“And when I am ill, it is Allah who heals me.”
Surah Ash-Shu’ara The Poets: 26:80 A supplication of Prophet Abraham
Introduction
Softly whirring in the background, the thrum of the dialysis machine contrasted against the sharp antiseptic hospital smell. Aida Touré was laying on her left side, her left arm half on and half off the bed where the machine connected into her body, her blood running out to be cleaned and filtered by the machine and then run back into her body through the same surgically implanted fistula.Footnote 1 Aida’s hypertension had become so severe her kidneys were permanently damaged and required dialysis. Her youthful age, thirty-six at the time, made her illness even more devastating to comprehend. “This [illness] is God’s will. If you have that illness, it was God who has decided, we just have to accept and try to live with it,” Aida shared. In the same conversation, her mother stated, “Aida is a fervent believer. She never complains nor cries about her illness. She is always joyful.” This sentiment was one her doctors and nurses echoed, sharing the ways Aida made people around the hospital laugh and smile on the days she came in for dialysis, her happy nature in sharp contrast to the grimness of her disease experience.
Living with chronic illness requires many shifts in the ways individuals and their families experience the everyday. Most Senegalese women’s lives changed drastically with the onset of symptoms from hypertension, diabetes, and kidney disease or failure. Conceptions of self, kin structures, and social support networks were all transformed and had to be renegotiated in the face of metabolic diseases. Religious faith was central to women’s navigation of their illness and to how they talked about and understood their illnesses. Faith was also central to caregivers and healers working with and treating the afflicted. Islam was a central way of understanding bodily changes and a way of navigating the increased strain on family members.
Women’s sense of faith surfaced as powerful and agentive, a way to reclaim a sense of dignity and connectedness and maintain moral identity within kin and social networks (Hamed and Daniel Reference Hamed and Daniel2017). For Aida, faith was a way of making sense of her disease, a way of coping with her illness, and a way of maintaining connection with others. Faith was also a way for her mother (and primary caregiver) to understand and navigate the debilitating illness of her daughter and what was asked of and required of her as a caregiver in the face of such an illness. Islamic tenets around illness provided both women a way of maintaining a sense of place and purpose in the complex moral economy of their kin and social structures, despite not having financial resources, time, or the ability to reciprocate in the ways they had been able to prior to the onset of Aida’s disease.
Faith centers relationships within webs of care. Public health and social science literature have examined resilience and coping in the face of hardship, but these studies often focus on individuals (Willen et al. Reference Willen, Williamson, Walsh, Hyman and Tootle2022), while faith is relational (Hardin Reference Hardin2020). Relationality is key to understanding Senegalese navigation of illness experiences (Bunkley Reference Bunkley2022, Reference Bunkley2025) and the same is true for the ways women evoked an understanding of faith and religion. Social scientists and scholars of religious studies have written about religion as a form of medicine and as a way of coping, accepting, flourishing, navigating, and making sense of unstable worlds (Abraído-Lanza et al. Reference Abraído-Lanza, Vásquez and Echeverría2004; Ahmadi et al. Reference Ahmadi, Khodayarifard, Zandi, Khorrami-Markani, Ghobari-Bonab, Sabzevari and Ahmadi2018; Ai et al. Reference Ai, Park, Huang, Rodgers and Tice2007; Celik et al. Reference Celik, Yilmaz and Anataca2022; Cummings and Pargament Reference Cummings and Pargament2010; Fanany Reference Fanany2013; Hardin Reference Hardin2018; Nairn and Merluzzi Reference Nairn and Merluzzi2003; Onyishi et al. Reference Onyishi, Eseadi, Ilechukwu, Okoro, Okolie, Egbule and Asogwa2022; Roger and Hatala Reference Roger and Hatala2018; Şentürk et al. Reference Şentürk, Keskin and Turan2022). This paper explores how Islamic faith in Allah allowed Senegalese women experiencing chronic illness to maintain relationship, connectivity, dignity, and a place within their social moral economies in three ways, through 1) acceptance; 2) nattu—Wolof for faith in Allah’s will; and 3) duty.
Setting and methods
This ethnographic research took place over fifteen months from February 2018 to May 2019 in Saint-Louis, the former French colonial capital, in northwestern Senegal. I worked with two research collaborators, Fatoumata Diagne and Ndèye Aminata Mbaye, who were both completing their Master’s degrees in English and Translation at Université Gaston Berger in Saint-Louis. Together, we recruited women who had a clinical diagnosis of hypertension, diabetes, kidney disease/failure (metabolic disorders broadly) and who were interested in participating in research on their experiences with one or more of these ailments. We met women at the Saint-Louis public hospital and from the two volunteer-run locations of the Diabetes Association on the island of Saint-Louis. These Diabetes Associations were affiliated with the public hospital while also receiving funding from external nongovernmental organizations such as Sister Cities. This mix of recruitment location ensured we had representation from varying socioeconomic backgrounds. Almost all the women who participated identified as Wolof. We initially conducted 4 standardized surveys with 107 women.Footnote 2 Surveys used were: 1) a combined version of Household Food Insecurity Scale and the Household Hunger Scale, 2) Health Related Quality of Life, 3) Hopkins Symptoms Checklist, and 4) National Institutes of Health Social Relationship Scale. Our research team translated these surveys from English into both French and Wolof and back translated into English. We had an independent check of survey translations by a person who was not involved in either the translation or back translation.
