Handbook of Healthcare in The Arab World 2021 PDF

Ismail Laher
Editor
Handbook of
Healthcare in
the Arab World
Handbook of Healthcare in the Arab World
Ismail Laher
Editor
Handbook of Healthcare in
the Arab World
With 388 Figures and 346 Tables

Editor
Ismail Laher
Faculty of Medicine
Department of Anesthesiology
Pharmacology and Therapeutics,
The University of British Columbia
Vancouver, BC, Canada
ISBN 978-3-030-36810-4 ISBN 978-3-030-36811-1 (eBook)

ISBN 978-3-030-36812-8 (print and electronic bundle)
https://doi.org/10.1007/978-3-030-36811-1
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Preface
The “Arab World,” with its varying definitions (Blair et al. 2014), is a region
undergoing social, economic, and political transformations in its identity, all of
which are influenced by numerous internal and external forces that it has been
exposed to for some time. A crucial area receiving constant attention is healthcare
in the Arab World (Batniji et al. 2014; Eltaybani et al. 2020). The current population
of the Arab World, around 400 million (excluding expatriates and migrant workers),
has more than doubled during the last 30 years. While the region has generally
benefited from improved education, higher life expectancies, and unprecedented
investments in infrastructure, particularly in wealthier countries, the fact remains that
healthcare priorities vary across the Arab World: with civil war raging in Yemen, the
population is currently facing immense poverty and starvation while in other Arab
countries there is rampant obesity; Somalia, for example, has a high rate of infant
mortality; more than 40% of Lebanese are smokers; and wealthier Arab countries are
struggling with ever-increasing premature deaths due to motor vehicle accidents
(Christensen-Rand et al. 2006). A common thread across the Arab World is a
sedentary lifestyle that is exacerbating an ongoing crisis of overweight/obesity and
metabolic diseases that is evident in about 60% of the region (Sharara et al. 2018).
Healthcare in the Arab World is receiving renewed attention, likely due to a
variety of factors such as disparities in access to healthcare by marginalized persons
(including migrant workers, refugees, asylum seekers, people living in remote
regions, economically and physically/mentally disadvantaged persons), and the
inevitable hardships created by ongoing and protracted civil wars. War-torn coun-
tries lose healthcare providers and experience destruction of healthcare infrastruc-
tures and mass displacement of all segments of society – Arab populations account
for 40% of the global refugee population. Additional factors include shortages of
skilled personnel (The Economist 2020) as well as the unique cultural and religious
values in the region and their impact on seeking healthcare services (Inhorn and
Serour 2011; Alsharif et al. 2019; Mohammad et al. 2020; Al-Allawi et al. 2020;
Lawrenz et al. 2019) as well as healthcare decision-making. The health effects of the
high rates of consanguineous marriages in the region (Tay et al. 2020; El Sabeh et al.
2021; AlHarthi et al. 2020; Ahmad and Chanoine 2017; Bakoush et al. 2016;
Tadmouri et al. 2014; Khan et al. 2020; Almazroua et al. 2020; Hazan et al. 2020)
v
vi Preface
cannot be underestimated, with consanguineous marriages ranging from 20% to

50% in the 22 Arab countries (Tadmouri et al. 2009).
It is evident that healthcare in the Arab World faces many unique challenges. A
new challenge is related to the impact of COVID-19, particularly in terms of its
ability to cause widespread infections, hospitalizations, and deaths in some of the
world’s largest yearly mass gatherings that occur in the Arab World (Mahdi et al.
2020). There are also the serious ethical, moral, humanitarian, and legal concerns
about the issuances of COVID-19 vaccinations to marginalized people in the Arab
world, such as migrant workers, and Palestinians and other prisoners.
Many Arab countries lack adequate services for palliative and hospice care, long-
term care, and dental and mental health clinics. An emerging area of concern is
patient safety in the Arab World (Elmontsri et al. 2017, 2018). Equally important is
the startling realization that there is a lower priority placed on improving healthcare
in the region: governments in the region continue to spend more on strengthening
their militaries than on providing better healthcare and education for their citizens.
Cultural barriers have created a stigma associated with mental health diseases and
physical/congenital disorders (Lindheimer et al. 2020). Added to this complexity is
that several countries in the Arab World are reforming the financing of their
healthcare systems based on restructuring their economies, adding to the already
complex issues faced by the healthcare sector in the region (World Health Organi-
zation 2019). Topics such as sexual health and drug/alcohol abuse in the region are
not openly discussed (DeJong and El-Khoury 2006), and the hidden agendas of
political decisions, be it directly or indirectly, on the healthcare sectors often cause
many patients to remain untreated or to eventually die.
This Handbook of Healthcare in the Arab World is a collection of chapters on
various social (Pande et al. 2017), ethical (Arawi 2010), and economical (Pourreza
et al. 2017) drivers of healthcare. Each chapter has been independently reviewed and
aims to discuss current healthcare challenges and their possible solutions based on
evidence and global best practice so that countries in the region can benefit from the
shared experiences of the collective. Efforts were made to be as inclusive as possible,
even though many authors and important topics are not represented in this collection
– this lack of transparency of healthcare in the Arab world is in part due to the
longstanding concern about the lack of published data related to many aspects of the
health and well-being of the people living and working in the Arab world (Makhoul
and El-Barbir 2006; Rawaf et al. 2006). It is hoped that this handbook initiates
conversations on identifying both the healthcare needs and the solutions for allevi-
ating disease burden, so that there are improvements in the health and well-being of
the people in the region, ideally by fostering greater collaboration within the region
and beyond.
BC, Canada Ismail Laher

August 2021
Preface vii
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Contents
Volume 1
Part I Women’s Health in the Middle Eastern Countries . . . . . . . . . 1

1 Reproductive Health in Arab Countries . . . . . . . . . . . . . . . . . . . . 3
Mohamed A. Abdelbaqy
2 Arab Women’s Health Care: Issues and Preventive Care . . . . . . 41
Jamila Abuidhail, Sanaa Abujilban, and Lina Mrayan
3 Social Determinants of Perinatal Health in Morocco . . . . . . . . . . 55
As. Barkat, M. A. Radouani, and A. Barkat
4 An Overview of Women’s Health in the Arab World . . . . . . . . . . 69
Al Johara M. AlQuaiz and Ambreen Kazi
5 Maternal and Neonatal Mortality in Mauritania . . . . . . . . . . . . . 95
Mohamed Lemine Cheikh Brahim Ahmed
6 Hormone Replacement Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Wendelyn Inman, Alexis Heaston, Revlon Briggs, and
Rosemary Theriot
7 Tobacco Use by Arab Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Najla Dar-Odeh and Osama Abu-Hammad
8 Epidemiology of Mental Health Problems in the Middle East . . . 133
Nahla Khamis Ibrahim
9 Achieving Sexual and Reproductive Health Equity in the
Arab Region: A New Role for the Health Sector . . . . . . . . . . . . . 151
Hoda Rashad, Sherine Shawky, Zeinab Khadr, Shible Sahbani, and
Mohamed Afifi
10 Cultural Barriers to Breast Cancer Screening in
Arab Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
Manal Alatrash
ix
x Contents
11 Violence Against Women in the Arab World: Eyes Shut

Wide Open . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
Saïda Douki Dedieu, Uta Ouali, Rym Ghachem, Hager Karray, and
Ilhem Issaoui
12 Spousal Violence in Arab Countries . . . . . . . . . . . . . . . . . . . . . . . 257
Hamid Yahya Hussain
13 Cultures of Resistance: The Struggle Against Domestic
Violence in Arab Societies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281
Lisa Hajjar, Eduardo de Leon Buendia, Patrick Fairbanks,
Emma Kuskey, Sasha Misco, and Ada Quevedo
Part II Health Needs of the Displaced and Refugee Population . . . 315

14 Maternal Health Care in a Multiethnic Setting with
Examples from Sweden,Scandinavia, and Europe . . . . . . . . . . . . 317
Pernilla Ny and Atika Khalaf
15 Mental Health and Well-being of Refugees . . . . . . . . . . . . . . . . . . 333
Muhammad Ilyas, Ammar Ahmed Siddiqui, Freah Alshammary,
Abdulmjeed Sadoon Al-Enizy, and Mohammad Khursheed Alam
16 Healthcare Among Immigrant and Refugee Arab
Americans in the United States . . . . . . . . . . . . . . . . . . . . . . . . . . . 355
Sara Alosaimy, Bashayer Alshehri, Raniah Aljadeed, Rana Aljadeed,
Dima Alnahas, Nada Alsuhebany, and Dima M. Qato
17 COVID-19 and Refugees’ Status of Permanent
“Out-of-Placeness”: A Necropolitical Neoliberal Construct . . . . . 377
Thalia Arawi, Taha Hatab, and Diana Mikati
18 Mental Health Care in Syrian Refugee Populations . . . . . . . . . . . 399
Kareem Sharif and Ahmad Hassan
Part III Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411

19 Cervical Cancer Screening in Arab Countries . . . . . . . . . . . . . . . 413
Osman Ortashi and Moza Alkalbani
20 Pediatric Oncology in the Arab World . . . . . . . . . . . . . . . . . . . . . 435
Iyad Sultan
21 Radiation Oncology in the Arab World . . . . . . . . . . . . . . . . . . . . 461
Layth Mula-Hussain, Shada Jamal Wadi-Ramahi,
Mohamed Saad Zaghloul, and Muthana Al-Ghazi
22 Cancer in War-Torn Countries: Iraq as an Example . . . . . . . . . . 481
Layth Mula-Hussain, Hayder Alabedi, Fawaz Al-Alloosh, and
Anmar Alharganee
Contents xi
23 Burden of Cancer in the Arab World . . . . . . . . . . . . . . . . . . . . . . 495

Ammar Ahmed Siddiqui, Junaid Amin, Freah Alshammary,
Eman Afroze, Sameer Shaikh, Hassaan Anwer Rathore, and
Rabia Khan
24 Oncology Care in the UAE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 521
Ibrahim Abu-Gheida, Neil A. Nijwahan, and Humaid O. Al-Shamsi
25 Cancer Care in Low- and Middle-Income Countries
Affected by Humanitarian Crises . . . . . . . . . . . . . . . . . . . . . . . . . 539
Jude Alawa, Adam Coutts, and Kaveh Khoshnood
Part IV Social Determinants of Health ...................... 575

26 Poverty Reduction Strategies and Health Outcomes: Jordan
as a Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 577
Thamer Sartawi
27 Environmental and Social Determinants of Health in
Palestine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 607
Yaser Y. Issa, Akram Amro, and Raghad K. Rajabi
28 Health-Risk Behaviors of Adolescents from Arab Nations . . . . . . 651
Caroline Barakat and Susan Yousufzai
29 Health Impact of Demographic Changes in the Gulf States . . . . . 677
Asharaf Abdul Salam
30 Communicable and Noncommunicable Diseases in
Conflict Zones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 699
M. Daniel Flecknoe, Mohammed Jawad, Samia Latif, and
Bayad Nozad
31 School Health in Arab Countries . . . . . . . . . . . . . . . . . . . . . . . . . 725
Hamid Yahya Hussain and Waleed Al Faisal
32 The Health of Arab Americans in the United States .......... 739
Nadia N. Abuelezam and Abdulrahman M. El-Sayed
33 Halal Certification of Food, Nutraceuticals, and
Pharmaceuticals in the Arab World . . . . . . . . . . . . . . . . . . . . . . . 765
Jawad Alzeer and Khaled Abou Hadeed
34 Tackling Noncommunicable Diseases in the Arab Region . . . . . . 789
Sameh El-Saharty, Toshiko Kaneda, and Aviva Chengcheng Liu
35 Sports Medicine in the Arab World . . . . . . . . . . . . . . . . . . . . . . . 837
Mohamad Y. Fares, Hamza A. Salhab, Hussein H. Khachfe,
Youssef Fares, and Jawad Fares
xii Contents
36 Social Determinants of Health in Fragile and Conflict Zones

Before and During the Coronavirus Pandemic, with a Focus
on the Gaza Strip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 851
Mohammed AlKhaldi, Samer Abuzerr, Hassan Abu Obaid,
Ghada Alnajjar, Ahmed Alkhaldi, and Abdulsalam Alkaiyat
37 Social Determinants of the Wellbeing of the Poor, the
Homeless, and the Imprisoned in Arab Countries . . . . . . . . . . . . 879
Nacer Amraoui
Volume 2
Part V Obesity and Systems Biology . . . . . . . . . . . . . . . . . . . . . . . . 891
38 Health Promotion for Preventing Obesity in the Arab

Gulf States . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 893
Anastasia Samara, Pernille T. Andersen, and Arja R. Aro
39 A Perspective on Female Obesity and Body Image in Middle
Eastern Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1003
Rabab B. Alkutbe
40 Diabetes in the Arab World . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1029
Rabia Khan, Ammar Ahmed Siddiqui, Freah Alshammary,
Sameer Shaikh, Junaid Amin, and Hassaan Anwer Rathore
41 Current Status of Diabetes in Palestine: Epidemiology,
Management, and Healthcare System . . . . . . . . . . . . . . . . . . . . . . 1053
Nuha El Sharif and Asma Imam
42 Diabetes Mellitus in Saudi Arabia . . . . . . . . . . . . . . . . . . . . . . . . 1083
Mohamed Abdulaziz Al Dawish and Asirvatham Alwin Robert
43 Type 2 Diabetes Mellitus (T2DM) in the Arab Society
of Israel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1101
Abdelnaser Zalan and Rajech Sharkia
44 Diabetes and Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1133
Nawar M. Shara
45 Overweight and Obesity Among Saudi Children: Prevalence,
Lifestyle Factors, and Health Impacts . . . . . . . . . . . . . . . . . . . . . 1155
Abeer M. Aljaadi and Mashael Alharbi
Part VI Mass Gatherings and Infectious Diseases . . . . . . . . . . . . . . 1181
46 Health Issues of Mass Gatherings in the Middle East . . . . . . . . . 1183

Amani Salem Alqahtani, Amal Mohammed Alshahrani, and
Harunor Rashid
Contents xiii
47 The Rise of Antimicrobial Resistance in Mass Gatherings . . . . . . 1199

Hamid Bokhary, Harunor Rashid, Grant A. Hill-Cawthorne, and
Moataz Abd El Ghany
48 Preparedness for Mass Gathering During Hajj and Umrah . . . . 1215
Iman Ridda, Sarab Mansoor, Revlon Briggs, Jemal Gishe, and
Doaha Aatmn
49 Middle East Respiratory Syndrome Coronavirus (MERS-CoV)
and Hajj Gatherings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1237
Jaffar A. Al-Tawfiq, Mamunur Rahman Malik, and Ziad A. Memish
50 Pandemic Viruses at Hajj: Influenza and COVID-19 . . . . . . . . . . 1249
Mohammad Alfelali, Parvaiz A. Koul, and Harunor Rashid
51 Mass Gatherings and Hazard Control: Agenda for Education
and Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1267
Francis T. Pleban
52 Meningococcal Disease During Hajj, Umrah, and Other
Mass Gatherings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1289
Sergerard Sebastian, Al-Mamoon Badahdah, Ameneh Khatami, and
Harunor Rashid
53 Pre-existing Health Concerns and Their Management in
Ramadan and Mass Gatherings . . . . . . . . . . . . . . . . . . . . . . . . . . 1311
Maria Kristiansen and Aziz Sheikh
54 COVID-19 in the Gulf Cooperation Council Countries:
Health Impact and Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1325
Sameh El-Saharty and Aviva Chengcheng Liu
Part VII Environmental Causes of Disease ................... 1359
55 Air Pollution and Health Outcomes in the Eastern

Mediterranean Region: Knowledge and Research Gaps
and Need . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1361
Yousef Saleh Khader
56 Vector-Borne Diseases in Arab Countries . . . . . . . . . . . . . . . . . . . 1405
Abdulla Salem Bin Ghouth, Ali Mohammad Batarfi,
Adnan Ali Melkat, and Samirah Elrahman
57 Health Impact of Airborne Fungi . . . . . . . . . . . . . . . . . . . . . . . . . 1421
Amal Saad-Hussein and Khadiga S. Ibrahim
58 Water Quality and Its Impact on Health Care in the
Arab World . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1437
Mohamed F. Hamoda
xiv Contents
59 Water, Sanitation, and Hygiene Within Healthcare Facilities in

Jordan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1463
Yousef Saleh Khader
Part VIII Health Systems and Health Management . . . . . . . . . . . . 1475
60 Health Policy and Systems Research in the Arab World:

Concepts, Evolution, Challenges, and Application Necessity
for COVID-19 Pandemic and Beyond . . . . . . . . . . . . . . . . . . . . . 1477
Mohammed AlKhaldi, Khaled Al-Surimi, and Hamza Meghari
61 Pharmaceutical Sector in Palestine . . . . . . . . . . . . . . . . . . . . . . . . 1503
Dima M. Qato, Jenny S. Guadamuz, Bashayer Al-Shehri,
Reem Al-Sultan, and Rania Shahin
62 Patient-Centered Care in the Middle East . . . . . . . . . . . . . . . . . . 1525
Hana Hasan Webair
63 Spirituality and Spiritual Care in the Arab World . . . . . . . . . . . . 1543
Mysoon Khalil Abu-El-Noor and Nasser Ibrahim Abu-El-Noor
64 Access to Health Using Cell Phones by War Refugees . . . . . . . . . 1571
Soha El-Halabi, Salla Atkins, Lana Al-Soufi, Tarik Derrough,
Lucie Laflamme, and Ziad El-Khatib
65 The Potential of Telemedicine in the Rural Eastern
Mediterranean Region for Noncommunicable Diseases: Case
Study from Jordan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1587
Soha El-Halabi, Salla Atkins, Yousef Saleh Khader, Adel Taweel,
Aiman Alrawabdeh, and Ziad El-Khatib
66 Healthcare Ethics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1603
Abdullah Saeed Hattab
67 Health Policies in Arab Countries . . . . . . . . . . . . . . . . . . . . . . . . . 1621
Hamid Yahya Hussain and Waleed Hassan Al Faisal
68 Access to Health Care in Saudi Arabia: Development in the
Context of Vision 2030 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1629
Abdulwahab Alkhamis and Shaima Ali Miraj
69 Exercise and Cardiovascular Health in the UAE . . . . . . . . . . . . . 1661
Sarah Dalibalta and Gareth Davison
70 Health Informatics in the Arab World . . . . . . . . . . . . . . . . . . . . . 1681
C. El Jabari and L. Adwan
71 Sleep Medicine and Sleep Disorders in Saudi Arabia and
the Arab World . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1693
Aljohara S. Almeneessier and Ahmed S. BaHammam
Contents xv
72 Patients’ Rights, as Part of Human Rights, in the

