Abstract
This article addresses access to basic health care facilities in Morocco, by emphasizing the issue of accommodation (Penchansky & Thomas, 1981). This article is based on data collected over three years spent in Rabat, Morocco, for fieldwork. The first year focused on hypertension. Research authorization was required for this research, which was obtained from the Ministry of Health. Research tools consisted of observations, in-depth interviews, and focus group discussions.
I argue that waiting is not a passive experience or state. It is experienced with and through a mindful body (Scheper-Hughes & Lock, 1987), as an active and dynamic process that happens in a waiting room. The waiting room is conceptualized as a sphere of coexisting heterogeneity (Massey, 2005), allowing the concomitant presence of the body-self, social body, and the body politic, equivalent to body-inside and body-outside, respectively. By relating multiplicity and heterogeneity to time—biomedicine’s time, different from patients’ time, but also from the body’s time or somatic time (Limor Meoded, 2018)—, I argue that the space of the waiting room brings these various temporalities together, commanding new configurations and processes (Massey, 2005). The dynamic process of waiting is embodied; it can burst out in the form of tension, when the concomitant presence of distinct trajectories, bodies, and temporalities inside the waiting room, sometimes generate violence (verbal and symbolic). Allowing this heterogeneity to coexist smoothly is the challenge of hospital architecture and its analysis from a phenomenological perspective will bring rich data to explore and extend the project of an anthropogeography of emotions and perception.
Introduction
This article addresses access 1 to basic health care facilities in Morocco, by focusing on the issue of accommodation defined according to Penchansky and Thomas (1981), as the relationship between the manner in which supply resources are organized to accept clients (including appointment systems, hours of operation, walk-in facilities. . .) and clients’ ability to accommodate to these factors and their perception of their appropriateness. The focus is on the waiting time, one social factor that with financial resources and the “image of the patient” pervade problem-solving in medical practice (Berg, 1992, p. 160). Rather than dealing with a flow of patients that has to fit with office hours or physicians’ timetables, deadlines for exams, etc., this article focuses on patients’ experiences of the waiting time.
Waiting seems to be one organic feature of the provision of care, and long waiting is one major reason for users’ dissatisfaction and low utilization of maternal health services in Africa (Fatti et al., 2018; Stekelenburg et al., 2004). According to a study conducted in Morocco, 88% of patients who had travelled more than an hour waited for at least another hour before seeing the doctor (Gruénais, 2011). If waiting time is reported as a constraint on the use of health services—if it has been measured to assess perceptions of “acceptable” waiting time among providers and clients (Tegabu, 2008)—there has been little research focusing particularly on users’ experiences of waiting in Morocco. This article will contribute to the filling of this gap.
In this article, I argue that in Moroccan basic health care facilities, waiting is far from being a passive experience or state, even when involving sitting, that is not absolute inertia (Jackson, 2011). It is experienced with and through a mindful body (Scheper-Hughes & Lock, 1987), as an active and dynamic process that usually happens in a waiting room, conceptualized as space—a sphere of coexisting heterogeneity, the product of interrelations constituted through interactions (Massey, 2005). Waiting is a concatenation of movements involving the body, the senses, imagination, and cognitive abilities to deal with the assemblage of heterogeneity and multiple trajectory characteristics of the waiting-room space. In this perspective, waiting time is not time suspended or put in parentheses. Actually, this dynamic process is embodied and sometimes bursts out in the form of a rise in blood pressure, or tension, as suggested in this article.
I examine waiting time as a process experienced in the basic health care facilities’ waiting rooms through the lens of Massey’s characterization of space, Scheper-Hughes and Lock (1987) proposal for the development of an epistemology and metaphysics of the mindful body.