From the 107 women who participated in survey collection, 36 women agreed to engage in ongoing, focused ethnographic methods—participant observation and ethnographic interviewing. In addition to interviewing women, our research team interviewed women’s kin, doctors, nurses, midwives, volunteers at the Diabetes Association, pharmacists, and traditional healers, culminating in a total of sixty-seven ethnographic interviews. The research team spent considerable time engaging in participant observation at the hospital, the two Diabetes Association locations, with women in their homes, at different pharmacies, and attending doctor’s appointments. All interviews were recorded, translated, and transcribed from French or Wolof to English and coded in MAXQDA using an inductive analytic approach. With respect for people’s privacy, all names have been changed to pseudonyms.
Diabetes in Senegal
This project was designed to understand the rise of metabolic disorders, namely diabetes, in Senegal. The World Health Organization (WHO) estimates that “more than half of people living with diabetes in the African Region are undiagnosed” (Reference Allred, Mbaye, Diagne, Harrell, McCurdy and Bunkley2023, 2). This has led the WHO to dub diabetes “a silent killer in Africa” (ibid.). In Senegal it is estimated there exists around 251,600 total cases of diabetes in adults (aged 20–79) out of an adult population of 8,743,400 (about 3.8 percent prevalence) (International Diabetes Federation 2024). These numbers are projected to double by 2045 (ibid.). Senegal lacks a robust biomedical response to noncommunicable diseases in general and diabetes in particular. Most women in Senegal arrived at a diagnosis of diabetes through a presentation of symptoms, rather than through extensive biomedical testing (Bunkley Reference Bunkley2025). Blood sugar could be tested for 500 XOF (about US$1) at the Diabetes Association, but this doesn’t provide the same level of accuracy as an HbA1cFootnote 3 test would provide. Doctors worked to manage symptoms, providing prescriptions of primarily Metformin and insulin, though insulin proved tricky both in women being able to keep it consistently refrigerated and in having to inject it themselves, as well as a lack of access to glucose monitors to know precisely how much insulin to take at any given time. Management of diabetes was very challenging, and the mismanagement or inability to manage diabetes often meant women felt discomfort in some form more often than not. Because of these challenges of diagnosis and treatment, “Africa has the highest level of undiagnosed diabetes and the highest level of mortality for individuals under age 60 due to diabetes in the world” (Bunkley Reference Bunkley2021; International Diabetes Federation 2019). I was particularly interested in the gendered nature of diabetes in Senegal. By focusing exclusively on women with clinical diagnoses of metabolic disorders, diabetes, hypertension, and kidney disease/failure, this research pushes global health to think about the gendered nature of chronic illness and to consider women’s health outside of maternal and child health, and African health outside of the narrow framework of infectious disease.
While this was not a study designed specifically to investigate religion, it is perhaps unsurprising how important religion proved to be for sick women. Religion came up, unprompted, in almost every conversation we had with women. The themes of acceptance, faith or nattu, and duty were prevalent across many of our conversations and stood out as a way of coping, navigating, and making meaning of an illness, especially against a backdrop of limited resources. These ideas were mobilized both by women who were formally diagnosed and experiencing metabolic disorders and by their caregivers.
Anthropologists and African studies scholars have contributed important research about health and healing across the Continent (e.g., Bledsoe Reference Bledsoe2002; Carruth and Mendenhall Reference Carruth and Mendenhall2018, Reference Carruth and Mendenhall2019; Hunleth Reference Hunleth2017; Hunt Reference Hunt1999, Reference Hunt2016; Janzen Reference Janzen1982; Livingston Reference Livingston2005, Reference Livingston2012; Vaughan Reference Vaughan2018; Wendland Reference Wendland2010). Much of this research emphasizes the communal and social nature of health and healing (Feierman and Janzen Reference Feierman and Janzen1992). While there have been notable research contributions on the role religion plays in various health and disease research in sub-Saharan Africa (e.g., Klaits Reference Klaits2010; Scherz et al. Reference Scherz, Mpanga and Namirembe2024), much of this research has focused on Christianity or the blending of Christianity and traditional religions. Carolyn Sargent’s work with West African migrants in France is a key addition to anthropological research on Islam and health. Specifically, her focus on the ways the Muslim body is viewed in France (Sargent and Larchanché Reference Sargent and Larchanché2007) and focus on Islamic discourse and reproductive strategies (Sargent Reference Sargent2006), as well as her special issue with Marcia Inhorn, which at the time of publication the authors believed to be the “first collection of articles specifically devoted to medical anthropology in the Muslim world” (Inhorn and Sargent Reference Inhorn and Sargent2006, 1). Though religion was not the initial focus of this project, it became clear that religion and faith were key elements of women’s pluralistic care. This work hopes to contribute more knowledge around Islam and health and healing in sub-Saharan Africa. What can we learn about African health, healing, and embodiment when we research the intersection of Islam and chronic illness? This work addresses the nuanced ways Islam influences health and healing in Senegal.
Islam in Senegal
It is estimated that 50 percent of the African continent identifies as Muslim and about 30 percent of sub-Saharan Africa identifies as Muslim (Hackett et al. Reference Hackett, Stonawski, Tong, Kramer, Shi and Fahmy2025). Senegal has a proud history of the Fula peoples bringing the original teachings of the Qur’an to Senegal in the eleventh century (Gellar Reference Gellar2020). An estimated 97 percent of the current population of Senegal identifies as Muslim (Pew Research Center 2025). Fula and Wolof scholars developed Ajami script, ensuring preservation of their history, heritage, and religious practices (Ngom Reference Ngom2016, Reference Ngom, Albaugh and De Luna2018). Ajami literacy is still taught today, mostly through Qur’anic schools, educating students outside of formal French-based state systems.
