Thursday, November 26, 2009

Reflections on Fieldwork at the Clinic

Tomorrow marks the end of my fourth week of research. And after twenty mornings of observation, 4 different wards, and more than 50 typed pages of field notes, I’m more excited than ever about this project.

I start each day at the réunion de staff, a meeting in which the residents and professors get together to discuss all new admissions of the day before. Afterwards I head to one of the wards, where I observe the daily goings-on. I sit in on medical consultations or meetings between nurses. I participate in recreational activities for patients, walk around the ward, look at the schedules and announcements posted in the nurses’ office, get a sense of the way in which records are kept, listen to doctors discussing treatment options with one another, or simply sit in a chair and watch. I have informal conversations with the staff, in which I’ll ask them about their method of diagnosis, their protocols for treatment, or about the backgrounds of their patients, and they’ll ask me about my research plans.

For the moment I am simply an observer; apart from these informal conversations I’m not engaging in any actual interviews yet. But even just these brief mornings of watching have produced more data than I had ever expected at this stage of research. Everything I see and hear at the Clinic is material. I’m picking up data and learning new things at multiple levels, all at the same time. I’m learning linguistically: I write down the French terms for disorders, symptoms, and other phenomena. I’m becoming so used to being in a francophone hospital environment that I’m beginning to have trouble thinking of the English equivalent for words like prise en charge (care), sevrage (withdrawal), or infirmier chef (head nurse?).

At the same time, I’m learning on a medical level: I’m becoming familiar with psychiatric symptomatology, its clinical presentations, and its biological consequences. I frantically write down every snippet of general medical information that I glean from my observations, and spend most of my afternoons googling the names of medications I’ve seen prescribed, the workings of different neurotransmitters, or the DSM-IV description of personality disorders.* I’m learning about the Clinic’s procedures for admission, treatment, and discharge, as well as national laws governing hospitalizations, and am getting a sense of how clinical observations are recorded and communicated between doctors and nurses.

And finally, I’m gathering ethnographic data. I observe how residents interact with their professors, how doctors talk to nurses, and how staff communicate with patients. I’m getting a sense of how patients express their symptoms, and how doctors listen to these explanations. I’m taking note of the gender balance and how this affects the relationship between patients and staff. I’m beginning to get a sense of how psychiatric theories interact with popular belief in spirits and magic, how medical knowledge is imparted to students, and of how medical expertise lends power.

All of this data makes for almost incessant note-taking, and a bit of internal conflict sometimes about what to write down, and what to let slide. In that sense I’m also learning about myself as an observer – about what I pick up on and what I miss, what I consider important, and how I position myself vis-à-vis the people among whom I am doing research. I spend a fair amount of time talking to two other foreign women spending some time at the hospital – a student of clinical psychology and a psychiatrist. As we exchange impressions and reflections, I find a lot of my observations reinforced, but also curiously take note of differences in interpretation, or of interesting bits of information I had completely missed. Their viewpoint is valuable to me – the extra eyes and minds add more data to my notes, but also allow me an additional dimension of reflection on what I’m seeing. Their experience of clinical practice in France provides me with a valuable comparison for the things that strike me about psychiatry here, and provide me with a sounding board on which I can test some of my own budding interpretations.**

This wealth of input only makes me hungry for more, and I’ve never felt more motivated or energetic about my project. At the same time, however, the wealth of sensory input gets a little overwhelming sometimes. There is so much to take in that I feel as though I’m left without enough time to process it all, to wrap my head around it and make sense out of what I’m seeing. As far as my ethnographic work is concerned, this might not be something to worry too much about. There’s something to say, perhaps, for just diving in at this stage of the project – of immersing myself completely and just letting it all flood over me. It might even be too early to try and distill some interpretations or theories out of what I’ve seen – if I draw conclusions now, perhaps I’ll blind myself to new evidence that might contradict what I think I’ve learned?

But personally, it’s difficult sometimes to relinquish that sense of control, that sense of knowing what’s going on. And for the purposes of this blog, I do wish that I were a little bit more able to distill a few coherent ideas out of my field notes, just enough for a post or two. There is so much I want to write about – the communication between doctors and patients, the concept of ‘psychiatric expertise’ and the way in which it shapes that communication, the notion of hysteria (so outdated a term in Europe and the US, but so commonly used here), the role of gender in shaping interactions, treatment plans, and diagnoses. All of these ideas are floating around in my mind, but I just can’t seem to find enough clarity to pin them down with adequate, descriptive words. Hopefully I’ll find a bit of coherence in due course. I’ll try to keep posting about once a week – and I’ll try to return to writing about things other than my research, as well.