Space as a Sphere of Coexisting Heterogeneity, Always under Construction
Massey (2005) advanced three characteristics of space: (a) space is the product of interrelations as constituted through interactions, from the immensity of the global to the intimately tiny; (b) space should be understood as a sphere of possibilities for the existence of multiplicity in the sense of contemporaneous plurality, as the sphere in which distinct trajectories coexist, and as the sphere therefore of coexisting heterogeneity; and (c) space is always under construction. Precisely because space in her reading is a product of relations—relations that are necessarily embedded in the material practices that have to be carried out—it is always in the process of being made: it is never finished, never closed. It is the sphere of the continuous production and reconfiguration of heterogeneity in all its forms—diversity, subordination, conflicting interests. The specificities of space are a product of interrelations, connections, and disconnections, and their combinatory effects (Massey, 2005). From Massey’s analysis, Corsin Jimenèz (2003) highlights a double constituency of space as a moment of action and a mode of presentation, which he conceptualizes as capacity (Corsin Jimenèz, 2003). He contends that people deploy capacities in their daily workings, carving out one of many possible forms of space through one of many possible forms of action. In looking for the salient carvings, one is looking for the distribution of agency. As mentioned, I examine waiting time as a process through the lens of Massey’s characterization of space, Scheper-Hughes and Lock (1987) proposal for the development of an epistemology and metaphysics of the mindful body.
From the Mindful Body to the Body-Inside and the Body-Outside
In their proposal, Scheper-Hughes and Lock (1987) considered three bodies: the body-self, the body politic, and the social body. Relying on Marcel Mauss (1985), they define the body-self as the intuitive sense of the self as existing apart from other bodies. Then, building on Mary Douglas (1970), they consider the social body as a representational use of the body, as a symbol to think about nature and culture. The body in health offers a model of organic wholeness, while the body in sickness offers a model of social disharmony, conflict, and disintegration. Finally, the body politic refers to the regulation, surveillance, and control of bodies in any form of difference, reproduction, sexuality, leisure, and health.
In describing waiting as a process, a concatenation of movements involving bodies, the senses, imagination, and the intellect, I will use the dichotomy of body-outside or social body/body politics and body-inside or body-self (Scheper-Hughes & Lock, 1987).
The space of the waiting room, I suggest, is a place of the concomitant and indistinctive presence of the social body and the body politic. In this article, the body politic/social body corresponds to the body-outside. In Morocco, high blood pressure is sometimes associated with disharmony in social relations (the social body), 2 and the management of high blood pressure and chronic diseases is regulated at the level of the state. A specific discipline for people with chronic diseases is promoted at the level of basic health facilities’ hygienic dietetic rules to readjust and align their bodies to conform to what is considered the norm according to age and gender (body politic). That is why, in this article, the inclusive concept of body-outside, encompassing the social body and body politic, is preferred. It also helps to direct attention toward the involvement of the body in interactions.
The body-inside includes the body-self as the intuitive sense of one’s own body existing apart from other bodies. It especially directs attention toward the health/disease dimension. The body-inside is the experience of the body’s (abnormal) animation or movements. As people wait and experience multiplicity—heterogeneity, mobility, different trajectories at the same time as their senses are put under pressure—I noted that they do not describe their disease experience and symptoms using biomedical or clinical categories. They articulate their body movements or their pain using the dichotomy of inside and outside the body. The body is spoken of in active terms, always in movement, animated—that is, saying what the body is doing or not doing any more, or doing abnormally inside or outside—rather than concluding what it has been doing, which belongs to the doctor, even though after the description, some patients may compare their experience and conclude from the doings of their own body and the doctor’s assessment of it. This seems relevant in the sense that even if the intellect is activated for different purposes during the process of waiting, the body experience, or the problem for which a doctor should be consulted, is not conceptualized and therefore, stabilized. As such, this is an attempt to analyze experiences of the waiting time in the waiting rooms of basic health care facilities in Rabat, Morocco, through a phenomenological approach. It is important to mention that Morocco is an Islamic country and, in this space, the observable relations to Islam were limited to the body-outside, mainly the veil worn by some women.
