In the early months of 1930, the senior medical officer (SMO) for the Ramallah subdistrict proposed dispatching nurses to local villages with the hopes of containing a “raging” measles epidemic.Footnote 1 In the officer's view, a trained nurse of appropriate age and estimable character could lessen the impact of the disease; the SMO cited as evidence the nurse in the town of Jifna, which in 1928 had a mortality rate from measles of only 3 percent.Footnote 2 The nurse stationed at the infant welfare clinic in Jifna during that year was thirty-five-year-old Hilweh Rizq (Hilwa Rizq).Footnote 3 A local of Jifna, Rizq does not appear on any of the lists of graduate nurses during the Mandate period, although she was licensed as a midwife in 1934 and had worked as a staff nurse in the Government Hospital in Ramallah.Footnote 4 In 1930, she earned £P102Footnote 5 as an annual salary as well as a cost of living allowance.Footnote 6 The archives reveal little more on Nurse Hilweh. No full employment records or complete biography exist to fully flesh out her life and work. Like most of her nurse colleagues, Rizq comes out of the historical record in spurts and traces. Yet, Rizq and her colleagues formed an essential piece of the Mandate's public health structure, and one that is too often overlooked.
Over the course of the Mandate period, hundreds of nurses like Nurse Hilweh became central to the politics of care in Palestine. This article follows these nurses through their training and careers in Mandate Palestine. I argue that the colonial state was, in part, constructed and filtered through the work of these women and dependent on the local institutional and interpersonal relationships they formed through their practices. Nurses were the social and political interlocutors in the provision of welfare governance that typified daily rule in the Mandate period. Engaging the frameworks of humanitarian governance developed by Ilana Feldman, Miriam Ticktin, and Keith Watenpaugh, I use the phrase “politics of care” to refer to the network of colonial state agencies, nongovernmental associations, and individuals that mediated social services for ordinary Palestinians. Feldman and Ticktin have argued that framing governance around the subject of “humanity” opened the growth of governing technologies that operated through traditional avenues of state power and through nongovernmental spaces and institutions.Footnote 7 Watenpaugh uses this conceptual framework to argue that subnational groups used humanitarian and welfare relief to create protostate or protogovernment entities.Footnote 8 Building on these works, I argue that the “politics of care” typified daily life in conjunction with the colonial state, not merely in its absence. Nurses were pivotal figures in the system of welfare governance; their lives and work reveal that system to be deeply embedded in local relationships and circumstances.
During the Mandate period, medicine and public health formed key sites for the construction of colonial governance in Palestine. Colonial medicine and public health extended beyond the boundaries of official administrative power. Furthermore, it was through the organizations and practices of social welfare, rather than formal politics, that most Palestinians interacted with institutions of daily governance. Illuminating how the system of colonial public health operated in Palestine helps to further break the historical silence around the lives of “ordinary” Palestinians in this period.Footnote 9
The history of Palestinian nurses expands discussions of power and colonial governance in the Mandate system. This article builds on works by Ronen Shamir, Jacob Norris, Laura Robson, and others, which argue for framing Mandate Palestine within a colonial or imperial lens.Footnote 10 Like those works, this study assumes that colonialism was a key feature in shaping the power relationships of everyday life in Mandate Palestine. I argue that Palestine's “coloniality” existed beyond the bounds of the British administrative Mandate state and Zionism's settler-colonial project. An examination of colonial medicine reveals a network of institutions and actors that operated both within and beyond the official Mandate administration. Palestinian nurses were pivotal figures in the constellation of colonial medicine, and thus in the construction of the colonial state itself.
The history of nursing also offers crucial ways of reconceiving the role of women in Palestinian history. Rather than focus solely on elite women or their place in the Palestinian nationalist struggle, the history of nurses recovers the lives of nonelite women, and, more significantly, of women at work.Footnote 11 Similar to Ela Greenberg's research on Arab women teachers, this article contributes to expanding Palestinian women's history by focusing on women as workers and their relationships to the governmental bureaucracy and the institutions they served.Footnote 12 This study adds to the historiography of Palestine one particular narrative of this class of women as well as of the interplay between gender and labor.
Inserting nurses into the narrative of Mandate Palestine opens up the larger story of 20th-century development, welfare, and expertise. Histories of development usually take as their central actors recognizable technocratic experts—the engineer, the economist, the soil scientist—who are invariably men and most often emanated from the colonial state (and later, the NGO) to the villages and towns.Footnote 13 The deference to this archetype of the expert and the reliance on his archives absents women, especially local women, from any story of development and expertise. Inserting women into the story of expertise is not incidental—as Sujani Reddy writes in her study of Indian nurses in the American imperial world, “It is insufficient, however, to merely add another name to the list—doctors, engineers, scientists, and nurses.”Footnote 14 Rather, recognizing nurses as experts fundamentally alters our assumed theoretical frameworks of expertise. This article shows that 20th-century expertise and governance in the Middle East was a story as much about interpersonalism as systemization, as much about local specificity as generalizable principles, and as reliant on women workers as it was on male scientists.
To tell the stories of these women, this study engages with several different archives and record types. These include employment data from the Mandate Department of Health, infant welfare center correspondence records, official government gazettes, Colonial Office pension petitions, and the archives of multiple missionary societies. Given that no single archive exists to house these nurses, their stories must be gathered from a multiplicity of sources, found across several physical sites.
THE MIXED ECONOMY OF NURSE TRAINING
Over the course of the Mandate period, around 950 women graduated from a training school as fully qualified nurses.Footnote 15 The system of nurse training rested on a collaboration between the Mandate government and private institutions, which served to entrench voluntary organizations as partners with the administrative state in public health governance and deepen institutional racial segregation in the nursing corps. Government regulations strove to organize nursing into a systematic, technical, and universal practice. The ambition of universality was assumed to both maximize the efficiency of the Mandate bureaucracy and meet the Mandate's duty of care to the population. The attempt at systemization, however, produced not homogenous state welfare, but a mixed economy of care. The Mandate government inherited sets of institutions and forms of knowledge from the pre-existing missionary and voluntary organizations of the 19th and early 20th centuries. It was this prehistory of nursing in late Ottoman Palestine that set up the cooperative institutional relationship between the voluntary associations and the colonial state over the training of nurses.
