Challenges of Public Health Service Delivery to a Semi-Nomadic Society: The case of the Jabaliyah Bedouin of the South Sinai Mountains
Situated in southern Sinai, the semi-nomadic Jabaliyah Bedouin live between two ‘worlds’ – a traditional nomadic life in their mountain gardens and a modern sedentary life in St. Catherine at the base of the mountains. These two ‘worlds’ are separated by a physical geographic barrier that makes penetration of healthcare services into the highlands difficult. How do we approach this physical boundary in such a way to improve public health? While living with the Jabaliyah, this problem became apparent to me. I observed the desire of the Jabaliyah to move back into the mountains after having been forced to settle in St. Catherine due to political and climatic factors. Improving cultural well-being involves helping the tribe translocate into the highlands. Public health service needs to be adjusted to their semi-nomadism by extending accessibility and making services culturally compatible. This article uses personal experience and literature sources.
The Jabaliyah tribe is the largest of four major tribes inhabiting the southern Sinai Mountains, an ‘ecological island’ of high mountains surrounded by vast desert expanses (Hobbs). Currently, the semi-nomadic Jabaliyah go between and benefit from two ‘worlds’ – a traditional nomadic life in the mountains and a sedentary life in the developed township, St. Catherine, at the base of the mountains (Figs. 1 & 2). The physical barrier between these ‘worlds’ poses multiple challenges to deliver public health services to the semi-nomads.
I believe that public health must consider not only the goals of promoting health and disease prevention, but also the cultural well-being of a community. Improving cultural well-being involves helping the Bedouin move back into the mountains, thereby respecting their desire to live semi-nomadically. In turn, overall public health services must be adjusted to their semi-nomadic lives. Public health services must be both accessible to the highlands as well as culturally compatible with Jabaliyan traditions.
While considering historical change of medical service to South Sinai, I will present the obstacles to public health service delivery and the current status of these services.
Historically, the Jabaliyah (‘mountain people’) – population of 2500 – practiced pastoral nomadism within the wadis (valleys) of the high mountains, cultivating gardens and maintaining goat and sheep livestock in the extreme environment with limited resources (Hobbs). Effects of climate change forced the Bedouin to translocate from the mountains into St. Catherine. Over the past 30 years, non-governmental organizations (NGO’s) have worked with the Bedouin to restore their mountain gardens. The Jabaliyah must be able to negotiate the boundary between sedentarism and nomadism comfortably. Approaches consist primarily of improving water availability – the primary constraint for resettlement in the highlands – but also of extending resources that generate income, such as tourism. In fact, our Concordia group worked in collaboration with an NGO and the Jebeliyah to build a dam to retain water for agricultural and domestic use.
Public Health Service Delivery:
Challenges in serving nomadic populations arise from their cultural uniqueness as a marginal Fourth World society, and in turn, their reaction toward development and modernization (Meir). As the Jabaliyah move back into their mountain gardens, public health service delivery must be adjusted to suit their semi-nomadic needs. Most Jabaliyah live in their mountain gardens two to six months out of the year. External pressures pushing the Jabaliyah toward sedentarization may increase Bedouin acceptance of public health services. But, conflict may arise due to their abandonment of cultural customs (Muir).
Acceptance is increased by improving accessibility and compatibility of services. Accessibility involves the spatial barrier: large distances, inadequate roads, and specific to the Jabaliyah, limited access to the rough terrain highlands. Compatibility of service includes Bedouin perception of healthcare and gender/child societal status.
Historical Medical Service to the South Sinai:
Historically, prior to Israeli rule, Bedouin medical practices revolved around traditional medicine (Romem). Beginning in the 1970’s, Sinai medical facilities were established by Israel, which occupied the Sinai from 1967 to 1982, yet accessibility was limited. As clinic development progressed into the construction of the St. Catherine community hospital, Bedouin attitude transformed from total distrust to cooperation. Still, as Bedouin move back into the highlands, public health services should adapt concurrently.
Accessibility of Healthcare Services:
As a result of accessibility challenges, there exists little epidemiological knowledge of the mountainous terrain. Additionally, prevention of disease transmission through the use of water sanitation and veterinary services is difficult to implement.
Despite superficial appearance of the extreme terrain of the Sinai Mountains, the ‘ecological island’ has the largest biodiversity in Egypt with rugged, red granite terrain forming a variety of habitats with distinctive water and vegetation regimes (Perevolotsky and Behnke). Epidemiological awareness is needed because such high biodiversity presents a unique environment for pathologies. For instance, the Sinai Mountains house a high diversity of commensalistic rodent communities that carry parasites, such as intestinal helminthes. Regional studies must contribute to the awareness of specific pathologies on which health services can provide focused treatment and prevention.
The spatial proximity of medical facilities to the highlands has been maximized with the establishment of St. Catherine medical center. Still, nomads should be educated about the closest medical service location, the current health concerns, and first aid procedures. To improve physical access, mobile health units designated for immunization, veterinary services, and water sanitation may be used to reach the highlands. These mobile units increase awareness via follow-up treatment requirements, act as a mediator between Bedouin patients and the main medical center, and increase Bedouin acceptance by showing the willingness of community health workers to reach out to nomads (Meir). Education about service access and local current health concerns should be of high importance because most Jabaliyah have access to St. Catherine at some time during the year.
