Q&A with Afaf I. Meleis

The population of the world’s urban centers is exploding. More than half of all humans—about 3.5 billion people—currently live in cities. By 2030, that number is expected to approach 5 billion.
Like their male counterparts, women migrate into cities from rural areas to find jobs and get better education for their children. But, says Afaf Ibrahim Meleis, dean of Penn’s School of Nursing, little attention, and even less scholarship, has been focused on how urbanization specifically affects the health of women. Gender, she says, matters.

“Too often, professionals from all fields, from healthcare professionals to policymakers to urban planners, assume that structuring a healthy environment for a woman is the same as structuring a healthy environment for a man,” Meleis writes in the introduction of a book on the topic she co-edited along with Eugenie L. Birch of PennDesign and Susan M. Wachter of Wharton. But it’s not.

The book, titled “Women’s Health and the World’s Cities,” examines the unique intersection of gender, health, and urban living in a collection of essays focusing on issues such as physical safety, female-friendly infrastructure, education, political empowerment, and economic inclusion. 

The book reflects Meleis’ dedication to furthering the serious study of women’s health in urban environments around the globe. On Tuesday, Jan. 24, from 5:30 to 7 p.m., the editors and contributors to the book will discuss their essays in the Ben Franklin Room of Houston Hall.

Under her leadership, Penn Nursing launched the Urban Women’s Health Think Tank in 2007, which evolved into the Urban Women’s Health Initiative. In 2010, Penn Nursing hosted the 18th Congress on Women’s Health Issues in partnership with the International Council on Women’s Health Issues.

Meleis was named the fifth dean of the School of Nursing in 2002, but her passion for the profession stretches back to her childhood in Egypt. Her mother was a nurse midwife, and was the first woman in Egypt to earn both a bachelor’s and master’s degree in nursing.

The Current sat down with Meleis to discuss how she also broke new ground in nursing by establishing the first school of nursing in Kuwait, her ongoing commitment to increasing the diversity of Penn Nursing, and her pride in the strong connection Penn Nursing has cultivated with the Philadelphia community.

Q. How did you get interested in nursing?
A. I grew up in Alexandria, Egypt and growing up there was a very profound experience. It’s so multicultural. I grew up with the Greeks, and the Italians, and the Jews, and the Muslims, and all of that. That’s where I got all my first impressions of the multiculturalism of the world. My mother was a nurse, and my father was a navy man. So, growing up in a close family, where nursing was part of my life, I either was going to be a captain in the navy or I was going to be a nurse. I’ve always thought of nursing as a fabulous career option. And at the time I was finishing high school, the University of Alexandria developed a brand-new college of nursing that was the first in the Middle East to offer a bachelor’s degree in nursing. That opened a door for me to pursue the passion I had developed for nursing through my mother. Also with that university program came the opportunity that if you excelled you could get a scholarship.

Q. You have called your mother a ‘maverick’ in nursing. Can you explain why?
A. One of the reasons I developed a view of nursing as a fantastic profession that opens many doors and allows us to make a difference in the world is my mother’s pioneering work. She was the first [woman in Egypt] to get a bachelor’s and master’s degree in nursing. She loved her profession. She was a nurse midwife. She told me lots of stories about the vulnerability of women, but also about the incredible inner strength and power of women. She would tell me how nursing can really make a difference, and particularly how nurse midwives can make a difference in the lives of people by empowering them and providing them with resources and with a support system. Also, I was inspired by seeing her go and continue her education, actually leaving us for two years to come to the United States to get a bachelor’s in nursing. 

