The “Arab World” is Not a Useful Concept When Addressing Challenges to Public Health, Public Health Education, and Research in the Middle East

Abstract

Interest in public health in the “Arab World” has intensified following the political and social changes that have affected the Middle East since 2010. A new text-book has been published (1), an international meeting has been held (2), a network of experts has been formed, and a special edition of major medical journal has been published (3). But how useful is the “Arab World” as a way of defining a geographical region in order to focus attention on the health challenges that it faces and in particular the challenges relating to public health research and education. In this brief essay, the authors argue that its usefulness is limited because the countries of the Arab World, however defined, are too heterogeneous to allow meaningful communal debate of their problems and solutions. As an alternative it is recommended that countries in the region form smaller more homogenous issue-specific groupings to discuss common challenges and action. The preferred definition of the Arab World is the 22 member countries of the League of Arab States. The Eastern Mediterranean Region (EMR) of the World Health Organization (WHO) is a second important classification in which the Comoros, Mauritania, and Algeria are moved to the WHO Regional Office for Africa and three non-Arab countries are added: Afghanistan, Iran, and Pakistan. In addition, South Sudan is included. A third widely used classification is the World Bank’s Middle East and North Africa (MENA) grouping of 22 countries, which takes WHO EMR and excludes Sudan, Somalia, and Pakistan but adds Israel. Irrespective of which grouping is chosen, while there are “linguistic, political, historical, and socio-cultural links” between these nations there are also major dissimilarities at many levels and their heterogeneity is a major challenge (4). The region divides geographically into the Maghreb, the Mashreq, and the Gulf but the most important differences relate to levels of economic development, demography, population health status, inequity, political stability, history of conflict or war, presence of refugee or displaced populations, and health system organization. Given these differences does it make sense for countries to come together as the “Arab World” or WHO EMR to seek solutions to the specific challenges they face or would smaller issue-specific groups provide a more efficient forum for collaboration and joint action. Attempts have already been made to define smaller more meaningful groups. On the basis of the World Bank income stratification, the Gulf States of Bahrain, Kuwait, Qatar, Saudi Arabia, United Arab Emirates, and Oman would be in a group of high income countries while Afghanistan, Comoros, Somalia, and South Sudan would be in a low income group while the remainder would be in a middle-income group. Furthermore, WHO already categorizes EMR countries into three groups based on health, health system performance, and expenditure on health (Table 1) and the Gulf States continue to work together through their health ministers’ executive board (5). Table 1. WHO EMR country classification. The main challenges facing the countries of the region have been identified as inequities in health, rising exposure to health risks, increasing health care costs and unacceptably low levels of access to quality health care (6). To these may be added under-investment in research for health and the need to reform public health education (2) and the continuing challenges faced by countries with complex emergencies (7). In terms of exposure to health risk factors and disparities in health status, the countries of the region vary (Table 2). Yemen and Sudan have not fully passed through the epidemiological transition and have a different set of key health risk factors and so it is unhelpful to group them with the other nations. This also applies to other EMR Group 3 countries (Afghanistan, Djibouti, Pakistan, and Somalia) and Comoros and Mauritania. These countries generally have not yet passed through the demographic transition either. The most recent data show that under-five mortality (per 1000) was 98.5 in Afghanistan, 80.9 in Djibouti, 85.9 in Pakistan, 147.4 in Somalia, 104 in South Sudan, and 73.1 in Sudan while the total fertility rate (per women) in Afghanistan, Pakistan, Somalia, South Sudan, and Sudan was 5.1, 3.5, 6.4, 6.7, and 3.9, respectively (8). However, with respect to risk factors and health status, amongst the other nations there may be enough similarities to justify a regional grouping. Table 2. Arab World/WHO EMR, life expectancy, GDP per capita, total expenditure on health, density of physicians, nurses and midwives, standardized mortality for selected conditions, main risk factors, selected countries, 2010. However, the usefulness of a regional grouping is once more in doubt when demography and health systems are considered. The countries of EMR Group 1 which are also the countries of the Gulf Cooperation Council (GCC) have unique population structures with large expatriate populations relative to the size of their national populations. A typical population pyramid is that of the UAE where, 50% of the population are non-citizen males of working age (9). This population structure along with rapid population growth from high net inward migration has necessitated high and increasing government spending on healthcare. Again, in the UAE, which is typical of other GCC countries, total expenditure on health (THE) has averaged between 2 and 4% of gross domestic product (GDP) over the past 15 years. Since UAE GDP has more than trebled in this time from $100 billion to $380 billion this means that THE has also increased from $752 (per capita) in 2000 to $1640 in 2011. Of this, about 75% comes from government and the remaining 25% from private sources namely insurance and out-of-pocket payments. Government...