The system of nurse training in Palestine began in the prewar medical landscape of the late Ottoman period, as a product of a primarily missionary network. The Tanzimat reforms of the mid-19th century and the 1877 Provincial Municipal Law spurred medical and public health modernization initiatives in the imperial center and provincial capitals, but these reforms reached the cities and towns of Palestine more slowly. Formal education in nursing, a new profession across the globe in the late 19th and early 20th centuries, began in Istanbul in 1912, through the Ottoman Red Crescent Association.Footnote 16 For nurses in Palestine in this period, the closest institution for formal nurse training was the Syrian Protestant College in Beirut. Although by the years before World War I a few Ottoman municipal hospitals had been established in cities such as Jerusalem and Nablus, a network of European missionary institutions provided most medical care.Footnote 17 These medical missions provided direct service care to their local communities and participated in the study of public health epidemics, such as malaria and trachoma. Missions also incorporated Palestinian women into their institutions, first as pupils and then as nurses. Integrating local women into the missions’ medical services had ideological, as well as practical, underpinnings. Much of the missions’ direct service work focused on care of women and children, especially gynecological and neonatal practices. As a form of undercompensated affective labor of care for pregnant women and their children, nursing was the type of work that was thought to be appropriate—even natural—for women.
The medical missions’ systems of nurse training in the years before the war were small and individually focused, but they established certain precedents that would influence nursing in the Mandate period. Palestinian women began sporadically appearing as nurses and nurse probationers in missionary records toward the end of the 19th century. In 1897, for example, the Haifa hospital Jerusalem and the East Mission (JEM) employed a trained and certified Palestinian woman, Nurse Basham, as the nurse-in-charge, and by 1906, Nurse Basham was training other Palestinian nurse probationers.Footnote 18 In 1908, St. Helena's, an organization of the JEM that attempted to establish a system of district nursing in Jerusalem, trained Nurse Probationer Victoria Addas. For the JEM, training local girls as nurses enabled the mission to extend its reach further into the local communities and, in the minds of the missionaries, elevated the whole society. As conduits of both religious messages and modern public health practice, nurses facilitated the realization of the mission's goals. In 1912 the Bishop of Jerusalem wrote that the future of Palestine lay in the hands of its women: “We want teachers and nurses in our mission stations … By educating and raising them to what they are certainly capable of, the whole future and status of the country is affected.”Footnote 19
The Church Missionary Society (CMS), another British mission with several medical outposts throughout Palestine, understood that training local women as nurses was also a matter of practicality. Correspondence records from the medical missions during the 1890s and early 1900s reveal a continual need for an increased nursing staff to alleviate the burden on the English nursing sisters. While the mission had a preference for English nurses, who were considered better equipped to spread the Gospel, by 1906 CMS missionary outposts were training local nurse probationers in Nablus, al-Salt, and Gaza.Footnote 20 Because the mission had access to local populations through the Christian Palestinian community, the majority of nurse probationers they trained were Christian women. The demographics of nurse training in the late Ottoman period would influence nurse training under the Mandate administration.
In the years before the war, the medical missions strove to develop a uniform standard of nurse training. In 1910, a subcommittee of the CMS medical mission proposed adopting a uniform training program for Palestinian probationers. The program would consist of three years of courses, with an exam at the end of each year, “in order that the native nurses might have the benefit of systematic training.”Footnote 21 The proposed course was meant to regularize nurse training not only across the Protestant missions in Palestine, but regionally as well. The course was proposed to align with the program of the newly established training school for nurses at the Syrian Protestant College in Beirut.Footnote 22 The subcommittee submitted the training school's syllabus to the English nurses in Palestine for review. After making some modifications, the missions adopted the program as the official training course for local nurse probationers in Palestine.Footnote 23
In the Mandate period, nurse training became one of many sites of cooperation between the new Department of Health and pre-existing voluntary organizations. Public health policy under the Mandate depended on a system of integration and exchange between government medical institutions and voluntary associations’ hospitals and clinics. The Department of Health explicitly delegated to voluntary organizations the provision of most direct medical services, while the department took charge of broader public health schemes, such as malaria prevention and food and drug oversight, as well as medical care for government employees. The training of nurses and their assignments to local clinics somewhat complicated this tidy division of labor between public and private institutions. In the early years of the Mandate, most nurses trained at voluntary hospitals. In 1921, of the forty-one probationers who successfully completed their first-, second-, or third-year examinations, thirty-three did so at voluntary hospitals, including all of the probationers who passed their final examinations.Footnote 24 Until 1930, only roughly a quarter of the nurses who qualified were trained at government hospitals.Footnote 25 The Department of Health outsourced the training of their nurses to the British missions for a number of reasons. Primarily, using the mission facilities and resources, which were privately funded through donations to the missionary societies, relieved the government of the financial burden of educating medical professionals. Secondarily, the mission hospitals likely had more expertise in working on the ground in Palestine than the newly formed Department of Health. Their staffs spoke Arabic and they were more familiar with the local communities from their previous experiences training local women as nurses and working with local doctors.
To become fully registered as graduate nurses under the Mandate's regulations, probationers had to have an elementary education and to complete a minimum of three years of courses and practical training at a designated nurse training institution. At the end of each year of training, the probationer nurses were examined by a board comprised of representatives of their particular training center as well as a government delegate. The nurses who completed their third examination received a graduation certificate endorsed by the Director of Health.Footnote 26 As Ela Greenberg has highlighted, the educational requirements barred many lower-class women from entering the nursing profession, especially in the earlier years of the Mandate regime. Additionally, because much of the elementary education available in Palestine—especially for girls—was provided through European missions, an overwhelming number of the Palestinian Arab women who were eligible for nurse training and certification were Christian.