Over the course of our ethnographic research, all the women and their caregivers interviewed identified as Muslim and referenced their faith and religion as an important part of their care, healing, and treatment. Research on the intersection of health, healing, and Islam often centers on the importance of spiritual healers responsible for healing spiritual matters, such as jinn possession or the evil eye (e.g., Pontzen Reference Pontzen and Terje2022; Kwame and Mananu Reference Kwame and Mananu2023). In Senegal, religious healers are often marabouts and Imams. Some of the women with whom we worked were engaging with these healers and these forms of religious healing, though they were often reluctant to speak with us about this. Tension existed between religious healers and biomedically trained doctors with the Senegalese government actively promoting a campaign against seeking out herbal remedies as treatments for any kind of ailment, but especially for metabolic disorders (Bunkley Reference Bunkley2025). This made people whom we interviewed wary to discuss their pluralistic or religious care. However, women and their caregivers were very open about the ways in which faith sustained them and the ways in which faith was mobilized to make sense of disease and caregiving responsibility. We argue that faith was critical for women and their caregivers to maintain relationships, connectivity, dignity, and a place within their social moral economies. We observed this in three specific ways: acceptance, nattu (Allah’s will), and duty. Conceptualizing faith as a cornerstone for women in maintaining their social worlds and moral economies enriches our understandings of how Senegalese women, caregivers, and broader society are navigating a rise in metabolic illnesses.
Acceptance
Acceptance was a theme that ran throughout conversations with women, clinical providers, volunteers at the Diabetes Association, and caregivers. The ability to accept one’s disease and one’s situation was believed (by doctors, nurses, and Diabetes Association staff) to be key to being able to cope and move forward with treatment. In many ways acceptance was what clinical staff saw as the beginning of successful biomedical treatment. Accept the disease. Accept a family member’s disease. Accept the amputation. Accept reduced mobility of a family member because of an amputation. Accept the need for chronic pharmaceutical use. Accept the expenses of chronic pharmaceutical use. Accept ongoing hospital strikes. Accept long wait times to receive clinical care. Accept that diets should change. Accept that diets likely would not change. Acceptance was the first step in recovery, and for many women acceptance was only possible with faith in Allah’s will.
Dr. Bâ, chief nephrologist at the Saint-Louis hospital, discussed the psychological effects of a diabetes diagnosis on his patients:
I will talk about three different groups. As a nephrologist, I may have patients suffering from diabetes without complications and some among those patients will easily accept the illness, very easily. For others, on the contrary, it is very difficult to accept it and those who hardly accept that they are sick are those who can’t accept that they will have to control their nutrition or to follow a diet. And the latter are more numerous than the first group. Also, those who accept their illness are most of the time intellectual people. I must confess that at the beginning it is depressing and stressful for them, but they will learn to accept and live with the illness. Another group of people who make (providing) the treatment easier for us (clinicians) is those from the middle class, the wealthy ones because they may not encounter difficulties to respect the specific diet. But when one cannot afford the specific diet required, it becomes very difficult to accept his/her condition. I can even say that over one-third of people living with diabetes cannot afford all the treatment fees and they will just end up eating the family lunches. The third group is composed of people doing dialysis sessions. Once they accept it there is less joy, they get depressed just because they know perfectly well their life depends on the machines and when one machine falls ill, they (patients doing dialysis) all become upset.
(Interview, October 10, 2018)Dr. Bâ’s response highlights that acceptance is not a simple act; being able to accept and then change is a luxury only some people can afford. Many people must continue to live in the same way because they cannot afford to change their diets, eat separately, go to doctor’s appointments, or fill prescriptions. But acceptance is not just about recognizing one has a disease that needs to be treated, it is also accepting that aspects of one’s life must change. Even if biomedical doctors are not consulted or prescriptions remain unfilled, the afflicted must “accept” or live with the pain and discomfort of disease.
Allah, religion, prayer—faith in a larger cosmic plan—are central to the ability to accept, to be able to live with the pain and the daily changes the pain brings. A few days before Dr. Bâ’s discussion on acceptance, his patient Aida Touré said to me, “Being ill doesn’t mean you have to give up on life, being angry all the time. It is a divine decision, and I have to accept that” (October 6, 2018). By divine, she meant from Allah, heavenly divine, a decision made by a larger and perhaps unknowable cosmic plan. Through acceptance of this cosmic plan, Aida Touré was also able to accept her disease of hypertension, her experience with ongoing dialysis, and her general poor state of health. Situating oneself within a larger cosmology does the work of restoring a sense of sociality for individuals who might feel isolated because of their disease. It also removes the potential for blame for a disease. In her work on Down syndrome in Jordan, Christine Sargent writes “Both parents described acceptance (taqabbul)… as a lifelong process of learning to resist the injurious ideas, beliefs, and practices that people without Down syndrome… attached to Down syndrome” (Sargent Reference Sargent2026, 2-3). She goes on to write “…I came to see acceptance as a mode of “being-with” (Al Mohammad quoted in Sargent Reference Sargent2026) and a mode of anticipation” (Sargent Reference Sargent2026, 3). The emphasis on acceptance as agentive seems to be a common theme across Islam and Islamic countries and allows for another understanding of what is meant by “acceptance” and how it is used as an active (versus passive) form of coping. Research on the relationship between Islam and acceptance, particularly of chronic diseases like diabetes, has been documented in other areas of the Muslim world, for example, see Chalmiers et al.’s (Reference Chalmiers, Istemi and Simsek2023) work or Celik et al.’s (Reference Celik, Yilmaz and Anataca2022) work in Turkey. Focusing on Islam and, in this instance, Senegal, widens an understanding of religiosity’s relationship to accepting, healing, coping, and flourishing with a chronic disease.
