Egypt discuss whether nurses should or should not cover their faces-or “Does a smile go a long way?”

In March, the Ministry of Health passed a seemingly innocuous decree, one that creates and mandates a uniform code for nurses in government hospitals. The code, billed as part of the ministry’s ongoing attempts to raise the level of professionalism in health care, assigns clothing style and color according to a nurse’s work unit and supervisory level. Some nurses, however, are complaining that the decree is, in effect, forcing them from their profession entirely — these women wear the niqab (full-face veil), which is now banned from the uniform.

Doaa Serour, a 27-year-old nurse with nine years’ experience working at Heliopolis Hospital, is wearing what she feels is an appropriate uniform: white slacks, tunic, jacket and matching niqab. She says that she was relieved of her duties even before the decree when into effect. “They [hospital administrators] told me that I have to work as a secretary so I don’t deal with patients — ever since November [2007], when they first announced they were going to set up a decree.”

Health Ministry spokesman Abdel-Rahman Shahin told the local press in November that teams of health care workers were being sent to all 27 governorates to assess the professionalism and overall performance of government nursing staff, especially those wearing the niqab. Shahin noted that the trend of munaqaba (face-veiled) nurses is rooted in areas such as Kafr El-Sheikh, Behaira and Sharqiyya; official figures tally munaqaba nurses as 35 percent of the nursing staff at many of these hospitals, with some hospitals having as much as 50 percent.

There are roughly 204,000 people in the nursing sector, 164,000 of whom are employed by the state, according to ministry statistics. Nearly four percent of nurses are college graduates and two percent graduates of technical institutes. The majority hold diplomas from nursing schools.

The new uniform regulations are part of an ongoing plan to improve conditions in hospitals and “upgrade the nursing profession in Egypt,” says Hoda Zaki, undersecretary to the minister and director of the Central Nursing Department, adding, “The [government] is always upgrading the general knowledge and skills of hospital staff as well as inspecting regulations and [performance].

“[The nurse] has to be wearing something that will allow her to practice her profession appropriately, [and at the same time] sanitation is taken into consideration,” she says. During her interview with Egypt Today, Zaki, who is also professor of nursing in Cairo University, was reluctant to address the niqab specifically. “The face is one issue, but the overall appearance is another. I’m talking about the uniform [in general].” She notes that the veil is not only allowed, but in fact, covering the hair is a requirement for nurses for sanitation reasons.

Mohsen Allam Ministry officials say the uniform decree will help “upgrade the nursing profession” in government hospitals.

Serour says the message that came through the hospital management was very specific. “The decree will forbid nurses from wearing the niqab. It was in the papers in November and we recently received a fax at the hospital from the Ministry of Health to that effect. They said that there’s no such thing as a munaqaba nurse.”

Last November, Shahin told Al-Ahram Weekly that the ministry’s investigation was meant to inspect and tally the nurses wearing a niqab, predicting that the decree would effectively ban them from hospitals.

According to Zaki, the Health Ministry consulted with designers about nursing uniform standards abroad, then modified those specifications to meet the needs of local culture. The ministry “took the feedback from nurses on how they want to look,” she says. “We asked them about the models and designs and got their opinions so there is an interaction. The majority is satisfied.”

About Face

Hamdy Hassan, a two-term member of the People’s Assembly and ex-spokesman for the banned Muslim Brotherhood, is not at all satisfied with the Health Ministry’s decree. “I don’t know what exactly the goal of this decree is other than to oppose Islamic culture. It’s a clear violation of the Constitution, especially since this is a religious right,” he asserts. “The minister never said anything about nurses that wear skimpy outfits. Why? Because it’s a human right. [By the same token,] I would reject forcing the niqab on all women. [The patient] only needs to be assured that he’s being taken care of by someone who’s kind and big-hearted, someone who treats him well and provides the necessary services. Why should a patient care if the nurse is black, white, pretty or not?”

Mohsen Allam Nurses who wear the niqab have been reassigned away from patient-care duties.

In November, Zaki said in an interview with Al-Ahram Weekly that the nurses could potentially “sue the ministry for interfering in their choice of dress and religious freedom,” noting that “in 2001, the Supreme Administrative Court ruled in the strongest terms that it is up to a woman to decide what to wear and she should not be discriminated against because of her dress code.”