Nurse training also deepened institutional segregation between Jewish and Arab nurses. Most Jewish nurses trained at the newly established Hadassah Nurses Training School run by the Jewish Agency and attached to the Rothschild Hospital in Jerusalem. The founders and leaders of Hadassah saw themselves as messengers of modern knowledge and mechanisms of nursing and medical care to a country awash in ignorance and ravaged by war. In a view heavily reliant on racialized hierarchies and imbued with the nationalist mission of Jewish renewal and state building, Hadassah leaders saw themselves as the standard bearers for public health development in Palestine.Footnote 27 Hadassah was, in any case, better funded than any other nursing outfit in Mandate Palestine. The nursing school drew its financial resources from the fundraising capacities of the American Zionist Medical Unit and the Joint Distribution Committee of American Funds for Jewish War Sufferers.Footnote 28 Additionally, American and British Jewish organizations raised money for individual nurse scholarships, including ones that sent nurses to the United States for training courses.Footnote 29
In theory, the Hadassah Nurses Training School was designed to create a local corps of trained nurses in Palestine and to address the public health crises created by the impact of World War I in Palestine. The reality of Hadassah's structure, however, as well as the parameters of its ideology, meant that the institution succeeded in creating an exclusively Jewish nursing program that was impenetrable to Palestinian Arab women. Knowledge of Hebrew was a prerequisite for acceptance in Hadassah's training school and Hebrew was also the language of instruction within the school. The emphasis on Hebrew in nurse training was part of the larger Hebraicization program of the Zionist movement in Palestine although it created logistical problems for the school, especially in the earlier years of the Mandate period, as most of the probationers and instructors were not native Hebrew speakers nor were nursing textbooks available in the language.Footnote 30 While some Hadassah graduate nurses did end up employed in government hospitals and clinics, most stayed within the circle of Hadassah medical institutions. Hadassah's progressivist notions of alleviating impoverishment and creating a sustainable public health regime through the training of a local nursing corps were limited, by virtue of the organization's nationalist aims, to the Jewish population of Palestine.
Although it was better funded and better resourced, the Hadassah nursing school did not fundamentally differ in content or pedagogy from the government and missionary hospitals in which Palestinian Arab nurses were trained. In 1924, a conference of doctors and nursing sisters from government and mission hospitals convened to establish a standardized curriculum for nursing education. In the same year, Hadassah submitted a similar curriculum to the Department of Health for approval.Footnote 31 At missionary hospitals, probationer nurses were trained directly by the missionary doctor and British nurse in charge. In order to be recognized by the government as a nurse training center, hospitals were required to offer a total of 173 hours of coursework in nursing over three years: mandatory topics included anatomy and physiology, hygiene and bacteriology, tropical diseases, elementary gynecology, skin diseases, surgery, and common eye diseases in Palestine.Footnote 32 Nurses training in Gaza, Nablus, or other peripheral cities were able to travel to Jerusalem to complete additional courses on infant welfare and midwifery.
The government's reliance on pre-established religious institutions to produce a qualified body of nurses had significant consequences for the social demographics of the profession in the Mandate years. The institutional structure of nurse training effectively segregated the Jewish and Palestinian Arab nursing populations. Although both Jewish and Palestinian Arab women could and did train in government hospitals, the vast majority of Jewish nurses attended the Hadassah School and over half of Palestinian Arab probationers trained at missionary hospitals. The government's reliance on missionary organizations in nurse training likewise influenced the demographics of the Palestinian Arab nursing population. Officials in the Department of Health expressed continual concern during the 1920s and 1930s about the lack of Muslim nurses. They attributed the demographic disparity to a cultural reluctance of Muslim families to allow their daughters to work in mixed-gender environments and attend to male patients. To attempt to recruit more Muslim nurses, the Department of Health opened a training center at the Government Hospital in Nablus (formerly the Watan Hospital) where nurse probationers could work solely in the women ward and children's ward under “harim conditions.”Footnote 33 The Nablus hospital did receive a handful of Muslim nurse trainees, but the profession remained dominated by Christian women.Footnote 34 Ela Greenberg has raised doubts about the strength of the cultural claim, noting that Muslim women did enter other gender-integrated professions, such as teaching.Footnote 35 While nursing demanded a more intimate gender mixing, with nurses having to attend to male bodies, gender segregation alone does not account for the exclusion of Muslim women from the profession. Another contemporary explanation for the lack of educated Muslim women entering nursing was the view of the profession as low-level, servile work. Several of the missionary sources note the struggle to promote nursing as a respectable profession. As Greenberg notes, however, that nursing was viewed as a low-class occupation does not explain why Christian women from well-to-do and educated families so readily entered into nurse training. Despite earlier wariness about the respectability of nursing, a letter from a CMS nursing sister in Nablus in 1926 remarked, “It really seems at last that more girls are thinking of nursing as a means of earning a livelihood. Up to the present they have all wanted to be school teachers, as nursing was considered degrading work and too hard.”Footnote 36 The turning of the tide in the respectability of nursing did little to ameliorate its demographic disparities as Muslim women continued to be underrepresented in the profession into the 1940s.
The influence of missions on the system of nursing in Mandate Palestine was structural as well as cultural.Footnote 37 Missions did not merely alter perceptions of nursing in ways that might make young women more inclined to take up the career; rather the institutional missionary network of nurse training that dominated Palestine before the war and upon which the Department of Health relied during the Mandate period decisively affected the demographic parameters of nursing in Mandate Palestine. The delegation of nurse training to religiously based voluntary organizations rendered those organizations unintentional gatekeepers of the nursing profession, determining who was welcomed in or kept out.
DISTRICT NURSING AND RELATIONSHIPS OF CARE
The work of nurses in local towns and villages reveals how the Mandate's system of colonial public health was filtered through local institutions and relationships. The nurses who were sent to staff village clinics entered into intimate relationships of care with local populations—relationships that complicated the Mandate government's vision of a fully systematized and interchangeable nursing structure. Unlike their counterparts who worked in urban hospitals, district nurses were deeply enmeshed in the local politics and social structures of the communities in which they worked, a fact that was a feature of the Mandate's public health system, rather than an aberration.
