Najaf: The doctor paused before banging on the front gate, gesturing to his companions who were wearing full hazmat suits, masks, goggles and gloves to stand back so they would not be the first thing the home's occupants saw.
"This is very sensitive, very difficult for our society," said Dr. Wissam Cona, who works with the provincial health department in the city of Najaf in southern Iraq. He now spends his days checking on families recently returned from Iran, which has suffered one of the world's most severe outbreaks of the coronavirus.
He said that the father of the family at this home had begged him not to come with a retinue of health workers, saying, "'Please don't park in front of our house. I feel ashamed in front of the neighbors. This is so difficult for my reputation.'"
For Iraq, one of the biggest obstacles for public health officials fighting the coronavirus is the stigma associated with illness and quarantine. It runs so deep that people avoid being tested, prevent family members who want tests from having them and delay seeking medical help until they are catastrophically ill.
The aversion to quarantine and the reluctance to admit illness may help explain why the number of confirmed cases in Iraq is relatively low, several Iraqi doctors said. A country of more than 38 million people, Iraq had recorded only 1,352 confirmed COVID-19 cases as of Monday.
Please don't park in front of our house. I feel ashamed in front of the neighbors. This is so difficult for my reputation.
By contrast, in neighboring Iran, with roughly twice Iraq's population, the official count exceeds 71,000. Neighboring Saudi Arabia, which has a smaller population than Iraq's, has more than three times as many confirmed cases.
"It is true we have cases that are hidden, and that is because people don't want to come forward and they are afraid of the quarantine and isolation," said Dr. Hazim Al Jumaili, a deputy health minister who is guiding the country's response to the coronavirus.
The stigma attached to illness and quarantine in Iraq and some other Middle Eastern countries largely reflects cultural and religious beliefs. But it also involves an ingrained distrust of the government, historical experience and the fear that given the ragged state of Iraq's health care system, going to the hospital could be fatal.
A recent video that was widely shared showed women patients in quarantine in a Basra hospital lying near each other without masks, coughing and calling for help as one of them died.
"Some believe the virus means that God is displeased with them, or maybe it is a punishment for a sin so they don't want others to see that they are sick," said Dr. Emad Abdul Razzak, a consultant psychiatrist at Iraq's Health Ministry.
"For many people it is a shame for a female to say she has this illness or any illness, even cancer or mental illness, and many people have no trust in the health system," he said.
So strong are the stigma and the aura of sinfulness surrounding the virus that families of those who have died of other causes oppose their loved ones' bodies being in the same morgue or even graveyard as those who have died of the virus.
In contrast to many Western countries, where celebrities have acknowledged having the disease, and even neighboring Iran, where senior political figures announced they were ill with the virus, there is only one instance in Iraq of a politician or prominent figure admitting to being infected.
Some of the fear surrounding the disease stems from the Muslim rituals surrounding death, said Sherine Hamdy, a professor of medical anthropology at the University of California at Irvine who has worked extensively in Middle Eastern communities.
"You don't want to be forced into quarantine, you don't want to be forced into the hospital because those social, family bonds are very strong," she said. "You want to die within the family.
"The worst thing in the world isn't to die, but it's to die away from your family and your community and to have no control over what happens to your body."
The Islamic tradition requires swift burial, preferably within 24 hours of death. The longer the delay, the more people fear for the soul of the deceased.
Adding to the problems is the tradition of washing the bodies of people who have just died, which the authorities fear could spread the virus.
"The coronavirus and pandemics overall cause disruptions of social and religious practices, and it's not easy to tell people that the coronavirus is stronger than God," said Omar Dewachi, a professor of medical anthropology at Rutgers University, who was born and brought up in Iraq.
Traditions and customs
Quarantining those who are infected imposes a double humiliation in many Iraqi communities. First, it assures that everyone in the neighborhood will learn about the illness. Second, if the victim is an adult male, it signifies that he is no longer able to protect his wife, his children or in the case of an elder brother, his younger siblings, and so has fallen short of fulfilling his role in the family.
More traditional families sometimes deny their female relatives a coronavirus test for fear that if she tests positive she will be removed from the fortress of her family and possibly be sexually compromised.
"In this society, it is not OK for a female to be apart from the family," said Dr. Mona Al Khafaji, a radiologist in private practice in Baghdad.
She mentioned the case of a 32-year-old female patient with fibrosis, which heightens her vulnerability to the coronavirus, who was having trouble breathing. Al Khafaji recommended the woman go for a COVID-19 test, but her father and brothers said no, and refused to budge even when her condition worsened.
Lately, in an effort to overcome the stigma and put together an accurate picture of the scope of the epidemic, the Iraqi Health Ministry has resorted to random testing. But this program has brought a new set of troubles.
For one thing, some healthy people could be falsely stigmatized. And to display its resolve, the government has assigned armed national security personnel to accompany health workers. Given Iraq's violent past, the presence of security forces is so unnerving it makes some people hide in their homes.
"It is so difficult in this culture because everything we do is a problem," said Dr. Mohammed Waheeb, a senior pulmonologist at Baghdad Medical City. "If we send an ambulance to pick up the patient, then people are upset because the neighbors will see it."
"The same happens or worse if we send the national security," he added. "Then people feel it is like under Saddam," he said, referring to Iraq's former strongman president, Saddam Hussein.
The Health Ministry says the use of security personnel is the only way to surmount the difficulties of persuading people to submit to quarantine. Doctors, however, say the security details are needlessly off-putting, at least when health teams are merely out collecting samples.
The second day of random testing in Sadr City, a sprawling, impoverished neighborhood in eastern Baghdad, illustrated the recurring problems. In this part of the capital, houses are patched heaps of corrugated metal and brick, with garbage strewn on streets that are often unpaved.
An old woman, wearing a long black abaya, opened her corrugated metal gate a crack and squinted into the brilliant noonday sun to see who had knocked. Looking down the street she saw more than 40 people - in surgical gowns and masks or full hazmat suits, accompanied by two or three television cameras, community police officers, young militia members from the organization of the nationalist cleric Muqtada al-Sadr and a few local sheikhs.
She slammed the gate closed.
People in Sadr City are skeptical of the Health Ministry, said Dr. Bassim Aboud, who oversees the area for the ministry, as he knocked futilely at the woman's gate.
"If people think I am with the government, they will shut the door," he said. "But if they see me as a doctor, they come to me for help. "