting but also to my interviewee’s audience, that is, to me. Only one physician, who was well known to me personally, ever brought up the topic of dārū-e gīāhī with me spontaneously. In all other cases, I had to probe for it. It seemed to me that this was not just because I was conducting interviews in an allopathic setting but also because to my interviewees it was not clear how I, an allopathic doctor from the West, stood in relation to native ideas about health and disease, i.e., whether I would take them seriously or dismiss them as superstitions because they were not grounded in allopathic fact. It usually took a bit of persuasion to get them to start talking about their native medicines, but once they did, it was even more difficult to get them to stop. Finally, the physical contextualization of allopathic knowledge is illustrated by the observation that allopaths readily turn to native healthrelated logics and therapies in extra-allopathic settings. “When I first went to medical school,” a young physician said, “my mother gave me a little bag of zenyūn, a powder that has a terrible bitter taste. When you mix it in some sugar and drink it, it doesn’t taste too bad and it is good for complaints of the gastrointestinal tract like dyspepsia and gastroenteritis as well as irregularities of the sympathetic and parasympathetic nervous systems. I had a roommate who didn’t believe in these things, but once during the semester break he got a bad gastroenteritis and I told him I would give him something but he wasn’t allowed to ask me what it was. I made him drink some zenyūn and he got better immediately. Then I told him what I had given him and he took all I had left to use himself in the future. Also, yoghurt sprinkled with wild mint is good for gastroenteritis. I always try these things first, and if they don’t work I go get the necessary laboratory tests.” A young physician’s refrigerator door was stocked to overflowing with skin creams and lotions. Some of these were recommended to her by a dermatologist-friend as scientifically “proven” to be the

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HEALTH AND MEDICAL PRACTICE IN IRAN “best” for preserving the skin. Others were concoctions of dārū-e gīāhī which had been recommended to her by friends and acquaintances. When her younger sister asked her what to do to get rid of the freckles in her face, she suggested a facial-paste of shark’s cartilage from an attārī alternately with a facial of mushed peaches. She laughed, “Ground shark’s cartilage is very expensive, more expensive even than the creams the dermatologist gave me, but it is the best!”

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“Sardī kardī (you made cold)” my physician-hostess diagnosed from looking at my face when I came home from a particularly trying morning at the police station. She gave me tea to drink with dates and sweets, and prepared lentils for lunch–all “hot” foods. The context of practice thus provides a structure allowing the two domains of thought about health and disease to be kept separate. Allopathy belongs to the domain of the allopathic setting; particularly, it is applied in clinics and hospitals to illnesses that have not yielded to traditional therapies. Traditional medicine provides easily accessible home remedies that are used as a first-line means of redress for feelings of ill health. Quite generally, then, contextual distinction potentiates conceptual distinction. Mutual Justification Allopathic and traditional conceptualizations of health and disease are never mutually exclusive. Most obviously, when faced with a serious illness in themselves or family members, i.e., even outside the clinic setting, allopaths will of course turn to allopathy to analyze and attempt to alleviate the problem. Likewise, native concepts are not kept completely out of a clearly allopathic setting. An internist said about two skin lesions on the palm of a patient’s hand, “Don’t be upset about them because they are ugly: they are good against the Evil Eye.” A university student went to see a doctor because of the severe pains she got periodically in her shoulders and neck. The doctor told her to assume a better posture while studying and, in case the pain got too bad, to heat salt in a pan, fill it into two cloth bags and put these over the shoulders for twenty minutes at a time, “to draw out the pain.”

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A doctor told a severely anemic patient who had just had a baby and was nursing to eat “strong” (qavīh) foods with lots of iron (lentils, dried fruits, beans, spinach, milk, eggs and tea) rather than taking iron supplements because the chemicals in the pills might get into the milk and be bad for the baby.

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A cardiologist holding a workshop on cardio-pulmonary resuscitation demonstrated the proper way of performing a “precordial thump,” a smart blow to the chest intended to get a stopped heart beating again. “Pretend you have a volume of the Korān-e karīm (dear Koran) held between your arm and your chest. This way you can’t raise your arm high enough to do damage to the chest when you bring your fist down, and God willing, thought of the Korān-e karīm in this time of need and crisis will be efficacious in bringing about the desired result.” Native and allopathic schemata, concepts and practices are not irrationally intertwined or admixed in either setting, however. Rather, they are brought together in a logical and predictable manner. To begin with, allopathic knowledge provides Iranians with convincing explanations and powerful therapies for certain conditions. Infectious diseases, surgical emergencies, vitamin and mineral deficiency states and infertility, for example, have been easily and readily identified by Iranians as being more reliably and efficaciously treated with allopathic measures than with any of the native systems of medicine. This acceptance has occurred for two reasons. At a superficial level, Iranians say that the “knowledge” of allopathic medicine is accepted and valued as such. Allopathy’s knowledge is said to have dispelled the ignorance which previously surrounded disease and which had led to beliefs and practices based in superstition. Superstitious beliefs and practices, such as putting amulets on children to protect them from childhood illnesses and performing incantations to protect crops, are derided by educated people as backward, uneducated and ignorant. Believing in practices or forces that have no grounding in scientific fact when a clearly more efficacious alternative is available is, in their estimation, truly stupid. Thus at a very general level, allopathic knowledge is valued and accepted qua knowledge which has allowed deaths to be averted and the quality of lives to be improved.

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“Our students do not find a contradiction between allopathic and traditional medicines,” a professor of pharmacology said, “and they have no difficulty learning medicine. It is an honor for them to be accepted to medical school and they learn the material just like students in other fields learn engineering or computers. It is knowledge, and students know they are privileged to have access to this knowledge and study hard to excel in it.” The allopathic knowledge that has been most easily accepted by Iranians is not only that which has proven to be efficacious but also that which is conducive to interpretation or understanding in terms of native concepts related to health and disease, including “stress” and “dirt,” balance, excess/deficiency states, and the system of “hot” and “cold” properties. Where allopathic medicine and traditional medicine are brought in line with one another on the basis of these concepts, especially convincing disease etiologies and especially convincing motivations for pursuing therapy emerge. Antibiotics clear out cherk, dirt, and are therefore considered a particularly powerful means of restoring tamīzī, cleanliness. Elevated blood sugar and blood cholesterol are, regardless of the intricacies of the metabolism of sugar and fat, understood to be due to excessive dietary ingestion of sugar and fat, respectively, causing their imbalance in the body. Likewise it can easily be understood that anemia (at least some forms of it) is due to iron deficiency and can be corrected by dietary manipulation, i.e., by consuming foods high in iron. And it is certainly not a misunderstanding of allopathic medicine to attribute elevated blood pressure to feshār, stress, and to argue further that blood pressure can be regulated by reducing one’s contact with stressful things–though according to allopathy, that is not all there is to it. The interpretation of allopathic diagnoses and therapies by means of native concepts and logics not only allows conceptual acceptance of the former but leads to reflex validation of the latter. Allopathic, i.e., scientific explanations for the efficacy of traditional medicines are proudly mentioned in discussions of traditional medical concepts and therapies. Lentils, spinach and liver have long been identified by the native medical system as “strong” (qavīh) foods which make the body more capable of doing work; allopathy’s demonstration that these foods contain iron (which is necessary for the delivery of oxygen to tissues so that they can work) provides a scientific explanation for and validation of this native knowledge. Similarly, the demonstration that fresh fruits and fruit juices contain vitamins and minerals provides a powerful justification for the native valuation of these foods. The

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recognition that microscopic organisms, mikrūb, are causative of disease gives powerful justification to Iranians’ almost obsessive attention to personal cleanliness. Allopathic demonstrations that certain foods and herbs long valued in the system of dārū-e gīāhī contain health-promoting substances were gleefully reported to me: St. John’s Wort for depression, foxglove for heart weakness, Vitex agnus castus for premenstrual stress, for example. Although herbal treatments and “hot” and “cold” properties of foods are not currently discussed in allopathic textbooks, Iranians– physicians and lay people alike –claim that once allopathy gets around to scientifically testing traditional Iranian medical knowledge, it will all be proven true and efficacious. Medical students and interns told me that one of their biochemistry professors had demonstrated to them in lecture the scientific basis of the system of “hot” and “cold.” A “hot” condition results from an excess of energy (sugar or protein), and “cold” conditions from an excess of the metabolites of carbohydrate digestion (lactic acid and acid in general). Therefore, “cold” conditions are due to an excess of acid, “hot” due to an excess of base. To correct a “cold” condition one should eat foods that are alkaline and provide a lot of protein-calories (traditional “hot” foods such as dates, figs, lentils, walnuts, grilled meats, tea); to correct a “hot” condition, ones that have more acid (traditional “cold” foods, such as lemon juice, pomegranates, citrus fruits, yoghurt, rice and bread). A recently-graduated physician working in a rural health clinic said, “The knowledge we have from the old masters is wrongly devalued by you Westerners. In the village where I grew up, old women used to give children with neonatal jaundice telanjebīn and shīr khesht. My professors in the neonatal intensive care unit did a study comparing phototherapy alone to phototherapy used in conjunction with telanjebīn and shīr khesht and found that the infants in the experimental group got better significantly more rapidly than those in the control group. So now all the newborns with hyperbilirubinemia get telanjebīn and shīr khesht, because this is also something that you can do at home; you don’t need to take the babies to the hospital. We tell the mothers to give the babies that have this condition telanjebīn and shīr khesht and put them in front of a window during the day so the sun will shine on them, and if they don’t improve to bring them back to the clinic.”

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HEALTH AND MEDICAL PRACTICE IN IRAN “You Americans don’t believe in applying hot salt to painful muscles and joints, do you?” a physician asked me. “You put ice on them to decrease the inflammation. That makes sense, but hot salt is efficacious; you just don’t believe it because you’ve never tried it. It doesn’t get rid of old pain, only fresh pain. It draws fresh pain right out of the body. Try it and you’ll see. One day they will do a study of it in the United States and be astonished that it is so much better than ice. Our old traditional doctors knew a lot more than you give them credit for.”

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In summary, allopathic medical explanations and therapies are accepted by Iranians if they can be understood in terms of traditional concepts related to health and disease and are particularly valued if they can be used to lend scientific credibility to native knowledges. It follows from this that, in the cases in which allopathic explanations or therapies cannot readily be cast in traditional terms, they are rejected. Native knowledge or “beliefs” thereby offer major resistance to the acceptance of allopathic explanations and implementation of allopathic schemata when these go counter to what is natively “known.” Unacceptable Allopathy An allopathic explanation for a disease or justification for therapy that either defies interpretation by native concepts or does not address known etiologic agents is simply not acceptable. Allopathic understandings of and treatments for high blood pressure, depression, menstrual cramps, tension headaches, low back pain and obesity are among those not satisfying to native logics. The first three are attributed, by allopathic medicine, to hormonal or metabolic derangements. While such derangements could conceivably be cast as “excess” or “deficiency” states, hormones and metabolites have no ready traditional Iranian counterpart, as do “infection” (dirt) or “iron” (strength). In the case of obesity, Iranians are not satisfied with the allopathic recommendation to cut fat from the diet. To a people with an elaborate conceptualization of the value and properties of individual food items, this recommendation is much too simplistic. I found that the diets most likely to be followed are ones that spell out to the half-hour and the half-gram what is to be eaten, when. High blood pressure, headaches and low back pain are “known” to be caused by stress, so treatment recommendations that do not take stress into consideration are bound to be perceived as inefficacious.

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In the case of low back pain, a neurosurgeon told me, it is more efficacious to prescribe tranquilizers than pain medications, because the former soothe the nerves so one is more resistant to stress while the latter just treat the symptom.

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Menstrual cramps occur only in virgins, doctors told me. The uterus has to contract in order to get the menstrual blood across the semiporous hymen. Both the build-up of blood behind the hymen and the contractions cause pain. Taking pills to still the cramps reduces the ability of the uterus to clear out the blood, so “dirt” accumulates, and anyway, the ultimate therapy is marriage (sexual intercourse), so why bother with pills? Similarly, allopathic treatment rationales are not acceptable when they are frankly contradictory to native logics, when they do not “make sense.” Despite their recommendation by allopathic professionals, despite repeated demonstration in the medical literature upon which allopathic practice is based of their efficacy, if it is not “logical” to take the medicines, they will not be taken. For example, pills, capsules and injections are commonly classified as “hot” or “cold” and accepted, i.e., taken by patients, only if the underlying disease process is thought to be due to the opposite state. The instances of outright rejection of allopathic pathophysiologic explanations and treatment recommendations on the basis of illogicality are, in all fairness, minimal in comparison to the efforts made by Iranian patients and especially allopaths to interpret allopathic medicine in native terms or at least to diminish dissonance between the two conceptual structures. Even the refusal to take “hot” medicines for a “hot” condition has its loophole: a “hot” pill can be taken with a glass of “cold” watermelon juice to neutralize its “heat.” Finally, much of allopathic knowledge is superfluous to natively cast understandings of disease causation or treatment. The intricacies of the hormonal and neuronal regulation of blood pressure are irrelevant when hypertension can simply be attributed to “stress.” The intricate feedback system of blood sugar and insulin production and secretion that is the basis of the allopathic understanding of diabetes is not of interest when diabetes is simply understood as an excess of sugar in the blood. Similarly, the role of prostaglandins in the etiology of menstrual cramps is irrelevant when the root of the problem is understood to be an imperforate hymen. In these cases, once native logic has been satisfied, any further knowledge may be academically interesting but pragmatically of no consequence, with the

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result that the underlying pathophysiologic process and treatment rationale are often misunderstood or under-understood.

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Personal Prejudices While the reasons given by lay and professional Iranians alike for the validity and efficacy of certain allopathic knowledges and practices are fairly uniform (e.g., infections are interpreted as “dirt,” antibiotics as cleansing agents, attention to personal hygiene as an important preventative strategy, anemia as due to a deficiency of a dietary ingredient, surgery as beneficial for certain life-threatening conditions because it clears out “dirt”), there is a great deal of variation in the manner in which allopathic medical principles and practices can be interpreted in terms of native knowledge and concepts. Take as examples justifications given by different doctors for or against the use of birth control pills in women who have not yet had children: A recently-married intern said, “It would certainly be inconvenient if my wife got pregnant, because I do not yet have a job and she is scheduled to start classes at the university in a few months. But there is no way that I am going to put her on birth control pills. All the textbooks say they are not harmful, once she stops taking them she can get pregnant, but I am not going to risk it. There are a lot of things that are just not true in the textbooks, and anyway, you can never be sure that you won’t experience an idiopathic effect.” An unmarried female medical student who had polycystic ovary disease said, “A lot of women in the dormitory have this disease because they put camphor in the cafeteria food–they say this decreases the sexual appetite so we can concentrate on studying. Many of these women don’t take medication [including oral contraceptives] for it because they are afraid it will make them infertile, but I am not worried because my mother said I should trust the doctors.” A physician said she put all the girls on her daughter’s swim team on birth control pills so they would not be menstruating at meets. She did this so they would be tamīz, clean, when they appeared in public and she derided the idea that oral contraceptives might be harmful to the girls’ fertility.

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“Be sure to stop taking these pills after Ramadan so you can become clean again!” an OB/Gyn told a patient who requested oral contraceptives to delay her menses so she wouldn’t have to interrupt her fast. For the intern, the value of children was so great that the fear of an “idiopathic” effect that would make his wife infertile (a fear derived from native conceptualizations of the “artificial” could not be stilled by his textbooks’ reassurances that modern oral contraceptives had no effect on future fertility. For the medical student with polycystic ovary disease, the respect she had for her mother, the system of medicine she was studying, and her doctors, who were both her professors and future colleagues, allowed her to overcome the fear her roommates had about oral contraceptives. And in the final examples, oral contraceptives were linked in two different ways to the notion of “cleanliness:” by not bleeding, the swimmers were “clean” but by menstruating, women become “clean” as well, both because of the cleansing flow of blood and because of the ritual bath taken at the end of menses. As these examples demonstrate, values held personally dear can easily be foregrounded and used to rationalize one’s actions. In fact, the self, the patient’s individual constitution, tab’ or hāl, is the ultimate arbiter of the soundness of a recommended plan of therapy. All the randomized, casecontrol studies in the world, all the experiments and scientific “proofs” upon which allopathic practice is based, cannot argue with the tab’. “I don’t care whether 500 women or 5 million women have taken birth control pills with no adverse effects on their future fertility,” the intern in the first example above continued. “Who is to say that birth control pills will agree with my wife?” “Be hāl-am sāzgār nīst (it doesn’t agree with me)” is incontrovertible. And the factors that can make a patient, lay or allopath, decide that a medication or recommended therapy does not agree with his or her constitution are numerous. Just as a medication or therapy can be rationalized into the existing medical framework by being linked to key positive concepts, so can it be rejected by being linked to their opposite: to the negative effect the therapy has on the tab’ or hāl by way of dirt, the “artificial,” an undesirable turn to a “hot” or “cold” state, weakness, stress, or to a derangement of a normal bodily process.

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An old widow suffered irreversible damage to a cartilage in her foot several years ago. It causes her great pain when walking, and this has made her significantly curtail the activities she previously enjoyed. She consulted several orthopedic specialists both in Iran and in the US for the problem, but refused each of the treatments they suggested for her. She said she couldn’t have had surgery at the time she injured her foot for various personal reasons. She rejected cortisone injections because she had been told by a beginning medical student that cortisone causes all the bones of the body to become hollow, weak and susceptible to fracture. Pain medication was not acceptable to her because, “When it wears off, the pain is still there, so what is the use?” The only advice from allopathic practitioners which she accepted pertained to life-style modifications: she performs range-of-motion exercises with the foot, sits or stands with it elevated at all times, and applies elastic bandages and heat to it when the pain gets particularly severe. In addition, in the latter instances, she soaks the foot in a pail of warm salt water to “draw out the pain.” She also follows a rigid diet to control her blood pressure, which, she maintains, aggravates the pain in her foot as it rises. Iranian allopaths ridicule or treat with resignation patients’ (and colleagues’) hesitations about taking medications because they are “not natural” or “don’t work” or “don’t agree with me.” What can be done, after all, for the woman who throws her entire supply of a hard-to-find but for her condition essential heart medication in the drainage canal because “hāl-am be ham khord (my health broke down)” after she took the first one? Or about the old man who stops taking the medication for his gastritis after just one day because “fāīde nadāsht? (it didn’t work)?” Or for the woman with severe pains in her foot who refuses to get a cortisone injection because she is afraid this will “weaken the bone” and in any case will not get rid of the problem? But even as Iranian allopaths resign themselves to these explanations, they recognize that it is their own native medical conceptual system that brings about allopathy’s failure. While they can deride their patients as “stupid” for not following allopathic recommendations, they cannot really fault them for wanting instant cures, for being concerned with the “hot” and “cold” properties of medications, for not wanting to take “artificial” drugs, for not wanting to feel polluted or for being afraid of risking the loss of their fertility, precisely because the reasons behind these prejudices are so understandable and incontrovertible.

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Medical Pluralism By mutual justification and accommodation, allopathic and traditional medicines have to a large extent been brought into alignment with one another. This is not to say that there exists a syncretic system of medicine in Iran. Rather, multiple explanatory and therapeutic strategies exist side by side. Any illness episode can be understood in terms of several explanatory systems and treated by several therapeutic modalities simultaneously. It can potentially be attributed to too much “hot” or “cold,” exposure to dirt, stress, striking of the Evil Eye, fate, or to pathophysiologic processes. Each explanation suggests a different strategy for alleviation of the disorder: treatment with herbal or pharmacologic medications, neutralizing the “hot” or “cold” state of the body by ingesting something of opposite value, purifying the body by blood letting, ingestion of “filtering” foods, or fasting. Prayer and pilgrimages can be performed at any time for any condition, and it never hurts to carry a bead against the Evil Eye. A middle-aged widow who was eking out a living for her large family from social security and small land holdings suffered severe low back and leg pain. She took Tylenol for several days but this did not cure her. Her son took her on pilgrimage to Mashhad, by airplane because the long bus ride would have been too strenuous for her. There she asked Imam Reza to cure her back pain but the pilgrimage “didn’t help.” While she was in Mashhad she also went to see an allopathic physician, a back specialist. He did not make a satisfactory diagnosis so her son took her to see a back specialist in Isfahan, eight hours by bus from the village in which they lived. This doctor, after a series of diagnostic studies, concluded that she had sciatic nerve damage and advised her complete bed rest on a hard surface for forty days. She did this, but the back pain did not improve. The pain in her leg did, and she attributes this to a hot paste of garlic, mint, unripe walnuts and figs, wild rue, and other herbal ingredients which she applied to her legs three times a day. Recently she sought the advice of yet another back specialist, this time in Shiraz, much closer to her home than Isfahan, and was told she would need an operation. Rather than scheduling it there, however, her son set up an appointment for her with a surgeon in a provincial town even closer to home, because he charges less than the surgeons in Shiraz.

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HEALTH AND MEDICAL PRACTICE IN IRAN A young woman from an impoverished background is married to a rich and very old man who has grown children and grandchildren from previous marriages. She was diagnosed with peritoneal tuberculosis after her husband could no longer ignore the complaints of abdominal pain she had been voicing for seven years because she lay in excruciating pain for two days and could not get her housework done. Though peritoneal TB carries a bad prognosis, she is primarily concerned with the fact that, after seven years of marriage, she has never gotten pregnant. She is compliant with the triple-drug therapy for TB though it causes stomach-pains, which she treats with a syrup made of acorns, because her doctors told her that God willing, she will get pregnant if she takes the pills. “But now I have been taking them for nine months and I am still not pregnant,” she said. The pathologist who diagnosed her TB, reading the surgical diagnosis of “frozen abdomen” [all the organs in her abdomen and pelvis are stuck together with dense adhesive tissue] shook his head in sympathy. “God willing, He will cure her,” he said to me. She herself says “my mother died; my father gave me to this old man who doesn’t want to spend the money to take me to a good doctor who will help me get pregnant. God is all I have left. God willing He will give me children.”

Moreover, there is nothing inherent in any of the conceptual systems that dictates a hierarchy of resort in any particular illness episode. As can be seen from even a superficial reading of the cases presented above, numerous factors external to explanations of disease causation impact the organization of therapeutic strategy. These factors include access to resources based on economic status, gender, age and the proximity of allopathic centers on the one hand, and on the other on the value placed on a particular explanation or strategy for action. Therefore, how an illness episode is conceptualized and dealt with depends, beyond assessment of an explanation’s or recommended therapy’s logical “soundness,” on the relative authority with which the various possible explanations and treatment strategies are invested. This authority is derived from factors external to the explanation of disease itself, which I will explore in the following chapters.

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PART TWO

The Contexts of Medical Practice

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Chapter 6

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The Economic Context of Allopathic Practice

Economics and Medicine from the Patient’s Point of View Iranians say that the primary determinant of access to medical resources in Iran is economic. The more money, time or effort is required in pursuance of a particular therapeutic strategy, the less likely the poor or those in positions of dependence (women, children and the elderly) will have access to it. For example, in 1999, when the average daily worker’s wage was 1,500 Toman (approximately $2 US, 1998) and an office visit to a general practitioner cost 600 Toman, a generalist in Tehran who called himself a “nutrition specialist” offered weight-reduction diets individualized to his patients’ needs and tastes for 3,000 Toman per office visit, with visits required every week for adjustments and modifications in the diet, indefinitely. Obviously, this doctor’s personalized services are a prerogative of the rich: the poor obese with diabetes, heart disease or elevated blood pressure are on their own. The costs of ground shark cartilage, electrolysis, laser ablation of nevi, plastic surgery and the various facial creams and lotions, which are all valued for their “beautifying” effects are prohibitive: only the rich can afford to have good skin, Iranians say. Most Iranian women say they would prefer to avoid the pain of childbirth, but at 70,000 Toman per elective Cesarean section in the public hospital in Shiraz (500,000 Toman privately in Tehran), poor women cannot afford to avoid the pains of labor. Of all the therapeutic resources available to Iranians, people attribute to allopathic consultations the greatest expenditure of time and money. Getting an appointment at the university clinic in Shiraz is a multi-step procedure, each of which requires long waits in long lines. First the patient or his/her representative must go in person to the physician’s secretary to get a payment form, this must be taken to the accounting office to pay the visitation fee and then be presented again to the secretary in return for an

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appointment (vaqt, time). Vaqts are given on a first-come, first-serve basis. Most physicians at the clinic are booked out for months in advance. The patient is assigned a date and a number, with which the secretary estimates when the patient can expect to be seen. Number 67, for example, is the sixty-seventh patient to be seen by the physician that day. If the clinic begins at 3:00 pm, the patient may be advised to expect to be seen anytime from 4:30 pm onwards. The physician rarely begins his/her clinic on time because of delays in the surgical suite, hospital, meetings or elsewhere, and the appointment time estimated by the secretary is based on an overestimation of the speed with which the physician sees patients. Thus the wait on the appointed day in the waiting room can take many hours. This is especially true for patients who come from far away, cannot call in advance to check on the physician’s progress and have no other place to wait. If the patient misses his/her turn, the process has to be begun all over again. Once the patient sees the physician, more likely than not some kind of diagnostic study will be ordered. Some of these are performed at the university clinic, others require trips, whether to a near-by facility across town or occasionally even to a distant city. All of them require more money, more waits. Many patients are seen by the physician after the laboratory has closed for the day, requiring a special trip back for the study and another appointment with the physician. General practitioners, besides ordering their own slew of tests, liberally refer patients to specialists, which again entails more money and more waits. In rural areas, the Iranian government has instituted measures to make allopathic medicine accessible. One of these is the establishment of rural government-financed clinics. From their inception in the 1960s, they were staffed by graduates of the nation’s medical schools, who were obliged to deliver medicine to underserved areas in fulfillment of their military service and as a prerequisite to being licensed to practice privately. Despite problems with the system, these clinics work very well in providing rudimentary primary care to populations which would otherwise be without medical services. They have been especially effective in providing family planning and maternal and child preventive care. For diagnostic studies, medications not available in the clinic pharmacy, or specialty consultations, rural patients still have to go to urban centers. In addition to the clinics, the government of the Islamic Republic has supported the opening of many new medical schools and residency programs, as well as the expansion of existing ones, in order to train many more physicians than before the Revolution. As a consequence, the number of generalists as well as specialists has risen sharply since about 1990.