For clinical providers and volunteers at the Diabetes Association, acceptance among the afflicted was viewed as a necessary first step towards patients’ ability to begin physically and emotionally coping with a diagnosis of hypertension, diabetes, or kidney disease/failure and seeking the help needed, both clinically and socially. From a clinical perspective, only if someone was able to accept their illness could they begin to move forward in a manner that embraced the necessary changes for living with metabolic disorders—dietary changes, pharmaceutical use, ongoing clinical appointments, and lab work. From a social perspective, accepting an illness meant the beginning of being able to ask for and receive help.
We first met Bineta Dioum in March 2019 at the Diabetes Association, a volunteer-run organization, located at the military hospital.Footnote 4 Bineta Dioum was young, around thirty years old, and had been diagnosed with diabetes after the delivery of her second child about three years earlier. She grew up on the coast outside Dakar and moved up to Saint-Louis when she married her husband. When we arrived at her house, she was sitting in the hall breastfeeding her youngest child, a one-year-old boy. She offered us chairs, bright light reflecting off both the sand and the Senegalese river into the hallway, illuminating the cream-yellow walls.
Bineta’s diabetes was diagnosed when she began rapidly losing weight and had frequent urination. She was treated with pills, likely metformin, and not insulin injections. She no longer had the means to afford these pharmaceuticals and instead relied on eating as many vegetables as possible and monitoring her sugar with semi-regular (about once every one or two weeks) testing at the Diabetes Association. Bineta shared that when she received her diagnosis, she was shocked and scared, overwhelmed. She cried and was very worried about her situation. We asked how she felt now, and she replied, “I am still feeling this way, I feel scared for no reason. Sometimes I feel angry or unhappy. I didn’t expect that [to have diabetes], but it is Allah’s will, we just have to accept it” (Interview, April 5, 2019). Her weight loss was very difficult for her. For a while she stopped going out because people were staring and gossiping about her, an isolating experience many women with metabolic disorders in Senegal experienced (Bunkley Reference Bunkley2025). When asked about her diet, what she felt was okay for her to eat, she shared:
It is difficult for me because it [the diet] is not what I want. I used to eat rice and it is what we have here in Senegal. It is difficult, very difficult, but that is what Allah has planned for me. I was advised to eat a lot of fish, but it is not okay to eat fish when you are nursing. When I was at the hospital, they told me to stop eating so many things that I was wondering what will be left for me to eat. The only thing we have here is rice.
(Interview, April 5, 2019)While clinical providers saw acceptance as key to treatment and changing lifestyle, the other side of this was accepting that sometimes there was nothing an individual could actually do. Bineta invoked Allah frequently when we spoke. She acknowledged the difficulty of her various situations and also seemed able to accept these difficulties by acknowledging they came from Allah. She could not afford pharmaceuticals and struggled to eat the “correct,” diabetic diet. But she found solace in knowing that this was the path Allah had planned for her—even if that path was hardship. Crucially, it also allowed her to accept that there was very little she could do to treat herself. Few women I spoke with were able to accept the disease and move forward with prescribed clinical changes. Far more often, women seemed to accept that they had a disease but were incapable of doing anything to address it, accepting that not only was it Allah’s plan for them to fall ill, but perhaps it was also Allah’s plan that they were unable to afford treatment or the “right” food. Acceptance is not always about the beginning of change, as clinical providers would hope. For many women in Senegal, acceptance was more often about accepting that circumstances were completely outside of one’s own control. In this way, acceptance was closely entwined with the concept nattu—or the belief that Allah had sent this particular affliction as a way of being close to the afflicted, as a way of letting the person know they were not alone and not forgotten by Allah.
Nattu—faith in Allah’s will
Maïmouna Diaw first introduced me to the concept of nattu. In late October 2018, while spending time with Maïmouna, her daughter, a neighbor friend, and the neighbor’s children, Maïmouna responded to the questions “what does health look like to you? What does health mean to you?”:
When you are healthy you can do whatever you want, the sky is the limit. If you spend a year without illness you have to wonder about your situation because illness is like a test Allah gives you and if you have no illness in a year you have to worry about your situation. Maybe you are enjoying life, not praying, not worried about your life. Illness makes you closer to Allah. If Allah tests [nattu] you [with illness] it means He loves you and does not forget you.
(Interview, October 21, 2018)Maïmouna was using the Wolof word nattu, a word for an obstacle or problem that manifests in a person’s life but specifically is connected to Allah testing that individual. Through sickness, Allah is showing a person that He has not forgotten them. Maïmouna then said, “you have to accept it” (Fieldnotes, October 21, 2018). In Wolof, nattu, the noun, or nàtt, the verb, is a way to describe Allah’s testing or trials of an individual; it is the hardship or suffering people face during their lifetime. The word nattu directly relates to the Arabic word Fitna. Islam teaches that everyone must go through hardship. It is only through struggle that people can be purified, find paradise, and avoid hell:
Misfortunes can only happen with God’s permission—He will guide the heart of anyone who believes in Him: God knows all things—so obey God and the Messenger. (The Qur’an 2005:377, 64 Mutual Loss 18:11)
Prophet Muhammad said If Allah wants to do good to somebody, He afflicts him with trials.