Cultural Compatibility of Healthcare Services:
Accessibility and cultural compatibility issues are interdependent. With trust in modern medicine, the Bedouin may make a greater effort to reach local medical facilities. Traditional Bedouin perception of medicine and socio-religious status should be considered in the effort to improve compatibility of service to the Jabaliyah.
Traditional Medical Perception and Practices:
Traditional perception of medicine and its associated treatments/cures can hinder compatibility with modern service. Historically, Bedouin have perceived medicine traditionally as a supernatural phenomenon grounded in God, contrasted with Westernized medicine grounded in the germ theory (Meir). Providing the best public health services proves a difficult task because it requires the breaking of this strong spiritual barrier while also respecting it. Whether the Bedouin visit a traditional healer or modern physician, traditional medicine perception may be maintained – either ‘healer’ being the route through which God works.
Herbal remedies are common within traditional Bedouin medicine. The Jabaliyah have a broad knowledge of the diverse mountainous plants and their medical uses, such as using herbs in tea to treat upset stomach. Herbal remedies are easily accessible and are at no cost. Camel milk is also used to treat digestive disorders, in addition to circulation and bone problems. Bedouin charms and stones are believed to have spiritual healing power. Yet, traditional medical practices may involve dangerous procedures with limited supporting medical evidence. For example, the Bedouin traditionally perform ritual uvulectomies (removal of the uvula hanging in the back of the throat) for thirst quenching in the dry climate and sore throat treatment (Beverley). This procedure can be dangerous, possibly causing severe complications such as infection, hemorrhage, and even passage of the removed uvula down the respiratory tract.
To compete with low cost traditional medicine, modern medical costs should be reduced. Local traditional medicine should be further researched, and Bedouin should be educated regarding risks and improvements of traditional practices. An intermediate approach may be established – education against uvulectomies, yet encouragement of appropriate herbal remedies.
Integration into the modern system will increase Bedouin awareness of symptoms and terminology, thereby improving early treatment and medical communication. Integration will also increase medical record documentation such as child growth rates since little historical records are available due to Bedouin concept of time (Meir).
Socio-religious Status of Women and Children:
Within Bedouin tribal structure, women are to have no direct contact with the external world, thereby restricting their contact with modern doctors unless permission is given by the men (Meir). Women are also given mistaken information by their husbands (due to miscommunication with the physician) as to the status of infants, causing even small illnesses to become emergency situations (Meir). Contact of female patients to female physicians should be regulated to respect Islamic traditions – limiting male to female private conversation and the intimacy required of a physical examination.
In 2008, the initiative of mobile health units in the wadis began. Efforts should continue to increase the number of mobile units, particularly those that target women and children. Traditional medical practices should be documented and the Bedouin should be educated against risky medical practices.
Accessibility and cultural compatibility issues in the provision of public health services have increased due to sedentarization; however, intermediate methods should be implemented to preserve Jabaliyan culture and gain/maintain acceptance. Progressive sedentarization has led to a narrowed cultural gap, decreased attachment of modernized Bedouin to the strict socio-religious beliefs, and increased basic medical knowledge through exposure to the modern medical system. We must be careful to not exploit semi-nomadic populations to the point of total abandonment of delicate socio-cultural customs. Cultural well-being and public health issues are interrelated. Therefore, NGOs and medical services should work together to improve overall Jabaliyan health and to support their pastoral nomadic lifestyles. The case of the Jebeliyah is a unique public health case due to the physical barrier that separates sedentary and nomadic lifestyles; however, the suggested public health methods may be extended to serve nomadic populations in general.
Behnke JM, Barnard CJ, Mason N, Harris PD, Sherif NE, Zalat S, Gilbert FS. 2000. Intestinal helminths of spiny mice (acomys cahirinus dimidiatus) from St. Katherine’s Protectorate in the Sinai, Egypt. Journal of Helminthology 74:31-43.
Beverley D and Henderson C. 2003. A cross-sectional survey of the growth and nutrition of the Bedouin of the South Sinai Peninsula. Annals of Tropical Paediatrics 23(209):214.
Hobbs JJ, Grainger J, El-Bastawisi IY. 1998. Inception of the Bedouin support programme in the St. Katherine Natural Protectorate, Sinai, Egypt. Mountain Research and Development 18(3):235-48.
Meir A. 1987. Nomads, development and health: Delivering public health services to the Bedouin in Israel. Geografiska Annaler Series B, Human Geography 69(2):115-26.
Perevolotsky A, Perevolotsky A, Noy-Meir I. 1989. Environmental adaptation and economic change in a pastoral mountain society: The case of the Jabaliyah Bedouin of the Mt. Sinai region. Mountain Research and Development 9(2):153-64.
Romem P, Reizer H, Romem Y, Shvarts S. 2002. The provision of modern medical services to a nomadic population: A review of medical services to the Bedouins of southern Sinai during Israeli rule 1967-1982. IMAJ 4:306-8.