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The health care system of Kuwait: The social paradoxes
Soc. Sci. & Med., Vol. 13A, pp. 743 to 749 Pergamon Press Ltd 1979. Printed in Great Britain
T H E H E A L T H CARE SYSTEM O F K U W A I T : THE SOCIAL PARADOXES AFAF IBRAHIM MELEIS University of California, San Francisco, School of Nursing, Department of Mental Health and Community Nursing, N505J, San Francisco, CA 94143, U.S.A. Abstract--The purpose of this paper is to describe and discuss the major paradoxes of the health care system of the rich and developing Sheikhdom of Kuwait. With the recent economic affÊuence that is experienced in the new rich countries of the world, the question is raised "How does such economic affluence affect health care?" Kuwait is a land of paradoxes. It is where the symbols of wealth, modernization and urbanization, conflict with the social behaviors that are the result of a still lingering desert life style. A newcomer to the country is dazzled by such symbols and thoroughly confused by actions that are incongruent with the symbols. Therefore, to understand the health care system of the country, an analysis of pertinent social and demographic properties of the country will be considered in conjunction with the major dimensions of health care system in Kuwait. The interaction between and among the social demographic properties of the country and the health care dimensions has created several major paradoxes that profoundly affect the health care in Kuwait. While citizens of Kuwait have developed individual strategies to deal with such paradoxes, it is only through collective awareness of such paradoxes that an organized governmental effort could be developed to deal with the paradoxes.
However, Kuwait is neither underdeveloped nor overdeveloped. Rather, it is a nation of paradoxes with simultaneous underdeveloped and overdeveloped characteristics as is discussed below.
population of Kuwait is characterized by three unique features. First, the peculiar population mix of nationalities. More than half are non-Kuwaitis which includes Palestinians, Jordanians, Egyptians and others as immigrants and workers. The second characteristic which is significant for an analysis of the country's health system is the age distribution. As indicated in Fig. 1, 60% of the population is under 20 years of age. Such an age distribution has significant consequences in health care. The third significant feature of the population of Kuwait is its Bedouins who are bedu, who migrated and continue to migrate across the Arabian Deserts. They established homes at the outskirts of the cities of Kuwait. They have their own health and education problems which are aggravated by their increasing numbers. They congregate in their own created slums while waiting for relocation to the government-built economy homes. Breadwinners of the Bedu who get citizenship are given civil servant jobs such as doorman, guards, etc. The areas for housing are divided geographically, Kuwaitis residential quarters (the more prestigious areas of the country), foreigners quarters, the economy housing areas and the Ashish (the slums of the Bedus). In the foreigners areas, certain districts are inhabited exclusively by particular nationalities. So specific is this housing division that a foreigner can learn in a short time to distinguish all the different housing areas. Therefore, in Kuwait, to know where a person lives, is to understand a great deal about his background. Such rigid segregation is a significant factor in planning health care and also has consequences that affect the health care system.
Population
Nationalism
The population of Kuwait has increased nearly 25% in the last half-dozen years, to slightly more than a million people. The average increase of 6% a year includes natural increases, immigration, and foreigners who come on temporary permits [2]. The
Outnumbered in their own country by foreigners and also having experienced the effect of colonization themselves, and in neighboring countries, Kuwaitis have become extremely nationalistic, both as individuals and as a government. Foreigners and Kuwaitis
SOCIAL DEMOGRAPHIC
PROPERTIES
Kuwait, a country roughly the size of Massachusetts, is located on the northwestern shore of the Persian Gulf. Its flat terrain extends 124 miles in length from north to south and 150miles from east to west. The weather is typical of the Sahara region, a temperature that ranges from 4(~140°F with humidity as high as 90%. Besides the mainland, several islands are scattered in the Arabian Gulf. It is a fast-changing Sheikhdom. Not too long ago, the entire economy was based on pearl diving and ship building. Today, it has one of the highest percapita incomes in the world due to its oil resources. Dr Hassan A1 Ibraheem [1] the chancellor of the University of Kuwait, maintains that Kuwait is different from other underdeveloped countries. His reasons are: 1. Kuwait was not born as a result of a political accident, as were many African countries. 2. It was not underdeveloped when independence was achieved. 3. Since a country's development is largely derived from its economic status, primarily a low percapita income and is not necessarily related to any specific social, political or legal system, Kuwait could be characterized in fact as an overdeveloped country [1, pp. 13-14].
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6o7 23 \ Age 5o-59/ distribution /
3.9 ,- ^
\
\
1975Census
\ 20-2/ 10-[9Z
0-9//
16.1 23 . 3
36.5 % of Populotion Fig. I
at a much higher value than its actual worth, the government was able t o pay owners more for land and then redistribute it to the citizens of the country. Also, housing was provided by allocating land and interest free loans to each Kuwaiti who was a civil servant. On many occasions these loans subsequently were cancelled by the government without being paid. Third, a substantial amount of the oil revenues is being spent on health, education and public works. In fact the education and health ministries enjoy around 20% of the total budget in Kuwait [3]. Although the health budget in Kuwait is greater than that of other countries of the Middle East, the ministry of Public Health continues to present data which compare Kuwait with western and other affluent countries to emphasize its limited health budget. However, the paradoxes which face the health system in Kuwait are of such nature that it will not be improved by merely increasing the budget for health care. Modernization
There are two ways to assess modernization of a country: one, by observing tools of modernization and two, by examining the effect of such tools on the people. A visitor to Kuwait begins noticing signs have, for instance, different legal and economic status of modernization upon landing at the small but which determine what work they can do and where modern and efficient airport. Outside the airport are they can live. As more foreigners come to work in broad highways which are part of an organized traffic the country, this sentiment becomes pronounced. system. This system is needed because there are half Kuwaiti citizenship is considered very prestigious and as many cars as persons of driving age. is not easily acquired. It is granted to very few resiHomes, apartment buildings and stores are well dents (the author's estimate would be not more than ' kept, and all have large water reservoirs and antennas ten per year). A resident can live and work in Kuwait on the roof. Every home has a television and several for years and even become invaluable in'a particular radios. These media are totally supported by the position, but will still be denied citizenship. government. Also, there are six daily newspapers and The sentiment of nationalism is so strong that even five weekly magazines. All major newspapers from the naturalized residents are classified as second class rest of the Arab world and many western newspapers citizens and are entitled to fewer privileges than first are also available. class citizens who are the original Arabian inhabitants To study the impact of this modernization on indiof Kuwait. viduals, Inkles interviewed subjects from six developThe government of Kuwait has succeeded in devel- ing countries [4]. He found there existed "a set of oping an'd maintaining the strong nationalistic feeling personal qualities which reliably cohere as a synin several ways. One is by providing preferential treat- drome and which identify a type of man who may ment to citizens in education, and health care, job validly be described as fitting a reasonable theoretical allocation, residential areas, and public services are conception of modern man" [4, p. 84]. Central to this all areas that benefit from Kuwaiti citizenship. syndrome of the modern man were these qualities: Obviously citizenship is a source of pride and yound children boast of it with pleasure. Paradoxi1. Openness to new experiences both with people cally, it is this very nationalism that creates problems and processes; 2. Assertion of increased independence for the country. from the authority of traditional figures such as parents or religious leaders with a shift of allegiance to Economics government leaders; 3. Belief in the efficient advanceThe economic uniqueness of Kuwait stems from ment of science and medicine with an abandonment three factors : first, the affluence of the country is rela- of passivity and fatalism in the face of life's difficultively recent. Although the development of oil fol- ties; 4. Ambition for oneself and one's children to lowed World War II, Kuwait did not gain its inde- achieve high occupational and educational goals; 5. pendence from England until 1961. This is a signifi- Interest in carefully planning one's affairs in advance; cant year for Kuwait, as it marks the beginning of therefore a futuristic look; 6. Participation in civic its efforts at modernization. Second, while some other and community affairs and local politics; and 7. newly-rich Arab states continue to be socially and Keeping up with the new world. politically conservative, much of Kuwait's wealth is being shared among its citizens and is profoundly Within this framework, Kuwait can be classified -changing their lives. In the early sixties the govern- as modernized. Through their continuous travels and ment found an ingenious way to distribute the meetings with consultants and foreign business country's new oil revenues. By reassessing property people, Kuwaiti citizens have learned how to be open
