In the old days, caravans used to carry salt and
slaves across the Saharan wastes. These days, they
carry medicine
It is perhaps hard to believe of western Europe’s
nearest neighbour. Despite a relatively peaceful
recent history, within eyeshot of Spain and strong
links to France, Morocco’s social indicators -
literacy and school enrolment - and health indicators
- infant mortality, say - are astonishingly poor --
even by Arab standards. According to WHO, mothers are
fives times as likely to die in childbirth as in
Tunisia; and children have a fifty percent greater
chance living to the age of five. Syria, hardly a
poster boy of progressivism, has half the infant
mortality and a quarter of the rates of tuberculosis..
The figures are bad because Moroccans score poorly on
another social statistics, that of access to care,
where the discrepancies with comparable Arab countries
are as bad, if not worse, leading for instance, to
many women choosing traditional midwives for births.
Lebanon, despite being long racked by civil war, still
manages to have five times as many doctors and has ten
times as many dentists.
Jordan has five times has many pharmacists and three
times as many trained nurses per capita. And these
countries are small, while Morocco is large and with a
heavy concentration of such care there is around the
northern coastal cities, making effective
discrepancies in access to trained medical staff for
large parts of the population even worse, compared to
its Arab cousins.
Groups of urban Moroccan doctors from the francophone
urban elite, fed up with their country’s poor record
on access, have recently taken matters into their own
hands. The elites of Casablanca and Rabat, elegant,
European, the most modern parts of Morocco, have
sometimes seemed to indulge its guilt in frivolous
campaigns such as civil society caravans, even fashion
caravans, bringing culture and political knowhow to
the regions for a weekend or two But inspired by
these a caravan movement of doctors has been launched,
whose benefits have turned out to be far more
substantial. Convoys of trucks and buses have with
filled with doctors from areas where they are most
concentrated - the big cities - and they have been
moved out to the provinces for weekends at a time to
carry out their duties free of charge in the remotest
desert areas of Morocco, where normally there might be
just one doctor per ten thousand population..
One of the leading lights of the so-called caravanes
medicales idea has been Dr Abdel El Hairy, 48, who
began the project after his father left a bequest to
build a village school and well. The Moroccan
bureaucracy insisted that any gift had to be
channelled through an NGO, and so he started one, AMI,
whose initials stand for locales in his father’s home
region. With money left over, the NGO funded a weekend
expedition, with three doctors, who carried out ten
consultations, in the local village hall. Since then
the idea of roughing it for a few days out of social
responsibility has grown hugely in popularity.
Word got out on the doctors’ grapevine, in Casablanca,
Morocco’s commercial capital and richest city, and
the numbers increased. Helped by French charity money,
which paid for the drugs, the most recent excursion,
in July, some sixty urologists, obstetricians,
dermatologists, gynecologists, paediatricians and
other doctors – many wealthy, with private clinics in
Casablanca - joined the caravan. In the evenings, they
had food cooked by berber women and compared rare
pathologies under the stars; in the daytime, they
carried out consultations – lots of cases of
tuberculosis, child meningitis; cancer of the uterus,
in adult males, skin and eye problems, were common.
They saw over three thousand in three days – in
chaotic conditions, with nomads arriving on camels
from a radius of dozens of kilometres away, and
patients queuing for hours .
Traditional cure
For what is the healthcare alternative for these
deprived Moroccans? In the company of some Casablanca
journalists, I went to see what an example of the
traditional medicine many Moroccans use, in the
impoverished Casablanca suburb of Hay Mohammadi.
Islamic parties are strong here, mainly because
Islamic activists have fulfilled some of the role of
the welfare state for the poor residents. Here, being
the city, there is theoretical access to medicine,
unlike the desert. But, in a country where 20 percent
of the population earns less than a dollar a day, few
can afford to have a basic consultation with a state
doctor, let alone a private one So they rely on
traditional doctors, the hajjamas - in the same way
the desert nomads are usually forced to do, though in
their case it is lack of access.