Q. That was quite a big decision for her to leave your family, wasn’t it?
A. The fact that she thought it was important enough to come to the United States when I was about 11 or 12 years old, and leave me and my sister, showed me how important nursing is as a career. She was gone for two years at a time when telephone calls were difficult. I would hear her voice about once every six months. I thought for a mother who is so committed to her family to sacrifice all that for nursing, nursing must be an amazing profession. My mother was a fantastic role model and mentor.
Q. Your father must have been highly supportive of her. This was not usual for that era, was it?
A. We could not have done it without my father. As a navy man, he usually traveled for many months at a time and he had to give that up and stay in Alexandria for two years to be both the mother and the father. Now, you have to remember this was back in the mid-‘50s. I think through both of them, I got my voice as a woman, and the knowledge of the importance of an education and a career.

Q. As for your own education, you received your bachelor’s degree in Alexandria in 1961. Where did you do your post-graduate work?
A. It’s important to remember that I got my voice as a nurse and a woman in Alexandria. And part of the attraction of the nursing profession for me was the potential of pursuing higher education. … I came to UCLA and got a couple of master’s degrees, one in public health and one in medical sociology, then a Ph.D. in medical sociology and social psychology. The reason I decided to go further with my education is that I had become inquisitive about some healthcare questions relating to women and family planning and contraception. ‘Why is it,’ I wondered, ‘with all of the advances in birth control that there are still so many unwanted children and so many unplanned families?’ And I knew that I needed to become a scientist to be able to answer those questions. So for me, UCLA was where I got my voice as a scholar, as scientist, and as a theorist.

Q. From Los Angeles you moved to San Francisco, correct?
A. My husband finished his Ph.D. in nuclear engineering and he got a great offer in San Francisco, so reluctantly, I left Los Angeles, and moved north to the University of California, San Francisco. UCSF is a campus with a strong faculty voice, and that is where I got my voice as a formal leader. I am what I call an accidental formal leader. It was never part of my plan to be in an administrative position. I liked my role as a scientist and a researcher. But in San Francisco, the position that was open was in administration and I took it. Then, I was invited to come to Kuwait for a couple of years and establish a school of nursing there. So there was another accidental leadership position. I went to Kuwait to be a dean for two years [1975 to 1977] with my husband and two young children.

Q. How did that assignment influence your development as a leader?
A. It was an important phase because of the multiculturalism. I had faculty from the United Kingdom, from Australia, from Iraq and Iran, from Egypt. I got to really work with them to develop a curriculum. My formal leadership in science, and leadership related to women’s health was really important to me, developing the capacity and the voices of women.

Q. So, how did you get to Penn?
A. Well, I got a call. I got a call from the search committee asking if I’d consider coming to the University of Pennsylvania, and I said: ‘I don’t think so, not at this time.’ But I agreed to serve as a consultant to the search committee, so I came to Penn and I fell in love with Penn.

Q. What exactly made you change your mind?
A. Of course, Penn School of Nursing is a leading school of nursing, and the faculty here is on the cutting edge of science. And it’s probably the only place where I have seen such an amazing interdisciplinary connection between the schools, and that was really appealing to me. I also saw the caliber of students here. But just as important was that I saw how the community and Penn are very much connected. The University is part of an urban area and the urban area is part of the University. That was unusual and very appealing to me.

Q. When you accepted the position what goals did you set as dean?
A. The reason I accepted the job was because I felt there was a real congruency between my strategic goals and the potential strategic goals for the school. Stemming from working with the faculty, my priorities were to increase the diversity of the faculty, increasing the diversity of the student body, making the culture here really inclusive and accepting and open. Globalization was something I wanted to see. I wanted to see a faculty of global citizens, and I wanted to make sure that we graduated global citizens. In this day and age, and this started 10 years ago, we could not graduate anybody who did not have a world-view and a global paradigm. These were the things I wanted to bring to the school. … We have excellent staff, faculty and students, and I want to ensure that everybody is not only working up to their full capacity, but is also evolving and developing in the way they want.

I wanted to see a faculty of global citizens, and I wanted to make sure that we graduated global citizens."