The health care system of Kuwait to new ways of doing things. They have faith in modern medicine, they are active participants in civic and community affairs, avid news readers and watchers, and have high ambitions for their children. Two qualities of the modern man (2 and 5) have different symbolic meaning in the Middle East and therefore will not be considered as signs of modernity nor lack of it. Education could be added as a significant social property of a modernized country. This is because education is the most important of the influences that move persons from traditionalism to modernity, (The single most significant variable in education is the amount of formal schooling.) Kuwait is a good example of this. Education
Kuwait has an impressive and an extensive educational program for all students. A Kuwaiti child can go from kindergarten through a doctoral program without having to pay for schooling, books, supplies, meals, uniforms, trips, etc. The Ministry of Education also sponsors hundreds of students who are studying at Universities in the United States, England, Egypt or Lebanon. Changes in the educational system in Kuwait are impressive and were made possible by the handsome budget allocation to the Ministry of Education. The result was a big increase in the number of students enrolled in school from kindergarten through Junior College between 1961-1975, (The number of kindergarten students tripled in number while high school Students increased 10-fold.) Also there was an increase in number of schools; in 1961 there were 3 high schools while in 1975, there were 13 high schools [5]. How did all this acceleration of schools, teachers and'students, effect the illiteracy rate in the country? Here is another paradox, the decrease in illiteracy is not as significant as one expects (Table 1). However, when the rates are considered within the context of improved surveys and reporting over the years and the contextual definition of illiteracy, an analysis of such figures becomes less puzzling. If illiteracy is defined as an inability to read or write, and it is assumed that children learn to read and write by age six with approximately 10,000 individuals in the 1975 census under the age of 6 years, perhaps a figure of 48.7% includes the percentage of population who are in the prereading and writing age. The same questions could be asked about the illiteracy rates among the non-Kuwaiti population. However, for them we should consider that these people are recruited to be part of the labor and professional work forces where recruitment is directed to educated persons. Besides the Kuwaiti children who have first priority in all educational system, the government allows Table 1. Kuwait: Illiteracy rates of Kuwaiti and NonKuwaiti citizens by year Year 1961 1975 s.s.M. 13/6A
:¢:
Illiteracy rate Kuwaitis Non-Kuwaitis 48.7~ 44.6~
42.8% 28.9%
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children of foreigner educators and physicians free public education. The rest of the alien children go to private schools, where fees are charged. There are also special private schools which have been estabfished by the British, American, Egyptia/a, and Palestinian embassies among others. Urbanization
Most of the Kuwaiti population live in cities. Therefore, several major characteristics of urbanization are considered [6]. An urban society is characterized by a diversified occupational structure with a complex, division of labor structure. This forms a major basis for a system of social stratification, social mobility, personal anonymity in interpersonal contacts and segmentalization of social roles and role interactions, marked functional dependence of the population, indirect modes- of social control, and normative deviance. Kuwait has moved from tribal living to a complex division of labor with a rather sophisticated occupational structure which theoretically allows for interdependence and mobility• However the country continues to utililize direct modes of control that are the antithesis of anonymity. An example of that is the Dewania (which is a regular social gathering of men) in which participants hold discussions about the social, political, and economic affairs of the country. These meetings serve as a means for reinforcing ideas and exercising the direct social control needed for conformity or implementation of change. If a person is in a leadership position in the country, or has decision-making capacity or is there as a consultant, that person's daily actions are the subject of these Dewaniahs. Dewaniah members are not bound by one Dewaniah group but tend to move around and infiltrate other gatherings. Communication, role and position interactions largely depend on the informal and direct social contact of these Dewaniahs: Women also have their own Dewaniah which are called "Shai", a word which means "tea". The intricate and complex dynamics of the Shai and Dewaniah have profound influence in the structure of the country. The Dewania is the media where influence and connections--the two major strategies for decision making on social order--are practiced. Here today, there tomorrow
A final significant social property of the country is the transient status of its inhabitants. Because of the summer heat, the high humidity and the limited resources for recreation in the country, as well as the means to do so, Kuwaitis and non-Kuwaitis are extensive travelers. Also non-Kuwaitis travel to visit their homes and families all over the world. Many of the Kuwaiti citizens travel on vacation, business trips, or for health reasons. Air travel and simplication of immigration procedures has made travel easier; therefore, people are in continuous flux. The result is a sense of transiency, temporariness, and culture shock as travellers adapt first to one culture then to their Own, then to another, etc. This obviously effects the health care system in many ways. The health care professionals, who are there on limited permits, no sooner adjust to Kuwait then it is time to leave• Clients continuously have
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to deal with new workers ignorant of the culture and the system or see one who lias been away and is in a transition state or suffering from a cultural shock. DIMENSIONS OF HEALTH CARE
The health care settin 9
In 1910 the Dutch reform church of America was asked by the Kuwaiti government to help in establishing health services in Kuwait. The first clinic was established in 1911, and the first small hospital was opened in 1912. This was the extent of health care facilities in Kuwait until 1950. In 1978 there is about 30 clinics and 11 hospitals with 4500 beds. The health professionals number about 1500 physicans and 4500 nurses [7]. All residents are registered at individual clinics and have a totally free health care based on both curative and preventive models. All diagnostic procedures, pharmaceutics and treatments, are dispensed free to all citizens of the country. Most of this is also available for residents and visitors. Free medical treatment abroad is also provided free of charge. When necessary, the health system even allows the accompaniment of a family member. The health care system is planned with the objective of providing health care on an equal basis, to the entire population, no matter where they are located. The country is divided into district dispensaries or primary care units, combined units and hospitals with emergency units and outpatient departments. Every person can register with the primary care unit nearest to one's home. The decision to build a primary care unit in a particular location in fact is based on the civic division of the country and the number of residents living in each division. Since residential areas are segregated, so are the clinics. There are 36 primary care units in Kuwait. Each is equipped with a general practitioner, or family doctor and one or two nurses. These units are the first step for entry into the country's health care system. The combined clinics have been planned to include a primary care clinic and several speciality clinics such as gynecology or pediatric. Clients who live closer to the combined clinic than to the primary one can have their primary registration in the combined clinic instead. Therefore, referrals from the primary care clinic will be directed to the combined clinics and then to the outpatient department of a hospital. There are also maternal and child health clinics equipped to handle normal deliveries. These clinics are staffed by midwives, obstetricians, nurses and aids. The third major subsystem in the health care setting is the hospital. Hospitals have increased in number from 4 to 11 within the last 10 years, with several more under construction. There are also private hospitals. Altogether in 1978there were 3452 beds for the country's one million population [8]. The primary care clinics, combined clinics and hospitals are all equipped to provide curative and preventive care, and have medication dispensaries and, often, laboratories. The emphasis is on curative care. Health teaching, and health education--the most significant components of preventive health services-are totally neglected in the different clinics. Nurses
perceive this as a service that should be offered by health educators. Physicians do not regard it as a significant component of their role [9]. Clients