Arab World . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1709
Layth Mula-Hussain, Souheir Jammal Alawieh,
Luqman Othman Ahmed, and Fathi Mohammed Fathi Al Hayani
73 Transforming Health Financing Systems in the Arab World
Toward Universal Health Coverage . . . . . . . . . . . . . . . . . . . . . . . 1723
Awad Mataria, Sameh El-Saharty, Mariam M. Hamza, and
Hoda K. Hassan
74 Health Systems for the Elderly in the Arabian Gulf Region . . . . 1773
Marwan Ramadan and Armaghan Butt
75 Baseline Health-Related Data for Monitoring Sustainable
Development Goals in Jordan . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1789
Yousef Saleh Khader, Moawiah Khatatbeh, and
Oumaima Mohammed-Salah Aouididi
Volume 3
76 The Health of Arab Israelis: A Population in Transition . . . . . . . 1813

Dov Chernichovsky, Chen Sharony, Liora Bowers, and
Bishara Bisharat
77 Cupping Therapy (Hijama) in the Arab World . . . . . . . . . . . . . . 1845
Tamer S. Aboushanab and Saud M. AlSanad
78 Privatization of Healthcare in Saudi Arabia: Opportunities and
Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1865
Abdulwahab Alkhamis, Shaima S. Ali Miraj, Khalid I. Al Qumaizi,
and Khalid Alaiban
79 Healthcare Systems in the Arab World . . . . . . . . . . . . . . . . . . . . 1909
Samer Hamidi and Ahmed Ankit
80 Pharmacovigilance in the Arab World . . . . . . . . . . . . . . . . . . . . . 1929
Thamir M. Alshammari
81 Palliative Care in a Society in Transition: How to Address
the Unmet Biopsychosocial Needs in Oman . . . . . . . . . . . . . . . . . 1959
Sara S. H. Al-Adawi, Zakiya Al Lamki, Ahmed A. Moustafa,
Salam Alkindi, and Samir Al-Adawi
82 Health Benefits of Exercise and Fasting . . . . . . . . . . . . . . . . . . . . 1979
Hassane Zouhal, Amal Salhi, Ismail Laher, M. Faadiel Essop, and
Abderraouf Ben Abderrahman
83 Herbal Remedies Use in Arab Societies . . . . . . . . . . . . . . . . . . . . 1999
xvi Contents
84 Literature on Sleep Disorders in Arab Countries . . . . . . . . . . . . . 2021

Samer Hammoudeh, Muna Maarafeya, and Ibrahim A. Janahi
85 Traditional Medicine and Its Use for Pain Management
in Saudi Arabia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2057
Sameer Shaikh
86 Medication Errors in the Arab World . . . . . . . . . . . . . . . . . . . . . 2087
Manal Elshayib, Bisher Abuyassin, and Ismail Laher
Part IX Selected Health Conditions . . . . . . . . . . . . . . . . . . . . . . . . . 2147
87 Geriatric Medicine in the Arab World . . . . . . . . . . . . . . . . . . . . . 2149

Abdulrazak Abyad and Sonia Ouali Hammami
88 Developmental Disabilities in the Arab World . . . . . . . . . . . . . . . 2177
Muhammad Ilyas, Ammar Ahmed Siddiqui, Eman Afroze,
89 Use of Medications in Arab Countries . . . . . . . . . . . . . . . . . . . . . 2197
Sanah Hasan, Muaed J. Al-Omar, Hamzah AlZubaidy, and
Yaser Mohammed Al-Worafi
90 Epidemiology of Parasitic Diseases in the Gaza Strip,
Palestine: A Continuing Health Problem . . . . . . . . . . . . . . . . . . . 2239
Adnan Ibrahim Al-Hindi
91 Surgery and Public Health in the Middle East and
North Africa Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2261
Jawad M. Khalifeh, Elie Ramly, and Haytham M. A. Kaafarani
92 Older Population and the Health System . . . . . . . . . . . . . . . . . . . 2271
Sonia Ouali Hammami, Ahmed Sami Hammami, and
Abdulrazak Abyad
93 Adolescents’ Sexual and Reproductive Health in the
Arab World . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2289
Mamdouh Wahba
94 Palliative Care in the United Arab Emirates (UAE) . . . . . . . . . . . 2315
Neil A. Nijhawan and Humaid O. Al-Shamsi
95 Pressure Ulcers in the Arab World . . . . . . . . . . . . . . . . . . . . . . . . 2333
Jamil Halabi
96 Substance Abuse in Arab World: Does It Matter and Where
Are We? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2371
Fares F. Alharbi, Ettab G. Alsubaie, and Khaled Al-Surimi
97 Eye Health and Illuminated Screen Usage in the Arab World . . . 2399
Maneesha Phadke
Contents xvii
Part X Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2417

98 Road Traffic Crashes in the Arab World: From Evidence to
Public Policy and Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2419
Wesley M. Rohrer, Khaled Al-Surimi, and Carroline P. Lobo
99 Burden of Road Traffic Injuries in the Eastern Mediterranean
Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2453
Mathilde Sengoelge, Lucie Laflamme, Abdullah Al-Maniri, and
Ziad El-Khatib
100 Traumatic Brain Injury in the Arab Middle East . . . . . . . . . . . . 2469
Ayman El-Menyar, Rafael Consunji, and Hassan Al-Thani
101 Prevalence of Intimate Partner Violence Against Arab
Women in Consanguineous Marriages . . . . . . . . . . . . . . . . . . . . . 2483
Nagwa Abdel Meguid and Anne Webb
102 Conflict Medicine in the Arab World . . . . . . . . . . . . . . . . . . . . . . 2503
Jawad Fares, Hussein H. Khachfe, Mohamad Y. Fares,
Hamza A. Salhab, and Youssef Fares
Part XI Childhood Diseases ............................... 2519
103 Asthma Among Children in the Arab World . . . . . . . . . . . . . . . . 2521

Mohammad Al-Motlaq
104 Cerebral Palsy in the Middle East: Epidemiology,
Management, and Quality of Life . . . . . . . . . . . . . . . . . . . . . . . . . 2539
Sami Mukhdari Mushta, Gulam Khandaker, Rosalie Power, and
Nadia Badawi
105 Developmental Care Practices at Neonatal Intensive Care
Units in Developing Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . 2573
Manal Kassab and Shereen M. Hamadneh
106 Integrated Management of Childhood Health in the Eastern
Mediterranean Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2589
Huda Omer Basaleem, Khaled Abdulla Al-Sakkaf, and
Amen Ahmed Bawazir
107 Childhood Diarrhea in the Maghreb Arabic Union and Health
Benefits of Rotavirus Vaccination . . . . . . . . . . . . . . . . . . . . . . . . . 2619
Mohamed Lemine Cheikh Brahim Ahmed and Abdallah El-Vally
108 Burden of Childhood Infectious Diseases in the Arab World . . . . 2629
Mohamed Lemine Cheikh Brahim Ahmed and Jorg Heukelbach
109 Birth and Neonatal Death Registrations in Jordan . . . . . . . . . . . 2641
Yousef Saleh Khader, Mohammad Alyahya, and Anwar Batieha
xviii Contents
110 Chronic Childhood Illness in the Arab World . . . . . . . . . . . . . . . 2653

Mohammad AL Jabery and Diana Arabiat
111 Cleft and Craniofacial Plastic and Reconstructive Surgery . . . . . 2673

Ghassan S. Abu-Sittah and Rawad S. Chalhoub
112 Sudden Unexpected Infant Death . . . . . . . . . . . . . . . . . . . . . . . . . 2681

Shereen M. Hamadneh, Manal Kassab, Arieanna Eaton,
Anne Wilkinson, and Debra K. Creedy
113 Perinatal and Neonatal Mortality in Jordan . . . . . . . . . . . . . . . . . 2695

Yousef Saleh Khader, Mohammad Alyahya, and Anwar Batieha
Volume 4
Part XII Smoking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2717
114 Cessation of Waterpipe Smoking . . . . . . . . . . . . . . . . . . . . . . . . . 2719

Kenneth D. Ward and Weiyu Chen
115 Smoking Dokha Tobacco Through a Midwakh Pipe:

An Alternative Tobacco Product Endemic to the
Arabian/Persian Gulf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2743
Scott Sherman, Omar El-Shahawy, Andrea Leinberger-Jabari,
Jenni Shearston, and Michael Weitzman
Part XIII Cardiovascular and Pulmonary . . . . . . . . . . . . . . . . . . . . . 2755
116 Cardiovascular Risk Factors in Adolescents . . . . . . . . . . . . . . . . . 2757

A. Khaddam
117 Chronic Respiratory Diseases in the Arab World . . . . . . . . . . . . . 2767

Yousser Mohammad, Mirna Waked, and Agnes Hamzaoui
118 Management of Chronic Obstructive Pulmonary Disease . . . . . . 2807

Maher Khdour, Hussein Hallak, and Hani Abdeen
119 Asthma Among Arab Nations: An Overview . . . . . . . . . . . . . . . . 2827

Samer Hammoudeh, Wessam Gadelhaq, and Ibrahim A. Janahi
120 Coronary Artery Disease in the Arab World . . . . . . . . . . . . . . . . 2855

Ilham Bensahi, Amal Elouarradi, Salma Abdeladim,
Mahassine Elharrass, and Mohamed Sabry
121 Oral Anticoagulant Therapy in the Arab World . . . . . . . . . . . . . 2871

Salma Abdeladim, Mahassine Elharrass, Ilham Bensahi,
Amal Elouarradi, and Mohamed Sabry
Contents xix
Part XIV Musculoskeletal and Dermatology . . . . . . . . . . . . . . . . . . 2897
122 Musculoskeletal Disorders Among Healthcare Workers:

Prevalence and Risk Factors in the Arab World . . . . . . . . . . . . . 2899
Sameer Shaikh, Ammar Ahmed Siddiqui, Freah Alshammary,
Junaid Amin, and Muhammad Atif Saleem Agwan
Part XV Central Nervous System . . . . . . . . . . . . . . . . . . . . . . . . . . . 2939
123 Mental Health Services in the Sultanate of Oman . . . . . . . . . . . . 2941

Hamed Al-Sinawi, Hassan Mirza, and Mohammed Al Alawi
124 Dementia in the Arab World . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2953
Hamed Al Sinawi, Tareq Qassem, and Ahmed Al Harrasi
125 Mental Health and Psychosocial Concerns and Provision
of Services for Adolescent Syrian Refugees in Jordan . . . . . . . . . 2967
Yousef Saleh Khader
Part XVI Infectious Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2991
126 MERS-CoV and Its Impact in the Middle East/Arab World . . . . 2993
Gouri R. Banik, Jen Kok, and Harunor Rashid
127 Infectious Disease in Relation to Climate Change in the
Arab World . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3007
Amal Saad-Hussein
128 Hepatitis C Virus in the Middle East and North Africa . . . . . . . . 3027
Hiam Chemaitelly, Sarwat Mahmud, Ghina R. Mumtaz,
Lenka Benova, Houssein H. Ayoub, Silva P. Kouyoumjian,
Zaina Al-Kanaani, and Laith J. Abu-Raddad
129 The HIV Epidemic in the Middle East and North Africa:
Key Lessons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3053
Ghina R. Mumtaz, Hiam Chemaitelly, and Laith J. Abu-Raddad
130 HIV Care in the Arab World . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3081
Rita Wilson Dib and Jacques E. Mokhbat
131 Epidemiology of Scabies in Palestine . . . . . . . . . . . . . . . . . . . . . . 3099
Omar Hamarsheh
132 Epidemiology of Leishmaniasis in Palestine . . . . . . . . . . . . . . . . . 3113
Ahmad Amro and Omar Hamarsheh
133 Antimicrobial Resistance in the Arab Region . . . . . . . . . . . . . . . . 3131
Tala Ballouz, Nesrine Rizk, and Souha S Kanj
xx Contents
134 Women with HIV Living in the MENA Region . . . . . . . . . . . . . . 3157

Doaa Oraby
135 Evidence-Based Interventions for Antimicrobial Resistance
in Conflict-Afflicted Arab Countries . . . . . . . . . . . . . . . . . . . . . . . 3177
Noora Reffat, Kaveh Khoshnood, and Louise-Marie Dembry
Part XVII Future Directions ............................... 3203
136 Academic Medicine and the Development of Future Leaders

in Healthcare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3205
Jawad Fares, Hamza A. Salhab, Mohamad Y. Fares,
Hussein H. Khachfe, and Youssef Fares
137 Priorities for Arab Health Policy Makers . . . . . . . . . . . . . . . . . . . 3225
Part XVIII Ethics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3259
138 The Lures of the Scalpel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3261

Thalia Arawi, Diana Mikati, and Ghassan S. Abu-Sittah
139 Personalized Medicine Via Narrative: Mental Health, Culture,
and the Encapsulated Self of a Middle Eastern Woman . . . . . . . 3275
Thalia Arawi
140 Islam, the Pursuit of Knowledge, and the Ethics of Research . . . 3285
Thalia Arawi
141 Social Construction of Arab Masculinity and Its Effects on
Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3295
Sarah El Halabi, Zeid N. Founouni, and Thalia Arawi
142 The Journey of the Nafs and the Muslim Physician: Moral
Plasticity in Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3307
Thalia Arawi, Maya Chebaro, and Wadad Hoss
143 War as an Endemic Disease: Towards a New Paradigm Shift . . . 3323
Thalia Arawi and Ghassan S. Abu-Sittah
144 Humanitarian Medicine and Moral Injury: An Inevitable
Aftermath in Humanitarian Rebellion . . . . . . . . . . . . . . . . . . . . . 3339
Thalia Arawi and Sarah El Halabi
145 Necroethics: An Emerging Ethics in Times of Pandemics
Focusing on the Elderly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3349
Thalia Arawi and Bashar Hassan
146 Clinical Medical Ethics and Arab Cultural Values . . . . . . . . . . . . 3363
Philip Crowell
Contents xxi
147 Deconstructing the Challenges of Doing Research in Conflict

Zones and Areas of Protracted Conflict: The Ecology of Life
in Gaza . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3379
Thalia Arawi
148 Deconstructing Palliative Care in Areas of Armed Conflict:
Needs, Challenges, and Concerns . . . . . . . . . . . . . . . . . . . . . . . . . 3395
Hammoda Abu-Odah, Diana Mikati, and Thalia Arawi
Part XIX Dental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3413
149 Trigeminal Neuralgia in the Arab World Together with an

Update on the Understanding, and Appropriate Strategies
for Its Diagnosis and Management by the Dental
Practitioners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3415
Sameer Shaikh, Muhammad Atif Saleem Agwan, Suresh Babu
Jandrajupalli, Freah Alshammary, Sundeep Subbaiah Bhagwath, and
Ammar Ahmed Siddiqui
150 Oral and Oropharyngeal Cancer in Arab Nations . . . . . . . . . . . . 3437
Omar Kujan, Majdy Idrees, and Camile S. Farah
151 Oral Health in the Arab World: The Silent Epidemic of
Dental Caries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3461
Nazik Nurelhuda, Hyewon Lee, and Gemma Bridge
152 Oral and Maxillofacial Afflictions in the Gulf Cooperation
Council (GCC) Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3481
Sameer Shaikh
153 Oral Health in Saudi Arabia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3511
Ammar Ahmed Siddiqui, Abdulmjeed Sadoon Al-Enizy,
Freah Alshammary, Sameer Shaikh, and Junaid Amin
154 Craniofacial Characteristics of Saudi Adults . . . . . . . . . . . . . . . . 3537
Mohammad Khursheed Alam, Ayesha Siddika,
Shaifulizan Ab Rahman, Ammar Ahmed Siddiqui, and
Muhammad Ilyas
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3557
About the Editor
Ismail Laher graduated from the University of London

(UK) and continued his studies in pharmacology at the
University of British Columbia (Canada), Memorial
University of Newfoundland (Canada), and the Univer-
sity of Vermont (USA). His research interests are in
determinants of vascular function in health and disease.
He has published over 200 peer-reviewed research arti-
cles and is also the editor of a 5-volume reference
collection Systems Biology of Free Radicals and Anti-
oxidants and the co-editor of Nutritional Antioxidant
Therapies: Treatments and Perspectives, both published
by Springer Verlag.
xxiii
About the Section Editors
Section: Central Nervous System

Hamed Al-Sinawi
Department of Behavioral Medicine
Sultan Qaboos University Hospital
Muscat, Oman
Section: Health Systems and Health Management

Asmaa Alyaemni
Health Administration Department
College of Business Administration
King Saud University
Kingdom of Saudi Arabia (KSA)
Riyadh, Saudi Arabia
xxv
xxvi About the Section Editors
Section: Childhood Diseases

Diana Arabiat
School of Nursing and Midwifery
Edith Cowan University
Joondalup, WA, Australia
Maternal and Child Nursing Department
Faculty of Nursing
The University of Jordan
Amman, Jordan
Section: Childhood Diseases

Huda Basaleem
Faculty of Medicine and Health Sciences
University of Aden
Aden, Yemen
Section: Ethics
Philip Crowell
Department of Pediatrics
Hematology/Oncology and Department
of Spiritual Health, Medical Ethics Educator
Faculty of Medicine
University of British Columbia
Sections: Health Systems and Health Management; Injuries

Ziad El-Khatib
Department of Global Public Health
Karolinska Institutet
Stockholm, Sweden
World Health Programme
Université du Québec en
Abitibi-Témiscamingue (UQAT)
Rouyn-Noranda, QC, Canada
About the Section Editors xxvii
Sections: Social Determinants of Health; Future Directions

Sameh El-Saharty
The Middle East and North Africa Department
The World Bank
Washington, DC, USA
Sections: Environmental Causes of Disease; Selected Health Conditions

Yousef Saleh Khader
Department of Community Medicine
Public Health and Family Medicine
Faculty of Medicine
Jordan University of Science and Technology
Irbid, Jordan
Global Health Development (GHD)/The Eastern

Mediterranean Public Health Network (EMPHNET)
Amman, Jordan
Sections: Health Needs of the Displaced and Refugee Population; Obesity

and Systems Biology
Atika Khalaf
Faculty of Health Science
Kristianstad University
Kristianstad, Sweden
College of Nursing
Sultan Qaboos University,
Muscat, Oman
xxviii About the Section Editors
Section: Ethics
Ismail Laher
Faculty of Medicine
Department of Anesthesiology
Pharmacology and Therapeutics
The University of British Columbia
Section: Mass Gatherings and Infectious Diseases

Ziad A. Memish
College of Medicine
AlFaisal University
Riyadh, Kingdom of Saudi Arabia
Section: Cardiovascular and Pulmonary