Methodology
This article is based on data collected over three years spent in Rabat, Morocco, for fieldwork. The aim was to find answers to the question: how does the political, economic, and social context influence biomedical knowledge and practices? To bring forth robust data, high blood pressure was used as the disease focus during the first year and basic health care facilities as main places of fieldwork. 3 Research authorization was required for this research, which was obtained from the Ministry of Health. 4 Research tools consisted of observations and in-depth interviews. I wanted as much as possible to “be with people” in the health care facilities studied. I started by sitting in the waiting room, observing interactions between patients, and listening to their worries, disputes, and comments about the provision of care. Then, I introduced myself to the doctor. I was authorized to follow and observe doctors during their daily activities (consultations, filling of papers, meetings, and appointments with representatives from pharmaceutical firms). In-depth interviews with General Practitioners (GPs) followed observations. They were occasions to check and expand on what doctors said during interviews. I paid particular attention to encounters where a high blood pressure diagnosis was disclosed. Questions included clarification of the process they followed to translate patients’ problems into hypertension, the difficulties encountered, their knowledge of the frame of reference (Berg, 1992) on which they leant for the management of high blood pressure, support from the Ministry of Health, appropriate devices for measuring blood pressure, and patient-practitioner relations. I visited 28 (over 29 existing) basic health care facilities in the city of Rabat and interviewed 28 doctors in charge of hypertension.
Interviews were recorded and transcribed verbatim. I was allowed to look into patients’ files stored at the level of the basic health care facilities. As is common in most health care facilities in Africa, doctors complained about the paperwork (Tantchou, 2018a). In Morocco, they perceived it as time-consuming and unrewarding because it is not translated into charts or graphics, allowing a single evaluation of activities and adjustments. I complemented these data by organizing in-depth interviews with specialists involved in the follow-up of patients with high blood pressure, mainly nephrologists and cardiologists, both private and public. I was sick myself during fieldwork, so I had the opportunity to experience the process of seeking care, the cognitive and social aspects (time, shortages in supplies) of the transformation of a patient problem into a solvable problem process.
Finally, I organized focus group discussions with women to investigate their perception of public health care facilities. I used NVivo 11 to organize and classify the data. In this article, I specifically used data deriving from observations in basic health care facilities and interviews with general practitioners at the level of basic health care facilities, supplemented by data coming from interviews with specialists and focus group discussions with women.
The following paragraphs are organized into two parts. I start by describing the whole involvement body-outside in the experience of waiting as users tried to access health care facilities. Then I highlight how the whole is fragmented throughout the process because of the different ways through which its various parts are involved. The second part deals with the body-inside in the process of waiting. Particularly highlighted is the involvement of the intellect to calculate, anticipate, and react at the right time. What is at stake is the numérou, or entering the doctor’s consultation room at one’s turn. Finally, I underline space changes because of movement to and from the doctor’s office, the latter physically connecting to the waiting room through the doors. However, as people deploy their capacities (Corsin Jimenèz, 2003) in the space, the doctor’s presence stretches to the waiting room through (sometimes misplaced) comments from people going into or coming out from the offices. The heterogeneous body-inside movements are evaluated and translated by others according to their own experience, comparable or not. The coexisting multiplicity, the deployment of capacities and the reconfiguration of spaces put bodies (inside and outside) in constant movement or under pressure. This allows us to suggest, as already mentioned, that waiting is not a static but a dynamic and active process involving the body as a whole, the body-inside (body-self), and the body-outside (social body/body politic).
Body-Outside under Pressure
Access to health care
Generally, an issue perceived as abnormal or as a problem brings somebody to the doctor. Berg (1992) defines a “problem” as whatever a person and/or his environment perceive to be an issue about which a doctor should be consulted. For this purpose, a person has to move from his house to a doctor’s office. The doctor can be a private or public practitioner, in a hospital, clinic, private, or a basic health care facility. In this article, our focus is on public practitioners in basic health care facilities.
Moving from one’s house to a basic health care facility is not simple for many patients. The body is at stake, under stress inside because of the “problem,” under constraint and pulled about on the outside, from the first feeling of symptoms to the moment the patient enters the doctor’s consultation room (the timeline focus of this article) and sometimes long after. According to the Ministry of Health, the mean distance to reach a health care facility in Morocco is 21.9 km. There is a huge difference according to location: 13.8 km in urban areas and 38.5 km in rural areas. On average, it takes 35 minutes for those living in urban areas to reach a health care facility, and 77 minutes for those living in rural areas. Overall, 41.1% of patients are over an hour away from the nearest health care facility. This is a serious issue when considering hospital care. Rural dwellers take at least 90 minutes to reach a hospital; urban residents take 53 minutes (Ministère de la Santé, 2007, p. 97). Lack of transportation is a major reason why, in rural areas, the majority of women do not deliver (only 46.2% do) in a medical facility (Gruénais, 2011).
