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Title: Philadelphia University Faculty of Nursing


1
Philadelphia UniversityFaculty of Nursing
  • Bedouin Health Project
  • Badia Health Education Module
  • Prepared by
  • Dr. Fadia Hasna
  • Philadelphia University, Faculty of Nursing
  • Dr. Mohammad Al-Smairan
  • Jordan Badia Research and Development Centre

2
Background
  • This Bedouin Health module is one of the proposed
    interventions of the Bedouin Health Project and
    it utilizes findings of the data collected in
    Northern Badia during the years 2007-2008 which
    builds on policy makers, health providers in
    Northern Badia, alternative healers and Bedouin
    men and women interviews in the Northern Badia.
  • Aim
  • The aim of this module is to sensitize
    nursing, social work and medical students to the
    Bedouin culture and health needs in Northern
    Badia of Jordan making them more aware and
    culturally sensitive to this local populations
    health, economic and psycho-social needs it was
    found out that many clinic staff interviewed
    during our field research work had little
    knowledge about the Bedouins culture or way of
    life.

3
Chapter 1
  • The Badia of Jordan

4
Outline
  • Intended Learning Outcomes (ILOs)
  • The Badia
  • Population Change in lifestyle
  • Physical Characteristics
  • Badia Resources
  • Some Touristic Sites in the Northern East Badia
  • Strengths of the Badia

5
Intended Learning Outcomes (ILOs)
  • At the end of this unit the student will be able
    to
  • Knowledge and understanding
  • Define Badia
  • List seven important tribes in Northern Badia
  • Discuss five physical characteristics in Northern
    Badia of Jordan
  • Intellectual Skills
  • Differentiate between Asheera ????? and Hamoula
    ????? in Northern Badia
  • Relate five major strengths in the Northern Badia
    to future strategic developments
  • Explain resources of Badia and relate them to the
    opportunities for development
  • Professional and Transferable Skills
  • Communicate with Bedouin in a respectful style
    based on the challenges in the Northern Badia
    context
  • Change attitudes towards Bedouin by refuting
    misconceptions

6
The Badia
  • - Badia is a classical Arabic word used to
    describe arid to semi- arid regions of the
    middle east, where rainfall averages less than
    200mm, which today makes-up part of Jordan,
    Syria, Saudi Arabia and Iraq.
  • - In Jordan, the Badia extends from north to
    south along the eastern portion covering about
    80 of the country's total area.
  • - At present it is home to about only 5 of the
    Jordanian population.
  • - Desertification is a common fear, which
    threatens that region, causing degradation of
    resources and most painfully demographic
    displacement.
  • - Desertification and wise use of natural
    resources is a shared concern in the Middle East
    and throughout the world.

7
Population Change in lifestyle
  • The total population of the Badia represents
    about 5 of the whole population of the country.
  • Today, an estimated 5-10 of the population
    remains nomadic, traveling the area in their
    black goat hair tents called beit shaar or "hair
    tent".
  • The majority of the population is now permanently
    settled in villages.
  • The Badia is home to numerous Bedouin tribes
    whose history lays at the foundation of western
    civilization.
  • At present, the most important tribes live in
    Northern Badia are Al- Maasaeed, Bani Khalid,
    Al- Serhan, Al- Shurufat, Al- Sardyih, Al-
    Adamat, Al- Essa, Zubaid and Al- Ghiath.
  • Any one of the a above tribes composed of more
    than one Hamouleh.

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9
Physical Characteristics
  • The Badia experiences huge seasonal temperature
    fluctuations.
  • In winter, the minimum mean temperatures may drop
    to 2o-9o degrees C and snowfall and sub-zero
    temperatures may occur.
  • The summer maximum mean temperature is around 35
    -38 C. Low humidity causes high levels of
    evaporation.
  • Rainfall between December and March, with great
    differences in the intensity of showers and
    storms.
  • The region is subdivided into three main
    geographical areas, as follows 
  • -The northern Badia, comprising 26,000 km. (
    shown in green )
  • -The middle Badia, comprising 10,000 km. (
    shown in light blue )
  • -The southern Badia, comprising 38,000 km. (
    shown in white )

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11
Badia Resources
  • The Badia holds numerous and rich natural
    resources in quantities adequate for overall
    development requirements.
  • Besides the vast area available for development,
    resources include mineral deposits, surface and
    groundwater, tourism sites, sunny weather,
    renewable natural range and cultivated land
    suitable for improved agriculture and livestock
    breeding.
  • The area also has the potential for the
    development of non-pollutant renewable energy
    sources, namely, solar and wind energy.
  • As the Badia extends into the borders of
    neighboring countries, there is the additional
    benefit of its being a junction for export-import
    activities at the regional level

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  • The Badia represents a strategic depth for the
    country because it provides Jordan with 
  • - 60 of groundwater needs.
  •  
  • - 90 of rangelands.
  •  
  • - 10 of conventional energy.
  •  
  • - 70 of the red meat needs. 
  • - 24.36 of GDP

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14
Some Touristic Sites in the Northern East Badia
ASEIKHIM
  • Um Al Jimal

Qasr Burqu
JAWA
15
Strengths of the Badia
  • Northern Badia is a priority on political agenda
  • New mobile military field hospital established
    and operating
  • Hashemite fund for Badia Development
  • Jordan Badia Research and Development Centre
  • MOH High coordination amongst MOH, Military and
    local institutes
  • Existence of Network of health centers at three
    different levels across a large rural area
  • - CHC
  • - Primary health centre
  • - Village center

16
Chapter 2
  • Population Characteristics and Socio-economic
    Conditions in Northern Badia

17
Outline
  • Intended Learning Outcomes (ILOs)
  • Introduction Transition in lifestyle in the
    Badia
  • Educational Levels
  • Marital Status
  • Fertility and Mortality
  • Causes of high Mortality
  • Morbidity
  • Employment
  • - Sectors
  • - Challenges