Q. What are some of the major achievements you have made since that time?
A. Achievements we have made as a faculty. We embarked first on articulating strategic goals for the first five years. They were: increasing diversity, globalization, eminence in science, and using the best models in education to graduate leaders for the future. We embarked first on changing the organizational structure of the school to reflect those goals, and that was really important. And then we completely renovated the building over four phases. We are going through the fifth phase now. Now you see a building that is hospitable, it is open, and it is responsive to students’ needs in terms of collaborative education and excellent labs. It’s a pleasant environment. Florence Nightingale said nursing is about making the environment healthy so you can make the patient healthy. That is what we did here.
We also became very globally connected. Our faculty is working collaboratively on research in different parts of the world. Their work is reflective of global issues in healthcare, and we are developing research centers that bring in a community of scholars from around the world to answer important research questions. We also spent a great deal of energy recruiting a diverse faculty with diverse voices and diverse points of view.

Q. You recently created a new Center for Global Women’s Health. Can you talk about that? 
A. Yes, the Center reflects my passion for healthcare for women and for empowering women internationally. Lynn Sommers [professor of medical-surgical nursing], a superb and well-established scientist, is the director. Her research is in injury science, but it’s injury from things like rape that women suffer from. The Center brings together so much of the work our faculty has done for so many years. The Center’s goals are to develop and train future scientists and scholars who are well versed on how to identify and answer questions related to issues in women’s health. It is also to decrease violence against women. And while reproductive health is, of course, important to us, we want to consider women as productive beings, rather than just reproductive beings. We want women to be people who are productive in their work, able to work up to their full capacity, and are compensated for their work up to their full capacity.

Q. You are one of the editors of a new book about the connection between women’s health and public policy issues such as urban and economic development. Why did you choose to write about that topic? 
A. You really can’t improve women’s health unless you think about urban areas, urban policy, and the environment. They are all interconnected. What is unique about where we are right now in women’s health and urbanization is that it is a frontier, an area that has not been looked at closely. We have not looked at how to develop cities that are friendly to women.

Q. Why is that important? 
A. Women are the center of families. They are the center of the community. You make a woman healthy, you make a home healthy, you make a city healthy. Women shop for food. Women put the kids in schools. Women worry about daycare. Women worry about care for the elderly. All these resources are in urban areas, and if they are not developed from a woman’s perspective in terms of the right transportation, a safe environment for them, then all these services won’t reach the family. The world is becoming more urbanized and it has to take women into account. That’s what I am saying with my co-editors of this book. They are scientists and scholars in urbanization and politics.
Women represent 70 percent of the poor in urban areas. That means they deal with poor transportation, poor lighting, violence, density, and a lack of resources for women to be able to run their lives. For example, if we want to think about decreasing obesity and hypertension, we need to think about their environment. We can’t say to them, ‘You need to be outdoors and you need to get exercise’ when it’s a violent area and there are no lights, or no sidewalks. You can’t really deliver the best models of healthcare unless you have an urban area that is cooperative in providing the structure and resources that are important to women.
Q. This is an emerging area of study. Can you tell me what insight you hope this book will lend to the understanding of these issues?
A. What is really interesting is how we got to the book. First, we brought together about 50 people from urban design, urban planning, nursing, architecture and medicine and asked them if they had talked to each other, and whether they had really thought about urban development from a gender perspective. That was our first attempt and that was a few years ago. At our very first meeting, we invited a leading person from [the National Institutes of Health] to talk about women and urban areas. She said to us that we don’t know how urban environments affect women and how women affect urban areas. That was the wake-up call to us that we needed to continue looking into this. So we said, all right, let’s open up this discussion.

Q. Is that what sparked the meeting of the International Council on Women’s Health Issues at Penn in 2010?
A. Yes, we got about 350 people from 32 countries and 17 disciplines to meet here at Penn, all thinking about women’s health and urban issues together. Our book is a product of that. We listened to the papers presented, some of which identified problems in places like India and Ghana, and the issues facing groups of women in different parts of the world. The participants also brought to us some amazing solutions to urban problems facing women. We decided to put this collection of insights together in a book that could become the impetus to increase scholarship into urbanization and women’s health, and also to make urban developers aware of how important gender is. Women often are harassed on public transportation and so they avoid it. As a solution, some countries have decided to have special buses, special trains or special sections that are just for women so they can feel safe.