Like other employment in the Mandate administration, nursing was hierarchical. Among the cadre of nurses that staffed Palestine's hospitals and clinics were British nursing sisters. Unsurprisingly, these women held the top nursing positions, as hospital matrons and supervisors. While all supervisors were British, not all of the British nursing sisters came to Palestine in that capacity and many served as regular staff nurses. British nurses were employed as members of the British colonial service and thus subject to different regulations than their Palestinian counterparts. In 1940, upon the creation of a Unified Colonial Nursing Service across the British Empire, new conditions were laid down for British nurses in Palestine: appointments were made for a three-year probationary period; nurses were provided subsidized accommodation by the government of Palestine as well as free passage to Palestine; nurses—unlike many other employees of the colonial bureaucracy—were not required to pass a language examination prior to appointment, but were expected to learn some colloquial Arabic during their first year of service.Footnote 38 After three years of service, nursing sisters became entitled to a pension. In the year the new conditions were established, thirty-three British women served in Palestine as staff nurses and hospital matrons. Atop the nursing hierarchy was the superintendent of midwifery and child welfare, who oversaw all midwifery work as well as the work at village clinics.
Although Palestinian nurses were not employed in supervisory roles, they nevertheless held a variety of nursing positions. Some nurses worked as staff nurses in hospitals, run by the government or by voluntary associations. Others, such as Hilweh Rizq, worked as district nurses in village clinics. District nursing was a growing branch of public health schemes. Though district nursing began in the late Ottoman period, after World War I the Mandate government in partnership with voluntary associations and missions expanded the scope of district nursing in its efforts to combat epidemics such as measles, smallpox, and trachoma and as a means of bringing down the country's high rates of infant mortality. Because district nursing involved sending nurses into local communities to do preventative care and treatment, it necessarily embedded nurses into the structures of those communities.
While district nurses undergirded the aims of the government's public health work, the nurses’ profiles did not always align with the government's regulatory ideals. Most hospital nurses held official certification, but not all of the women hired in village clinics did. Nurses working in villages and small towns might have held full graduate certification, have undergone partial training, and/or be licensed as midwives. Nurses who worked in villages, unlike their colleagues in hospitals, were often in charge of the daily operations of the clinics and were the sole medical staff person permanently in the area, which gave them unique roles in the local social and political scene. Although village nurses were, in many important respects, representatives of the colonial bureaucracy in a given locality, it is too simple to identify them only as such. There was no generalizable relationship between village nurses and the communities they served or between the nurses and the Department of Health under whom they were employed. Village clinics were sites of political contestation between local bodies and the government. As interlocutors in these processes, nurses found themselves amidst often-fraught and -contested political negotiations and uneven colonial relationships.
The nurses’ complicated relationships with local communities and with the Department of Health are evident in petitions, memos, and letters found in governmental files on village infant welfare centers. These petitions cannot be neatly slotted into narratives of colonial power and colonized resistance. Nurses petitioned the Department of Health as employees in a colonial bureaucracy. At the same time, many of the nurses had strong attachments to the localities they served and were the products of those very same communities.
Nurses’ experiences in village and town clinics depended on their particular relationship with the local community. Petitions and letters from town and village leaders to the Department of Health show how nurses became central figures in the structures of local politics as well as in local leaders’ attempts to command authority and power within an unequal colonial system. Some nurses were embraced by the village population. A petition from the local council of Beit Sahur in 1935 was sent in protest of the news that the Department of Health had plans to transfer their infant welfare nurse, Afifa Najjar to another location. Addressing the senior medical officer in 1935, the local council began by saying they had heard a rumor about the department's intention to move their nurse to another town. “This order,” the petition read, “harms our interests in several respects.”Footnote 39 First, the council argued, the nurse was an energetic employee who executed her duties well. Second, she was already familiar with the homes of the village and the children's diseases, which had been eliminated under her care. Finally, the petition argued, a new nurse would not be able to perform her duties because she would not know the houses or the conditions of the local population.Footnote 40 The petition concluded with the council asking the senior medical officer to consider the matter “with mercy and pity and let the situation remain as is.”Footnote 41 The original petition, which was written in Arabic, was followed quickly by another letter from the local council in English. Reiterating many of the points made in the first petition, the letter praised the work of the clinic nurse and emphasized the great public health needs of Beit Sahur.Footnote 42 The local council wrote that the village was in great need of the clinic's services, “especially because we have a very big number of infants and so many ignorant mothers who need a good and well-trained nurse (as our present nurse) to direct them.”Footnote 43 Another nurse could not be an appropriate replacement because it would take her too long to learn the specific conditions of the village and its needs.
The council's petitions did little good; Nurse Afifa Najjar was transferred away from Beit Sahur “in the interest of the service.”Footnote 44 Yet, fruitful or not, the petition tells us quite a bit about the relationship of the local community to their nurse. Moreover, as demonstrated in the case of Beit Sahur, it was often the local populations and local political leaders who defined what a well-trained nurse looked like. After all, Beit Sahur's local council cited two general reasons to keep Afifa Najjar in their village: first, she was properly trained and performed her duties well (that is, she met the new standards for nursing qualifications), and second, she was familiar with the particularities of the village and the families within it. Najjar's expertise arose not only from her educational background, but from her localized, specific experiences. Another nurse with the same credentials as Najjar would not have the proper expertise for the needs of this village.
Hilweh Rizq's experience of the measles outbreak at Jifna similarly highlights the perceived importance of a nurse knowing the locality. To be sure, from the Department of Health's perspective, Nurse Hilweh's local value partially came from the cost savings of not having to provide her accommodation. The memo from the Ramallah District SMO, however, also emphasized that Nurse Hilweh's success in Jifna arose from her particular suitability to the town. He remarked that the shortage of nurses had, at times, forced him to assign nurses to villages with which they had no common ground, citing a specific incident in which he posted a Jewish nurse to a Palestinian Arab town.Footnote 45 Nurses, the SMO reasoned, could only be effective if they were “accustomed to life [in the locality].”Footnote 46 Nurse Hilweh, as a local herself, understood the needs of the village and a commitment to the community that an outsider could not replicate.