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Physicians licensed to practice after their obligatory two years of government service previously could open a private practice in one of the larger towns or cities, but now they have to move farther and farther into rural areas to find an open niche. For example, thirty years ago the government clinic in a village in southwest Iran was served by a Pakistani physician because there was such a shortage of Iranian graduates that foreign physicians had to be imported to staff rural clinics. In 1998, the government clinic in the same village was staffed by two full-time Iranian physicians, a recent medical school graduate performing his obligatory medical service, and one full-time nurse who, along with three midwives, ran the family planning and maternal and child care programs. There were also two private physicians’ offices in the village. In addition, just forty minutes away by car, the provincial capital, which did not exist thirty-five years ago, provided the services of numerous private and government-financed generalists, specialists, clinics and hospitals. When faced with illness, these villagers thus have many more choices for allopathic therapy than they had thirty years ago. While the increased number of physicians and medical support services (laboratories, clinics and hospitals) has increased the accessibility of allopathic services for the majority of the rural population, they have not decreased medical costs. Besides the physician’s fee, patients must pay for diagnostic studies, drugs, referrals to specialists, and surgery. The government helps defray these costs by providing insurance to certain sectors. Government employees, military personnel and their families, university students and the rural poor are automatically covered; insurance for private companies and the self-employed is also available. Among the nearly two hundred patients seen by a general practitioner in the university clinic over the course of a week, not one paid the entire medical bill out-ofpocket. The co-payment is generally 1/3-1/4 of the fee, so that to seek the advice of a generalist who charges 600 Toman, a patient with insurance need pay only 150-200 Toman. Translated into US dollars (1998), the physician's fee is $1 and the copayment 15-20 cents. This is a staggering sum of money in the estimation of Iranians. When one considers that an average monthly salary for a government employee in 1998 was US $50 (30,000 Toman) this estimation is hardly surprising. But it is not only the poor who complain about the costs of health care. While the rich are willing to pay thousands of Toman for cosmetic surgery or elective Cesarean sections, they are as bitter as their poorer compatriots at having to pay 200 Toman for a consultation with a generalist, let alone 600 Toman or more to see a specialist. This indicates that, in fact, Iranians are addressing many more issues when they talk about

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the expense of going to see a doctor than just the monetary cost of health care. There are seven key issues underlying Iranians’ complaints about the cost of health care in the country. 1. The expectation that health care should be free. Part of Iranians’ disgruntlement about medical expenses stems from their expectation that the entire cost of medical care ought to be paid by the government. This is what they had been led to expect from their pre- and post-revolutionary governments’ propaganda, along with free education, free water, free gas and electricity, and free bread. Complaints about the cost of health care, especially by members of the middle and upper classes, are expressions of dissatisfaction with the non-fulfillment of these promises, with having to make do with a less than utopian situation. In the same vein, rich owners of swimming pools complain about the price of water, car owners complain about the price of gasoline (8 cents/gallon in 1999), and everybody complains about the government’s plan to stop the subvention of bakeries. 2. The unpleasantness associated with seeing a physician. There are the long waits in the waiting room with strangers, the impersonality of the audience with the physician, and the awkwardness of having to give the physician personal, sometimes even embarrassing, information. 3. Resentment of physicians’ economic status. The money spent on allopathic consultations is thought to go straight into physicians’ pockets to finance luxurious cars and houses and vacations in Europe. That a large percentage of physicians’ incomes goes to pay clinic overheads and nurses’ and secretaries’ fees is beside the point, because enough money still obviously goes to (some) physicians to allow Iranians to associate being a physician with an extravagant life-style. Though such a life-style is no longer attainable for the majority of recent medical school graduates, patients begrudge the doctors every single Toman of their income. 4. Doubt that a consult will yield the desired result. The economic cost of a consultation with an allopath is weighed against the expectation that such a consultation will be effective, i.e., will yield the desired result– preferably, a complete and instant cure. Iranians have no doubt about the efficacy of an appendectomy or triple-bypass surgery in extending one’s life in the case of appendicitis or coronary heart disease, no doubt that one needs a course of effective antibiotic therapy if one develops endometritis after childbirth, no doubt that a cancerous prostate should be removed, no doubt that a weak and sickly child needs to be tested and treated for anemia. In these instances, even the very poor will scrape together the funds. They can take loans, they can and will bargain over the price of

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surgery, they may go to a public clinic which requires a minimal, if any, copayment; pride will be swallowed and waits will be patiently endured. But doubt about the benefits of an allopathic consultation or intervention compounds the unattractiveness of its monetary cost.

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A middle-aged, retired schoolteacher suffered a number of vague complaints, from a headache after a minor accident to upper abdominal pain to pains in her knees. Upon the encouragement of foreign visitors, she went to consult a physician. After a series of laboratory tests, X-rays, CT scans and sonograms, correspondingly vague diagnoses were given (tension headache, fatty liver, nonspecific degenerative changes in the knee). She was advised to follow-up with a neurologist, gastroenterologist and orthopedic specialist. Considering the hassle involved in arranging such consults and the expenditure of time and money they would involve, she asked, “Was there something wrong with the X-ray machine when they took these X-rays? Was there something wrong with the CT machine? Was there something wrong with the sonography machine? None of these tests showed anything wrong with me, so what is the use of going to even more doctors?” An old, retired schoolteacher suffered pain in her upper arm for weeks. She spoke every day of having to go see an orthopod for this, but followed up immediately with, “But how can I go? I am an old woman. Just to walk from my doorstep to the street to get a taxi is hard for me. Then they give me no respect when I am there and make me wait forever for my turn. And what will be the use? He will tell me the skin on the arm-bone is inflamed and that I should go to physical therapy. I know this already, so why should I pay money to hear this again?” A middle-aged housewife bled excessively during her menstrual cycles. Being very devout, she was troubled by this not just because of the discomfort but because it meant she needed to abstain from religious devotions for even longer than usual during her menses. She finally went to consult a gynecologist, who performed a sonogram, told her she had a tumor in her uterus, and put her on birth control pills. She stopped taking these because of the sideeffects she experienced, and was having heavy menses again. “But what is the point of going to the doctor?” she asked. “I will have to

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give 400 Toman just to see him, he will perform another sonogram just to make money, and then he will tell me the tumor is still there. He cannot stop the bleeding, so what is the use?” 5. The severity of the illness. The expense of a therapeutic option is weighed against the perceived severity of the illness or its attendant disability. One does not go on a several-day trip to the shrine of Imam Reza in Mashhad for a self-limiting headache or a cold, neither does one spend money and time at the clinic for it, but treats it from one’s own stock of home remedies. On the other hand, in the face of severe, intractable illness such as chronic back and leg pain, cancer, infertility, or a child who has suffered brain damage, greater expenses and efforts are justified. In fact, in these cases, as long as finances allow, no road is left untravelled. Cures are sought at increasingly more powerful centers: specialty university clinics, referral centers in large towns and cities, larger and more important shrines, even medical centers in the US or Europe and the holiest of Shi’a shrines in Syria and Iraq. 6. Access to resources within a family. Just how severe an illness or its attendant disability is and how much expense it justifies is left to the estimation of the person who controls a family’s finances. In this respect, women, children and the elderly face an additional obstacle in access to allopathic health care. They need to garner permission, help and/or money for allopathic consultations, tests and referrals from the men upon whom they are dependent–fathers, husbands, brothers or sons. It is the religious and social duty of these men to provide for their dependents, but how, or when, or after how much cajoling, needling, wheedling, manipulating and threatening by the ill person and his/her allies in the family they will discharge this duty depends entirely on the style of their interpersonal relations. In the best of cases, best in the estimation of Iranians themselves, a visit to a doctor requires no explanation or justification: the head of the household grants the permission and resources just for the asking. In the worst of cases, men face no sanctions, except being bad-mouthed, for not providing this support at all. For the most part, women, when faced with illness, need to either scrimp and save from household money to get to see a doctor without their responsible man’s knowledge, or else need to discuss the problem and justify the visit to the doctor with yet another person. The hierarchy of resource allocation in families follows lines of gender, then of age and marital status. Males have more access to resources than females, regardless of age; adult, married women have more power than unmarried, young or old ones. Thus the adult, married woman of the

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household is responsible for the care of old and young household members, which includes assuming an advocacy position on their behalf when they require allopathic attention. If, for example, a mother-in-law and sister-in-law do not get along well, which proverbially is the case and also to be expected from the patrilineal, patrilocal structure of Iranian families, then the old woman must turn to other family members who might have influence over her son, such as her daughters. (For literature on family, social structure, gender and marriage in Iran, see: Aghajanian, 1994; Betteridge, 1988; Esfandiari, 1994; Friedl, 1994; Haeri, 1989; Hoodfar, 1997; Kandiyoti, 1996; Mir-Hosseini, 1993; Moghadam, 1993; Pakzad, 1994; Wright, 1978). The husband of a woman with peritoneal TB refused to organize consultations with an eye specialist for his wife, though he had been told personally by her doctors that the antibiotics she was taking could cause serious, irreversible eye damage if her vision was not monitored frequently during the course of therapy. The woman said, “My father came and offered to sell one of his cows to send me to the eye specialist; his sons [from a previous marriage] came and told him his behavior was not right, but does he care? And do I look like the kind of person who will pick up and go see the doctor all by myself?” An old, frail, illiterate woman lived with her youngest son and daughter-in-law and their seven children. She complained loudly and bitterly every day about feeling ill, weak, and ready to die. These complaints were not even attended to; they were a background noise which everyone ignored. When she complained about itching on her face, no one listened, either, and she developed a patch of raw, peeling eczema which stretched across her entire face. Even after this was finally noticed, her son hesitated to take her to the clinic because he did not want to pay for the consultation and the medication. His sisters were the ones who remonstrated with him for his neglect of their mother. The person who controls the finances may, as is evident in the cases above, not attribute the same degree of severity to an illness episode as the actual sufferer, and so not be willing to devote resources to it. The husband of the woman with peritoneal TB is not invested in helping her overcome her infertility, though the fact of her childlessness is devastating to her,

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because he already has several sons and grandsons. A man is less likely to seek treatment for his old, frail mother’s endometrial cancer than for his wife’s cervical cancer, since his mother is a drain on the family’s resources while he needs his wife to take care of his children, and he will likely find his wife’s complaints of vaginal spotting easier to ignore than his own frequent trips to the bathroom because of an enlarged prostate. 7. God’s will: When to call enough, enough. When a patient has come to the end of his/her resources, when all avenues of potential recourse have been explored, when no help is anticipated anymore, then the illness is relegated to “fate,” put in God’s hands: “whatever God wishes.” An illness episode is one’s fate from the very outset, but one has a religious obligation to do all one can do to address it. One who does not treat an illness to the best of his/her ability is a religious derelict. It is a violation of God’s order to not take a child suffering from meningitis or a woman in labor with a breech presentation to the hospital. God has provided humans with the knowledge to treat many diseases, Iranians say, and therefore not seeking treatment and claiming that an illness is one’s “fate” is stupid as well as religiously objectionable. Two old sisters were discussing unpleasant events that had occurred in the past. “What do I know what God wants with us,” one of the old women sighed. “Vai!” the other retorted, “don’t hang everything on God’s neck. We do something stupid and come to grief and say it’s what He wishes. Is our stupidity His fault?” Practically, then, “fate” is a diagnosis of hindsight, and the point at which to start having this hindsight is at individuals’ discretion. For Iranians, fate begins where personal will and resources leave off. Like the determination of the severity of an illness episode, when to stop trying is usually in the hands of the person controlling the family finances. The woman with peritoneal TB, though theoretically she could still seek help from infertility specialists in the cities and make pilgrimages to the larger shrines, has already had to entrust her fate to God because her husband will not stand for further expenses. On the other hand, a widow with vertebral disc damage who manages her own finances has made vows to Imam Reza in Mashhad, gone to see at least two specialists in distant cities, culled generations of wisdom about herbal medications, and scheduled surgery in yet another town: she makes no indication that she is about to surrender to fate, yet. “Insh’allah [God willing] the surgery will be effective” is the only concession she makes to God at this point.

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In summary, patients deliberating their therapeutic options see the purely monetary economic cost of allopathic consultations in relation to a whole host of extra-economic factors: the ideal of free medical care, the hassle involved in seeing an allopathic doctor, resentment of doctors’ extravagant life-styles, perception of the severity of the illness episode, access to resources within the family, the anticipated efficacy of the recommended therapy, and the religious obligation to take care of oneself and one’s dependents. Economics and Medicine from the Practitioners’ Point of View Very often when I told Iranians, physicians and lay people, the topic of my research, they told me this was not a difficult topic “because it all boils down to the poor economic situation in Iran.” They attributed what they saw as shortcomings of the medical system to both a lack of resources (emkānāt) and an oversupply of physicians. While certain practices (e.g., physical exams not performed thoroughly, if at all, patient histories taken on the fly, well-to-do patients referred to private clinics and hospitals, not keeping up with literature in the medical journals, and performance of blatantly unethical practices) obviously fell short of the ideal taught in medical school, Iranians nevertheless felt these were justifiable given the economic constraints within which physicians are forced to practice medicine. In fact, they claimed that economic constraints were the biggest factor in shaping medical practice in Iran: because of them Iranian allopathic medicine is in a “broken” (kharāb or be ham rīkhte) state and physicians are forced to practice “impetuous” or “hasty” (houlakī) medicine. To begin with, people say that technological, pharmacological, spatial and temporal resources necessary to practice state-of-the-art medicine, incorporating both the newest and best diagnostic and therapeutic strategies as well as attention to medical and Islamic ethics, are simply not available in Iran. This is true especially in rural areas. The pharmacologic and technical resources are not available for the physician in rural government clinics to provide more than very basic medical care: stitches for minor trauma, childhood immunizations, medication for common complaints such as sinusitis, reflux gastritis, urinary tract infections, depression, anemia or asthma. For these ailments, diagnosis and treatment are done presumptively, that is, without the aid of even rudimentary technologies such as those necessary to perform urine cultures or blood chemistry analyses, let alone endoscopies, microbial susceptibility tests, pulmonary function tests or EKGs.

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Likewise, the freedom to dispense medications is restricted by limited resources. Certain medications are just not available locally or in Iran generally, and others are not affordable for many patients. In government clinics, the pharmacy is given a monthly supply of medications, such as ampicillin. If the doctor prescribed ampicillin for infections based on the “treatment of choice” as taught in medical school, the entire supply would be gone by the middle of the month. So the physician must decide in every instance whether the second-choice treatment would do as well, and offer the patient the option of going to the city to purchase ampicillin out-ofpocket. In other instances, the patient may demand a second-choice therapy because it is less expensive than the first-choice one. Though the physician is aware that this provides less than optimal therapy and is associated with many side-effects, economic realities cannot be dismissed. A physician performing his obligatory rural medical duty confessed that even though he gets to return to his home in Shiraz for three days of every week he never goes to the library to read the medical journals. “Because it is all theoretical. For example, the textbooks say the treatment of choice for meningitis is a third-generation cephalosporin, but we don’t have those in Iran, so what are we supposed to do? Now think of all the information that comes out in the journals, every week new drugs and new uses for old drugs and most of them we don’t have here, so what is the use of knowing about them? That’s only for the good of the university professors, so they have something to talk about: ‘in the US they use such-andsuch for the treatment of this disorder.’” An Iranian medical school graduate doing her residency in the United States said, “The biggest difference between the practice of medicine in the US and in Iran is that in the US, a lot of resources are spent managing complicated cases, like advanced diabetes with hypertension, angina and peripheral neuropathy. In Iran we just give up on these because the resources are not available to help the patients anymore, but in the US such cases are routine. That is very challenging and interesting, unlike anything I had ever seen in Iran during training.” A general surgeon in a small town in one of the poorer provinces of Iran said, “I have three operating rooms but usually I don’t have any staff and have to operate all alone. I had one patient who was run

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over by a car, his liver and spleen were smashed flat and his intestines torn apart. I was in the operating room all by myself, cut him open from his thorax to his pubis and was frantically tying off all the bleeding vessels. I had to work fast and hard to prevent the patient from bleeding to death right there on the operating table, so my system was flooded with adrenalin. An operating room technician came by and I asked him to come in and help. He said he was hungry and was going to get something to eat instead and walked away. It was all that adrenalin in my system: I put a wet towel over the patient and ran after the tech and cut a ten centimeter long gash in his upper arm. I couldn't control myself.” The most important “resource” in short supply in Iran, physicians claim, are patients. Physicians blame the government for having ruined the profession by having trained and continuing to train far too many physicians to meet the actual demand, the number of patients. Therefore, competition among physicians for patients, that is, income, is extremely high, and this, they say, leads to not only sub-standard but blatantly unethical practices. The ideals and high standard of practice physicians learned in medical school and were sworn to with licensing are not tenable in the real world, they say: practicing ideal medicine leads to starvation. They feel they must structure their practice so that they see as many patients and do as many procedures as possible, even at the risk of, in the former case, treating symptoms rather than making definitive diagnoses, and in the latter, performing unnecessary procedures. A young man performing his obligatory rural medical service said, “On the one hand you have hunger and on the other your conscience. Even if you can stand hunger for yourself you can’t stand to see your family hungry. So you have to design your practice with money in mind: see more patients, do more procedures. If a patient comes in with a headache you could just give a diclofenac injection but you get more money if you write for normal saline and then inject the diclofenac in the bag and give it intravenously. Last week a mother brought her three children to see me, they all had a cold. I was just going to charge her one office visit, but the administration told me no, I had to charge her three individual ones. Even if you want to work from your conscience, you can’t do it. The culture is such that you give up. You start out idealistic and want to know the cause of the patient’s problem and then you end

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up treating symptoms because that is quicker. Like someone comes in with knee pain and without asking any more questions you inject cortisone and he comes back later blessing you because you’ve taken away his pain, but you haven’t solved his problem and he doesn’t know it. That is how it is in Iran: it is a culture of thieves (dozd). I don’t mean the kind of thief who comes in over the wall at night and takes your gold, I mean cheating, making people pay for something by making them believe it is necessary. That is our culture, that is a reality. Doctors begin their practice simply, full of all the knowledge that they learned in the university, and then they set up shop, really they become shopkeepers (maqāze-dār). They start to trade off what they have learned, using it to make money.” A young physician studying for the residency entrance examination said, “Nowadays you have to be really zereng (clever, strong) to be a doctor. For example, when a patient comes with sinusitis, you have to write for three different antibiotics to be sure that at least one of them will work, because there is always the chance that the treatment of choice given in the textbook is not available in the pharmacy or not effective for this particular patient. If the treatment fails for whatever reason, the patient won’t come back to see you, and you end up with an expensive office and no clients.” An orthopedist trained in Europe said, “Patients don’t trust doctors: they collect opinions from them. It isn’t like in the West where a patient chooses one doctor and whatever that doctor says they adhere to. Here, patients go to see one doctor and if they don’t like what he says they go to another one, or two or three. So most of our time is spent giving third and fourth opinions. We call it houlakī (impetuous, hasty) therapy. Because doctors don’t take time to talk to their patients, to really listen to them and examine them and treat them well. For example, a woman I knew had been treated for six months with physical therapy for pain in her back, and wasn’t improving. Because she was a friend of the family, I went to visit her, and I talked to her. I asked if she did breast exams and she said she had noticed a lump and gone to the doctor and was told she should have a biopsy, but she never had it done. I told her to have it done and sure enough, it was cancer, and the pain in her back was due to metastases to her vertebrae. Because of my intervention, she lived for another two years. That was only because I took the time to

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examine her case thoroughly and ask all the right questions, and I did that because she was a friend. That is what medicine is like here, we are forced to practice it houlakī.” The ideals of practice are furthermore corrupted by patients themselves, physicians claim, as patients demand substandard and often unethical practices and services. They ask for abortions; they ask to be given cheaper, though less than optimal, medications; they resist going out of their way for diagnostic procedures or to procure medications; they do not come for follow-up visits or routine physical examinations.

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A neurosurgeon said, “Patients expect us to make them one hundred percent better, immediately. If I tell them that they have a 90 percent chance of improvement of their condition with the surgery I am recommending, they will not come for it because they are afraid they will be in the 10 percent that the operation will not help. They will go to the doctor who will assure them, though there is no way he can really be sure, ‘100 percent you will be better.’” A young physician said, “We do not rely on clinical data as much as you do in the United States. When a patient comes complaining of pain with hunger, that indicates that s/he has gastric ulcers. If the pain comes after eating, then it is most likely a duodenal ulcer. Of course, the definitive diagnosis can only be made with endoscopy, but patients wouldn’t go for that. If I sent all my patients with this kind of pain to the city for endoscopy to rule out pancreatitis or gastric cancer, none of them would come back to see me again. Because most of them will just have ulcers and improve with standard antibiotic therapy, so they say, ‘My uncle went to Dr. X and he gave him a medication and his pain went away, so why are you sending me to have a tube put down my throat?’ If it is something more serious, they will be back and then you work them up further.” Iranian physicians say these three factors–the lack of medical technologies and pharamaceuticals, the number of patients in relation to the number of doctors, and the expectations and demands of patients themselves–put them in a bind when it comes to actually practicing medicine in the real world. The ideals they are taught in medical school are corrupted by economic realities to the extent that some physicians, finding

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they make less money with a lot more hassle “trading” off their knowledge than investing in private business enterprises (poultry farms, stone quarries, orchards and vineyards, plumbing shops, used-car shops), leave medical practice entirely.