Yousser Mohammad
National Center for Research on Chronic Respiratory
Diseases and Co-morbidities
Tishreen University
Lattakia, Syria
Syrian Private University
Damascus, Syria
About the Section Editors xxix
Section: Health Needs of the Displaced and Refugee Population

Dima M. Qato
Program on Medicines and Public Health
School of Pharmacy
University of Southern California
Los Angeles, CA, USA
Section: Mass Gatherings and Infectious Diseases

Harunor Rashid
National Centre for Immunisation
Research and Surveillance (NCIRS)
The Children’s Hospital at Westmead
Westmead, NSW, Australia
The Discipline of Child and Adolescent Health
Faculty of Medicine and Health
Sydney Medical School
University of Sydney
Sydney, NSW, Australia
Section: Infectious Diseases

Amal Saad-Hussein
Department of Environmental and
Occupational Medicine
Environmental Research Division
National Research Centre
Cairo, Egypt
xxx About the Section Editors
Section: Obesity and Systems Biology

Anastasia Samara
Unit for Health Promotion Research
University of Southern Denmark
Esbjerg, Jutland, Denmark
Section: Dental Health

Eli Whitney
Faculty of Dentistry
University of British Columbia
Contributors
Doaha Aatmn California University of Science and Medicine, San Bernardino,

CA, USA
Shaifulizan Ab Rahman Oral and Maxillofacial Surgery Department, School of
Dental Science, Universiti Sains Malaysia, Kota Bharu, Malaysia
Moataz Abd El Ghany The Westmead Institute for Medical Research, The Uni-
versity of Sydney, Sydney, Australia
The Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of
Sydney, Sydney, Australia
Hani Abdeen Faculty of Medicine, Al-Quds University, Jerusalem, Palestine
Salma Abdeladim Department of Clinical and Interventional Cardiology, Univer-
sity Med VI of Health Sciences – International Universal Hospital Cheikh Khalifa,
Casablanca, Morocco
Mohamed A. Abdelbaqy Research Department, Alexandria Regional Centre for
Women’s Health and Development, Alexandria, Egypt
Abderraouf Ben Abderrahman Higher Institute of Sport and Physical Education
of Ksar-Said, Tunis, Tunisia
Tamer S. Aboushanab Cairo, Egypt
Mysoon Khalil Abu-El-Noor Faculty of Nursing, Islamic University of Gaza,
Gaza, Palestine
Nasser Ibrahim Abu-El-Noor Faculty of Nursing, Islamic University of Gaza,
Gaza, Palestine
Ibrahim Abu-Gheida Emirates Oncology Society, Dubai, United Arab Emirates
Radiation Oncology Department, Burjeel Medical City, Abu Dhabi, United Arab
Emirates
College of Medicine and Health Sciences, United Arab Emirates University, Abu
Dhabi, United Arab Emirates
xxxi
xxxii Contributors
Osama Abu-Hammad School of Dentistry, University of Jordan, Amman, Jordan

College of Dentistry, Taibah University, Al Madinah Al Munawarah, Saudi Arabia
Hammoda Abu-Odah School of Nursing, The Hong Kong Polytechnic Univer-
sity, Kowloon, Hong Kong
Laith J. Abu-Raddad Infectious Disease Epidemiology Group, Weill Cornell
Medicine-Qatar, Cornell University, Qatar Foundation – Education City, Doha,
Qatar
Department of Healthcare Policy and Research, Weill Cornell Medicine, Cornell
University, Ithaca, New York, NY, USA
World Health Organization Collaborating Centre for Disease Epidemiology Analyt-
ics on HIV/AIDS, Sexually Transmitted Infections, and Viral Hepatitis, Weill
Cornell Medicine – Qatar, Cornell University, Qatar Foundation, Doha, Qatar
Ghassan S. Abu-Sittah Division of Plastic Surgery, Department of Surgery, Amer-
ican University of Beirut Medical Center, Beirut, Lebanon
Nadia N. Abuelezam Boston College, William F. Connell School of Nursing,
Chestnut Hill, MA, USA
Jamila Abuidhail Faculty of Nursing, Hashemite University, Zarqa, Jordan
Sanaa Abujilban Faculty of Nursing, Hashemite University, Zarqa, Jordan
Bisher Abuyassin Experimental Medicine Department, King Abdullah Interna-
tional Medical Research Center/King Saud bin Abdulaziz University for Health
Sciences, King Abdulaziz Medical City, Ministry of National Guard Health Affairs,
Samer Abuzerr Department of Social and Preventive Medicine, School of Public
Health, University of Montreal, Montréal, QC, Canada
Quality Improvement and Infection Control Unit, Ministry of Health, Gaza,
Palestine
Abdulrazak Abyad Abyad Medical Center, Middle East Academy for Medicine of
Aging, Middle East and North Africa Association on Aging and Alzheimer’s,
Tripoli, Lebanon
L. Adwan College of Pharmacy Nursing and Health Professions, Birzeit Univer-
sity, Birzeit, Palestine
Mohamed Afifi United Nations Population Fund - UNFPA, Arab States Regional
Office, Cairo, Egypt
Eman Afroze Private Dental Practice, Islamabad, Pakistan
Muhammad Atif Saleem Agwan Division of Endodontics, Department of Restor-
ative Dental Sciences, College of Dentistry, Qassim University, Qassim, Saudi
Arabia
Contributors xxxiii
Luqman Othman Ahmed College of Law, University of Mosul, Mosul, Iraq

Mohamed Lemine Cheikh Brahim Ahmed The Mauritanian Association for
Scientific Research Development (AMDRS) and Unity of Molecular Epidemiology
and Diversity of Microorganisms, Department of Biology, Faculty of Sciences and
Techniques, University of Nouakchott El-Asriya, Nouakchott, Mauritania
Research Unity on Public Health and Epidemiology (URSPE), Faculty of Medicine,
University of Nouakchott Al-Assriya (UNA), Nouakchott, Mauritania
Mohammed Al Alawi Department of Behavioral Medicine, Sultan Qaboos Uni-
versity Hospital, Muscat, Oman
Mohamed Abdulaziz Al Dawish Department of Endocrinology and Diabetes,
Diabetes Treatment Center, Prince Sultan Military Medical City, Riyadh, Saudi
Arabia
Waleed Hassan Al Faisal Faculty of Medicine, University of Damascus, Dubai
Health Authority, Dubai, United Arab Emirates
Ahmed Al Harrasi Department of Behavioral Medicine, Sultan Qaboos University
Hospital, Muscat, Oman
Fathi Mohammed Fathi Al Hayani College of Law, University of Mosul, Mosul,
Iraq
Mohammad AL Jabery Faculty of Educational Sciences, Department of Counsel-
ling and Special Education, The University of Jordan, Amman, Jordan
Zakiya Al Lamki Paediatric Haematology Unit, Department of Child Health,
College of Medicine and Health Sciences Sultan Qaboos University Muscat, Mus-
cat, Sultanate of Oman
Hamed Al Sinawi Department of Behavioral Medicine, Sultan Qaboos University
Samir Al-Adawi Department of Behavioural Medicine, College of Medicine and
Health Sciences Sultan Qaboos University Muscat, Muscat, Sultanate of Oman
Sara S. H. Al-Adawi Surgery Resident Program Oman Medical Speciality Board
Muscat, Muscat, Sultanate of Oman
Fawaz Al-Alloosh Iraqi Cancer Board – Ministry of Health, Baghdad, Iraq
Abdulmjeed Sadoon Al-Enizy College of Dentistry, University of Ha’il, Ha’il,
Saudi Arabia
Muthana Al-Ghazi Chao Family Comprehensive Cancer Center – University of
California, Irvine, CA, USA
Adnan Ibrahim Al-Hindi Medical Laboratory Sciences Department, Faculty of
Health Sciences, Islamic University of Gaza, Gaza, Palestine
xxxiv Contributors
Zaina Al-Kanaani Infectious Disease Epidemiology Group, Weill Cornell Medi-

cine-Qatar, Cornell University, Qatar Foundation – Education City, Doha, Qatar
Abdullah Al-Maniri Department of Research and Planning, Oman Medical Spe-
cialty Board, Muscat, Oman
Mohammad Al-Motlaq Department of Maternal Child and Family Health, Hash-
emite University, Zarqa, Jordan
Muaed J. Al-Omar College of Pharmacy and Health Sciences, Ajman University,
Ajman, United Arab Emirates
Khaled Abdulla Al-Sakkaf Department of Community Medicine and Public
Health, Faculty of Medicine and Health Sciences, University of Aden, Aden, Yemen
Bashayer Al-Shehri Department of Pharmacy Practice, University of Illinois
College of Pharmacy, Chicago, IL, USA
Hamed Al-Sinawi Department of Behavioral Medicine, Sultan Qaboos University
Lana Al-Soufi Department of Public Health Sciences, Karolinska Institutet, Stock-
holm, Sweden
Reem Al-Sultan Department of Pharmacy Practice, University of Illinois College
of Pharmacy, Chicago, IL, USA
Khaled Al-Surimi College of Public Health and Health Informatics, King Saud bin
Abdulaziz University for Health Sciences (KSAU-HS), College of Public Health and
Health Informatics, Riyadh, Saudi Arabia
Healthcare Management Consultant, Saudi Commission for Health Specialties,
King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
School of Public Health, Faculty of Medicine, Imperial College, London, UK
Jaffar A. Al-Tawfiq Specialty Internal Medicine and Quality Department, Johns
Hopkins Aramco Healthcare, Dhahran, Saudi Arabia
Indiana University School of Medicine, Indianapolis, IN, USA
Johns Hopkins University School of Medicine, Baltimore, MD, USA
Hassan Al-Thani Trauma and Vascular Surgery, Hamad General Hospital, Doha,
Qatar
Yaser Mohammed Al-Worafi College of Pharmacy and Health Sciences, Ajman
University, Fujairah, United Arab Emirates
Hayder Alabedi Iraqi Cancer Board – Ministry of Health, Baghdad, Iraq
Khalid Alaiban Department of Public Administration/Health Administration, Col-
lege of Business Administration, King Saud University, Riyadh, Saudi Arabia
Contributors xxxv
Mohammad Khursheed Alam Orthodontic Division, Preventive Dentistry

Department, College of Dentistry, Jouf University, Sakaka, Al Jouf, Saudi Arabia
Manal Alatrash School of Nursing, California State University, Fullerton, CA, USA
Jude Alawa Stanford University School of Medicine, Stanford, California, USA
Souheir Jammal Alawieh Faculty of Pharmacy, Lebanese University, Beirut,
Lebanon
Mohammad Alfelali Department of Family and Community Medicine, Faculty of
Medicine in Rabigh, King Abdulaziz University, Jeddah, Saudi Arabia
Fares F. Alharbi King Abdullah International Medical Research Center, Riyadh,
Saudi Arabia
College of Medicine, King Saud bin Abdulaziz University for Health Sciences,
Ministry of the National Guard Health Affairs, Riyadh, Saudi Arabia
Mashael Alharbi Curriculum and Pedagogy Department, Faculty of Education,
University of British Columbia, Vancouver, BC, Canada
Anmar Alharganee Oncology Hospital – Baghdad Medical City Complex, Bagh-
dad, Iraq
Shaima S. Ali Miraj Department of Public Health, College of Health Sciences,
Saudi Electronic University, Riyadh, Saudi Arabia
Abeer M. Aljaadi Department of Food, Nutrition, and Health, Faculty of Land and
Food Systems, University of British Columbia, Vancouver, BC, Canada
Department of Clinical Nutrition, Faculty of Applied Medical Sciences, Umm
Al-Qura University, Makkah, Saudi Arabia
Rana Aljadeed College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
Department of Pharmacy, University of Arizona/Northwest Medical Center, Tucson,
AZ, USA
Department of Pharmacy, Houston Methodist Hospital, Houston, TX, USA
Raniah Aljadeed College of Pharmacy, King Saud University, Riyadh, Saudi
Arabia
Department of Pharmacy, University of Arizona/Northwest Medical Center, Tucson,
AZ, USA
Abdulsalam Alkaiyat Faculty of Medicine and Health Sciences, An-Najah
National University (NNU), Nablus, Palestine
Moza Alkalbani Sultan Qaboos University Hospital, Muscat, Oman
Ahmed Alkhaldi Faculty of Sciences, Al-Azhar University, Gaza, Palestine
Al-Awa’ael Investments and Trading, Gaza, Palestine
xxxvi Contributors
Mohammed AlKhaldi Council on Health Research for Development, COHRED,

Genève, Switzerland
Department of Public Health, Unit of Health Systems and Policies, Swiss Tropical
and Public Health Institute (Swiss TPH), Basel, Switzerland
Faculty of Science, University of Basel, Basel, Switzerland
Faculty of Medicine and Health Sciences, An-Najah National University (NNU),
Nablus, Palestine
Faculty of Medicine, McGill University, Montreal, Canada
Abdulwahab Alkhamis Department of Public Health, College of Health Sciences,
Saudi Electronic University, Riyadh, Saudi Arabia
Salam Alkindi Department of Haematology, College of Medicine and Health
Sciences Sultan Qaboos University Muscat, Muscat, Sultanate of Oman
Rabab B. Alkutbe School of Biomedical Sciences (Faculty of Health: Medicine,
Dentistry and Human Sciences), University of Plymouth , Plymouth, UK
Aljohara S. Almeneessier Department of Family Medicine, College of Medicine,
King Saud University, Riyadh, Saudi Arabia
University Sleep Disorders Center, College of Medicine, King Saud University,
Dima Alnahas Department of Pharmacy, University of Kalamoon, Deir Atiyah,
Syria
Ghada Alnajjar Ahli Arab Hospital, Gaza, Palestine
Sara Alosaimy Department of Pharmacy, Brigham and Women’s Hospital, Boston,
MA, USA
College of Pharmacy, Wayne State University, Detroit, MI, USA
College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
Amani Salem Alqahtani Saudi Food and Drug Authority, Riyadh, Saudi Arabia
Al Johara M. AlQuaiz Princess Nora Bent Abdullah Chair for Women’s Health
Research, College of Medicine, King Saud University, Riyadh, Saudi Arabia
Department of Family and Community Medicine, College of Medicine, King Saud
University, Riyadh, Saudi Arabia
Aiman Alrawabdeh American Healthcare Technology Solutions, Jordan
Healthcare Initiative – Cisco Systems, Amman, Jordan
Saud M. AlSanad Complementary and Alternative Medicine, College of Medi-
cine, Imam Mohammad Ibn Saud Islamic University (IMSIU), Riyadh, Saudi Arabia
Amal Mohammed Alshahrani Armed Forced Hospitals Southern Region, Khamis
Mushayt, Saudi Arabia
Contributors xxxvii
Thamir M. Alshammari College of Pharmacy, Riyadh Elm University, Riyadh,

Saudi Arabia
Medication Safety Research Chair, King Saud University, Riyadh, Saudi Arabia
Freah Alshammary Division of Pediatric Dentistry, Department of Preventive
Dental Sciences, College of Dentistry, University of Ha’il, Ha’il, Saudi Arabia
Humaid O. Al-Shamsi Emirates Oncology Society, Dubai, United Arab Emirates
College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
Department of Medical Oncology, Burjeel Medical City, Abu-Dhabi, United Arab
Emirates
Bashayer Alshehri Department of Pharmacy, Brigham and Women’s Hospital,
Boston, MA, USA
Ettab G. Alsubaie College of Medicine, King Saud bin Abdulaziz University for
Health Sciences, Riyadh, Saudi Arabia
Nada Alsuhebany Department of Pharmacy Systems, Outcomes and Policy, Uni-
versity of Illinois College of Pharmacy, Chicago, IL, USA
Mohammad Alyahya Department of Health Management and Policy, Faculty of
Medicine, Jordan University of Science and Technology, Irbid, Jordan
Jawad Alzeer Department of Chemistry, University of Zurich, Zurich, Switzerland
Hamzah AlZubaidy College of Pharmacy, University of Sharjah, Sharjah, United
Arab Emirates
Junaid Amin Department of Physiotherapy, College of Applied Medical Sciences,
University of Ha’il, Ha’il, Saudi Arabia
Nacer Amraoui Bedford, UK
Ahmad Amro Faculty of Pharmacy, Al-Quds University, Jerusalem, Palestine
Akram Amro Department of Physiotherapy, Faculty of Health Professions/Phar-
macy, Al-Quds University, Abu Deis-Main Campus, Jerusalem, Palestine
Pernille T. Andersen Unit for Health Promotion Research, University of Southern
Denmark, Esbjerg, Jutland, Denmark
Ahmed Ankit Hamdan Bin Mohammed Smart University, Dubai, United Arab
Emirates
Oumaima Mohammed-Salah Aouididi Faculty of Medicine, Jordan University of
Science and Technology, Irbid, Jordan
Diana Arabiat School of Nursing and Midwifery, Edith Cowan University,
Joondalup, WA, Australia
Maternal and Child Nursing Department, Faculty of Nursing, The University of
Jordan, Amman, Jordan
xxxviii Contributors
Thalia Arawi The Salim El-Hoss Bioethics and Professionalism Program, Depart-
ment of Internal Medicine, American University of Beirut Medical Center, Beirut,
Lebanon
Head of Division of Plastic & Reconstructive Surgery, American University of
Beirut Medical Center, Beirut, Lebanon
Arja R. Aro Unit for Health Promotion Research, University of Southern Den-
mark, Esbjerg, Jutland, Denmark
Salla Atkins Department of Public Health Sciences, Karolinska Institutet, Stock-
holm, Sweden
Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
Houssein H. Ayoub Department of Mathematics, Statistics, and Physics, Qatar
University, Doha, Qatar
Al-Mamoon Badahdah National Centre for Immunisation Research and Surveil-
lance (NCIRS), The Children’s Hospital at Westmead, Westmead, Australia
Department of Family and Community Medicine, Faculty of Medicine in Rabigh,
King Abdulaziz University, Jeddah, Saudi Arabia
Discipline of Child and Adolescent Health, The Children’s Hospital Westmead
Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney,
Australia
Nadia Badawi Discipline of Child and Adolescent Health, Sydney Medical
School, University of Sydney, Camperdown, NSW, Australia
Cerebral Palsy Alliance Research Institute, Sydney, NSW, Australia
Ahmed S. BaHammam University Sleep Disorders Center, College of Medicine,
King Saud University, Riyadh, Saudi Arabia
The Strategic Technologies Program of the National Plan for Sciences and Technol-
ogy and Innovation, Riyadh, Saudi Arabia
Tala Ballouz Division of Infectious diseases, Department of Internal Medicine,
American University of Beirut Medical Center, Beirut, Lebanon
Gouri R. Banik National Centre for Immunisation Research and Surveillance, The
Children’s Hospital at Westmead, Kids Research, Sydney Children’s Hospitals
Network, Westmead, NSW, Australia
School of Medical and Molecular Biosciences, The i3 Institute, Faculty of Science,
University of Technology, Sydney, Ultimo, NSW, Australia
Caroline Barakat Faculty of Health Sciences, Ontario Tech University, Oshawa,
ON, Canada
As. Barkat Equipe de recherche en santé et nutrition du couple mère enfant,
Faculté de médecine et de pharmacie de Rabat, Université Mohammed V, Rabat,
Morocco
Contributors xxxix
A. Barkat Equipe de recherche en santé et nutrition du couple mère enfant, Faculté

