3. DISTRESS O F THE HEART
Shortly after we arrived in Maragheh, a shopkeeper told me that he had been having heart problems and, knowing that I was associated with the Health Office, wondered if I could help. He illustrated how his heart pounded (fist against his hand, "tak, tak, tak"), and replied to my query tha t he had already been to several doctors without success. At the same time, my wife , who regularly observed a family planning clinic, began to note that women constantly complained that the contraceptive pill caused them to be ill. The most common complaint was of 'heart distress' ( narahatiye qalb); many women gave this as their reason for leaving the program, a problem which had serious consequences for the whole family planning effort. It was puzzling to us that people should complain so much about their hearts. Beginning with the simple hypot hesis that people in Iran attend closely to their pulse and define heart palpitations as illness, we were compelled to pursue the question "What does it mean when a person says 'qalbim narahatdi, my heart is uncomfortable or upset'?"
Heart distress is a category of disease ( maraz) in Maragheh. Its symptoms are described in very physical terms. 'My heart is pounding' ( qalbim vurur); 'my heart is trembling' (qalbim tittirir), or 'fluttering' ( chirpinir), or 'beating rapidly' (dovinir, or tez tez vurur); 'my heart feels pressed or squeezed , bored or lonely' (qalbim sixilir, daruxir). These statements are often illustrated graphically, fist pounding on the chest, or hand squeezing together to illustrate a 'pressed heart'. Each of these are members of a general class of sensations described as 'heart
distress' (qalbim narahatdi, 'my heart is uncomfortable, upset, in distress, uneasy or in "dis-ease" ').
Heart discomfort has several degrees of severity. According to one informant :
If I come from the bazaar, for example, and you say my brother has come, my heart starts pounding ( vurur), because I worry he ma y be in a fight, or someone is sick or something. But no, this isn't really an illness. However, if I don't go to the doctor and get something to cure the problem, it can get much worse. It may get so bad that my heart 'goes to sleep' (qalbim yattar ). There are two meanings of this; either the person dies (yo! gider , 'he goes on
the road'), or he becomes unconscious ( behush, hesh ozu bilmirir , unconscious, 'doesn't even know himself').
You know the heart is like a motor, the motor of the body. If the heart goes bad, then everything else may.
Thus heart distresses range along a continuum from mild excitation of the heart to chronic sensations of hea rt irregularities, to fainting and heart attack (saxteye qalb).
This statement also indicates a central characteristic of heart distress: it is a complex of physical sensations associated with particular feelings of anxiety. Not all occurrences of a rapid pulse are considered to be signs of illness. Some women in Maragheh told us that sexual intercourse can lead to or aggravate disease, because it makes one's heart beat rapidly. It should therefore be avoided if one has heart distress. But clearly not all persons consider a rapid pulse during intercourse as a sympt om of illness. On the other hand 'the heart' often represents the subject of experience (e.g., 'my heart longs for you . . .'; see below), but saying 'my heart is uncomfortable' does not mean simply 'I am uncomfortable'. Heart distress or discomfort is experienced as a physical sensation and as a stage of illness that may eventuate in a heart attack. It is when certain physical sensations are linked with certain feelings of anxiety that a person labels the sensations symptoms of illness. Examination of this illness complex must thus focus on those particular anxieties that are articulated in the idiom of heart discomfort. First, a general epidemiological profile of the illness will be given, two cases will be described, and the explanatory model of the heart which provides the cognitive framework for the illness will be discussed. These will then provide the data for an analysis of the meaning of heart distress in popular medicine in Maragheh and an examination of the particular cluster of social stresses that are experienced, communicated and dealt with as heart ailments.
Heart distress is a commonly experienced illness, in Maragheh, particularly amongst women of the lower social classes. In a survey we did of a stratified population of 750 persons in Maragheh and three surrounding villages, we asked respondents whether anyone in their family had been sick (maris) with heart distress in the past eight months; if so, who, what treatment was sought, and what was believed to have caused the illness. Nearly 40% of all households had had at least one person who suffered heart distress in eight months. Table I indicates the incidence by household as reported by men and women. The incidence is highest in bazaari and working class households, and is uniformly higher as reported by women in comparison with men. This is because, as Table II shows, heart distress is most commonly an illness of women , particularly of women of childbearing age. Of all reported cases, 55% were women of fifteen to forty-four years of age, and 73% were women of more than fifteen years of age. But it is important to remember that the illness is not limited to women.
When respondents were asked what they believed to be the cause of the illness, almost 40% of the causes suggested were specifically emotional and