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“The leaders of the Islamic Republic have ruined our profession,” an intern claimed, “by allowing far too many physicians to be trained. There are so many physicians now that there is no guarantee that we will ever find a job. With so many people being trained who do not know how to comport themselves as physicians, the status of physicians in society has decreased. In addition, the money physicians make is nowhere near what it used to be. So people are leaving the profession because they see that to have a nice house and a nice car, it is easier to go to the market and buy and sell pipes and electrical sockets, or to buy things in Dubai and Kish and sell the goods at inflated prices, than to sit in a clinic dealing with people’s unhappiness.” The arguments Iranian physicians put forth to justify their medical practices reveal a tacit expectation that medicine be a lucrative business. This does not differentiate them from physicians elsewhere, except for the explicitness with which Iranians talk about it. US physicians are perhaps shielded from having to give such obvious thought to methods of meeting their economic expectations by already inflated salaries and vast business structures which do this thinking for them. However, Iranian physicians’ admissions that their standard of practice suffers in many ways because of their economic concerns indicates a deep-seated economic pragmatism which takes priority over ethical considerations. Satisfying one’s own demands, and those of one’s family, is more important than doing right by patients. And it is not just a matter of “putting bread on the table.” It is a matter of financing big houses and luxurious cars and vacations in Europe and shopping-trips to Tehran, Dubai, Kish and even Paris. For most physicians and trainees I spoke to, being a physician meant not only access but entitlement to the material trappings of the upper classes. A professor of OB/Gyn listened quietly as students and residents complained to him, during morning rounds in the obstetrics ward, about the sad state of affairs facing medical students after graduation: the shortage of jobs, the shortage of opportunities for residency training and the necessity of having to perform the obligatory

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medical service. After letting them vent for quite a while he narrated, at length, the difficulties he had encountered when he first began practicing OB/Gyn thirty-five years ago: the scarcity of resources, the large numbers of patients he had calling him out of bed every night, the lack of staff in the hospital and clinics. “Do not think when you see me driving my nice car and living in my nice house that I had that all waiting for me when I graduated from medical school. Where I did my obligatory service, there wasn’t even an outhouse in the courtyard where I lived. You think you should have it all without having worked like we did?” he concluded. The students and residents did not look reconciled to the state of affairs, however. Patients recognize physicians’ expectations of a grand life style, and this is one of the things they resent about allopathic visits, as described previously. However, these alone cannot be held accountable for the houlakī (hasty, impetuous), zereng (clever), and maqāze-dār (businessoriented) medical practices. Rather, physicians’ economic expectations, a true shortage of technological and pharmacological resources and patients’ expectations of treatments and cures together shape medical practices in Iran. Shortcomings of Economic Justifications It is tempting at this point to stop the analysis of allopathy in Iran and “explain” it in purely economic terms. I could provide an outline of a calculus patients make when they weigh the expense of allopathic consultations against their expected benefit, taking into consideration the individual patient’s estimation of the severity of the illness, the control s/he has over resources, his/her sense of religious obligation, and his/her expectations of a cure. Likewise, from the practitioners’ point of view, I could conclude that standards and ethics of practice are undermined by economic considerations. While neither of these conclusions would be false, economic models fall short of providing a satisfactory description of medical practice in Iran. There is no doubt that money influences every aspect of life in Iran: concern with it amounts nearly to an obsession. It is the ultimate motivator, the ultimate means, the ultimate end. It is a marker of social status. It accrues to those who have it and brings other riches with it, such as beauty, comfort, and honor. “It’s the reality of life,” I was frequently told, “If you want to live, you have to have money.” At the same time as everyone wants,

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or needs, money, the prices of staples are rising exponentially and the goods considered “staples” are increasing in number. A large house, a car, private tutors for the children, private lessons in anything from martial arts to cake baking, computers, satellite dishes and cellular telephones are by now considered standard and necessary items in the middle classes not only for comfort but for the social advancement of oneself and especially of one’s children. Consequently, Iranians take loans far beyond any expectation of repayment. They dabble in buying and selling anything from real estate to antiques, they hold several jobs and drive taxis by night, they look out for their best monetary interest wherever they can. It is small wonder, then, that physicians feel they become shopkeepers (maqāze-dār), trading off their knowledge, that patients estimate whether a consultation with a physician will be worth its cost, that physicians feel few if any compunctions cutting corners in the interest of seeing as many patient/clients as possible, that patients are likely to delay pursuing costly therapies to the point where an effective treatment is no longer a possibility, that physicians, not seeing a lucrative future, leave practice entirely. Money justifies Iranians’ health-related practices at another level as well. By referring to Iran's economic condition as an “explanation” for the way medicine is practiced in Iran, Iranians can put the blame for substandard and unethical practices on the shoulders of an ephemeral victim: one cannot, after all, take “economics” to court. It is fully justifiable, in their eyes, that doctors and patients look out for their own economic security, since the government is not doing this for them. Nothing can be done about Iran’s economic crisis at an individual level except try to keep one’s head above water. In addition, they say, it isn’t even their own economic security they are looking out for, but the comfort and future of their families, especially of their children. How can one blame anyone for wanting the best for one’s children, regardless the cost? And meanwhile, patients and physicians alike can continue to hope that one day the government will be able to pull itself together and provide free insurance to every patient, an EKG machine to every rural clinic, free gas, bread and water to everyone, and a salary sufficient to buy real estate and cars to first-year medical graduates. In such an ideal setting, medicine will be practiced ideally. While there is no doubt that economic factors do motivate Iranian patients’ and physicians’ health-related practices, these practices cannot be reduced to economic goals and motivations entirely. Economic explanations given in Iran are too facile, too pat, too incontrovertible and too generally applicable to be satisfying. Iran’s poor economic condition is used as a

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readily-available explanation of and even justification for a large array of behaviors and attitudes. It falls glibly from the tongue in any context. It is an especially convenient formula for expression of dissatisfaction.

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“My daughter went to her last birthday party yesterday. She will not be able to go to any more,” an OB/Gyn told me sadly. “They are so expensive: the decorations, the food, the cake. Who can afford to have them anymore? And not just the hosts: the guests have to look nice and bring presents, too. Even if you go to only five parties a year, that is five dresses and five presents. Who has that kind of money? So you see how it is in Iran: the economic condition is even ruining children’s fun!” The discussion of passengers traveling from Shiraz to a village two hours away in a private taxi was about Iran’s poor economic condition. Each of the passengers in turn complained about the effects of the economic shortage on his own career in psychology, urban planning, medicine, teaching, and the free market. In their tales barriers other than economic ones were mentioned: the psychologist who said he did not have sufficient funds to study for an advanced degree abroad was tied to Iran by a family reluctant to leave jobs, schools, extended family and friends; the urban planner having difficulty finding a job was unwilling to move to an area of the country where his skills were in greater demand because of personal prejudices against it; the medical student resented having to perform his obligatory military duty; the teacher mentioned political disputes in his school’s administration; the businessman had a feud with his business partner, who had been his best friend. But these factors were not elaborated on at all in their narratives. Rather, Iran’s economic condition was identified as lying at the root of all their problems. The contexts in which economic factors are mentioned as “explanatory” indicate that for the most part, complaints about the economy are post-hoc rationalizations of beliefs, practices or states of affairs motivated by other factors or structured on other bases. In the context of medicine, for example, there is an obvious contradiction between physicians’ claims that there are not enough patients and the fact that they see a large volume of patients at break-neck speed: each can be rationalized by reference to the economic situation, but together they contradict one another. Moreover,

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economic factors do not explain why the cutting of corners in medical practice takes quite the shape it does. They do not describe what it is about physical examinations, about patient education, about the nature of lifethreatening conditions that allows them to be performed or discussed in the way they are. If time is money, why can a great deal of it be spent with a patient talking about her “beauty” but not on educating her on the necessity of taking medication for a chronic disease? What could be the economic rationale behind listening for the sounds of blood flow through three layers of clothing? What could be the economic rationale for not telling patients with life-threatening diseases their diagnoses? If a patient is concerned about the cost of a consultation or a treatment, why is s/he more likely to consult a second, or third, or fourth doctor for the same condition rather than follow the therapy(ies) recommended by the first? Obviously, economic explanations do not get to the root of the matter. Medical practice in Iran is not just economically based, but stems from ideologies and concepts so matter-of-fact or common-sensical to Iranians that they need not be mentioned by them in explanations. In the following chapters I will attempt to delineate these common-sense ideas by starting with the hypothesis that the concept of authority, which has implications for ethics, lies at the root of allopathic practice in Iran. This hypothesis is derived from closer readings and closer observations of what patients and physicians say and do. From the “patient’s point of view” emerges an alienation from medical knowledge. Patients do not appear to have cognitive recourse to medical knowledge in the sense that they can or even want to understand the implications of a diagnosis in the manner in which it is written about in textbooks. Even if the pathophysiology of their condition were described to them in lay terms–so what? What patients want to know is what to do, how to get rid of the disease, how to reverse it. It is the expectation patients have that an allopathic practitioner will be able to authoritatively answer these questions that ultimately motivates patients to pursue or not to pursue allopathic consultations and therapy. From the point of view of the practitioners, that medical practice in Iran falls short of the standard espoused in American medical textbooks and journals and reported by the physician-professors who saw training abroad can be explained by the obvious fact that native Iranian ethics and American medical ethics are not identical. Practice in Iran is shaped by an Iranian ethic shared by Iranian patients and practitioners and is therefore, while in some instances undesirable to both patients and practitioners, neither substandard nor unethical except from an American point of view.

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In summary, while economic factors in Iran provide a powerful motive shaping therapeutic strategies and medical practice, they cannot describe or predict their actual shape. Rather, economic explanations provide a model applicable to a wide range of Iranian behaviors and experiences which allows these to be justified. They do not represent in its entirety the calculus by which Iranian patients make therapeutic choices or by which Iranian physicians structure practice. I will argue in the following chapters that this calculus is based on ideologies or key concepts by which patients decide whether to trust allopaths, and how patients and physicians expect to be treated by one another. In other words, it reduces to the topics of authority and of ethics.

Chapter 7

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Roots of Authority: Knowledge

Medicine is not just about treating disease: it must first and foremost “make sense” of a biological phenomenon. Medical systems inform the recognition and interpretation of symptoms so that they resonate with what is already known about the world, specifically, about health and about oneself. In other words, they bring an extra-cultural occurrence, such as the thirst of diabetes, the wasting of cancer, the elevated numbers of a blood pressure reading, or the stiffness of arthritis, into a cultural frame. It can, of course, be argued that these “natural” or “biological” phenomena are cultural constructs to begin with, as has been argued for the symptoms of menopause (Lock, 1993). However, for the sake of simplicity I will grant that there are physical sensations consistently interpreted as “abnormal” by the members of a culture, and that medical systems revolve around “making sense” of these abnormal sensations. The authority of physicians is crucial in this sense-making process, and not just in Iran. Whether or not the advice of a particular physician is sought and whether or not that advice becomes motivational, i.e., becomes integrated into a patient’s knowledge structure such that it becomes a basis for action, depends on the degree to which the patient grants the physician the right to be authoritative. The manner in which the patient is attended to, personal characteristics of the physician and what the physician does or does not say, influence the patient’s evaluation of a physicians’ authority, and through this, the patient’s evaluation of the cause of the illness, its severity and how to treat it. Authority infuses the physician-patient relationship from long before the actual office visit to long after. In this chapter I will explore one of the factors by which patients in Iran grant their physicians authority, namely, by evaluation of the extent to which a physician is knowledgeable.

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The Nature of Knowledge In Iran, the word ‘elm (science, knowledge, learning; from the Arabic root ‘ulm, plural ‘olūm) figures prominently in talk about allopathic capabilities, and is key to understanding physicians’ authority. The following description of the semantic field of ‘elm is presented not in order to exoticize the range of its meanings, which admittedly overlaps with English cognates, but to delineate the roots of physicians’ authority. Analysis of what ‘elm is in relation to medicine and medical knowledge allows us to understand what kind of expectations patients have of physicians and derivatively, what kind of authority physicians have. In the context of a university, “’elm” is used in place of the English word “science.” In fact, Iranians assured me that the two words were entirely synonymous. The medical school at the University of Shiraz is the “University of Medical Sciences” (dāneshkade-ye ‘olūm pezeshkī) and the information contained in textbooks and journals is called “medical science” (‘olūm-e pezeshkī). When discussing the content of classes and clerkships, the English word “science” was used by students and professors to stress that the ‘olūm-e pezeshkī taught at the medical school did not differ in substance or kind from the “medical science” learned in medical schools in the West. In the sense of “science,” ‘elm stands in the titles of many other university departments as well, from political science (‘olūm-e sīāsī) to oceanography (‘olūm-e darīāī va oqīānus). Like the English word “science,” ‘elm also refers simply to a body of knowledge: that which is known. In this sense it is synonymous with dānesh, knowledge, and does not necessarily imply active research (subsumed under tahqiqāt or pazhuhesh) or address the fluid and emergent nature of knowledge. ‘Elm and dānesh are talked about as seemingly clearly bounded objects which can be acquired in their entirety, held, shared, kept to oneself, wasted, disseminated, used or stored. A young man was interested in learning calligraphic painting. “My uncle is a master calligrapher. He has never taken any students but when I asked him to teach me, he made an exception. In four hours he taught me everything he knew (tamām-e ‘elm-esh) about calligraphy.” “She knows chemistry,” an elderly lady said of a niece, “she learned all of chemistry at the university, and now her husband won’t let her work. What a pity, all that knowledge going to waste!”

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Specifically, ‘elm is described as knowledge that can be used to improve the quality of life. The disciplines of chemistry and physics, for example, yield an understanding of the laws of nature which can be manipulated to alleviate the hardships of life, people say. The refrigerator, the car, plastic and steel are cited as products of ‘elm or dānesh which have directly and positively impacted the way humans live. Likewise, medical knowledge improves life by reducing suffering due to disease. In the context of religion and ethics, ‘elm refers to the knowledge needed to live humbly and purely in the path of God, to garner His satisfaction and to thereby secure oneself a place in paradise. Like the English “knowledge,” the referent of ‘elm and dānesh is not bounded by the scientific method, such that knowledge derived from personal experience (such as effects of foods on the tab’) or about humanistic subjects is considered to be ‘elm or dānesh as much as that derived from methodical collection of data with the intention of testing a hypothesis. In fact, the scientific method is identified by Iranians as but one of several means of improving the quality of life. Iranian medical knowledge, for example, is based on “science” (allopathic medicine) as well as on personal experience (how one’s personal tab’ responds to environmental factors) and on anecdotal evidence (e.g., medicinal attributes of herbs, passed informally from one generation to the next). Similarly, ethical and religious ‘elm is derived from study of Islamic texts and their exegeses by Islamic scholars. Thus ‘elm, though in one sense translatable as “science,” does not signify knowledge based only on the scientific method. Similarly, those who possess ‘elm, an ‘ālem, doktor or ostād, are not “scientists” in the sense of necessarily being actively engaged in scientific research. An ‘ālem is a learned person, a wise person, a scholar, one who has amassed a large amount of knowledge and can be appealed to for advice on the basis of his wisdom. The advice sought from an ‘ālem is spiritual, moral or ethical. The ‘ulamā (plural of ‘ālem), for example, are scholars who have demonstrated mastery of religious texts and the ability to interpret these. On the basis of this knowledge they are supposed to have the authority to give advice on the proper conduct of an Islamic society. Doktor is a title adopted from the educational system in the West and, as in the West, is properly applied to anyone who has an advanced degree from a university (though the default doktor is a medical doctor). A doktor may, but does not necessarily have to be, engaged in research. The title implies more the expectation that the ‘elm of the doktor be practically applied rather than expanded by scientific inquiry. Like an `ālem, a doktor has mastered a body of knowledge and is supposed to be engaged in

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applying it for the betterment of society. What differentiates the ‘ālem from the doktor is the nature of what each has studied and of what each is engaged in doing. The wisdom a doktor has is practical, that of an ‘ālem is moral and ethical. A doktor is expected to apply his or her knowledge towards a practical end: building a bridge, curing a disease, managing a fish hatchery or designing economic policy, for example. An ‘ālem, on the other hand, is expected to convert his or her knowledge into advice that can help one live a morally and religiously sound life. A medical doctor can also be an ‘ālem, but only if s/he is able, on the basis of his/her study of religion and ethics, to suggest, in an impartial manner, how to lead a “good” (khūb), simple, clean, healthy, humble life. An old woman showed me her collection of books on Galenic and herbal medicines, which she consults on occasion to treat illnesses in herself or her family members. Many of these books attribute the knowledge therein to Imams, refined and elaborated over the centuries by traditional as well as allopathic doctors. In addition to listing the health-promoting properties of various herbs and foodstuffs, these books contain advice on how to avoid ill health by living humbly, paying attention to personal cleanliness and following God’s orders to pray and give alms. “There is so much knowledge in these books,” she said. “What a pity doctors don’t study it anymore. They spend years and years in training and in the end, what do they know? The people who wrote these books are truly ‘ālem. If you were to dedicate yourself to study of the Koran and avail yourself of the knowledge in these books, in addition to that which you have learned in medical school, you would become an ‘ālem, too.” Unlike ‘ālem and doktor, ostād is a master of a skill or trade who is or can be engaged in teaching it to others. The skill can be anything from construction to calligraphy to curing. The title alone does not discriminate a master tailor from a professor of Persian literature or a master architect from a health care professional engaged in teaching medical students. The skill an ostād has can have been acquired formally (at a university or through an apprenticeship) or informally (through private study), but more important than the mode of its acquisition is the fact that it has been forged and refined through experience. Being an ostād does not necessarily require certification or credentials: anyone who is popularly recognized as a master of a skill to the extent that s/he can be engaged in teaching it,

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whether officially (in a school) or unofficially (a neighbor teaching literacy to refugee children), is an ostād. In a university context, professors are ostād; professors of medicine are both doktor and ostād, whereby their being ostād ranks them higher in the estimation of patients than their being a doktor.

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The Value of Knowledge Knowledge, ‘elm, is highly valued in Iran, and people who are in possession of knowledge, whether religious, scientific or practical, are held in high esteem. The Prophet Mohammad is often quoted as having said that no expense should be spared in seeking ‘elm. People say this is because knowledge cannot only improve the quality of life if directly applied, but even more so, because a well-educated populace improves the social fabric in general. A group of women medical students were discussing the careers of some of their female colleagues who had recently graduated and finished their obligatory rural service. A few were offered government jobs, a few were studying for the residency entrance examination, but many had quit medicine entirely. “Oh, well, what can we do,” they said. “It is so difficult to establish a private practice, and anyway, we say that a woman who studied medicine will be a better mother because, since she has studied nutrition and knows all about diseases, she knows how to raise healthy children.” Knowledge or learning may be valued for its social benefits, or at least, used as a rationalization for the social status quo, but the fact that a higher education enables social as well as personal advancement is not overlooked, and it is generally expected that people should be recompensed for sharing their knowledge with society. Thus an education is regarded as a form of capital, a possession which can potentially bring in an income. The more one has of it, the more profit one should be able to make of it: a college graduate expects to make more money than someone with just a high school degree, and a cardiologist expects to make more money than a general practitioner. Derivatively, garnering an education for one’s children is considered to be securing their financial future. This expectation that knowledge can be converted into money is to a large extent frustrated in Iran today. Students spend years studying under intense pressure for the university entrance examination with little hope of finding a job based on a university education. It is estimated that in 1996,

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600,000 university graduates in Iran were unemployed (Kian-Thiebaut, 1999), and the number has most certainly risen with the worsening economy. Many more graduates find jobs in the informal sector of the economy where use is not made of their expertise. Medical students also complain that there is no guarantee that they will find a job at the end of their studies, and they easily cite instances of relatives, friends and acquaintances who quit a career in medicine to open a lucrative business. Unemployed high school graduates (diplom bīkār), college graduates holding jobs totally unrelated to their majors, and university professors and physicians investing in or even running their own business are so common as to not only not cause surprise but even be accepted as the norm. “What business are you in?” was a question I frequently heard physicians asking each other. An OB/Gyn buys apartments to rent out, an orthopedic surgeon has fruit orchards and a poultry farm, an ophthalmologist owns a shop selling plumbing hardware, a midwife may be visited in the same office by patients as well as clients coming to “buy and sell” carpets, cars or real estate with her. What frames youths’ choice of what to study or even whether to study at all is the poor economic environment, and not merely an idealistic consideration of the importance of ‘elm. An education is to serve personal advancement in the first line, they say, and any good it may do socially or for one’s spiritual salvation is a secondary consideration at best. By extension, if an education doesn’t give access to a well-paying job, why bother with it, they argue. And just as the conversion of knowledge into money is not as straightforward as young people have been led to expect, they say that being educated does not yield the same kind of social respect it formerly did. Education used to count for more in the past, they say; now, all anybody thinks about is money. A recent graduate of medical school rationalized her choice of residency, rehabilitation medicine, by saying, “Physicians don’t make any money anymore, so why should I work like a dog and waste my life? Rehab is easy: all you have to do is read EMGs and make recommendations for physical therapy, and you still charge the same for a patient visit as any other specialist.” “There is no ‘elm in Iran because it doesn’t count for anything,” a nurse in a government clinic said. “Medicine in Iran today is gone to pieces (be ham rīkhte). Doctors work only for money anymore; they have no conscience.”

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In their negativity, these statements actually underline the importance with which ‘elm is, in fact, regarded in Iran. To have knowledge that can be offered society for its improvement is identified as being of value and deserving of social and financial recognition. The link between social and personal gains inherent in the conceptualization of ‘elm allows people who possess ‘elm to simultaneously be respected and not respected. The conceptualization of ‘elm contains an inherent contradiction which makes it problematic as a basis for a physician’s authority. The Problem with Knowledge Patients’ recognition that ‘elm can be converted into money undermines the respect which physicians consider their due. This is because of the expectation that, just as monetary wealth is to be shared with society through the giving of alms, so people who have knowledge should share it freely with those who do not.

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A retired schoolteacher quoted the poet Sa’adi as having said that there are two kinds of bad people in the world: those who have money and don’t share it and, even worse, those who have ‘elm and don’t share it. An elderly woman who had been widowed at a young age and raised her five children alone said that the hardest thing in her life had been that no one had given her any guidance. No one had ever come and said, “Ma’am, don’t go that way, do this instead.” “That is the problem with this country,” she said. “Those in the know don’t take the responsibility to help the rest of us.” The expectation that physicians, in possession of ‘elm, should share their knowledge magnanimously with people in need stands in stark contrast to the fact that physicians are concerned with their own financial gains. Thus the very fact that they charge patients for their advice casts doubt on that advice. It fuels the suspicion that physicians order tests and suggest procedures out of financial interests rather than for the good of the patient. The patient is therefore always in a position to second-guess the physician’s recommendations: is surgery really necessary to cure a condition? is a sonogram really necessary to make a diagnosis? is an EKG really indicated? or are the physicians making these recommendations in order to be able to pay the fine for filling their swimming pool, pay for their children’s braces

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and private English lessons, or even simply pay off the costs of expensive medical equipment? Physicians’ relationship to ‘elm is made even more problematic when one takes into consideration that the basis of financial success in Iran is said to be zerengī, shrewdness or cleverness. The trait of zerengī is greatly admired in Iran, but it does not have purely positive associations. Zerengī is the ability to act on an advantage without being held back by consideration of the fairness of the transaction. A person who is zereng is admired for perceiving and exploiting such advantages (even, through deceit, creating them for exploitation), but begrudged for being clever at others’ expense. While zerengī describes the positive attributes of intelligence and sharpness of wit, it also connotes thievery, cheating and taking advantage of others’ weakness or ignorance. A general practitioner recounted with obvious delight the story of an Iranian physician who went around to garage sales in Los Angeles picking up Iranian antiques from unwitting Americans for a pittance. Once he found a samovar from the 19 century that had a recess in the bottom for hot coals. “He showed it to the lady who was selling it and said, ‘Too bad somebody ruined this thing by making a hole in the bottom. It’s perfectly useless this way. I will take it off your hands for $5.’ And she thanked him for taking it!” Later that same day the physician loudly and angrily cursed a man who had, many years ago, bought a piece of property from her aunt for a fraction of what it was worth. “The man made zerengī by saying the land was so far from the city no one else would buy it from her. He knew he was cheating her, too, for why else would he have backed out of the room after she signed the deed over to him, with his hand over his heart, bowing with every step, saying, ‘Forgive me, forgive me’?”