The traditional doctors work from shed-like workshops
on the edge of the quarter, and they seem to have one
cure-all treatment: la saignee, the bloodletting,
using crude instruments.. They often double as
barbers, and that is also an alibi.
Mohammed, aged 60, had teeth that did not look like a
brilliant advertisement for hygiene and care. At first
he denied he worked as a doctor, “I only did this in
the past”. (The practice is allegedly illegal). But
soon he confessed with a smile: “I still have to work
because my children are lazy. My son just smokes hash
all day.” With a colleague in another shop he was then
quite keen to show how the saignee worked. . The
patient – usually elderly - sits in the barber’s
chair in front of a mirror, the usual hair dressing
bric-a-brac – lotions, razors. Always a portrait of
Hassan II and his son Mohammed VI, past and present
kings. After partaking in several cups of mint tea,
his hair is ritually shaved, a 5cm incision is made in
the back of the head (cheeks if a woman) and blood is
withdrawn by attaching a pipe like object to the back
of the head. sucking produces a vacuum which draws
blood into the receptacle. “It cures everything,” said
Mohammed said confidently.
Others are less convinced. One Moroccan journalist,
Rida Addam, medical correspondent for Le Matin
newspaper, described to me witnessing another saignee
nearby: a 78-year-old night guard entered a nearby
shop with his twenty something son, who was clearly
sceptical.
As tea was prepared, the son angrily told Addam about
the way he was spoken about by the hajjama. "I tell my
father that this won’t cure his health problems.. But
the hajjama just says 'does Little Mohammed want some
tea, as if I was still the little boy he once
circumcised'."
He sighed deeply, ignoring the glances of pity from
the two elders, and finally rose to leave. His father
wished him good luck, and then proceeded to have the
blood letting. Ten minutes later he rose, looking
rather weak, said Addam. “One is always under the
protection of saints,” affirmed the “doctor”, one of
Mohammed’s many colleagues in the area. The old man
staggered out, accusing his son of “lacking faith”,
while the doctor cleaned his equipment in preparation
for another patient.
Mobile hospital
It is clear that the caravanes medicales play a useful
role in those areas they can are able to cover. They
make the role of the local hajjama redundant, even
carrying out circumcisions. “Entirely voluntarily,”
said one urologist, who normally runs a clinic off the
fashionable boulevard Hassan II. “And safer.”
Fortunately their popularity as caught on – not just
in numbers within caravans, but the number of regular
caravan projects has now grown to about twelve,
including one comprised of dentists, Enfant Sourire,
(Child’s smile.). Each dentist will see up to 50
patients a day.
The caravan concept itself is beginning to move on,
too – thanks to another Moroccan expatriate Dr Hassan
Zahouani, a professor in Lyon.
Until now, the projects have worked out of the largest
building in the village, or in tents if in desert. But
from next June a prototype mobile hospital, a 450
square metre structure that can be set up and
dismantled in hours, will be ready. Its design will
be modular, adaptable to different demands, reducible
into smaller-sized units, says Zahouani, who once
worked for the European Space Agency and was inspired
by
the modular design of the international space
station, Sponsored by the French firms Dassault, a
defence contractor, and L’Oreal, the cosmetics firm,
the 1m euro hospital will be made of covered steel
especially adapted to the desert’s extreme conditions
and have laser-equipped operating theatres to deal
with that scourge of the UV-rich desert, cataracts,
which have already made 150,000 Moroccans blind. The
hospitals could also be useful for other desert areas,
Iraq say, said Zahouani.
Western Sahara
All good? It might be churlish to raise any criticism
of all these projects, given that access to health in
Morocco is so poor. The projects have been lauded in
Morocco’s francophone media. But if a small criticism
may be made a foreign critic might note that, in the
choice of places to visit, the ostensibly independent
caravans have chosen, unwittingly or not, destinations
that further the government’s political agenda.