When a patient reaches the health care facility, he walks through the main gate and the door. The door can open onto a gloomy and dirty space or to the surprise of a luminous, wide, and clean space; that is how one recognizes renovated basic health care facilities and, in hospitals, places dedicated to wealthy patients. Once in the facility, the patient goes to the registration desk. He has to show his identity card or a paper with his address. This is to ascertain if he actually resides in the area served by the facility. Otherwise, he will be referred to the right health care structure; the one targeting his place of residence: “when you go to a health care facility different from your place of residence, they don’t receive you, and if they do, they will not give you any medication” (Woman, Focus group, Salé, 31 March 2017). Once the identity is checked, the patient is asked the reason for his visit. This is the first place where he may have to face differential treatment (Andersen, 2004). Visitors lacking language skills and basic spatiality skills 5 (Lussault, 2010) appropriate to the setting may be treated roughly because they do not know how to stand in front of the desk: they lack the adequate body language and the discursive skills to answer the questions asked.
According to the nature of his problem, the patient is given a ticket with a number, the numérou, and asked to find a seat in the waiting room. Numérous are of different colors to differentiate requests: children, general consultations, chronic diseases, etc. When giving the numérou, the civil servant at the desk will stretch his finger or turn his head in a particular direction to indicate the door of the doctor receiving patients with the type of problem stated by the patient.
Waiting as mentioned is a common feature in hospitals: When you go to a health care facility or hospital, be prepared to spend at least the first part of the day or for one consultation, you spend the whole day; you wait to enter the health care facility, you wait to see the doctor, you wait to know if he is available, you wait to know if you will be consulted. Then, after waiting from seven to twelve hours, while you had an appointment, you will hear that, finally, you will not be received. You then have to wait to have another appointment. (Woman, Focus group, Salé, 31 March 2017)
I observed patients spending 30 minutes in the health facility as well as those spending an hour or two and a half hours’ waiting their turn, mainly those with chronic disease like high blood pressure or diabetes coming for a follow-up. This, as can be noted from one doctor’s comment, is not a matter for discussion: Yes, if we want to spend the necessary time for patients to go out without worries, we should give each patient the time he needs. That means others have to wait. Actually, in general, this is not a problem, as they know their turn will come and we will also spend time with them. In this case, waiting is not problematic. It is normal; we can’t do anything about. We have many patients; we want to spend time with each one of them. We are dealing with chronic diseases, which means they have to know what is going on and we have to allow them to share their worries. We are talking about building confidence. That requires time. A lot of time. (Doctor, Rabat, 22 June 2015)
The body-outside under pressure: Fragmented
In general, there is one waiting room in basic health care facilities. In some of them with medical specialties like pediatrics, gynecology, dermatology, endocrinology, or gastroenterology, each specialty has its own waiting space (Figure 1). Otherwise, patients—adults and children, with chronic and acute diseases—share the same waiting space. Thus, they are crowded and noisy. In the following, I deal with this latter type of space.
Waiting room for patients with high blood pressure in a health care facility with medical specialties.
As mentioned, the waiting process is experienced in/through the body-inside and the body-outside. Senses and the cognition are involved. The ears and nose are the most solicited: while the other senses can be voluntarily involved in the process, the large scale of continuous noise and smells in the waiting make constant demands on the ears and nose.
Noises come from the coexisting contemporaneous plurality—distinct trajectories, their continuous reconfiguration, and interactions with the materiality of the waiting room, the floor, doors, and benches.