18
Intended Learning Outcomes (ILOs)
  • At the end of this unit the student will be able
    to
  • Knowledge and understanding
  • Describe kinship relationships in the Badia and
    relate the to fertility behaviours
  • Describe four marital status characteristics in
    Northern Badia
  • Explore important Bedouin lifestyle habits
  • List common misconceptions about Bedouin
  • Identify main nutritional components of Bedouin
    diet in Northern Badia
  • List five most important health needs of the
    following Bedouin population groups women,
    children, pregnant women, older age group
  • Describe housing pattern in Northern Badia

19
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  • Intellectual Skills
  • Relate current Bedouin lifestyle challenges to
    health status of Bedouin in Northern Badia
  • Discuss how nutritional status in the Badia
    affects the health of the local population
  • Relate how male preference affects reproductive
    behavior in Northern Badia
  • State fertility, morbidity and mortality trends
    in Northern Badia
  • Explain causes of high mortality in Badia
  • Explain educational level of Bedouin and relate
    it to their lifestyle challenges
  • Identify employment challenges in Northern Badia
  • List household facilities and relate them to
    socio-economic challenges in Northern Badia
  • Professional and transferable skills
  • Communicate with Bedouin in a respectful manner
    based on an appreciation of their local context
  • Provide culturally-sensitive attitude towards
    Bedouin (stigma free)
  • Act as a health promotion advocate for the
    Bedouin population in Northern Badia

20
Introduction Transition in Lifestyle in the
Badia
  • Life in the desert has always depended on
    striking a balance between human and animal
    populations and the natural environment
  • In general, the Badia has developed and changed
    in step with the rest of the urban-based economy
  • The government has provided roads, health
    clinics, water supplies, schools and other
    services which has directly raised living
    standards in the Badia, but at the same time may
    have made an indirect contribution to the loss of
    go-ahead individuals.
  • Return flows of the earnings of migrants,
    especially those in the army and the police
    force, undoubtedly make a significant
    contribution to the support of the families
    remaining in the Badia.

21
Educational Levels
  • The level of education in the Northern Badia were
    slightly below the national average and even
    below those for the settled population in rural
    areas of Jordan,
  • A number of factors was responsible for these low
    educational levels which in turn had a bearing on
    the welfare and economic opportunities open to
    the population of the Badia,
  • - First, the Badia population being only a
    small fraction of the total population, seemed to
    have received less than their fair share of
    attention from the educational planners,
  • - A second factor related to educational levels
    and school attendance figures was that the kind
    of work available in the Badia did not require
    the kind of skills which could be obtained in
    schools

22
Marital Status
  • The Marriage was almost universal and began at an
    early age for females
  • The mean age at marriage for females around 18
    years compared to an age around 24 years for
    males (Abu Jaber and Gharaibeh)
  • Girls in the Badia married earlier than their
    counterparts elsewhere on the other parts of
    Jordan
  • In general, it seems that a more traditional
    marriage pattern prevails in the Badia with girls
    marrying early and very few remaining single
  • The marriage of widowers and of divorcees is
    easily accomplished since the bridge price for
    second marriages is lower and the marriage
    ceremonies much simpler.

23
Fertility and Mortality
  • It seems that fertility in the Badia is high,
    higher than the other parts of Jordan, where the
    total fertility rate of 7.8,
  • Plainly, fertility in the Badia is uncontrolled
    and close to a natural regime in which the
    duration of post-partum amenorrhea is the
    principle factor affecting the length of
    inter-birth intervals,
  • In Northern Badia, some direct evidence of a slow
    decline in mortality over the last twenty years,
    but the overall mortality levels are still
    slightly high by national standards.

24
Causes of high Mortality
  • The high infant mortality rate in the Badia is a
    result of several sets of factors
  • - Some of the babies in the Badia are still born
    at home especially for nomadic Bedouins
  • - The short supply of clean and reliable sources
    of water
  • - The lack of specialist health clinics and
    hospitals, especially in the remote areas
  • - Poor diet which leaves people exposed to
    infection especially during the damp cold winters

25
Morbidity
  • Low standard of sanitation and hygiene,
    malnutrition and a harsh environment go together
    to make the Bedouin prone to various classes and
    types of diseases
  • The most common of which are internal and
    respiratory diseases, such as chest conditions,
    brucella, hypertension, kidney diseases, dental
    caries and diabetes
  • Ailments such as hepatitis and dysentery are
    widely reported
  • Other intestinal afflictions such as worms of
    various types are also prevalent
  • Respiratory diseases especially inflammation of
    the eyes is even more common among children than
    among adults
  • Milk may also be a health hazard in the region.
    One of the major products consumed raw and
    unprocessed

26
Employment
  • Sectors
  • - Aside from self-employment in herding or
    farming, work opportunities in the Badia are
    indeed very scarce
  • - Government is the largest single employer
    followed by farming
  • - Government sector include Jordan army mainly,
    Ministry of education
  • - Farming sector include herding, planting
    vegetables and fruits, etc.
  • - Private sector composed a small portion of the
    employment in Northern Badia and include, trading
    in shops, livestock, land and other small business

27
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  • Challenges
  • Bedouin economy revoled around the occupation
    of camel, sheep and goat husbandry. In such an
    economy, livestock is considered the principal
    asset, hence, wealth as well as status were
    judged by the size of the animal herd.
  • The size and composition of the herd has
    recently undergone considerable changes
  • - The size of the herd has decreased
    substantially due to severe livestock losses and
    liquidation,
  • - Many Bedouin have taken to settled life in
    order to profit from the services provided in
    their habitat

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  • - Manpower shortages in the region resulting
    from adult out-migration to urban centers for
    employment has forced herd owners to reduce the
    number of animals
  • - The lack of industrial projects
  • - The lack of manpower training
  • - Drought years

29
Chapter 3
  • Determinants of Health Community Services and
    Facilities and their Impact on Badia Health

30
Outline
  • Intended Learning Outcomes (ILOs)
  • Introduction gradual settlement of the Bedouin
  • Determinants of Health
  • - Lifestyle and Behavior
  • - Environment
  • - Housing
  • - Schools
  • - Disability services
  • - Water and Electricity
  • - Household Facilities
  • - Communications
  • - Agricultural Services
  • - Diet
  • - Nutritional Status
  • - Poverty and Social Welfare

