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Jumping cultural hurdles to keep fit in the Middle East
World Report
Jumping cultural hurdles to keep fit in the Middle East Women in the Middle East face cultural barriers to exercise, but some positive examples of initiatives in the region could provide models for other countries. Sharmila Devi reports.
www.thelancet.com Vol 388 September 24, 2016
Faten Ben Abdelaziz, coordinator for health promotion at WHO’s Prevention of NCDs Department, told The Lancet. “There is insufficient knowledge about the link between health and physical exercise and the WHO regional office for the EMR is working with member states to promote awareness about the health benefits of physical activity”, she said.
“‘The main change since the 2012 Olympics is that Saudi women themselves are insisting on the right to exercise and sports’...”
New initiatives Reflecting the Middle East’s wide diversity, a range of government and civil society initiatives have flourished in the past few years ranging from football camps for girls in Jordan, religiously-approved women advisers in Morocco, walkathons in Oman, and media campaigns. Mass media campaigns promoting exercise were found to be costeffective and they also address cultural barriers and belief systems, said Abdelaziz. But awareness raising alone is not sufficient. Physical activity levels are also determined by the environment. A lack of adequate physical infrastructure and public transport, coupled with high reliance on cars and limited sports facilities, are among the main obstacles to promoting physical exercise. But change is happening. Abdelaziz recounted the story of a Bahraini friend who said she had no idea that lack of exercise was a contributor to NCDs and that WHO recommended at least 150 minutes of exercise weekly through various activities, including
dancing “Now she dances whenever she can”, said Abdelaziz.
Gender inequality Measurement and surveillance systems in the different countries are often patchy. But anecdotally, there seems to be some slow progress amid bureaucratic and other hurdles, said Minky Worden, director of global initiatives at Human Rights Watch (HRW), which has documented gender discrimination and barriers to exercise in Saudi Arabia. “The main change since the 2012 Olympics is that Saudi women themselves are insisting on the right to exercise and sports”, she told The Lancet. “But the lack of government progress since then means that another generation faces preventable health problems.” There are plans to introduce mandatory physical education to Saudi Arabia’s public schools, attended by some 95% of girls, with sports such as volleyball but not football, which is seen as too masculine. The country is also creating a legal framework for women’s gyms, which currently have to operate unlicensed. The International Olympic Committee (IOC) has been firm in
See Series pages 1325 and 1337 For the HRW report see https://www.hrw.org/ news/2016/08/04/saudi-arabiawomen-are-changing-game For the Institute of Gulf Affairs report see https://www. gulfinstitute.org/wp-content/ uploads/2014/12/Killing-ThemSoftly.pdf For the article in Time magazine see http://time.com/4194111/ prince-ali-of-jordan-footballcan-help-refugees/
AFP/Stringer
Saudi Arabia sent four female athletes to the Rio Olympics this year, double the number it sent to London 4 years ago, raising hopes it will fulfil plans to ease barriers to physical exercise among women and girls, which would be closely watched in the region. The kingdom is the most socially conservative in the Middle East and any relaxation in cultural limitations could help to reinforce the message of a growing number of doctors, teachers, Islamic scholars, and policy makers that physical education is vital to stem a tide of non-communicable diseases (NCDs). “Going to Brazil affected us all because they take sports so seriously whereas it’s not part of the social fabric here”, a source within Saudi Arabia’s General Sports Authority told The Lancet. “I am hopeful that sports and exercise will increase because there is real government commitment to it now.” Some of the highest levels of physical inactivity among women are found in the Middle East. The four main NCDs—cardiovascular diseases, cancer, diabetes, and chronic respiratory diseases—are the largest contributors to mortality in most countries in the WHO’s Eastern Mediterranean Region (EMR). WHO estimates that physical inactivity accounts for 3·2 million deaths from these diseases each year globally. But more people now understand that inadequate physical exercise, along with tobacco and alcohol use and unhealthy diet, is a key cause. “We have a saying in Arabic, al haraka baraka, which means movement is blessing. This saying shows there are no religious, rather cultural barriers, to physical exercise”,
An Iranian women’s football team in training
1267
World Report