(Reference al-BukhariSahih al-Bukhari: Volume 7, Book 70, Number 548)Trials, such as sickness, can be seen as a gift to the afflicted, allowing them a way to be tried here on earth so that they might reach Paradise after death. Studies have shown that Muslim diabetic patients in Pakistan, and Iran similarly invoke this idea of medical conditions being a gift from Allah (Onyishi et al. Reference Onyishi, Eseadi, Ilechukwu, Okoro, Okolie, Egbule and Asogwa2022; Kazemi Reference Kazemi2010). In a study with cancer patients/survivors in Iran, this idea of Allah using sickness as a way of testing individuals was called “Benevolent Religious Reappraisal,” which the authors define as “using religion to redefine the stressor as benevolent and potentially beneficial” (Ahmadi et al. Reference Ahmadi, Khodayarifard, Zandi, Khorrami-Markani, Ghobari-Bonab, Sabzevari and Ahmadi2018, 726). In “Benevolent Religious Reappraisal,” sickness brings the sufferer closer to Allah. What happens to an individual only happens through Allah’s will. Everything happens with His knowing and having been the root cause. In Islam there is also the belief that if there is a disease on earth, there is also a cure because Allah will only give a problem like a disease if it also has a solution:
The Prophet said, There is no disease that Allah has created, except that He has created its treatment. (Reference al-BukhariSahih al-Bukhari Book 76, Hadith 1)
Though what the cure is or would be, is debatable. Women often talked about praying for a cure. But many women found solace in the experience of their disease, knowing that the disease experience brought them closer to Allah. Women believed that Allah gave them their trials for a reason and found solace in knowing that through their illness, Allah was always with them:
Indeed greater reward comes with greater trial. And indeed, when Allah loves a people, He subjects them to trials .
(Reference al-BukhariSahih al Bukhari Book 36, Hadith 94)The very act of being tested, of being ill, means that Allah is present with the afflicted, making His presence and love known to them. These verses from the Qur’an and the Sunni Hadiths illustrate that trials are part of a Muslim’s journey. It is through acceptance of these, patience, and faith in Allah’s will, that an individual accepts their situation and can feel closer to God.
For the afflicted and their social networks, nattu is part of the multi-causality negotiation in understanding why a person has a disease (Kleinman Reference Kleinman1980, Reference Kleinman1986; Janzen Reference Janzen1982; Poss and Jezewski, Reference Poss and Jezewski2002). These negotiations are dynamic, not fixed. Throughout our research, people explained their suffering from diabetes/hypertension as being due to the foods they ate (Bunkley Reference Bunkley2021), because of their mothers (Bunkley Reference Bunkley2022), or because of nattu. These various explanatory models of disease changed depending on the story being told or the questions asked. Nattu and Allah were seen to be key reasons behind disease causality for many people and their caregivers but not the only reasons.
Nattu is a way for afflicted individuals and their social and kin networks to maintain moral identities and also maintain a place of worthiness within these moral economies. Nattu might be invoked by the individual, but as my research has shown, the individual is not the only one experiencing and living with diabetes, hypertension, and other metabolic disorders (Bunkley Reference Bunkley2022, Reference Bunkley2025). The invocation of nattu is integral in maintaining kin and social relations for women suffering from illness. The chronic nature of diabetes and hypertension means afflicted individuals are in need of chronic support often without an ability to reciprocate. For close kin, support comes in the form of physical and emotional care and caregiving, in addition to financial support. Nattu does work in two ways. First, it allows for families to make sense of receiving, often in a long-term way, while being unable to reciprocate. Second, it allows for strained kin and social support networks to decline providing support. In both instances nattu buffers expectations that cannot be fulfilled. Suffering from disease and illness affects the entire family. Sometimes members of social networks are called upon to provide money or physical care they are not capable of providing in that moment. Nattu allows for a way for these relationships to be maintained and continued, and not seen as failed, even when those relationships cannot provide support. When a family is unable to support another member, the entire family, as well as the afflicted, can evoke nattu as a way of giving grace (Bunkley et al. Reference Bunkley, Diagne, Mbaye, Mendenhall and Hardin2025). The alternative might be to cut off the afflicted, or distance oneself from the family. Nattu seems to be a way to maintain social relationships and connections with kin even when they are no longer able to help.
In addition to allowing the afflicted and their family members to maintain a moral identity, nattu allows for afflicted peoples’ experiences to move from the level of the individual to the structural. Nattu imbricates the experience of the suffering in a web of political, economic, and social issues (Farmer Reference Farmer2004; Kleinman et al. Reference Kleinman, Veena and Margaret1997). The experience of nattu is inherently an experience of lack of control. This helps recognize the influence of larger institutions such as national health programs, global health funding, and environmental pollution, on individual and household health.
Astou Kébé, fifty-nine years old at the time of our interviews, lived near the military hospital on the northern part of the island of Saint-Louis. She and her family had a few rooms on the ground floor of a building whose top floor was occupied by another family. The walls of her home were painted a warm, butter yellow. Astou had divorced her husband and then he had passed away several years later. She had four children, at least one of whom was living with Astou and raising her children in the home.