31
Intended Learning Outcomes (ILOs)
  • At the end of this unit the student will be able
    to
  • Knowledge and understanding
  • Explain five main strengths in health provision
    in the Northern Badia
  • Differentiate and explain the various services in
    Northern Badia schools, water and electricity,
    communication and agriculture
  • List the determinants of health in Northern Badia
  • Intellectual Skills
  • Relate the determinants of health to the various
    services in Northern Badia
  • Professional and transferable skills
  • Provide culturally-sensitive attitude towards
    Bedouin (stigma free)
  • Act as a health promotion advocate for the
    Bedouin population in Northern Badia

32
Introduction Gradual Settlement of the Bedouin
  • A host of factors appears responsible for Bedouin
    settlement.
  • Water is one of the most important factors
    underscoring Bedouin settlement
  • Other factor play varying role in Bedouin
    settlement is the loss of much of the herds as a
    consequence of prolonged drought
  • Availability of services such as roads,
    telecommunications, electricity, schools are
    other factors responsible for Bedouin settlement
  • Despite government efforts aimed at providing the
    Badia with basic services, the quantity and
    quality of these services are judged inadequate.

33
Determinants of Health
  • Lifestyle and Behavior
  • - Some of babies in the Badia are still born at
    home. The midwife (daya) or an elder women often
    use procedures during and after delivery (e.g.
    wrapping a new baby in a cloth sprinkled with
    dung to deceive the evil eye) which are
    inherently unhealthy
  • - A baby girl is universally less welcome than
    a boy, she gets less attention and more work even
    at an early age
  • - The boy eats with the men, but the girl and
    her mother often eat what is left of the meal
  • - Also, some of the lifestyle habits specific
    to Bedouin that increase communicable health
    disease incidence in the Northern Badia are
    Raising livestock, drinking unpasteurized milk
    and milk products, drinking from rain water in
    the ponds and some times drinking and eating from
    the same cub and the same dish

34
Environment
  • Environmental Health
  • There were a number of concerns and these
    varied according to area.
  • The ecology of the region (dust and the average
    of the temperature in summer and winter), poor
    living conditions and low living standards are
    some of the factors affecting health in the
    Northern Badia
  • There were concerns expressed about the quality
    of water, water being brackish with too much
    fluoride, and having a high dust content.
  • Sewage disposal and Solid waste management was a
    concern as in many of these encampments and
    villages.
  • there is a lack of infrastructure and this is a
    public health concern.

35
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  • Also there is a problem with the water, it only
    comes one day a week, and when it goes into the
    tanks it has rust in it. The water is polluted,
    if you come and test the water you'll find that
    it's not suitable for human consumption and
    everyone suffers from this problem (NBM2)
  • We have a lot of flies and mosquitoes and the
    percentage of chlorine and not chloral is high in
    the area. We want something to fight all this..
    Once I went to buy some bread from the bakery
    which was full of flies. The bread was full of
    flies. The MoH must inspect the bakeries (NBM4).

36
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  • When the water comes. It stays running from 10
    2 o'clock It is yellow and it has some soil with
    it. The pipe in the main line has sediments from
    the past time... This is the main thing.. The
    main point is establishing a hospital for North
    Badia. It is a very wide area and it needs a
    hospital. The second point, we need sewage
    system, because the sewage is polluting the area.
    The whole sewage system needs changing (NBM3).
  • The sewage pits in the area. We don't have a
    sewage system, instead we have sewage pits all
    over the village. When it's summer and the
    weather is hot and dry with no wind, the
    mosquitoes appear (RHCLM5).

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38
Services in the Badia
  • The distribution and quality of services in the
    Badia as of early 1976
  • Schools
  • - Everywhere you go in the Badia, you find
    schools, primary, elementary and secondary for
    boys and girls
  • - The geographic distribution is adequate, the
    quality of physical facilities and teachers is
    often not very good
  • - The educational apparatus in the Badia is far
    from satisfactory and suffers from two cases of
    problems, physical plant and staff
  • - The severe shortage of trained staff is a
    major problem. Teachers, male and female are hard
    to recruit for the Badia, especially for the
    remote areas.

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40
Disability services in North Badia
  • The disability in Northern Badia is slightly high
    because of the relatives marriage
  • The disabilities concentrated in the field of
    mental, hearing and movement disability
  • Most of these disabilities are concentrated in
    male, but may be covered disability in females
  • In Northern Badia, there is just one society that
    deals with this group of community
  • Child Caring Society is the only one that is
    found in Northern Badia at Al-Saydiya village, 25
    kilometer east of Mafraq

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42
Water and Electricity
  • The Badia draws its water supplies from
    multiplicity of sources
  • Piped water systems are found in about 95 of the
    villages
  • Groundwater are used for human uses where the
    service water resources are used for animals and
    other uses
  • These sources, however are inadequate leaving the
    water supply situation critical in most of the
    Badia
  • Since the Badia is an arid region with scarce and
    undependable water resources, most of the
    population relies on rainwater collecting schemes
    for their supplies especially for those that have
    animals.
  • In his modern day counterpart seems helpless and
    since he has practically settled down he has lost
    his traditional independence and initiative

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  • Electricity is universally available in the Badia
  • About 99 of the villages in North Badia are
    offered electricity
  • In the North Badia a single company monopolizes
    electricity generation for the whole governorate
    (Irbid Governorate Electricity Company)
  • There are some small settlement in the
    Northeastern part of the Badia near Ruwashid uses
    Renewable Energy (Photovoltaic solar energy
    systems) for electrification

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45
Housing
  • The proportion of true nomads had steadily
    declined and the proportion of tent-dwellers also
    declined,
  • Nowadays, a small figure of households were still
    to live in the hair tent (bait shaar)
  • The typical tent was rectangular in shape and
    made of black goat-hair and divided by a screen
    into two quarters, one for men and one for women
  • Like the rest of the population, the residents of
    the Badia now live in stone or concrete houses,
  • Almost all the dwellings were owner-occupied
  • House furnishing was sparse and limited to basic
    necessities, but however, a few modern pieces of
    furniture in the form of steel, bedsteads, chairs
    and tables appeared in the houses of income
    families

46
Household Facilities
  • Most of the population in the Badia have piped
    water either in their homes or at a stand-pipe,
  • As expected in a comparatively poor population,
    possession of household facilities is slightly
    restricted,
  • Electricity is widely available except in a very
    small groups of households with their own
    generators or stand-alone photovoltaic solar
    energy systems,
  • The most common domestic appliances are radio,
    TV, Refrigerator and washing machine.