Doors here are rarely sliding; they open inwards or outwards leading to the doctors’ offices, arranged in a square, or in a U-shape around the waiting room. Each office has one door. Doors only open onto the waiting room, so the doctors can be observed walking to their offices when arriving late and representatives from pharmaceutical firms are observed going in and out of doctors’ offices. Doctors are rarely alone with their patients in a consultation room. Even in that case, the door of the doctors’ offices will open quite frequently because a nurse needs advice, precision on a prescription; a friend is visiting; representatives from pharmaceutical firms have arrived (Tantchou, 2018a). Doors are not neutral features. Doors reveal status and functionality, they clarify who is authorized and not authorized, they help to manage privacy, enable a retreat from people, exert control over information and the regulation of interactions (Kupritz, 2000), and create one’s own space. Yet, creating space in hospital wards means establishing boundaries: developing connections, electing those who are authorized to cross the boundaries and those who are not, having the opportunity to close one’s door. Doors configure interactions in health care settings, thus care practices, reinforces professional, social structures/status, and power relations. In this context, entering the doctor’s office without a numérou, reveal status.
So, while sitting in the waiting room, people will frequently hear a loud, slight, or gentle knock, then the twist of a door handle, the creaking of the door opening, a question, an answer, then the twist, the creaking and sometimes the heavy sound of the lock. They will also hear the scraping sound of clothes, coats, the rattling of watch straps, bracelets, the clinking of bunches of keys, the creaking of the benches as somebody sits. They will hear breathing, wheezing, people trying to get their breath back.
The nose will be working, sometimes overwhelmed by myriads of fragrance and odors at the same time. Here, times of truce for the nose will happen, periods when the same smell permeates the place with deepness and insistence, times when you try to distinguish between two, three perfumes and times when it is overwhelmed by fragrances and the smell of bodies’ emissions. The latter sometimes precede or follow the brief sound of heels tapping on the floor. The clicking, tapping, knocking, or heavy sounds will depend on the type of shoes, the walking style, the height, and the width of the heel. It can be the sound of gladiator sandals, Y-shape sandals, or the rubber soles of mules, because some users manage not to raise their feet and place them one in front of the other when walking, but raise their foot slightly and drag their feet one after the other across the floor. The shuffling long or brief sound will depend on the thickness of the shoe, its heaviness, the weight of the person, and the speed at which he walks.
Eyes notice the sometimes gloomy and poorly furnished space, its arrangement, the unmovable wooden or concrete benches, the dirty floor, anxious or tired faces, heads bent, people coming in and going out, people wearing white coats, some wearing suits and with a briefcase.
The body-inside and body-outside are not at rest. Senses are constantly activated, mainly the ears. Bodies move voluntarily or are pressed to do so for people coming after to have a chance to sit. As such, depending on the space, the patient’s size, you observe clothes folding back and stretching following the sinking of the body sitting. The clothes will graze slightly or intensely on the skin; an adjustment of the cloth and repositioning of the body on the bench will be necessary, which reconfigures the coexisting multiplicity (Massey, 2005). This is done by shaking the shoulders, using hands to arrange the cloth, rising up slightly, or moving from the right to the left or the other way around. As a consequence, some of the people sitting on the bench will have to adjust their position and rethink their trajectory to the doctor’s office.
Then people will hear people whispering, talking, and discussing, forming and dismantling groups according to the subject discussed and the time span between two consultations. At times, you will also hear dispute. Generally, this emerges from the desire to avoid waiting or to reduce the waiting time. If cognition is involved throughout the process, this is where it directly plays a part.
The intellect, the imagination is put under pressure. That is one reason why waiting should be understood as a dynamic rather than a static and balanced process. Patients think while waiting, not only about the problem at issue for which they want to see the doctor, the one that moves them to the health care facility or those that they are facing in their different social insertion. Waiting implies thinking about waiting, finding a waiting strategy, observing movements, trajectories, yours and those of the others in the room. It implies analyzing noises to separate those that are relevant from those that are useless. It supposes paying attention to discourses and disputes in order to be reactive by anticipating people’s behavior. What is at stake is the numérou or, put another way, being consulted by the doctor at one’s turn. That means preventing others from jumping the queue.