de médecine et de pharmacie de Rabat, Université Mohammed V, Rabat, Morocco
Service de médecine et réanimation néonatales, Centre National de Néonatologie et
Nutrition, Hôpital d’Enfants, Centre hospitalier Ibn Sina, Rabat, Morocco
Huda Omer Basaleem Department of Community Medicine and Public Health,
Faculty of Medicine and Health Sciences, University of Aden, Aden, Yemen
Ali Mohammad Batarfi Hadramout University, Yemen, Yemen
Anwar Batieha Department of Community Medicine, Public Health and Family
Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid,
Jordan
Amen Ahmed Bawazir Department of Community Medicine and Public Health,
Faculty of Medicine and Health Sciences, University of Aden, Aden, Yemen
Lenka Benova Infectious Disease Epidemiology Group, Weill Cornell Medicine-
Qatar, Cornell University, Qatar Foundation – Education City, Doha, Qatar
Faculty of Epidemiology and Population Health, London School of Hygiene and
Tropical Medicine, London, UK
Ilham Bensahi Department of Clinical and Interventional Cardiology, University
Med VI of Health Sciences – International Universal Hospital Cheikh Khalifa,
Casablanca, Morocco
Sundeep Subbaiah Bhagwath Division of Oral Pathology, Department of Basic
Bishara Bisharat The EMMS Nazareth Hospital, Nazareth, Israel
Hamid Bokhary Umm Al-Qura University, Makkah, Saudi Arabia
School of Public Health, The University of Sydney, Sydney, NSW, Australia
Liora Bowers Taub Center for Social Policy Studies in Israel, Jerusalem, Israel
Gemma Bridge Leeds Business School, Leeds Beckett University, Leeds, UK
Revlon Briggs Department of Public Health, Health Administration, and Health
Sciences, Tennessee State University, Nashville, TN, USA
Eduardo de Leon Buendia University of California – Santa Barbara (UCSB),
Santa Barbara, CA, USA
Armaghan Butt Department of Geriatrics and Home Health Care Services, Hamad
Medical Corporation, Doha, Qatar
Royal College of General Practitioners, London, UK
Rawad S. Chalhoub Division of Plastic and Reconstructive Surgery, American
University of Beirut Medical Center, Beirut, Lebanon
Maya Chebaro International College, Beirut, Lebanon
xl Contributors
Hiam Chemaitelly Infectious Disease Epidemiology Group, Weill Cornell Medi-

Department of Infectious Disease Epidemiology, Faculty of Epidemiology and
Population Health, London School of Hygiene and Tropical Medicine, London, UK
Weiyu Chen Division of Social and Behavioral Sciences, School of Public Health,
The University of Memphis, Memphis, TN, USA
Dov Chernichovsky Ben-Gurion University of the Negev, Beer-Sheva, Israel
Rafael Consunji Injury Prevention, Trauma Surgery, Hamad General Hospital,
Doha, Qatar
Adam Coutts Department of Sociology, University of Cambridge, Cambridge, UK
Debra K. Creedy School of Nursing and Midwifery, Griffith University, Brisbane,
QLD, Australia
Philip Crowell Department of Pediatrics, Hematology/Oncology and Department
of Spiritual Health, Medical Ethics Educator Faculty of Medicine, University of
British Columbia, Vancouver, BC, Canada
Sarah Dalibalta Department of Biology, Chemistry and Environmental Sciences,
American University of Sharjah, Sharjah, UAE
Najla Dar-Odeh School of Dentistry, University of Jordan, Amman, Jordan
Gareth Davison Sport and Exercise Science Research Institute, Ulster University,
Jordanstown, UK
Louise-Marie Dembry Yale School of Medicine and School of Public Health, New
Haven, CT, USA
Tarik Derrough Vaccine Preventable Diseases, European Centre for Disease Pre-
vention and Control (ECDC), Stockholm, Sweden
Saïda Douki Dedieu Faculty of Medicine of Tunis, University Claude Bernard,
Lyon, France
Arieanna Eaton Department of Integrated Physiology and Health Sciences, Alma
College, Alma, MI, USA
Nuha El Sharif Faculty of Public Health, Al Quds University, Jerusalem, Palestine
Soha El-Halabi Skoun, Lebanese Addiction Center, Beirut, Lebanon
Department of Learning, Informatics, Management and Ethics, Karolinska Institutet,
Stockholm, Sweden
Faculty of Health Sciences, University of Balamand, Beirut, Lebanon
Contributors xli
Ziad El-Khatib Department of Global Public Health, Karolinska Institutet, Stock-

holm, Sweden
World Health Programme, Université du Québec en Abitibi-Témiscamingue
(UQAT), Rouyn-Noranda, QC, Canada
Ayman El-Menyar Clinical Research, Trauma and Vascular Surgery, Hamad Gen-
eral Hospital, Doha, Qatar
Clinical Medicine, Weill Cornell Medical School, Doha, Qatar
Sameh El-Saharty The Middle East and North Africa Department, The World
Bank, Washington, DC, USA
Abdulrahman M. El-Sayed Wayne State University, Detroit, MI, USA
Omar El-Shahawy NYU/Abu Dhabi Public Health Research Center, Abu Dhabi,
UAE
Department of Population Health, NYU School of Medicine, New York, NY, USA
College of Global Public Health, New York University, New York, NY, USA
Abdallah El-Vally The Mauritania Association for Scientific Research Develop-
ment (AMDRS), University of Nouakchott Al-Assriya (UNA), Nouakchott,
Mauritania
Research Unity on Public Health and Epidemiology (URSPE), Faculty of Medicine,
University of Nouakchott Al-Assriya (UNA), Nouakchott, Mauritania
Mahassine Elharrass Department of Clinical and Interventional Cardiology, Uni-
versity Med VI of Health Sciences – International Universal Hospital Cheikh
Khalifa, Casablanca, Morocco
Amal Elouarradi Department of Clinical and Interventional Cardiology, Univer-
Casablanca, Morocco
Samirah Elrahman University of Gezira, Wad Medani, Sudan
Manal Elshayib Riyadh, Saudi Arabia
M. Faadiel Essop Centre for Cardio-metabolic Research in Africa (CARMA),
Department of Physiological Sciences, Stellenbosch University, Stellenbosch,
South Africa
Patrick Fairbanks University of California – Santa Barbara (UCSB), Santa
Barbara, CA, USA
Waleed Al Faisal Dubai, UAE
Camile S. Farah UWA Dental School, The University of Western Australia,
Nedlands, WA, Australia
Australian Centre for Oral Oncology Research and Education, Nedlands, WA,
Australia
xlii Contributors
Jawad Fares Department of Neurological Surgery, Feinberg School of Medicine,

Northwestern University, Chicago, IL, USA
Mohamad Y. Fares Neuroscience Research Center, Faculty of Medicine, Lebanese
University, Beirut, Lebanon
Faculty of Medicine, American University of Beirut, Beirut, Lebanon
College of Medical, Veterinary, and Life Sciences, University of Glasgow, Glasgow,
UK
Youssef Fares Neuroscience Research Center, Faculty of Medicine, Lebanese
University, Beirut, Lebanon
M. Daniel Flecknoe Derby Teaching Hospitals NHS Foundation Trust, Derby, UK
University of Sheffield, Sheffield, UK
Faculty of Public Health, London, UK
Global Violence Prevention Special Interest Group, London, UK
Médecins Sans Frontières, London, UK
Zeid N. Founouni Salim El-Hoss Bioethics and Professionalism Program, Amer-
Wessam Gadelhaq Medical Education, Sidra Medicine, Doha, Qatar
Rym Ghachem Hôpital Razi, La Manouba, Tunisia
Abdulla Salem Bin Ghouth Hadramout University, Yemen, Yemen
Jemal Gishe Department of Public Health, Health Administration, and Health
Jenny S. Guadamuz Department of Pharmacy Systems, Outcomes and Policy,
University of Illinois College of Pharmacy, Chicago, IL, USA
Institute of Minority Health Research, University of Illinois at Chicago, Chicago, IL,
USA
Khaled Abou Hadeed Department of Chemistry, University of Zurich, Zurich,
Switzerland
Halalopathic Research Unit, Dübendorf, Switzerland
Lisa Hajjar University of California – Santa Barbara (UCSB), Santa Barbara, CA,
USA
Department of Sociology, UCSB, Santa Barbara, CA, USA
Jamil Halabi Faculty of Medicine, University of Balamand, Balamand, Lebanon
Sarah El Halabi Salim El Hoss Bioethics and Professionalism Program, Depart-
ment of Internal Medicine, American University of Beirut Medical Center, Beirut,
Lebanon
Contributors xliii
Hussein Hallak Faculty of Medicine, Al-Quds University, Jerusalem, Palestine

Shereen M. Hamadneh Department of Maternal Child Health, Faculty of Nursing,
Al al-Bayt University, Al-Mafraq, Jordan
Nursing and Midwifery Research Centre, School of Nursing and Midwifery, Edith
Cowan University, Joondalup, Australia
Happy Baby Association, Ministry of Social Development, Amman, Jordan
Omar Hamarsheh Department of Biological Sciences, Faculty of Science and
Technology, Al-Quds University, Jerusalem, Palestine
Department of Life Sciences, Al-Quds University, Jerusalem, Palestine
Samer Hamidi Hamdan Bin Mohammed Smart University, Dubai, United Arab
Emirates
Ahmed Sami Hammami Faculté de Médecine, Université de Monastir, Monastir,
Tunisia
Sonia Ouali Hammami Internal Medicine Department, Geriatric Unit, CHU F
Bourguiba Monastir, Research Lab; Human Nutrition and Metabolic Disorder,
University of Monastir, Monastir, Tunisia
Samer Hammoudeh Medical Research Center, Research Affairs, Hamad Medical
Corporation, Doha, Qatar
Mohamed F. Hamoda Environmental Engineering, Department of Civil Engineer-
ing, Kuwait University, Safat, Kuwait
Mariam M. Hamza The World Bank, Washington, DC, USA
Agnes Hamzaoui Department of Paediatric Respiratory Diseases, Abderrahmen
Mami Hospital, Ariana, Tunisia
Tunis Medicine School, Tunis El Manar University, Tunis, Tunisia
Sanah Hasan Department of Clinical Sciences, College of Pharmacy and Health
Sciences, Ajman University, Ajman, United Arab Emirates
Ahmad Hassan Department of Neuroscience, Yale University School of Medicine,
New Haven, CT, USA
Bashar Hassan The Salim El-Hoss Bioethics and Professionalism Program, Amer-
Hoda K. Hassan Eastern Mediterranean Regional Office, World Health Organiza-
tion, Cairo, Egypt
Abdullah Saeed Hattab Public Health, University of Aden, Aden, Yemen
Taha Hatab The Salim El-Hoss Bioethics and Professionalism Program, American
University of Beirut, Beirut, Lebanon
xliv Contributors
Alexis Heaston Department of Public Health, Health Administration, and Health

Jorg Heukelbach Department of Community Health, School of Medicine, Federal
University of Ceará, Fortaleza, CE, Brazil
Grant A. Hill-Cawthorne School of Public Health, The University of Sydney,
Sydney, NSW, Australia
Wadad Hoss International College, Beirut, Lebanon
Hamid Yahya Hussain Faculty of Medicine, University of Baghdad, Dubai Health
Authority, Dubai, UAE
University of Baghdad, Baghdad, Iraq
Khadiga S. Ibrahim Department of Environmental and Occupational Medicine,
National Research Centre, Cairo, Egypt
Nahla Khamis Ibrahim Community Medicine Department, Faculty of Medicine,
King Abdulaziz University, Jeddah, Saudi Arabia
Epidemiology Department, High Institute of Public Health, Alexandria University,
Alexandria, Egypt
Majdy Idrees UWA Dental School, The University of Western Australia,
Nedlands, WA, Australia
Muhammad Ilyas Department of Management and MIS, College of Business
Administration, University of Ha’il, Ha’il, Saudi Arabia
Asma Imam Faculty of Public Health, Al Quds University, Jerusalem, Palestine
Wendelyn Inman Department of Public Health, Health Administration, and Health
Yaser Y. Issa Environmental Health Department, Ministry of Health (MoH),
Hebron Public Health Directorate, Hebron, Palestine
Ilhem Issaoui Hôpital Razi, La Manouba, Tunisia
C. El Jabari Hebron University, Hebron, Palestine
Ibrahim A. Janahi Medical Education, Sidra Medicine, Doha, Qatar
Pediatric Pulmonology, Pediatric Medicine, Sidra Medicine, Doha, Qatar
Suresh Babu Jandrajupalli Division of Periodontology, Department of Preventive
Mohammed Jawad Faculty of Public Health, London, UK
Imperial College London, London, UK
Contributors xlv
Haytham M. A. Kaafarani Department of Surgery, Massachusetts General Hos-

pital and Harvard Medical School, Boston, MA, USA
Toshiko Kaneda The Population Reference Bureau, Washington, DC, USA
Souha S. Kanj Division of Infectious diseases, Department of Internal Medicine,
Hager Karray CHS Annecy, France
Manal Kassab Department of Maternal and Child Health, Faculty of Nursing,
Jordan University of Science and Technology, Irbid, Jordan
Faculty of Health, University of Technology, Sydney, Ultimo, NSW, Australia
Happy Baby Association, Ministry of Social Development, Amman, Jordan
Ambreen Kazi Princess Nora Bent Abdullah Chair for Women’s Health Research,
College of Medicine, King Saud University, Riyadh, Saudi Arabia
Department of Family and Community Medicine, College of Medicine, King Saud
Hussein H. Khachfe Faculty of Medicine, American University of Beirut, Beirut,
Lebanon
Neuroscience Research Center, Faculty of Medicine, Lebanese University, Beirut,
Lebanon
A. Khaddam Faculty of Medicine, Cardiology, Damascus University, Damascus,
Syria
Yousef Saleh Khader Department of Community Medicine, Public Health and
Family Medicine, Faculty of Medicine, Jordan University of Science and Technol-
ogy, Irbid, Jordan
Global Health Development (GHD)/The Eastern Mediterranean Public Health Net-
work (EMPHNET), Amman, Jordan
Zeinab Khadr The Social Research Center, The American University in Cairo,
Cairo, Egypt
Faculty of Economics and Political Science, Cairo University, Cairo, Egypt
Atika Khalaf Faculty of Health Science, Kristianstad University, Kristianstad,
Sweden
College of Nursing, Sultan Qaboos University, Muscat, Oman
Jawad M. Khalifeh Washington University School of Medicine, Saint Louis, MO,
USA
Rabia Khan Department of Bio Engineering, Lancaster University, Lancaster, UK
Gulam Khandaker Public Health Unit, Central Queensland Hospital and Health
Service, Queensland Government, Springsure, QLD, Australia
xlvi Contributors
Discipline of Child and Adolescent Health, Sydney Medical School, University of

Sydney, Camperdown, NSW, Australia
Asian Institute of Disability and Development (AIDD), University of South Asia,
Dhaka, Bangladesh
Ameneh Khatami Discipline of Child and Adolescent Health, The Children’s
Hospital Westmead Clinical School, Faculty of Medicine and Health, The University
of Sydney, Sydney, Australia
Department of Infectious Diseases and Microbiology, The Children’s Hospital at
Westmead, Westmead, Australia
Moawiah Khatatbeh Faculty of Medicine, Yarmouk University, Irbid, Jordan
Maher Khdour Faculty of Pharmacy, Al-Quds University, Jerusalem, Palestine
Kaveh Khoshnood Yale School of Public Health, New Haven, CT, USA
Jen Kok Centre for Infectious Diseases and Microbiology Laboratory Services,
NSW Health Pathology-Institute of Clinical Microbiology and Medical Research,
Westmead Hospital, Westmead, NSW, Australia
Parvaiz A. Koul Department of Internal and Pulmonary Medicine, Sher-i- Kashmir
Institute of Medical Sciences (SKIMS), Srinagar, India
Silva P. Kouyoumjian Infectious Disease Epidemiology Group, Weill Cornell
Medicine-Qatar, Cornell University, Qatar Foundation – Education City, Doha,
Qatar
Maria Kristiansen Center for Healthy Aging and Department of Public Health,
University of Copenhagen, Copenhagen, Denmark
Omar Kujan UWA Dental School, The University of Western Australia, Nedlands,
WA, Australia
Emma Kuskey University of California – Santa Barbara (UCSB), Santa Barbara,
CA, USA
Lucie Laflamme Department of Public Health Sciences, Karolinska Institutet,
Stockholm, Sweden
Institute for Social and Health Sciences South Africa, University of South Africa,
Johannesburg, South Africa
South African Medical Research Council, University of South Africa’s Violence,
Injury and Peace Research, Johannesburg, South Africa
Ismail Laher Faculty of Medicine, Department of Anesthesiology, Pharmacology
and Therapeutics, The University of British Columbia, Vancouver, BC, Canada
Samia Latif Faculty of Public Health, London, UK
Contributors xlvii
Public Health England, London, UK