47
Communications
  • Most villages in North Badia are connected to a
    main highway by a secondary road
  • These secondary roads are characteristically
    asphalted, and wide enough to accommodate a two
    motor vehicle comfortably
  • In addition, most of these villages are connected
    to each other with a road and these roads are in
    a good condition in most cases
  • Telephone services is widely available in North
    Badia, fixed or mobile, also internet services is
    available in some villages in North Badia, where
    the first IT center in Jordan was established in
    Safawi village in 2000
  • The post office is one of the most effective form
    of long-distance communication in the Badia

48
Communications
  • Picture

49
Agricultural Services
  • Agricultural Services in the Badia such as
    cooperative, savings and credit societies,
    extension and veterinarian services are not
    widely available
  • Social Welfare Services
  • - Most of the social welfare services performed
    in the Badia have been initiated by organizations
    from outside the region such as
  • Royal Court
  • Jordan Army
  • Public sector Ministry of Planning
  • Hashemite fund
  • Jordan Badia Research and Development Centre
  • NGOs Noor Al-Hussain Foundation and Jordan River
    Foundation
  • - These social services in the region have had
    a positive effective and raising the living
    standards of the Bedouin community

50
Diet
  • For the Badia population, food consumption
    patterns have changed somewhat during the past
    few decades
  • The Bedouin of the past ate less and with less
    variety
  • Their meals used to consist of milk and milk
    products, they hardly ever consumed vegetables
    and meat was limited to festive occasions
  • Now when the Bedouin took to a settled way of
    life, and especially for those who live in towns,
    vegetables are consumed
  • Today, milk and milk products like Yoghurt,
    Labneh and ghee, burghul, vegetables, bread, meat
    and sometimes fruit are consumed
  • The most important health conditions relating to
    diet among Bedouin are Anemia, stunting and
    osteoporosis among older women,

51
Nutritional Status
  • The average Bedouin calorie is to be below the
    national average
  • This situation is a reflection of the low living
    standards among the population
  • The Bedouin diet is monotonous, insufficient,
    unbalanced and seriously deficient in animal
    protein
  • For girls and women the food consumption is below
    that of the average male because of the
    prevailing traditions
  • Cultural habits relating to beliefs, attitudes
    and practices affect the nutritional status
    especially among females
  • Female early marriage and multiple pregnancies
    continue to act as a further drain on their
    health status

52
Chapter 4
  • Health Services

53
Outline
  • Intended Learning Outcomes (ILOs)
  • Health Care Systems
  • - Primary health care services
  • - Differentiate between village, primary and
    CHCenters
  • - Referral system
  • - Network and coordination among the sectors
    providing health services
  • Health Services
  • - Availability of health insurance
  • - Availability of RH
  • - Availability of dental health
  • - Availability of doctors, dentists and nurses
  • Strengths of the system

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  • Issues
  • 1- Centralisation of health care system
  • 2- Staff morale
  • 3- Views of staff on Bedouins
  • 4- Staff training needs
  • 5- Reproductive Health
  • 6- Immunizations
  • 7- Outreach Services
  • Views of Bedouin on Service Provision
  • 1- Communication
  • 2- Payment policy and emergency services
  • 3- Views of Bedouin on their situation
  • - Wasta A common barrier for providers and the
    community of Bedouin
  • - Traditional medicine

55
Intended Learning Outcomes (ILOs)
  • At the end of this unit the student will be able
    to
  • Knowledge and understanding
  • List five environmental factors affecting health
    in the Northern
  • Recall important Bedouin lifestyle habits
  • List three determinants of health affecting
    Bedouin in Northern Badia housing , poverty,
    health behaviors, occupation etc
  • List five communicable diseases found in Northern
    Badia
  • List five chronic conditions found in the
    Northern Badia Diabetes, hypertension, chest
    conditions, skin conditions etc
  • List five most common herbal remedies used in the
    Northern Badia
  • List other alternative therapies and healing
    practices in the Northern Badia
  • List five most important health challenges found
    in the Northern Badia
  • Discuss three types of health centers found in
    Northern Badia village centers, primary health
    centers, comprehensive health centers
  • Describe the most important challenges met by
    Bedouin to access health services in Northern
    Badia
  • List unmet health needs of the following Bedouin
    population groups women, children, elderly and
    pregnant women
  • Analyze ten issues in health service provision in
    Northern Badia

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  • Intellectual Skills
  • Explain how these environmental factors impact
    health
  • Relate these communicable diseases to lifestyle
    and the environment
  • Explain conditions for which these herbal
    remedies are used in Northern Badia
  • Explain the difference between comprehensive
    health center, primary and village health centers
  • Professional and transferable skills
  • Explain role of traditional healers in the
    Northern Badia
  • List most important service barriers met by
    Bedouins in the health centers
  • Propose strategic solutions to the challenges in
    service provision
  • Provide culturally-sensitive attitude towards
    Bedouin (stigma free)
  • Act as a health promotion advocate for the
    Bedouin population in Northern Badia
  • Propose strategic solutions to the challenges in
    service provision

57
Health Care Systems
  • Primary Health Care Services
  • The national system of three levels of primary
    health care clinics may not necessarily be the
    most suitable for this large rural area that is
    sparsely populated with huge distances.
  • Owing to the presence of sub-centres, there is a
    problem of expectations alongside quality of
    care.
  • The community have unrealistic expectations of
    round the clock excellent primary health care
    close to home, which is not possible to provide
    within the constraints and resources of the MoH
    budget for primary health care.