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th

In Iran successful physicians are said to be “making zerengī.” Often, this involves merely basic business tactics. A good example is the cooperative out-patient clinic formed by university-affiliated physicians in Shiraz. All university-affiliated physicians were invited to invest in the cooperative, but those invited to staff the clinic were the ones with the largest patient loads. Part of the clinics’ profit is used to purchase diagnostic technologies such as a CT scanner and an MRI machine. There is an out-patient surgical suite on the top floor and physicians’ offices are well supplied with the newest technologies. In 1999, the group was also building a hospital with an adjacent hotel. Patients were attracted to the clinic because of the big-name

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physicians on staff and its high-tech capabilities, which are heavily advertised. Having a lot to offer and presenting it in a clean, “modern,” glitzy setting is one form of zerengī. Physicians who do not have such resources while attempting to build their private practices must use other tactics. Examples of zerengī in medical practice that physicians themselves identified and told me about included: giving symptomatic treatments (e.g., cortisone for joint pain) in the absence of a clear diagnosis, giving medications on demand rather than for an allopathically justifiable reason (e.g., calcium injections are demanded by women for the comfortable, “hot” feeling they cause), prescribing multiple medications for one condition to ensure that at least one of them will work and the patient will be satisfied, performing unnecessary procedures (EKGs, sonograms) so as to be able to charge for them, and referring well-to-do patients seen in public clinics to private ones for procedures. The recognition that physicians “make zerengī,” whether justified in any particular instance of practice or not, undermines patients’ trust in their doctors. How can they trust someone whom they suspect of treachery, they ask. The answer refers back to ‘elm: the core of respect due to people with advanced knowledge is still there. While association of what physicians do for money may be grounds for distrusting their recommendations and for seeking a third or fourth consultation, it does not influence the value of what physicians know, of ‘elm in the abstract. Consequently, what patients look for in choosing a physician or in deciding whether to follow his/her treatment recommendation is demonstration that s/he is knowledgeable and experienced, i.e., truly possesses ‘elm, and that s/he can be trusted to make a recommendation out of consideration of the patient’s best interest, not his or her own. Assessment of the former is done on the basis of formal and informal credentials; assessment of the latter is made by evaluation of whether the physician is using his/her knowledge honestly. How a Claim to ‘Elm is Evaluated Physicians’ formal authority stems most obviously from their training, which is under close professional surveillance. Their progress through the medical curriculum, including acceptance to medical school and to a residency training program, is regulated and determined by performance on standardized tests taken at various stages of their training. A license to practice medicine is dependent on successful completion of medical school as well as two years of obligatory government service (tarh), and specialty licensing is dependent on completion of a residency training program and participation on a formal, standardized specialty board examination. The

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tests for acceptance to medical school, advancement through the medical school curriculum, acceptance into a residency program and specialty board certification are, Iranians’ acknowledge, impervious to cheating, bribery and personal favoritism. There are many fewer medical school and residency spots than there are people qualified to fill them, so that qualifying examinations have the power to make or break medical careers based on a single point difference in score. Consequently, students are in fierce competition with their classmates to score well on the exams, which in itself is thought to ensure the quality of physicians. While students’ mental aptitude is ostensibly the basis for advancement through a career in medicine, the government can and does control students’ progress through the academic curriculum on the basis of extracurricular considerations. Women, people of rural origins and people who fought or lost a family member in the war are given prerogatives. A percentage of spots in medical school and residency programs is reserved for students from these demographic groups, leaving a way open for zerengī to be made. For example, since students from cities have to score higher on exams than students from rural areas to get into medical school, some urban high school students establish residence in a village to improve their chances of success. And “Victim of War” cards, like any other form of identification, can be faked. In addition, students’ politically correct “Islamic behavior” is closely monitored throughout their course of study. Their personal files contain information on their political orientation, on whether they pray and fast and behave modestly with members of the opposite sex, and on breaches of Islamic conduct. The content of these files is taken into consideration when students face academic promotion. Consequently, though they might study to the point of exhaustion, students still feel that whether or not they succeed in their academic curriculum is largely beyond their control. “All the cards are stacked against us,” a male intern said. “Thirty percent of spots in medical school are reserved for the ‘Victims of War’, another 30 percent are reserved for women, another 30 percent for students coming from disadvantaged areas. How are the rest of us supposed to have a chance for a career in medicine?” A female medical student had her heart set on a residency in cardiology. She out-performed by far all the other students who sat for the very difficult residency admissions examination. However, the position was awarded to someone who had scored nineteen

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points less on the exam but was granted twenty “free” points based on “Victim of War” status. Though designed to be fair and free from corruption, the credentialing process in Iran is not impervious to zerengī and does not guarantee that the academically “best” are chosen for training positions. In the eyes of physicians and patients alike, this casts aspersions on the quality of medical education, despite the rigorous credentialing process. Physicians do not hang their diplomas on the walls of their offices, but the course of their training is public knowledge. What university they went to, whether or not they went on a “Victim of War” ticket, their origin from a village or from a city, where they did their specialty training, whether they went abroad for training and if so, where to–this information is generally discussed and easily accessible to patients. Other patients waiting their turns, the secretary in charge of appointments, the guard at the door can all be asked and freely discuss physicians’ credentials. Even before making an appointment, a patient likely will have inquired into these issues by discussing them with relatives, neighbors or acquaintances who have consulted the physician before. Patients evaluate their physicians’ aptitude on the basis of ten qualities or circumstances that include but go beyond their formal credentials. The order in which I present these does not reflect their order of importance. Which of these is considered to be most important varies by patient, by illness episode, and by time during the treatment course at which the evaluation is solicited. For example, a physician’s “Victim of War” status may not be so important for a patient that s/he will not make an appointment, but may become a justification for not following the physicians’ recommendations after having been seen. 1. The status of the medical school. Any of the older medical schools in the large cities are said to give a “better” education than the newer, smaller ones and the “free” (āzād; tuition-based) universities. It is assumed that the “better” faculty are attracted to the larger cities and larger medical centers, that the volume and types of cases seen at the larger medical centers provide greater experience to students, and that, with more faculty, larger medical centers provide their students with more teaching and more supervision. Thus the medical schools of the Universities of Tehran, Isfahan and Shiraz are identified as the “best” in the country, and graduates of these schools receive more respect than colleagues from newer, smaller schools.

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2. Demographic group. Having gone to medical school on a “Victim of War” ticket undermines a physician’s claim to knowledge. A lazy, stupid person can get through medical school and even into and through a residency program just for being from a “victim of war” family, people say. The same is true, they say, though to a lesser extent, of students from rural areas (dehhātī). The latter claim is consistent with a cultural stereotype of the people from the dehhāt (rural areas, villages) as being backward, uneducated, unrefined and uncultured. 3. Foreign training. Having “seen” training abroad, for whatever duration and in whatever foreign location, is taken as a guarantee for superior knowledge: only the “best” students go abroad, and the “best” knowledge is available only abroad. Likewise, anyone who can claim to having practiced abroad is considered to be superior, because his/her competency was “proven” on the international scene. This attitude derives from the general valuation of all that is foreign, as discussed in more detail in Chapter 8. Foreign training may lend additional value to a person’s ‘elm, but because it is valued, it is yet another site for zerengī to be made. Physicians readily pointed out to me colleagues who saw only a few months of practice, and this without clinical responsibilities (because of practice requirements in the US and Canada), yet make a big deal of their experience when they return to practice in Iran. 4. Practice location. It is said that the “best” physicians practice at university clinics or privately in cities. This claim is based on the observation that physicians’ careers take them from rural areas in which they serve their two years of obligatory government service to increasingly larger urban centers and potentially even university appointments as they prove their advanced understanding, knowledge and skills. With the current glut of physicians looking to establish their practices it is felt even more strongly that only the best can succeed in the cities. Those practicing in smaller towns or in rural areas are considered good enough for common afflictions, a bout of asthma, a headache, a urinary tract infection, a cold, because they have seen these before. For rarer or more serious conditions it is best to see a physician in the city who has more experience and more diagnostic and therapeutic technologies at his/her disposal. Thus just the fact of practicing in a city gives physicians authority, independent of where they received their training. 5. Age. Older, more mature physicians are preferred over recent medical school graduates on the grounds that they have more experience, i.e., their knowledge and skills have been honed to a greater extent.

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6. Personal recommendations are taken from people with a personal connection to or personal experience with a physician, or from people with “insider knowledge.” A physician who successfully cured a patient’s aunt of stomach pains, treated a neighbor’s son’s third-degree burns or helped a distant relative overcome her infertility is by the recounting of these acts recommended to the patient. In the absence of such testimony, people who “should know” are turned to for advice. This could be the guard of the clinic parking garage, the wife of the brother of the hospital janitor, the neighbor’s wife whose sister is a nurse. These are, so the reasoning goes, in a position to give advice because they “see”, i.e., hear about, what goes on in the clinic or hospital every day: they know who is good and who is bad, who cures patients and who is ineffectual. A neurosurgeon laughingly said that his biggest friend–and potential enemy–was the guard of the parking garage at the hospital in which he practiced. “I saw four years of rigorous training in Shiraz with the best surgeons, and then got sub-specialty training in the US, but patients don’t care about that. As long as the illiterate guard of the parking garage pronounces that I am a good surgeon, I will continue to have patients. But heaven forbid I forget to give him a gift for his kids on New Year’s!” 7. The ability to achieve a cure. In other people’s recountings and recommendations patients look for positive outcomes: cures. Reference to formal credentials speaks to the expectation that the physician has the power to apply his or her body of knowledge to an individual’s condition in order to make a diagnosis and recommend a successful treatment. In other words, medical knowledge alone is not enough to justify a physician’s authority: the physician must be able to convert this knowledge into something practical or beneficial, just as anyone else who is “learned” or “wise” is expected to be able to give useful advice. The more intractable, serious or rare the treated illness is, the better the physician who cures it is estimated to be. The respect given physicians thus increases the more narrow and focused their area of expertise becomes. An OB/Gyn doing everything from delivering babies to treating polycystic ovary disease and excising uterine and ovarian tumors is “good” enough for these common conditions, but not as “good” as an infertility specialist who helps countless women achieve pregnancy, or an ultrasonography specialist who diagnoses rare gynecologic conditions. The paradox that the circumscription of physicians’ area of expertise augments his or her putative

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curative power leads some patients, especially those with little formal education, to consult specialists for problems outside their specialty, just because they are considered to be “good” doctors.

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A renowned ophthalmologist reported that frequently patients come to her with complaints having nothing to do with their eyes. When she asks them why they have come to see an ophthalmologist to treat a skin cancer or a child’s hydrocephalus, for example, they respond that she had achieved a remarkable cure in a relative and thus must be a very good physician. 8. The ability to make a diagnosis. Contained within the criterion of a physician’s ability to achieve a cure is the prerequisite ability to make a diagnosis. This ability is popularly thought of not in terms of the time, care or attention given to making a diagnosis, as through careful study of laboratory results, inspection of the patient and diagnostic visual images, or consultation of medical journals. Rather, it is the ability of a physician to immediately identify what is wrong with a patient without having to ask questions or order tests. Stories are proudly told by patients and physicians alike of physicians who could, on giving a man a handshake, tell him that he had too much iron in his blood, on hearing a woman’s dry cough identify that she was not tolerating her blood pressure medication, on witnessing someone’s bad mood conclude that he suffered from ulcers, on seeing a pair of bulging eyes know that the person’s thyroid gland was diseased. The story of the patient who, in response to the physician’s query as to what is wrong, responds, “I’ve come for you to tell me that!” is recounted with great delight as representing, albeit at an absurd level, what medical practice is all about. When Iranians talk about Ibn Sina, whom they consider to have been the greatest physician ever, they invariably, reverently mention his blindness. A masterful physician does not need to even literally see a patient: s/he intuits what is wrong. A surgeon said, “Patients don’t like us to take our time making a diagnosis. If we take time, they think we don’t know what we are doing. If we want to study an X-ray, we have to do it out of sight of the patient. In front of the patient, we just take the radiograph out of the folder, take a quick glance at it, put it away again and pronounce the diagnosis. Patients expect us to be able to tell what is wrong with them just by taking one look at them or asking them one question.”

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An orthopedist proudly recounted how he had diagnosed breast cancer in a friend’s wife by “asking just one question: do you perform self-breast exams?” Consequently, a physician who practices thorough (according to American standards) medicine runs the risk of being considered “no good.” A patient who is given a thorough physical examination is likely to suspect the physician for not “seeing” what is wrong. It would be absurd for a physician to check the ears, nose, mouth and throat of a patient complaining of difficulty urinating, or to ask about a woman’s reproductive history when she complains about abdominal pain. Both physicians and patients consider even looking at something the patient has already described as absurd. If the patient claims not to have noticed any deformity or abnormality in her neck or shoulder that might be the cause of arm pains, the physician’s examination should not be necessary. A patient’s description of the color and smell of her vaginal discharge is perfectly adequate for determining whether to prescribe an antifungal or an antibiotic medication, physicians assured me. 9. Physician’s decisiveness. Patients expect physicians to know not just immediately but also definitively what the problem is. A physician who says, in front of a patient, “I think . . .” or “according to the studies . . .” or “the way I see it . . .” has lost the patient’s respect. Either s/he “knows” or s/he “doesn’t know,” and knowledge lies somewhere else. Opinions do not count. The decisive, self-assured manner with which physicians interact with patients is therefore integral to the establishment and maintenance of their authority. 10. Gender. Men are considered to be better doctors than are women. This opinion exists despite the fact that men and women receive the same training, take the same exams, fulfill the same responsibilities and are licensed based on the same criteria. External qualifications notwithstanding, male and female patients, students and professionals alike assured me, the very fact of a person’s gender determines his or her capabilities as a physician. Attitudes about gender in medicine follow from cultural definitions of gender in Iran, about which much has been written (Aghajanian, 1994; Betteridge, 1988; Esfandiari, 1994; Friedl, 1994; Haeri, 1989; Hoodfar, 1997; Kandiyoti, 1996; Mir-Hosseini, 1993; Moghadam, 1993; Pakzad, 1994; Wright, 1978). It is not my goal to review this literature here, only to discuss those gender-related issues that bear a direct relation to the practice of allopathy in the Islamic Republic.

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Women are considered to be naturally nurturing, empathetic, careful, patient and supportive. These qualities make them well suited for pediatrics and OB/Gyn, it is said, because children and women, being more easily frightened and anxious by illness than adult men, require reassurance and support when they are ill. Women are also said to be indecisive, not aggressive, and easily swayed by emotions because their ‘aql (reason) is not as strong as that of men. In fields in which rapid decision-making is essential, such as surgery, women can never be as good as men, Iranians say. Although women can learn medical science to the same extent as their male colleagues, their ability to apply it in real-life settings, to real patients, in the real context of the clinic, hospital and operating room, is necessarily less. A recent male medical graduate said, “Women are very careful and emotional, while men are quick to get things done. For example, a physical exam-diagnosis-treatment job that would take a man one hour to do, takes a woman two or three. Women are that way by nature, don’t you agree? If a man decides to go out this door he’ll get up and go out the door, while a woman hesitates–should I go, should I not go, maybe there is someone out there, maybe I should telephone rather than go in person–before she finally goes. This indecisiveness can be to the disadvantage of the patient. Doctors must make immediate decisions and do the job that needs to be done. Also women are more emotional. If a wife yells at her husband, what does he do? He tells her to shut up and goes about his business as if nothing ever happened. But if a husband yells at or beats his wife, what does she do? She sits in a corner and cries. Whenever we had to go draw blood from a patient, men just went and did it; if it hurt the patient, so what. The job needed to be done. But women see that they are hurting the patient and hesitate, ‘Oh no, this hurts, the poor patient. How should I do it so it won’t hurt,’ and again the delay can be harmful to the patient.” In addition, while women are striving for excellence in the execution of their clinical duties, they are still expected to be wives and mothers, i.e., care-takers of the home, husband and children. Not only can they not dedicate themselves to their patients to the same extent as men can, time spent away from the clinic detracts from their ability to acquire “experience” in clinics. This a sentiment shared by men and women, professionals and lay Iranians alike.

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A (female) OB/Gyn resident said: “Our male professors are truly excellent, but there is only one really good female professor and she doesn’t have any children. The expectations our society has of us are too great for us to be good physicians as well. My husband lives in another city, and when he comes to visit he sits here in the living room and watches TV while I am in the kitchen preparing dinner and thinking about the exam that I should be studying for. He would never think to offer to make dinner so I can study, and I would never think to not do it, because that isn’t done. Men can be in the clinic and in the hospital taking care of their patients 24 hours a day, but we are expected to take care of the children and put dinner on the table, too, and we just can’t spend the time or energy that men do taking care of patients. If men were allowed into the residency program, they would be much better than we are because they don’t have all those other things to worry about.” A female medical student said, “I love surgery. I love it so much that whatever rotation I am on, I try to find an excuse to get into the operating room whenever I can. Dr. X, whom I always try to follow because he is such a good surgeon and teacher, laughs at me. He says I should get the idea out of my head; surgery is no field for women. And he is right. No patient will go to a female surgeon if they have a choice. It would be very difficult to establish a practice.” A middle-aged schoolteacher said, “It is true that men and women get the same training and theoretically are the same in their knowledge and ability. I want my daughter to get into medical school just as much as my son. Still, if I am sick I prefer to see a male doctor.” The Patient’s Knowledge The quintessence of a “good” doctor in Iran is an older, upper-class male working in an urban setting who had the financial and mental means to study abroad and who interacts in a benevolent but authoritative manner with his patients. The criteria by which a physician’s competence is judged cast the physician in the role of omniscient master who has the authority to make decisions about other’s lives because he knows what is best for them. The paternalistic structure of patient-physician interactions is thus not one that is simply imposed on unwitting patients but created and reproduced by patients’ expectations of a “good” doctor.

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Within this paternalistic frame, distances between the patient and the physician are maintained and fostered on a number of different fronts. Differences in social status and educational achievement are acknowledged during the ritualized processes of greeting and departure. The domain of medical ‘elm is marked off spatially and temporally from the domain of daily life by the time frame of patient visits (long waits punctuated by the short but intense attention of the physician) and by the physical proximity of the physicians’ practice to medical technologies (microscope, microbiology laboratory, CT scanner). Emotional distance is maintained by the physician not indulging in patient’s “narratives of illness.” And, probably most importantly, distance is maintained between the physician’s specialized knowledge and the patient.

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In a public women’s clinic in Shiraz a patient, at the end of a threehour long work-up, was told, “Mother dear, listen. You have some tissue hanging out of your uterus and it has to be taken out surgically, which we will do on Tuesday. We also have to take some tissue for biopsy, and then we need to cryo the cervix. Come to the clinic tomorrow to be checked in for surgery. Bye, now.” The patient left without asking a single question. A patient who had been cleared for surgery by an anesthesiologist asked the OB/Gyn resident performing the pre-operative physical examination whether the surgery was truly necessary, because she was afraid her large goiter would choke her if she went under general anesthesia. Without making eye contact with the patient, the resident said, “The specialist [anesthesiologist] said there will be no problem, but if you think you know better you can stay home.” An intern listening in on the conversation added, “The doctor determines for you, not you for the doctor!” The deliberate alienation of patients from information pertaining to their disease, whether the specifics of diagnosis and prognosis or of pathophysiology and pharmacology, stands in contrast to physicians’ expectation that patients “know” what kind of information the physician will need to make a diagnosis and that they will “know” to give this information without having to be prompted. The physician can adhere to the “ask one question” maxim by assuming that the patient is an accomplice in the diagnostic process, that the patient will report everything of importance pertaining to his/her health status.

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An OB/Gyn was perfunctorily asking a patient’s gynecologic history. The patient hesitated before answering some of these questions, apparently not expecting them (date of last menstrual period, age at menarche, number of miscarriages). The physician became increasingly impatient with the woman’s delays. Finally, she berated the patient. “Why didn’t you make a note of the answers to all the questions that I am asking you before you came to see me? Other patients give me this information even as they are sitting down in that chair. That is how good they are. I shouldn’t need to ask these things of you. If you don’t know these things, who should? It is you I am talking about, after all!” A patient “knows,” the reasoning goes (or at least should know), through careful attention to experience, what is “normal” for his/her body and will be in tune to any deviations from this state. These deviations are the reason why the patient consults the doctor, so necessarily s/he will tell the physician all about them. The physician translates this information into knowledge, ‘elm, accumulated through formal learning and experience, and on the basis of his/her understanding of what the patient has said, recommends a course of therapy. It is not expected that the physician doubt the completeness and accuracy of the patient’s information, and conversely it is not expected that the patient be told how the physician arrives at the diagnosis, i.e., why certain tests were ordered and how they point to the diagnosis, nor about the pathophysiology of the condition. All the patient needs and expects are detailed orders about what to do to alleviate the condition. Physicians are evaluated by their patients according to the extent to which they can “see” what is wrong and “know” how to correct it. They are not concerned with medical ‘elm itself, nor with evaluating whether a particular diagnosis is appropriate and which therapeutic option is best. Rather, they appeal to a physician as one appeals to any other learned person for informed, impartial and honest advice. In fact, it is the patient’s “knowledge” about his/her own body which is the ultimate arbiter of the soundness of a physician’s advice. Treatment recommendations are evaluated not only on the basis of whether they “make sense” in terms of native conceptualizations of disease, as discussed in the previous chapter, but also as to whether they effect a suitable response in the patient’s condition (tab’). In this regard, medical ‘elm, science, carries no demand for subjugation; its claim to omniscience and universality is vacuous. Science in Iranian medicine is merely one form of knowledge, and it must prove its

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mettle in practical applications, i.e., by assessment of its effects on individuals’ tab’s. In this chapter I have presented some of the main factors patients take into consideration when they evaluate a physician’s credentials and authority, and ultimately, whether to take a physicians’ advice. Just as the concepts of nature and moderation evaluate the logical soundness of allopathic treatment schemata, so informal evaluation of physicians’ knowledge informs the decision whether or not to engage them. Definitions of knowledge, ‘elm, and expectations of those who possess it are therefore powerful arbiters of the manner in which allopathy is received and practiced in Iran. In the following chapter I will describe how certain common medical practices (not telling patients worrisome diagnoses, spending minimal time with them, and the use of English for professional communications) are derived from extra-medical key concepts which link the valuation of a physician’s knowledge to the paternalistic frame of medical practice.

Chapter 8

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The Relationship of ‘Elm to Medical Practice

In this chapter I will discuss a few characteristics of Iranian medical practice, namely, the use of English for professional communications and rapid patient turn-around times. These practices are structured on common cultural values which link ‘elm to authority. I will therefore expand on the discussion of ‘elm from the previous chapter and demonstrate how this concept is linked to ethical principles which inform social intercourse. Through this discussion it will become apparent that the conceptualization and implications of ‘elm in Iran inform the expectations patients and physicians have of one another and therefore the manner in which allopathic medicine is practiced. The Use of English for Professional Communications At the University of Shiraz School of Medicine, professors, students and para-professionals are proud of the fact that they use English for professional communications. The arguments they present to justify this practice include: 1) to maintain a monopoly over medical knowledge. If patients found out what drugs to take for what condition, they would not feel the need to consult physicians anymore. 2) To preserve patient confidentiality. Charts, order forms and specialty consult reports are kept by the patient, so if these were written in Farsi, the reasoning goes, anyone who got hold of them could find out all about the patient’s medical condition. 3) To keep patients from worrying. If the patient should find out s/he has a severe disease, Iranians claim, s/he would lose hope and quickly die. 4) To adhere to the tradition of the medical school. The language of the medical school in Shiraz and its associated hospitals and clinics has always been English. 5) To understand medicine. One needs to be able to read English

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because that is the proper language of medical ‘elm, just as in order to really understand the Koran one needs to be able to read Arabic. These justifications for the use of English were given me with utter conviction by medical personnel and “lay” people alike, but at face value I found them far from convincing. To begin with, even if patients are not told the names of prescribed drugs, these are prominently written on drug packages in both English and Farsi. Common medical conditions are discussed or presented by medical professionals on television and radio programs in state-sponsored efforts at public education. Such conditions, their histories and treatments in friends and relatives, and the uses and sideeffects of common medications are also frequent topics of social discussions. Physicians could safely assume that patients have at least a rudimentary knowledge of common medical conditions (diabetes, hypertension, cervical and breast cancer, asthma, common childhood infections and heart disease) and the medications commonly used to treat these. A young physician quizzed her mother, a retired middle-school teacher who has six additional children: “What is ampicillin for?” “Sinusitis.” “What is gemfibrozil for?” “Fat blood.” “What is acetaminophen for?” “They give that when you have a cold, but it doesn’t get rid of the cold; it just makes you feel better.” “What is prednisolone for?” “That is what they give my mother when her asthma gets bad.” The young physician laughed. “I had to go to medical school for seven years to learn all this, and you learned it all from life!” “Wouldn’t it be better for me to take hydralazine for my blood pressure than metoprolol?” I was asked once during a social call. “My aunt takes that and she doesn’t have any problems with it.” The claim that the use of English helps preserve patient confidentiality does not hold water because there is no such thing, except in theory. Patient confidentiality requires at the very least an investment in space (private exam rooms) and time (waiting for patients to get ready). In the public OB/Gyn clinics in Shiraz, offices are packed with patients and their attendants, and staff. Students, interns, nurses and midwifes examine patients and discuss with them symptoms, conditions and treatment plans all in the same room at the same time. Physical exams are performed in tiny cubicles cordoned off by curtains which are constantly fluttering as the staff

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and patients’ attendants rush in and out looking for residents and for one another, and students and interns crowd around patients in order to get some teaching if a resident is performing the examination. Even in private practice, up to three or four patients may be in the physician’s office at the same time, and conducting the interview in a hushed voice may be the only concession made to patient confidentiality. In the sonography clinic at the university hospital the nurse makes sure there are three patients (often with their attendants) in the exam room simultaneously, so no time is wasted waiting for patients to dress and undress. From my notes: “Patient #12 is taking off her underwear while #10 is being examined. #11 is ready to get on the table, staring at the sonography screen while the doctor performs the exam on #10.”

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An older man was advised by a physician in the village in which he lived to have a mole on his cheek biopsied because it looked suspicious for cancer. He responded, “Well, I will go to the city to have that done, because if I had it done here, and the results were bad, before nightfall everybody would know about it.” The use of English may keep potentially worrisome information from patients, but it is not a fool-proof plan to keep them from worrying. English is so well known outside the medical establishment that patients could, if they wanted to, either read their own reports or easily find someone who can. This would not be productive, however, since the report would still need to be interpreted by someone with medical knowledge. Whether the report is in Farsi or in English should in this regard not make any difference. Also, patients worry about what is not told them at least as much as about what is. Expecting not to be told if they have a terminal condition, they can never be sufficiently assured that they do not have one. Reports written in English provide additional insecurity as patients can never be sure that all of it has been read to them or completely and correctly translated. And when a diagnosis truly implies a bad prognosis, the altered behavior of patients’ own attendants and the stepped-up medical attention they receive in themselves speak volumes. During a social call, a middle-aged woman handed me a report of a myelogram, asking, “Is there something on there the doctor isn’t

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telling me? Doctors don’t tell you if there is something seriously wrong with you. Tell me honestly: what is written?”