Hyewon Lee Department of Dentistry, Mount Sinai Hospital, New York, NY, USA
Andrea Leinberger-Jabari NYU/Abu Dhabi Public Health Research Center, Abu
Dhabi, UAE
Aviva Chengcheng Liu Public Health Policy Consultant, The World Bank, Wash-
ington, DC, USA
Carroline P. Lobo Department of Health Policy and Management, University of
Pittsburgh, Graduate School of Public Health, Pittsburgh, PA, USA
Muna Maarafeya Pediatric Pulmonology, Pediatric Medicine, Sidra Medicine,
Doha, Qatar
Sarwat Mahmud Infectious Disease Epidemiology Group, Weill Cornell Medi-
Mamunur Rahman Malik Eastern Mediterranean Regional Office of WHO,
Cairo, Egypt
Sarab Mansoor The University of Sydney School of Pharmacy, NSW, Australia
Awad Mataria Eastern Mediterranean Regional Office, World Health Organiza-
tion, Cairo, Egypt
Hamza Meghari Research Committee Advisor,Women Deliver Organization, New
York, NY, USA
Global Health and Development, Institute for Global Health, University College
London UCL, London, UK
Nagwa Abdel Meguid Human Genetics, Research on Children with Special
Needs, National Research Centre, Cairo, Egypt
Uppsala University, Uppsala, Sweden
Yale University, New Haven, CT, USA
Adnan Ali Melkat Hadramout University, Yemen, Yemen
Ziad A. Memish College of Medicine, AlFaisal University, Riyadh, Kingdom of
Saudi Arabia
Diana Mikati The Salim El Hoss Bioethics and Professionalism Program, Amer-
Shaima Ali Miraj Department of Public Health, College of Health Sciences, Saudi
Electronic University, Riyadh, Saudi Arabia
Hassan Mirza Department of Behavioral Medicine, Sultan Qaboos University
xlviii Contributors
Sasha Misco University of California – Santa Barbara (UCSB), Santa Barbara, CA,
USA
Yousser Mohammad National Center for Research on Chronic Respiratory Dis-
eases and Co-morbidities, Tishreen University, Lattakia, Syria
Syrian Private University, Damascus, Syria
Jacques E. Mokhbat Department of Medicine, Gilbert and Rose-Marie Chagoury
School of Medicine, Lebanese American University, Beirut, Lebanon
Ahmed A. Moustafa School of Social Sciences and Psychology, Marcs Institute of
Brain and Behaviour Western Sydney University Penrith, Penrith, NSW, Australia
Lina Mrayan Faculty of Nursing, Hashemite University, Zarqa, Jordan
Layth Mula-Hussain Department of Radiation Oncology, Cross Cancer Institute –
University of Alberta, Edmonton, AB, Canada
Ghina R. Mumtaz Infectious Disease Epidemiology Group, Weill Cornell Medi-
Department of Epidemiology and Population Health, American University of Beirut,
Beirut, Lebanon
Sami Mukhdari Mushta Department of Curative Programs and Preventive Med-
icine, Public Health Department, Khamis Mushayt Health Sector, Ministry of
Health, Khamis Mushayt, Saudi Arabia
Neil A. Nijhawan Radiation Oncology Department, Burjeel Cancer Institute,
Burjeel Medical City, Abu Dhabi, United Arab Emirates
Department of Palliative Care and Hospice, Burjeel Medical City, Abu Dhabi,
United Arab Emirates
Bayad Nozad Faculty of Public Health, London, UK
Global Violence Prevention special interest group, London, UK
Nazik Nurelhuda Faculty of Dentistry, University of Khartoum, Khartoum, Sudan
Pernilla Ny Kristianstad University, Kristianstad, Sweden
Hassan Abu Obaid Ministry of Health, Indonesian Hospital, Gaza, Palestine
Doaa Oraby Cairo, Egypt
Osman Ortashi Obstetrics and Gynaecology Department, Sidra Medicine, Doha,
Qatar
Uta Ouali Hôpital Razi, La Manouba, Tunisia
Contributors xlix
Maneesha Phadke DHA Primary Health Care Clinic, Dubai, UAE

Francis T. Pleban College of Health Sciences, Department of Public Health,
Health Administration and Health Sciences, Tennessee State University, Nashville,
Tennessee, USA
Rosalie Power Discipline of Child and Adolescent Health, Sydney Medical
School, University of Sydney, Camperdown, NSW, Australia
Asian Institute of Disability and Development (AIDD), University of South Asia,
Dhaka, Bangladesh
Tareq Qassem Maudsley Health, Dubai, United Arab Emirates
Al-Amal Hospital, Dubai, United Arab Emirates
Ain Shams University, Cairo, Egypt
Mohammed Bin Rashid University of Medicine and Health Sciences (MBRU),
Dubai, United Arab Emirates
Dima M. Qato Program on Medicines and Public Health, School of Pharmacy,
University of Southern California, Los Angeles, CA, USA
Ada Quevedo University of California – Santa Barbara (UCSB), Santa Barbara,
CA, USA
Khalid I. Al Qumaizi Department of Family Medicine, College of Medicine, Al
Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia
M. A. Radouani Equipe de recherche en santé et nutrition du couple mère enfant,
Faculté de médecine et de pharmacie de Rabat, Université Mohammed V, Rabat,
Morocco
Service de médecine et réanimation néonatales, Centre National de Néonatologie et
Nutrition, Hôpital d’Enfants, Centre hospitalier Ibn Sina, Rabat, Morocco
Raghad K. Rajabi Furat Food Industry, Hebron, Palestine
Marwan Ramadan Department of Geriatrics, Hamad Medical Corporation, Doha,
Qatar
Weil Cornell school of medicine, Doha, Qatar
Elie Ramly Department of General Surgery, Oregon Health and Science Univer-
sity, Portland, OR, USA
Hoda Rashad The Social Research Center, The American University in Cairo,
Cairo, Egypt
Harunor Rashid National Centre for Immunisation Research and Surveillance
(NCIRS), The Children’s Hospital at Westmead, Westmead, NSW, Australia
l Contributors
The Discipline of Child and Adolescent Health, Faculty of Medicine and Health,
Sydney Medical School, University of Sydney, Sydney, NSW, Australia
Hassaan Anwer Rathore College of Pharmacy, University of Ha’il, Ha’il, Saudi
Arabia
School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
Noora Reffat Yale School of Public Health, New Haven, CT, USA
Iman Ridda Department of Public Health, Health Administration, and Health
Nesrine Rizk Division of Infectious diseases, Department of Internal Medicine,
Asirvatham Alwin Robert Department of Endocrinology and Diabetes, Diabetes
Treatment Center, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
Wesley M. Rohrer Department of Health Policy and Management, University of
Pittsburgh, Graduate School of Public Health, Pittsburgh, PA, USA
Amal Saad-Hussein Department of Environmental and Occupational Medicine,
Environmental Research Division, National Research Centre, Cairo, Egypt
Mohamed Sabry Department of Clinical and Interventional Cardiology, Univer-
Casablanca, Morocco
Shible Sahbani United Nations Population Fund - UNFPA, Arab States Regional
Office, Cairo, Egypt
Asharaf Abdul Salam Center for Population Studies, King Saud University,
Hamza A. Salhab Faculty of Medicine, American University of Beirut, Beirut,
Lebanon
Neuroscience Research Center, Faculty of Medicine, Lebanese University, Beirut,
Lebanon
Amal Salhi Higher Institute of Sport and Physical Education of Ksar-Said, Tunis,
Tunisia
Anastasia Samara Unit for Health Promotion Research, University of Southern
Denmark, Esbjerg, Jutland, Denmark
Thamer Sartawi Saint Louis University, St Louis, MO, USA
Sergerard Sebastian National Centre for Immunisation Research and Surveillance
(NCIRS), The Children’s Hospital at Westmead, Westmead, Australia
Mathilde Sengoelge Department of Public Health Sciences, Karolinska Institutet,
Stockholm, Sweden
Contributors li
Rania Shahin Ministry of Health, Nablus, Palestine

Sameer Shaikh Divisions of Oral Diagnosis and Oral Medicine, Department of
OMFS and Diagnostic Sciences, College of Dentistry, University of Ha’il, Ha’il,
Saudi Arabia
Nawar M. Shara Department of Biostatistics and Biomedical Informatics, George-
town University, BERD-CTSA (Georgetown-Howard), MedStar Health Research
Institute, Hyattsville, MD, USA
Kareem Sharif Department of Neuroscience, Perelman School of Medicine at the
University of Pennsylvania, Philadelphia, PA, USA
Rajech Sharkia Human Biology Department, The Triangle Research and Devel-
opment Center, Kfar-Qari, Israel
Beit-Berl Academic College, Beit-Berl, Israel
Chen Sharony Ben-Gurion University of the Negev, Beer-Sheva, Israel
Sherine Shawky The Social Research Center, The American University in Cairo,
Cairo, Egypt
Jenni Shearston NYU/Abu Dhabi Public Health Research Center, Abu Dhabi, UAE
Aziz Sheikh Usher Institute of Population Health Sciences and Informatics, The
University of Edinburgh, Edinburgh, UK
Division of General Internal Medicine and Primary Care, Brigham and Women’s
Hospital, Boston, MA, USA
Centre for Population Health Sciences, The University of Edinburgh, Edinburgh,
UK
Scott Sherman NYU/Abu Dhabi Public Health Research Center, Abu Dhabi, UAE
Ayesha Siddika School of Dental Science, Universiti Sains Malaysia, Kota Bharu,
Malaysia
Ammar Ahmed Siddiqui Division of Dental Public Health, Department of Pre-
ventive Dental Sciences, College of Dentistry, University of Ha’il, Ha’il, Saudi
Arabia
Iyad Sultan Department of Pediatrics, King Hussein Cancer Center, Al-Jubeiha,
Jordan
Adel Taweel Department of Computer Science, Birzeit University, Birzeit,
Palestine
Department of Informatics, King’s College London, London, UK
lii Contributors
Rosemary Theriot Department of Public Health, Health Administration, and

Health Sciences, Tennessee State University, Nashville, TN, USA
Shada Jamal Wadi-Ramahi King Faisal Specialist Hospital and Research Center,
Mamdouh Wahba Arab Coalition for Adolescent Medicine, The Egyptian Society
for Adolescent Medicine, Cairo, Egypt
Mirna Waked St George Hospital University Medical Center, Balamand Univer-
sity, Beirut, Lebanon
Kenneth D. Ward Division of Social and Behavioral Sciences, School of Public
Health, The University of Memphis, Memphis, TN, USA
Hana Hasan Webair Hadhramout University, College of Medicine, Mukalla,
Yemen
Anne Webb Canadian Research Institute for the Advancement of Women, Ottawa,
ON, Canada
Natural Sciences and Engineering Research Council of Canada, Ottawa, ON,
Canada
Michael Weitzman NYU/Abu Dhabi Public Health Research Center, Abu Dhabi,
UAE
Department of Pediatrics, NYU School of Medicine, New York, NY, USA
Anne Wilkinson Nursing and Midwifery Research Centre, School of Nursing and
Midwifery, Edith Cowan University, Joondalup, Australia
Rita Wilson Dib Department of Medicine, Medical College of Georgia, Augusta
University, Augusta, GA, USA
Susan Yousufzai Faculty of Health Sciences, Ontario Tech University, Oshawa,
ON, Canada
Mohamed Saad Zaghloul Radiation Oncology, Children’s Cancer Hospital and
National Cancer Institute – Cairo University, Cairo, Egypt
Abdelnaser Zalan Human Biology Department, The Triangle Research and Devel-
opment Center, Kfar-Qari, Israel
Hassane Zouhal Movement, Sport, Health and Sciences Laboratory (M2S), Uni-
versity of Rennes 2-ENS Cachan, Rennes, France
Part I
Women’s Health in the Middle Eastern
Countries
Reproductive Health in Arab Countries
1
Mohamed A. Abdelbaqy
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Indicators of Reproductive Healthcare Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Types of Services and Accessibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Family Planning Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Female Genital Mutilation (FGM) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
The Medicalization of FGM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Maternal Healthcare Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Fertility Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Cesarean Section . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Abortion Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Adolescence and Young Population Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Marriage Patterns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Marginalized People and Refugees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Sexual and Reproductive Health Rights of Lesbian, Gay, Bisexual, and Transgender
(LGBT) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Sexually Transmitted Infection (STI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Financing Sexual and Reproductive Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
The Funding Gap in Population Assistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Reproductive Cancers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Overview of Gynecological Cancers in the Arab Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Reproductive Health and Genetic Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
The Prevention and Management of Genetic Disorders in Arab Countries . . . . . . . . . . . . . . . . . 32
Reproductive Healthcare Services After the Arab Spring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
M. A. Abdelbaqy (*)
Research Department, Alexandria Regional Centre for Women’s Health and Development,
Alexandria, Egypt
e-mail: abdelbaqym@alexu.edu.eg; mohamedbaqy@gmail.com
© Springer Nature Switzerland AG 2021 3

I. Laher (ed.), Handbook of Healthcare in the Arab World,
https://doi.org/10.1007/978-3-030-36811-1_1
4 M. A. Abdelbaqy
Abstract
Reproductive health in the Arab region is of great local interest. Traditions and local
cultures with the differences in healthcare policies help to shape services available in
the region. This chapter reviews healthcare services in different Arab countries, with
a focus on the general situation in the Arab region and a comparison between various
Arab countries. The topics covered include the types of services and accessibility,
family planning, female genital mutilation, maternal healthcare services, fertility
services, cesarean section, abortion, adolescence health, marriage pattern, reproduc-
tive healthcare for refugees, financing sexual and reproductive health (SRH),
reproductive cancers, and genetic and congenital anomalies. In general, the lack of
awareness and poor resource availability negatively affect women in the region,
particularly related to their reproductive health and rights.
Keywords
Reproductive health · Arab · Woman · Family planning · FGM · Maternal ·
Abortion · Cesarean section · Cancer · Genetic · Adolescence
Introduction
The Arab region is an area rich in history and tradition that includes 22 countries
varying in resources, income per capita, available healthcare services, population
density, and growth rates (Mirkin 2010). Reproductive healthcare in particular seems
to be of low priority in the Arab region, even though access to basic reproductive
healthcare services is a human right. Reproduction is an important component of
health and well-being in both men and women (Cook et al. 2003). However, women
in almost all cases carry the burden or the responsibility of reproductive health,
including diseases and the social aspects. Sexual and reproductive health continues
to be a sensitive topic because of sociocultural or religious sensitivities in the Arab
world, which adds to concerns about the treatment of women and the poor access to
information and services (Hahn and Inborn 2009).
The definition of health as published by the World Health Organization (WHO) in
1987 and adopted by the International Conference on Population and Development
(ICPD) in 1994 is a state of complete physical, mental and social well-being and not
merely the absence of disease or infirmity. As per this statement, reproductive
healthcare can be defined as the constellation of methods, techniques and services
that contribute to reproductive health and well-being by preventing and solving
reproductive health problems. It includes maternal and perinatal health, family
planning, preventing unsafe abortion, prevention and treatment of sexually trans-
mitted diseases and promoting sexual health (Cook et al. 2003).
Our understanding of sexual and reproductive health has radically changed
during the second half of the last century due to a greater appreciation of its many
subtleties and multidisciplinary approaches. The following is a discussion of some
determinants of reproductive health in the Arab world, emphasizing the recent status
1 Reproductive Health in Arab Countries 5
of healthcare services in the region in order to improve our understanding of

reproductive health and services provided in the Arab region.
Indicators of Reproductive Healthcare Services
The Arab countries are undergoing significant changes that impact economic devel-
opment and demographic transition. This transition also affects women’s health and
reproductive healthcare services. A detailed overview of the reproductive healthcare
profile in the Arab region is available in the global indicators adopted by the WHO
(UNDP 2016), and some important indicators are summarized in Table 1.
(I) The total fertility rate in the Arab countries has decreased since 1990 (Fig. 1).
For example, the fertility rates in 2015 ranged from 6.4 births per woman in
Somalia to 1.7 births per woman in Lebanon. Thirteen Arab countries [Syria,
Djibouti, Algeria, Oman, KSA, Morocco, Libya, Tunisia, Bahrain, Kuwait,
Qatar, UAE, Lebanon] reported total fertility rates below the global estimate
of 3.3 births per woman, while the birth rates were equal to or higher than 3.3
births per woman in nine countries [Somalia, Mauritania, Sudan, Comoros,
Iraq, Palestine, Yemen, Jordan, Egypt].
(II) The availability of contraceptive measures is generally low in Arab countries.
The use of contraception is less than 25% in most countries; for instance, the
rates are very low in Comoros (14.2%), Djibouti (18%), Mauritania (10, 1%),
Oman (18.8%), and Sudan (11.7%), while the use of contraceptives is higher in
some regions such as Morocco (58.6%) and Egypt (59.0%) which almost
remained constant from 2005 until 2015 (Ministry of Health and Population
et al. 2015). The universal estimate for the use of contraception is 48.7%.
(III) Skilled health staff attends to births in about 78% of instances worldwide and
almost always (99%) in high-income countries. In the Arab region, these
estimates are higher than global estimates, reaching 100% in Bahrain, Jordan,
Libya, Palestine, Qatar, and UAE, but lower in Yemen (45%) (Data from 2016).
(IV) The percentage of pregnant women who receive antenatal care in the region is
generally high when compared to global estimates (84%). Nearly all women (99%)
received antenatal care in Oman, Jordan, and Palestine, while in Yemen only 60%
of women received antenatal care (where it had the lowest available data).
(V) Maternal mortality rates are generally high in the Arab region, and there is a gap
between the reported cases and the modeled estimates. These results highlight
the underestimation of recorded cases and unrecorded cases. According to
modeled estimates in 2015, Somalia (732/100,000) and Mauritania (602/
100,000) have the highest numbers, which represents an improvement from
the 1990s where the rates were 1210/100,000 in Somalia and 859/100,000 in
Mauritania. Only three countries in the region achieved the low maternal
mortality rates (less than 10/100,000) which were classified as high-income
countries. These three countries are Libya (9/100,000), UAE (6/100,000), and
Kuwait (4/100,000) (World Health Organization 2016a; World Bank 2018)
6
Table 1 Reproductive health indicators in the Arab world (UNDP 2016)

2.14 Reproductive health
Demand
for family Pregnant
planning women Lifetime
satisfied by receiving risk of
Total fertility Adolescent modern Contraceptive prenatal Births attended by maternal
rate fertility rate methods prevalence care skilled health staff Maternal mortality ratio mortality
Modern National Modeled
methods estimates estimates
% of
married
women
Births per with
1,000 demand for Per
Births per women family % of women 100,000 Per 100,000 Probability:
woman aged 15–19 planning aged 15–49 % % total live births live births 1 woman in
1990 2015 2015 2008–2016 2008–2016 2008–2016 1990 2008–2016 2008–2016 1990 2015 2015
Algeria 4.7 2.8 10 77.2 49.5 93 77 97 – 216 140 240
Bahrain 3.7 2.1 13 – – – – 100 17 26 15 3,000
Comoros 6.4 4.4 67 27.4 14.2 92 – 82 172 635 335 66
Djibouti 6.1 2.9 21 – 18 88 – 87 380 517 229 140
Egypt 4.7 3.3 51 80 56.9 90 37 92 52 106 33 810
M. A. Abdelbaqy
1
Iraq 5.9 4.4 85 59.3 35.9 78 54 91 35 107 50 420