Tafilalet for instance, where the hospital will
circulate, is uncontroversial, because it has always
been part of Morocco. But several caravans have
visited the Morocco-controlled Western Sahara, where
the Polisario armed independence movement has been
agitating for independence on behalf of the ethnically
different Sahrawis since 1975. The area is secured,
and so is safe for NGOS. Here the caravans have been
helping the Sahrawi people, showing up the contrast
with the many refugees displaced by the Moroccan army
into Algeria in 1975, and have spent all their lives
in that country, in refugee camps, under terrible
conditions. Morocco may need to win hearts and minds:
a UN peace process, which looks as if it will restart
after dormancy, is trying to broker an agreement that
would lead to a referendum on the future final status
of western Sahara..
Providing health is perhaps one means of killing
yearning for independence by kindness, in the same way
the government has provided the western Sahara with a
superior road and buildings infrastructure, though
leaving the area undermedicalised..
The caravans' effects given absence of other
healthcare may be good, but could the help dispensed
be interpreted as an endorsement of the brutal way
Moroccan government deals with relatively peaceful
expressions in favour of independence?
Just two months ago, a Moroccan court jailed 12
Western Saharan separatists, handing out sentences of
up to eight years for charges including “vandalism,
resisting arrest and joining an armed crowd”. The
activists were among fifty arrested in May when
demonstrating for independence. The conflict is
complex and by no means black-and-white.
The world’s longest serving prisoners of war, 404
Moroccan ex soldiers, were released a few weeks ago by
Polisario having been held captive for an appalling 20
years in detention camps in southern Algeria. Yet the
sense of injustice at the arrest is clearly enormous:
12 have recently (14 September) been transferred into
hospital after having been on hunger strike for over
five weeks.
It is difficult to get a straight answer on this, part
of the circumspection comes from the need for local
military logistics cooperation, partly because, I
suspect, doctors I spoke to, like many in their
profession, just want to get away from politics and do
their jobs. Yet politics is there all the same.
The future
The caravans, for all the help they give, are clearly
not a sole solution, since they reach relatively few
people, thousands rather than millions.
But the government seems to be doing something. “The
new king, Mohammed VI, who is just 37, really cares
about the people,” said one doctor. “He really wants
to help poor communities.” In the support of this
statement, the doctor pointed to the king – whose
power is great in Morocco – launching a slum clearance
programme as one of the key priorities of his reign.
Meanwhile the health ministry says has looked at
medical caravans as a possible model for public funded
similar action in rural areas. There will be an
extension of health insurance, assurance de maladie,
from five to ten million – though that will still
leave 20 million Moroccans without health insurance..
The national literacy campaign has doubled its
efforts, targeting women, whose literacy rate is a
modest 38 per cent, the third worst in the muslim
world, after Afghanistan and Somalia.
This illiteracy is said to result in women still using
traditional midwives - because of apparent ignorance
rather than lack of money, since one of the few perks
of the poor is to have free births in hospital. The
Islamic family code is being replaced by laws that ban
child brides and put partners on an equal footing in
the hope that empowered women hold the key to rural
health education – though established practices are
hard to abolish with the stroke of a pen. The health
budget, insists the government, has risen by ten
percent a year since 2002.
Zahouani disputes the rosy picture, saying the
government stil lacks a serious strategy for dealing
with its rural communities.. Other doctors say that,
though health spending may have increased, it has been
inexpertly targeted: the capping of doctors’ salaries
as a proportion of the health budget has led to
doctors being put out of work, emigrating to France,
and leaving newly built hospitals being closed.
Both government and its critics might agree though
that, whether developments are going in the right
direction or not, Morocco still has a long way to go
before catching up with the rest of the Arab world.
“We had no oil money, but that is no real excuse. We
also had an elite that was only interested in fighting
for and securing well-paid public sector jobs, no
entrepreneur class, as in Lebanon, interested in
creating wealth. No one paid attention to rural
poverty,” said one doctor. “The neglect will take a
long time to be put right.”
One small positive side to the neglect, though, has
been that Morocco has pioneered a concept that has
tentatively been copied in other undermedicalised,
large countries, Egypt for instance. But the concept –
both the caravan andn the mobile hospital – deserves
to be spread even further, says El Hairy – Afghanistan,
perhaps, or Sudan, if those countries ever achieved piece.
In Morocco, meanwhile, the caravans keep rolling on.