Astou was diagnosed with hypertension soon after her mother passed away from a stroke. The doctors were concerned about her sugar levels, but said she was not yet considered diabetic. The doctors told her she would be diabetic if she was unable to get her sugar levels down. She had her blood sugar checked occasionally by walking over to the Diabetes Association in the military hospital. When asked how she treated her hypertension and her blood sugar she pulled down a purse from the top of her wardrobe. From within this cherry-red, patent leather bag she removed all her medical records from a blue plastic bag of the sort used at every corner shop. Her medical records contained her Diabetes Association membership card, old prescriptions, requests for lab analysis, and various doctor’s notes.
When asked about her diabetes she responded: “You can do nothing about what Allah gives you. If Allah decides that you will have diabetes, no one can do anything about it. Allah creates death and every day someone dies. We all die” (Interview, February 8, 2019). She went on to say that if she could reduce her sugar, she would be fine. Women she had met in the pharmacy waiting for a prescription to be filled had warned her against taking any pills for her condition and suggested she just try and lower her blood sugar by changing her diet. When asked how she would lower her blood sugar she said, “avoid sweet food” and also “drinking a tea of laurier, or bay leaves, is known to help lower sugar levels.” When asked whether or not she went to see a doctor regularly and if so, how she paid for those appointments and any pharmaceuticals she might use, be they laurier or biomedical treatments (such as metformin), Astou responded, “It is Allah’s affair. I trust Allah.” She meant that if she was supposed to go to the appointment or to buy pharmaceuticals, Allah would provide her the money in time to do such a thing. If not, then she was not meant to access those things at that time. In the study with Iranian cancer patients/survivors, Ahmadi et al. (Reference Ahmadi, Khodayarifard, Zandi, Khorrami-Markani, Ghobari-Bonab, Sabzevari and Ahmadi2018) call this “Passive Religious Deferral” whereby people wait for Allah to take control of the situation. While this might seem passive, in Senegal this actually was very much an active way to continue to mobilize networks of kin and also continue navigating the structural issues of living in a low-resource setting.
Astou’s disease experience seemed to be one that was always in flux. Some days she felt bad and others she was fine. Some days her sugar was high and other days it was normal. Sometimes she had money for a doctor’s appointment and other days she did not. Other women in this research were incredibly sick. Their sugar levels were always extremely high, their pain levels nearly unmanageable. Astou’s experience represented many women who are on the edge, women who are not yet diabetic but are headed towards diabetes; women who have family members with severe history, such as Astou’s mother dying of stroke, but they themselves are not yet alarmingly ill.
A week later in another interview with Astou, the television on in her room with news commentary about the approaching presidential election in Senegal, Astou said she was happy. When asked what a happy day was like for her, what makes her happy, she responded:
All good things, positive things, make me happy. We never wish to have negative things or bad events in our life, but when it is Allah’s plan you can do nothing about it. If we were the masters of our lives, we would only have happy experiences, but it is Allah who decides. It is Allah who gives us those trials. You cannot do anything about that. But I just give thanks to Allah because there are people who live worse than what we are living right now. I do not envy people who have better living conditions than me. I keep in mind those who do not even have what I have, and this can make me happy and feel really grateful.
(Interview, February 15, 2019)Using the word nattu, Astou further explained “‘moy tégué, moy tégué,’ meaning Allah is the one who gives us all those troubles, all those trials and he is the only one who can help us get rid of those troubles” (Interview, February 15, 2019). Astou has given herself over to Allah’s plan. While this may appear passive, this is quite active as a way of accepting and coming to peace with the situation as it is and is more in line with “Collaborative Religious Coping,” as found in Ahmadi et al.’s (Reference Ahmadi, Khodayarifard, Zandi, Khorrami-Markani, Ghobari-Bonab, Sabzevari and Ahmadi2018) study with Iranian cancer patients. Collaborative Religious Coping puts the afflicted in relationship with Allah where the two are working together in partnership (Reference Ahmadi, Khodayarifard, Zandi, Khorrami-Markani, Ghobari-Bonab, Sabzevari and Ahmadi2018, 729).
Nattu and acceptance are more than just an ability to change, in the ways many providers and Diabetes Association volunteers thought. Acceptance is also accepting that things are as they are and that they will not change. There was a sense of release and a freedom in this version of acceptance. Nattu, a test from Allah, allows a person to see chronicity and pain in a new light, one in which Allah is intimately involved and where one is liberated from blame or shame or responsibility of having brought this illness upon themselves (especially with diabetes, which is linked so closely to nutrition which is seen as a choice made over and over). Nattu allows afflicted individuals to take comfort in their affliction, to be closer to Allah. It is also a way of navigating the conditions of living in low-resource settings with many structural inequalities and facing issues such as ongoing strikes and long wait times for access to clinical spaces and inability to afford the “right” foods or pharmaceuticals.
Duty
Chronic disease requires chronic care. The burden of physically and emotionally caring for someone with a chronic disease is often placed on household and family members. Chronic care requires a shift in lifestyle not just for the afflicted, but also for those around them who assist with their daily activities. Thus, caregivers must also accept the disease and its permanence; acceptance that their life and their role within the family have also changed. Family members spoke of this in terms of duty—often the duty an individual has to a parent. Islam teaches that a child has a duty to her parents. By caring for parents, a child is honoring the parents and honoring Allah:
Surah 17 The Night Journey, Allah says,
Your Lord has commanded that you should worship none but Him, and that you be kind to your parents. If either or both of them reach old age with you, say no word that shows impatience with them, and do not be harsh with them, but speak to them respectfully and lower your wing in humility towards them in kindness and say, “Lord, have mercy on them, just as they cared for me when I was little.