Jordan 5.5 3.4 23 58 42.3 99 87 100 19 110 58 490
Kuwait 3 2 9 – – – – 99 2 7 4 10,300
Lebanon 3 1.7 12 – 46.8 – – – – 74 15 3,700
Libya 5 2.3 6 – – – – 100 – 39 9 4,200
Mauritania 6 4.7 78 23.8 10.1 84 40 65 630 859 602 36
Morocco 4.1 2.5 31 74.8 58.6 77 31 74 110 317 121 320
Oman 7.2 2.7 8 19.1 18.8 99 – 99 12 30 17 1,900
Qatar 4 1.9 10 68.9 34.4 91 100 100 13 29 13 3,500
KSA 5.9 2.6 8 – – 97 88 98 14 46 12 3,100
Somalia 7.4 6.4 103 – – – – – – 1,210 732 22
Sudan 6.2 4.6 72 30.2 11.7 79 69 78 220 744 311 72
Syria 5.3 3 39 53.3 37.5 88 – 96 – 123 68 440

Tunisia 3.5 2.2 7 73.2 50.9 98 69 74 – 131 62 710
UAE 4.5 1.8 30 – – – 99 100 – 17 6 7,900
Palestine 6.7 4.1 58 64.8 44.1 99 – 100 – 118 45 490
Yemen 8.6 4.1 61 46.9 29.2 60 16 45 150 547 385 60
KSA, Kingdom of Saudi Arabia; UAE, United Arab Emirates
7
8 M. A. Abdelbaqy
Fig. 1 Total fertility rate trends of 15–49-year-olds in selected Arab countries (ICF 2018)
Types of Services and Accessibility
Sexual and reproductive healthcare and services are fundamental to achieving

universal health coverage. Reproductive health services typically cover the topics
of family planning, management of sexually transmitted diseases (STDs), and
prevention and treatment of maternal and perinatal mortality and morbidity. This
includes educational, counselling, and medical support (Gagnon et al. 2002; UNFPA
2016). Reproductive healthcare facilities are either integrated with other medical
services or can be provided as specialized services in the Arab nations (El-zein et al.
2014). Although most reproductive healthcare services are available, access to them
is often poor in Arab countries due to a series of limitations such as having a
traditional background, poor economic conditions, and, most importantly, lack of
awareness. There is a real and urgent need for reform and an integration policy to
ensure greater availability and accessibility to reproductive healthcare services in the
Arab region (UNFPA 2016; Dejong and Heidari 2017).
The political system in the Arab region differs from one country to another and
demonstrates differences in political participation and community engagement. As a
result, there are many challenges facing the integration of maternal and child
healthcare services in most Arab countries. Inadequate policies and an unregulated
private sector (which requires out-of-pocket expenditure) act as barriers for access
equity. Unstable security and political situations in many countries reflect a lack of
understanding by policymakers and also create shortages of healthcare workers
(World Health Organization 2015a; Sumpf et al. 2016; Bou-karroum et al. 2019).
Weak health systems in many Arab countries lead to high levels of social and
political fragmentation in the healthcare system in general, particularly related to
access equity. The fragmentation is a direct result of a weak coordination between
stakeholders, inadequate health information system, and a lack of financing systems
for effective resource merging and risk sharing. This creates an urgent need to
address all available resources and create a single health plan to cover the needs of
reproductive, maternal, newborn, child, and adolescent healthcare. (World Health
Organization 2015a; Alwan et al. 2016; El-zein et al. 2016; Alami 2017).
The unmet need for reproductive healthcare services in Sudan creates high
maternal and neonatal mortality rates that may be related to an unequal distribution
of healthcare providers as well as to the quality of healthcare facilities (Abdel-tawab
and El-rabbat 2010). Access to reproductive healthcare services in Egypt is greater in
urban compared to rural areas, which is an important consideration bearing in mind
that Egypt largely consists of rural areas. The overall utilization rates of maternal
services were 76%, and of these births, skilled professionals attended to 92% in 2014
(Ragab 2010; Ministry of Health and Population et al. 2015).
The situation in Morocco is influenced by local traditions that restrict accessibility
of maternal and reproductive healthcare services. Women do not have free mobil-
ity or financing, with a further complication being that women are generally poorly
educated in Morocco. Although the neighboring country of Tunisia has the same
predictors of maternal health services (maternal, educational, demographical), Tuni-
sian women receive at least twice as much antenatal care and have six times more
hospital childbirth delivery services. It is likely that isolated populations in rural
areas and the geographical characteristics of Morocco lead to poor utilization of
reproductive healthcare services (Obermeyer 1993; Hotchkiss et al. 2003).
There was notable progress in reproductive and women’s health in Syria before
the current conflict, where the government improved healthcare in general rather
than focusing specifically on women’s health needs. The utilization rates of repro-
ductive health services are higher in the capital (Damascus) than in other regions of
the country (Bashour et al. 2008; World Health Organization 2013). The effects of
the ongoing Syrian civil war on the healthcare system, particularly related to
women’s reproductive health, are not clear; but there is some evidence of deteriora-
tion in the general situation. For example, birth registrations are low due to the
security concerns and limited access to healthcare services. Also, antenatal care and
the presence of skilled attendants at delivery decreased by almost 25% with no
available data on postpartum service (Dejong et al. 2017).
Inadequate maternal health services and poor referral systems lead to poor
perinatal care in Somalia. A lack of obstetric referral care for complicated births is
an important consideration in the high rates of mortality and morbidity for women in
Somalia, where skilled professionals attend to an exceedingly low (9% in 2014) rate
of births. Due to many years of conflict, basic facilities, such as referral hospitals and
maternal and child health (MCH) facilities and services, have either been damaged
or destroyed. The authorities in Somalia, in collaboration with the WHO, adopted
three main axes for a plan of action: (1) making pregnancy and childbirth safer, (2)
promoting healthy families, and (3) promoting beneficial practices and addressing
harmful ones (Regional Health Systems Observatory- EMRO 2006; Sorbye and
Leigh 2015).
After the International Conference on Population and Development in Cairo in
1994, the Palestinian Authority adopted the conference recommendations regarding
comprehensive reproductive health services that led to improved reproductive
healthcare services. For example, 90% of deliveries took place in hospitals, and
96% of all pregnant women received antenatal care, while postnatal care was
delivered in 30% of cases in 2016; more impressively, there were no patient costs
10 M. A. Abdelbaqy
for maternal and child care services. Breast and cervical cancer screening was also
introduced to provide an expanded and integrated reproductive health service in
Palestine (World Health Organization 2010a; Brown 2012).
While healthcare services are not tailored to the specific social, cultural, and
economic needs of Bahraini women, an emphasis remains on disease management.
The challenges of the health system in Bahrain include increasing demand on health
centers and provision of comprehensive health services specific for women. An
absence of women’s representation in the planning of health policies has contributed
to the limitations of improving women’s healthcare needs in Bahrain (Mukhaimer
2010).
Data from the DHS Program STAT was used to compile a selection of maternal
health indicators from some Arab countries and is shown in Table 2 (ICF 2018).
Family Planning Services
Family planning is a fundamental part of a woman’s health and family. Moreover, it

can facilitate progress by reducing poverty and hastening the achievement of the
national development goals. Although fertility rates are declining in several Arab
countries, the overall Arab population continues to grow rapidly. Therefore, most of
the Arab countries have adopted their own policies for family planning services.
Family planning is defined by comprehensive medical, educational, or social activ-
ities which enable individuals to determine freely the number and spacing of their
children and to also select the means by which this may be achieved (Cook et al.
2003; Kronfol 2012; Roudi-fahimi et al. 2012).
The benefits of family planning are notable in many ways: preventing pregnancy-
related health risks in women, reducing infant mortality, empowering people,
enhancing education, and slowing population growth rate (Faour 1989; Crane
et al. 2011; World Health Organization Department of Reproductive Health and
Research (WHO/RHR) and Johns Hopkins Bloomberg School of Public Health/
Center for Communication Programs (CCP) 2018).
Married women who are able to conceive but would prefer to avoid pregnancy
need family planning. They may wish to postpone their pregnancy for 2 years at least
or to stop childbearing altogether. According to the WHO, women with an unmet
need for family planning are those who are fecund and sexually active but are not
using any method of contraception and report no desire to have children or may wish
to delay their next child. The unmet need is concentrated in adolescents, migrants,
urban slum areas, refugees, and women in the postpartum period (The POLICY
Project 2005; Guttmacher Institute 2010; Nahar et al. 2018).
The use of family planning methods is on the rise since the 1990s. In 1990, the
total demand for family planning in the Arab countries was 57.8%, which increased
to 70.4% in 2000 and to 75.6% in 2015. The annual rate of increase in using family
planning methods between 2000 and 2015 was 0.5%. Simultaneously, the unmet
need for family planning methods has decreased, where the unmet need for family
planning was 19.0% in 2000 and 16.6% in 2015. The annual rate of reduction of
1
Table 2 Selected maternal health indicators in some Arab countries in 2018 (ICF 2018)
Ever use of any Unmet Antenatal Antenatal Antenatal Antenatal Antenatal No postnatal
method of need for care from a visits for visits for visits for visits for checkup for
contraception family skilled pregnancy: pregnancy: pregnancy: pregnancy: newborn within the
(all women) planning provider None 1 2–3 visits 4+ visits first 2 days of birth
5 years 5 years 5 years 5 years 5 years
preceding preceding preceding preceding preceding
the survey the survey the survey the survey the survey
Country Year Total Total Total Total Total Total Total Total
Comoros 2012 32.3 92.1 6.9 3.3 26.1 48.9 86.8
Comoros 1996 28.7 35.6
Egypt 2014 12.6 90.3 9.7 0.6 6.6 82.8 85.8
Egypt 2008 80.6 11.6 74.2 25.8 0.4 6.5 66.5
Egypt 2005 79.6 12.3 71.4 28.5 0.9 9.2 60.7

Egypt 2003 78.9 11.8 70.6 29.4 1.4 9.7 57.5
Egypt 2000 75.1 13.7 55.7 44.2 3.3 9.5 39
Egypt 1995 68.4 20.2 42.5 57.4 2.1 9.1 30.4
Egypt 1992 64.6 22.9 57.1 42.8 12.9 18.8 24.7
Jordan 2012 11.7 99.1 0.9 0.6 4 94.5 25.3
Jordan 2009 81.7 13.4
Jordan 2007 79.5 13.8 98.8 1.2 0.6 3.9 94.1
Jordan 2002 79.7 14.9 98.6 1.4 1.4 6.2 90.9
Jordan 1997 77.8 20.1 95.9 3.7 2.5 7.3 86.3
Jordan 1990 63.7 26.5 82.4 17 3.5 9.9 68.8
Mauritania 2000–01 13.3 32.1 64 34.7 6.8 39.7 16.4
Morocco 2003–04 11.9 67.8 32 8 29.1 30.5
Morocco 1992 38.9 23.5 37.3 62.6 10.8 17.2 9.4
Morocco 1987 28.5
11
(continued)
12
Table 2 (continued)
Ever use of any Unmet Antenatal Antenatal Antenatal Antenatal Antenatal No postnatal
method of need for care from a visits for visits for visits for visits for checkup for
contraception family skilled pregnancy: pregnancy: pregnancy: pregnancy: newborn within the
(all women) planning provider None 1 2–3 visits 4+ visits first 2 days of birth
5 years 5 years 5 years 5 years 5 years
preceding preceding preceding preceding preceding
the survey the survey the survey the survey the survey
Country Year Total Total Total Total Total Total Total Total
Sudan 1989–90 71.2
Tunisia 1988 62.1
Yemen 2013 28.7 59.8 38.4 12.4 23.1 25.1 88.8
Yemen 1997 37.7 40 36.7 62.5 11.1 12.8 12.5
M. A. Abdelbaqy
unmet need for family planning during the period from 2000 to 2015 was 0.9%
(United Nations and League of Arab States 2010; UNFPA 2016; Alsaedi et al. 2018).
The use of family planning methods in general is varying on the country level.
Countries like Egypt, Jordan, Syria, Iraq, Lebanon, Kuwait, and Yemen demon-
strated increase in the use of family planning methods. Despite that increase, some
countries like Yemen, UAE, Saudi Arabia, Comoros, Djibouti, Oman, and Maurita-
nia showed low prevalence of family planning use. However, countries with high
prevalence rate remain similar (Algeria and Tunisia) (Table 3; United Nations and
League of Arab States 2010; Roudi-fahimi et al. 2012; Marnicio 2015; Ministry of
Health and Population et al. 2015). The most common modern contraceptive method
used in the region are contraceptive pills, with high rates in Algeria (88%), Djibouti
(80%), and Morocco (73%). Intrauterine device (IUD) use is somewhat lower in
Palestine (64%), Egypt (53%), and Syria (60%) (United Nations and League of Arab
States 2010; Roudi-fahimi et al. 2012; Howse 2014; Ministry of Health and Popu-
lation et al. 2015).
The rising in numbers of married women of reproductive age parallels the
growing need for family planning services. The percentage of family planning
method use was up to 40% by women who are using modern methods (e.g., IUD)
in the Arab countries (Robinson and Ross 2007; Marnicio 2015).
Another important issue in family planning is emergency contraception, as
unintended pregnancy is a common occurrence in the Arab region. Almost a quarter
of pregnancies in the region are unintended, which leads to unsafe abortions, so
jeopardizing family health in general and woman’s health in particular. Emergency
contraceptive methods are medications or devices that are used after intercourse to
reduce (but not eliminate) the risk of pregnancy. High dose of contraceptive pills and
a copper IUD are the most common methods in the Arab countries since their
introduction in the early 2000s. Therefore, there are some similarities in regular
family planning and emergency contraceptive methods. Emergency contraceptive
methods are available through family planning services (Wynn et al. 2005; Karim
et al. 2015; Alsaedi et al. 2018; World Health Organization Department of Repro-
ductive Health and Research (WHO/RHR) and Johns Hopkins Bloomberg School of
Public Health/Center for Communication Programs (CCP) 2018).
The main reasons for the unmet need for family planning are mainly the lack of
knowledge and awareness. Reasons also include religious backgrounds, fear of side
effects, and the assumption that a lactating woman does not need contraception.
Other reasons are the lack of availability and accessibility of family planning
services in some areas (The POLICY Project 2005; United Nations and League of
Arab States 2010; Nahar et al. 2018).
Arab countries support their family planning services as a part of their maternal
health and safe motherhood programs, and even countries that in the past aimed to
maintain or even increase population growth have modified their stand and intro-
duced family planning and contraception services. These countries include Djibouti,
Mauritania, Oman, and the UAE. Family planning methods in the Arab countries are
accessible, low cost, safe, and effective (Mirkin 2010; United Nations and League of
Arab States 2010).
14
Table 3 Percentage of family planning use in Arab countries (1995–2016)

Year
Country 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
United Arab Emirates 27.5
Bahrain 61.8
Comoros 21 25.7 19.4
Djibouti 9 17.8 22.5 19
Algeria 56.9 64 57 61.4 55.9 57.1
Egypt, Arab rep. 47.9 47.9 54.5 54.5 56.1 60 59.2 60.3 58.5
Iraq 43.5 49.8 52.5
Jordan 52.6 55.8 57.1 59.3 61.2
Kuwait 50.2 52
Lebanon 61.1 62.7 58 58 54.5
Libya 45.2 41.9
Morocco 50.3 58.4 63 67.4
Mauritania 8 9.3 11.4 17.8
Oman 23.7 31.7 24.4 29.7
West Bank and Gaza 45.2 51.4 50.6 50.2 52.5 57.2
Qatar 43.2 37.5
Saudi Arabia 31.8 31.8 20.8 23.8 24.6
Sudan 7 9.5 9 12.2
Somalia 7.9 14.6
Syrian Arab Republic 45.3 46.6 58.3 53.9
Tunisia 60 65.5 62.6 60.2 62.5
Yemen, rep. 20.8 23.1 27.7 33.5
World 60.2 62.7
M. A. Abdelbaqy
Female Genital Mutilation (FGM)
Female genital mutilation is a common health problem and represents violence

against women and against the rights of females in Arab countries. FGM is all the
procedures that involve partial or total removal of the external female genitalia or
any injury to the female genital organs for nonmedical reasons (Cook et al. 2003;
Abdulcadir et al. 2015). The prevalence of FGM is generally high in countries that
practice FGM: Somalia (98%), Djibouti (93%), Egypt (92%), Sudan (88%), Mauri-
tania (69%), and Yemen (19%).
The practice of FGM is based on traditional beliefs such as preserving virginity or
being a prerequisite to marriage. Furthermore, Arab communities associate FGM to
Islamic roots even if it is not mentioned in any Islamic literature (DeJong et al. 2005;
Regional Health Systems Observatory- EMRO 2006; Andersson et al. 2012; Min-
istry of Health and Population et al. 2015).
The procedure of FGM varies from one country to another, creating four different
types of FGM. According to the WHO, the classification of FGM types depends on
the practice itself, where type I is total or partial removal of the clitoris and type II
extends to the labia majora or minora, while type III is narrowing of the vaginal
orifice and type IV is any other harmful procedures to the female genitalia (OHCHR
et al. 2008; Abdulcadir et al. 2015).
FGM has no benefit, only harm. The harm starts with psychological stress and
shock of the procedure itself at childhood. This could have a negative impact on the
behavior of the female victim such as anxiety and depression, in addition to sexual
dysfunction. The physical impact of FGM could occur immediately after the proce-
dure and includes severe pain and bleeding which may lead to shock and even death.
Dysuria and infectious diseases are commonly recorded, especially diseases such as
urinary tract infection (UTI). Alternatively, long-term reproductive tract infections,
dysmenorrhea, obstetric complications (e.g., lacerations and obstetric fistula), and
even hemorrhage are common. Moreover, FGM is associated with an increased risk
of infant resuscitation at delivery and intrapartum stillbirth and even neonatal death
(OHCHR et al. 2008; Andersson et al. 2012; Abdulcadir et al. 2015; Reisel and
Creighton 2015).
The Medicalization of FGM
The medicalization of FGM is a backdoor to practice FGM under the coverage of

law. The term “medicalization of FGM” means performing FGM by a healthcare
provider, such as a community health worker, a midwife, a nurse, or a doctor. In
Egypt, FGM is prohibited by law (since 2008), with a new amendment in 2016 to
criminalize both the parents and practitioner involved in the action, with stricter
penalties of up to 15 years of imprisonment. Also, FGM is prohibited by law in
Mauritania (since 2005) and Sudan and Djibouti (since 2009) (OHCHR et al. 2008;
World Health Organization 2010b; Feldman-Jacobs and Clifton 2014).
16 M. A. Abdelbaqy
Maternal Healthcare Services
Maternal healthcare services are all the medical services that are provided for women
during pregnancy, childbirth, and the postpartum period. Maternal healthcare ser-
vices are antenatal, delivery, and postnatal care (Mirkin 2010; Abdillahi and Van
Staden 2013; Paavilainen 2013). Improving maternal healthcare services decreases
maternal morbidity and mortality rates. In the Arab region, maternal healthcare
services are provided by both public and private sectors and in many cases are
integrated with primary healthcare services (Makhlouf et al. 1991; Obermeyer 1993;
DeJong et al. 2005).
The main obstacles against improving maternal healthcare services in the region
are low community awareness of the safe practices and health-seeking behaviors.
This lack of awareness is in addition to cultural and financial factors (Borghi 2001;
Maternal and Neonatal Program Effort Index 2003; Mahaini and Mahmoud 2005).
Maternal healthcare services are available in many countries with variations in
quality. In addition, the utilization of maternal health services is determined by many
factors such as the level of education, the political situation in the country, the type of
services, and whether it is out of pocket or nationally funded and cultural influences.
The coverage and quality of maternal healthcare services are diverse from one
country to another (Makhlouf et al. 1991; Obermeyer 1993; Dejong and El-khoury
2006; Brown 2012).
Antenatal care coverage for at least four regular visits is high in some countries,
with high rates in Bahrain, Palestine, Kuwait, Oman, Qatar, Saudi Arabia, UAE, and
Jordan (> 90%) followed by Egypt, Iraq, and Djibouti (<75%) and very low rates in
other countries like Yemen and Somalia (<45%) (AbouZahr et al. 2003; World Bank
2018).
Another important indicator of maternal healthcare services is the percentage of
births attended by skilled health personnel, which is high (>95%) in Bahrain,
Palestine, Kuwait, Oman, Egypt, Qatar, Saudi Arabia, UAE, Jordan, and Libya
and lower (<50%) in countries such as in Somalia and Yemen (Mahaini and
Mahmoud 2005; World Health Organization 2015b; World Bank 2018).
The antenatal utilization rate in Egypt is ~90%, with 80% of all maternal services
occurring in the private sector using out-of-pocket financing. The delivery rates are
61% in private hospitals and 26% in public hospitals, with 14% of the deliveries
occurring at home (Ministry of Health and Population et al. 2015).
Fertility Services
Infertility is of global concern, and in countries with high populations as is the case
in most Arab countries, it has a double burden in terms of family planning programs
and the adoption of small family-size norms. This has caused policymakers and
researchers to be more concerned about overpopulation rather than infertility. Dif-
ferent assisted reproductive technology (ART) methods are used in the region
including in vitro fertilization (IVF), intracytoplasmic sperm injection (ICSI), frozen
embryo replacement (FER), gamete intrafallopian transfer (GIFT), oocyte donations