The client's perception of health and illness is one of the variables that is considered by medical sociologists to be the crux of health care utilization. How exactly do the Kuwaitis perceive health and illness and specifically, how do they perceive Western medicine? Are there other kinds of healing being practiced? To answer these questions, the author will draw freely from the results of a research project which was conducted with a sample of 152 clients of health service from three combined clinics [10]. Most of the population of Kuwait value and prefer Western medicine over any other mode of care. All the subjects in the sample either made an immediate decision to come to the clinic directly or--as one fourth of the sample did--they consulted briefly a member of the family before coming. None attempted to diagnose their own ailments nor seek treatment elsewhere. Only did nonKuwaiti women utilize non-Western medicine (such as herbs, plants, incense, and the like) in conjunction with Western medicine. Another indication of this preference for Western medicine was demonstrated during the seasonal campaigns for immunization and vaccinations. The clinics became overutilized and overcrowded by the seekers of immunizations. Because records are not kept, it is not possible to discover the percentages of those who utilize this service or any details of utilization. When questions related to immunization are asked at every history taking, there is the potential for misunderstanding of the questions or the response. This is due to the extensive communication problem that exists in the country between the different nationalities. (Not necessarily language problem.) There are two values that exist side by side with Western medicine. One is the Evil Eye and the other concerns the rank order of the type of treatment, When a person does anything that attracts attention-he asks for a disaster which can eventually attract the evil eye. Consequently, a child is never publicly praised. This would attract the evil eye [11]. Even if praise is given, it must be denied. It is better to denigrate the child and call him names in order to disguise the true feelings of the parent. Questions of personal or family health, business, or social status are replied to by some health care utilizers with the shaking of the head indicating not knowing, silence or by unrelated accounts. Such practices need to be considered when interviewing patients in the health care setting. If the evil eye cannot be prevented and finds its way inside the body, then curative medicine must be used. Therefore, western curative medicine is highly valued even though the belief in the evil eye still exists. The second important value is related to the rank ordering of medical treatment. Patients will not use oral medication if they can obtain an injection, believing it to be more potent. The health care providers
Physicians and nurses working in Kuwait have been educated and trained in many countries and in
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The health care system of Kuwait many diverse educational programs. About 10~o of the physicians are Kuwaitis; the rest are foreigners. These physicians and nurses hJtve different orientations to patient care and also speak different dialects and or different languages. Therefore, many problems of communication existed between the utilizers and providers of the health care system. Now with the addition of newly recruited Korean nurses, there is not only a language problem between nurses and patients, but between nurses and physicians. No statistics exist regarding the number of nurses in the country by nationality. However, there is information on physicians indicating that 50~ are Egyptians, 25~ Jordanian and Palestinian, 15~o other non-Arab, and 10~ Kuwaiti. Sixty percent of the physicians are assigned to hospitals and 40~ practice in primary care units. However, there are' imbalances within this division. Most of Egyptian physicians for instance work in primary care units while most of the others, particularly the Jordanians and Palestinians, practice in the hospitals [12]. The Kuwaiti physicians choose to practice in hospitals. The significance of such observations are apparent when paradoxes are considered. It is impressive to note (Table 2) that the country made great strides in its recruitment efforts to bring the ratio of population to nurses and physicians and beds closer to those standards enjoyed in the more developed countries.
Education for the health professionals Only nursing and medicine will be considered and since nursing is more paradoxical, most of the comments will be devoted to it. Nursing education began in Kuwait in 1962 with a program admitting students who had completed the equivalent of a junior high school education. The preparation of teachers, engineers and other occupations followed the same pattern. The Nursing Institute was planned, developed, and supported by the Ministry of Health, while most of the vocational schools were budgeted through the Ministry of Education. In the early 70's the Ministry of Education extensively reviewed and evaluated its philosophy, objectives and future plans: Later when the University of Kuwait was established, the vocational schools were reassessed. They were phased out and replaced by junior college programs, As of 1977, the last Ministry of Education vocational school was closed. The Ministry of Education is again evaluating its educational preparation of school teachers at the junior college level. This is a result of the need for more qualified teachers and the increasing interest in university education. In all this reassessment of educational and occupaTable 2. Kuwait: Ratio of population to hospital beds, physicians and nurses Year
Beds
1970 1975 1976 1980
202 238 243
Physicians 958 830 794 500 Proj.
Nurses 26½ 236 237 150 Proj.
tional opportunities, the Ministry has given much thought to planning for opportunities for women. Most women have been attracted to the teaching profession even though they can enter any arena they choose. This is probably because of the working hours, vacations and sex segregation which teaching provides. The Ministry of Education created a program to prepare school health nurses in 1974. This was to fill the need for more nurses in the country with higher professional training. This program attracted approximately 100 students per year all of whom are Kuwaitis. In 1975-77, Kuwait had a well-established junior college program to prepare school health nurses. Also work had started to establish a B.S. program in nursing and a high school program to prepare for nursing specialities. Today, there is a high school nursing program that graduates approximately 40 nurses per year, 90% of whom are Kuwaiti citizens. There are also junior college programs whose graduates are 10~ Kuwaitis, a university education program for nurses is in the idea phase anu a university education for medicine is in its third year. Also, the country continues to draw health workers from other countries and will continue to do so. PARADOXES
The interaction between the country's social properties and the health care dimensions have created a number of paradoxes. Each paradox profoundly affects the quality of health care in Kuwait. The three most significant paradoxes are "peril and refuge", "satiety and deprivation" and the "In's and Out's'. Each will be discussed.
Peril and refuge Gulick, has written about the concept of "peril and refuge" in the Middle East [13]. He argued that the identity of a person in the Middle East and their membership in social group does not depend on occupation, social class, or ethnicity. Rather, it depends on one's language, religion, sex, country of origin, and ancestory. This is true in Kuwait. There are four questions which are always asked before a matter is judged or a decision is made. They are, in descending order of significance: 1. What is the person's citizenship? 2. Who are the person's ancestors? 3. What is the person's religion (if Moslem, what sect of Islam). 4. What is the person's sex? The answers to these questions determine whether a person will be admitted to a group, more significantly, whether a person is thought to be trustworthy. SociolOgists continue to maintain that a client/professional relationship depends on the degree of trust that develops in the relationship [t4]. This trust is needed both between professionals and their clients, as well as between the professionals themselves. The property of the Kuwaiti population and its composition precipitates the paradox under consideration. Not only is it that less than half of the population (47~) are Kuwaitis but even this group is not homo-
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AFAF [BRAHIM MELEIS
geneous. The Kuwaitis are divided into categories according to their ancestory. Those who come from a Saudi Arabian descent are'at one end of the continuum and those who acquired citizenship through naturalization at the other end. Distinct (both formal and informal) categories exist on the continuum. The other 53% non-Kuwaitis are quite heterogenous. They are Palestinians, Egyptians, Indians, Pakistanians among many other nationalities represented in the country. They are further divided according to their sex, language, religion, etc. Because the country is still developing, many educational and medical needs must come from foreigners. This temporary dependency can cause tension in a society that includes or excludes people on the basis of the variables which have been outlined. Belonging to a group can have positive aspects such as providing a sense of refuge, but also it can have negative aspects such as creating a sense of mistrust and even peril toward those outside the group. This exaggerated sense of cohesiveness can instil feelings of mistrust between professionals and their colleagues as well as their clients, which is the very antithesis of an effective professional relationship. Peril and refuge threaten the health system of the country in that it encourages the patient's suspicion of the health profession. It also encourages them to continually seek health professionals with whom they feel there are variables in common. This "hopping and shopping" strains an already over-burdened health system. Even with a system of registration, patients often go to two or three different physicians in two or three different clinics. This greatly increases workload and confusion. This desire to find a health professional with whom one thinks there is something in common also places great emphasis upon the benefits of ancestry, influence, andwhom one knows. Consequently, certain nhysicians are Overwhelmed by patients who feel that only they are suitable to meet their needs, whereas, less favored physicians may suffer in their practice, even thougt-/they are just as competent. This imbalance leads to the second paradox of satiety and deprivation.