its insistence on gender equality. An HRW report, Saudi Arabia: Women are ‘Changing the Game’, released in August, said that Thomas Bach, IOC president, last year rejected a suggestion by Saudi Arabia that it cohost a sex-segregated Olympics with Bahrain, with men competing in Saudi Arabia and women in Bahrain. A set of reforms adopted by the IOC in 2014 called Olympic Agenda 2020 included for the first time a bar on the selection of a host country that discriminates against women and girls. But aside from the Gulf’s desire for prestige by hosting international sports tournaments, health concerns are a major impetus for change. “Women in Saudi Arabia are being killed softly by their government”, Ali Al-Ahmed and Ossob Mohamud wrote in the Insitute for Gulf Affairs report Killing Them Softly: Saudi Ban on Women’s Sports is Harming Their Health. “Not by public executions or brutal rapes and beatings, but by dayto-day restrictions imposed on them by their government.” Exercise is acceptable as long as girls and women are segregated, said a Gulf official. “But women do face attacks and threats if they’re seen as going against what is morally acceptable by conservative elements. A lot of men don’t see why their daughters should exercise when they could be studying”, he said. In Jordan, one programme that started out as an exercise towards social cohesion between Jordanian host communities and Syrian refugees has had the additional benefit of promoting health, said Marta Garbarino, coordination and civil society affairs specialist for UN Women in Jordan. The agency organised football camps for adolescent Jordanian and Syrian girls to help build trust between them and trained 25 physical education teachers and football coaches on non-violent communication and negotiation skills under a project called Empowering Girls and Building Social 1268
Cohesion through Sports and Physical Education. Jordan hosts more than 1·5 million refugees, some 85% of them living in cities and villages, not refugee camps, Garbarino said. Schools have introduced a doubleshift system with Jordanian and Syrian children being taught separately.
“‘A lot of men don’t see why their daughters should exercise when they could be studying’...” “It’s really hard for girls to have the chance of physical activity. Sport is not seen as one of the basics of life and the idea of girls being publicly exposed is condemned”, she told The Lancet. “As well as lack of facilities, girls face mobility issues and have to be accompanied by their father or brother if they want to go training.”
Changing attitudes But women are becoming more proactive, she said. A good example is SheFighter, the first gym in Jordan founded to provide specialised selfdefence and martial arts training for women. It was founded in 2012 by Lina Khalifeh after she saw a colleague being physically abused by her brother. “The culture is definitely changing and young people are at the forefront of this and they are thinking about the good of their community”, said Garbarino. After government efforts to boost women’s football, Jordan will become the first Middle Eastern country to host an international women’s football competition, the International Federation of Association Football (FIFA) Under-17 Women’s World Cup, starting on Sept 30. “We must continue to remove barriers to women playing”, wrote Prince Ali bin Hussein of Jordan, president of the Jordan Football Association, in Time magazine earlier this year. “It is for this reason I led the push to overturn
FIFA’s 2007 ban on women playing football in the hijab, the traditional Islamic head covering.” In Morocco, physical activity is being promoted by morchidat—female religious leaders approved by the Ministry of Islamic Affairs—who aim to educate and counter radicalisation by working with women and girls in schools, mosques, and prisons, said Amal Alla of the epidemiology department at Morocco’s ministry of health. “A multisectoral action plan has been devised to promote healthy living, including encouraging physical activity”, she told The Lancet. Meanwhile, a media campaign earlier this year was “the first opportunity to teach Moroccans of all ages on the need to undertake at least 30 minutes of non-restrictive physical activity a day”. Tunisia is also forging ahead with a national NCD strategy, including the media promotion of exercise aimed at men and women, Jalila El Ati of the National Institute of Nutrition and Food Technology told The Lancet. “The Olympics aligned with government change in Tunisia this year”, she said. “But it’s fair to say that Tunisians may be more concerned by their financial and security worries than by the results of their compatriots who competed in Rio.” Ruth Mabry, a WHO technical officer, has lived in Oman for 20 years and while she sees more women out walking—thanks to the promotion of walkathons, halting traffic for set times in some areas, establishing gender-segregated walkways, and educational campaigns—it was hard to quantify the change. “Oman was one of the first countries in the region to adopt a healthy lifestyles project in 1999 and evaluation has showed some changes in attitudes and behaviour”, she told The Lancet. “It’s easy to be pessimistic but I do see a huge amount of enthusiasm.”