Body-Inside under Pressure
Waiting while thinking about waiting
People do not like waiting; they will complain about waiting while waiting. Many of them will try different strategies to avoid waiting. That is, among others, the reason why even if you have a numérou: it is possible that somebody coming after you will be received before you. One of the reasons is that they are known by the staff: “when I reach the health facility, I don’t wait because I know everybody and everybody knows me there” (Woman, Focus group, Salé, 31 March 2017). Also, assuming that they are in a hurry, or it is not acceptable to wait to see a doctor, or their case is an emergency, they will try to succeed in their different strategies to jump the queue. That is why patients do not sit anywhere in the waiting room: they will particularly pay attention to the calling of numbers and the opening and closing of doctors’ office doors.
When somebody’s numérou is called, he enters the office of the doctor who will be in charge of transforming his problem into a solvable problem. As mentioned, according to Berg (1992), the term “transformation” implies a process in which the patient’s problem is translated and remolded. A problem is solvable when the doctor is able to propose a limited set of actions he or she perceives to be a sufficient answer (at this time and place) to a specific patient’s problem (disposal). This does not necessarily imply that the patient’s problem is relieved: what matters is that the physician knows what to do next. The physician makes a patient’s problem solvable by reducing the infinite array of possible actions to just one. This is not a linear process. Here, the body-inside is put under pressure.
When a door opens, people in the waiting room are able to understand the dialogue going on behind the door. They pay attention to ascertain whether the words are those of acknowledgment, meaning the encounter is closing. In this case, the patient with the next number moves close to the door.
Sometimes, people sitting on the bench near the door will move closer to one another in order to create an empty space on the bench so that the patient can sit at the door. When the preceding patient comes out of the office, the next patient stands right in front of the door to rush in at the call of his number. Among patients, some are old or too weak to react quickly. In general, they are accompanied by a family member. The family member will move near the door and enter the doctor’s office at the calling of the number, while the patient will manage, with the help of other people waiting, to enter the doctor’s office. This makes sure that nobody jumps the queue and that the patient will be received when his turn comes.
But there are patients too bold to be stopped by these strategies. Some create disputes by showing clearly that they intend to jump the queue. They stand right before the door like representatives from pharmaceutical firms, holding their health booklet as a way to give clear evidence of their status as a patient. This always creates discussion, sometimes violent disputes, as those among the people waiting who know the strategy will raise their voices to protest.
On one instance, a woman entered the health care facilities and went right in front of the doctor’s office, with her numérou. She stood in front of the doctor’s office; turning her back toward the doctor’s door, she looked at those sitting on benches. A man stood up and said loudly with anger: you should sit and wait like everyone here. She looked at him scornfully and turned her head toward another direction. Thus, the man moved toward the woman saying, all of us in this room, we have an issue that can be considered an emergency. There are children in the room, and no one has the right to believe his problem is more urgent than other people’s to jump the queue. As he was speaking the woman looked at him silently with a body language (eyes, mouth and shoulders engaged in a certain way) associated with arrogance. The man turned to other people in the room, asking if they found the woman’s attitude right. Some of them replied, insulting her indirectly saying, he should not pay attention, when people are raised like savage they remain as such. He should calm down, knowing that no matter what happens everybody will enter the doctor’s office. The man didn’t calm down until a doctor came out asking what was going on. He left the door open and the woman took advantage of the diversion to enter the office; she took a sit. It was impossible to convince her to get out and wait for her turn. Thus, the doctor asked those in the room to allow him to take the man complaining just after the woman, in order to settle the issue, to what everybody agreed.
I actually noted that often in these cases, the only solution to calm the atmosphere will be to allow the person willing, to jump the queue. On one occasion, a woman waiting with her daughter was so frustrated by the dénouement that, to protest, she prevented the door from closing by placing one of her feet between the door and pushing back when the patient tried to close it. Such action does not prevent the patient being consulted, but shows the potential for resistance, or a form of resistance of the weak when the distribution of agency is felt to be unjust. Put differently, it shows how, in a situation where there seems to be no alternative, when the reconfiguration of the space and distribution of agency (Corsin Jimenèz, 2003) is perceived as unjust, people try strategies, even those that seem useless, to express their frustration or discontentment.