and a written form must be presented to the employer. This, also overloads an already burdened health system. The female clients, on the other hand, defined their illness in terms of a medical model of signs and symptoms and whether they had any pain. Both definitions presuppose a subjective referrent: and for both the physician has to depend upon the client for his decision. Therefore, a trust has to be established. What is wanted from the health care system depends upon the definitions of illness. Some desire an official medical excuse which will allow responsibilities to be temporarily relinquished while others require medication to relieve pain. What if the health system gave medication to the men and sick leave to the women, would not the needs of the patient fail to be met by the health system? One consequence of not having one's expectations met is that the patient goes from one clinic to another, shopping for the health care personnel who will provide what is needed and whether bargaining for a number of days of legitimized absence or free medication whichever is desired. (There is preference for injections over pills.) This may be the reason why unopened medication packets are to be found in the trash cans of clinics. It may be why clinics are congested and overcrowded, and health personnel are overloaded. In the absence of statistics on why a clinic is utilized by the patient, the author asked nurses and physicians what were the most common reasons for clients to seek help. Usually, there was agreement that the majority were at the clinic because: i. They needed a legitimization slip as required by their employers. 2. They needed a place to meet other clients, for affiliation, to meet their social needs. This was true more of the women. Men have other means through which they can meet other men. 3. They were run down and needed vitamins. 4. They had colds or the flu. 5. They were there for vaccination and immunizations. 6. They were there for pain, medications, for minor pains and aches and wanted pain relievers. 7. A small percent were there for specialized treatment and therefore, be referred to the outpatient clinics and emergency rooms of hospitals.
Satiety and deprivation As the patient shops repeatedly for the ideal physician, thesystem becomes overloaded and paradoxically cannot provide the quality health care that it How does one differentiate between all these should. However, this overload is not caused simply groups? One way is careful history taking, with a because of patients shopping and hopping. The careful review of previous utilization patterns, and a patient goes to the health provider for many other careful diagnosis. All of this takes time and decreases reasons. the number of patients to be seen during the working To further develop this paradox, a study was done hours of the health personnel. Those who cannot be by the author in cooperation with students in Kuwait seen for history taking must be attended to by other ~_15]. The study tried to identify perceptions and pro- health professionals which increases their patient cesses of health and illness that clients used to make load. The group pressure to minimize such increases decisions about their health and illness. There were is a strong deterrent to careful diagnosis. significant differences in results between sexes. Males defined illness in terms of a social model. They The in's and the our's regarded illness as a lack of ability or energy to perThis third paradox derives from the overcrowding form one's duties and social obligations. of the primary and combined clinics. Primary care, Male clients would come to the clinic to get a which is so important at this level of the health care required medical confirmation of their illness. This system, is not where it should be. Most health profeswould allow them to take an official sick leave. All sionals, prefer the greater challenge of the hospital. medical excuses have to be approved by physicians Here the physician can demonstrate specialized skills
The health care system of Kuwait and expertise. And also the pat)ent s prefer th~ hospital. F r o m the physician's point of view there is a rank order of preferred site for practice. The primary care unit is at the low end of the scale and the hospital at the other. Physicians do not regard most o f the clinics as needing their special expertise. There is much more challenge for them at the hospital especially when they are allowed to practise their speciality. Furthermore, the clinics require a minimum quota of patients/day/physicians, while hospital physicians enjoy less stringent quota requirements. It is also perceived by health care givers that citizenship affiliation influences the type of assignment in the health care system. A similar rank order exists from the client's point of view; clients who have entry into the health care system through the hospital---emergency room or out-patient d e p a r t m e n t - - d o so without going through the clinics. They do it through professional affiliation, connections, ancestory and citizenship. Those who have no entry to the health care system except through clinics will use the clinics until they are able to get into the preferred part of the system. Who gets assigned to a particular clinic or hospital, has much to do with what is conceptualized here as the "In's" and the "Out's'. How physicians are assigned to the hospital clinics depend on whether they are "In" or "Out". This is also true for the patients, though the parameters o f " I n ' s " and "Out's" are not totally clear, there are guidelines. First is citizenship, so Kuwaitis get first choice in type and location. Always the "In's" can have their choice of either health care or place for practice. Influence and connections are the mechanisms that assist in the desired assignments. Another paradox derives from the power inherent in Kuwaiti citizenship, or of anyone who is "In". It is such that the patient may have more authority than the physician. This, is often true, since the majority of physicians are foreigners, either Palestinian, Jordanian or Egyptians. T h e . Kuwaiti patient may actually choose to go to a foreign physician simply to get what he wants. Therefore the patient's choice of his health care professional is often for all the wrong reasons. This same thinking can also apply to the physician who may choose to work at a hospital, because the patient is more dependent there and less likely to dispute the course of treatment. • CONSEQUENCES What are the consequences of all this? In spite of all the paradoxes, health indicators are encouraging. Life expectancy is high (63 years) when compared with other countries in the Middle East. The infant mortality rates, which are a significant indicators of the health status of a country, do not show dramatic changes. However, there are decreases in the birth and infant mortality rates. The causes of death and disease which have existed for thousands of years in Kuwait are now passing. Health care will soon enter a new age, instead of gas-
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troentriitis, accidents (cardiovascular and mechanical) will be the leading causes of death and disability. These conditions are largely the result of modern technology which is supposed to cure them. The over prescription of drugs because of the fascination with western medicine, is a possible danger. Diseases of stress and adaptation will increase. The new technology, which has come about in the last 12 years will continue to pose dilemmas and to offer solutions. Most significantly will be the country's attempts to deal with the paradoxes created by the interplay of the social properties of the country and its health care system. The Kuwaitis have conquered the desert and have been able to create within two decades a health care and educational systems that are the envy of many Middle Eastern countries. The paradoxes presented here are but a few of the challenges an affluent country must consider in planning for health care for the future. To recognize the paradoxes that profoundly affect the quality of health care is a first step in dealing with them. But to shy away from such recognition and instead address tangential issues could delay the country's diligent efforts in improving health care. 7 REFERENCES
1. Al-Ibraheem H. Kuwait: A Political Study. Kuwait University, 1975. 2. Ministry of Health, Kuwait. Health, Budget, and Performance Analysis, Budget and Statistics Bureau, Kuwait, 1976--1977 (Also from an update Statistics received by personal correspondence). 3. Health, Economics and Productivity Report. Ministry of Health, Kuwait, 1970-1977. 4. Inkles A. and Smith D. H. The fate of personal adjustment in the process of modernizations. Int. J. Comp. Sociol. XI (2), June 1970. 5. Ministry of Education, Kuwait. Statistics, Budget and Statistic Bureau~ Kuwait, 1975-1977. 6. Wirth L. Urbanism as a way of-life. Am. J. Sociol XLIV, 1-24, 1938-9. 7. Ministry of Health, Kuwait. Budget and Performance Analysis, Budget and Statistics Bureau, Kuwait, 1976-1977 (Also from an update Statistics received by personal correspondence). 8. Ministry of Health, Kuwait. Budget and Performance Analysis, Budget and Statistics Bureau, Kuwait, 1976-1977 (Also from an update Statistics received by personal correspondence). 9. Banoub S. Personal communication regarding preliminary findings in his doctoral dissertation. 10. Meleis A. I. Health and illness behavior in Kuwait. Paper presented at the American Sociological Association, Nurse Sociologist Section, August 1978. l l, Shiloh A. The Interaction Between the Middle Eastern and Western Systems of Medicine. Soc. Sci. Med. 2, 235-248, 1968. 12. Banoub S. Personal Communication regarding preliminary findings in his doctoral dissertation, t3. Gulick J. The Middle East: An Anthropological Series. Goodyear, California, 30~52, 1976. 14. Blau P. Power and Exchange in Social Life. John Wiley, New York, 1964. 15. Meleis A. I. Health and Illness Behavior in Kuwait. Paper presented at the American Sociological Association, Nurse Sociologist Section, August 1978.
