In the Land of Invisible Women

A Female Doctor's Journey in the Saudi Kingdom
By Qanta A. Ahmed

Sourcebooks, Inc.

Copyright © 2008 Qanta Ahmed
All right reserved.

ISBN: 978-1-4022-1087-7

Chapter One

The Bedouin Bedside

Seeking respite from the intensity of medicine, I trained my eye on the world without. Already, the midmorning heat rippled with fury, as sprinklers scattered wet jewels onto sunburned grass. Fluttering petals waved in the Shamaal wind, strongest this time of day.

In a pool of shade cast by a hedge, a laborer sought shelter from the sun. An awkward bundle of desiccated limbs, the Bengali lunched from a tiffin. His shemagh cloth was piled into a sodden turban, meager relief from the high heat. Beyond, a hundred-thousand-dollar Benz growled, tearing up a dust storm in its steely wake. Behind my mask, I smiled at my reflection. Suspended between plate glass, a woman in a white coat gazed back. Externally, I was unchanged from the doctor I had been in New York City, yet now everything was different.

I returned to Khalaa al-Otaibi, my first patient in the Kingdom. She was a Bedouin Saudi well into her seventies, though no one could be sure of her age (female births were not certified in Saudi Arabia when she had been born). She was on a respirator for a pneumonia which had been slow to resolve. Comatose, she was oblivious to my studying gaze. A colleague prepared her for the placement of a central line (a major intravenous line into a deep vein).

Her torso was uncovered in preparation. Another physician sterilized the berry-brown skin with swathes of iodine. A mundane procedure I had performed countless times, in Saudi Arabia it made for a startling scene. I looked up from the sterilized field which was quickly submerging the Bedouin body under a disposable sea of blue. Her face remained enshrouded in a black scarf, as if she was out in a market scurrying through a crowd of loitering men. I was astounded.

The scraggy veil concealed her every feature. From the midst of a black nylon well sinking into an edentulous mouth, plastic tubes snaked up and away from her purdah (the Islamic custom of concealing female beauty). One tube connected her ventilator securely into her lungs, and the other delivered feed to her belly. Now and again, the veil-and-tubing ensemble shuddered, sometimes with a sigh, sometimes with a cough. Each rasp reminded me that underneath this mask was a critically ill patient. Through the black nylon I could just discern protective eye patches placed over her closed eyelids. Gently, the nurse lifted the corner of the veil to allow the physician to finish cleansing. In my fascination, I had forgotten all about the procedure.

From the depths of this black nylon limpness, a larger corrugated plastic tube emerged, the main ventilator circuit. It snaked her breaths away, swishing, swinging, with each machine-made respiration. Without a face at the end of the airway, the tubing disappeared into a void, as though ventilating a veil and not a woman. Even when critically ill, I learned, hiding her face was of paramount importance. I watched, entranced at the clash of technology and religion, my religion, some version of my religion. I heard an agitated rustling from close by.

Behind the curtain, a family member hovered, the dutiful son. Intermittently, he peered in at us. He was obviously worrying, I decided, as I watched his slim brown fingers rapidly manipulating a rosary. He was probably concerned about the insertion of the central line, I thought, just like any other caring relative.

Every now and again, he burst into vigorous rapid Arabic, instructing the nurse. I wondered what he was asking about. Everything was going smoothly; in fact, soon the jugular would be cannulated. We were almost finished. What could be troubling him?

Through my dullness, eventually, I noticed a clue. Each time the physician's sleeve touched the patient's veil, and the veil slipped, the son burst out in a flurry of anxiety. Perhaps all of nineteen, the son was demanding the nurse cover the patient's face, all the while painfully averting his uninitiated gaze away from his mother's fully exposed torso, revealing possibly the first breasts he may have seen.

Each staccato command was accompanied by the soggy mumblings of Arabic emerging from behind the physician's mask, asking the nurse to follow suit and fix the veil. The physician sounded unconcerned, yet the son was suspended in an agonizing web of discomfort. He paced in anxiety about his mother's health, anxiety about her dignity, and anxiety about her responsibilities to God. The critically ill, veiled face and her bared breasts, pendulous with age, posed an incredible sight. I was as bewildered as the Saudi son.

I gazed at the patient, completely exposed, except for her veiled face, and her fragile son supervising (why not a daughter, I thought). The veiling, even when her face slept, deeply comatose from sedation, was disturbing. Surely God would not require such extreme lengths to conceal her features from her doctors who needed to inspect her body? Did an unconscious sickly Muslim have the same responsibilities as a conscious, able-bodied one? Although a Muslim woman myself, I had never faced such questions before. My debate was internal and solitary; those around me were quite clear of their obligations. The patient was a woman and needed to be veiled. The physician was instructing the Filipina nurse throughout to comply with the son's concerns. The Filipina was obviously inured to the whole spectacle. The son knew his duties to his mother. Only I remained locked in confusion.