Q. Do people tend to think this is an issue only for developing countries, and not for so-called first-world nations?
A. These issues are in our own backyard. We are talking about our cities, about our low-income populations, about women who are working in service occupations. Let’s say they clean houses, but they can’t leave early enough to get to work because there is no transportation. Or they want to feed their family fresh, healthy food, but in their neighborhood they can only find canned food and junk food. They have to walk on broken sidewalks, and there is no access to healthcare near their homes. We scold them for not taking their babies for immunization, but there is no transportation available for the mothers to take them. There is no comprehensive clinic in the neighborhood. And if they do go to get immunizations, they are going to lose wages from their work.
I did my research in Brazil, Colombia, San Francisco, Egypt, Kuwait and I did it with low-income and no-income women and it’s the same story. They want to know why they can’t have clinics near them where they can get comprehensive care early in the morning or at night. They ask, ‘Why do I need to go one place for a mammogram, another for a pap smear, a third place for immunization for my kids. How do I live?’

You make a woman healthy, you make a home healthy, you make a city healthy."

Q. What would a gender-aware city look like?
A. My dream is for—let’s call her Alice, who lives in a poor area in Philadelphia—to be able to get up in the morning to give her kids oatmeal and fresh fruit in the morning, and then put her kids in a stroller and take them two blocks on a sidewalk that’s not broken to leave them at a daycare that is affordable. Also in the neighborhood is an elder care center where her mother can be, and a nurse practitioner works in each of those centers. Then, Alice takes the bus to work, where she is able to find a breast-feeding room where she can pump her breast milk and take it home. You make a city accessible and healthy for women, you make it accessible for men and for families, too. … This book is really about giving voice to women in urban planning and once you give them a voice in urban planning, you give them a voice in taking care of their health, too.

Q. This seems like feminist theory applied in a very pragmatic way.
A. It’s not middle-class feminist theory. It is feminist theory that we have learned from our colleagues internationally. It’s about getting rid of colonization and getting rid of oppression at the structural level. We are learning about feminist theory from our colleagues in Latin America and our colleagues from the Middle East who look at it in terms of governmental, structural, economic oppression.

Q. It seems that what you are doing is taking an interdisciplinary look at healthcare. What role does nursing in particular play? 
A. Nursing plays a vital role. Nurses are concerned about being advocates, being a voice for the vulnerable. When you are a patient you are vulnerable, whether you are lower class, middle class, or upper class. Nurses are really good at understanding that vulnerability. They put themselves in their patients’ shoes, give them a voice, and respond to their needs until those people are well enough to have their own voice and to take care of themselves.

Q. In your lifetime how has the face of nursing changed?
A. The giving and the caring and nurturing, and being compassionate, has not changed. What has changed tremendously is the science. These days you should not be taken care of by a nurse who does not have a scientific background. You should be taken care of by a nurse who is managing your pain not just out of compassion, but also because he or she has the knowledge of what the best medication is for your level of pain.
Also what has changed is the acknowledgment of what nurses do and the visibility of nursing and the appreciation of how vital their role is in the healthcare system. The third way it has changed is in the collaboration and teamwork nurses do with physicians. Today, they work together for the patients. 

Q. Where do you want to take the School of Nursing in the future?
A. I want to ensure the sustainability of our research centers. I want to make sure they are sustained financially and in terms of all resources. Also, we are embarking on redesigning our simulation laboratories. My goal is to ensure that all the technological changes we make here are well-integrated into our curriculum, without losing the essence of what our discipline is about, which is a focus on individuals and families. And, we also want to have a strong voice in government to ensure that every human being has access to the best possible healthcare. I also want to increase the number of younger people who are getting higher education in nursing.

Afaf I. Meleis