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A woman with cervical cancer had received radiotherapy but had not subsequently had her cervix removed, as was recommended. A year later she reported to her OB/Gyn that her symptoms had recently appeared again. The physician leafed through the patient’s chart and muttered, “What a bad thing you have done!” She sent the patient in to the exam room to get undressed and had a hurried, whispered conversation with the patient’s daughter about the bad prognosis and the need for rapid attention to the problem. When the physician and patient returned from the exam room, the daughter was clearly anxious, pale and nervous, but she attempted to smile cheerfully at her mother and said, “Don’t worry about anything!” The physician wrote pages of requests for laboratory and imaging studies and handed them to the patient, saying, “I have ordered a few tests. Go have them done and return as soon as possible with them. Don’t be worried about anything. We will do everything we can for you.” Finally, even the claims that professionals use English in order to adhere to tradition and because English is the proper language of medical knowledge is problematic. Other medical schools in Iran have never had such a tradition and yet are recognized for providing an education at least as good as that in Shiraz. The government has decreed that all lectures at the university are to be held in Farsi, so officially this tradition is not seen as necessary for the provision of a good education, either. In addition, many students confess their preference for reading medical texts in Farsi translation for ease of comprehension. Moreover, the English that is used in the medical context is, even by the admission of the Iranian physicians who use it, not very good. An administrative assistant told me proudly that I should have no difficulty understanding the lectures at the medical school because 80 percent of the language used in them is English. In reality, this language consists of English terms and phrases used as though they were Farsi. Medical students and para-professionals memorize lists of medical terms and phrases and insert them into their Farsi syntax, claiming that thereby they are speaking English. Professors use English terms and phrases in their lectures in a similar manner, or else may translate them into Farsi while speaking and use them at the same time in English on their visual aids. These are filled with

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spelling errors, and the English that is used on lab forms, in patient charts, on referral requests or specialists’ consultations often verges on unintelligibility. The poor quality of English tends to obfuscate rather than facilitate the transmission of medical information.

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An intern gave the following presentation of a patient (the English words were spoken as such): “Source of history: khodesh [self]. She is competent to give history. Chief complaint: chest pain. History of present illness: present karde bā crushing and tearing pain dar chest ke radiate karde be har do shoulder . . . [she presented with crushing and tearing pain in her chest which radiated to both shoulders].” A woman came to the public women’s clinic saying that her bleeding becomes “nok.” She was passed from the student to the intern to the junior and finally the senior resident, none of them understanding what she meant by it. Finally the patient said, “I don’t know what that means, either, but the doctor I saw last time told me that was my problem.” The medical residents discussed among themselves what this might mean until the senior resident concluded, “It must be an English term we are not familiar with.” Only one physician I spoke to, a European-trained surgeon working outside the university system in Shiraz, expressed his disapproval of the use of English in the medical context. He claimed the physicians who used English on their report and referral forms were putting on airs and that he himself chastised his colleagues for sending him patients with requests and reports that he could not read. The remainder of the physicians I interviewed, however, shrugged their shoulders at this criticism: they were using English, after all. Who cared if it was not perfect? Closer examination of the contexts in which physicians use English and the value placed on the use of English outside the medical setting reveals that English is used to validate and enforce the value of that which physicians know, their medical ‘elm. It serves to distance physicians socially and intellectually from their patients by marking medical knowledge as something to be valued for being “foreign.” In Iran, the importance of a “foreign” (khārejī) connection is allpervasive (see also Chapter 1). Any foreign commodity is super-valued over its indigenous counterpart. Khārejī (of foreign origin) is an adjective Iranians apply to anything from thread to teapots, industrial machinery to

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foodstuffs, art to computers, and likewise to knowledge and education, that was not produced in or did not originate in Iran. A foreign connection imparts value to any item. Aside from carpets and caviar (Iranian products which have proved their value on the international market), the “best” that is available in Iran, in Iranians’ estimation, is of foreign origin or, at least, an indigenous replica of foreign-produced items.

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A European woman living for many years in Iran told me, “Grocers only carry Turkish noodles, but they are awful. Everyone complains about them sticking together. The Iranian noodles are so much better, but they are hard to find. The same with jams: Iranian jams taste so much better than the stuff they import. But still the grocers give me the khārejī jams because they think they are better just because they are imported.” Overheard in various shops: “I need some eyeliner. Do you have any khārejī?” A shoe-store owner standing by the cash register and clicking on his laptop computer said, “We make the shoes here, but I got the design off the internet.” A couple brings home exemplars of European children’s fashions every season, reproduce them locally, and sell them at European prices with the justification that they represent khārejī fashions. A jewelry salesman said to a shop full of clients, “Everything I have is Italian, it is the best. If you do not like it, bring me a picture of what you want and I will make it for you.” “The khārejī thread is better, of course. Anything khārejī is better.” A young child was trying to wheedle his mother into buying him a pair of sandals. Against her remonstrances he said, “But they are khārejī!” At the same time as Iranians “have their eyes sewn to the West” (cheshm be khārej dūkhte), they take great pride in indigenous talents and abilities. While items from the khārej are identified as most valuable and references to Western products and brands are ubiquitous (e.g., plastic Mont Blanc pen replicas, shoes and purses with the word Titanic written on them, a Mercedes-Benz sign screwed onto the front of an Iranian-model car, Adidas stripes embellishing women’s Islamic coats), Iranians claim the superiority of their own reproductions of Western products. They claim that computers assembled in Iran with Chinese chips are “better” than the original because they last longer, replicas of designer jewelry are “better” than the original because they are made of 18 karat rather than 14 karat

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gold, traditional music produced in Iran is “better” than that made by Iranian expatriates in California because those who remained in Iran have preserved the spirit of Iranian music, Iranian youth are academically “better” than foreign students because they routinely sweep international science olympiads.

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An electrical engineer gave me a tour of the thousand-bed hospital and clinic the Iranian Social Security Organization was building in Tehran in 1997-98. He proudly pointed out to me that Iranians had been able to build it on their own, from scratch, i.e., without needing foreign advisors or, except for the most specialized machinery, foreign products. Even the panels holding the electrical wires in the patient rooms and the cabinets in the pathology laboratories were pointed out to me as having been manufactured locally: “Just as good as the original and much cheaper!” As we were leaving, he made sure I got another overview of the entire structure and asked, “Do you recognize the building? It is an exact replica of a hospital in Chicago. The architect got the blueprints from the United States and made improvements on them.” It should be of no surprise then that the cultural valuation of the “foreign” extends to medicine. Physicians are proud of the extent to which they replicate the practice of American allopathic medicine in Iran. They quickly point out that they learn medicine from the same textbooks as are used in the United States and get training modeled after that in the United States. Textbooks of medicine are not written by Iranian medical scholars but are translated by them from the English originals. Moreover, medical training in Iran is considered by Iranian physicians to excel that in the United States because students in Iran receive more hands-on experience. Physicians trained in Iran who take the United States three-part National Medical Licensing Examination are claimed to easily score in the 90th percentile. The nationality of Iranian physicians who hold prestigious positions at medical schools and hospitals in the United States is proudly pointed out as demonstrating Iranian physicians’ superior aptitude. When physicians have a chance to see practice in the United States or Canada, they are amazed at the few responsibilities, from “scut work” (changing bandages, putting in urinary catheters, drawing blood for tests) to actual procedures (lumbar punctures, putting in intravenous lines, intubations, suturing) students are expected to perform in comparison to students in Iran. Residents as well are given so much responsibility in Iran and are

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under such time pressure to execute these that in terms of practical skill, it is claimed, they far surpass their foreign counterparts. The head of the OB/Gyn residency program said, “Our residents often ask those of us who have been abroad how they compare to foreign students, and without lying I can tell them that they have nothing to worry about. In terms of theoretical knowledge, foreign students are better, of course, because they have so much more time to read and keep up with the literature. But practically, our residents are superior to any.” A surgeon said, “A few years ago a group of Italian surgeons came to do some training here and we were all in awe because we thought ‘Oh wow, foreigners!’ But it was pathetic: they worked so slowly, as though they had no idea what they were doing. At the end of three weeks here their skills had greatly improved.”

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As described in the previous chapter, a physician’s connection to the

khārej is highly valued when a patient is evaluating whether or not to trust a physician. To have studied medical ‘elm at a university is good because it was acquired in a manner consistent with its transmission in the khārej. But a direct foreign connection is best. Ideally, patients would consult physicians abroad for their health complaints. When visiting relatives living abroad, they take the opportunity to visit doctors for chronic medical problems (elevated blood pressure, sciatica, allergies, diabetes or coronary heart disease) already being monitored or managed by physicians at home. And like so many other commodities, medications from the khārej are considered to be better than Iranian-produced ones. An older woman saw three different physicians for management of her elevated blood pressure: one in her hometown, Shiraz; another, recommended as “the best” by her brother on the basis of his European training, in Tehran; and a third on her annual visits to her daughters in the United States. She claimed the only medication she could tolerate was the one she had bought in the US on the recommendation of her physician there, but she did not take it because she did not want to impose on her daughters to have to send her refills.

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At the airport in Vienna an Iranian man residing in Austria was looking for a passenger to take a few tubes of an ointment for relief of rheumatic pains and a pair of orthopedic shoes to his sister in Tehran. “This is the only cream that gives her any relief,” he said seriously. “The cream available in Iran doesn’t do her any good.” In the absence of the ability to get to the khārej, Iranian patients select the next best thing: physicians who have seen some training abroad or, even better, have worked there as a physician. Such physicians can bank on getting more respect from patients, i.e., they can expect that patients will be less hesitant to follow their advice and less hesitant to pay for it. A generalist in Tehran can charge two days’ laborer’s wages per office visit for the special diet he “learned in India;” a surgeon who saw a few months of specialty service in the United States, though he was not even legally allowed to touch patients during this observation time, boosts his practice by claiming foreign training; and I, who had not even finished medical school yet, was consulted for intractable medical problems with the expectation that because of my American education I would have more curative power than Iranian specialists. In this frame physicians’ use of English, riddled with errors though it may be, is an obvious connection to the khārej which serves to convince both the patient and the physician using it that the physician is in touch with the khārej and is therefore superior. In this context the claims made by physicians about the use of English, which I found wanting from an outsider’s (and admittedly snootish) standpoint, speak to the very heart of the issue. The former Pahlavi University used English in its training programs because it was staffed almost exclusively by foreigners, primarily Americans, and foreign-trained Iranians. This strong historical connection to the khārej is identified as the basis for the university’s excellence. The use of English today is therefore a tradition which recalls the university’s days of glory and reinforces the impression that the education it offers is still “the best.” Textbooks identified as the gold-standards of medical knowledge by Iranians are written in English, not Farsi or Chinese or French. In this sense English is indeed the language of medical ‘elm, and to be proficient in it indicates that one has direct access to it. While the use of English cannot guarantee that medical knowledge will be kept from the patient and the patient’s attendants, it does help to assure them that the vast body of khārejī medical knowledge, the “best” and most powerful medical knowledge available, has been applied to his/her condition and that they therefore need not worry any longer.

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In summary, the use of English in the medical setting follows from physicians’ interest in associating themselves with the powerful khārej. Underlying this interest is the assumption that patients’ acceptance of claims to medical knowledge, more particularly, their acceptance of advice derived from such knowledge, is fostered by an obvious association of that knowledge with the khārej. It needs mention in this context that it appeared to me that students, residents, paraprofessionals and administrators were more likely to use English words and phrases than physician-professors, who often used Farsi terms even for anatomical parts and physiological processes. This observation inclines me to suggest that the use of English in the medical context is a crutch for those who do not have access to other sources of authority, such as proven skill and competence or male gender, rather than an absolutely necessary ingredient of authority. In other words, Iranian patients are not duped into thinking that just because their physician uses English, all will be well. ‘Elm, skill, competence are still prerequisite; the foreign connection just gives these a great deal of added validity. Large Patient Volume and Short Contact Time Iranian physicians spend minimal time with their patients. Interviews and examinations are performed at lightning speed and large sections of these are dispensed with entirely. Physicians may see upwards of sixty patients in half a day, and senior residents are responsible for all patients on the hospital services and in the specialty clinics, together often numbering in the hundreds. Physicians and residents at the university are also expected to teach, which also demands time. It is no wonder, with such volumes, that physicians refrain from engaging in social intercourse with their patients. And by watching the behavior of their teachers, medical students unofficially learn how to take short-cuts in patient care and how to justify this by claiming that it is the reality of practice and they better get proficient at it. “The problem with practice in America,” an OB/Gyn who had received fellowship training in Canada said, “is that no one respects the doctors’ time. They waste so much of it talking about all kinds of inconsequential stuff with the patients, like picnics and Beanie Babies and the weather. They are always complaining about not having time, but 15 minutes for an office visit is more than enough! I used to tell them to quit the chatter, just do their job, but they told me they can’t because otherwise the patients will complain.” She

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HEALTH AND MEDICAL PRACTICE IN IRAN smiled. “As long as you help the patients, what do they have to complain about?”

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An OB/Gyn designed her office in a private clinic so that she can process five patients at the same time. Two cubicles for physical examinations are located behind two desks at the center of the office, separated from these and from one another by thin wooden partitions. At one of the desks, the physician takes and records patients’ histories. At the other, her nurse writes treatment protocols (e.g., for infertility) and instructs patients already seen by the physician how to follow these. In front of the desks is the waiting area, in which the next one or two patients sit, getting primed to fire off their histories once called to the desk. A bed for pre-natal examinations stands behind a curtain in the waiting area, to the left of the desks. With this arrangement, the physician never has to wait for patients to make their way to the office, take off their clothes, put them on again, or even just get themselves adjusted in the chair by her desk. Medical professionals at all levels, from sub-specialists to students, mention the time pressure they are under as undesirable. Ideally, they would like to get to know their patients better and get to do a complete physical exam. They feel stressed by the sheer volume of patients they see and are responsible for. Yet the alternative, cutting down on the number of patients they see, is not an alternative at all in their eyes. The reason they give is, tautologically, that there are too many patients. At the university clinics and hospital, the waiting areas are swamped with patients and their attendants. An OB/Gyn who scolds her patients for not being prepared to answer her questions begins to see patients in her clinic in the early afternoon, after already spending a busy morning in the hospital and operating room, and often does not leave until well after midnight. In a university hospital birthing clinic, the women coming for pre-natal checks, who must all be “seen” by a single senior resident, number in the hundreds daily. All these patients come to be taken care of, the argument goes, and so they must be seen. Because there are more patients than can reasonably be examined in the time available, the thoroughness of the examination must be compromised. At the same time as Iranian medical professionals point out that there are too many patients, they complain that the government has intentionally ruined the medical profession by training too many physicians. It is said that

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both generalist and specialist physicians are having to go further and further into rural areas to find room to open a clinic because towns and cities are already oversupplied. Physicians running themselves ragged trying to meet their clinical, surgical, teaching and research obligations shake their heads sadly at the competition. Not one of them is willing to give up patients, even if it would reduce their own work load and give others a chance to establish practice. The argument that there are too many patients to be able to devote adequate time to them has both economic and ethical components. Obviously, it is in the best economic interest of the physician, or the clinic, to see as many patients as show up at the door. The importance of economics in structuring physician practice I have already described in a previous chapter, and the fact that physicians will act on an advantage, i.e. “make zerengī,” by, for example, performing unnecessary procedures or selecting patients for surgery at private clinics on the basis of their ability to pay higher fees, has been mentioned as well. Obviously physicians are “in it” for the money, but the feeling that patients should not be turned away cannot be reduced simply to economic interests. There exists in Iran an unspoken social obligation to give of one’s time, knowledge or effort to anyone who demands these. It is assumed that patients coming to the public and university clinics, which offer medical services at a discounted rate, cannot afford to go anywhere else. In other words, clinics and physicians cannot turn patients away because there is nowhere else for them to go. Patients may request services from physicians based on a personal connection to them, such as through relatives, colleagues, friends, acquaintances, private servants or public ones who have helped them in the past. The physician has the vazife (duty) to help these people; it would be unthinkable to turn them away. Apparently this vazife extends as well to patients who cannot make such a personal claim for a physician’s attention. The effort to come to a physician’s office is taken as an indication that the patient bestows trust and respect on this one particular physician alone. S/he is not willing to submit to another’s authority and is appealing for this one’s consideration. This trust, respect and appeal for help cannot be violated or disregarded. I asked a general practitioner who was complaining about the volume of patients she had to see on her clinic days why she didn’t limit her practice. She thought a while, obviously taken aback by the idea. “But where would the patients go? They know I am their only

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A senior resident in the public women’s health clinic diagnosed a pregnancy in a woman whose husband had had a vasectomy. Clearly, the child was not his, and the woman was concerned about the repercussions on her marriage if her husband were to find out about her condition. The woman begged the resident to perform an abortion and was severely chastised for even suggesting such an unIslamic procedure. After the patient left, clearly distressed, the resident was lost in thought for a few moments. “For sure we will have to admit her in a few days with a severe uterine infection. She will go somewhere where they use dirty instruments and botch the job and we will have to clean her up again. Ugh! Why do they get themselves into such states and then make matters worse by killing the child? But what can we do? We have to take care of the patients when they walk in the door, no matter how sinfully they have acted. That is our duty!” “We have to take care of patients when they walk in the door”–this is an ethical cornerstone of allopathic medical practice in Iran. Physicians consider it unethical to choose to treat or not treat patients based on economic considerations, social class, personal prejudices or lack of time. They occupy a position of authority from which they are to treat patients, all other considerations aside. This ethical stance is linked by Iranians to the Islamic injunction to serve society, to which the value placed on knowledge and education is likewise linked. Ideally, an educated person uses his or her knowledge for the benefit of society, regardless of personal gain or discomfort. Ideally, a true Muslim physician holds no prejudices and treats anyone and everyone who shows up in his/her office to the best of his/her ability. Of course, the superstructure of allopathic practice in Iran is such that physicians can choose what patients they will see and can fill their pockets. Practicing privately they can make more money than when working as a salaried physician in a government clinic. Patients are screened at clinic doors based on their ability to pay physicians’ fees. How much respect physicians show their patients depends on their perception of the patients’ socioeconomic background and personal familiarity with them. Ethics are not incorruptible in the face of economic and social gains, but neither are

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they totally avoidable. Patients who show up in one’s office have to be seen: if one can make a bit of money in the process, so much the better. Short patient contact times are facilitated by the fact that patients do not expect a “good” (knowledgeable and skillful) physician to spend time with them, or to explain to them pathophysiologic details or diagnostic and therapeutic strategies. They expect their physician to intuit what is wrong after a minimal verbal and visual examination and to act decisively. The physician is to apply his/her ‘elm to the circumscribed problem with which the patient presents and to give the patient just as much information as is necessary to restore well-being , i.e., orders. The big picture, the “narrative of illness,” is not important for the physician, and the details of medical diagnosis and therapy are not properly in the domain of pertinent knowledge for the patient.

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An elderly engineer who broke his arm was asked to sign a consent form before an operation to surgically reduce the fracture. He waved the form aside, saying “I am here for the physician to do what is best for me. He should decide what needs to be done, not me!” Moreover, the skill of a physician is thought to stand in direct correlation to his/her work load. Physicians who limit their practice size cannot be “good.” Physicians who are demanded simultaneously in the operating room, in the clinic, at meetings and research symposia and in attendance at different hospitals are “good.” They are “good” because their colleagues respect them for their mastery of medical ‘elm, because they have shouldered responsibilities and because their patients trust them. A short visit with a physician is therefore not only to be expected but a sign of the physician’s excellence. In fact, the crowds of patients milling in front of a physicians’ door are in themselves recommendations of the physician’s skill and knowledge. The assumption that the details of medical ‘elm are not considered to be properly in the domain of what patients need to know also facilitates short contact times, because details of diagnosis, prognosis and therapy do not need to be discussed with patients. This assumption actually follows from another ethical cornerstone of medical practice in Iran, namely, that patients should be prevented from worrying. It is not just that patients do not want to know anything that would make them worry, the argument goes, but that it would be harmful if they did know because they would stop treatment out of fright, loss of hope or denial of the diagnosis.

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I have described the importance of having khīāl-e rāhat (a mind at ease), of not having asāb-e khūrd (frayed nerves), in the context of indigenous conceptualizations of health and disease. Good health is felt to hinge in large part on not having to think about problems, on being free from worry. More than this, worry is thought to be pathogenic. It can aggravate the patient’s condition, bring on a different one or at least stand in the way of effective treatment. So large is the pathogenicity of worry thought to be that physicians themselves assured me that they would not want to be told about a life-threatening condition if they developed one. Thus in the physician-patient encounter it is felt that any time spent addressing patients’ concerns indulges these and that letting patients talk about their illness or discussing the details of the diagnosis or therapy with them brings their worry, thoughts, khīāl, to the surface, where they can do harm. Engaging in such acts would be counter-productive to the goal of patient consultations. Time spent with patients is best spent assuring them there is nothing wrong, that their concerns are not important, or that their problems are in the hands of the people most competent to deal with them. A physician who gives a patient medical information, whether this portends a poor prognosis or not, gives him/her potentially worrisome information and is thereby breaking a tacit agreement made outside the medical context that this information be withheld. Such a physician is both doing potential harm and violating the patient’s trust. My father was handed a specialists’ consult form during a social call with a middle-aged public servant with the request to “read it.” Before even having looked at it, my father told his host that he should be aware of the fact that whatever stood in the report, good or bad, he would tell him. Muttering disgustedly, his host snatched the piece of paper from my father’s hands before he had even glanced at it and stuck it back in the crumpled plastic bag from which it had come. It is up to the physician to estimate, based on his/her perception of the patient’s education, general state of health and level of anxiety, how much information to divulge, and to whom to give it. The more worried the patient or the patient’s attendant is, the more effort the physician will make to reassure him/her that all is being done to address the problem. The feeling is clearly that the patient should not be concerned with details of disease causation, diagnosis and treatment because thinking about these things is in itself a form of worry. Physicians do not volunteer any

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information and side-step patients’ questions by telling patients not to worry. The primary objective of “talking to” patients is to allay their fears. A patient came to her OB/Gyn for her first follow-up exam after a hysterectomy with a list of questions. The first was whether she could ever have sexual relations with her husband again. Reassured, the patient went on to her next question, about an area of the incision which looked worrisome to her. The physician cut her question short: “If your other questions are all about the work I did, don’t even bother asking them because there is no reason to worry about them. I have examined you and I am satisfied with the way everything looks. Come back in a week or sooner if you have fever or the incision opens. Do what I tell you and you will have no reason to worry.”

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“What would a patient think if I told her she had ‘fibroids’ or a ‘uterine polyp’?” an OB/Gyn resident said. “She’d get all worried and think she was going to die and not come for the operation because she was scared. All she needs to know is that she should come for an operation. That is all that we tell her.” A senior medical student said, “During one of my first presentations of a patient to an attending, I said, ‘marīz pāsokh nadāde be gentamicin’ [the patient did not respond to gentamicin]. The attending got angry and said that I should say ‘patient respond nakarde’ rather than saying it all in Farsi because now, the patient will worry about why he didn’t respond to the antibiotic. He said if he ever caught me using Farsi in front of patients again he would fail me.” In summary, the practice of seeing large volumes of patients in short amounts of time can be traced to popular ethical principles which frame the physician-patient encounter. Having ‘elm grants the physician the authority to act decisively, but along with this authority come grave responsibilities: the physician must make decisions in the best interest of the patient, the physician must give freely of his ‘elm to whomever stands in need of it, and the physician must try to keep his patients from worrying. Short patient contact times are virtually mandated by these expectations.

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The Nature of Medical ‘Elm, Again In the previous chapter I discussed some of the main criteria by which a physician is granted the right to claim possession of knowledge and to make authoritative pronouncements about patients’ conditions and treatment regimens. In this chapter I have expanded on the discussion of ‘elm by demonstrating its ties to some wider cultural principles which structure practice, namely, valuation of the foreign and ethical obligations to share one’s knowledge and to protect others from worry. These principles can be seen as “key concepts” which inform physicians’ and patients’ expectations of and behavior toward one another. They are criteria by which physicians and patients judge their own and each other’s behaviors as appropriate to the patient-physician encounter. While physicians are concerned with maintaining their authority in the eyes of patients, patients expect physicians to use their ‘elm responsibly. In other words, conceptualizations of ‘elm and its ethical implications provide the context in which allopathic schemata are engaged. Allopathic schemata are modified or adapted to become consistent with cultural expectations of physician and patient alike. The practice of medicine, the execution of allopathic schemata, occurs in the social relationship pertaining between patient and physician, and therefore behaviors pertaining to medicine, the “how to . . .” of allopathic scripts, must conform to culturally consistent expectations of this social relationship. In Iran, these expectations derive in part from the connection between ‘elm, authority and ethics.