Speaking with Egypt Today several months later, Zaki says the decree does not interfere with anyone’s freedom. “What I’m saying is that there are certain regulations for professions and now [we’re] addressing the regulations of the profession, not the personal freedoms of any [individual].

“The professional regulations apply to any profession,” she continues. “Anyone can do whatever they want to outside the professional regulations. Within the professional regulations, they have to adhere to [the rules] and this applies to nurses as well as others. So it’s not [just] nursing-specific — police, physicians, cleaners, everyone.”

Egypt is not the first country to grapple with religious attire in the workplace. “Some countries do not allow dramatic religious expressions in public offices, such as a large cross or hijab, definitely not the niqab,” says Bahieldin Elibrachy, a specialist in labor law at Ibrachy & Dermarkar law firm. “France, Germany and Turkey have regulations along those lines.”

While Egypt differs from the above countries in that it is a Muslim country with laws based on Shariah, Elibrachy says that the Health Ministry’s decree is not a constitutional issue. “There is no constitutional right when it comes to a dress code. You can’t show up to work in your underwear and say ‘this is my dress code.”

Article 46 of the Constitution guarantees the freedom of belief and the freedom of practicing one’s religion, as long as the religion is recognized by the state. “Even this personal right [of religious expression] is not absolute,” Elibrachy notes. “If you protect any right absolutely, you harm the rights of others.”

Using the uniform decree as a case in point, he poses the question, “Are there rights for patients to request a certain dress? Or is the right for the employees only?”

The lawyer says the workplace uniform could be associated with a constitutional right only if the dress itself is a religious mandate; in that case it would be considered a right of belief. “Definitely, without a doubt, there is nothing in the religion that [calls for] the niqab. In fact, in order to circle the Kaaba on a pilgrimage you’re required to take the niqab off.”

According to Elibrachy, since the niqab is a tradition and not a religious necessity, it is therefore not a valid protected form of religious expression. Religion in Egypt, he says, should not be judged by one’s personal views since there are “objective standards” appropriated by the state, which will always strive to maintain the balance between what is included or recognized by religion and what is not.

Between the November announcement and press time, the Health Ministry adjusted its policy for those who do not comply with the decree: Instead of dismissal, as was originally announced, nurses not following the uniform code will face salary deductions or reassignment to administrative work, such as in the case of Serour.

Surface Treatment

Dr. Reham Rizk, a family-medicine physician of six years with the Egyptian Fellowship program, thinks the Ministry is focusing on the wrong issues. “What about solving the problem of missing medicines in hospitals?” she claims. “Patients go to these hospitals and aren’t treated properly because the nebulizer [for administering liquid medicine] is broken and are given cortisone for their bronchial asthma instead, and this is what the government is focusing on?

“There are more important issues of sanitation that need to be addressed. The niqab that these ladies wear is cleaner than most bed sheets in hospitals,” she asserts. Rizk believes that the decision is too superficial to have any effect; a better solution, she suggests, is for veiled nurses to work only with female patients.

Serour’s colleagues at Heliopolis Hospital also seem skeptical of the decree’s contributions to patient care. Wary of putting their own careers on the line, however, they agreed to be interviewed on the condition of anonymity.

“We have two nurses here that are munaqabeen but they aren’t allowed to treat patients and are stuck doing secretary work,” one nurse says. “It’s not really fair; it should be her right.”

Another nurse chimes in, “How does a niqab interfere with her work if she’s wearing a name tag?”

“Well there’s the issue of infections,” a third nurse concedes, “and also the patient wants to see a face when he’s being treated.”

“No, but the government shouldn’t be able to demand them to remove it by force,” responds the first nurse. A doctor in the group seconds the comment.

Serour still wears the niqab and acknowledges that no one has ordered her to take it off. Still, she says she doesn’t see why she should be reassigned away from patients. “I’m wearing a uniform that doesn’t bother anyone, not even the patient. I abide by the uniform’s requirements and even stopped wearing gloves, may God forgive me, for the sake of my kids,” says Serour. “Most patients felt comfortable and seemed happy that I was working with the niqab on.”

“A Smile Goes a Long Way”

Elibrachy says that given that the niqab is personal religious preference and not a requirement, the next question is “is it reasonable for purposes of work and accountability to have a woman with a niqab?”