The officials’ stress on the importance of village nurses knowing the localities in which they worked—even better if they themselves were locals—reveals a tension in the conceptions of the role of nurses and the nursing profession. As the training regime indicated, the government meant nurses to be uniform and interchangeable. In this respect, nurses were like the other professionals who staffed the colonial bureaucracy. At the same time, however, nurses—and village nurses in particular—were deemed most effective when they had individual and personal relationships to the specificities of a locality. Nurses themselves operated on both of these levels—as scientific agents in the broad bureaucracy and as individuals with community connections and obligations. While Nurse Hilweh, the SMO surmised, would be reluctant to leave her hometown amid an epidemicFootnote 47 and the local leaders of Beit Sahur demanded that their nurse remain with them, many nurses did transfer between villages and cities, using their professional credentials as entrée to new places. This tension was emblematic of a form of 20th-century governance that aspired to standardization and cohesion and depended on a growing class of technocratic experts, while simultaneously turning to new policies of welfare care that brought the colonial state into the intimate spaces of family life.Footnote 48 Nursing, like all facets of colonial governance at this time, was practiced according to both generalizable scientific principles and deeply interpersonal and intimate interactions.
The duality of the nurse's position as an interlocutor in both local and colonial institutional relationships sometimes led to contests over medical expertise and authority within the colonial public health system. The case of a nurse in al-Bira in the early 1940s illustrates this point. Insaf Mahmud ʿAli was an Egyptian nurse, trained, by her own account, at the Egyptian College of Medicine and a former member of the Egyptian Welfare Committee. She came to Palestine at some point in the early 1940s and was hired to run the infant welfare center in al-Bira in 1944.Footnote 49 Some time later, the SMO wrote that the nurse appeared ignorant of the objectives of the infant welfare center. Nurse ʿAli, the complaint continued, seemed more interested in “showy matters” and her own midwifery practice than in providing the lectures, demonstrations, and village home visits that made up the center's preventative and instructional work.Footnote 50 The medical officer also alleged that Nurse ʿAli had attended only two of seven required days at the Jerusalem Infant Welfare Center during her training. The complaint gave Nurse ʿAli one month to make improvements or the center would be closed.Footnote 51
The concerns expressed by the SMO centered on two issues embedded in the department's understanding of the role nurses played. The first problem identified in the complaint was the nurse's sense of autonomy, especially her disregard for the objectives of the clinic and focus on her own private medical practice. The superintendent of midwifery, Ellen Rogers, who visited the clinic sometime after the medical officer, raised similar concerns about the nurse's actions. Primary among the superintendent's allegations was that Nurse ʿAli was presenting herself as a doctor to the villagers and asking them to address her as such. The nurse, according to Rogers, disparaged both the local medical officer and Rogers herself, claiming to be a superior practitioner and belittling the government nurses as “painted and powdered and [knowing] no work.”Footnote 52 When Rogers appealed to a member of the al-Bira local council for assistance, he appeared to agree with the nurse, affirming the quality of her work and saying that she should be addressed as doctor since the local medical officer rarely visited the clinic.Footnote 53
The second allegation against Nurse Ali focused on the professionalism—or lack thereof—of her appearance. The SMO's initial complaint had ordered her to remove her pieces of jewelry as they “are not clean and do not make a good impression on her health activities.”Footnote 54 Additionally, he insisted that she keep the center and her private premises clean to make a good example to the mothers who attended the clinic. Miss Rogers was similarly concerned with Nurse ʿAli's attire, describing her as clothed in an “Army Sister's Cap, a large ordinary pin holding up her belt and large fancy glass buttons on her overall.”Footnote 55 Nurse ʿAli's dress was an affront not only to the authority of the department, but to the particular professional image of nursing that the department had hoped to promote. The nurse's garb was meant to signal both her professional role—that she was separate from the community she served—and her subordinance to a bureaucratic hierarchy.
Nurse ʿAli had her own understanding of her role and relationship to the Department of Health. She refuted the allegations against her by the SMO, especially the charge that she had abandoned her duties to the clinic in favor of private midwifery practice. She highlighted her qualifications—diplomas with distinction in nursing and midwifery as well as her former role of inspector at the village health office in Egypt.Footnote 56 She insisted that she had visited the Jerusalem infant welfare center to observe the work done there but had not been welcomed by the government nurses. Nurse ʿAli attributed some of the perceived coldness she experienced to being Egyptian.Footnote 57 The biggest complaint she and the local council leveled at the Department of Health was an accusation that Miss Rogers beat and cursed her in front of the clinic patients. Rogers and the department readily dismissed the claim as mere insolence and insubordination and threatened that if Nurse ʿAli did not attend two weeks of retraining at the Jerusalem infant welfare center, her contract would be broken on the basis that she lacked interest in the welfare of women and children.Footnote 58 The local council of al-Bira, however, sided with their infant welfare nurse, not only affirming the quality of her work, but submitting their own complaint against Miss Rogers and corroborating Nurse ʿAli's story. Furthermore, the local council took the treatment of their nurse by the department as part of broader intrigues against the infant welfare center.Footnote 59 When the department threatened to close the clinic, the council accused the Department of Health of neglecting the sanitation of their village and retaliating against them for hiring Nurse ʿAli by withholding medical equipment.Footnote 60 The entire episode concluded with Nurse ʿAli's disappearance to Egypt and the local council's eventual termination of her contract. The infant welfare center in al-Bira closed soon after.
The case of Insaf Mahmud ʿAli shows how the colonial project of public health operated at the local level in three respects. First, she was embraced by members of the local population as part of the community. She was their nurse, and although she was an employee of the Department of Health, the local council distinguished her from a colonial administration that they felt underserved them. Second, although the community of al-Bira may have seen Nurse ʿAli as one of their own, she was not local. Trained in a different British colonial environment in Egypt, Nurse ʿAli journeyed across a transcolonial public health regime that worked through unrecognized actors, such as nurses. Colonial officials who headed the Mandate administration moved horizontally throughout the British imperial world, bringing strategies and practices from other parts of the empire to Palestine.Footnote 61 Nurse ʿAli's journey reveals a different type of imperial exchange, one shared more by missionaries and relief workers than colonial officials. Finally, Nurse ʿAli was part of the colonial public health regime, but that regime was fractured and contested. At the heart of the exchanges between Nurse ʿAli and the Department of Health was a struggle over expertise, knowledge, and authority.