* This level of learning has made me particularly conscious of how much I miss medicine. How intrigued I am not just by the human mind, but by the human body as well. I don’t want to use the word regret because I don’t for a moment regret choosing anthropology, but I do regret making a choice in general; I regret having decided at some point that I wouldn’t be able to do both medicine and anthropology. It’s never too late, I suppose, and in theory I could apply for medical school once I finish my PhD. When that time comes, I guess I’ll have to ask myself what I’d rather do: start another rigorous four years of education when I’m in my early thirties, or spend the rest of my life knowing that a part of me will always miss medicine?
** In addition, I’m finding it incredibly valuable to be able to talk about what I’ve seen with others who have shared the experience. I’m observing at the Clinic’s emergency room this week, and a few of the people who’ve come in for psychiatric help have really struck me in their sadness and hopelessness. More so than on the other wards, observation this week has affected me emotionally, and it’s been helpful to talk about these observations with others who were there.

Wednesday, November 18, 2009

Ethnography of a Psychiatric Ward: The Meaning of Psychosis

“What’s the point?” she asks. She looks fragile as she sits in that chair, her shoulders drooping and her face nearly hidden by the pink hoodie she’s pulled over her hair. She looks at the doctor with a bit of frustration in her eyes, her hands digging themselves deeper into her hoodie’s pockets.

“It’s gone, and I feel good. Isn’t that all that matters?”

Doctor Mourad leans back, and lets out a subtle sigh. Then he responds:

“But it’s important that we talk about this, you and me, so that I can help you.”

The consultation is suddenly interrupted when the door swings open and another resident walks in. She shares this consultation room with Dr. Mourad, and she’s here to pick up her bag. As the two physicians exchange a few pleasantries, I notice the patient’s head sinking lower and lower, until it is cradled by her hands. Rhythmic tremors running through her shoulders betray that she is crying.

But she has not given in. After the female resident leaves, Dr. Mourad tries again, to no avail. He is hoping to convince his patient to talk about her experience of possession by what she calls a diable, a devil (or, in Arabic, a shaitan*). I cannot help but think that he’s doing so in part for my benefit; ever since the doctors on this ward have learned about my research interests, they are constantly calling me in to observe their interaction with patients who claim to have been possessed or cursed – an experience the doctors categorically define as a particular kind of hallucination. None have been as unwilling to discuss the subject as this young woman, and I am struck by her defensiveness.

Her next argument calls on notions of expertise and authority, as she hopes to excuse herself from the responsibility of having to explain what happened to her:

“You shouldn’t ask me,” she says. “I don’t know anything about jnoun, diables or shaitans. All I know is what it says in the Qur’an. If you want any explanations, don’t ask me. You need to talk to an expert, some kind of scholar.”

The doctor tries to explain that he’s not interested in theory; he just wants to know what happened to her. But it’s no use, and a few minutes later we escort the patient back to her room. She’s staying in the closed women’s ward: a dreary concrete courtyard where about twenty five very sick women spend their days doing little more than wandering around. Paint flakes off the walls and ceilings, there is little more than a few rusty old hospital beds to sit on in the recreational room, and a stale smell of abandonment hangs in the air. It is a far cry from the state of the art facilities where I spent my first week at the Clinic. Having moved on to a third ward at the time of writing, I’ve learned that this closed ward is by no means representative of the rest of this hospital. Nevertheless, it struck me in its sadness, and I think the difference in environment between this and other wards is worth exploring.

The dreariness of this ward is matched by a complete lack of stimulation or activity for the patients. Doctors tell me that a hair dresser comes to the ward to do the patients’ hair once in a while, and nurses will sometimes hang out with the women, listening to music or dancing a little. But there is no exercise equipment like there was on the addiction ward, nor are there musical instruments, books, or a television. Nothing is allowed on the ward; in their psychosis or suicidality, a fair amount of these women cannot be trusted not to do something harmful. On the one hand, I wonder how these women make it through the day, with nothing to do. On the other, even I can see that the majority of these patients are too sick to be able to participate in any kind of activity.

Most of the patients on this ward suffer from a psychotic disorder. They are heavily medicated: each morning, the nurses enter the ward with a tray full of Haldol, Largactil,** and other anti-psychotics and tranquilizers. The medication is often administered by injection – pills can be refused, I guess. There is no privacy; each room accommodates five to six women. Without curtains or doors to hide behind anywhere, patients are injected right there on the courtyard, en plein public.