Chapter 9

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Medical Knowledge and Islamic Ideals

In this chapter I make a distinction between a “popular” ethic underlying daily behaviors and the state or ideologically-derived ethic underlying public policy in Iran. The popular ethic, of which providing to the needy and preventing others from worrying are just two examples, will in Iran necessarily be attributed to Islamic injunctions, because, after all, physicians and trainees very seriously consider themselves to be Muslim and to practice according to the guidelines of Islamic ethics. But the popular ethic entails principles which hold in Iran as a matter of conscience, vojjdān, and which do not need necessarily to be codified or formally taught. This stands in contrast to Islamic law, which, under the guidance of religious scholars, informs state ideologies. Principles derived from Islamic law are not always consistent with the popular ethic. While religious and state ideologies can offer physicians another recourse to authority, they also ultimately challenge the authority of medical ‘elm. The relationship of physicians’ authority to popular and formal ethics takes three forms: 1) The physician as religious broker. In relation to aspects of medical practice which overlap religious concerns, the physician may assume a position of religious authority, i.e., the right to interpret religious doctrine as it impacts medical issues. 2) The imposition of state ideologies. Physicians’ claim to authority is challenged on at least two fronts: the training of a large number of physicians in Iran, and the tarh-e entebāq, a proposal to keep male physicians from seeing female patients. 3) The relationship of ethics to social and economic pragmatics. The medical ideal of “do no harm” can be interpreted in a socially consistent manner to support Islamically un-ideal behavior.

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The Physician as Religious Broker Physicians have the authority to interpret religious principles when these pertain to health. For example, physicians have the responsibility of determining for individual patients whether it would be meritorious for them to fast during the month of Ramadan. Guidelines as to how to make this decision are given in the Koran: if it were detrimental to a person’s health to fast, doing so would carry no religious merit, at best, and at worst, be sinful. In any case in which fasting would cause excessive stress (e.g., in travelers, the sick and the elderly) it must be abstained from, though the missed fast should be made up at a later time or by the giving of alms. If someone is not sure whether it would be meritorious to fast, this decision is to be made by his/her physician.

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A gynecologist reassured a pregnant patient that it would not be harmful for her or the baby for her to fast, as long as she ate nutritious food and drank lots of fluid between sundown and sunup. Before turning to the next patient, she called a general surgeon who was to perform a skin biopsy on her mother the following day to ask whether the procedure would preclude her mother’s fast. Physicians also are consulted by women to interpret the religious meaning of menstruation. Women are prohibited from performing their daily prayers, and from fasting during the month of Ramadan, when in an “unclean” state, i.e., during menses. Being prevented from their devotional acts provokes discomfort and anxiety in some devout women. They may take birth control pills to delay menses so as not to have to interrupt their fast, but this in turn may cause them to worry about the potential ill effects of delaying the discharge of unclean tissue from their bodies. In such cases, physicians interpret medical knowledge in the context of religious principles. A middle-aged woman asked her OB/Gyn whether delaying her menses by taking birth control pills had caused any harm. “I didn’t bleed for several weeks after stopping the pills, and then when I did there were just black spots. It wasn’t right to do that, was it? Now I have all this dirt in me?” The OB/Gyn reassured her that birth control pills prevent the build-up of tissue so no “dirt” accumulates while they are taken, and that the patient could expect to bleed normally again in a few more months.

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A patient who had heavy vaginal bleeding for twenty days confessed to her OB/Gyn that she was distressed by having had to abstain from prayer all this time. She asked how long it would take before she were “clean” again so she could resume her devotions. “Who said you are not allowed to pray?” the OB/Gyn asked her sternly. The patient answered, “I called the religious scholar who answers questions on the radio and she said that as long as a woman is bleeding, she is unclean.” The physician rumpled her nose. “That goes to show how much they know. What right does a degree in theology give her to talk about medicine? If you have a medical question, come ask me. It is true that during your menses you are unclean, but menses are defined by bleeding lasting from three to seven days. Anything going beyond seven days is an illness, like a cold or a headache. Does it say in the Koran that you are not allowed to pray if you have a headache? After seven days, your bleeding does not stand in the way of your prayer.” Some physicians do not restrict the opportunity to interpret religious principles to these issues, but expound on patients’ faith, morality or proper behavior during routine patient visits. In fact, these physicians would argue, it is their responsibility to uphold, in their practice, the values of life, faith and social conscience. A woman suffering depression confided to her psychiatrist that she did not get along with her mother-in-law, with whom she was cohabiting. Her husband made enough money that the two women could live in separate homes, but he would not listen to his wife’s complaints, yelled at her to tolerate his mother, and on occasion even beat her. The psychiatrist gave the woman a personal letter for her husband, in no uncertain terms ordering him to come with the woman to her next appointment, in a week’s time. After the woman left the physician turned to me and said: “It is our responsibility to help our patients, and in this case it means telling the woman’s husband that his behavior has a direct adverse impact on her health. He will come to the next appointment, and I will tell him what he needs to do for his wife to feel better and need to come see me less often. Whether he will do as I say I don’t know. Maybe he will go home and beat her even more, but at least I will have done everything I can.”

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“Say, ‘Ya ‘Ali’!” [“Oh ‘Ali,” an expression of faith or trust in God], a general practitioner demanded of a patient’s husband who was complaining about the expense of the laboratory tests, referrals and medications she had ordered for his wife. He demurely whispered, “Ya ‘Ali.” “Louder!” the physician ordered, and then lectured him sternly about the need to behave responsibly towards his dependents in order to procure God’s favor. Physicians enhance their authority by advancing principles pertaining to proper conduct and to faith in their practice. They demonstrate that they are doing right by patients, that they are behaving towards them in an ethically sound and just manner, and that they are therefore honest and worthy of their patients’ trust. Moreover, they assume authoritative powers which parallel, even sursede those of religious functionaries by interpreting religious matters on the basis of their medical knowledge. They deflect doubts about their competence by invoking God’s will and by associating God’s wisdom with their own when they cast patients as supplicants at once for God’s and the physician’s benevolence. “Have faith in God and don’t question the surgeon’s skill,” a generalist told an anxious patient: God and the surgeon know what is best for you, submit to their wisdom. The authority religion grants medicine, however, ultimately faces limits when the state, on the basis of religio-political ideals, interferes with the structure of medical practice. The Imposition of State Control One of the ideals of the Islamic state is that everyone should have equal access to medical care. This follows from recognition that medical care is a basic human right and from the ideal that a truly Islamic society should be class-less, i.e., everyone should have access to the same resources, regardless of socioeconomic class or ethnic background. As pertains to medical care, the government has supported and implemented measures designed to provide at least rudimentary health care to all sectors of the population, including the poor, the rural and the indigent. One of these measures is the tarh, an obligation imposed on medical school graduates to practice for two years in a government clinic in an underserved area of the country (see Nia and Bansal, 1997 for a critical examination of the role of the tarh in health care delivery in Iran). In fulfillment of the tarh there are a few positions available in the epidemiologic service and in clinics in poor areas of major cities, but most students are sent to provide primary care to rural populations, which represent about 65 percent of the country’s total

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population. Men’s tarh simultaneously fulfills their two years of obligatory military service, but women have to do the tarh as well. Some problems with government clinics have been discussed in Chapter 6. Here I will mention problems specifically related to the tarh. Medical students and professionals uniformly protested the imposition of the tarh. It had been established long before the Revolution, so even senior physicians could narrate stories of the horrors of having to deliver medical care to “dirty,” “ignorant,” “backward” patients out of clinics devoid of technological, pharmacological and professional support services. Generally, the tarh is considered by medical professionals to be a waste of time. They say the government salary does not compensate for the income they could be making in private practice during these two years; the remoteness of the clinic precludes their being able to keep up with the literature in medical journals (subscriptions are too costly for physicians to afford individually, so journals can only be found in medical school libraries); they lack any kind of supervision; they have no one to consult about difficult cases; the work is tedious, does not take advantage of their specialized training, and does not allow them to apply and practice the advanced skills necessary for diagnosis and treatment of complex diseases they had begun to acquire in medical school. On the personal side, the boredom of having nothing to “do” in these rural areas and the loneliness of being apart from family and friends are intolerable. An older university professor recounted how he had spent entire afternoons during his tarh squirting water at flies on the wall of his office with a syringe, out of boredom. A recent medical school graduate in the second year of his tarh spends fourteen hours on public transportation on dusty roads in order to see his family every weekend. “I’d go crazy there week in, week out,” he said. “My mother here in town would go even crazier from being apart from her son.” Similarly, physicians argue against the government’s decision to increase the number of physicians trained in the country. There are three times as many medical schools as before the Revolution. In 1988 there were 21.5 physicians per 100,000 population, in 1998 there were 31 (Iran Statistical Yearbook, 1998). The government has expanded medical education in the country for the same reason as it enforces the tarh. With an increasing number of physicians, these have to move into rural areas to find a patient

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base, thereby providing medical care to hitherto underserved areas of the country. Iranian physicians perceive their numbers to be excessive and claim that increasing their work force has ruined the status of the profession. On the one hand, patients now have the option to choose their physicians, thereby implicitly undermining physicians’ authority, and on the other hand, the training of people from demographic groups which have no “experience” with the status of physician (women, villagers and members of the lower classes) has debased the cultured, high-status image of the medical doctor. In fact, physicians see the state’s control over practice location and physician numbers as a deliberate strategy of the conservative religious establishment to undermine the authority of the profession. It used to be, physicians said, that, as the most highly trained and educated people in the country, they held the highest status. Their authority extended not just to medical care but to all issues, from the familial to the governmental. The religious scholars, seeing their authority paramount, resented physicians’ authority and so sought ways to destroy it, physicians say. They did this did by interfering in an area that was not firstly of religious concern: medical care. While at a theoretical level medical professionals uphold the ideal of universal health coverage in the country, practically they do not want to accept responsibility for this. Physicians have no problem interpreting religious doctrine as it pertains to health in the setting of individual patient encounters, or in using religious authority to augment their own, but they are resentful that the ideological goal of providing equitable access to health care in the country is being met at the expense of their personal careers, their freedom to choose where they want to live, and the reputation of their profession. Similarly, Iranian physicians are resentful of the tarh-e entebāq, a proposal passed by the Iranian parliament in 1998 which forbids male doctors from seeing female patients. According to the religio-political leaders who introduced and supported the bill, in an Islamic society women patients should be seen only by women physicians. The reason for this is that it is sinful for women to be seen by an unrelated male because the sight of women’s hair, skin and above all genitalia arouses men’s sexual desires. Women who sexually arouse a man, whether intentionally or not, are committing a sin, for they are tempting him into irresponsible, unsocial or even anti-social behavior. For the moral protection of women and the protection of society from men’s anti-social tendencies, women should not be put in a position from which they are a temptation to men (e.g., as the

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patient of a male physician). The plan to match patients with physicians on the basis of sex should have no impact on the quality of care women receive, the argument goes, because officially no difference is recognized in the medical capabilities of male and female doctors. In fact, some people continued, women would be ensured better care because female physicians are innately more empathetic to female concerns than are male ones. After the Revolution, the government prohibited men from entering OB/Gyn residency programs for the same reasons. Any male OB/Gyns already trained, or those who recently received training abroad, were allowed to continue to practice, but new ones would no longer be trained in the Islamic Republic. At the University of Shiraz, efforts had also been made to prohibit male medical students from participating in the OB/Gyn rotations before the tarh-e entebāq had even been passed. The rector of the university, a highly respected surgeon, and the head of the department of OB/Gyn had successfully resisted these efforts by claiming that the medical training of male physicians would be incomplete if they had no practical experience examining the female body and treating its diseases. The rector had even threatened to close the OB/Gyn clinics to all students and interns, both male and female, if such a measure were to be enforced. Since the work of the clinics is done primarily by students and interns, barring them from participation would essentially have closed the clinics down entirely. At least until the tarh-e entebāq was passed, no further efforts were made to separate the teaching of medicine by sex. The reasons physicians and medical trainees gave for opposing the tarhe entebāq were: 1. Incompleteness of medical training. Students who were denied training in OB/Gyn were not fully equipped to take on the responsibilities of the tarh, at least. In rural settings, men cannot rely on OB/Gyns being near at hand to see female patients, and female patients will come to them for advice on at least common female complaints, such as vaginal itching, menstrual irregularities, and problems with pregnancy. A physician who is not trained to evaluate and treat these is not truly a physician. The tarh-e entebāq puts the value of full possession of medical ‘elm in a secondary position behind Islamic ideals. 2. Alternate interpretations of religious texts pertaining to the issue are valid. The tarh-e entebāq is superfluous, physicians argue, because God had already declared, through the Prophet Mohammad, that physicians were religiously safe (mahram) to female patients. It is not sinful for a woman to be seen by a male physician because the latter is, for the purpose of the physical examination, exempt from the general injunction against her being

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seen by an unrelated male. Supporters of the tarh-e entebāq made the counter-argument that according to the scriptures, a male physician would be mahram to a woman patient only in the case that an equally well-trained female physician were not available for her to consult. Ideally, female physicians in all specialties and sub-specialties should be available to meet the needs of the female population, and the tarh-e entebāq stipulates that guidelines pertaining to admissions to medical school and residency programs be adjusted accordingly. 3. The outlay of resources necessary to enforce the tarh-e entebāq is prohibitive. To begin with, physicians said, it would take decades, if it could ever be accomplished, to train a female physician for every male one, even when guaranteeing women half the spots in medical school and residencies every year. There would have to be not only separate generalists but also specialists: eye doctors, heart and lung specialists, sports doctors, even transplant surgeons and psychiatrists. And every support position would have to be filled in duplicate as well. Every clinic, emergency room and operating room would have to have two sets of nurses and nurse’s aides in addition to two physicians. Such a situation was economically unfeasible and irrational, physicians said, and they appeared to be consoled by the fact that at least in this instance, the current economic situation of Iran was to their advantage. 4. The proposal is economically unfair to men. Already men are restricted from a lucrative specialty, OB/Gyn. OB/Gyn is a surgical field and surgeons, because of the highly involved and technical procedures they do, make more money than any other specialist. “Of course I would be interested in studying OB/Gyn,” a male intern said, “one hour in the operating room and you make more money than seeing thirty patients!” In addition, by restricting male physicians’ practices to male patients, the proposal eliminated half their potential income base, regardless of their specialty. This is especially unfair, I was told, because men are the primary bread-winners in families: women’s incomes from the field of medicine are considered to be a luxury while men’s are a necessity. Restricting men’s income base was therefore unfair not just to them but to their families as well. 5. The proposal does not take into consideration men’s and women’s aptitudes. There are male medical students who would be interested in the field of OB/Gyn for other than merely economic concerns. One such student confessed to me that he dreamed of being able to go abroad to study OB/Gyn, but was careful whom he mentioned this to for fear of being labeled a lecher. Also, there is a general sentiment in Iran that women do

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not make as good physicians as men do (see Chapter 8). Even OB/Gyn residents (all women) claimed this. While no difference is recognized in intellectual aptitude between men and women, women’s innate characteristics and conflicting social demands are thought to make them inferior to men as physicians. Restricting men from seeing female patients thus barred female patients from access to the best medical care. 6. The proposal casts doubt on the moral integrity of male practitioners. The possession of ‘elm, the proposal says, does not guarantee men to be in control of their own sexual desires. Yet for male medical professionals at any level of training, this accusation was absurd. Examining women’s bodies became routine after the first few, they claimed, just as listening to the heart or looking into ears did. “They say that a man should not examine a woman or be present at delivery because he would become excited looking at her genitalia,” a male recent medical school graduate said. “But honestly, when I was performing a pelvic exam or assisting a woman in delivery, the last thing I thought about was sex. Here the baby is coming–what is the presentation, why is it taking so long, the woman has to push harder, what are the baby’s blood gases. Where is there room for sexual thoughts?” Physicians oppose the tarh-e entebāq because, in their eyes, it devalues ‘elm; it casts doubt on a physician’s morality; it imposes an economic burden, not just on male practitioners but on the entire country; and it threatens to reduce the quality of care female patients can expect to receive. The decision whether to see a male or female physician should not be codified by religious scholars on the basis of extra-medical considerations, they say, but be left to the patient herself, even in the field of OB/Gyn. Some female patients are more comfortable being seen by female doctors, they say, others by male ones. In either case, it should be hoped that the patient has chosen the physician on the basis of the extent to which the physician is in possession of ‘elm, is good, competent, skilled, and understanding of the patient’s concerns. State control over physicians’ practice location and client base threatened the omnipotence and autonomy physicians had come to associate with their profession, and threatened to cast doubts on their skill, competence and authority in the eyes of their patients.

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Conscience and Pragmatics Islamic law in Iran defines the ethics pertaining to the beginning and end of life. Physicians’ interpretations of medical ethics in these contexts are usually consistent with official ones, i.e., they accept the verdicts of religious scholars without attempting to interfere or reinterpret them. For example, while all kinds of infertility treatments are available in Iran, fertilization of ova with donated sperm is not performed. By Islamic law and common social understanding, sperm donations are precluded because the paternity of a child must be known for it to be legitimate and because a woman is not allowed to have more than one “husband” at a time. In order to receive another man’s sperm, even if all parties were willing that the donor should be known and identified, the woman would first have to be divorced from her husband, marry and then divorce the donor, then remarry her original husband. By law, the donor would still have rights to parentage over the child and could claim custody of it. (Egg donation is not a problem, for the husband need only make a temporary second marriage with the donor for the purpose of the donation.) For these religio-cultural reasons, there is no demand for sperm donation in Iran, and the “technological imperative” loses its force in the face of religious and cultural prejudices. Physicians and religious scholars alike have no difficulties arguing against it on the same grounds. Abortion provides another illustration of how Islamic ethics frame medical practice. Abortion is against Islamic law except in the case that the health of the mother would be endangered by the pregnancy. Birth control measures that prevent conception are legal and generally available: condoms, vasectomies, tubal ligations, intrauterine devices and various ingestible, injectable or implantable hormone preparations can be had for the asking, most even without charge. However, performing an abortion for the sole purpose of terminating an unwanted pregnancy is illegal by Islamic law because it extinguishes a life which has already begun. It is punishable by heavy fines, loss of medical license, imprisonment or even execution. But because certain pregnancies do endanger the life of the mother and so can legally be terminated, residents are trained to perform abortions. The decision whether or not an abortion is legal is made by courts on the advice of forensic specialists, physicians specifically trained in issues of legal medicine. The courts and physicians asked to perform abortions for “legal” reasons argue that, though abortion violates the ethical postulate of not ending life, since the mother’s frail health is jeopardizing the lives of both the fetus and herself, terminating the pregnancy would save at least one of

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the two lives. This rationalization is not always convincing to those asked to perform the abortion, however.

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“Ugh!” a senior resident said after signing a patient on to the surgical roster for an abortion. “This woman has lupus. She has four children already, and knowing that she shouldn’t get pregnant again because of her health, she didn’t take any precautions. Why didn’t she have her tubes tied before this? Who has four children anymore? It was her own fault that she got pregnant and now we have to terminate her pregnancy. Even though the courts said it was okay to do it, still it is bad. It is still ending a life. It was all her fault and now we have to bloody our hands!” There are certain other decisions the courts make, physicians told me, which go counter to medical ethics. For example, punishment for crimes by lex talionis, the law of retribution (qassās) is legitimate according to Islamic law, as long as the punishment is executed in the least harmful way possible. A man who caused another to lose his sight by splashing acid in his eyes, for example, should be blinded, not by having acid poured in his eyes but by cutting his optic nerves. This would need to be done by a physician, but finding one who will perform this operation is impossible, physicians and trainees assured me, because it would be going against the medical ethical principle of not doing harm. An OB/Gyn said, “Yes, qassās exists in our country and is proper according to Islamic law. But physicians do not execute the courts’ orders, because it is wrong to do harm to patients. If someone else goes and cuts off the guilty man’s hands or plucks out his eyes or whatever, then it is our responsibility to stop the bleeding and clean up the wound and prevent infection, but we would never cause harm even if the courts ordered it, because we have taken the Hippocratic oath.” The claim of physicians that they feel morally tainted when asked to perform a procedure identified by Islamic courts as just indicates that there exists a disjoint between medical and Islamic ethics, or between popular ethics and Islamic jurisprudence. Medical ethics enjoin physicians to “do no harm,” and at this general level is completely in accord with Islamic principles. The injunction becomes problematic in real life applications by differential estimation of to whom “harm” is done by medical interventions.

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Performing an abortion in the case in which pregnancy threatens a mother’s life does harm to the fetus, but allowing the pregnancy to continue will probably do harm to the mother. Should the mother be held accountable for her pregnancy even if her own life is at risk? Letting a criminal go unpunished “harms” society, but are the rights of society or the rights of an individual more important? A pregnant woman who had been in a motor vehicle accident was brain dead on admission, but the fetus’s heart was beating strongly. The woman’s heart and lungs could have been kept going for the few weeks it would have taken for the fetus to reach viability. She was allowed to die, however, and the fetus expired as well. During the OB/Gyn Grand Rounds during which this case was presented, the residents who had been responsible for the patient argued that their decision not to keep the woman alive mechanically had been justified because (a) scientific studies have shown that fetuses brought to maturity in bodies artificially kept alive suffered emotional, physical and mental problems during life; and (b) aside from the economic expense of keeping the woman in the intensive care unit for several weeks, devoting its resources to her would have deprived other critically ill patients of potentially life-saving interventions. The professors to whom the case was presented argued that the residents had acted unethically by not upholding the fetus’ right to life. One professor in particular argued that physicians must preserve life if they have the means to do so, that they did not have the right to terminate life under any circumstances. “Dr. Kevorkian would be put to death here because he murders people. Whether they ask for it or not, it is nobody’s right but God’s to make that decision!” He said the residents should have tried to find a place in Tehran, where there are more resources than available locally, to keep the woman alive until the fetus had matured. In this latter case, the residents argued from popular and pragmatic implications of the “do no harm” principle, maintaining that preserving the life of the fetus would damage the child emotionally, physically and mentally, and that devoting resources to it would deprive other critically ill patients of potentially life-saving interventions. Their professor argued from the Islamic ideal of the “sanctity of life,” which is really a variation of “do no harm” but identifies the fetus itself as the person who should be protected. The residents had not made the decision to not keep the woman alive

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mechanically without consulting other attendings, however, so it was not simply the matter that they had never heard about the sanctity of life principle or that their arguments had not made sense to other, ultimately responsible, physicians. For these, the pragmatics of economic cost and of the burden to society of a potentially damaged life (not to mention empathy for the child itself who would have to live with the damage so incurred) weighed heavily against the ideal of the sanctity of the fetus’ life. Not ending life is all well and good, they seemed to be saying, but what about the reality of life? The point of this excursion is that the residents and the attendings they had consulted in making this decision had assumed the right to interpret an ethical principle according to their own pragmatic concerns rather than with respect to religious authority. Religious scholars had long declared it unethical to allow a fetus to die, though they had not yet passed a resolution pertaining to just such a case of a brain-dead mother and a live fetus, and at least some of the senior physicians were adamant as well in arguing for the fetus’ right to life. Yet in the face of these arguments, the residents had felt they were authorized to take matters into their own hands and act in accord with an alternate interpretation of the “do no harm” principle. Thus the right physicians feel they have to interpret religious doctrine in the medical setting does not end with determination of who is allowed to fast, or whether prolonged menses preclude prayer, but extends to any ethical issue pertaining to medicine, even those already codified by Islamic law. Conscience and Ideals Three types of ideals impact medical practice. There are first the ideals of medical diagnosis and therapy, which are learned in medical school and identified qua “ideals” by Iranian physicians and medical students. These include such things as taking a full patient history and performing a full physical examination, treating patients on the basis of a proven diagnosis rather than in response to symptoms, and not doing procedures that are not indicated. Then there are social ideals, which derive from and are consistent with inter-personal relations outside the medical setting. These include the withholding of worrisome diagnoses and the obligation to see everyone who shows up at one’s clinic, as well as a perceived duty to assume an advocacy position for a patient in regard to socioeconomic conditions which are felt to be negatively impacting his/her health. Finally, there are Islamic ideals, i.e., ones that are derived directly from Islamic teachings. Medical and social ideals are “Islamic” as well, because it is said that any “good” behavior is “Muslim” behavior. But some ideals are attributed directly to Islamic

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teaching, such as the injunctions to treat all patients equally, to make medical care available to all the population, to protect women from committing sin by preventing them from being seen by male physicians, and to uphold the “sanctity of life” principle. Social ideals, such as preventing patients from worrying or making clinic time for anyone who can claim a personal relationship, appear to follow unquestioned, ingrained standards of social intercourse. There are no alternatives open for consideration. If these standards or expectations are accidentally infringed upon, e.g., if the kin-relationship of a patient is not recognized during an office visit, lengthy apologies, explanations and restitutions follow. The principles underlying these behaviors are not even mentioned when physicians and trainees speak about “ethical” behavior, so obvious are they. Medical and Islamic ideals, however, can become problematic in the context of social expectations. I have already described (Chapters 6 and 7) how ideals of medical diagnosis and therapy are adapted to the economic constraints and to physicians’ and patients’ expectations of one another. The same pertains to those ideals that are derived directly from Islamic injunctions. To a large extent, these are compromisable. They not only go beyond the call of duty but beyond what is socially expected, required or desired of a physician. In the public women’s health clinic, an old woman told the senior resident who was putting her name on the surgical roster that she didn’t have the money for the recommended operation. The resident, without making eye contact with the patient, said “Vai! How many more troubles are you going to dump on my shoulders? I spent so much time to find out what is wrong with you, I am making myself available to perform the operation for you, and now I’m supposed to find you the money for it, too?” On the wall of the examining room in a public women’s health clinic hangs a sign which reads, “Speak to patients with the best voice with which you would like to be spoken to.” Sitting at a desk under the sign, a senior resident said, “The women who come to this clinic are from the lower socioeconomic classes and so they don’t expect to be treated with the same respect as the women going to private clinics.” “The Islamic Republic doesn’t recognize different social classes, so shouldn’t everyone be treated the same?” I asked. The resident responded icily, “Of course there are differences. Ideals are for