(The Qur’an 2005: 176, 17 The Night Journey 9:23–24)This form of duty is also a way of worshipping Allah. There is a fundamental blessing embedded in the act of caring for one’s parents. Duty and care become spiritual acts. In this way, duty to care for one’s ailing parent, is a way to be closer to Allah.
In early November 2018, we searched for Koumba Camara at the dialysis center at the hospital. We knew she had brought her mother, Thiané Wade, to receive one of her thrice weekly dialysis sessions. We found Koumba sitting in the hospital’s main courtyard playing on her phone while she waited for her mother’s session to end. Koumba had a young face and dressed youthfully with black cat-eye frame glasses and a white shirt and white pants; her dark blue headscarf tucked into her denim jacket. Koumba was thin and tall and twenty-one years old when we first met her. She spoke calmly and quietly, with a demeanor that seemed unflappable.
Koumba had been accompanying her mother to her dialysis appointments for the past three months. Before that, one of her sisters had accompanied their mother. Koumba and two of her sisters rotated care for their mother who could not bathe herself and needed someone to cook and clean for her as well. Thiané Wade’s husband was still alive, but men of a certain social class typically do not engage in any kind of domestic activities once they are married. Thiané’s reliance on her daughters for help doing basic daily activities, such as bathing, was something I saw with most participants in my research. If women were older with daughters, their daughters took care of them. Some women relied on daughters-in-law, though being cared for by your own daughter was much preferred. Thiané had one son who worked outside of the house; while he provided financial support for his mother’s medical expenses, he would not have been asked to help with activities such as bathing.
Koumba had her baccalaureate, the French educational equivalent of a high school diploma. She had completed one year of university but had been forced to withdraw to help care for her mother. Since Koumba had finished high school, she was eligible for teacher training, which she successfully completed and was just waiting to be assigned to a school by the Ministry of Education. The Senegalese Ministries of Health and Education decide where people’s initial appointments will be, with staff competing for future relocation. Most people prefer to be in larger cities and there are many rural areas in the country that would not have teachers, nurses, or doctors without this planned assignment of staff. Koumba was clear that being a teacher was not her dream, but it was necessary for helping her family because it would mean a steady paycheck. Her brother’s wages were not enough for the family to live on and to support Thiané’s medical expenses. This theme of doing what was necessary came up throughout all interviews with caregivers. When Koumba was asked how she felt about her and her sister’s ability to support her mother she responded:
In the beginning, mom has always helped all of us, considering that it’s our turn to help her now that she needs us, all of us are ready to help her. Whoever is available, assists her. We make sure she is never alone at home. Even when she does not need anything, we avoid leaving her alone. We always make sure one of us stays with her, because loneliness can affect her psychologically. Since the very beginning, all of us daughters are ready to help. There are those of us that mom prefers to be with, because there are some who may have a better outlook and there are some of us who cannot cope with it. She has disputes with them, and they end up getting mad, then they decide to stop helping. For example, sometimes, her emotions may change, and she would get angry and start insulting me, things like that. But I tell myself that it’s a duty for me to assist her. I do not have to wait for anybody to do it before me. Even though I’m the youngest, I take my responsibilities to assist her.
(Interview, November 5, 2018)Koumba was one of the daughters Thiané felt closest to, though the impression was that this affection towards one daughter would change over time and the daughters shifted responsibilities accordingly.
In January 2019, Thiané shared that Koumba had been assigned to the region of Matam in northern Senegal and would begin teaching there immediately. While this was good for the family financially, Thiané seemed distraught. On the edge of tears Thiané shared, “I live in loneliness.” She spoke extensively about being alone, feeling alone. She felt her illness had taken her ability to feel close to anyone. She no longer went out or had any friends. Koumba’s move to Matam and profession as a teacher seemed necessary for the household’s financial situation, especially for Thiané to continue her treatments, pharmaceutical regimes, and doctor’s appointments. It meant, however, that Thiané no longer had her primary emotional support by her side.
Back in November 2018, in the interview with Koumba, when asked if her mother’s illness had changed her activities. She explained:
Yes, the illness has really limited the activities of all of us [her sisters]. For instance, we are unable to pay visits to our friends, but they understand us. They know it’s because our mom is ill. Besides, we are no longer able to go together to ceremonies like weddings. Because, before the illness, we could go to weddings together all of us leaving mom, dad and our sister-in-law. But we can no more do that. One or two of us always stay at home to assist our mom. Our sister-in-law is at home, but she cannot assist her as we do. We are always at home unless we have emergencies or classes, or meetings for example. And we ask someone else to stay with mom.
(Interview, November 5, 2018)Sirah, Koumba’s sister was another caregiver for Thiané. Koumba, who normally took her mother to her dialysis appointments, had an exam and wasn’t able accompany her mother on this particular day, so Sirah had stepped in. Sirah was training to be a nurse. Her mother’s illness had inspired her to help other people. Sirah had to drop out of school for a year to help her mother, taking her to dialysis sessions in Dakar before they were able to get a spot at the dialysis center in Saint-Louis. Sirah explained the difficulties of caring for her mother, that it took much of her time, how she and her sisters no longer attended weddings or naming ceremonies, themes echoed a month later in our interview with Koumba. Sirah said that she felt very depressed at the beginning of the dialysis sessions. She felt cut off from her own friends and way of living. She said she had to accept this, that only by accepting this reality, could she move forward. She also shared, “this is something you do, you sacrifice” (Interview and fieldnotes, October 10, 2018).