(OD), and intrauterine insemination (IUI). Women can face domestic, physical, and
emotional violence and may even face divorce due to their failure in pregnancy, even
if it was due to factors related to the male partner. Although ART was established in
1978 in the UK, the first ART in the Arab region was established in the late 1980s in
Egypt, Jordan, and Saudi Arabia (Faour 1989; Cook et al. 2003; King and Davis
2006; Inhorn 2009; Inhorn et al. 2017).
Infertility is a medical condition that also has social and economic consequences.
In most cases, women carry a large portion of this burden due to many cultural and
traditional beliefs in Arab countries. The choice of being a mother or nothing/
nobody remains to this day. Devastated infertile couples often report low quality
of life due to poor marital relationships, previous in vitro fertilization attempts, lower
mental health scores, poor social functioning, and emotional behaviors (King and
Davis 2006; Cook et al. 2003; White et al. 2006).
Seeking medical help brings with it a high risk of social consequences, causing
stress, anxiety, and low self-esteem. In addition, ART services are expensive, adding a
large economic burden for couples, particularly those who may be using ART services
for a second cycle (after the failure of the first one). ART services are not supported by
public services or private insurance (Serour 2008; Greil and Slauson-blevins 2010).
Providing ART services in Arab countries is regulated by legislation (e.g., Saudi
Arabia) or by guidelines (e.g., Egypt). Some countries (examples) have neither
legislation nor guidelines to conduct ART services – making the monitoring of
these centers difficult and very subjective. (Mansour and Abou-Setta 2006;
Abduljabbar and Amin 2009)
Male infertility is a health and social problem that remains hidden in the Arab
societies, due to the stigmatization. Such stigmatization is mistaken with impotency,
as both affect a man’s ability to impregnate a woman and to prove one’s virility and
manhood (Kols and Nguyen 1997; Inhorn 2004; Inhorn 2009).
Cesarean Section
The cesarean section as a delivery method is frequently used as a convenient method

of birthing. There are medical indications for performing a cesarean section, but
oftentimes it is performed without medical indications and purely upon the mother’s
request. The number of mothers requesting cesarean delivery is increasing univer-
sally and especially so in the Arab region. Despite improvements in anesthesia and
surgery, the mortality and morbidity is greater with elective cesarean sections
compared to vaginal deliveries. Other maternal and political factors contributing to
an increased request for cesarean sections include social, cultural, and psychological
factors. Some of the political factors contributing to the increasing number of
cesarean deliveries are unregulated privatized hospitals, absence of laws or national
guidelines, and opposition of powerful stakeholders including obstetricians. Finan-
cial factors could contribute to the decisions of the mothers and also politicians
(Mukherjee 2006; Das 2013; Moussawi et al. 2015; Batieha et al. 2017).
18 M. A. Abdelbaqy
According to the WHO, cesarean section should not exceed 10–15% in any country.
In recent years, the rate of cesarean deliveries increased dramatically globally and also in
the Arab region. Egypt has the highest cesarean section rate in the region where it
jumped from 20.9% in 2000 to 26.2% in 2003. This is followed by Sudan (20.4%),
Jordan (18.2% in 2002 and 30.3% in 2012), Lebanon (18.0%), Bahrain (16.3%), Qatar
(16.3%), UAE (15.2%), and Syria (15.0%). Lower rates are reported in Kuwait (11.5%
in 1996), Palestine (14% in 2003), Tunisia (10.2% in 1995), Morocco (9.3 in 2004),
Saudi Arabia (10.6% in 1997 and 19.1% in 2006), Libya (7.6% in 1995), Oman (7.4% in
1995), Algeria (6.4% in 1993), Yemen (6.3% in 1997), and Mauritania (6.6% in 2001).
The evidence suggests that the rates of cesarean section doubled in the past two decades.
Abortion Services
While a woman may not always want an abortion, there is sometimes a need for
abortion. For every six pregnancies in Arab countries, at least one ends with an
abortion, which sometimes is illegal and unsafe (Cook et al. 2003). The main
problem with performing abortions is unsanitary or unsafe conditions. Traditional
herbal and mechanical methods are used for inducing abortion in the Arab region,
causing a high prevalence of permanent disability or even death (Table 4) (Hessini
2007; Dabash and Roudi-fahimi 2008; Eladawy 2010).
The legality of abortion varies in Arab countries, and many factors contributed to
controlling abortion: health aspects for the mother and fetus, social and economic
factors, and legality of the pregnancy as well as per mother’s request.
Saving a woman’s life: Abortion is lawful in all Arabian countries if there is a
threat to a woman’s life in circumstances of continuing pregnancy.
Preserving a woman’s physical health: The law protects women’s health and
allows abortion if there is a threat to the physical well-being of the mother. This legal
ground is applied in ten countries (UAE, Bahrain, Algeria, Iraq, Jordan, Kuwait,
Morocco, Qatar, Saudi Arabia, and Tunisia). Generally, there is no gestational limit
for that condition.
Preserving a woman’s mental health: All countries that allow abortion for saving
women’s physical health also allow abortion for saving mental health. Only UAE
from the above list is not adopting this ground.
In case of rape or incest: Some Arabian countries legalize abortion if the
pregnancy happened due to sexual assault (Bahrain, Iraq, Morocco, Saudi Arabia,
Tunisia, and Sudan).
Fetal impairment is another cause that allows abortion in eight countries (Bah-
rain, Iraq, Tunisia, Sudan, Jordan, Kuwait, Qatar, Oman).
The last two grounds are either socioeconomic reasons or on request and are
adopted only by two countries in the region (Bahrain and Tunisia). This is only
allowed in the first 3 months of pregnancy (Shapiro 2014; United Nations, Depart-
ment of Economic and Social Affairs 2014).
The legality of abortion limits the post-abortion care; in fact, post-abortion care is
either unsafe or offered in private sectors for out-of-pocket expenditure only (Dejong
Table 4 Different legal grounds for abortion in the Arab countries and mortality percentage
To To In
preserve preserve case Mortality
a a of For percentage
To save a woman’s woman’s rape Because of economic among unsafe
woman’s physical mental or fetal or social On abortions
Country life health health incest impairment reasons requesta (1005–2000)
United XX XX 0.06
Arab
Emirates
Bahrain XX XX XX XX XX XX XX 0.06
Comoros XX
Djibouti XX
Algeria XX XX XX 0.15
Egypt, XX 0.12
Arab rep.
Iraq XX XX XX XX XX 0.10
Jordan XX XX XX XX 0.08
Kuwait XX XX XX XX 0.07
Lebanon XX 0.05
Libya XX 0.16
Morocco XX XX XX XX 0.15
Mauritania XX 0.69
Oman XX XX 0.13
Palestine XX 0.14
Qatar XX XX XX XX 0.07
Saudi XX XX XX XX 0.13
Arabia
Sudan XX XX XX 0.27
Somalia XX
Syrian XX 0.09
Arab
Republic
Tunisia XX XX XX XX XX XX XX 0.22
Yemen XX 0.14
a
Before 3-month gestational age
and Bashour 2016). Effective family planning use is critical to reduce unintended
pregnancies, regardless of legal restrictions on abortion. This will reduce the mor-
bidity and mortality due to unsafe abortion (Asman 2004; Roudi-fahimi et al. 2012).
Adolescence and Young Population Health
Adolescents are defined as individuals between the ages of 10 and 19 and include a
larger group aged between 10 and 24 years old according to the WHO classification
(World Health Organization 2011). Adolescents represent almost one-third of the
20 M. A. Abdelbaqy
total population in the Arab world. The new generation of young people has better
healthcare facilities, higher awareness, and education. However, young individuals
are more vulnerable to some risks related to reproductive health, particularly sexu-
ally transmitted infections, unintended pregnancies, complications from pregnancy
and childbirth, and poor access to reproductive healthcare services (Dejong and El-
khoury 2006; DeJong et al. 2007).
With traditional taboos about sexuality and in a male-dominated culture, there are
some obvious barriers to proper information and reproductive healthcare facilities
(DeJong et al. 2005; Dejong and El-khoury 2006). Barriers to reproductive health
include the following:
• Family planning, unwanted pregnancy, and abortion dilemma

Utilization of family planning services is dramatically low in the younger popu-
lation. According to the DHS, the percentage of use of family planning by ever-
married girls aged 15–19 years old in five Arab countries (Egypt, Morocco,
Yemen, Sudan, and Jordan) is 6%. Moreover, unmarried young people are
unlikely to utilize family planning services due to fear of stigmatization. As a
direct result, unwanted pregnancy occurs and forces a choice between unsafe
abortion and an unsafe delivery. Abortion services in Arab countries (where
available) are to be used only to save a mother’s life (Roudi-fahimi 2003; DeJong
et al. 2005; Center for Reproductive Rights 2008).
• Maternal mortality and morbidity
Maternal mortality rates in Arab countries are relatively high in comparison to
universal statistics. Some studies report that the younger population is at a higher
risk of maternal mortality – especially in Yemen, Sudan, Djibouti, Morocco, and
Egypt. Lack of information and fear of stigma are the main reasons hindering
utilization of reproductive health services (Roudi-fahimi 2003; DeJong et al.
2005; Ragab 2010).
• Gender-based violence (GBV)
Gender-based violence continues without engagement of the government. In the
Arab region, violence against women and spousal violence are high, and honor
crimes are documented frequently (DeJong et al. 2005, 2007).
The following are services that could be provided to the younger population:
1. Access to information
An accurate source of information regarding reproductive health is needed,
regardless of the rapid change in family lifestyle in the Arab region due to
urbanization and globalization. Even with minimal sexual education integrated
in the school curriculum, teachers are either not well trained or nor comfortable
enough to deliver it. As a result, young individuals seek information from their
peers or through untrusted internet sources. Only Tunisia offers proper life skills
education curricula that include sexual and reproductive health topics (Jaffer et al.
2006; Soliman et al. 2009; DeJong et al. 2007).
2. Access to reproductive healthcare services

Government health services in the Arab region do not recognize the need for
reproductive health services in young people, particularly those who are unmar-
ried. There is a societal reluctance to address these issues due largely to cultural
and religious sensitivities. On the other hand, there are some innovative small-
scale programs that exist and that could be an asset for the future. Although there
are many services available for young people, such as the emergency contracep-
tive methods offered in Egypt, Lebanon, Algeria, and Libya, young people are not
always aware of the availability of such services. Other services related to HIV
testing are widely available in countries such as Egypt, Syria, and Lebanon; but
there is stigmatization and low awareness of their availability.
There are telephone hotlines offering reproductive health and HIV information
in a confidential and anonymous manner in many countries in the region (e.g., in
Oman, Saudi Arabia, Egypt, Tunisia, and Algeria), but it is insufficient to meet
the needs of the young population. However, these hotlines provide an important
service for the unmarried youth (Roudi-fahimi 2003; Dejong and El-khoury
2006; Center for Reproductive Rights 2008).
3. Access to youth-friendly services
Young people are in need of accessible reproductive healthcare services from
well-trained providers who can offer adolescent-friendly services with confiden-
tiality. The mandate of the services should include counselling, educational
services, family planning, pregnancy, abortion, and prevention and management
of sexually transmitted diseases. The availability of such youth services was
increased in number through responsibilities of NGOs in the region. However,
there is an absence of a clear evaluation and documentation process. Tunisia is the
only country where there is a national program addressing the healthcare needs of
young people through an integration of governmental and local strategies (Center
for Reproductive Rights 2008; Soliman et al. 2009; Allotey et al. 2011; DeJong
et al. 2007).
Marriage Patterns
Marriage by definition is a socially or ritually recognized union between men and

women that establishes rights and obligations between spouses, as well as any
resulting biological or adopted children and affinity. The topic “marriage” in the
Arab region has traditions and social aspects similar to elsewhere, with some unique
aspects such as early marriage, consanguinity, and polygamy (Jurdi and Saxena
2002; Tadmouri et al. 2009; Kakar et al. 2017). The laws between countries have
variations in allowable age of marriage in the Arab region. While most of the Arab
countries agreed that the legal age of marriage is 18 years old or older for both
genders, some Arab countries legalized a young age when females can marry –
females in Yemen and Kuwait can marry when 15 years old (see Table 5).
22 M. A. Abdelbaqy
Table 5 Age of marriage by national legislation (United Nations 2018)

Country Male Female
Algeria 21 18
Egypt 18 18a
Iraq 18 18
Jordan 18 18
Kuwait 17 15
Mauritania 18 18
Morocco 18 18
Oman 18 18
Saudi Arabia 20 17
Tunisia 20 20
Yemen 15 15
a
The minimum age of marriage for females in Egypt raised from 16 to 18 years by presidential
declaration in 2010 (Salem 2015)
The issue of early marriage changes from a social and legal concern to a matter of
public health (Talajeh Livani 2007; International Centre for Missing & Exploited
Children 2013; Roudi-fahimi and Ibrahim 2013; Sundby 2014). Early marriage stops
schooling for females, enforces sexual relations, leads to spousal violence and early
childbearing with negative consequences on economic status and health, and
increases fertility rates. These in turn impede economic and social development.
From a public health perspective, early marriages increase the risk of obstetric
mortality and morbidity. Moreover, young girls are less likely to know about family
planning methods and sexually transmitted diseases (DeJong et al. 2005; Interna-
tional Centre for Missing & Exploited Children 2013; Roudi-fahimi and Ibrahim
2013).
Local tradition such as preserving virginity and family honor is the main moti-
vation for parents to marry off their daughters at a young age (DeJong et al. 2005;
Talajeh Livani 2007; International Centre for Missing & Exploited Children 2013).
Although still a problem, the phenomenon of early marriage is declining in many
parts of the region. The percentage of females aged 15–19 who are married declined
between the 1970s and 2000s: in Egypt from 22% to 10%, in Tunisia from 40% to
1%, and in Palestine from 17% to 14% (Rashad et al. 2005).
Marriage between relatives is another characteristic feature of “consanguinity” in
Arab families. Families, who prefer consanguinity, relay on social and cultural
considerations as strengthening family ties, try to ensure proper treatment of their
daughters, increase chances of compatibility, and try to maintain inherited family
wealth. On the other hand, consanguinity can have negative consequences on the
female. The right to choose a partner freely is violated and greatly increases the
probability of hereditary diseases.
The prevalence of consanguinity is much higher in some countries in the region.
The highest prevalence is in Oman (56%) followed by Sudan, Libya, UAE, and
Saudi Arabia, where 40–50% of spouses are married to their first cousins. In Algeria,
Egypt, Jordan, and Kuwait, the prevalence ranges from 20% to 30%, while in the
remaining countries the rate is under 20% (Jurdi and Saxena 2002; DeJong et al.
2005; Tadmouri et al. 2009; Abdalla and Zaher 2013).
Another pattern of marriage in the Arab region is “unprotected marriage,” where
the age of girls is falsified to meet the minimum age of legal marriage, creating
consequences such as loss of schooling and others. In addition, customary marriage
(urfi) was reported where this contract fulfills the religion requirements, but
does not provide legal, economic, and health protection for girls. Other forms of
marriages include “summer marriage” in some countries where girls from a poor
family marry wealthy grooms from another country (DeJong et al. 2005; Welchman
2007).
Marginalized People and Refugees
The Arab region has the largest number of refugees and displaced populations in the
world (Table 6), where many people are forced to leave their counties for political
and safety reasons. In such instances, women are usually more vulnerable, and this
gives rise to undesirable effects on reproductive health outcomes and severely limits
Table 6 The distribution of refugees in the Arab countries (World Bank 2018)
No. of refugees
Country Name 2011 2014 2017
United Arab Emirates 677 417 874
Bahrain 199 311 255
Djibouti 20,340 20,530 17,548
Algeria 94,148 94,128 94,243
Egypt 95,087 236,090 232,617
Iraq 35,189 271,143 277,663
Jordan 2,430,589 2,771,502 2,896,162
Kuwait 335 614 608
Libya 10,130 27,964 9342
Morocco 736 1216 4678
Mauritania 26,535 75,635 77,400
Oman 83 151 308
West Bank and Gaza 1,895,043 2,051,098 2,213,963
Qatar 80 133 188
Somalia 2099 2729 14,555
Syrian Arab Republic 1,242,391 677,756 569,774
Tunisia 4097 901 701
Yemen, rep. 214,740 257,645 270,898
Arab world 6,657,656 8,375,066 9,056,647
World 15,202,527 19,535,060 25,376,316
24 M. A. Abdelbaqy
access to health services. The following summarize issues of women’s health in