Despite this medication, the women seem truly sick. Many of them spend their days walking around the courtyard, talking animatedly to the voices in their head. They slur their speech when they talk, and jump from one subject to the next. They crowd around the locked glass door that separates the ward from the nurses’ area, and sing famous Sherine songs.*** When they notice me, sitting there with the staff, they blow me kisses, and call out that I’m trop belle. A few of them even begin to recite the Fatiha, the first verses of the Qur’an. I’m struck by this ‘strange’ lack of inhibition, and take it as a sign that these women are really sick. Nevertheless, when that glass door opens and they all come in to greet me, they are friendly, and normal, and simply curious. They just want to know my name, where I’m from, how I’m doing. The next day, I see genuine recognition in their eyes as they greet me again.

A lot of the patients, the doctors tell me, believe they have been possessed, or cursed. One of the residents tells me, almost self-consciously, that for a psychiatrist, this is a hallucination. An anthropologist might feel differently, she adds, but for her, it is part of a psychotic symptomatology. I don’t have time to respond – she’s in consultation with a patient at the moment, and simply turns to me once in a while to ‘translate’ what the patient is saying into psychiatric terms. But it makes me realize that I need to come up with a ready answer for questions such as these. I am so often asked these days if I believe in possession, or in the effectiveness of countercurses. Regardless of how I might feel about these issues, I think I’ll say “I don’t know.” True objectivity is an illusion, I know that, but I think it’s a better idea not to weigh in on these questions with the people who are participating in my research, and try to maintain some kind of neutrality.

A central question in my research, however, is what happens when two different theories about mental illness meet. What does it do to a person’s experience of being sick, when his or her belief about possession is explained (dismissed?) by a psychiatrist as a ‘hallucination’? I cannot help but wonder if this has anything to do with that young woman’s unwillingness to tell Dr. Mourad about her experience. As we talked about her reticence, Dr. Mourad explained that she might worry that her diable will come back if she talks about it. Alternatively, she might be afraid that talking about devils will lead doctors to conclude that she warrants longer hospitalization. Dr. Mourad, however, feels that she will not truly be well enough to leave until she is able to talk openly about her experience. I can see his point; I tend to believe in the idea that talking – externalizing – provides a necessary kind of catharsis. Nevertheless, I wonder what it’s like for a patient like this young woman; to be asked to open up about a very traumatic experience to someone who might not agree about what that experience meant, and who has no more than twenty minutes a day to speak with you.

All of it makes me wonder about the nature or definition of ‘pathology’. Who has the right to define what’s normal and what’s not, and who gets to decide what it all means, or what should be done about it? I’m thinking here not just about the meaning of possession. Aside from these beliefs, another problem most of the patients had in common was a history of prostitution. Nearly every patient I met on the ward had, according to the doctors, engaged in some kind of prostitution at some moment in time. This behavior was often seen as a symptom of illness: a sign of mania, or psychosis. Some patients talked openly about it all, while others denied ever having sold their bodies – a sign, for the psychiatrist, of that patient’s impaired judgment. I couldn’t help but wonder, though, whether it might not be at least a little understandable that a woman might deny having engaged in something considered to be so shameful?

In addition, I wonder how much cultural beliefs and social expectations have weighed in on the high occurrence of ‘prostitution’-as-pathology among these patients. Morocco is a modernizing country, but extramarital sex is still, and will probably long remain, highly unacceptable for a woman. Does that mean, I wonder, that the definition of ‘prostitution’ here in Morocco is broader than ours? Once, when discussing an alcoholic male patient’s extramarital affairs with girls, a resident insisted that he must have slept with prostitutes. Anything else was simply not possible, she said; any girl who has extramarital sex is by definition a prostitute. Perhaps some of these female patients had engaged in behavior that, by Western standards, would not necessarily be termed prostitution? And in the same way, I wonder if the particular unacceptability of extramarital sex might mean that doctors here are more likely than elsewhere to label promiscuous behavior as ‘pathological’? Excessive promiscuity is often included on lists of the kind of reckless behavior that the DSM-IV lists as a possible symptom of mania, or various personality disorders. Nevertheless, I wonder if cultural mores weigh in here to create this particular tendency to label people with deviant sexual behavior.

I spent a lot of my time on this ward in a chair in the nurses’ lounge, observing the women on the ward through that glass door. And as they crowded up against that door to wave or sing to me, I began to wonder: what really is the difference between me and them? Aren’t we both curiously and unabashedly observing the other? I am as interested in them as they are in me. As a foreigner I, too, don’t always behave according to the social rules. Aren’t I, then, as abnormal as they are? When the nurse pulls a screen in front of the door, I am not sure whose gaze she is trying to avert – theirs, or mine.