The story of al-Bira shows the limits of the reach of the Department of Health as a centralized institution and the complexities of how local councils related to the colonial administration. Insaf Mahmud ʿAli's case was extreme in its level of discord, but she was not unique in registering complaints about working conditions with the Department of Health. The inclusion of letters, complaints, and requests from nurses themselves in the government files of infant welfare centers reveals the nurses’ centrality in the construction and operation of the infant welfare network. As in al-Bira, regardless of any system of governmental oversight, the nurses were usually the sole medical practitioners for smaller towns and villages. As such, they had a great deal of influence over the actual practice of infant welfare on the ground. And though they were, in many respects, agents of the colonial administration, they were just as often brought into conflict with it.
Most nurses’ petitions to the Department of Health revolved around conditions of work. In Jifna, for example, one nurse asked the Department for a donkey to help her travel to nearby villages where she provided care.Footnote 62 Other nurses wrote to the department requesting additional supplies or registering problems with the physical conditions of the clinics. In 1939, the nurse of the Dura clinic wrote to the medical officer requesting urgent repairs to the roof as it was sagging in from heavy rain.Footnote 63
Nurses also wrote to the Department of Health to lodge complaints about their relations with the local community. In 1941, Janette Daʿiq, the nurse in the Dura clinic, reported a physical altercation with a woman from the town. According to Nurse Daʿiq's account, the woman threw stones at her while the nurse was attempting to protect the clinic servant from attacks by other local women. Nurse Daʿiq reported that she had previously been insulted and cursed at by this particular woman and had a gold watch stolen from her by an unknown person from the community.Footnote 64 The medical officer who took this report noted in the clinic's file that this incident was not the first time the inhabitants of Dura had caused trouble for government officials at the clinic.Footnote 65 The archives do not yield a further explanation of the causes of the poor relations between this nurse and members of the local community, although the few scant biographical details that exist about her offer a few suggestions. We do not know exactly where Nurse Daʿiq came from, but she was licensed as a midwife in Jerusalem in 1941.Footnote 66 While working at the clinic in Dura, she lived not in the village, but in nearby Hebron.Footnote 67 It is possible that some of the members of the town saw her as an outsider in their community.
In the Dura incident, a fairly stark line was drawn between the nurse and the community she served—the nurse was a representative of the government administration, perhaps resented as such by members of the village. At other times, however, there was far less clarity to which sector the nurse belonged and, more importantly, who had jurisdiction over her. In Ramallah, for example, Nurse Nasab Tannus signed a contract with the mayor that stipulated that she should communicate directly with the municipality on matters of working hours and pay, that she not be permitted any medical practice outside of the clinic, and that she submit a full report on the clinic to the municipality every month.Footnote 68 This contract was signed in the absence of the government medical officer and caused great concern among members of the Department of Health. “For some time,” the medical officer wrote to his superior, “the municipality has been attempting to rule over the Centre and the Nurse … It is considered unnecessary for the municipality to interfere with the work of the Nurse and the Centre which has been successfully carried out so far.”Footnote 69 Nurses were employees of the Department of Health, but they were often funded by the municipality, or even local private organizations. The question of to whom they were accountable became a source of contestation between municipalities, voluntary organizations, and the government.
District nursing brought the government's public health regime into the intimate spaces of village life, but that regime was uneven, ad hoc, and highly dependent on the individual nurse. The architects of the Mandate's Department of Health had initially assumed that the administration would focus on the management of infectious diseases and the treatment of British personnel and leave most direct service work to pre-existing voluntary associations. Whereas the financial straits that most voluntary associations found themselves in following World War I forced the Department of Health to take a more active role in providing services to local populations, the desire to reduce administrative costs and the particularities of the structural development of the profession gave individual nurses disproportionate influence in towns and villages. As both representatives of the colonial state and players in local power dynamics, nurses were fulcrum figures in the daily work of governance and the construction of public health.
NURSES AS EMPLOYEES AND RELATIONSHIPS OF LABOR
Nurses were important social and political interlocutors of welfare in Palestinian village life, but they were also integrated into the Mandate labor market as professionals and workers. The previous section showed how the nurse was an essential figure in relationships of care, but her own identification was equally that of an employee. While nurses could be understood as publicly partaking in the affective labor of care—especially for children—that was expected of women, they did not seem to think of themselves as public mothers.Footnote 70 Palestinian nurses, who, after all, had achieved the title by meeting the rigorous educational standards of their profession, seemed to understand themselves, first and foremost, as government employees and workers. Most of the communication between the infant welfare nurses and the Department of Health focused on working conditions or questions of compensation. Nurses petitioned for the benefits enumerated to them—pensions in the cases of on-the-job injury, medical leave, and housing allowances. Nurses also transferred between various infant welfare clinics and hospitals, demonstrating that they were tied to a professional network across Palestine rather than to a specific geography.
What kind of worker was the Palestinian nurse? On the one hand, she was a government employee, similar in position and education to the many clerks, inspectors, and administrative officers who staffed the colonial government. Nurses, whether stationed at village clinics or in hospitals, however, earned far less than most of their colleagues under contract with the administration. The archives do not yield anything resembling a statistical cache of data on nurses’ salaries, but the information that is contained in Department of Health files is still useful in trying to locate the nurses within the broader milieu of working people and professionals in the Mandate period. In 1929, for example, salaries ranged among thirteen Palestinian nurses from a low of £P72 per year to a high of £P150 per year, with an average salary of £P98 per year.Footnote 71 By comparison, in the same year, medical officers and administrative officers earned annual salaries between £P300 and £P550.Footnote 72 Nurses, British and Palestinian, were paid on a special scale that was independent of the normal ranking of government employees. The British nurses, who took the positions of matrons in the hospitals, unsurprisingly earned somewhat higher wages than their Palestinian counterparts, though the difference was perhaps not as great as might be expected. In 1936, while the average annual salary of the Palestinian nurses was £P115, the average annual salary of the British nursing sisters was £P174.Footnote 73 Only one Palestinian nurse earned a wage equivalent to the average wage of the British nursing staff. The British nurses that served as hospital matrons earned more than both their nonmatron British colleagues and their Palestinian subordinates. In 1936, British matrons earned between £P204 and £P240. The British superintendent of midwifery, Vena Ellen Rogers, earned £P384 that year.Footnote 74
Overall, as professionalized workers, nurses outearned their conationals employed in less specialized and nongovernmental jobs. Nurses outearned most workers in the agricultural sector, unskilled industrial laborers, and women employed in both agriculture and industry. Nurse salaries generally fell in the range of the salaries of skilled, industrial male workers or slightly below.Footnote 75 Individual nurses with years of experience and full qualifications might earn equivalently to the upper salary range of a skilled industrial worker; new nurses or those without complete certification were more likely to earn salaries closely equivalent to domestic servants. While an individual nurse's salary might increase (marginally) with experience, salaries overall did not rise very much from the late 1920s to the early 1940s. Indeed, although the average nurse salary increased slightly over the 1930s, the low salary of all nurses in 1943 was the same as it was in 1927. Much of the stagnation of these wages was due to the economic depression of the 1930s, which hit Palestine—and Palestinian Arabs particularly—harshly. The cost of living, as recorded in the Palestine Blue Books, fell almost continuously through the late 1920s and early 1930s, and the lack of movement in wages tended to reflect that shift.