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those who have no interaction with society. There is no room for them in medicine. We have to deal with reality.” Physicians justify upholding social norms by referring to the medical principle “do no harm.” It is without a doubt that abortion is morally condemnable because it ends a life, they might argue, but the repercussions for the woman if the pregnancy were not terminated (e.g., divorce, shame, a penniless life) would be harmful, as well–is there no merit in preventing that harm? There is no doubt that giving a calcium injection to a perfectly healthy person can cause fatal irregularities in heart beat, but since that potentiality is quite slim and the recipient of the injection would be so pleased with the results (a comfortable, warm feeling), it would be sinful (gonāh dāre) not to give it. According to religious teachings, it is not right for a “sick” person to fast, but if a patient really wants to fast, does the fact that he is taking a once-daily medication for high blood pressure really warrant the physician declaring him to be “sick?” Cesarean sections, like any other surgical procedure, carry significant risks of injury, and so should not be performed unless there is clear indication that a vaginal delivery will harm the child, but gonāh dāre to make a woman writhe and groan with the pains of labor when an alternative is so readily available. Thus a social understanding of proper behavior informs medical practice regardless of medical and religious ideals. Physicians and trainees claim it is their conscience (vojjdān) that guides proper behavior in the medical context. They identify vojjdān as the internal drive that makes them do right by patients, do their best for patients, do all in their power to help alleviate patients’ suffering. They say that vojjdān is something they bring with them from home, i.e., that it is shaped even before they go to medical school, and that the formalized instruction they receive during training in Islamic and medical ethics contributes very little if at all to their behavior vis-à-vis patients. Rules of social interaction and popular understandings of harm and suffering threaten to override and undermine purely medical and religious ideals of medical practice. Necessarily vojjdān must incorporate medical and religious ideals or ethics in the medical context, but the extent to which these inform behavior is not given by medical education or by the structure of medical practice per se. In practicing according to their conscience, physicians feel thwarted, on the one hand, by patients asserting their autonomy and, on the other, by state control over practical and ethical issues pertaining to medicine. Ultimately, patients will determine for themselves which physician to see and whose advice to follow. As long as they stick to it, patients believe they

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will find the physician who will give what they are seeking: a complete cure from rheumatic pains, an abortion, a cheaper blood pressure medication, or one that will be more suitable to their hāl. In the face of patients’ expectations, physicians can only stand to lose if they insist on complying with medical and Islamic ethics to the letter. At the same time, physicians are ultimately responsible to the state for practicing medicine consistent with Islamic ideologies. Medical and Islamic ideals do not need to be sacrificed for social propriety if the physicians can convincingly demonstrate to the patient that they know what is best and that therefore the patient should submit to their authority. Physicians can do this by demonstrating to the patient mastery over social skills, medical knowledge and religious issues. Socially, authority entails knowing one’s position as socially superior benefactor and acting accordingly (e.g., wearing a spotlessly clean and ironed white coat, not divulging details of diagnosis and prognosis, not arguing with the patient). Medically, authority entails showing the patient that one is in possession of medical ‘elm (by, e.g., making rapid and definitive diagnoses, littering one’s speech with English and giving definitive orders). And the religious aspect of authority entails aligning one’s powers with God, recalling the patient’s faith, demonstrating that one is a just and honest Muslim and capable, at least as pertains to issues related to health, of interpreting religious doctrine. In summary, patients’ autonomy and state control over practical and ethical issues pertaining to medicine threaten to undermine the authority that comes from possession of medical ‘elm. Physicians can circumvent this problem by presenting an authoritarian front predicated on medical, social and religious authorities. Ultimately, however, the extent to which a physician adheres to medical and religious ideologies depends on his/her personal values, beliefs or conscience.

Chapter 10

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Conclusion

A Cognitive Take on Medical Systems What I have described in this book are the cultural paradigms from which Iranian allopathic practice emerges. These include both conceptualizations of health and disease as well as the factors which structure social relationships in general, from definitions of authority to ethics and political ideologies. What I will do in this final chapter is describe how the various influences on medical practice relate to one another during the generation of behaviors in the therapeutic setting. This discussion is conducted within the conceptual framework of cognitive anthropology. Central to this is the idea of schemata. There is no uniformly accepted definition of a schema in the cognitive anthropological literature, but in essence it is a calculus by which the environment is interpreted and behaviors are generated. A schema consists of key-concepts, well-formedness conditions and goals. These are not necessarily discrete entities. Key concepts are the terms in which the environment is interpreted. They identify characteristics of the environment as worthy of attention or valuable or meaningful. Well-formedness conditions are the guidelines by which an interpretation of the environment and the behavior generated from it are judged to be culturally consistent or acceptable. Behaviors are not only logical but also purposive, i.e., they are structured around a goal or an end. If there is no goal or purpose then there is no reason to act and indeed no need to interpret the environment in the first place. Thus schemata are contextually determined and open to revision and negotiation as progress toward a goal is periodically re-assessed (Keller and Keller, 1996). Key concepts, well-formedness conditions and goals are all parts of schemata, but where one begins and the other ends is not always clear. It cannot categorically be said that one comes before or determines the other, but one may be derived from the other, and even be the same as another. 1

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Key concepts provide the terminology and ideology with which the environment is perceived, and at the same time they are the wellformedness conditions of an interpretation. For example, in Iran, the key concepts of “dis-ease” (“dirt,” “purity,” and so forth described in Chapter 3) provide both the terms of interpretation as well as the logic by which alternate explanations (e.g., allopathic disease nosologies) are deemed acceptable. Likewise, goals can be implicit in key concepts and wellformedness conditions. For example, interpreting illness as a shift in the body’s balance implies that behaviors should be initiated to restore this balance. In essence, schemata provide the logic that structures interpretations of the environment and the behaviors generated from these interpretations. For descriptive purposes, this logic is at various times a key concept, wellformedness condition or goal. The descriptors merely highlight different functions and facilitate discussion of schemata. The schemata of allopathic medicine are structured on key concepts and well-formedness conditions derived from mechanistic interpretations of the body and from the scientific method. The body is thought of as a machine and allopathic medical treatments as ways of optimizing the working of the body’s parts, whether by repairing them, cleaning them, taking out non-essential ones or putting in replacement parts. The well-formedness conditions of treatment recommendations include the large, randomized, placebo-controlled, generalizable clinical studies which determine the “truth,” validity or evidence upon which medical behavior is structured. Execution of allopathic schemata includes identification of salient data (symptoms, signs, clinical tests), interpretation of these within a framework that yields information about what body part needs to be fixed, and instructions for repair. In native Iranian medicine, the key concepts are different, the interpretations are different and the goals are different, but only in content. Native Iranian medicine does not subscribe to a mechanistic view of the body but rather a mercantile one, in which the body is positioned in a matrix of delicately balanced scales. The key concepts identified as salient (symptoms of, e.g., “hot,” “cold,” “tired,” “nervous”) are subjective assessments of the body’s state in this matrix of dichotomies, and the goal is to restore the body to an optimally balanced state. The arbiter of native Iranian medical knowledge is the experience of each individual body as it is exposed to environmental stimuli. Well-formedness conditions of Iranian traditional medicine thus foreground experiential, personal perceptions of

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the body’s response to environmental stimuli over statistical interpretations of experimental results (see Loeffler, in press). Though different in content, allopathic and native Iranian medical schemata are similar in the abstract. They both interpret salient features of the environment in terms of what these imply about the functioning of the body, and then structure behaviors around this interpretation with the goal of returning the body to a more healthful state. Both are concerned with physiology and pharmacology, with how to identify ill-health and what to do about it. Both provide “how-to” templates which are executed in limited contexts and take into consideration only a small part of lived experience. As discussed in detail in Chapter 1, the body is more than a machine or balance-scale: it is embedded in social and political-ideological webs of meaning, and therefore key concepts, well-formedness conditions and goals of other domains of social intercourse impact or inform the therapeutic process as well. In the doctor-patient relationship, for example, there are key concepts of authority, race and gender, and well-formedness conditions pertaining to economic exchange. State ideologies impose goals emerging from key concepts or values such as capitalism or Islamic egalitarianism, which again have economic implications. Social ethics define what is right or wrong, how to deal with suffering, what is appropriate treatment, how far to go to preserve life. The schemata of allopathic/native medicine do not pertain to social, ideological or economic issues, and they do not contain key concepts or well-formedness conditions with which to address them. The “father of medicine,” Hippocrates, formulated the oath to which allopathic physicians, whether in America or Iran, are sworn still today, namely, to alleviate suffering and not do harm in the process. Noble as this advice is, there is nothing inherent in medical schemata that ultimately allows judgment over what is in the best interest of the patient. Alone the fact that Hippocrates’ advice to keep the patient’s best interest in mind is still the ethical cornerstone of allopathic medicine underlines the medical vacuousness of the statement. It was as applicable to Greece in the 5 century BC as it is to both native and allopathic medicine in Iran today as it is to allopathic medicine practiced in a predominantly Christian setting. What counts as suffering and harm is deliberated outside the domain of medicine proper. What emerges then is a hierarchical model of schemata (D’Andrade, 1992). Medical schemata, be they allopathic or native, provide “how to” rules: how to interpret what is wrong with the body and how to restore it to health. These are executed within higher-order sets of well-formedness 5

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conditions and goals that inform allopathic schemata in the socio-political, ideological, economic and psychological contexts. In the setting in which patients and physicians hold in common a set of key concepts or values, allopathic schemata can be executed without obvious reference to the others. Those are transparent, their footprints and influence not seen or felt. This is the context in which compliance is achieved (Trostle, 1988; Zola, 1980). When doctor and patient share a belief in the scientific basis of medicine, in the conceptualization of the body as machine, in the experimental demonstration of the efficacy of pharmaceuticals, and operate within the same frameworks of religion, politics, ethics and economics, then they can cooperatively strive toward the same goals of treatment. It is when doctor and patient do not subscribe to the same key concepts or values, are not operating with identical schemata, do not adhere to the same rules of social interaction, and do not identify the same goals, that contestation occurs. And it is when an anthropologist asks how “Western” allopathic medicine can be practiced in a setting in which all else is not “Western,” that the external structures, motivators, and key concepts emerge from the background culture. Beyond describing these, what is left to do is to examine how these factors interact with one another in the emergence of medical practice. Copyright © 2017. I. B. Tauris & Company, Limited. All rights reserved.

6

The Relationships of Schemata Impacting Medical Practice I began the description of allopathic medical practice in Iran by elucidating native conceptualizations of health and disease and analyzing these to a set of key concepts which provide 1) etiologic explanations of illness, 2) criteria by which to assess the logic and appropriateness of proposed explanations and therapeutic strategies, and 3) motives for action. The key concepts pertaining to explanations of disease in Iran provide a logic for both native and allopathic explanations and treatment recommendations. Thus “native” and “allopathic” medical systems in Iran do not stand as mutually exclusive entities. Rather, physicians as well as patients cognitively integrate the two systems by applying the same set of well-formedness conditions to the etiologies and therapies recommended by each. Allopathic recommendations that do not “make sense” by Iranian logics, such as polypharmacy or sperm donation, will not be accepted as valid therapeutic options by physicians or patients. In Iranians’ estimation, common sense cannot be suspended for statistical interpretations of reality. Conversely, those recommendations which can be understood in terms of native logics are condoned by what is already known, regardless of their scientifically proven efficacy. 7

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The second part of the book explores extra-medical influences (economics, social authority, social ethics and state ideologies) on the practice of allopathic medicine in Iran. These can be thought of as frameworks or models from which predictions about health-related behaviors of patients and physicians can be made. Behaviors and attitudes of physicians and of patients can be described within any of these frameworks, but none of the frameworks can describe medical practice exclusively. For example, the medical model does not provide a calculus by which patients decide to consult an allopathic physician in the first place, the use of English for professional communications cannot be explained in terms of economics, and medical knowledge cannot be extrapolated from rules of social intercourse. Each of these frameworks fulfills the criteria of a schema, in that they provide the terms in which the environment is interpreted, well-formedness conditions with which the logical soundness of proposed courses of action is judged, and plans for action or execution of goal-oriented behaviors. These schemata are, however, not of the “how to” sort: they do not provide reflexive patterns of behavior analogous to those described in allopathic textbooks. They are not applicable to limited contexts and are not exclusive. Rather, they provide over-arching goals, generic well-formedness conditions and general key concepts in the context of which the “how to” schemata of allopathic medicine are executed. The goals and well-formedness conditions of these higher-order schemata simultaneously impact medical practice. Events, conditions, stimuli, symptoms lend themselves to more than one interpretation and may have various implications in various contexts. For example, the presentation of “irregular menstrual bleeding” unleashes a diagnostic workup in the medical setting, while from the point of view of social structure, when and whether the patient will actually get to see a doctor depends on her relationship with the authority figure in her household; how far the diagnostic and therapeutic endeavor will be taken depends on economic resources at her disposal; and which doctor she will see depends on ideological concerns of the government. More than one set of wellformedness conditions applies to any behavior undertaken in conjunction with medicine, and every therapeutic venture embodies more than one goal. The simultaneous applicability of various well-formedness conditions and goals to an interpretation of the feeling of ill-health implies that these can be mutually supportive or mutually contradictory. In the former instance, a particular course of action is “doubly good,” justifiable by separate lines of reasoning. For example, turning a patient away without

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seeing him/her violates a standard of social intercourse and is illogical from an economic point of view. Taking a patient’s blood pressure through three layers of clothing is said to protect patients from “dirt” accumulated on the head of the stethoscope and, in case the physician is a man and the patient a woman, is religiously condonable. Contradiction arises both within models and between them. For example, within the domain of traditional Iranian medical knowledge, the suspicion cast on pharmaceutical drugs because of their “artificial” (unnatural) origin stands in contrast to the value that is placed on ‘elm and, derivatively, on scientific knowledge. Conflict arises between physicians, patients and state ideals even over the very goals of treatment, over what counts as “harm” and “suffering,” let alone over economic and ethical issues. Patients come with their own understandings of disease and goals of therapy and are likely to simply disregard the physician’s advice if it does not “agree” with them. The government demands that recent medical school graduates practice for two years in rural clinics, but does not outfit these with more than, at best, rudimentary diagnostic and therapeutic technologies and pharmacologies. The state identifies women as equal in competence to men in the medical field and supports their medical careers, but social norms identify men as better than women, and so cast doubt simultaneously on the ability of women physicians to fulfill the goal of “alleviating patient suffering” and on the state’s goal of building an egalitarian society in which all members have access to equally good health care. To make money is a goal of medical practice, but so, as far as the state is concerned, is the provisioning of health care to the indigent. The fact that the interpretations derived from and goals inherent in these five extra-medical models of medical practice may be mutually supportive of or stand in opposition to one another means that there is a great deal of ambiguity, indeterminateness and flexibility in the relationship of allopathic medicine to culture in general. In the case in which models are mutually supportive of one another, physicians can choose between multiple explanations or logics when they rationalize their practices. More importantly, in the case in which there is contradiction, physicians face multiple, equally well-formed but problematic, options for practice. Contradictions may be resolved by one clear principle, such as by laws based on religio-ideological considerations, as pertain for example to abortion. But even where one model is given clear priority, it can be challenged and is pervious to contradictory but still culturally logical arguments. A physician may resent being ordered by the court to terminate a pregnancy which is endangering the health of the mother on the grounds

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that doing so “dirties my hands,” while another physician may take the risk of performing an illegal abortion by arguing that it is a lucrative procedure and/or it would do social harm to the woman if she were forced to have the child. Similarly in the matter of Cesarean sections: as a surgical procedure, a C-section carries significant risks and so, according to American ethics, should be performed only when there is a clear medical indication. Yet the elective C-section rate in Iran in some hospitals is over 50 percent (in comparison to the goal of 20 percent in the United States). Iranian physicians prefer C-sections because they have greater control over their working hours and have greater income; Iranian patients prefer C-sections because, they say, operative births are more “comfortable” (rāhat) than vaginal ones. The schemata derived from extra-medical frameworks are not bound in a hierarchy of importance: none is given absolute priority in structuring practice, and there is no exclusive commitment to any of the models. In particular, the key concepts and goals of allopathic medicine are not foregrounded, given priority or considered inviolable simply because of their “allopathic” or scientific nature (Loeffler, in press). Not all models may apply to all situations. Some may be more motivational than others for some physicians or in some instances, and some principles may be more pervious to corruption than others. Physicians and patients can appeal to a large range of arguments in rationalizing or justifying the manner in which they practice or expect medicine to be practiced. As a consequence, new conditions, new potentials (e.g., new allopathic technologies), new restrictions (e.g., the tarh-e entebāq), or newly perceived deficiencies (e.g., of allopathic knowledge to satisfactorily address depression) can be met and dealt with by picking and choosing arguments and practices from these models, without shaking the foundations of medical practice. Ambiguity and ambivalence in and between the models stabilize the system by allowing for both reproduction and innovation in medical practice. The decision about which of multiple possible courses of action or which of several plausible lines of logic to follow in constructing or rationalizing practice requires consideration of formalized laws pertaining to practice and malpractice, social norms, economic factors and allopathic ideals in relation to physicians’ personal values and characteristics. A devout physician may not be persuaded to perform an abortion under any circumstances, for example, while one who was attracted to the profession for its promise of economic advancement may. A doctor from an urban background may resent being sent to a village in fulfillment of the tarh, while one who grew up in such a village and suffered under the “stress” of

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living in a large city during training embraces the opportunity to return to his roots. A physician who devalues native knowledge in comparison to allopathic knowledge will not give patients advice on dārū-e gīāhī, and so forth. Thus, appreciating how the various models impact practice in any given instance lies not only with further analysis of the relationships of the models to one another, but in exploration of personal, psychological motivators of individual practitioners or patients which, as part of the context of experience, necessarily will impact the manner in which medical practice is structured. This is not to say that the structure of medical practice is created anew in every instance of practice, in every patient-physician encounter. Just as execution of allopathic schemata in the medical clinic is routinized during training, so patterns of extra-allopathic medical behavior are learned by students in the clinical portion of their training, not didactically as are allopathic schemata and the ideals of practice, but as lived experience. Witnessing their superiors interacting with patients and peers, students learn how patients are charged, how they are talked to; how physical exams are done and where short-cuts are taken, what kind of information to give patients, what kind of things one complains about and in what terms these complaints are voiced, that one wears a clean white coat and why; what kind of behaviors are expected of physicians; how to circumvent norms of social intercourse which pose barriers to the efficient processing of patients without insulting the patient; and so forth. Beyond this, patterns of medical practice emerge naturally or logically from native knowledge, from native understandings of reality, i.e., they make sense in the larger world-view of physicians qua Iranians. The logic of most practices needs to be contested or discussed only in response to the questions of an anthropologist. For an Iranian physician, it is a matter of fact extending beyond the medical setting that one withholds worrisome information, identifies foreign goods and knowledge as valuable, pays attention to and guides one’s actions on the basis of the state of the hāl or tab’, or complains about the economic situation in Iran and about state interference in private matters. There is nothing inherently “medical” about these modes of thought: they are already given in the culture and applied to medicine as to any other form of social intercourse. Whether one stops the analysis at the level of description of the models or delves further into the interconnections between the knowledge and goals pertaining to medical practice, what is clear in any case is that allopathic medicine is integrated reflexively in the native medical system. It is brought in alignment not only with native ideas about health and disease but with the

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entire social, economic, political and religious or ethical contexts of practice (and presumably also with the psychological ones). This is done actively, as physicians are faced with choices for structuring and arguing about practice, and it is done automatically, as practice is structured by patterns of behavior and thought which emerge through repeated experiences of the physician qua social person in Iranian culture. Moreover, it is not just the physician who is achieving this integration. At the state level, policy is formulated pertaining to health care delivery. At the social level, physician and patient together negotiate the practical, economic and ethical implications of diagnosis and therapy. At the level of individual patients, calculi are performed as to the appropriateness of particular pathophysiologic explanations or therapeutic suggestions. Thus political, economic, social and individual processes together achieve the integration of allopathic medicine with local cultures. More important than the fact that this integration is achieved, or the site of its achievement, is the point that it has to be achieved. In a social/political/ideological context, the schemata of allopathic medicine do not carry their own motivators, and the idealistically but basically vacuous motive of “alleviating patient suffering and not doing harm in the process” cannot, on its own, structure medical practice. Without precise social goals, allopathic schemata cannot be executed: they are impotent. The motives of allopathic practice come ultimately from the contexts of its use, i.e., from cultural, economic, political, social, ethical, ideological and psychological frameworks. It is from interconnections between these that practice emerges, and it is with these that allopathy must establish interconnections in order to gain validity and authority, and to be practiced at all. Native culture is the bed in which allopathy must lie. For this reason allopathy “goes native.”

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Endnotes

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Chapter 1 1. For example, chronic degenerative diseases such as atherosclerosis, diabetes, hypertension and some forms of cancer appear to result from a sedentary life style and a high-fat, high-carbohydrate diet which induce metabolic states opposite to those to which humans are adapted (Cohen, 1989; Eaton et al., 1988; Wiedman, 1987), and the incidences of most infectious diseases, from HIV-positivity to typhoid, are linked to sociopolitical conquests and inequalities (Blackburn, 1991; Carlson, 1996; Farmer, 1994; Takahashi, 1998; Zinsser, 1963). For full discussions of biological medical anthropology, see Brown, 1998; Mascie-Taylor, 1993. 2. See, e.g., Boddy, 1989; Crapanzano, 1973; Evans-Pritchard, 1977; Foster, 1976; Frake, 1961; Geertz, 1977; Kiev, 1964; Levi-Strauss, 1963; Turner, 1967; Whiting, 1950; Witherspoon, 1977. 3. See, for the former, Hahn, 1985; Lucas and Barrett, 1995; Pliskin, 1995; Rhodes, 1990; Romanucci-Ross et al., 1997; Young, 1980; and for the latter, Eddy, 1984; Gill et al., 1996; Nordin-Johansson and Asplund, 2000. 4. I am aware that some allopathic practitioners object to the term (Gundling, 1998), but their objection appears to be due to unfamiliarity with allopathy’s history and philosophy, and they have not suggested a more suitable alternative. 5. Contrast this with the status and credibility of homeopathy, along with many other “alternative” medical systems, in Europe today. 6. For the history of allopathic medicine, see (e.g., Foucault, 1973; Martensen, 1995; Starr, 1982), the doctor-patient relationship (e.g., Bellisari, 1987; Brody, 1988, 1992; DiGiacomo, 1987; Erwin, 1987; Latimer, 1999; Mathews, 1983; The et al., 2001; Trostle, 1988; West, 1998; Young, 1997; Zola, 1980), health policy (e.g., Angrosino and Scoggin, 1987; Ingman and Thomas, 1975; Weaver, 1985), medical ethics (e.g., Jordan and Irwin, 1987; Lock, 1995), medical education (e.g., Becker et al., 1961; Good, 1994; Good, 1995; Raikes, 1975), patient narratives of health and disease (e.g., Connors, 1995; Farmer and Kleinman, 1998; Garro, 1994; Hyden, 1995; Kleinman, 1988; Taussig 1980), health management decision making (e.g., Epling et al., 1975; Gould, 1977; Janzen, 1978; Romanucci-Ross, 1969), the

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10. 11.

