Assessing Reproductive Health Care amongst Marginalized Communities: Bedouin in Lebanon
Panel 204, 2009 Annual Meeting
On Tuesday, November 24 at 10:30 am
Panel Description
Basic health care provision for pastoral peoples in the Middle East has been largely overlooked by governments in the region due to the general remoteness and mobility of these peoples. Most government services are designed for fixed, permanently domiciled populations; people who move part of the year or seasonally or even those ‘settled’ in unrecognized or unofficial hamlets and villages are generally excluded from government services. In the arena of health care, marginal, mobile or recently settled populations have limited access to government health care provision. This panel aims to present the findings of a three year health care study among Lebanon’s Bedouin. The study set out to assess the current health status, health seeking behaviour and practices of marginal pastoral peoples in relation to reproductive and child health; and to assess the scope of current health care delivery and the views of stakeholders-policy makers, health personnel and Bedouin themselves. In a final phase, the study will develop model interventions to improve access to and quality of reproductive and child health care; and to evaluate and disseminate the interventions locally, nationally and regionally
The four papers which make up this panel are as follows. The first paper explores the history of the long unacknowledged association of Bedouin with Lebanon. It seeks to contextualize current attitudes regarding Bedouin in Lebanon as an explanatory element in assessing contemporary reproductive health care of Lebanon’s Bedouin.
The second paper assesses the awareness and knowledge of policy makers regarding the health policies and health status of the Bedouin community in the context of Lebanon. It relies on the findings from a formal audit of six clinics and dispensaries and on in-depth interviews conducted with health policy makers from the government, private, non-governmental organization sectors.
The third paper presents an analysis of perceptions with regard to reproductive health care drawn from semi-formal and in-depth interviewing with Bedouin women in the study area;
It addresses views on health and health-seeking behavior against a backdrop of marginality, discrimination and dire socio-economic constraints.
The fourth paper explores the local articulations of the health care needs and the way they are prioritized by the Bedouin community from an anthropologically informed perspective. It focuses on the various modes of expression (sensorial, spatial, and cognitive), as well as on including the views of the less empowered groups within the community.
Community-based research has been the focus of current public health research. It requires the involvement of both the community and researches to investigate the influence of political, social, and structural factors on health. However, there exist several emerging obstacles when planning and implementing such an intervention.The current intervention intends to train Bedouin community health volunteers (CHVs) to spread reproductive and child health knowledge in the community and encourage uptake of services offered by two partnering health centres. The challenges relate to the existing political atmosphere and the difficult process of building and maintaining a partnership with the Bedouins.
A portion of the Bedouins residing in Beqaa valley continue to be deprived of a nationality; thus they can not enjoy the same privileges or have access to basic resources as Lebanese citizens do. Health may not even be a priority. Moreover, overcoming the different political affiliations of the Bedouins, ensuring a comprehensive representation of the community, and reaching a consensus on common goals are other emerging obstacles. Finally, the lack of policies that advocate the rights of the Bedouins has further exacerbated their marginalization. This led to losing trust in collaborations intended to improve their status. The participation of the community is crucial for this project's success. However, the clash between the agenda of the researchers and that of the community is present. The Bedouins presented expectations beyond the scope of the research. Also, time consuming steps seemed to frustrate the Bedouins who were eager to see tangible results. Currently we are working on establishing a committee that will eventually handle the ownership of the project. Building trust was also difficult, especially with the high turnover of researchers.
In conclusion, obstacles need to be solved as they emerge so as not to overweigh the positive outcomes of community-based interventions.
In the last 20 years, Bedouin populations in the Bekaa Valley of Lebanon gradually moved from a mobile to a sedentary way of life. This transition changed their perceptions of health issues and practices bearing a significant impact on their health seeking behaviour. In particular Bedouin women’s perceptions of reproductive and child health practices have increasingly accommodated the biomedical model along with other traditional practices. This paper examines the broader socio-political factors that shaped the changes in Bedouin women’s attitudes and the implications on their health seeking behaviour.