I had hoped to do my research on this ward, but the level of pathology might pose a problem. I can interview only those who are capable of understanding the goals of my research, and of providing informed consent for participation. I did not meet a single patient who would have met those criteria – an observation later corroborated by most of the residents. I haven’t yet visited the open women’s ward, but hope this may be a better fit. Part of me is relieved, not to have to spend a few months on that dreary, tragic ward. But the other part of me continues to think about the women I’ve met there, wondering how they’re doing now, half a week since I last saw them, wondering also where they might end up, once they leave the Clinic.

* though curiously, this woman argued that a diable is not the same thing as a shaitan. It was one of the few things she was willing to explain – though she couldn’t tell us what exactly the difference was. I continue to be intrigued by the way in which Moroccans mix French and Arabic - and her distinction between these two concepts interestingly contradicts the idea that the two languages are conceptually interchangeable...
** Largactil is known as thorazine in the US, I believe.
*** Sherine is a famous middle eastern singer. Egyptian, most likely.

Thursday, November 12, 2009

Ethnography of a Psychiatric Ward: Addiction in Rabat

Mr. Abbas is a thin, clean-shaven man in his fifties. He is well-spoken, but restless as he meets with his treating physician, a young petite woman in her second year of psychiatric residency. Sitting on the edge of his seat, he keeps getting up and walks around the room, as though he is acting out the story he is telling. He is beating around the bush, and the resident repeatedly calls him on it: you’re not answering my question, she tells him.

He isn’t providing the resident with the information she is looking for. Neither is he speaking her language: while she poses her questions in Moroccan Arabic, he insists on answering in French, and utters not a word in dialect throughout the meeting. At first I think he may be doing this for the benefit of the observers in the room: two master’s students in clinical psychology, a psychiatrist from France, and myself. Our presence probably did have something to do with his conduct. But there was more to Mr. Abbas’ very performative behavior.

Mr. Abbas is an alcoholic, and he has checked himself into the Clinic in order to conquer his addiction. When his doctor introduces us, the observers, during this particular consultation, Mr. Abbas responds with a polite and pleasant enchanté, and proceeds to introduce himself with a quite elaborate story. He is a successful lawyer, he tells us, well-educated and fluent in French. Over the course of the consultation he talks about his practice, his nice car, his wife – none of which the resident asked about. After he leaves, his doctor tells us that Mr. Abbas hasn’t worked in three years. His wife has left; in fact, the life he just described to us has been destroyed by his addiction. What emerges at that point is the sad picture of a man dethroned; a man who has lost everything he thought to validate his existence; a man who desperately tries to maintain an image he knows he has already lost.

And it made me wonder. What does alcoholism mean for a Moroccan man? Alcoholism is destructive to anyone, but in this country, where alcohol is forbidden by religious decree, what does it mean to be an alcoholic? What does it do to Mr. Abbas’ sense of who he is? To his identity as a man, as a Moroccan, as a Muslim?

Mr. Abbas is but one of the patients I met during my week of observation on the service de toxicomanie, the Clinic’s addiction ward. It was the inaugural week of my research project; though I will not actually be able to do anything I mention in my research proposal until I obtain authorization from a local ethics board, the Clinic’s director has given me permission to kick-start my research with a period of general observation. Dr. Rachidi and I designed a schedule that would put me on a different ward each week, and as of last Monday, I spend every weekday morning looking around, shadowing doctors and nurses, and sitting in on meetings and rounds.

The service de toxicomanie has been running for a number of years, but recently moved into new housing: a newly built two-storey construction just inside the hospital grounds. Clearly the recipient of considerable funding, the service stands out from the rest of the hospital by virtue of its size and its modern and clean appearance.

But despite its large quarters, the service is small. Aside from Dr. Rachidi, who is the attending on this ward (here she is called professeur), the place is staffed by two residents (résidents) and about three nurses per shift. The number of patients, too, is small; I can count them on my two hands. All are male, and most are there because of their dependence on alcohol. From a poster that charts the service’s functioning over the past five years, I learn that this is the norm for the ward. The men range from late adolescence to late adulthood, and come from equally varied backgrounds. I see wedding rings on a few hands, and I wonder about their families, their friends. Who comes to visit them? I’ve already learned that the patients themselves are not allowed to communicate with the outside world; one of the first things I am shown is the therapeutic contract that each patient is asked to sign upon admission (all patients on this ward are admitted to the hospital voluntarily). This list of rights and obligations indicates that each patient is to surrender all means of communication. A total of two visiting hours are scheduled for the weekends. I wonder what this restriction of contact is like for a Moroccan family – togetherness is so important here, and I get the sense that that is especially true in times of sickness. The crowds of loved ones around each hospital bed left a lasting impression on me when I visited a public hospital in Fes, a few years ago.