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HEALTH AND MEDICAL PRACTICE IN IRAN relationship of allopathic medicine to political and economic systems (e.g., Arnold, 1993; Baer, 1982, 1989; Comaroff, 1993; Elling, 1981; Farmer 1992; Morsy, 1990; Onoge, 1975; Scheper-Hughes, 1992; Young, 1995); textbooks of allopathic medicine (e.g., Hahn, 1995; Martin, 1994; Tomlinson, 1999), and physicians’ self-reflections (e.g., Cassell, 1996; Hahn, 1985; Helman, 1985; Konner, 1987). The same, incidentally, is true in Iran. By extension, indigenous state and professional organizations which identify the needs of the population and control the practice of allopathic medicine are equally divided along two lines. Health policy, medical ethics, the education and licensing of health care professionals, reimbursement of medical services, the equitable distribution of allopathic care to all segments of the population, must be arranged in the context of demands of “state-ofthe-art” allopathy, international priorities, and the social, economic and political realities of each individual country. See e.g., Arnold, 1993; Baer et al., 1986; Baer et al., 1997; Comaroff, 1993; Cunningham and Andrews, 1997; Elling, 1981; Morsy, 1990; Onoge, 1975; Scheper-Hughes, 1992. See e.g., Friedl, 1979a; Good, 1980; Janzen, 1978, Whittaker, 1999. Berlin, 1992; Bowker and Star, 1999; Burling, 1964; Coleman and Kay, 1981; de Munck, 2000; Dougherty, 1975, 1978; Frake, 1961; Lakoff, 1987; Lakoff and Kövecses, 1987; Metzger and Williams, 1963; Murphy and Medin, 1985; Ngokwey, 1995; Rosch and Rosch, 1978; Shore, 1991, 1996; Sweetser, 1987; Young, 1978. Keller and Keller, 1991, detail the cognitive processes of assessment and reassessment in the execution of a task in the context of a blacksmith working iron. For example, while scientific medical research has demonstrated that both men and women can shed the virus(es) responsible for genital herpes even in the absence of symptoms, physicians tend to screen only women for herpes. In their justifications of this practice, Pliskin (1995) identified a “folk model” of male and female reproductive organs which identifies the vagina as moist (hospitable to foreign organisms) and invisible (frightening) and the penis as dry and visible. This folk model underlies the common tendency in Western societies to hold women responsible for ills associated with sexuality, from rape to unwanted pregnancy and the transmission of HIV. In the allopathic setting, “patients don’t read textbooks” means simply that patients may present with atypical symptoms or respond idiosyncratically to therapeutic measures. The additional meanings given here are not ones that surface in the context of hospitals or clinics.

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15. Rarely, the social, psychological, economic and/or political causes of disease, such as post-traumatic stress disorder, chronic pelvic pain, or obesity are recognized by physicians, and attempts are made to “medicalize” the illness. The only (productive) schema available to allopaths with which they can address these is by interpreting the disease as “somatization” and attempting to alleviate it by a combination of anti-depressant/anxiolytic pharmaceuticals and “cognitive therapy,” getting the patients to think differently so as to be better able to handle the stressors in which they are suspended.

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Chapter 10 1. I introduced this concept in Chapter 1. 2. See Brewer, 1999; D’Andrade, 1992; D’Andrade and Strauss, 1992; Holland 1992a; Lehman, 2000; Strauss 1992 for other descriptions of schemata. 3. Since the early work in cognitive anthropology it has become apparent that “key concepts” are more than just labels we put on things or the terms with which we verbally classify objects in the environment. Rather, key concepts are intricately tied to a context of use (see, e.g., Dougherty, 1978; Friedl 1979b) so that, e.g., plants are named as long as they have value, whether as food or firewood or construction or medicine, but once the use has fallen away the terms do to. 4. See, e.g., Martin’s (1987) seminal work on the body-as-machine metaphor. 5. Both allopathic and native Iranian medicine have roots in classical Greek medicine. While native Iranian medicine is directly derived from Unani medicine in content, allopathic medicine ultimately rejected (though only very recently) the concept of humoral physiology while retaining its emphasis on evidence-based medicine. 6. The execution of the “how-to” schemata of medical systems thus becomes a site of contestation of various ideologies. Though not discussed in the conceptual framework of cognitive anthropology, the usurpation of the body for ideological debate and political control is well described in, e.g., Arnold, 1993; Baer, 1989; Bellisari, 1987; Boddy, 1989; Carlson, 1996; Comaroff, 1993; Connors, 1995; Farmer, 1992; Filkins, 1998; Jordan and Irwin, 1987; Koenig, 1988; Lantos, 1997; Lock, 1995; Myntti, 1988; Scheper-Hughes, 1992; Singer et al., 1998) 7. See Nunley, 1996 for a description of the key concepts informing polypharmacy in psychiatric practice in India. 8. Though allopathic schemata are spelled out in a “how to” manner in allopathic textbooks, it would be inaccurate to describe allopathic practice, even in the cases in which all else is equal, as “reflex.” Every patient interview and therapeutic plan requires assessment and reassessment of one’s

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11.

12.

HEALTH AND MEDICAL PRACTICE IN IRAN knowledge about and the goals of the therapeutic endeavor, as described by Keller and Keller (1996) for the work of blacksmithing. While the expert may have internalized the “how to” business of a schema, progress toward the goal requires constant redesigning of the therapeutic plan both in relation to the patient and in relation to changing scientific knowledge about the disease. I have no evidence that Iranians actually think of their medical system and medical choices in these terms. Whether or not they represent what is “in the mind” of Iranians, these models are useful for defining the key concepts and goals which inform medical practice. Harkness (1992) and Holland (1992a) describe other examples of how multiple schemata can simultaneously apply to particular decisions in different cultural contexts. Some of the contradictions which seemingly arise between or within the models do not actually arise in practice because of contextual separation. For example, the argument that there are too many physicians does not ever really stand in contradiction to the argument that there are too many patients. The two complaints are voiced in different contexts and trigger different explanations: the former is used to complain about state control over medical practice, the latter is used to highlight a goal for medical practice, i.e., that every physician should have “too many patients.” See, e.g., D’Andrade (1992), Harkness et al. (1992), Holland, (1992a&b), Lutz (1992) and Quinn (1992) for discussion of the role of motivation in execution of schemata.

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Kleinman, eds. The Relevance of Social Science for Medicine. Boston, MA: D. Reidel Publishing Company.

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Index

Allopathic medicine, see Medicine American Medical Association, 3 American Psychiatric Association, 4, 189 Anatomy, 12, 38 Anemia, 49, 80, 91-92, 96 Anesthesiology, 139 Anthropology cognitive, 9-15, 175-178, 187 ethnography, 10, 16-42 fieldwork methodology, 16-42 medical, 1-15, 185 participant observation, 26 Antibiotic, in relation to Iranian traditional medicine, 6, 51, 74, 92, 96, 106 Anxiety, 56, 156, 160, 162 see also, Stress ‘Aql, 58-59, 137 see also, Reason Ārāmesh, 72, 73, 75, Asāb, 54, 72, 156 see also, ‘Aql, Emotion, Reason, Stress, Nature Attāri, 49, 50, 90 Authority, 32, 120, 121, 122-141, 151, 153, 175, 177, 179, 183 Avicenna (Ibn Sina), 38, 75, 135 Backache, 55, 56, 57 see also, Stress Bacteria, see Mikrūb Balance, 71-86, 92, 176 see also, Humoral system Beauty, 60, 61, 72-80, 117, 120 Behavior and authority 52, 109, 161 and cognition, 9-11, 175-183 and health 51, 52, 71 "Islamic", 21, 131

Behavior, cont., in relation to Islam and ethics 159, 161, 168-173, 175-183 Bīābūnī, 73 see also, Nature Bīmār, 46 see also, Health, Patient Biomedicine, see Medicine Blood in humoral physiology 47, 48, 53, 99 as polluting 52, 95, 97, 99, 107f, 160f pressure, see Hypertension sugar 65, 66, 81 Body and beauty 77, 78 in humoral physiology 47, 51, 52, 74, 76, 160, 176f as metaphor 178, 187 purification of, 83, 99 temperament of, see Constitution Cancer, 5, 64, 65 as life-threatening diagnosis 68, 108, 110, 114, 144, 145 Canon, 38; see also, Avicenna Cesarean section, 66, 105, 173, 181 Cheshm nazar, cheshm shūr, see Evil Eye Cleanliness, in relation to health 51-54, 78, 83, 85, 92, 93, 96, 97, 125, 161 see also, Dirt, Mikrūb Clinic and allopathic schemata 14, 88, 90 government, 104, 111f, 162f

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Clinic, cont., OB/Gyn, 27, 41, 143, 144, 152 pharmacy, 104, 112 physicians' cooperative, 129 private, 35-37, 105, 130, 152f, public, 84, 107, 139, 143, 153, 172 as research setting, 22, 23, 2528, 35-37 rural, 33, 37, 39, 68, 180 see also, Clinic:government university, 27, 35-37, 103f, 108, 133, 152, 153 University of Shiraz Physicians’ (Motahari), 63 Cold (sard)/Hot (garm) attributes, 46-50, 60, 65, 69, 74, 77, 80, 83, 87-100, 130, 176 see also, Food, Humoral system Constitution (hāl, mezāj, tab’'), 4651, 65, 67, 69, 71, 74, 80, 86, 97f, 140f, 174, 182 Culture, 1-10 and illness 122, 175-183 and medical practice 1-10, 35, 113, 114 physician as participant in 7-9, 13, 158

Dānesh, see 'Elm, Knowledge Dārū-e giāhi, 74f, 88f, 90, 93, 182 see also, Attāri Del, 58f, 72, 85 see also, Emotion Depression, 55f, 58, 81, 84, 86, 93, 94, 111, 161, 181, 187 see also, Stress Diabetes, 65, 66, 80f, 88, 95, 122, 149, 185 Diagnosis, allopathic, 65-69, 140, 171 diagnostic process 30f, 37, 99f, 104f, 107, 115, 130, 135f, 139f informing patients of 68, 141, 120, 144, 156 and schemata 10-12, 87-90, 180f

Diet, see Food Dirt, (cherk, kesāfat), 50-54, 67, 69, 71, 72, 75, 76, 78, 80, 84, 86, 92, 94, 95, 96, 99, 160, 176 Disease, allopathic explanations, 90, 91, 178 as cultural construct, 1-5 vs. illness, 13 native conceptualizations, 14, 15, 45-70, 80, 86, 87, 90, 92f, 94f, 156, 176 see also, Diagnosis, Humoral System, Illness, Stress, Therapy Djinn, 59 Doctor, see Physician Doctor-patient relationship, 3, 2324, 27, 29, 31, 68, 122, 136, 138f, 151, 156, 157, 158, 177, 182, 185 Drug, pharmaceutical, 56, 67, 75, 86, 96f, 98, 99, 112, 143, 180 see also, Medication Economics of health care in Iran, 105-121 Education, foreign training 133, 148 health 6, 79 medical, see Medical School primary, 7 university, 33, 87, 90, 96, 105, 123, 125, 126, 127, 163 university graduate, 34f, 40, 127 vs. suspicion, 59, 68, 91 see also Knowledge ‘Elm, 122-141, 142-158, 159, 165, 167, 174, 180 see also Knowledge Emotion, 54-59, 81, 137 see also Constitution, Nārāhat, Stress Ethics, 111-115, 159-174, 179 Evil Eye, 41, 59, 60f 64, 71, 88, 90, 99

see also Cheshm nazar

INDEX

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Family, 108-110, 111, 113, 116, 153, 163, 166, 172 Fasting, 53, 54, 74, 97, 99, 131, 160, 171, 173 Fertility, 62, 69, 77, 91, 96, 97, 98, 108, 109, 110, 134, 152, 168, 178 Feshār, 49, 50, 54, 72, 92 see also, Stress Feshār khūn, see Hypertension Flexner, Abraham, 39 Food, Diet, 92, 94, 150 hot/cold, 41, 47, 49, 65, 74, 80, 88, 93, 95, 99 khārejī, 147, 150 preparation of, 51f properties of, 47-50, 80-83, 91 see also Cold, Hot, Humoral system Gender, 31, 42, 136-138, 164-167, 177, 180 see also, Tarh-e entebāq God, faith in, for healing, 24, 64, 65, 83, 91, 174 health-related commands, 51f, 165 intercession with, 62, 63 and nature, 71, 74 and purity, 60, 78f source of suffering 58, 71 God's will, 69, 71, 100, 110, 170 Gynecology, see Obstetrics and Gynecology

Hāl, Hālat, see Constitution Healer, see Physician Health, Care, 106, 108, 162-164, 167, 172, 183 and culture, 1-6, 8, native conceptualizations of, 14f, 22, 45-70, 71-86, 87, 92-94, 156, 175, 178, 180 public 16, 39, 52

207 Health, cont., see also, Constitution, Disease, Illness, Tarh-e Entebāq Herbalism, 49, 67, 69, 88, 93, 99 see also, Attāri, Food, Medicine: Ayurvedic, Galenic High blood pressure, see Hypertension Hippocratic oath, 169, 177 HIV/AIDS, 5, 8, 184, 186 Homeopathy, 2, 3, 185 Hospital, Nemazee, 32f staff, 33, 117, 130 university (teaching), 32, 34, 3537, 38, 152 Hot/cold, see Cold/Hot see also, Food, Humoral system Humility, 51, 80-86, 125 Humoral system, 37, 46-50 see also, Medicine: Greek Hypertension, effect of food on, 47, 49, 54, 75 and stress, 56, 57, 81, 92, 95 Ibn Sina, see Avicenna Illness, cultural construction of, 1, 8, 161 experience, 12, 13, 22 meanings of, 4-5, 6, 14, 99, 122 narrative of, 7, 11, 155 native explanations of 46-70, 71-86, 178 treatment for 90, 100, 111, 103121 134 see also, Disease, Health, Therapy Imām, 59, 61, 62, 63, 125 Imam Hussein, 61, 62-63 Imam Reza, 61, 62, 99, 108, 110 Imāmzādeh, 59, 62, 63, 69 Infection, 5, 6, 56, 65, 68, 74, 94, 112, 133, 143, 154, 169 Insurance, 105, 118 Intern, 23, 68, 88, 93, 96, 97, 131, 139, 143-144, 146, 165, 166

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Iran, Islamic Republic of, 1, 6, 9, 14, 15, 17, 104, 136, 165, 172 Foreign Ministry, 20 government of, 16, 17, 18, 104, 105, 106, 113, 116, 118, 126, 145, 152, 162, 163, 164, 165, 179, 180 Ministry of Education, 32 Ministry of Health, 21, 33, 40 relations with international community, 17-19 war with Iraq, 16, 34, 36 Islam, 18, 59, 61, 124, 154, 159174 Islamic Revolution, 16, 17, 32, 33, 39, 73, 104, 106, 163, 165

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Jegar, 58f Kevorkian, Dr., 170 Key concept, 10f, 14f, 71-86, 97, 121, 141, 158, 175-178, 181, 187, 188 see also Schemata Khārej, 17-19, 146-151 Khatami, Mohammad, 16, 17 Knowledge allopathic medical 83, 89, 92, 159-174 and authority, 122-141 and medical practice, 142-158 native medical, 83, 180, 182 patient’s, 138-141 value placed on, 125-128 see also, ‘Elm Koran, 59, 60, 74, 81, 91, 125, 143, 160, 161 Language, 28-29, 142-151 Arabic, 143 English, 24, 29, 31, 33, 35, 40, 65, 68, 123, 142-151, 174 physicians’ use of, 142-151, 179 Farsi, 142, 144, 157 see also, Medical school, Medical student, Physician, Textbook

Lex talionis, see Qassās Mahmoody, Betty, 18, 199 Medical license, 33, 39, 40, 104, 113, 130, 136, 168, 186 see also, Tarh Medical Licensing Act (1910), 39 Medical school admission to, 33f, 130, 166, 173 author’s training at, 5, 19, 26, 29- 31, 41 curriculum, 3, 32, 35, 39, 130f graduate of, 34f, 104f, 112, 137, 162f homeopathic, 3 Jundhi Shapur, 38 number of, 33, 163 quality of, 34f, 41, 149 research at, see Research specialty training, 39, 132, 163 status of, and authority, 132 textbooks, 148 University of Shiraz, 23, 29, 3235, 123, 129, 132, 142, 145, 165 see also, Education, Medicine: history, Pahlavi University,Tarh Medical student, clinical responsibilities, 36 as research subject, 23-26 see also, Medical school: graduate, Intern Medication, 68, 75, 95, 98, 104, 109, 112, 115, 130, 143, 149, 174 see also, Drug Medicine allopathic, 2-4, 15, 39f, 69, 86, 87-121, 142, 148, 154, 175-183 anthropology of 1-15, 122, 185 Ayurvedic, 2, 8, 10-15 biomedicine, 2, 7 Galenic, Greek, Unani 2, 39, 46-50, 125, 187 herbal, 49, 74, 75, 125 see also, Attāri history of, 38-41, 185 houlaki, 111, 114, 115, 117

INDEX native, 7, 15, 45-70, 87-100, 176, 177, 187 see also, Cold/Hot, Constitution, Humoral system pluralism, 5-7, 15, 99-100 research in, see Research specialization, 31, 33, 35, 40, 142, 146 state control of, 162-167, 173, 174, 182, 188 see also, Ethics,Tarh-entebāq Mezāj, see Constitution Midwife, 22, 50, 105, 127, 143 Mikrūb, 51, 52, 76, 84, 93 see also, Dirt Mirza Taqi Khan Amir Kabir, 38 Moderation, 80-86 Mohammad, Prophet, 51, 52, 53, 59, 61, 63, 73, 82, 83, 126, 165 Muslim, 83, 85, 159, 171

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Nākhosh, 46 Nārāhat, Nārāhat ī, 45, 54, 58, 69 see also Emotion, Stress Nature, 71-86 Nurse, 5, 22, 26, 55, 77, 88, 105, 106, 127, 134, 143, 144, 152, 166 Nutrition, 13, 16, 69, 105, 160 see also, Food OB/Gyn, see Obstetrics and Gynecology Obesity, 56, 80, 94, 105, 187 Obstetrics and Gynecology, 31-32, 137f, 165-167 see also, Clinic: Gynecology Orthopedics, 32, 98, 107, 114, 127, 136, 150 Pahlavi University, 32-34, 36, 150 see also, University of Shiraz, Medical School Pāk, see Cleanliness Pasteur, Louis, 39 Paternalism, 31, 138-139, 141 Pathology, 28, 30, 148

209 Pathophysiology, 59, 65, 66, 71, 81, 95, 96, 99, 120, 139, 140, 155, 177, 183 Patient, allopathic knowledge of, 68f, anthropology of, 5-14 compliance of, 6, 13-14, 178 economic costs to, 105, 112, 118 expectations of physicians, 67, 105-111, 115, 117, 120, 128, 132, 135-139, 149f, 158, 160f, 174 female, 24, 31-32, 164-167, 179 information given to, 120, 139, 150, 155, 156, 182 physicians expectations of, 24, 68, 139, 140, 152, 157 privacy, 24, 27-28, 142-144 at teaching hospitals and clinics, 34, 36, 85, 172 trust, 130, 155, 156, 162 volume, 113, 129, 142, 144, 151-157, 188 Pediatrics, 32, 63, 137 Pharmacology, 92, 111, 139, 177, 180 Physical examination, in medical school, 34, 36 privacy in, 27, 143 as schema, 10, 11 thoroughness of, 111, 114, 115, 152, 171, 182 Physician, allopathic, 11-15, 30, 55, 177, 179 authority of, 122, 128-138, 141, 142-158, 159, 160-162, 164, 167, 174 career expectations, 106, 116, 164 economics of practice, 111-121 and use of English, 142-151 and ethics, 68, 85, 168-174 foreign, in Iran, 32f, 38f, and gender, 136-138 and khārej, 67, 133, 134, 138, 146-151

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Physician, cont., licensing, 39 see also, Tarh in medical anthropology, 1, 3, 7-9 and medical pluralism, 179-183 native, 7-10, 14f, 35 and native conceptualizations of disease, 45-100 and patient relationship, 139f, 151-157 see also, Doctor-patient relationship and practice setting, 22-25, 103105, 106, 129, 133-138, 144, 152, 153, 162-164 as religious broker, 159, 160162 as research subject, 22-25 and the state, 161-167, 178, 179 teaching staff, 32f, 36f, 40 training of, see Medical School see also Doctor, Healer, Intern Pilgrimage, 61, 62, 99, 110 Pollution, 52, 83, 98 see also, Cleanliness, Dirt, Ugly Practitioner, see Doctor, Physician Pregnancy, 100, 154, 160, 165, 168, 169, 170, 173, 180, 186 Prejudice, 96-98, 119, 154, 168 Prognosis, 100, 139, 144, 145, 155, 156, 174 Psychiatry, 4, 8, 27, 64, 161, 166, 187 see also, American Psychiatric Association Psychology, 65, 119, 183 Public policy, see Clinic: rural, Tarh, Tarh-e entebāq, Purity, 51, 53, 54, 60, 67, 71-86, 176 see also, Cleanliness Qajar Shah, 39 Qashang, 78, 79, 85 see also, Beauty Qassās, 169 Qavīh, 47, 48, 91, 92

Ramadan, 97, 160 see also, Fasting Razes, 38 Research author’s, 1, 8, 14f, 16, 19-22, 32, 35, 37, 41f, 111 and ‘elm, 123f medical, in Iran, 21, 33, 38-41, 85, 153 methodology, 22-27 Reason, 54-59, 67 see also, 'Aql Religion, 124, 159, 160-162, 164168, 169-171, 173, 174, 178, 180, 183 see also, Islam, Physician: as religious broker Residency program, 104, 114, 126, 130, 131, 133, 138, 149, 165, 166 Rūh, 54 Sa’adi, 128

Sabok, 48 Sangīn, 47, 48 Sayyid, 59, 63 Schemata, 10-15, 42, 65-69, 88, 87100, 141, 158, 175-183, 187, 188 Shah Cheraq, 62 Shah Nasr al-Din, 38, 40 Stress, 5, 46, 54-59, 60, 67, 69, 71, 72, 74, 80, 83, 86, 92, 94, 95, 97, 99, 152, 160, 181 see also Anxiety, Feshār Supernatural forces, 1, 2, 46, 5965, 80, 86 Superstition, 89, 91 Symptom, 4, 12, 14, 95, 113-114, 122, 143, 171, 176, 179, 186

Tab’, see Constitution Tabī’ī, 72, 74 see also, Nature Tahqiqāt, see Research Tamīz, see Cleanliness Tarh, 162f see also Clinic: rural

INDEX

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Tarh-entebāq, 24, 130, 133, 159, 162, 163, 164, 165, 166, 167, 181 Tehran, 17, 19, 20, 22, 28, 29, 33, 38, 49, 52, 105, 116, 148, 149, 150, 170 Textbook, 3, 11, 12f, 24, 29, 32, 34, 35, 36, 37, 38, 65, 81, 88, 93, 96, 97, 112, 114, 120, 123, 145, 148, 150, 179, 186, 187 Therapeutic community, 5, 6 Therapy, allopathic, 65, 69, 86, 88, 94-96 anthropology of, 6, 10-13, 14, 122, 175-183 and authority, 67, 122, 155, 158 cost of, 105-110, 111, 118, 121 and ethics 111-117, 154-157 evaluation of, 86, 96-98, 140 and medical pluralism, 88-100, native medicine, 46-50, 56, 68, 87 and zerengī, 130 Ugliness, 52-53 see also, Beauty ‘Ulamā, 124, 125

211 United States, author’s background in, 20, 25, 29 as source of authority, see Khārej dominance of, 7 history of medicine in, 3, 39f medicine, in comparison to Iranian, 34, 35, 85, 94, 112, 115, 116, 151, 181 relations with Iran, 17, 32, 35, 38

Vaqt, 104 Vazīfe, 153 Victim of War, 131, 132, 133 Vitamin, 49, 77, 83, 91, 92 Vojjdān, 159, 173 Well-formedness condition, 175179 White Revolution, 39 Yunani (Unani) medicine, See Medicine: Greek

Zerengī 78, 117, 129-133

Agnes G. Loeffler

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Agnes G. Loeffler is Associate Professor at the Department of Pathology and Laboratory Medicine, University of Wisconsin School of Medicine and Public Health. She completed her PhD in Cultural Anthropology at the University of Illinois, Champaign-Urbana, and received her MD from the same institution. In addition to her contributions to anthropology, she publishes in the allopathic medical field, including the co-edited volume Introduction To Human Disease: Pathophysiology For Health Professionals.

Health and Medical Practice in Iran

‘A thorough, insightful portrayal ... this volume will appeal both to medical anthropologists and to people interested in Iranian culture in general, as well as in modernisation and globalisation in Iran and elsewhere.’ Mary Elaine Hegland, Anthropology of the Middle East

Traditional Culture and Modern Medicine

alth ddical ctice ran

Allopathy is often described as ‘western’ medicine, the antithesis of homeopathy, yet all medical systems are infused with culture-specific values, ideas and beliefs. Agnes Loeffler’s insightful and original book investigates how allopathic knowledge, theories and practice guidelines come to be understood and applied by practitioners in a non-western context. Based on research amongst doctors in Iran, Loeffler describes how the system of allopathic medicine has adapted to local explanations of health and disease and to the economic, social and religio-political realities framing contemporary Iranian life and culture. This approach simultaneously problematises the view of allopathic medicine as a ‘western’ entity exerting a hegemonic influence over non-western cultures, and provides a rare glimpse of the complexities of modern Iranian society – exploring the interfaces between culture, health and the experience of illness.

Heal and Medi Pract in Ira

Health and Medical Practice in Iran Traditional Culture and Modern Medicine Agnes G. Loeffler

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