NAJAF, Iraq – The doctor paused before knocking on the front gate, gesturing to his companions who wore protective clothing, masks, glasses and gloves to step back, so that they were not the first thing the occupants of the house saw.
"This is very sensitive, very difficult for our society," said Dr. Wissam Cona, who works with the Department of Health in the city of Najaf, in southern Iraq. He now spends his days checking families who have recently returned from Iran, which has suffered one of the world's most severe coronavirus outbreaks.
He said the father of the family in this house had begged him not to go with an entourage of health workers, saying, "Please don't park in front of our house. I feel ashamed in front of the neighbors. This is so difficult for my reputation. & # 39; "
For Iraq, one of the biggest obstacles for public health officials fighting coronavirus is the stigma associated with disease and quarantine. It is so profound that people avoid getting tested, prevent family members who want to have tests, and delay seeking medical help until they are catastrophically ill.
Aversion to quarantine and reluctance to admit illnesses may help explain why the number of confirmed cases in Iraq is relatively low, several Iraqi doctors said. A country of more than 38 million people, Iraq registered only 1,352 confirmed cases of Covid-19 on Monday.
On the other hand, in neighboring Iran, with almost twice the population of Iraq, the official count exceeds 71,000. Neighboring Saudi Arabia, which has a smaller population than Iraq, has more than three times the number of confirmed cases.
"It is true that we have hidden cases, and this is because people do not want to present themselves and are afraid of quarantine and isolation," said Dr. Hazim al-Jumaili, deputy health minister who is guiding the country's response to coronavirus.
The stigma associated with disease and quarantine in Iraq and some other countries in the Middle East largely reflects cultural and religious beliefs. But it also involves a deep-seated mistrust of the government, historical experience and the fear that, given the irregular state of Iraq's health system, going to the hospital could be fatal.
A recent video that was widely shared showed women patients quarantined in a hospital in Basra, next to each other without masks, coughing and asking for help when one of them died.
"Some believe that the virus means that God is unhappy with them, or perhaps it is a punishment for a sin, so that they do not want others to see that they are sick," said Dr. Emad Abdul Razzak, consultant psychiatrist at Iraq & # 39; s Health. Ministry.
"For many people, it is a pity that a woman says she has this disease or any other disease, even cancer or mental illness, and many people do not trust the health care system," he said.
So strong is the stigma and aura of sinfulness that surround the virus that the families of those who died from other causes are opposed to the bodies of their loved ones, being in the same morgue or cemetery as those who died of the virus.
Unlike many Western countries, where celebrities recognized the disease, and even neighboring Iran, where high-ranking political figures announced they were sick with the virus, there is only one example in Iraq of a politician or prominent figure who admitted to being infected .
Part of the fear surrounding the disease stems from the Muslim rituals surrounding death, said Sherine Hamdy, a professor of medical anthropology at the University of California at Irvine, who has worked extensively in communities in the Middle East.
"You don't want to be forced into quarantine, you don't want to be forced into the hospital because these social and family ties are so strong," she said. “You want to die within the family.
"The worst thing in the world is not dying, but dying away from your family and community and having no control over what happens to your body."
Islamic tradition requires a quick burial, preferably within 24 hours of death. The longer the delay, the more people fear for the deceased's soul.
In addition to the problems, there is a tradition of washing the bodies of people who have just died, which the authorities fear may spread the virus.
"Coronavirus and pandemics in general cause disruptions in social and religious practices, and it is not easy to tell people that the coronavirus is stronger than God," said Omar Dewachi, professor of medical anthropology at Rutgers University, who was born and raised in Iraq.
The quarantine of those infected imposes a double humiliation on many Iraqi communities. First, it ensures that everyone in the neighborhood learns about the disease. Second, if the victim is an adult man, it means that he is no longer able to protect his wife, children or in the case of an older brother, his younger brothers and therefore has not fulfilled his role in the family. .
Sometimes, more traditional families deny their relatives a coronavirus test for fear that if she is positive, she will be removed from her family's stronghold and possibly be sexually compromised.
"In this society, it is not certain that a woman will leave the family," said Mona al-Khafaji, a radiologist in a private practice in Baghdad.
She mentioned the case of a 32-year-old patient with fibrosis, who increases her vulnerability to coronavirus, who was having trouble breathing. Dr. Al-Khafaji recommended that the woman take the Covid-19 test, but her father and brothers said no, and refused to move, even when her condition worsened.
Iraq is not the only country in the Middle East that is fighting the stigma surrounding the virus.
Egyptians' aversion to quarantines dates back to at least the beginning of the 20th century, when cholera and tuberculosis took turns devastating the country. Some who were quarantined did not survive.
Similar fears have arisen in Afghanistan, where people have attacked health workers and left hospital windows to escape quarantine. One day last month, nearly 40 patients attacked health workers at a hospital in Herat province and escaped quarantine there.
Lately, in an effort to overcome stigma and build an accurate picture of the scope of the epidemic, Iraq's Ministry of Health has resorted to random tests. But this program brought a new set of problems.
On the one hand, some healthy people can be falsely stigmatized. And to show its determination, the government has appointed armed national security personnel to accompany health professionals. Given Iraq's violent past, the presence of security forces is so unnerving that it makes some people hide in their homes.
"It is so difficult in this culture because everything we do is a problem," said Mohammed Waheeb, a senior pulmonologist at Baghdad Medical City. "If we send an ambulance to pick up the patient, people will be upset because the neighbors will see them."
"The same is true or worse if we send national security," he added. "So people think it's like Saddam," he said, referring to former Iraqi president Saddam Hussein.
The Ministry of Health says that the use of security personnel is the only way to overcome the difficulties of convincing people to undergo quarantine. Doctors, however, say the security details are unnecessarily discouraging, at least when health workers are just collecting samples.
The second day of randomized tests in the city of Sadr, a sprawling and impoverished neighborhood in eastern Baghdad, illustrated the recurring problems. In this part of the capital, houses are assembled with corrugated pieces of metal and brick, with garbage scattered on the streets that are generally not paved.
An old woman, wearing a long black abaya, opened the corrugated metal gate a crack and looked up at the bright midday sun to see who had knocked. Looking out onto the street, he saw more than 40 people – in surgical gowns, masks or full suits, accompanied by two or three television cameras, community police, young militiamen from the organization of nationalist cleric Moqtada al-Sadr and a few local sheiks.
She slammed the gate closed.
People in the city of Sadr are skeptical of the Ministry of Health, said Bassim Aboud, who oversees the ministry area, as he knocked futilely on the woman's gate.
"If people think I am in the government, they will close the door," he said. “But if they see me as a doctor, they seek help. "
Mujib Mashal contributed from Kabul, Afghanistan, and Falih Hassan, from Baghdad.