Sharmila Devi www.thelancet.com Vol 388 September 24, 2016
Jumping cultural hurdles to keep fit in the Middle East Women in the Middle East face cultural barriers to exercise, but some positive examples of initiatives in the region could provide models for other countries. Sharmila Devi reports.
www.thelancet.com Vol 388 September 24, 2016
Faten Ben Abdelaziz, coordinator for health promotion at WHO’s Prevention of NCDs Department, told The Lancet. “There is insufficient knowledge about the link between health and physical exercise and the WHO regional office for the EMR is working with member states to promote awareness about the health benefits of physical activity”, she said.
“‘The main change since the 2012 Olympics is that Saudi women themselves are insisting on the right to exercise and sports’...”
New initiatives Reflecting the Middle East’s wide diversity, a range of government and civil society initiatives have flourished in the past few years ranging from football camps for girls in Jordan, religiously-approved women advisers in Morocco, walkathons in Oman, and media campaigns. Mass media campaigns promoting exercise were found to be costeffective and they also address cultural barriers and belief systems, said Abdelaziz. But awareness raising alone is not sufficient. Physical activity levels are also determined by the environment. A lack of adequate physical infrastructure and public transport, coupled with high reliance on cars and limited sports facilities, are among the main obstacles to promoting physical exercise. But change is happening. Abdelaziz recounted the story of a Bahraini friend who said she had no idea that lack of exercise was a contributor to NCDs and that WHO recommended at least 150 minutes of exercise weekly through various activities, including
dancing “Now she dances whenever she can”, said Abdelaziz.
Gender inequality Measurement and surveillance systems in the different countries are often patchy. But anecdotally, there seems to be some slow progress amid bureaucratic and other hurdles, said Minky Worden, director of global initiatives at Human Rights Watch (HRW), which has documented gender discrimination and barriers to exercise in Saudi Arabia. “The main change since the 2012 Olympics is that Saudi women themselves are insisting on the right to exercise and sports”, she told The Lancet. “But the lack of government progress since then means that another generation faces preventable health problems.” There are plans to introduce mandatory physical education to Saudi Arabia’s public schools, attended by some 95% of girls, with sports such as volleyball but not football, which is seen as too masculine. The country is also creating a legal framework for women’s gyms, which currently have to operate unlicensed. The International Olympic Committee (IOC) has been firm in
See Series pages 1325 and 1337 For the HRW report see https://www.hrw.org/ news/2016/08/04/saudi-arabiawomen-are-changing-game For the Institute of Gulf Affairs report see https://www. gulfinstitute.org/wp-content/ uploads/2014/12/Killing-ThemSoftly.pdf For the article in Time magazine see http://time.com/4194111/ prince-ali-of-jordan-footballcan-help-refugees/
AFP/Stringer
Saudi Arabia sent four female athletes to the Rio Olympics this year, double the number it sent to London 4 years ago, raising hopes it will fulfil plans to ease barriers to physical exercise among women and girls, which would be closely watched in the region. The kingdom is the most socially conservative in the Middle East and any relaxation in cultural limitations could help to reinforce the message of a growing number of doctors, teachers, Islamic scholars, and policy makers that physical education is vital to stem a tide of non-communicable diseases (NCDs). “Going to Brazil affected us all because they take sports so seriously whereas it’s not part of the social fabric here”, a source within Saudi Arabia’s General Sports Authority told The Lancet. “I am hopeful that sports and exercise will increase because there is real government commitment to it now.” Some of the highest levels of physical inactivity among women are found in the Middle East. The four main NCDs—cardiovascular diseases, cancer, diabetes, and chronic respiratory diseases—are the largest contributors to mortality in most countries in the WHO’s Eastern Mediterranean Region (EMR). WHO estimates that physical inactivity accounts for 3·2 million deaths from these diseases each year globally. But more people now understand that inadequate physical exercise, along with tobacco and alcohol use and unhealthy diet, is a key cause. “We have a saying in Arabic, al haraka baraka, which means movement is blessing. This saying shows there are no religious, rather cultural barriers, to physical exercise”,
An Iranian women’s football team in training
1267
World Report