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  • Differentiate between village, primary and
    CHCenters
  • - Village center, mostly composed of two to
    three rooms and rented in the small villages,
    have a nurse and visited by doctor two to three
    times a week and opened three to four hour a day
  • - Primary Health Center, this is larger than
    the village center, good infrastructure, have the
    primary requirement like GP, lab, pharmacy,
    dental, emergency, immunization and ambulance and
    opened from eight to three evening
  • - Comprehensive Health Center, this is larger
    than the above two, good infrastructure, have the
    primary requirement like GP, lab, pharmacy,
    dental, emergency, x-ray, immunization,
    ambulances and visited by specialist doctors two
    to three times a week and opened from eight to
    three evening and twenty four hours for emergency

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62
The Main Key Indicators of the Area Population,
Comprehensive Health Centers
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  • Referral system
  • - The referral system in the health caring
    system in Northern Badia is depend on the
    available of the health center, and the distance
    between the villages
  • - in general, when the patient visit the
    village center and he have the solution of his
    problem, then he does not need to visit other
    clinic
  • - If no, the GP referral him to the nearest
    primary health center
  • - The primary health center referral the
    patient to the comprehensive health center for
    more check if the patient required that

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  • Network and coordination among the sectors
    providing health services
  • - High coordination amongst MOH, Military and
    local institutes.
  • The coordination with the private sector
    takes place through municipalities and the
    community Health Committees that are formed by
    the local community with representatives such as
    school principals, sheikhs, and chiefs
    (Mukhtars). The purpose of such committees is to
    identify and classify the health problems
    according to the priorities of local community in
    order to solve these problems. There is
    cooperation with the sport clubs and youth
    centres in the field of awareness raising, health
    education, surveys and research, and
    dissemination of information for the local
    community especially about diseases such as HIV
    and Aids (PM7).

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Health Services
  • Health services in the Badia are in the form of
    government-operated clinics
  • Availability of health insurance
  • Health insurance is one of the problems that
    confront us nowadays. Many people ask for it and
    they ask for comprehensive health insurance. The
    MOH of course aims to implement comprehensive
    health insurance and we could say that we already
    have a comprehensive health insurance because the
    MOH covers 70 of the cost and the people - even
    those who can pay- cover the rest (30) of the
    cost only (PM3).

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  • Availability of RH
  • For the pregnancies and health care, we have
    a maternity section in the health centre. The
    obstetrician checks the female clients, and gives
    them advice, vaccines and contraception. The
    contraception could be through the rhythm method,
    the pills injections or by IUDs. Pregnant women
    are checked from the beginning of pregnancy by an
    obstetrician. It is free of charge Each case has
    a file, we have midwives who weigh the pregnant
    women and monitor her during the pregnancy till
    she gives birth, These services are free of
    charge including contraception. We also have
    coils for those women who do not want children or
    for spacing between pregnancies. All these
    services are free of charge (PM5).

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  • The MoH provides postnatal care however, the
    problem is that women after delivery do not visit
    the clinic. This is a problem and we need health
    education in this area. We should teach them that
    you should not care about your health only when
    you feel you are ill. You should maintain your
    body because your body is like a machine which
    needs regular maintenance. You need immediate
    intervention to fix a problem. Sometime you need
    to do preventive care before any complications
    for example dental check ups (PM6).

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  • Availability of dental health
  • The dental medicine is available in this
    remote area other clinics which are 200 KM away
    from here like the Irbid clinic offer the same
    services (RUP6).
  • Availability of doctors, dentists and nurses
  • All things are available, Pharmacy, medical
    secretary, laboratory if there is one at the
    health centre, a dental clinic, and a medical
    clinic, etc (PM4).
  • Of course services are available until 2 pm,
    full services from nursing to MCH and delivery,
    laboratory, pharmacy, X-ray department,
    accountants, doctors and dentists. All of that is
    available.(AZCLP6 ).

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Strengths of the System
  • Availability of a database
  • We now have a database that we have created
    to capture the pattern of settlement and movement
    (PM2)
  • I think the strongest point is that we know
    Bedouins places and we can follow them. We have
    enough knowledge about their places and we have
    outreach clinics and outreach teams who go out
    and reach them (PM3).
  • Outreach activities
  • There is health education especially during
    vaccinations and outreach vaccination campaigns.
    We go out with a midwife or a nurse. We also have
    vaccination campaigns in schools, and we do
    environmental inspections at schools regarding
    the quality of drinking water. We also visit
    citizens outside the centre and give them health
    education (AZCLP1).

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Tally Sheet of Monthly Reports Used In Northern
Badia Comprehensive Health Centres
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Tally Sheet of Monthly Reports Used In Northern
Badia Comprehensive Health Centres (Cont.)
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  • National Immunization campaign
  • we have the national official programme which
    contains different kinds of vaccines against
    polio, DT (Diphtheria Tetanus), measles and the
    package of 5 vaccines (DPT H. InflHBV
    Diphtheria, Pertussis, Tetanus, Influenza and
    Hepatitis B virus). These vaccines are provided
    through a planned programme that starts from
    three months old and above.
  • We have mobile immunization teams that work
    in the field in the whole Ruwaished area. They
    move from tent to tent in encampments in the
    desert. Every year we have an immunization
    campaign against polio. The campaign continues
    for 4-5 days with two doses of polio vaccine. The
    campaigns include providing one dose of vaccine
    and another dose a month later. We do a
    comprehensive field survey and we vaccinate all
    children who are under five years of age (PM5)

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  • Availability of health insurance
  • Health insurance is one of the problems that
    confront us nowadays. Many people ask for it and
    they ask for comprehensive health insurance. The
    MOH of course aims to implement comprehensive
    health insurance and we could say that we already
    have a comprehensive health insurance because the
    MOH covers 70 of the cost and the people - even
    those who can pay- cover the rest (30) of the
    cost only (PM3).
  • Availability of dental health
  • The dental medicine is available in this
    remote area other clinics which are 200 KM away
    from here like the Irbid clinic offer the same
    services (RUP6).
  • Availability of doctors, dentists and nurses
  • All things are available, Pharmacy, medical
    secretary, laboratory if there is one at the
    health centre, a dental clinic, and a medical
    clinic, etc (PM4).
  • Of course services are available until 2 pm,
    full services from nursing to MCH and delivery,
    laboratory, pharmacy, X-ray department,
    accountants, doctors and dentists. All of that is
    available.(AZCLP6)