To and from the doctor’s office: Flows on hold
The process of waiting involves the body-outside, the sense and the intellect. It also involves the body-inside. The body-inside is put under pressure by the presence of representatives from pharmaceutical firms. They are a major source of anger. This is because of their sometimes uninterrupted succession, which puts the flow of patients to and from the doctors’ office “on hold.” As they are not sick and do not accompany a sick person, they do not sit on benches to wait like patients in the waiting room: their presence brings disorder, as the waiting room is no longer associated with sickness and disease only, but with markets and the possibility of being excluded because of a lack of resources. Actually, access to health care is free of charge at the level of basic health care facilities. Medications are provided free of charge when available and for chronic diseases like high blood pressure, shortages are frequent. In these cases, patients are asked to buy their treatment in pharmacies, and many of them lack resources. The lucky one, according to what doctors know about their social status, will be given a sample from among those left by the representatives, while others receive nothing. That is what can be perceived from the following excerpt: We wait about four hours while there are people coming with medications. They don’t wait. . .. It is amazing; it is not only one person getting in, but you have five persons entering, one after the other, while we wait. They enter directly because they provide doctors with medications. . .. Then the doctors, to distribute the medication, will distinguish between their network and the one able to corrupt. . .. I saw the medication I wanted and that was in shortage and asked: the doctor answered they weren’t for me. (Woman, Focus group, Salé, 31 March 2018)
Added to this, among the patients reaching the health care facilities, “some have been facing their symptoms for many days or weeks. They are already anxious” (Doctor, Rabat, 22 June 2015). Others are already under treatment and they are bringing the results of their examinations to the doctor for a follow-up. Many are not able to read French, the language in which biomedicine is written. In Morocco, the practice of medicine is linguistically dual. Encounters are in Darija (Moroccan colloquial language), while files, examinations and biological analyses are completed and reported in French. Thus, patients lacking language skills are unable to check the results in order to be somehow reassured. Sometimes, even if the results are explained by the laboratory technicians or the radiologists, they stay anxious because what really counts is their usual doctor’s opinions and comments.
Also, patients will comment on the doctor’s attitude when coming out of his office, redesigning the atmosphere in the waiting room while putting the body-inside under pressure by elevating the level of anxiety among some patients. For example, one day a patient entered one doctor’s office, his eyes looking hesitant; he sat and crossed his hands, stretching them and closing them, while rubbing them together, not as if he was celebrating something but as if he was nervous. The doctor has been following the patient for many months, so she knew he was talkative patient. However, that day, he was silent. He was bringing examination results and the numbers were good, as the doctor commented. Usually, this would lead to manifestations of joy and thankfulness. As the patient remained silent, the doctor asked if he had specific concerns, he wanted to share with her. The patient answered that nothing was wrong so the doctor changed her voice intonation and asked firmly and directly why he was so frightened. He answered that the preceding patient told those waiting that they should be careful because she was in a very bad mood. The doctor laughed and asked if she was screaming at him or if he felt she was rough with him. He answered no, but what the other patient said determined him to stay quiet and listen. “You did it very well,” said the doctor, “but don’t listen to what others say.” The patient thanked the doctor and left the consultation room. The doctor commented the following: “You see, if you don’t ask questions, you will miss many things. That is how you explain some of the patients’ attitudes you barely understand. They enter your office and they don’t dare to answer when you ask questions; they are afraid because somebody’s comment was misplaced or untrue.”