its insistence on gender equality. An HRW report, Saudi Arabia: Women are ‘Changing the Game’, released in August, said that Thomas Bach, IOC president, last year rejected a suggestion by Saudi Arabia that it cohost a sex-segregated Olympics with Bahrain, with men competing in Saudi Arabia and women in Bahrain. A set of reforms adopted by the IOC in 2014 called Olympic Agenda 2020 included for the first time a bar on the selection of a host country that discriminates against women and girls. But aside from the Gulf’s desire for prestige by hosting international sports tournaments, health concerns are a major impetus for change. “Women in Saudi Arabia are being killed softly by their government”, Ali Al-Ahmed and Ossob Mohamud wrote in the Insitute for Gulf Affairs report Killing Them Softly: Saudi Ban on Women’s Sports is Harming Their Health. “Not by public executions or brutal rapes and beatings, but by dayto-day restrictions imposed on them by their government.” Exercise is acceptable as long as girls and women are segregated, said a Gulf official. “But women do face attacks and threats if they’re seen as going against what is morally acceptable by conservative elements. A lot of men don’t see why their daughters should exercise when they could be studying”, he said. In Jordan, one programme that started out as an exercise towards social cohesion between Jordanian host communities and Syrian refugees has had the additional benefit of promoting health, said Marta Garbarino, coordination and civil society affairs specialist for UN Women in Jordan. The agency organised football camps for adolescent Jordanian and Syrian girls to help build trust between them and trained 25 physical education teachers and football coaches on non-violent communication and negotiation skills under a project called Empowering Girls and Building Social 1268
Cohesion through Sports and Physical Education. Jordan hosts more than 1·5 million refugees, some 85% of them living in cities and villages, not refugee camps, Garbarino said. Schools have introduced a doubleshift system with Jordanian and Syrian children being taught separately.
“‘A lot of men don’t see why their daughters should exercise when they could be studying’...” “It’s really hard for girls to have the chance of physical activity. Sport is not seen as one of the basics of life and the idea of girls being publicly exposed is condemned”, she told The Lancet. “As well as lack of facilities, girls face mobility issues and have to be accompanied by their father or brother if they want to go training.”
Changing attitudes But women are becoming more proactive, she said. A good example is SheFighter, the first gym in Jordan founded to provide specialised selfdefence and martial arts training for women. It was founded in 2012 by Lina Khalifeh after she saw a colleague being physically abused by her brother. “The culture is definitely changing and young people are at the forefront of this and they are thinking about the good of their community”, said Garbarino. After government efforts to boost women’s football, Jordan will become the first Middle Eastern country to host an international women’s football competition, the International Federation of Association Football (FIFA) Under-17 Women’s World Cup, starting on Sept 30. “We must continue to remove barriers to women playing”, wrote Prince Ali bin Hussein of Jordan, president of the Jordan Football Association, in Time magazine earlier this year. “It is for this reason I led the push to overturn
FIFA’s 2007 ban on women playing football in the hijab, the traditional Islamic head covering.” In Morocco, physical activity is being promoted by morchidat—female religious leaders approved by the Ministry of Islamic Affairs—who aim to educate and counter radicalisation by working with women and girls in schools, mosques, and prisons, said Amal Alla of the epidemiology department at Morocco’s ministry of health. “A multisectoral action plan has been devised to promote healthy living, including encouraging physical activity”, she told The Lancet. Meanwhile, a media campaign earlier this year was “the first opportunity to teach Moroccans of all ages on the need to undertake at least 30 minutes of non-restrictive physical activity a day”. Tunisia is also forging ahead with a national NCD strategy, including the media promotion of exercise aimed at men and women, Jalila El Ati of the National Institute of Nutrition and Food Technology told The Lancet. “The Olympics aligned with government change in Tunisia this year”, she said. “But it’s fair to say that Tunisians may be more concerned by their financial and security worries than by the results of their compatriots who competed in Rio.” Ruth Mabry, a WHO technical officer, has lived in Oman for 20 years and while she sees more women out walking—thanks to the promotion of walkathons, halting traffic for set times in some areas, establishing gender-segregated walkways, and educational campaigns—it was hard to quantify the change. “Oman was one of the first countries in the region to adopt a healthy lifestyles project in 1999 and evaluation has showed some changes in attitudes and behaviour”, she told The Lancet. “It’s easy to be pessimistic but I do see a huge amount of enthusiasm.”
Sharmila Devi www.thelancet.com Vol 388 September 24, 2016