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  • Availability of RH
  • For the pregnancies and health care, we have
    a maternity section in the health centre. The
    obstetrician checks the female clients, and gives
    them advice, vaccines and contraception. The
    contraception could be through the rhythm method,
    the pills injections or by IUDs. Pregnant women
    are checked from the beginning of pregnancy by an
    obstetrician. It is free of charge Each case has
    a file, we have midwives who weigh the pregnant
    women and monitor her during the pregnancy till
    she gives birth, These services are free of
    charge including contraception. We also have
    coils for those women who do not want children or
    for spacing between pregnancies. All these
    services are free of charge (PM5).
  • The MoH provides postnatal care however,
    the problem is that women after delivery do not
    visit the clinic. This is a problem and we need
    health education in this area. We should teach
    them that you should not care about your health
    only when you feel you are ill. You should
    maintain your body because your body is like a
    machine which needs regular maintenance. You need
    immediate intervention to fix a problem. Sometime
    you need to do preventive care before any
    complications for example dental check ups (PM6).

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Issues
  • 1- Centralisation of health care system
  • Whilst it is strength for training staff, and
    providing national care, local directors are
    limited in their ability to act
  • "We dont buy anything directly. We do not
    have the authority to spend.
  • There is central control (PM8)
  • Within the MOH there is no decentralization.
    The Director in the health directorate does not
    have the power to decide on expenditure or on
    appointing staff.. We do not deal with financial
    resources as we do not have the authority. We
    have something called financial income (that is
    the budget we are allocated). As a directorate we
    have shortages in equipment and supplies of
    medicines and technical staff. But the Director
    has no power to control it . There is shortage in
    the supply of almost 200 medicines (PM8).

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  • We face problems in remote areas such as Azraq.
    The ministry is centralized in its structure and
    organization and provides the staff. If there was
    decentralization, the work in the health centers
    would be better, and administratively there would
    be more delegated power of decision making in the
    areas of finance, administration and appointing
    staff. There would be no problems. Currently when
    the director faces problems, these are referred
    to the central offices of the Ministry (PM8).
  • For example if there are maintenance problems
    which requiring financial expenditure, we have a
    problem of purchasing if there is technical or
    electrical defect, and similarly if we need to
    fix machines, equipment and vehicles. This is
    centralization and is not within the authority of
    the director. It would be better if there was
    more decentralization. There was a study done on
    this. They gave two hospitals some kind of
    decentralized powers and they were well
    administered. The project is over"(PM8).

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  • 2- Staff morale
  • Staff feel isolated and often are living far
    away from their families, working long hours with
    little time off and feel not valued and
    underpaid.
  • no extra fuel allowances and few incentives for
    working in these areas.
  • The accommodation is often of poor quality.
  • Rural Population very doctor focused and lack of
    awareness to what nurses can provide.
  • Qualified doctors are reluctant to serve in rural
    areas.

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  • Other challenges are pertinent to the best use of
    the resources some times we face some problem
    such as the brain drain. For instance, if we have
    a vacancy for a physician to serve in an urban
    area, 30 doctors might apply, but if we say that
    the vacancy is in Ma'an 10 doctors might apply
    only for in reality none of them will accept to
    go there. There are qualified people in Amman but
    they refuse to serve in the rural areas (PM3).
  • We have a kitchen but it is empty. The staffs
    after 24 hours of work have to cook for
    themselves. There should be meals for the staff
    that are on duty (NBCLP3).
  • I wish they would let me go home at 8 o'clock
    instead of 10 o'clock, I asked for that but they
    refused. I work 30 or 32 hours but they don't
    care about our suffering (NBCLP12).

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  • 3- Views of staff on Bedouins
  • Many staff interviewed had little knowledge about
    the Bedouins culture or way of life
  • The majority of Bedouins live in the desert.
    This type of Bedouin is not interested in
    education, health or drinking water. His sole
    object is to stay with his herd, buy, sell and
    trade. So, if you ask him to bring his child to
    school, he might ask his child to drop out from
    school and work as a shepherd. It does not matter
    for him if water is clean or unclean. He will
    draw water from wherever he found water in the
    desert to irrigate his sheep and himself. He does
    not care about other things, he does not care
    about having health awareness, or social
    awareness, watching TV and seeing the world or
    civilization. He will be away from the wider the
    world without water or electricity or anything as
    long as he keeps staying in the desert. He
    depends on the resources which exist in the land
    around him. If he finds pasture he will bring his
    herd to graze. If he finds water he will collect
    it with his vehicle and drink it. (PM5)

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  • 4- Staff training needs
  • Staff are not from the area and lack knowledge
    about the local population.
  • Lack of Bedouin staff.
  • Lack of communication skills.
  • Staff would like more pre and in- service
    training.
  • They should do more courses for us. They
    should teach us more and give us training, so
    that we become stronger in our field and provide
    people with better services. (AZCLP4)
  • The department is equipped but it needs
    medical staff. We have a lack of medical staff
    here, especially nurses. Unfortunately all the
    appointments here in the centre are people who
    have a lack of experience. I mean they graduate
    from college or university and then they directly
    start working here in Ruwaished. So what we have
    here is a lack of practical experience ( RUP4)

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  • The MoH do not pay attention to the Badia.
    For example they don't do courses and workshops
    here. During the last year and a half I haven't
    seen the MoH do any course to remind us of the
    things that we studied. They honestly don't do
    anything like that at all. (NBCLP3)
  • My recommendations are to enhance the health
    services in the area and provide pre-service
    training for the staff in the art of
    communication with people NBCLP7.
  • We should organize training courses for staff
    even in the field of culture, education,
    awareness raising, updating, etc. . We have some
    courses but they are limited and we do not
    participate because our MoH does not participate
    and rejects covering any financial fees. We need
    continuous education and awareness. .The
    equipment is available but becomes out of service
    because the staff are not trained to use them
    (NBCLP6).