Finally, discussing with other patients who may not be aware of your condition, have no idea about it, but conclude that your case is difficult or that it is worse than theirs, is a source of anxiety. This is a reason why, among doctors, some advocate the arrangement of waiting rooms according to diseases. This will allow patients with the same condition to sit together, so that patients can share tips, worries, reassure, and encourage one another: We observed that in the basic health care facilities with specialization waiting rooms, if a patient is anxious when diagnosed, afterwards, when he comes for the follow-up and watches other people with the same condition looking good, laughing, and taking things well, he is encouraged and anxiety gradually disappears. (Doctor, Rabat, 31 March 2015)
For all the aforementioned reasons, doctors dealing with patients with high blood pressure see the waiting room as a special concern. One raises the idea of a “waiting room raised blood pressure”: I always ask my patients to measure their blood pressure at home or in a pharmacy. Some of them actually do it. Nevertheless, when they come, as they are waiting here, with the noise, the dispute, their blood pressure rises. When I measure it in my office, the numbers are different. I wonder if there is an association between waiting room and raised blood. I asked to do something about that. (Doctor, Rabat, 9 December 2014)
Conclusion
Access to health care is not only an issue of geography, as Penchansky and Thomas (1981) demonstrate in their broad perspective. It is also the way health care facilities are arranged to provide care. When the doctor mentioned the idea that the waiting room raised blood pressure, she was also highlighting the need to rethink the space. If waiting is organically connected to the provision of care, there is a need to rethink spaces to allow smooth connections and a continuum of multiple places, from places of living to the hospital, or from the hospital to houses; the smooth coexistence of heterogeneity and multiple trajectories. This also depends on how spaces are connected—thus the infrastructure, the materiality that configures the interactions with spaces (Lussault & Stock, 2010).
I tried to show that waiting is a dynamic process that happens in a waiting room conceptualized as a sphere of coexisting heterogeneity (Massey, 2005). The waiting room allow the conjoint presence of distinct trajectories and bodies. This coexisting heterogeneity can burst out in the form of tension or lead to verbal and symbolic violence. The space of the waiting room also brings different temporalities together—biomedicine’s time different from patients’ time, but also from the body’s time or somatic time (Limor Meoded, 2018)—and their translation in the body’s (abnormal) movements is at stake. The diagnosis is a picture of the body at a moment in the body’s lifetime and the patient’s time. When the disclosure happens—which can sometimes take a lot of time—the body is not where it was when the first encounter happened. The body’s movement is continuous, while time in the clinic is discontinuous. Diagnosis may be accurate in terms of biomedical criteria, but the doctors are not really talking about the body as a whole but about the state of the body at one moment. When the somatic experience is transformed into symptoms, the body is somewhere else: the patient exists in his social life as well as in the biomedical knowledge. Waiting in a waiting room brings all these distinct temporalities together at the same moment, imposing new configurations and processes in a single space (Massey, 2005).
In the context studied, waiting rooms, as highlighted, are crowded and noisy. Noisy spaces drain mental and emotional resources, undermining patient-provider relations (Tantchou, 2018a, 2018b). It is advised to measure blood pressure after patients have rested for a while in the waiting room. This article shows that the configuration of waiting rooms and the dynamic characteristics of these spaces make it somehow an ideal to think patients will actually rest while waiting. The Moroccan government is working on the humanization of health care facilities. Waiting rooms are one of the concerns. The idea is to render the waiting room comfortable for patients, family members and health providers.
This is in line with the body of research that has emerged since the mid-1980s (associated with hospitals, but also relevant to basic health care facilities) indicating that the conventional way that hospitals are designed causes stress, danger (nosocomial infections) and negative impacts on outcomes (Cama, 2009; Kellert & Heerwagen, 2013; MacLennan, 2013; Rechel et al., 2009; Ulrich, 1984, 1991; Ulrich et al., 2004, 2008). Focusing on the idea of the hospital as an instrument of cure, these studies have brought strong scientific evidence to support the therapeutic value of appropriate architecture for staff performance and medical outcomes. From this perspective, the built environment should be designed to allow the connections of places and coexistence of heterogeneity to take place smoothly. That is the challenge of hospital architecture and its analysis from a phenomenological perspective will bring rich data to explore and extend the project of an anthropogeography of emotions and perception.
Filière des soins pour la prise en charge des maladies chroniques. Source: Ministère de la santé-Service des maladies cardiovasculaires, 2016, 32.
Footnotes
Acknowledgements
The author is particularly grateful to the ministry of health (direction de l’épidémiologie, service des maladies cardiovasculaires, direction du bâtiment et de l’architecture) for support and assistance during fieldwork and restitution of the study results to health providers. I will also like to express my gratitude to patients, staffs, and general practitioners at the level of basic health care facilities, for enabling me to observe their daily activities and giving their time so generously.
Declaration of Conflicting Interests
The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author received no financial support for the research, authorship, and/or publication of this article.