T H E H E A L T H CARE SYSTEM O F K U W A I T : THE SOCIAL PARADOXES AFAF IBRAHIM MELEIS University of California, San Francisco, School of Nursing, Department of Mental Health and Community Nursing, N505J, San Francisco, CA 94143, U.S.A. Abstract--The purpose of this paper is to describe and discuss the major paradoxes of the health care system of the rich and developing Sheikhdom of Kuwait. With the recent economic affÊuence that is experienced in the new rich countries of the world, the question is raised "How does such economic affluence affect health care?" Kuwait is a land of paradoxes. It is where the symbols of wealth, modernization and urbanization, conflict with the social behaviors that are the result of a still lingering desert life style. A newcomer to the country is dazzled by such symbols and thoroughly confused by actions that are incongruent with the symbols. Therefore, to understand the health care system of the country, an analysis of pertinent social and demographic properties of the country will be considered in conjunction with the major dimensions of health care system in Kuwait. The interaction between and among the social demographic properties of the country and the health care dimensions has created several major paradoxes that profoundly affect the health care in Kuwait. While citizens of Kuwait have developed individual strategies to deal with such paradoxes, it is only through collective awareness of such paradoxes that an organized governmental effort could be developed to deal with the paradoxes.
However, Kuwait is neither underdeveloped nor overdeveloped. Rather, it is a nation of paradoxes with simultaneous underdeveloped and overdeveloped characteristics as is discussed below.
population of Kuwait is characterized by three unique features. First, the peculiar population mix of nationalities. More than half are non-Kuwaitis which includes Palestinians, Jordanians, Egyptians and others as immigrants and workers. The second characteristic which is significant for an analysis of the country's health system is the age distribution. As indicated in Fig. 1, 60% of the population is under 20 years of age. Such an age distribution has significant consequences in health care. The third significant feature of the population of Kuwait is its Bedouins who are bedu, who migrated and continue to migrate across the Arabian Deserts. They established homes at the outskirts of the cities of Kuwait. They have their own health and education problems which are aggravated by their increasing numbers. They congregate in their own created slums while waiting for relocation to the government-built economy homes. Breadwinners of the Bedu who get citizenship are given civil servant jobs such as doorman, guards, etc. The areas for housing are divided geographically, Kuwaitis residential quarters (the more prestigious areas of the country), foreigners quarters, the economy housing areas and the Ashish (the slums of the Bedus). In the foreigners areas, certain districts are inhabited exclusively by particular nationalities. So specific is this housing division that a foreigner can learn in a short time to distinguish all the different housing areas. Therefore, in Kuwait, to know where a person lives, is to understand a great deal about his background. Such rigid segregation is a significant factor in planning health care and also has consequences that affect the health care system.
Population
Nationalism
The population of Kuwait has increased nearly 25% in the last half-dozen years, to slightly more than a million people. The average increase of 6% a year includes natural increases, immigration, and foreigners who come on temporary permits [2]. The
Outnumbered in their own country by foreigners and also having experienced the effect of colonization themselves, and in neighboring countries, Kuwaitis have become extremely nationalistic, both as individuals and as a government. Foreigners and Kuwaitis
SOCIAL DEMOGRAPHIC
PROPERTIES
Kuwait, a country roughly the size of Massachusetts, is located on the northwestern shore of the Persian Gulf. Its flat terrain extends 124 miles in length from north to south and 150miles from east to west. The weather is typical of the Sahara region, a temperature that ranges from 4(~140°F with humidity as high as 90%. Besides the mainland, several islands are scattered in the Arabian Gulf. It is a fast-changing Sheikhdom. Not too long ago, the entire economy was based on pearl diving and ship building. Today, it has one of the highest percapita incomes in the world due to its oil resources. Dr Hassan A1 Ibraheem [1] the chancellor of the University of Kuwait, maintains that Kuwait is different from other underdeveloped countries. His reasons are: 1. Kuwait was not born as a result of a political accident, as were many African countries. 2. It was not underdeveloped when independence was achieved. 3. Since a country's development is largely derived from its economic status, primarily a low percapita income and is not necessarily related to any specific social, political or legal system, Kuwait could be characterized in fact as an overdeveloped country [1, pp. 13-14].
743
744
708
AFAF IBRAHIM MELEIS
6o7 23 \ Age 5o-59/ distribution /
3.9 ,- ^
\
\
1975Census
\ 20-2/ 10-[9Z
0-9//
16.1 23 . 3
36.5 % of Populotion Fig. I
at a much higher value than its actual worth, the government was able t o pay owners more for land and then redistribute it to the citizens of the country. Also, housing was provided by allocating land and interest free loans to each Kuwaiti who was a civil servant. On many occasions these loans subsequently were cancelled by the government without being paid. Third, a substantial amount of the oil revenues is being spent on health, education and public works. In fact the education and health ministries enjoy around 20% of the total budget in Kuwait [3]. Although the health budget in Kuwait is greater than that of other countries of the Middle East, the ministry of Public Health continues to present data which compare Kuwait with western and other affluent countries to emphasize its limited health budget. However, the paradoxes which face the health system in Kuwait are of such nature that it will not be improved by merely increasing the budget for health care. Modernization
There are two ways to assess modernization of a country: one, by observing tools of modernization and two, by examining the effect of such tools on the people. A visitor to Kuwait begins noticing signs have, for instance, different legal and economic status of modernization upon landing at the small but which determine what work they can do and where modern and efficient airport. Outside the airport are they can live. As more foreigners come to work in broad highways which are part of an organized traffic the country, this sentiment becomes pronounced. system. This system is needed because there are half Kuwaiti citizenship is considered very prestigious and as many cars as persons of driving age. is not easily acquired. It is granted to very few resiHomes, apartment buildings and stores are well dents (the author's estimate would be not more than ' kept, and all have large water reservoirs and antennas ten per year). A resident can live and work in Kuwait on the roof. Every home has a television and several for years and even become invaluable in'a particular radios. These media are totally supported by the position, but will still be denied citizenship. government. Also, there are six daily newspapers and The sentiment of nationalism is so strong that even five weekly magazines. All major newspapers from the naturalized residents are classified as second class rest of the Arab world and many western newspapers citizens and are entitled to fewer privileges than first are also available. class citizens who are the original Arabian inhabitants To study the impact of this modernization on indiof Kuwait. viduals, Inkles interviewed subjects from six developThe government of Kuwait has succeeded in devel- ing countries [4]. He found there existed "a set of oping an'd maintaining the strong nationalistic feeling personal qualities which reliably cohere as a synin several ways. One is by providing preferential treat- drome and which identify a type of man who may ment to citizens in education, and health care, job validly be described as fitting a reasonable theoretical allocation, residential areas, and public services are conception of modern man" [4, p. 84]. Central to this all areas that benefit from Kuwaiti citizenship. syndrome of the modern man were these qualities: Obviously citizenship is a source of pride and yound children boast of it with pleasure. Paradoxi1. Openness to new experiences both with people cally, it is this very nationalism that creates problems and processes; 2. Assertion of increased independence for the country. from the authority of traditional figures such as parents or religious leaders with a shift of allegiance to Economics government leaders; 3. Belief in the efficient advanceThe economic uniqueness of Kuwait stems from ment of science and medicine with an abandonment three factors : first, the affluence of the country is rela- of passivity and fatalism in the face of life's difficultively recent. Although the development of oil fol- ties; 4. Ambition for oneself and one's children to lowed World War II, Kuwait did not gain its inde- achieve high occupational and educational goals; 5. pendence from England until 1961. This is a signifi- Interest in carefully planning one's affairs in advance; cant year for Kuwait, as it marks the beginning of therefore a futuristic look; 6. Participation in civic its efforts at modernization. Second, while some other and community affairs and local politics; and 7. newly-rich Arab states continue to be socially and Keeping up with the new world. politically conservative, much of Kuwait's wealth is being shared among its citizens and is profoundly Within this framework, Kuwait can be classified -changing their lives. In the early sixties the govern- as modernized. Through their continuous travels and ment found an ingenious way to distribute the meetings with consultants and foreign business country's new oil revenues. By reassessing property people, Kuwaiti citizens have learned how to be open