When visiting Thiané and discussing her loneliness and Koumba’s move to Matam, Sirah hovered at the edge of conversation. She watched her mother talk, interjected at moments, tried to help her mother remember things she seemed to have forgotten. Her voice was low and gentle. She seemed acutely aware of her mother’s sadness and when her mother spoke of her loneliness she nodded in agreement. Thiané confided that she could not talk with her husband, she could only talk with her daughters. Her husband did not listen to her. If she shared her problems with him, he would become angry with her. Desiring peace in her house, Thiané chose to not talk about her illness with him.
The primary caregivers for most women were their daughters or their granddaughters. Having daughters was viewed as critical for women’s perception of the type of care they received. Though daughters-in-law were not viewed as providing the same level of care or having the same emotional closeness or physical tenderness towards their mothers-in-law, duty in caring for parents or parents-in-law was seen as a blessing, a form of worship, and a way of achieving Paradise:
Surah 31 Luqman, Allah says,
We have commanded people to be good to their parents: their mothers carried them, with strain upon strain, and it takes two years to wean them. Give thanks to Me and to your parents—all will return to Me.
(The Qur’an 2005: 262, 31 Luqman 31:14)Anyone who is ill requires social support networks. For women, this is especially important. Women’s social support networks and kin networks are their safety nets. Most women depend on these networks for monetary support as well as for the labor of physical and emotional care. An emphasis on understanding the needs of caregivers and their caregiving practices is critical for better understanding how to best care for afflicted women (Agbo et al. Reference Agbo, Johnson, Sopoh and Nichter2019, Bunkley et al. Reference Bunkley, Comfort, Sarah, Lindsey, Sam and Jean2024). Caregivers are fundamental to both the household production of health, and the pluralistic health care sick individuals seek out. The strength (or weakness) of women’s social support networks determines their acute and chronic disease experiences.
The women with whom we spoke were all trying their best to provide care and be caregivers. Acceptance of one’s duty was the theme caregivers invoked—duty to a parent or a grandparent. Caregiving duty was viewed as spiritual, a blessing through the act. A way for the caregiver to be closer to Allah. A way of worshipping and finding solace in a difficult situation. Acceptance of one’s duty is a form of coping, a way of understanding and making sense of the hardship caregivers are facing with chronic illness of loved ones.
Conclusion
Faith was central to women’s and caregivers’ ability to sustain relationships, dignity, and sense of social belonging. Women’s navigation of their illness journeys was intimately connected to their understandings of Islamic teachings. Faith was important for meaning making, allowing for women and their caregivers to experience a sense of understanding why they were ill or why they had to care for a chronically ill person. Senegalese women with metabolic disorders and their caregivers mobilized Islam as a way of accepting the chronicity of disease, maintaining good moral standing within social networks, and making meaning of why they were experiencing such hardship. Unlike communicable diseases, the chronicity of noncommunicable disease often means permanent radical shifts in individual’s lives—chronic care, chronic therapeutic regimes, and chronic suffering. It challenges the afflicted’s sense of place in the world, sense of self, and what is possible in the future. Faith was a way of making sense and finding strength and connection in one’s affliction.
Understanding the role of Islam in health and healing for women in Senegal experiencing metabolic disorders adds to growing research on how people around the world are navigating the rise of chronic disease and especially metabolic disease. Attention to the intersection of Islam and metabolic illness in Senegal, in particular, further illuminates the importance of social worlds, the deep interembodied connections between the ill and their caregivers, and the role Islam plays in people’s healing journey—not just physical healing but also psychological, emotional, and spiritual.
Acknowledgements
Eternal gratitude to the women who participated in this research, for their generosity of time and openness to sharing experiences. Thank you to amazing research collaborators, Fatoumata Diagne and Ndèye Aminata Mbaye, without whom this research would not have the same richness. Many additional thanks to the doctors, nurses, and hospital administrative staff at the Saint-Louis public hospital, individuals who work tirelessly to provide care to the people of region. The team also recognizes and thanks the volunteers at the Diabetes Association, pharmacists, and healers. This work benefitted from the careful comments of mentors at University of Arizona, Drs. Ivy Pike, Susan Shaw, Mark Nichter, and Janelle Lamoreaux. Thank you to the Auraria Librarians, especially Eric Baker, for their wonderful, invaluable help finding resources and to El Brush for additional insights into the thinking behind this piece. Special thanks to Christine Sargent for last minute help and advice. This project was approved by the University of Arizona Institutional Review Board (Protocol Number 1711070105R002). This project received research clearance from the Senegalese Ministry of Health and Social Action (Protocol number SEN18/13) and the Saint-Louis Public Hospital (Protocol number 00000032). As a member of the West African Research Center, based in Dakar, this project received clearance from the Senegalese Ministry of Higher Education and Research (Protocol numbers 0000267 and 0001717). This research has received additional clearance from the Colorado Multiple Institutional Review Board (Protocol Number 23-0092).
Funding Sources
Fieldwork was made possible through the Fulbright Institute for International Education (2018–2019). Data analysis and writing up were made possible by the National Science Foundation Graduate Research Fellowship Program (2015–2020) and University of Arizona School of Anthropology Haury Dissertation Writing Fellowship (2020–2021). Additional funding was made possible through the University of Colorado Denver Office of Research Services Seed Grant (Spring 2024).
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