The following piece is taken from Avoir et Sexe dans une Bureaucratie moderne : la relation entre le personnel paramedical et les usagers illettres du service de sante publique comme un champ de lutte de classes, Fatima Mernissi, Rabat, Morocco (1977). Mimeograph, contribution to a special number of the North African Directory. It is translated from the French original by ISIS.

There are two major reasons why women have become predominant as users of health care services. One is due to the growing importance of the notion of prevention within the State health policy, the other is a socio-cultural phenomenon due to changes which have affected the family structure in Morocco.

1. Factors due to a preventive health policy

Preventive health care has by definition to go beyond the narrow walls of medical bureaucracy because it has to deal with the physical and social environment in which people live. It is, in fact, aimed at the domestic sphere; subjects like nutrition, family planning or the eradication of epidemic diseases are dealt with in terms of bringing a new awareness and behavior to the individual within his/her environment. The role of women as the people who manage the home and who are in charge of the basic activities of life such as eating, drinking, sleeping, defecating and washing, is absolutely central to successful preventive health care.

Services such as child care or family planning are exclusively aimed at women. The fact that planners have decided to concentrate on the child as a priority in health policy and to take care of the mother from the first days of pregnancy and the child from birth to two years old, means that the woman, who is the main person responsible for the child, plays a decisive role as the "partner" of the State within this policy.

A brief look at the statistics from two health centers during two different time periods shows (1) a much larger number of women using the services than men, and (2) an extraordinary number of children treated by the mobile health units. These children are frequently brought by women alone." This is for socio-cultural reasons, of which the most important are the changes which have shaken the family structure and crystallized the contradictions within It.

2. Factors due to changes within the Moroccan family structure

A complex series of circumstances has led to a situation where women have become primarily responsible for children's health. Thus it is they who must take the children to the Public Health Service.

One of the effects of the breakdown of pre-capitalist rural economy, urbanization and industrialization, is the destruction of the traditional extended family into nuclear units. Older women such as mothers-in-law, aunts, etc. used to help and advise the young married women and initiated her to motherhood. In the nuclear family of the urban (lumpen) proletariat, the mother is isolated in a hostile and foreign environment. Very often her neighbours are as young and inexperienced as she is. So she Is dependent on the public health service which gives advice on pregnancy, birth and child nutrition, thus entirely replacing the family circle in this area. The legitimacy of caring for children's health has thus passed from the hands of older women into those of white-coated experts backed by Western science and technology.

This does not mean, in fact, that the role of traditional healers and medical authorities (Fquihs, fguihas, sherifs) who are invested with powers of curing children with texts or touching, has diminished. The young mother will often consult both the fquihs and the nurse. Yet what might seem to be a '"harmonious duality" of two kinds of medicine is often hazardous, uncertain, unchecked and of relative help only.

Another reason that women have become "partners of the State" in its public health policy on children, is that very few women are gainfully employed; and especially in poor families which have recently arrived in town, only 7% of the "active" (i.e. gainfully employed) female population is married.

In fact one of the paradoxes of modernization is that women have become even more excluded from the means of production. Of the families in this survey the majority of wives who did weaving at home before migrating to the town had to give this up because (a) it meant buying the raw wool and (b) they had no commercial outlets. Thus women have become .entirely economically dependent on their husbands. This in turn has pushed both men and women even more into their traditionally-assigned roles.

Children, and especially young children, are in any case traditionally identified with the mother, and are left entirely in her care. Very often the husband, who is unemployed, will go and play cards or sit and drink while his wife, for lack of ' other assistance, has to take two or three young children to the health center when only one child is sick. Because masculine "honour" and "pride" are continuously threatened and degraded by unemployment and the insecurity inherent in the urban slums, men become even more aggressive in affirming their virility. Any desire a man has of sharing child care with his partner who is overworked and isolated is killed by a fear that such jobs will make him "feminine". If a man does make an effort to break the fetters of sex roles, he is often greeted with scorn or condescending humour. Para-medical personnel, for example, do not appreciate fathers who take the initiative to bring their children the clinic because they usually cannot give the answers critical questions such as

• "when was the last time he went to the toilet ?"
• "what did he eat yesterday ?"
• "Has he ever had such and such a disease ?"

One of the most frequent complaints of paramedics is about the incredible noise in the clinics, made by all the children that mothers bring along because they can't be left else where. There are no urban social facilities for child care. An it is important to remember that a visit to the PHS can la many hours or even days.

A mother whose child has ear-ache (otitis), for example, will have to go first to the clinic to see a nurse who will decide whether she is to go on to see the doctor or not (first queue) She will then go to the pediatric section of the health center (30 minutes' walk). She may then have to go the following day to the special ear nose and throat diagnostic center where she will queue four more times : once to have an appointment, once to see the specialist who gives her a ticket to have a bio-gram test, once for the bio-gram and once to g and get the results. This will usually take two days. Three o four days later she returns to queue again to see the specialist who prescribes some form of treatment. She then has to (r back to the health center to get an "agreement to tip.:i! which is issued by another doctor. With this agreement sh can get the necessary medicine (if it is available). Finally, sh has to go back to the clinic with the child three times a week in order to receive the medicine (which is given directly there). Sometimes she may have to go every day.

The tensions and resentments which inevitably build up between the para-medics and the users of the health service in such conditions have to be understood within the broader socio-political context. The noisy procession of healthy children who play and fight in the narrow corridors of the hospital because there is nowhere else for them to go is a perfect example of social factors interfering with the health service The nurses who are overloaded with work cannot help bu shout at the children to be quiet. Sometimes they even push them roughly aside, mumbling such banalities as "women are just baby factories" or "they know exactly how to get them, but looking after them is another matter".

It is hardly surprising that mothers who have to queue for hours become angry.