The health care system of Kuwait to new ways of doing things. They have faith in modern medicine, they are active participants in civic and community affairs, avid news readers and watchers, and have high ambitions for their children. Two qualities of the modern man (2 and 5) have different symbolic meaning in the Middle East and therefore will not be considered as signs of modernity nor lack of it. Education could be added as a significant social property of a modernized country. This is because education is the most important of the influences that move persons from traditionalism to modernity, (The single most significant variable in education is the amount of formal schooling.) Kuwait is a good example of this. Education
Kuwait has an impressive and an extensive educational program for all students. A Kuwaiti child can go from kindergarten through a doctoral program without having to pay for schooling, books, supplies, meals, uniforms, trips, etc. The Ministry of Education also sponsors hundreds of students who are studying at Universities in the United States, England, Egypt or Lebanon. Changes in the educational system in Kuwait are impressive and were made possible by the handsome budget allocation to the Ministry of Education. The result was a big increase in the number of students enrolled in school from kindergarten through Junior College between 1961-1975, (The number of kindergarten students tripled in number while high school Students increased 10-fold.) Also there was an increase in number of schools; in 1961 there were 3 high schools while in 1975, there were 13 high schools [5]. How did all this acceleration of schools, teachers and'students, effect the illiteracy rate in the country? Here is another paradox, the decrease in illiteracy is not as significant as one expects (Table 1). However, when the rates are considered within the context of improved surveys and reporting over the years and the contextual definition of illiteracy, an analysis of such figures becomes less puzzling. If illiteracy is defined as an inability to read or write, and it is assumed that children learn to read and write by age six with approximately 10,000 individuals in the 1975 census under the age of 6 years, perhaps a figure of 48.7% includes the percentage of population who are in the prereading and writing age. The same questions could be asked about the illiteracy rates among the non-Kuwaiti population. However, for them we should consider that these people are recruited to be part of the labor and professional work forces where recruitment is directed to educated persons. Besides the Kuwaiti children who have first priority in all educational system, the government allows Table 1. Kuwait: Illiteracy rates of Kuwaiti and NonKuwaiti citizens by year Year 1961 1975 s.s.M. 13/6A
:¢:
Illiteracy rate Kuwaitis Non-Kuwaitis 48.7~ 44.6~
42.8% 28.9%
745
children of foreigner educators and physicians free public education. The rest of the alien children go to private schools, where fees are charged. There are also special private schools which have been estabfished by the British, American, Egyptia/a, and Palestinian embassies among others. Urbanization
Most of the Kuwaiti population live in cities. Therefore, several major characteristics of urbanization are considered [6]. An urban society is characterized by a diversified occupational structure with a complex, division of labor structure. This forms a major basis for a system of social stratification, social mobility, personal anonymity in interpersonal contacts and segmentalization of social roles and role interactions, marked functional dependence of the population, indirect modes- of social control, and normative deviance. Kuwait has moved from tribal living to a complex division of labor with a rather sophisticated occupational structure which theoretically allows for interdependence and mobility• However the country continues to utililize direct modes of control that are the antithesis of anonymity. An example of that is the Dewania (which is a regular social gathering of men) in which participants hold discussions about the social, political, and economic affairs of the country. These meetings serve as a means for reinforcing ideas and exercising the direct social control needed for conformity or implementation of change. If a person is in a leadership position in the country, or has decision-making capacity or is there as a consultant, that person's daily actions are the subject of these Dewaniahs. Dewaniah members are not bound by one Dewaniah group but tend to move around and infiltrate other gatherings. Communication, role and position interactions largely depend on the informal and direct social contact of these Dewaniahs: Women also have their own Dewaniah which are called "Shai", a word which means "tea". The intricate and complex dynamics of the Shai and Dewaniah have profound influence in the structure of the country. The Dewania is the media where influence and connections--the two major strategies for decision making on social order--are practiced. Here today, there tomorrow
A final significant social property of the country is the transient status of its inhabitants. Because of the summer heat, the high humidity and the limited resources for recreation in the country, as well as the means to do so, Kuwaitis and non-Kuwaitis are extensive travelers. Also non-Kuwaitis travel to visit their homes and families all over the world. Many of the Kuwaiti citizens travel on vacation, business trips, or for health reasons. Air travel and simplication of immigration procedures has made travel easier; therefore, people are in continuous flux. The result is a sense of transiency, temporariness, and culture shock as travellers adapt first to one culture then to their Own, then to another, etc. This obviously effects the health care system in many ways. The health care professionals, who are there on limited permits, no sooner adjust to Kuwait then it is time to leave• Clients continuously have
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AFAF IBRAHIM MELEIS
to deal with new workers ignorant of the culture and the system or see one who lias been away and is in a transition state or suffering from a cultural shock. DIMENSIONS OF HEALTH CARE
The health care settin 9
In 1910 the Dutch reform church of America was asked by the Kuwaiti government to help in establishing health services in Kuwait. The first clinic was established in 1911, and the first small hospital was opened in 1912. This was the extent of health care facilities in Kuwait until 1950. In 1978 there is about 30 clinics and 11 hospitals with 4500 beds. The health professionals number about 1500 physicans and 4500 nurses [7]. All residents are registered at individual clinics and have a totally free health care based on both curative and preventive models. All diagnostic procedures, pharmaceutics and treatments, are dispensed free to all citizens of the country. Most of this is also available for residents and visitors. Free medical treatment abroad is also provided free of charge. When necessary, the health system even allows the accompaniment of a family member. The health care system is planned with the objective of providing health care on an equal basis, to the entire population, no matter where they are located. The country is divided into district dispensaries or primary care units, combined units and hospitals with emergency units and outpatient departments. Every person can register with the primary care unit nearest to one's home. The decision to build a primary care unit in a particular location in fact is based on the civic division of the country and the number of residents living in each division. Since residential areas are segregated, so are the clinics. There are 36 primary care units in Kuwait. Each is equipped with a general practitioner, or family doctor and one or two nurses. These units are the first step for entry into the country's health care system. The combined clinics have been planned to include a primary care clinic and several speciality clinics such as gynecology or pediatric. Clients who live closer to the combined clinic than to the primary one can have their primary registration in the combined clinic instead. Therefore, referrals from the primary care clinic will be directed to the combined clinics and then to the outpatient department of a hospital. There are also maternal and child health clinics equipped to handle normal deliveries. These clinics are staffed by midwives, obstetricians, nurses and aids. The third major subsystem in the health care setting is the hospital. Hospitals have increased in number from 4 to 11 within the last 10 years, with several more under construction. There are also private hospitals. Altogether in 1978there were 3452 beds for the country's one million population [8]. The primary care clinics, combined clinics and hospitals are all equipped to provide curative and preventive care, and have medication dispensaries and, often, laboratories. The emphasis is on curative care. Health teaching, and health education--the most significant components of preventive health services-are totally neglected in the different clinics. Nurses
perceive this as a service that should be offered by health educators. Physicians do not regard it as a significant component of their role [9]. Clients