If aggregate nurse wages remained fairly stagnant throughout the late 1920s–1940s, an individual nurse's salary could change as she became more experienced and rose through the professional ranks, especially if she moved to hospital work. Take, for example, the case of Nasima ʿAwad.ʿAwad began training as a probationer nurse in 1922, at the age of twenty. For the three years she was a probationer, ʿAwad earned between £E24 and £E36 annually, with free room and board included as a benefit.Footnote 76 In her first year after qualifying, ʿAwad had the title of “Special Nurse” and earned £P60.Footnote 77 As an unclassified nurse, she likely worked in a village clinic rather than a government hospital, or was still undergoing additional training. In 1927, she became a district nurse, with a Grade V government rank in a pensionable position and a salary of £P90 per year.Footnote 78 Her salary rose by £P6 increments per year until her death in 1934 when she was earning £P120.Footnote 79 Not all nurses saw such steady wage increases; several of the women for whom there exists multiyear records saw no salary increases or increases of only two or three pounds over the course of five or six years, especially in the first half of the 1930s.Footnote 80
The archives do not provide many instances of nurses directly protesting their level of pay, but there are some indications that low salaries might have deterred some women from the profession or from Palestine itself. In 1926, when the Ramallah infant welfare committee was searching for a nurse to staff its new clinic, members offered the position to Philomena Yazigi (Philomena Yaziji), a Syrian Christian woman who had trained at the nursing school at the American University in Beirut and received a certificate in midwifery from the Queen Charlotte's Hospital in London.Footnote 81 Yazigi responded to the committee with requests for more information about the position, including the salary and living allowance. Yazigi ended up declining the position. Although her response did not specify a reason, members of the committee speculated that the salary was not satisfactory and that her experience warranted more.Footnote 82 The committee attempted to negotiate with both Yazigi and the director of the Department of Health, but no resolution was found. The director responded that it was inconceivable to offer a nurse more than £P10 per month for infant welfare work and that the committee would have to wait for local girls to finish training.Footnote 83
A memo from the high commissioner in 1935suggested that low salaries were preventing the Department of Health from properly staffing its hospitals and clinics with nurses. Under the system at the time, all graduate nurses were appointed with an initial annual salary of £P90.Footnote 84 Those who did not receive free housing accommodation as part of their contract would receive an additional £P3 living allowance. In the memo, the high commissioner wrote that he and the director of medical services thought that no graduate nurse should be appointed at a net salary of less than £P6 per month because it was already difficult to find enough nurses willing to work for that wage.Footnote 85
As the Church Missionary Society nurse had remarked in 1926, Palestinian women clearly looked at nursing as a means of earning a living. Certainly not all of them were entirely financially dependent on their nursing salaries, but it stands to reason that many were. When Julia al-Khawaja, a staff nurse at the Government Hospital in Jerusalem, died of typhoid fever contracted in the course of her work in 1934, her mother petitioned the government for compassionate gratuity for the family. Julia had been earning £P72 per year, a wage that, as the application argued, provided almost the entire livelihood for her mother and two younger siblings.Footnote 86
Nurses represented their own work as above all a livelihood and themselves as professionals entitled to the benefits enumerated to them under their contracts. The stories of two individual nurses illustrate this point. Born in 1903, Phoebe Khadder (Phoebe Khadar) started her training as a student nurse at the Government Hospital in Jerusalem in 1920, at the age of seventeen. In 1923, Khadder qualified as a graduate nurse and began working in government service. In 1925, she was transferred to the Hospital of the Order of St. John, a long-running institution in Jerusalem that specialized in eye diseases and ophthalmic care. Two years later, Khadder was retransferred to government service as a Grade V ophthalmic nurse.Footnote 87 On 17 July 1928, while examining a patient afflicted with trachoma, Khadder's own eyes became infected. Following a month of preventative treatment provided to Khadder from the government at no cost, the infection permanently damaged both corneas, resulting in near-total blindness. On her application for pension, the pension board stated that Khadder's ability to contribute to her own support was “totally destroyed.”Footnote 88
Khadder applied for a government pension on the grounds that she had been permanently injured on the job. Her application, however, was complicated by the multi-institutional trajectory of her career. Because Khadder had spent two years in the employ of St. John's Hospital and had only returned to government service a year prior to her injury, the administration was not convinced that she was entitled to a pension. As a Grade V nurse, Khadder was not a pensionable officer, nor had she completed the ten years of service necessary to receive a pension.Footnote 89 The director of the Department of Health, however, argued that upon the establishment of a cadre of nurses, Khadder would have been considered in a pensionable position and thus should receive the pension he assumed she would have been eligible for in the future. The pension board decided, in light of the “tragic” nature of Khadder's injury, to grant her sick leave from the date of her hospital admission until the cessation of treatment and a pension upon retirement. Under the 1925 Pensions Ordinance, Khadder was entitled to receive £P 32.308 per year, roughly a third of her annual salary.Footnote 90
Six months after the board's decision, the high commissioner of Palestine wrote to the Colonial Office in London, asking for a review of Khadder's case. The pension rate Khadder was given, he argued, was calculated based on misleading information about the length of her service. The original pension allotment took the start of Khadder's employment to be October 1927, the date she was retransferred to government employ.Footnote 91 Using this date to calculate a pension allotment, the high commissioner argued, unfairly penalized Khadder because it ignored her previous work for the government, prior to her special assignment with the Order of St. Johns. The high commissioner therefore requested that Khadder's pension be recalculated to reflect her work with the government since the beginning of her training in 1920 and be dated from the time she turned twenty. This recalculation would raise her annual pension from £P32.308 to £P36.923.Footnote 92 Phoebe Khadder applied for a pension under the assumption that as a government employee, she was entitled to compensation for on-the-job injuries, even if her initial contract was not for a pensionable position. Her application reflected an understanding that the administration had an obligation to her and that she should interface with the government as one of its employees, not merely one of its subjects.