The average length of stay is a month, though some stay longer. When I arrive with the doctors around 9.30 every morning, the men are usually grouped together in a small courtyard off the main corridor. This is the only place where they are allowed to smoke, and all of them make eager use of this right. They lounge on benches or hang around in the doorway, chatting with one another, occasionally requesting something from a doctor or nurse. The patients don’t seem to get much of this kind of down time, however. Their days are highly structured; a weekly timetable posted on the bulletin board in the main corridor allocates every hour of every day to a particular activity. An hour of every morning is scheduled for consultations with the médecin, the doctor, and each day devotes an additional hour or two to a particular form of therapy (group discussions, during which patients discuss a theme of their own choosing, but always related to addiction and substance abuse; motivational therapy; psycho-éducation, during which awareness is created about the negative impact of substance abuse; or relaxation therapy, for instance). Afternoons and evenings promise activities of a more recreational variety, such as television, reading, ping-pong, or cards. There is time for exercise, and even for music – I have already seen the well-equipped gym and music room upstairs. It is a full schedule and indeed, it seems that the patients and staff are always either coming from one activity, or about to start another.

The doctors (and I) begin their mornings at the Clinic-wide staff meeting, where they discuss new admissions. The presentation of patients is formalized; it is formulaic and ritualistic. In contrast, on-ward communication between doctors, nurses, and patients is informal and easy. After the doctors’ arrival on the ward, the staff briefly gathers to exchange pertinent information from the past night or weekend. They meet in one of the recreational areas off the main corridor or in the nurses’ station, a round space enclosed by glass at the end of the corridor. This room is furnished with a desk and a few bookcases that hold all records, files, prescription pads, and other necessities. The station makes me think of a Foucaultian watchtower; as particular patients are discussed, I notice doctors and nurses glancing at the man in question through the glass, sometimes even pointing as they review his behavior last night.

While the Clinic-wide staff meetings are held exclusively in French, the conversation between doctors and nurses is an even mix of French and Arabic. When speaking the latter, everyone addresses one another with the familiar tu. There are jokes and laughter, and everyone speaks at once. No one wears a name tag, and only the two residents walk around in white coats. There are no pagers; just cell phones. Dr. Rachidi is warm and approachable toward everyone; while she does not hesitate to point out flaws in her residents’ approach to their prise en charge (care), her criticism is always constructive. “You’re supposed to make mistakes,” she even tells them during one particular meeting, “you’re residents, you’re here to learn, not to do everything perfectly at once.”

Both residents on this ward are female. This reflects a general Clinic-wide gender-balance: of the 22 residents being trained here, sixteen are women. Likewise, there are three women among the six professors of psychiatry that teach and practice at the Clinic. In contrast, most of the nursing staff is male. The French psychiatrist, who began a six month fellowship here during the same week that I began my observation, tells me this is common at psychiatric wards throughout the world; a big strong man is often better able to deal with aggressive patients than a woman, she explained. Nevertheless, this particular gender balance provides an interesting contrast with traditional notions of professional roles within the world of healthcare, where men are in charge as doctors, and women are nurturing nurses. It’s a contrast also with traditional Arab conceptions of masculinity and femininity – conceptions that are very much alive here in Morocco. I very much wonder what this inversion of traditional roles does to the balance of power on the Clinic’s wards – especially on a service such as this one, where the patients are so predominantly male. For patients such as Mr. Abbas, who feel so dethroned, I wonder what it’s like to be treated by a female doctor. I’m curious to see how this plays out on other wards, and it could be an interesting angle for my research.

This week, I've moved on to a different service (more ethnographic sketches to come…). Toxicomanie is not the ward where I will be doing my research. Nevertheless, I was reticent to leave – not only because I found everything about the place so interesting, or because I would like a chance to answer the questions this week has brought up. I’m also reluctant because I was finally beginning to feel a bit more comfortable with my presence there. I had become familiar with the doctors, the nurses, the patients, the languages. I was losing some of my reticence about bothering busy doctors with my questions, or disturbing a patient with an inappropriate question. I am more of a wait-and-see person than a go-get-‘em-girl, preferring the slow, subtle approach to the direct and bold one. This can work well in anthropology, but not necessarily during the set-up phase of research; I often have to push myself to be assertive and ask the questions I want an answer to.