Findings from 50 in-depth interviews with Bedouin women and health professionals, as well as observations of the health encounters in reproductive health clinics indicate that the shift in perceptions is associated with two sets of interrelated socio-political factors. First, as the Bedouin populations settled they largely embraced modern medical reproductive and child health paradigms in an effort to integrate in a society that largely excludes them as outsiders. However the persistent exclusion by mainstream health providers, manifested in low outreach of health services to the Bedouin settlements, results in fragmented access to health care and distorted and partial information on health issues among Bedouin women.
Second, the biomedical model in Lebanon places a high value on ‘expertise’ which nurtures a dependent role for patients and allows practitioners to promote modern medical practices as effective tools for validating local cultural perceptions on fertility and gender relations. As a result of these invasive medical practices, Bedouin women engage in an uneasy relationship with health services both in terms of professional trust and financial burden.
The paper concludes with conceptual and policy implications of the changing perceptions and health seeking behaviour by asserting the importance considering broader socio-political factors, not least gender and social exclusion, in health-related provision and practices.
Bedouins in Lebanon are estimated to represent 2-3% of the population, where most of them benefited from the 1994 normalization law and are domiciled in their majority. Being in rural areas and underprivileged neighborhoods, Bedouins continue to suffer from issues like social exclusion and poor health care provision. The aim of this paper is to assess the awareness and knowledge of policy makers regarding the health policies and health status of the Bedouin community in the context of Lebanon. In-depth interviews were conducted with nine health policy makers from the government, private, non-governmental organization sectors, and UN agencies (UNFPA, UNICEF) on topics of Bedouin status and livelihood, health policies and current health provision and utilization in relation to reproductive and child health, and interventions towards improving access to and quality of reproductive and child health and well-being. Results showed that most of the policy makers interviewed had weak to absent knowledge about Bedouin population estimates, identity status and normalization, geographical distribution within the rural peripheral areas of Lebanon, range of mobility, common health problems, and health service provision and utilization. In addition, policy makers stated that they had no plans currently and in the future related to health policies or procedures regarding Bedouin community, but they expressed willingness to contribute to any interventions aimed to improve Bedouin’s health and well-being. In Lebanon, where public health sector remains feeble and inequitable, mostly affecting marginalized and underprivileged communities including the Bedouins, policy makers continue to hold unrealistic stereotypes about Bedouins and Bedouin health issues, and comprehensive health policies that integrate Bedouins remain nonexistent.
The populations of the Middle East have experienced particularly rapid socio-economic change over the past forty years due largely to the discovery and exploitation of oil, and the consolidation of the nation-state. The basic social, political and cultural rights of the pastoral populations ( the Bedouin ) of the peninsula have largely been ignored, in part due to their remoteness and inaccessibility, but also due to the very fact of their mobility and physical marginality. Government services, based upon Western models, are designed for fixed, permanently domiciled populations. Pastoral society organization, with its mobile and constantly shifting households, does not fit into existing paradigms of Western-inspired development. Shortage in resources and funds of ministries of health, have restricted public health services and the establishment of services specifically designed to reach such peoples. In the arena of health care, these marginal, sometimes mobile, and often remote populations have largely been excluded or have excluded themselves from government reproductive health care efforts.
Reproductive health has been a major issue for the Arab world with findings of national studies of maternal mortality creating particular concern. Further studies have taken place on gynecological morbidity, family planning utilization and the quality of care. None of these studies included marginal, mobile and/or settled Bedouin. Those that have settled have had only limited provision within or nearby their rural hamlets. In addition attitudes towards such peoples have often been negative because of the historical marginalization of Bedouin who are considered by some to be “uncivilized” or even ‘ignorant and dirty’. This paper seeks to explore the history of the long unacknowledged association of Bedouin with Lebanon. It seeks to understand whether, with the recent settlement of Bedouin in the country over the past three decades, the earlier marginalization and discrimination of these peoples is being transformed as they enter into more regularly contact with local and regional Lebanese authorities. In this way, the paper seeks to contextualize current attitudes regarding Bedouin in Lebanon as an explanatory element in assessing contemporary reproductive health care of Lebanon’s Bedouin.