The client's perception of health and illness is one of the variables that is considered by medical sociologists to be the crux of health care utilization. How exactly do the Kuwaitis perceive health and illness and specifically, how do they perceive Western medicine? Are there other kinds of healing being practiced? To answer these questions, the author will draw freely from the results of a research project which was conducted with a sample of 152 clients of health service from three combined clinics [10]. Most of the population of Kuwait value and prefer Western medicine over any other mode of care. All the subjects in the sample either made an immediate decision to come to the clinic directly or--as one fourth of the sample did--they consulted briefly a member of the family before coming. None attempted to diagnose their own ailments nor seek treatment elsewhere. Only did nonKuwaiti women utilize non-Western medicine (such as herbs, plants, incense, and the like) in conjunction with Western medicine. Another indication of this preference for Western medicine was demonstrated during the seasonal campaigns for immunization and vaccinations. The clinics became overutilized and overcrowded by the seekers of immunizations. Because records are not kept, it is not possible to discover the percentages of those who utilize this service or any details of utilization. When questions related to immunization are asked at every history taking, there is the potential for misunderstanding of the questions or the response. This is due to the extensive communication problem that exists in the country between the different nationalities. (Not necessarily language problem.) There are two values that exist side by side with Western medicine. One is the Evil Eye and the other concerns the rank order of the type of treatment, When a person does anything that attracts attention-he asks for a disaster which can eventually attract the evil eye. Consequently, a child is never publicly praised. This would attract the evil eye [11]. Even if praise is given, it must be denied. It is better to denigrate the child and call him names in order to disguise the true feelings of the parent. Questions of personal or family health, business, or social status are replied to by some health care utilizers with the shaking of the head indicating not knowing, silence or by unrelated accounts. Such practices need to be considered when interviewing patients in the health care setting. If the evil eye cannot be prevented and finds its way inside the body, then curative medicine must be used. Therefore, western curative medicine is highly valued even though the belief in the evil eye still exists. The second important value is related to the rank ordering of medical treatment. Patients will not use oral medication if they can obtain an injection, believing it to be more potent. The health care providers
Physicians and nurses working in Kuwait have been educated and trained in many countries and in
747
The health care system of Kuwait many diverse educational programs. About 10~o of the physicians are Kuwaitis; the rest are foreigners. These physicians and nurses hJtve different orientations to patient care and also speak different dialects and or different languages. Therefore, many problems of communication existed between the utilizers and providers of the health care system. Now with the addition of newly recruited Korean nurses, there is not only a language problem between nurses and patients, but between nurses and physicians. No statistics exist regarding the number of nurses in the country by nationality. However, there is information on physicians indicating that 50~ are Egyptians, 25~ Jordanian and Palestinian, 15~o other non-Arab, and 10~ Kuwaiti. Sixty percent of the physicians are assigned to hospitals and 40~ practice in primary care units. However, there are' imbalances within this division. Most of Egyptian physicians for instance work in primary care units while most of the others, particularly the Jordanians and Palestinians, practice in the hospitals [12]. The Kuwaiti physicians choose to practice in hospitals. The significance of such observations are apparent when paradoxes are considered. It is impressive to note (Table 2) that the country made great strides in its recruitment efforts to bring the ratio of population to nurses and physicians and beds closer to those standards enjoyed in the more developed countries.
Education for the health professionals Only nursing and medicine will be considered and since nursing is more paradoxical, most of the comments will be devoted to it. Nursing education began in Kuwait in 1962 with a program admitting students who had completed the equivalent of a junior high school education. The preparation of teachers, engineers and other occupations followed the same pattern. The Nursing Institute was planned, developed, and supported by the Ministry of Health, while most of the vocational schools were budgeted through the Ministry of Education. In the early 70's the Ministry of Education extensively reviewed and evaluated its philosophy, objectives and future plans: Later when the University of Kuwait was established, the vocational schools were reassessed. They were phased out and replaced by junior college programs, As of 1977, the last Ministry of Education vocational school was closed. The Ministry of Education is again evaluating its educational preparation of school teachers at the junior college level. This is a result of the need for more qualified teachers and the increasing interest in university education. In all this reassessment of educational and occupaTable 2. Kuwait: Ratio of population to hospital beds, physicians and nurses Year
Beds
1970 1975 1976 1980
202 238 243
Physicians 958 830 794 500 Proj.
Nurses 26½ 236 237 150 Proj.
tional opportunities, the Ministry has given much thought to planning for opportunities for women. Most women have been attracted to the teaching profession even though they can enter any arena they choose. This is probably because of the working hours, vacations and sex segregation which teaching provides. The Ministry of Education created a program to prepare school health nurses in 1974. This was to fill the need for more nurses in the country with higher professional training. This program attracted approximately 100 students per year all of whom are Kuwaitis. In 1975-77, Kuwait had a well-established junior college program to prepare school health nurses. Also work had started to establish a B.S. program in nursing and a high school program to prepare for nursing specialities. Today, there is a high school nursing program that graduates approximately 40 nurses per year, 90% of whom are Kuwaiti citizens. There are also junior college programs whose graduates are 10~ Kuwaitis, a university education program for nurses is in the idea phase anu a university education for medicine is in its third year. Also, the country continues to draw health workers from other countries and will continue to do so. PARADOXES
The interaction between the country's social properties and the health care dimensions have created a number of paradoxes. Each paradox profoundly affects the quality of health care in Kuwait. The three most significant paradoxes are "peril and refuge", "satiety and deprivation" and the "In's and Out's'. Each will be discussed.
Peril and refuge Gulick, has written about the concept of "peril and refuge" in the Middle East [13]. He argued that the identity of a person in the Middle East and their membership in social group does not depend on occupation, social class, or ethnicity. Rather, it depends on one's language, religion, sex, country of origin, and ancestory. This is true in Kuwait. There are four questions which are always asked before a matter is judged or a decision is made. They are, in descending order of significance: 1. What is the person's citizenship? 2. Who are the person's ancestors? 3. What is the person's religion (if Moslem, what sect of Islam). 4. What is the person's sex? The answers to these questions determine whether a person will be admitted to a group, more significantly, whether a person is thought to be trustworthy. SociolOgists continue to maintain that a client/professional relationship depends on the degree of trust that develops in the relationship [t4]. This trust is needed both between professionals and their clients, as well as between the professionals themselves. The property of the Kuwaiti population and its composition precipitates the paradox under consideration. Not only is it that less than half of the population (47~) are Kuwaitis but even this group is not homo-
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AFAF [BRAHIM MELEIS
geneous. The Kuwaitis are divided into categories according to their ancestory. Those who come from a Saudi Arabian descent are'at one end of the continuum and those who acquired citizenship through naturalization at the other end. Distinct (both formal and informal) categories exist on the continuum. The other 53% non-Kuwaitis are quite heterogenous. They are Palestinians, Egyptians, Indians, Pakistanians among many other nationalities represented in the country. They are further divided according to their sex, language, religion, etc. Because the country is still developing, many educational and medical needs must come from foreigners. This temporary dependency can cause tension in a society that includes or excludes people on the basis of the variables which have been outlined. Belonging to a group can have positive aspects such as providing a sense of refuge, but also it can have negative aspects such as creating a sense of mistrust and even peril toward those outside the group. This exaggerated sense of cohesiveness can instil feelings of mistrust between professionals and their colleagues as well as their clients, which is the very antithesis of an effective professional relationship. Peril and refuge threaten the health system of the country in that it encourages the patient's suspicion of the health profession. It also encourages them to continually seek health professionals with whom they feel there are variables in common. This "hopping and shopping" strains an already over-burdened health system. Even with a system of registration, patients often go to two or three different physicians in two or three different clinics. This greatly increases workload and confusion. This desire to find a health professional with whom one thinks there is something in common also places great emphasis upon the benefits of ancestry, influence, andwhom one knows. Consequently, certain nhysicians are Overwhelmed by patients who feel that only they are suitable to meet their needs, whereas, less favored physicians may suffer in their practice, even thougt-/they are just as competent. This imbalance leads to the second paradox of satiety and deprivation.