But I’ll do as much pushing as I have to. This week has proven, I think, that it pays to be direct, to stop worrying about things like bothering people, or misunderstanding them, or worse – not being able to make myself understood. For the first two days on the service de toxicomanie, I was incredibly anxious about issues of communication. I worried that I wouldn’t understand everything; my exhaustion at the end of each day reminded me how much energy it takes me to follow a conversation in medical French or Arabic. I panicked every time I realized I’d been dozing off and had missed a crucial turn in the discussion – something that tended to happen particularly at those moments that I spent worrying. I was even more nervous not being able to make myself understood: of tripping over words or, worse, not being able to think of any. I spent those mornings’ rounds in fear that I’d be asked to explain my research, to explain why I chose Morocco. But on day three I began to realize that, despite exhaustion, I had actually been understanding enough to have a good sense of what’s going on. And later that day, I suddenly found myself in various conversations, perfectly able to describe what I was doing there, even receiving a compliment on my French. And so I moved on to the next ward, perhaps not fearlessly, but at least with a good dose of faith that maybe, just maybe, this project of mine will be doable, after all…

Monday, November 9, 2009

Things to Do in Rabat on a Saturday Night

Last Saturday night, I believe temporarily forgot that I was in Morocco.

Around seven PM, I met up with a group of NIMAR-affiliated ladies downtown. After a pleasant dinner at Le Petit Beur, a small restaurant close to the Parliament, we headed over to Théatre Mohammed V for “ABBA the Show,” a big spectacle, as the Théatre always calls it, of classic ABBA songs put on by a sizeable and very enthusiastic ABBA cover band. Complete with lighting effects, original ABBA members and 1970s costumes, the show was fabulously entertaining. The theater was packed with fans screaming and singing aloud so fervently that one would have thought the original singers were up there on stage. Had it not been for subtle references to Morocco through the lighting effects (a ‘DH’ sign lighting up on the stage backdrop amidst Euro and Dollar symbols during the song Money, Money, Money; a collection of red and green lights creating an image of the Moroccan flag at the end of the show – and sending the crowd into ecstasy), the entire ambience would have made me forget where I was.

The Théatre National Mohammed V is one of Rabat’s primary theater venues. It offers a wide variety of entertainment to the Rbati public, from plays in Moroccan dialect to Flamenco concerts and hip hop dance performances – to quote a few offers from the upcoming winter program. But those who seek to spend a soirée out on the town have more than just this theater to choose from. The various cultural institutes scattered around the city center (The German Goethe Institut, the Spanish Instituto Cervantes, and the Institut Français, for instance) each offer their own selection of music, films, and other performances around town. The result is a weekly offer of cultural activities that will certainly not leave you wanting for entertainment.

You might start your cultural evening out at one of Rabat’s many decent restaurants – in one’s choice of price range and cuisine – and end it at a swanky bar or nightclub. For contrary to what one might think about a country where alcohol is prohibited by law to 99% of the population, nightlife in Morocco’s larger cities is alive and thriving. The offer of venues runs the full gamut from dark and dingy dive bars, where the only women present are there in a professional capacity, to hip and trendy nightclubs. The latter are places to see and be seen. Dressed to the nines, groups of men and women lounge around the table they’ve reserved, making their own drinks from the bottle of alcohol they’ve purchased and the mixers – coke, sprite – they’ve been given for free. They laugh, chat, and occasionally dance – first to American hip hop, later to the techno and house that follow it. Girls wear revealing tops and skinny jeans; boys wear shiny fitted shirts and leather shoes. There is an ease of interaction between the sexes that seems to contrast with daytime social conventions.

Whenever I am out, whether it be at the theater or at a club, I cannot help but wonder about the identity of the people I see around me. Who frequents these places – from what socio-economic background do they originate? The nightclubs I have seen are a swanky affair. There seems to be an elitism to the whole experience, a suggestion of luxury; the advertisement of a certain level of wealth and a certain brand of modernity. It’s in the way people dress – the glitter, the brand names – but it’s also in the money one ostensibly spends for a night of dancing. The cover charge for Amnesia, one of Rabat’s most famous clubs, is 200 Dirhams – a small fortune, if you imagine that a large proportion of the Moroccan population lives on a salary of 1500 a month or less. Admission comes with a free drink, but any subsequent beverage runs at least 80 Dirhams.

However, my friend Hatim tells me that the real regulars never pay. The secret, he tells me, is to get to know the bouncer. To strike a deal, and get a discount. It’s not the upper classes that one will encounter at the club, he explained – those elites have their own, private, establishments. No, the trendy patrons at Amnesia are individuals just like you and me; they’ve just managed to bargain their way inside, to an evening of luxury at a discount price. Once again, the suggestion emerges that everything in Morocco is negotiable, and nothing is as simple as it seems (… but the true elite always remains out of reach).