Information about Khadder's life and employment as a nurse is necessarily sparse. It can only be pieced together from the snippets contained in her pension applications; the employment records of Hana Abdo (Hanaʾ ʿAbdu), by contrast, are somewhat more robust and offer a view not only onto the interactions between nurses and their employers, but also onto the ways in which nurses viewed their jobs. Hana Abdo began her nurse training in 1933 or 1934 at the Government Hospital in Nablus. She qualified as a graduate nurse in 1937 and received her midwifery certification in 1940. From 1937 to 1947, she worked at the hospital in Nablus. Abdo was employed on a salary scale of £P 90-8-144, and her file indicates that she received wage increases of £P 8 on a regular basis.Footnote 93 Through the duration of her tenure in Nablus, Abdo consistently applied for and took regular vacation leaves of twenty-one days. Most of those vacations were spent in the town of al-Mujaydil—presumably where her family lived, some fifty kilometers away. Abdo also applied three times for sick leave—once for a fractured wrist and twice on account of her rheumatism.Footnote 94 Abdo’s regular communications with the Department of Health seem a matter of routine, but that they were routine remains significant. As an employee, Abdo was entitled to numerous benefits—salary increases, vacation, and sick leave—and she clearly advocated for her rights to take them.
Abdo's employment records indicate that she was born around 1920, which would make her seventeen when she qualified as a graduate nurse. Even if the records are slightly incorrect, she was fairly young when training and working in Nablus. If she was indeed from al-Mujaydil or if her family lived there, as her annual vacation leaves seem to indicate, then she left home to pursue her education and career at quite a distance and quite an early age. Whether that move was driven by financial necessity or a simple desire to work in the medical field, it flies in the face of any assumption that even professional women were somehow bound to their families and localities above any professional endeavors.
Abdo's career trajectory also refutes notions that nursing was merely a temporary means of employment rather than a career. In 1945, she married a British sergeant. Although the law technically required women employed with the government to retire upon marriage, Abdo requested—and was granted—permission to continue work as a staff nurse.Footnote 95 Furthermore, for the first year of their marriage, Abdo (now Hanna Chappell) remained in Nablus, while her new husband was stationed in Haifa. In 1947, she requested a transfer to the hospital in Haifa because she and her husband found the separation “inconvenient.”Footnote 96 Abdo was transferred to the Government Hospital in Haifa in an exchange with Afifa Najjar (formerly of the infant welfare clinic in Beit Sahur). She spent the remainder of her time in Palestine working in the maternity ward. Abdo and her husband left Palestine in 1948 with the British withdrawal.Footnote 97 A final note in her file contains a general letter of recommendation on her behalf from the British matron of the Haifa hospital, indicating that Abdo intended to find similar work in England.Footnote 98 Clearly for Abdo, nursing was meant to be a life-long career, one that would not be subsumed by marriage and that would, at least at times, take precedence over her new married life. Although she certainly fought very hard to be transferred near her husband, she did not relocate until a job was available for her. Abdo's geographic journey, as well as that of Najjar (who, according to available records, worked in at least four separate locations over sixteen years), suggests a professional mobility not often ascribed to Palestinian women of the time. Nursing, at least to some of these women, was a long-term pursuit. It was also, however, a job. In 1947, Abdo earned £P148, exceeding her initial pay scale. Although she remained in service after her marriage, she still lobbied to receive the £P93 marriage gratuity she felt was owed her under the terms of her contract.Footnote 99
As the cases of Khadder and Abdo demonstrate, Palestinian nurses advocated for themselves as workers and employees. In working as nurses, they had entered a professional network that, at times, took them far from their homes, brought them into close and contested relationship with the colonial governmental regime, and gave them access to certain rights and benefits not available to most of their conationals.
CONCLUSION
From 1923 to 1948, around one thousand women qualified as graduate nurses in Palestine. Still other women worked as midwives and nurses without formal qualifications in village and town clinics throughout the country. Palestinian nurses operated within a politics of care that constituted colonial governance in the Mandate period. As this article has shown, Palestinian nurses were important figures in the intimate relationships that characterized daily welfare governance, mediating the provision of public health care between localities and the colonial regime. They were the experts depended upon by the governing power to carry out public health schemes and they greatly complicate ideas of what experts and expertise might look like. They were also professionals integrated into a colonial labor market and as such offer new ways of locating Palestinian women's histories.
Following the lives and work of these women gives us a clearer view of all facets of colonial public health governance. In analyzing the public–private system that trained nurses, we see how Mandate governance was built upon cooperation between the colonial administration and pre-existing nonstate institutions, and in particular the role missions played in daily governance. The nurses’ myriad institutional and interpersonal relationships in their town and village clinics demonstrate the ways in which the colonial public health system emerged from the specificities of local political constellations. Finally, understanding these women as professionals within a colonial labor structure highlights how colonial governance operated through unrecognized actors and posits labor as a central concern in Palestinian women's history. Pulling nurses out of the archive is an act of historical recovery. But beyond recovering their lives and experiences, by focusing on the stories of these women we can illuminate the construction and operation of daily governance under the Mandate.