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  • 5- Reproductive Health
  • Postnatal services are not systematic or regular.
  • Family planning services are varying from area to
    another.
  • Family planning in relation to Intra-uterine
    devices are not always available owing to staff
    not being trained to insert them.
  • There is a need for more female staff.
  • They are in a hurry. Most women dont wait
    five minutes only when they come for
    immunization. They ask me to queue them because
    they have children at home waiting. Sometimes
    they dont come and they send their mums, their
    sisters or their aunts. The habits and the
    customs also play a role in this matter. It is
    difficult for women to come out of their houses
    before 40 days of delivery (SSP4).
  • They come for immunization or for family
    planning. These things are more important to them
    than the puerperium period (SSP4)

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  • 6- Immunizations
  • Immunization services are available at the
    clinics and through outreach with regular
    campaigns but sometimes they are unable to reach
    all of children of families that are nomadic or
    semi-nomadic to ensure complete coverage.
  • The Bedouins are more distant than us from
    civilization. We have to take the information to
    them. The last time we did a vaccination campaign
    we were searching for them because they wouldn't
    receive us. We would tell them that the
    vaccination is good for you and immunizes you
    from diseases. They would say no either because
    they were afraid or because they were far from
    civilization. That is what we face (AZCLP4).
  • In Azraq the citizens hear that there is a
    vaccination campaign and it's not even for them,
    but they come to get vaccinated although the
    campaign isn't for them. Since they are near in
    this area they come. As for the tents that are
    30-40 km, if we can reach them, we vaccinate
    them, but if we don't reach them and the
    information about the campaign didn't reach them
    they don't get vaccinated in our last
    immunization campaign three weeks ago people ran
    off and refused to be immunized (AZCLP3).

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  • 7- Outreach Services
  • Outreach faces a plethora of obstacles such as
  • Lack of awareness among Bedouin that drives some
    of them to escape the immunization campaigns
  • The coverage of outreach is not comprehensive due
    to staff, facilities and equipment shortages
  • Mobility of Bedouins disturbs the comprehensive
    coverage of immunization.
  • Mobile clinics are not cost- effective
  • "They are more distant than us from civilization.
    We have to take the information to them. The last
    time we did a vaccination campaign we were
    searching for them because they wouldn't receive
    us. We would tell them that the vaccination is
    good for you and immunizes you from diseases.
    They would say no either because they were afraid
    or because they were far from civilization. That
    is what we face." (AZCLP4).

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  • There are a lot of mobile Bedouins here, they
    live in an area and then they move to another
    one. We even found this problem in schools some
    students repeat the same classes because of the
    absence. They live here for a year and next year
    they decide to live in another place. This is the
    problem we face with vaccination, its hard to
    know 100 (RUP1).
  • We thought a lot about the provision of
    mobile clinics and sometimes with help from the
    private sector we make a mobile clinic for eye
    examinations or for other things. But this is
    not easy and it costs a lot without any profit.
    We think that these clinics cost a lot of money
    however the number of people who are served is
    little. We study both sides of this issue (PM3).

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Views of Bedouin on Service Provision
  • Communication
  • The attitudes of some staff as well as their lack
    of knowledge about Bedouins impairs the quality
    of care owing to poor communication.
  • The lack of understanding of primary health care
    amongst the community also means that their
    demands may be unreasonable and their use of the
    health care system not optimal.
  • The nurses' treatment of people is very bad.
    They don't treat us kindly, and honestly there
    aren't any services. So I prefer to borrow money
    from someone to go to a private doctor rather
    than go to the health centre..They don't treat
    us well. We complained to the district chief, but
    everything stayed the same. Nobody listens. Where
    are we supposed to go?!(AZW3).

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  • The treatment in Mafraq hospital is not good
    at all. I will never go there for delivery if I
    am pregnant now. I decided not to have more
    children after my last delivery in Mafraq
    hospital. They sent me home the next day of
    delivery at midnight. They did not look after
    patients properly. In delivery, you become sick,
    fed up, and you are bleeding but they do not care
    about you!
  • The Refa'eat Health centre is pointless. I
    had fights with the GP and the pharmacist who
    works there. I always tell them that we come at
    600 am and keep on waiting till 1100 AM and
    the doctor doesn't arrive (MACLW8).
  • There isn't an otolaryngologist at the
    centre, or a cardiologist, or an ophthalmologist,
    or dermatologist. Also we don't have a female
    gynaecologist here. We have a male gynaecologist
    but you know it's a sensitive issue to people
    here. I complained more than one time about it,
    but they told me that no female doctor would come
    and work here. I do not understand why can't she
    come here?! If she is an employed and accepted
    the job that she has to be committed to, the
    government can make her go to the end of the
    world. We used to have a female doctor here in
    the end they transferred her (RUM3)

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  • Payment policy and emergency services
  • Bedouin who move seasonally and then attend a
    clinic other than where they are registered are
    charged an additional fee. This is deterrent to
    completing immunizations.
  • Attending the clinics in the afternoon is
    sometimes necessary owing to an emergency or to
    transport only being available in the afternoon.
    Fees are charged.
  • When drugs are not available, people are referred
    to private pharmacies.
  • Fees are higher if people are not insured and
    this excludes those who are more marginal.
  • Another problem is that although there is a
    decision to cure who are less than six years old
    free of charge, they still ask us to pay for
    those who are under six. They ask us to pay even
    if they are 10 tablets of Aspirin (AZM1).

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  • They use another manoeuvre they ask us to
    pay 25p for the drug, but the drug is nothing, it
    is just two suppositories or some tablets of
    Revanin (painkiller) and they register them. ..I
    have Asthma but I do not have insurance. I have
    only the white card. I havent got insurance
    although I am unemployed and I have got asthma. I
    buy the inhaler from outside. When I go to the
    centre they ask me for a fee. I am sick and
    unemployed. I have asthma and I want inhaler but
    they refuse to prescribe medicine for me (AZM4).
  • The first problem with the Health Centre is
    related to fee. They charge us more after working
    hours. They have two different rates one for the
    working hours and the other for the afternoon.
    Not only the fee but also the medicine becomes
    more expensive, almost like the regular prices
    outside the center's pharmacy. As a consequence,
    some patients prefer to delay their visit to the
    next day, and visit the centre in working hours
    to avoid paying extra fee (NBM2).

