This part of Iraq, says Dr. Ayad al-Hadithy, is so conservative that a man would rather have his pregnant wife die in labor than be touched by a male nurse or doctor.
It's just one of the difficulties faced by U.S. and Iraqi officials as they struggle to nurse the war-ravaged province of Anbar back to health. One showcase of their efforts is the reopening last year, for women only, of the Nursing School in Anbar's capital, Ramadi. Another is a field school in the town of Saqlawiyah that has just graduated its first batch of 10 female nurse's aides.
Nowhere are nurses more badly needed than in Saqlawiyah and its surrounding villages, where 50,000 people have no women doctors and only one female nurse and one midwife, both old and overworked.
The area's most recent records, from five years ago when the anti-U.S. insurgency was just beginning, show that one in five women dies in childbirth, and many women never even see a doctor.
The strictures on women as nurses stems from the province's strong tribal society and its puritan reading of Islam. But al-Hadithy, a 49-year-old mother-and-child care specialist, doesn't accept it.
"This is ignorance, not Islam," he said. "Nowhere does Islam say: 'Let your wife die.'"
Another obstacle, he said, is the reluctance of husbands to let their wives travel 25 miles to Ramadi to train as nurses. So three months ago, the center in Saqlawiyah was opened.
But first al-Hadithy had to persuade the village imams to back the project — or at least not preach against it — and the husbands to let their wives train with him.
Yet another problem is that female nursing is a profession held in low regard by Iraqis, because it requires night work and contact with male patients. "But I knew if I could teach them some basic first aid — how to give a shot or take someone's blood pressure — these women would be accepted," al-Hadithy said.
'Bringing it to them'
Muzdalifa Hamza, 33, was told about the program by her cousin, Saqlawiyah's only ambulance driver. Her husband approved and the mother of four even persuaded her sister Khulud, 40, to come along.
"When someone knocks on my door in the middle of the night, I now know enough to go out and help a sick person," Hamza said. "But someday I want to be a real nurse." In the fall, she plans to enroll in a three-year course at the Nursing School.
The Saqlawiyah project was spearheaded by Vernon Pressley, a senior public health adviser from the Atlanta-based Centers for Disease Control and Prevention and the head of the local U.S. reconstruction team attached to the Marines in Ramadi.
"The sheiks would never have agreed to let women leave for training far away, so I thought of bringing it to them," Pressley said. The Saqlawiyah project has cost $12,000, and the 10 trainees share a monthly wage of $250.
The sum is small compared with the $847 million the U.S. says it has spent on Iraq's health needs since the 2003 U.S.-led invasion. But in Anbar, the security issue was huge. The province was a stronghold of the insurgency and the Saqlawiyah center couldn't open until after tribal sheiks switched sides two years ago and joined U.S. troops in the fight.
Hollowed-out health system
The nursing shortage is only part of Iraq's hollowed-out health care system, plagued by corruption, mismanagement and a lack of equipment and medicines.
Iraqi medical professionals started leaving in the 1990s, during Saddam Hussein's rule. Since the invasion, thousands have fled abroad, while of those who stayed, at least 620 have been killed, among them 134 doctors, some gunned down in their own clinics.
Dr. Ahmed Ibrahim Salih, Ramadi's city health director, has escaped three assassination attempts that killed his assistant, five of his co-workers and a bodyguard.
Iraq's violence has ebbed and Anbar is quiet, but Salih still works from a heavily guarded office. Meanwhile, the strengthened tribal mores have brought their own restrictions on females, so much so that women interviewed at Ramadi's Nursing School asked not to be fully identified. They attend classes wearing all-covering dark robes and head scarves.
Finding respect, restoring hospitals
F.R., one of 10 siblings, is a high school graduate who persuaded her family to let her study nursing, telling them that someday she would have a job and bring in money.
"I believe women can work and still be respected," the 20-year-old said.
But their teacher, Suad Aziz, says old prejudices run deep, even in urban Ramadi.
"It's the attitude that nurses are loose women," said Aziz. She looks at her class with hope, saying: "Once we have them graduate and working, things will change."
Salih, the Ramadi health chief, says that since the invasion, 30 percent of the province's doctors, about 800 of them, have left and 80 percent of the medical infrastructure, from health centers to hospitals, are in ruins.
Salih pushed the government in Baghdad to open the three nursing schools in Anbar, starting with Ramadi, with Fallujah and Haditha to follow. He believes they could solve the province's nursing shortage in five years.
'Our hands are tied'
That is providing they get jobs. A nurse earns about $300 a month, but barren Anbar depends for funding on the Baghdad government, which has budget problems and must approve any hiring.
"If I could, I would hire all the Nursing School graduates, tomorrow," says Khamis Musharaf, a pediatrician at the province's only maternity and children's hospital. "But the government won't let us. Our hands are tied."
The 250-bed hospital has no nurses, and relies on mothers to tend their sick children.