Yet my question remains. Who, then, frequents places like Amnesia? Where do they come from, and where do they live? What kind of jobs do they hold, where do they go to school, and how does their behavior at the club fit into their daytime social roles?

When thinking about these questions I often catch myself imagining each of these nameless young individuals to be a kind of Jekyll-and-Hyde – possessors of a nighttime alter ego whose behavior is incommensurable with their daytime identity. I’m intrigued by the contrast that seems to exist between the social conventions of Moroccan society, and the vibe I encounter at these clubs. On this blog, I often write about the various ways in which ‘tradition’ is idealized and upheld by Moroccan society, and the ways in which particular interpretations of ‘modernity’ emerge and interact with old customs and conventions. I’m interested in the ways in which these two concepts seem, ostensibly, to contradict one another. And so I take note of the way in which I see girls dress and behave at Amnesia – and then contrast it with the grumpy man Fatima and I once encountered as we walked home at 3 AM, who asked my friend if her mother knew she was out so late, and then added that she must be a prostitute.

But if there is one thing I have learned about Morocco, it is that nothing is ever as simple as it seems. ‘Modernity’ and ‘tradition’ are not entities but ideas with very fluid boundaries. They are not polar opposites but rather converging and diverging ideologies about the meaning of our socio-cultural rules and conventions. We all live lives that combine elements of the modern with notions of tradition, and this need not make us Jekyll-and-Hydes, unless we ourselves allow it to. So, too, for the men and women I see at Amnesia. Because in the end, what is so strange about a girl who dances in an outfit she’d never wear to work, or a boy who purchases more alcohol than he’d ever admit to his parents? Don’t we all behave a little more freely under the cover of dimmed lighting, thumping beats, and a bit of alcohol?

Thursday, November 5, 2009

About pregnancy

Last Friday, Moroccan blogger calabamuse posted an article about the following magazine cover:

This is the November issue of Femmes du Maroc, and the cover prefaces a multi-page feature on pregnancy. Beside the article discussing this particular television personality’s impending accouchement (labor, childbirth), the magazine includes an exposé on the deplorable state of OB-GYN facilities at public hospitals and clinics, advice about how to deal with post-partum depression, a description of a cesarean section, and even a special on fashionable maternity clothes.

I picked up this issue myself last Thursday while shopping at Marjane, and was completely intrigued by the provocativeness of the cover. And indeed, this is the main theme of Calabamuse’s thought-provoking post. The writer suggests that pregnancy, like many other issues relating to sex or the reproductive system, is a phenomenon that makes Moroccan society highly uncomfortable:

The exclusionary and sometimes castigating treatment pregnant women are subjected to is a leading cause of abortion in Morocco where the number of out of wedlock pregnancies have dramatically risen. The pool of medical doctors performing abortions today has grown exponentially. They charge 3000 Dirhams ($391.00). Additionally, an increased number of women, especially in rural areas where medical oversight is minimal and sometimes non-existent, die from standard pregnancy complications.
The message of the magazine’s cover is a loud and clear confirmation of the self: I am pregnant; I am beautiful, and I exist. I agree. In our society, pregnant women need to feel less excluded and be viewed in a more gratifying fashion. For a country like Morocco, where television channels are flipped at the mere sight of a man an a woman kissing, where, in neighborhood foodstuff stores, menstrual pads are stuffed in a black plastic bag to conceal them from the embarassed looks of customers, the idea is outrageous.

Intrigued by this apparently ambiguous regard for pregnancy, I decided to ask around. I used a word that Calabamuse didn’t, and ultimately proved to be too strong a connotation: was pregnancy hshouma, shameful?

Yes, Farid told me, he did think that pregnancy is shrouded in a kind of hshouma, but I needed to be aware that there are two ways to translate this culturally powerful term. Pregnancy is not so much a source of shame, he explained, as it is a source of embarrassment. There are certain topics you simply don’t discuss with certain people, like your parents or your boss, and pregnancy is one of them. It’s a matter of respect, Farid added. As he said this, I suddenly remembered how reluctant Karima, the NIMAR’s housekeeper, had been to discuss her pregnancy in the presence of our director or any other male associate.* Exactly, Farid said. This reluctance wasn’t shame so much as it was just the maintenance of a certain kind of propriety.