I studied her more closely, trying to understand more. Thin arms lay flaccid at the side of her supine body, palms upwards, pools of lax flesh puddling under feeble triceps. She seemed very short, perhaps four and a half feet tall at most. On each palm, in the center, I could see bluish stigmata. These were the dark, circular marks of tribal tattoos. The nurse removed the veil to attend to the airway, suctioning out the frothing saliva which had collected in the last half hour.

Now that the limp black nylon was lifted, I could finally see Mrs. al-Otaibi. Her weathered, leathery face was in pain. Congealed tears streaked from under the taped eyelids. I called to the nurse for some pain relief, following the silent tears as they wound to her receding jaw. They pooled into deep wells in a face made ancient by sun-lashed desert winds. Proud cheek bones climbed high above hollows where her teeth should have been. Her chin met in a defiant point, conferring a determined, dour look. I wondered what she was like when awake.

Her facial markings belied a woman of status. Now I could see complicated blue tattoos in cross-like formation. They centered on the exact middle of her cheeks, much like marks delineating fields of radiation in a cancer patient, but bigger. She had similar marks on her brow, centrally placed above her balding eyebrows, perfectly symmetrical. All this painful decoration only to remain concealed behind a veil? Wondering what the marks could mean, I asked my Arab colleagues. She turned out to be a senior elder in her tribe, the tattoos on her face defining her rank, they explained, already bored by my curiosity. Obviously, they had seen many such tattooed Bedouin women. To them there was nothing remarkable about Mrs. al-Otaibi.

Small brown hands were clenched in a sleeping fist. I unpeeled them and looked at the stubby, anemic, orange-tipped nails. This color I knew to be henna. I looked at my own hands grasping hers, my glossy, noired nails contrasting against her orange manicure. Mine were Western, hers Eastern, so different but both seeking the same folly: to change the color of our nails.

I smiled in silence at the first similarity I could draw between us. Saudi Bedouin women would wear this cosmetic coloring often, placing a viscid blob of the dark green henna in the palm of their hand and then holding it tight in a fist, burying the tips of their nails into the pool of thick dye. The women would often sleep like this, securing their hands with string, to wake later with orange-tipped fingernails. This is what Mrs. al-Otaibi must have done, some weeks earlier, when she had been well. I looked up at her straggly, sweaty hair and saw the streaks of henna there too, slowly losing the battle against a burgeoning mass of white roots.

On her rotund belly, several inexplicable scars, small, puckered, and paler than the surrounding skin, peppered the surface. They were evenly distributed over the right upper quadrant of her abdomen. They were in the wrong place for laparoscopic surgery but I knew of no other tool that left such marks. I looked up at my colleague, puzzled.

"She went to the shaman, the Bedou healer. They all do that. We often see these marks on our liver patients." He went on, "The shaman uses a branding iron to treat pain which the patient probably had months ago."

Later I would observe that many patients carried these same marks, often seeking relief from the pain of enlarging, inflamed livers. Hepatitis is common in Saudi Arabia and indeed my new workplace, the King Fahad National Guard Hospital in Riyadh, was a center of excellence for treating liver disease. There we saw hundreds of patients with liver failure. The poorer patients had avoided the many public health centers in the Kingdom, instead choosing traditional healers; by the time they came to us, their diseases were often too advanced.

So, in the midst of the familiar, shiny, high-tech intensive care environment in which I was so at home, I encountered the unfamiliar. I was deeply perplexed by the active ancient practices which this woman's body disclosed. Even more disturbing, what role did shaman and other pagan healers have in a world which subscribed to Islam, a religion which enshrines the advancement of knowledge?

I wondered about the lengths to which the son continued to veil his mother, even when she was gravely ill. Couldn't he see it was the least important thing for her now at this time, when her life could ebb away at any point? Didn't he know God was merciful, tolerant, and understanding, and would never quibble over the wearing of a veil in such circumstances or, I doubted, any circumstances?

Somehow I assumed the veil was mandated by the son, but perhaps I was wrong about that too. Already, I was finding myself wildly ignorant in this country. Perhaps the patient herself would be furious if her modesty was unveiled when she was powerless to resist. Nothing was clear to me other than veiling was essential, inescapable, even for a dying woman. This was the way of the new world in which I was now confined. For now, and the next two years, I would see many things I couldn't understand. Even though I was a Muslim, here I found myself a stranger in the Kingdom.


Excerpted from In the Land of Invisible Womenby Qanta A. Ahmed Copyright © 2008 by Qanta Ahmed. Excerpted by permission.
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