Dr. Mohamed Abdel Rahman, a professor of Internal Medicine and Nephrology in Cairo University with 34 years experience in health care, says he believes the niqab is not reasonable in health care; in his view, it’s about time that nurses wear “professional uniforms.”

“I agree with the decision, especially because nurses know from the start that their job requires a great deal of interaction with patients, and will have to tend to the needs of the sick,” Abdel Rahman says. “The profession of nursing requires a face-to-face interaction. You can’t have a nurse cover her face while performing analysis, administering medicine and looking after the patient.”

Abdel Rahman points out that while Egypt is a Muslim country, it’s not considered Haram (sinful) here for women to show their faces. What is sinful, according to him, is eltabarog (loose morals). “I’m not asking that nurses be morally corrupt, but a nurse’s smile goes a long way. It can give hope to her patients. The patient needs some compassion.”

The doctor says the niqab also raises security and accountability concerns, just as it does for public institutions such as airports and universities. “[As a patient] how do I know this is a nurse, the one that’s been taking care of me?” Abdel Rahman says. “It’s a security threat. A criminal could easily disguise himself and encroach upon the hospital’s sanctity and integrity. It’s not hard to believe that a patient in a hospital can be a potential target.”

Like Rizk, however, Abdel Rahman, feels that the niqab does not have any drastic effects on sanitation. “Covering of the hair is a good cautionary measure and should be a requirement, which it is,” he says. “It’s more an issue of [appearance] and the ability to build rapport with the patient. The niqab won’t affect sanitation so much, but it will impair the psychological well-being of the patient, which is crucial.”

Dar Al Fouad Medical Director Samir Moussa also says he is pleased to hear about the decision, even though his facility, as a private hospital affiliated with the Cleveland Clinic in the United States, is not affected. “I fully agree with the ministry that [the lack of a standard uniform] is a problem — not because it’s the ministry or a ministerial decree, but because we have a lot of obstacles [facing] the professionalism of nursing and the nursing practice itself.”

Moussa says that Dar Al Fouad does not have munaqaba nurses on staff. Also a medical education consultant, Moussa has practiced in the United States, the United Kingdom and India, with extensive experience in pediatrics and family medicine. He says that the lack of sanitation is an even bigger issue than just professional appearance, noting that the niqab collects bacteria and viruses because it is constantly clinging to the nose and mouth. “If there’s open air [in front of her face] infection is minimized,” he points out.

Given that infection control is of such critical importance in a health care environment, Moussa believes that clothing shouldn’t be adding to the risk. “The spread of infection can also be brought on by the type of clothes itself,” he says. “The niqab is usually polyester, which [plays a role] in spreading [germs]. Another [factor] is that the nurse is always in constant motion physically — bending over patients, picking things up — so it’s easy for dirt to get picked up. This is why we have a unit for infection control and take necessary measures to monitor it.”

In terms of appearance, he also feels that the niqab interferes with the function of nurses. “The patient needs a certain level of eye contact with his care-provider. So this is a barrier,” he says, noting that a major function of the nurse is to provide comfort emotionally. “I’m sure the ministry considered all these things when making their decision.”

Moussa is not unsympathetic to the dilemma that munaqaba nurses are now facing, but says it doesn’t have to mean the end of their careers. “[A simple solution would be] for them to wear protective medical masks; it covers the portion of the face she needs to cover and she can wear it all day. It won’t transfer infection and patients wouldn’t mind it, even if they miss out on a [caring] smile, because they know it’s a health measure.” He feels that patients would be willing to sacrifice for a medical mask easier than for a complete face-veil.

In response to Rizk’s suggestion of assigning niqab-wearing nurses to female patients, Moussa believes this could have the unintended consequence of dividing the hospital’s staff and lowering morale. “At the end of the day, you’d discover that you have a hospital for women and a hospital for men, and maybe even a stigma on the nurses that chose to still work with the [male patients]. It’s not practical.”

In the meantime, munaqaba nurses are looking for the same compassion they provide their patients. “I have two options,” Serour says. “To take off the veil so I can work and make a living or to keep the veil on and leave it up to God’s will. I don’t want to take it off. There’s no work. What can I work as? Should I leave my specialty and go out and etmurmut (struggle) in work not meant for me?”

Unless hospitals decide to implement a compromise such as the medical face masks suggested by Moussa, munaqaba nurses are facing a tough decision. et