A new part-time co-worker at the NIMAR, Aicha, likewise didn’t think pregnancy was seen as shameful. She did, however, remember being told to cover up her pregnant belly in looser clothing when going outside, and she recalled how surprised her parents had been to find out that she had been open about the development of her second pregnancy toward her young son. There did seem to be a kind of discomfort about open manifestations of pregnancy, she concluded. Her environment tended to explain this as a way of avoiding the evil eye.**

These stories do betray a clear sense of ambiguity with regard to the phenomenon of pregnancy. It doesn’t seem to be a source of outright, negative shame, but it certainly makes people uncomfortable. It’s the clear connection to sexual intercourse, Farid explained with slight embarrassment. Pregnancy may be the source of new life, but it is also an unconcealable confirmation of a woman’s nature as a sexual being.

And that, I think, is true for every civilization on earth. I think that pregnancy may harbor that double meaning for almost all of us, because it lies at the heart of the very conflicted way in which nearly every culture deals with human sexuality. Sex is powerful: not only because it is one of our most primal and strongest instinctual drives, but also because it is fundamental to the propagation of our species and civilization. It signifies the glory of future development, but in its sheer primal power can also lead to utter chaos and the destruction of any kind of social order. This is why nearly every civilization has sought to exercise control over its society through the strict regulation of sex.

And let’s not forget the Madonna/Whore complex that torments so many of us. We want to see women as mothers, as the innocent and morally upright nurturers who teach our future generations about right and wrong – but we also want to see women as sexual objects, as the embodiment of sexual desire. Perhaps because we are conscious of the potentially destructive power of sex, we see these two identities as polar opposites that cannot be reconciled with one another – yet they are merged, in the phenomenon of pregnancy.

And so, as curious as I think the abovementioned attitudes toward pregnancy are, I don’t think the ambiguity of it is typically Moroccan, per sé. The way in which it is expressed may be culturally specific, but I’m inclined to believe that this particular stance is one we all have in common as humans who are overwhelmed by the power of their own sexuality. I agree with Calabamuse that pregnancy must be celebrated as something beautiful – but I think a larger problem highlighted by this month’s Femmes Du Maroc is the deplorable state of OB-GYN facilities in the country’s public hospitals and clinics.*** These places suffer from a desperate lack of resources, which results in understaffing, a lack of necessary equipment, and thus a lack of adequate care. Patients are obligated to purchase and bring all necessary materials by themselves: from towels to sedatives to suturing thread, it is the patient’s responsibility to make sure these items are present, because the hospital simply does not provide. Femmes Du Maroc also describes widespread corruption: nurses and other staff provide their services only in exchange for ‘bonuses’ of a few hundred Dirhams. Public healthcare services are officially offered free of charge, but adequate care is thus ultimately received only if one has a considerable sum of Dirhams to spend.

Add to these issues the fact that in rural areas, even such public clinics are few and far between. Obstetric facilities have this in common with nearly every other kind of medical service – including that of psychiatry. Reforming the healthcare system is an important part of Morocco’s development goals, and this month’s Femmes Du Maroc also features an interview with Morocco’s minister of health, Yasmina Baddou, who speaks of everything that’s already been done and who is optimistic about further improvement. I’m hopeful, and curious to see what reforms and improvements will be implemented in Morocco’s healthcare system over the next few years.

* Two months ago, Karima gave birth to a baby boy. When I and a few other female NIMAR co-workers went to visit her and her family, she never talked about how the actual labor and birth had been. We didn’t ask, but amongst ourselves did speculate about how it had been. I remember finding this surprising. This is the kind of thing Dutch women talk about readily, but clearly not something Karima wanted to discuss.
** According to the literature, individuals in transitional phases are particularly susceptible to the gaze of the evil eye. Newborn babies, newlyweds, and pregnant women are often cited as examples. The evil eye can be seen as a kind of curse that can lead to all kinds of malaise. If caught, it can be fought off in a variety of ways, including herbal concoctions or counter-spells. A shouafa, or medium, can often help.
*** At the time of writing, Femmes Du Maroc’s website did not yet publish the article. But here is their website.

Wednesday, November 4, 2009


After a vacation of what turned out to be about five weeks, I am back in Rabat. I won’t deny that I miss home and that this kind of extended vacation was exactly what I needed, but I’m also happy to be back and excited to get started on my research. As of this past Monday, I’ve started spending my mornings at the Clinic, where I have begun a period of general observation. Until my permission from the local Moroccan ethics commission comes in, I’ll spend a week on each of the Clinic’s wards, following doctors and nurses around as they go about their work. So far, it’s been utterly amazing. I feel as though the three mornings I’ve observed so far have already provided me with enough material for twice as many blog posts, so if I can work my random observations into a coherent post, I’ll be sharing some of my experiences with you soon. In the meantime, now that my vacation is over, I hope to be back to my regular schedule of posting twice a week… I hope I still have some readers left! If so, thanks for sticking around…