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Views of Bedouin on their situation
  • Bedouin felt that their community is neglected.
  • There were some issues in particular in Azraq at
    the clinic owing to the mixed population of the
    town and the clinic staff being solely Druze.
  • They dont care about Bedouins in the eastern
    parts of the country. We feel we havent got
    anything (MACLW7).
  • There is a lot of neglect at the health
    centre in Ruba'a (SSW5).
  • The GP just asks you and writes the
    prescription which is mostly pain killers or
    aspirin or whatever is available. He tells you
    "this is what I have here". There is no test or
    check. We are disconnected and isolated here
    (SAM5)

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Wasta A common barrier for providers and the
community of Bedouin
  • The exchange of favours is part of the wider
    society and can be both a facilitator or a
    barrier to accessing health care. This can exert
    pressure on staff when faced with requests as
    well as result in resentment amongst patients.
  • Yes he does but he is under pressure. If we
    want to change the arrangement, hundred Wasta
    will come to convince us that the drivers are
    poor and they want to earn their bread and their
    work is so tiring, so it is not easy to change
    it.
  • Wasta makes trouble for us. It do you mean
    include? embraced the director of the centre and
    the GP ( SSP6)
  • Wasta plays a role, because some patients
    who make trouble have relatives inside the centre
    and in order to keep good relations with your
    colleagues, you have to be tolerant (SSP1).
  • Regarding the children and like I said before
    any transfer, we have to take an appointment. If
    you have a Wasta they might give you an
    appointment after a week in the external clinics.
    I mean when I went for the first time they told
    me 12 days or maybe a week (MACLM2)

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Traditional medicine
  • Most common herbal remedies used in Northern
    Badia are chamomile, thyme, sage, ??? sheeh,
    Jaadat el subian???? ???????
  • Most of these herbal remedies used for stomach
    cramps, nausea and common cold
  • In the Northern Badia there are other alternative
    therapies and healing practices such as using
    cautery ???? for therapy, visiting the graves for
    therapy ????? ?????? and taking some soil and
    mixing it with olive oil and painting the skin
  • In the past the role of the traditional healers
    in the Northern Badia was important, especially
    for born the babies
  • Today, as the health care is widely available,
    the role of the traditional healers dramatically
    decreased in the Badia

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  • The most common diseases are the diseases related
    to children, for example the disease that doctors
    call measles, we call it "Fushit Dam", and we
    give the child "sheep Magher" which is the
    colouring on the sheep's back like red soil. We
    mix it with water and give it to the child to
    drink, and then we dress the child with a red
    dress, and with God's help he cures the next day
    (AZAH1).
  • We have a proverb which is "give a child Marmaka
    and Anzout (herbs) and through him away". It
    means when the child drink from these herbs he
    will be recovered. We used to spread the child
    body with Marwaha (herbs) if he has sun stroke
    and ask him to sleep until he sweat. Then he will
    become fine. We use Marmaka for diarrhoea
    (AZAH1).
  • I order the things from herb seller. They are
    expensive, for instance, if a mother became
    pregnant while she is breastfeeding a previous
    child, her child will suffer from severe
    diarrhoea. In this case we give the child a mix
    of honey and (Biradeh) which is prepared by the
    herb seller. Another example, we cauterise the
    woman who has repeated miscarriages, and give her
    Ja'edeh and another herb. We boil the mix and ask
    her to drink it (SAAH2).

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  • I buy the stuff I need from a herb seller in
    Mafraq. After I buy them I grind the ingredients
    and bring some incense and ember, I then put the
    stuff on the ember. After that I bring some
    Za'ut, put some incense with it, and if a person
    is vomiting or has diarrhoea and you gave it to
    him, they become better immediately (NBAH3).
  • For Ukht IlA'iel, it's when the child stops
    eating, vomits and has diarrhoea. He eats food
    and after that he collapses, it's like he gets
    poisoned, and the child also suffers from stomach
    aches (NBAH4).
  • After the hospital opened I stopped delivering
    babies. They bring children to me as to treat
    them. Dr.A (a doctor who used to work in the
    hospital) used to send women to me to treat their
    children. Doctors have science, while we Dayahs
    have life experience. I used to go with my mother
    and see how women give birth. I helped women
    deliver their babies two times on my own, one of
    those times a woman gave birth to twins (RUAH5).

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Use of Traditional Medicine and Herbs among
BEDOUIN
  • Measles Fushit Dam
  • The most common diseases are the diseases related
    to children, for example the disease that doctors
    call measles, we call it "Fushit Dam", and we
    give the child "sheep Magher" which is the
    colouring on the sheep's back like red soil. We
    mix it with water and give it to the child to
    drink, and then we dress the child with a red
    dress, and with God's help he cures the next day
    (AH1)
  • Khaitahred spots like ant bites on chest and back
  • Rx sheep Magher and dressing child in red
  • RXWe give him herbs (White shohout, Red shohout
    , White Titwanah, Alhasan Alyousef, Kaset
    Aloukht, egg).
  • Also a child might come with Khaitah which is red
    spots like ant bites on his chest and back. We
    give him herbs (White shohout, Red shohout ,
    White Titwanah, Alhasan Alyousef, Kaset Aloukht,
    egg). We mix them, and cook them, and then spread
    them on the child's body, we also give the child
    a little bit of coffee to drink, and after that,
    and with God's help, he becomes better. (AH1)

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Traditional Medicine (continued)
  • Diarrhea
  • For Ukht IlA'iel, it's when the child stops
    eating, vomits and has diarrhoea. He eats food
    and after that he collapses, it's like he gets
    poisoned, and the child also suffers from stomach
    aches.(AH4)
  • Post Delivery
  • Frequent miscarriages
  • Marmaka, Biradeh, Anbar Zaut
  • We have a proverb which is "give a child Marmaka
    and Anzout (herbs) and through him away". It
    means when the child drink from these herbs he
    will be recovered. We used to spread the child
    body with Marwaha (herbs) if he has sun stroke
    and ask him to sleep until he sweat. Then he will
    become fine. We use Marmaka for diarrhoea. (AH1)
  • Yes, Qasumeh, Shihah, Ja'det Alsubyan, Chamomile,
    Za'tar I get all these things from the wild.(AH4)
  • In this case we g
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