and a written form must be presented to the employer. This, also overloads an already burdened health system. The female clients, on the other hand, defined their illness in terms of a medical model of signs and symptoms and whether they had any pain. Both definitions presuppose a subjective referrent: and for both the physician has to depend upon the client for his decision. Therefore, a trust has to be established. What is wanted from the health care system depends upon the definitions of illness. Some desire an official medical excuse which will allow responsibilities to be temporarily relinquished while others require medication to relieve pain. What if the health system gave medication to the men and sick leave to the women, would not the needs of the patient fail to be met by the health system? One consequence of not having one's expectations met is that the patient goes from one clinic to another, shopping for the health care personnel who will provide what is needed and whether bargaining for a number of days of legitimized absence or free medication whichever is desired. (There is preference for injections over pills.) This may be the reason why unopened medication packets are to be found in the trash cans of clinics. It may be why clinics are congested and overcrowded, and health personnel are overloaded. In the absence of statistics on why a clinic is utilized by the patient, the author asked nurses and physicians what were the most common reasons for clients to seek help. Usually, there was agreement that the majority were at the clinic because: i. They needed a legitimization slip as required by their employers. 2. They needed a place to meet other clients, for affiliation, to meet their social needs. This was true more of the women. Men have other means through which they can meet other men. 3. They were run down and needed vitamins. 4. They had colds or the flu. 5. They were there for vaccination and immunizations. 6. They were there for pain, medications, for minor pains and aches and wanted pain relievers. 7. A small percent were there for specialized treatment and therefore, be referred to the outpatient clinics and emergency rooms of hospitals.
Satiety and deprivation As the patient shops repeatedly for the ideal physician, thesystem becomes overloaded and paradoxically cannot provide the quality health care that it How does one differentiate between all these should. However, this overload is not caused simply groups? One way is careful history taking, with a because of patients shopping and hopping. The careful review of previous utilization patterns, and a patient goes to the health provider for many other careful diagnosis. All of this takes time and decreases reasons. the number of patients to be seen during the working To further develop this paradox, a study was done hours of the health personnel. Those who cannot be by the author in cooperation with students in Kuwait seen for history taking must be attended to by other ~_15]. The study tried to identify perceptions and pro- health professionals which increases their patient cesses of health and illness that clients used to make load. The group pressure to minimize such increases decisions about their health and illness. There were is a strong deterrent to careful diagnosis. significant differences in results between sexes. Males defined illness in terms of a social model. They The in's and the our's regarded illness as a lack of ability or energy to perThis third paradox derives from the overcrowding form one's duties and social obligations. of the primary and combined clinics. Primary care, Male clients would come to the clinic to get a which is so important at this level of the health care required medical confirmation of their illness. This system, is not where it should be. Most health profeswould allow them to take an official sick leave. All sionals, prefer the greater challenge of the hospital. medical excuses have to be approved by physicians Here the physician can demonstrate specialized skills
The health care system of Kuwait and expertise. And also the pat)ent s prefer th~ hospital. F r o m the physician's point of view there is a rank order of preferred site for practice. The primary care unit is at the low end of the scale and the hospital at the other. Physicians do not regard most o f the clinics as needing their special expertise. There is much more challenge for them at the hospital especially when they are allowed to practise their speciality. Furthermore, the clinics require a minimum quota of patients/day/physicians, while hospital physicians enjoy less stringent quota requirements. It is also perceived by health care givers that citizenship affiliation influences the type of assignment in the health care system. A similar rank order exists from the client's point of view; clients who have entry into the health care system through the hospital---emergency room or out-patient d e p a r t m e n t - - d o so without going through the clinics. They do it through professional affiliation, connections, ancestory and citizenship. Those who have no entry to the health care system except through clinics will use the clinics until they are able to get into the preferred part of the system. Who gets assigned to a particular clinic or hospital, has much to do with what is conceptualized here as the "In's" and the "Out's'. How physicians are assigned to the hospital clinics depend on whether they are "In" or "Out". This is also true for the patients, though the parameters o f " I n ' s " and "Out's" are not totally clear, there are guidelines. First is citizenship, so Kuwaitis get first choice in type and location. Always the "In's" can have their choice of either health care or place for practice. Influence and connections are the mechanisms that assist in the desired assignments. Another paradox derives from the power inherent in Kuwaiti citizenship, or of anyone who is "In". It is such that the patient may have more authority than the physician. This, is often true, since the majority of physicians are foreigners, either Palestinian, Jordanian or Egyptians. T h e . Kuwaiti patient may actually choose to go to a foreign physician simply to get what he wants. Therefore the patient's choice of his health care professional is often for all the wrong reasons. This same thinking can also apply to the physician who may choose to work at a hospital, because the patient is more dependent there and less likely to dispute the course of treatment. • CONSEQUENCES What are the consequences of all this? In spite of all the paradoxes, health indicators are encouraging. Life expectancy is high (63 years) when compared with other countries in the Middle East. The infant mortality rates, which are a significant indicators of the health status of a country, do not show dramatic changes. However, there are decreases in the birth and infant mortality rates. The causes of death and disease which have existed for thousands of years in Kuwait are now passing. Health care will soon enter a new age, instead of gas-
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troentriitis, accidents (cardiovascular and mechanical) will be the leading causes of death and disability. These conditions are largely the result of modern technology which is supposed to cure them. The over prescription of drugs because of the fascination with western medicine, is a possible danger. Diseases of stress and adaptation will increase. The new technology, which has come about in the last 12 years will continue to pose dilemmas and to offer solutions. Most significantly will be the country's attempts to deal with the paradoxes created by the interplay of the social properties of the country and its health care system. The Kuwaitis have conquered the desert and have been able to create within two decades a health care and educational systems that are the envy of many Middle Eastern countries. The paradoxes presented here are but a few of the challenges an affluent country must consider in planning for health care for the future. To recognize the paradoxes that profoundly affect the quality of health care is a first step in dealing with them. But to shy away from such recognition and instead address tangential issues could delay the country's diligent efforts in improving health care. 7 REFERENCES
1. Al-Ibraheem H. Kuwait: A Political Study. Kuwait University, 1975. 2. Ministry of Health, Kuwait. Health, Budget, and Performance Analysis, Budget and Statistics Bureau, Kuwait, 1976--1977 (Also from an update Statistics received by personal correspondence). 3. Health, Economics and Productivity Report. Ministry of Health, Kuwait, 1970-1977. 4. Inkles A. and Smith D. H. The fate of personal adjustment in the process of modernizations. Int. J. Comp. Sociol. XI (2), June 1970. 5. Ministry of Education, Kuwait. Statistics, Budget and Statistic Bureau~ Kuwait, 1975-1977. 6. Wirth L. Urbanism as a way of-life. Am. J. Sociol XLIV, 1-24, 1938-9. 7. Ministry of Health, Kuwait. Budget and Performance Analysis, Budget and Statistics Bureau, Kuwait, 1976-1977 (Also from an update Statistics received by personal correspondence). 8. Ministry of Health, Kuwait. Budget and Performance Analysis, Budget and Statistics Bureau, Kuwait, 1976-1977 (Also from an update Statistics received by personal correspondence). 9. Banoub S. Personal communication regarding preliminary findings in his doctoral dissertation. 10. Meleis A. I. Health and illness behavior in Kuwait. Paper presented at the American Sociological Association, Nurse Sociologist Section, August 1978. l l, Shiloh A. The Interaction Between the Middle Eastern and Western Systems of Medicine. Soc. Sci. Med. 2, 235-248, 1968. 12. Banoub S. Personal Communication regarding preliminary findings in his doctoral dissertation, t3. Gulick J. The Middle East: An Anthropological Series. Goodyear, California, 30~52, 1976. 14. Blau P. Power and Exchange in Social Life. John Wiley, New York, 1964. 15. Meleis A. I. Health and Illness Behavior in Kuwait. Paper presented at the American Sociological Association, Nurse Sociologist Section, August 1978.