refugees and asylum seekers (El-zein et al. 2014):
– Fertility rates
There are two scenarios observed regarding fertility rate. The first one states that
fertility rates decrease in refugees and asylum seekers due to fear of an uncertain
future, economic issues, and partner separation. Another scenario is that there are
increases in fertility rates to counteract loss of nationality, when there is better
access to healthcare services (Gagnon et al. 2002; El-zein et al. 2014).
– Gender-based violence (GBV) and STD
Although GBV is very high in refugees and asylum seekers, it is still greatly
underestimated. It is directed particularly against young women from specific
ethnic groups. Also, there is evidence of enforced sex and rape during conflicts
which increase the chance of sexually transmitted infections including HIV
(Gagnon et al. 2002; Dejong and El-khoury 2006; UNHCR 2014).
– Pregnancy and delivery
The outcome of pregnancy and delivery is worse in refugees and asylum seekers
(when compared to the local population). Poor pregnancy outcomes are due to
poor living conditions, stigma, low awareness, and low availability and accessi-
bility of healthcare services. Moreover, lack of family planning services is another
dilemma facing refugees and asylum seekers (Gagnon et al. 2002; Riccardo and
Sabatinelli 2011; World Health Organization 2013).
– Availability and accessibility of healthcare services
National healthcare providers in many cases are not aware of the rights of
refugees and asylum seekers, even though health concerns are very high in this
group. In addition, language and culture barriers are another factor even among
those who speak the same language but with different tongues. Furthermore,
women among refugees and asylum seekers might not know the types of services
and their locations (World Health Organization 2013; UNHCR 2014; UNFPA
2016).
The status of reproductive health outcomes in Syrian refugees in neighboring

countries varies. Family planning service utilization by Syrian refugees in Jordan
was 88.7% and 63.9% in Lebanon (in 2017). Other reproductive health services,
including skilled birth attendance at delivery, were underutilized due to financial
factors, distances involved, and limited availability of same-sex service providers
(Doedens et al. 2013; World Health Organization 2013; UNHCR 2014; Dejong et al.
2017). The number of registered Syrian refugees in Egypt has increased significantly
in all governorates, creating an increased need for health services especially in
reproductive healthcare. Moreover, the types of services required are the same as
those already provided to the local Egyptian population. Furthermore, Egypt also
provides secondary and tertiary healthcare services for Syrian refugees in collabo-
ration with the WHO and Ministry of Health and Population. Primary healthcare
services including reproductive health are supported by UNFPA and UNICEF
(World Health Organization 2013; UNHCR 2014).
Sexual and Reproductive Health Rights of Lesbian, Gay, Bisexual,

and Transgender (LGBT)
Another marginalized group of people with reproductive health needs are the LGBT
population. Although there is some social awareness across the region since ICPD
1994, there is still a frank taboo regarding homosexuality due to cultural and
religious beliefs. The taboo is translated to the criminalization of any act, and
punishments range from prison sentences to death penalties (Needham 2013;
Ilkkaracan 2015). Even in HIV/AIDS communities in some countries (e.g., Egypt
and Lebanon), they identified men who have sex with men (MSM) as a subgroup of
the population most at risk. Outreach and prevention activities are faced with huge
challenges, as the LGBT population and distribution in the Arab countries is difficult
to determine due to social stigma and discrimination and legal status (Mohamed
2015).
The ignorance of the needs of the LGBT community arises from a lack of
communication, illness-related education, adequate screening, and intervention pro-
grams for communicable diseases including sexually transmitted infections (Alaouie
et al. 2017; Hafeez et al. 2017).
Sexually Transmitted Infection (STI)
The prevalence of sexually transmitted infections (STIs) is underestimated in most

parts of the world due to issues of reporting, asymptomatic disease patterns, and self-
treatments (Kumar and Gupta 2014). The situation in many Arab countries (as other
low-income countries) is worse because of stigma and healthcare utilization behav-
iors, underdiagnoses, and shortages of healthcare facilities specialized for diagnosis
and treatment of STIs (Abdel Aziz et al. 2016; World Health Organization 2016b).
Moreover, most of the data are obtained from cross-sectional studies (and not a
surveillance system) and many with improper sample techniques (World Health
Organization 2016b; Mohammed et al. 2016).
There is limited data on the epidemiology of STI in the Arab countries, which can
be used to create view of the general situation of the region (World Health Organi-
zation 2016b). The prevalence rate of gonorrhea in governmental hospitals in
Kuwait is 31.5% and nongonococcal urethritis and chlamydia is 23.6% and 4.1%,
respectively. Furthermore, Chlamydia trachomatis infection in Jordan is 0.6%, N.
gonorrhoeae is 0.9%, and T. vaginalis is 0.7% in symptomatic women attending
gynecology and family planning clinics. Infection with C. trachomatis in Gaza is
8.3% and Candida albicans is 5.2% in pregnant women attending child and mother
healthcare centers (Afrakhteh et al. 2008). The median prevalence of syphilis in the
Eastern Mediterranean region (with most countries being from the Arab region) is
0.8% (Bakhoum et al. 2014) (Smolak et al. 2018).
The prevalence of HIV/AIDS in the Arab countries is generally low, but is
increasing in the region. The epidemic is concentrated in key populations at risk of
HIV. The unavailability of data on key populations in several countries (e.g., the Gulf
26 M. A. Abdelbaqy
Table 7 The prevalence and incidence of HIV infection in selected countries by 2017
(UNAIDS 2018)
Selected regions Prevalence Incidence
United Arab Emirates 0 [... – ...]a 0 [...–...]a
Bahrain 310 [250–350] 20 [20–20]
Djibouti 9100 [6,300–13,000] 560 [300–1,000]
Algeria 14,000 [13,000–15,000] 1,200 [1,200–1,400]
Egypt 16,000 [15,000–18,000] 2,300 [2,100–2,600]
Jordan 0 [... – ...]a 0 [... – ...]a
Kuwait 540 [480–640] 70 [50–90]
Lebanon 2,200 [1,900–2,500] 150 [130–170]
Morocco 20,000 [16,000–27,000] 990 [700–1,600]
Oman 0 [... – ...]a 0 [... – ...]a
Qatar 240 [220–250] 20 [20–20]
Saudi Arabia 0 [... – ...]a 0 [... – ...]a
Sudan 51,000 [27,000–84,000] 4,700 [1,500–9,600]
Somalia 11,000 [10,000–12,000] 470 [430–510]
Syrian Arab Republic 0 [... – ...]a 0 [... – ...]a
Tunisia 3,000 [2,300–4,200] 300 [190–470]
Yemen 0 [... – ...]a 0 [... – ...]a
a
Countries with no available data
countries, Iraq, and Syria) and the underestimation in other countries (e.g., Djibouti,
Egypt, and Morocco) are another difficulty (see Table 7) (Karamouzian et al. 2016;
International Monetary Fund 2017; Joint United Nations Programme on HIV/AIDS
2018; UNAIDS 2018).
Obtaining an STI surveillance system remains very challenging due to social
barriers, the stigma affecting utilization of healthcare services, and the limited diag-
nostic capacity. Thus, the WHO recommended a minimum dataset for STI surveillance
consisting of syndromic surveillance and periodic laboratory testing in resource-limited
settings (Mohammed et al. 2016; World Health Organization 2016a).
Financing Sexual and Reproductive Health Services
Improving sexual and reproductive health outcomes for women is a critical step in
improving their well-being; the Arab region is diverse economically, many high-
income countries and some middle- and low-income countries. However, the Arab
countries face major challenges in maintaining sufficient funds to meet the need for
sexual and reproductive healthcare; reasons for this likely are related to financial
constraints (e.g., military funding and others), male-dominated governments and
policymakers, ignorance, and gender inequity in terms of prioritizing healthcare
expenditures (Allotey et al. 2011; Abdelgawad 2014; UNFPA 2015).
During the ICPD 1994 in Cairo, the estimated costs for financing programs in
population dynamics and reproductive health were projected until 2015, where two-
thirds of the funds would be mobilized domestically in developing countries and the
remaining one-third would be supported by international assistance. Accordingly,
from 1995 until 2015, Arab countries received international assistance funding
annually (Table 8). Sudan received the largest amount in 2011 (41 million USD),
followed by Jordan (37.5 million USD). Domestic funds were allocated from
different resources including governmental, nongovernmental, and private sectors
and consumers, the last two sectors being difficult to classify as national funds
(UNFPA 2011a, 2015).
In general, health systems in Arab countries vary greatly and cover a wide range of
needs including preventive and curative services. These different services can either
be offered free of charge or by fee; the financing methods also vary either through
taxation, social and private insurance, community financing, or direct payment by
patients (World Health Organization 2006a, b; Allia 2014; UNFPA 2015).
The Funding Gap in Population Assistance
For budgeting and planning purposes, as well as to identify the funding gaps in the
field of population activities including reproductive health activities, there should be
monitoring of the progress of achieving financial resources. National monitoring is
needed for all expenditures, especially in integrated services with sexual and repro-
ductive health components. More resource mobilization activities are needed at a
national level to bridge the gaps in financing reproductive health activities in Arab
countries (UNFPA 2011a, 2013, 2015; Allia 2014).
Reproductive Cancers
Cancer is the leading cause of death worldwide. Gynecological cancers are 19% of
all cancers. Cancer registries are the main source of data regarding the national
burden. The main indicators for cancer burden are incidence, mortality, and preva-
lence. The first national cancer registry was established in Kuwait in 1987; and
cancer registries were later established in Lebanon, Saudi Arabia, and Qatar (2004)
and then in Algeria, Bahrain, Egypt, and Tunisia (2007). Such cancer registries are
very limited due to the mechanism of registration or considering the large
populations involved particularly when the private sector is not included, emphasiz-
ing the need for a systematic establishment of cancer registries at national and
regional levels (Sankaranarayanan 2006; Salim et al. 2009).
Cancers are generally diagnosed at a late stage in the Arab region, particularly in
the case of gynecological cancers where there is low awareness and a stigma related
to gynecological cancers. The healthcare services of cancer should be created using a
multidisciplinary management concept consisting of (1) primary prevention, (2)
secondary prevention, (3) treatment of established disease, and (4) palliative care
for advanced disease (Sankaranarayanan 2006; El Saghir et al. 2007, 2011).
28
Table 8 Population assistance to countries in the Arab region, 2002–2011 (UNFPA 2011a)
Country 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Algeria 3,574 1,379 1,079 2,140 3,485 1,811 5,120 2,673 1,824 1,184
Djibouti 579 3,237 694 4,758 4,363 4,607 4,390 3,961 3,707 3,366
Egypt 46,754 33,417 40,447 35,400 38,679 48,792 51,906 41,428 40,687 15,600
Iraq 378 14,330 8,832 6,324 61,211 44,197 13,593 6,157 18,618 1,210
Jordan 16,796 27,202 25,602 9,678 3,006 4,361 20,532 28,887 38,735 37,533
Lebanon 1,383 1,261 1,702 1,615 5,527 4,179 5,065 3,537 5,242 3,235
Libya 69 0 53 3 536 1,539 11,206 4,342 114 8,859
Morocco 12,818 9,123 9,518 11,925 16,832 17,323 20,782 23,710 21,908 18,121
Oman 36 162 6 79 6 30 30 866 503 0
Palestine 3,728 12,613 8,837 13,364 18,882 11,237 9,587 13,738 5,609 432
Somalia 1,256 3,240 1,380 6,032 8,854 8,747 5,936 20,148 20,860 29,436
Sudan 6,064 11,875 9,550 22,425 43,513 22,058 68,086 88,565 96,303 40,820
Syria 4,062 3,550 2,538 3,304 3,367 2,257 2,311 8,244 7,668 2,045
Tunisia 888 1,474 1,374 558 5,224 7,030 6,263 6,241 7,008 3,386
Yemen 4,684 7,816 10,836 22,981 23,896 27,065 28,646 36,491 37,897 19,023
Regional 43,523 9,926 14,599 12,380 9,347 32,125 31,100 37,481 50,255 130,488
Total 146,592 140,605 137,047 152,966 246,728 237,358 284,553 326,469 356,938 314,738
M. A. Abdelbaqy
1. Primary prevention means controlling risk factors to prevent cancer occurrence.

An example of preventable cancer is cervical cancer as there is a vaccination for
the causative agent (human papillomavirus, HPV). Better management of the
obesity epidemic can also reduce the incidence of obesity-related cancers such as
endometrial cancer (Calle and Thun 2004; Ortashi and Kalbani 2013).
2. Secondary prevention through screening and early detection programs is very
suitable for breast cancer and cervical cancer. Although cancer screening pro-
grams are very cost effective, financing for screening programs in low-resource
countries is a low priority, especially considering the high burden of cancer
diagnoses at the late stages of the disease (Saghir et al. 2007; Ortashi and Kalbani
2013; Sancho-garnier et al. 2013).
3. Treatment of diagnosed cancers. This requires a multidisciplinary approach
consisting of gynecologists, radiologists (imaging and therapy), oncologists, and
psychologists to manage cancer cases including gynecological cancers. The high
cost of cancer healthcare services and infrastructure costs create an extra burden in
low-resource areas, which is the case in many Arab countries. Central tertiary
hospitals exist in many Arab countries, and this raises financial and access (mostly
transport-related) barriers for women. There is also a shortage of trained staff and
appropriate equipment needed in fully functional cancer centers (Sankaranarayanan
2006; Saghir et al. 2007; Ortashi and Kalbani 2013; Sancho-garnier et al. 2013).
4. Palliative care for advanced disease. Most cancers in women are diagnosed late in
the disease progression; this is especially the case of gynecological cancers. The
palliative care services needed to support such patients and their families are
uncommon in the Arab region, either due to a lack of existing services, a lack of
awareness by healthcare providers, or a lack of awareness by patients and their
families (Sankaranarayanan 2006; El Saghir et al. 2011; Ortashi and Kalbani
2013). Is it also not related to cultural barriers?
Overview of Gynecological Cancers in the Arab Region
Breast Cancer
Breast cancer is the most frequent gynecological cancer worldwide, and this is the case
in Arab countries as well where the incidence of breast cancer in young age is higher
than universal rates – and with a presentation that is more aggressive and usually with a
bad prognosis. The average age of diagnosis of breast cancer in Egypt, UAE, Bahrain,
Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia, Sudan, Tunisia, and Yemen
ranges from 48.0 to 48.5 years of age, while in industrialized countries it is at 63 years of
age (El Saghir et al. 2007; Salim et al. 2009; World Health Organization 2018).
Breast cancer screening programs are generally not available in the Arab region
except in some countries such as Egypt and countries in the Arabia Peninsula. These
programs have limited quality control and poor data reviewing. Awareness cam-
paigns using local initiatives have a limited effect. Imaging services are usually
offered through physician referrals, and there is no coverage from public or private
insurance (El Saghir et al. 2007; Najjar and Easson 2010; Corbex and Harford 2013;
Abdel-Hadi and Abdelbaqy 2015).
30 M. A. Abdelbaqy
Radiation therapy centers are present in only some countries, likely because of the
high prevalence of total mastectomy compared to other choices such as partial and
conservative mastectomy. Clearly, access to multidisciplinary cancer management
team will improve breast cancer care, but such approach is at low frequency in the
region and in most cases doesn’t go through (El Saghir et al. 2007, 2011).
Endometrial Carcinoma
Endometrial cancer is typically diagnosed in the early stages due largely to mis-
diagnosis of abnormal symptoms or vaginal bleeding; however, most women with
postmenopausal bleeding in Arab countries are either not aware of the significance
of this type of bleeding or unwilling to seek medical advice. The incidence of
endometrial cancer varies in the Arab region and is either less than 2/10,000
(Morocco, Tunisia, Egypt, and Oman), between 2 and 4/100,000 (Mauritania,
Algeria, Libya, Sudan, KSA, Iraq, Somalia and Djibouti, UAE and Kuwait), or
4–6/100,000 (Syria, Jordan, and Yemen) and 8–10/100,000 (in Palestine and Leb-
anon) (Sankaranarayanan 2006; Salim et al. 2009).
Many risk factors for endometrial cancer are common in high frequencies in the
Arab region, including obesity, vaginal bleeding, abortion, and the number of
ovarian cycles. Health-seeking behaviors of Arab women often act as barriers to
the utilization of health services available in the region. Many women get
embarrassed to discuss gynecological symptoms. Moreover, the low availability of
female doctors in rural or remote areas is also likely another barrier. Generally, there
is a need for increased awareness by women and girls in the region on improving
health-seeking behaviors (Sankaranarayanan 2006; Arab et al. 2014).
Cervical Cancer
Cervical cancer is the second most common cancer in women worldwide. Human
papillomavirus (HPV) infection is the main cause of cervical cancer. In the Arab
region, cervical cancer has a relatively low incidence. Many predisposing factors of
cervical cancers are dominant in the Arab region, such as early marriage, frequent
coitus starting early in life, and the increasing number of pregnancies. The incidence
of cervical cancer varies in the Arab region, being high (>25/100,000) in Maurita-
nia, Algeria, Somalia, and Djibouti and ranging from 10 to 20/100,000 in Sudan,
Libya, Egypt, and Morocco and ~10/100,000 in Tunisia and the Asian part of the
Arab region (Salim et al. 2009; Abdel-Hadi et al. 2015).
Although cervical cancer is a preventable cancer due to the presence of HPV
vaccine and the effectiveness of Pap smear screening program, neither program is in
place (Clifford et al. 2003; Sancho-garnier et al. 2013).
Establishing a national cervical cancer screening program requires large funding,
and there may be concerns about its cost-effectiveness in terms of early detection of
cervical cancer. However, some screening activities have started in some countries,
and the UAE has established a national screening program.
The vaccination against HPV as a preventive measure for cervical cancers has
been approved in Arab countries. However, there are many challenges, such as the
reluctance of parents to offer the vaccine for their young daughters (10–15 years
old), and the availability of the vaccine in low-resource countries is limited (Sanjose
et al. 2011; Arab et al. 2014).
Ovarian Cancer
Ovarian cancer is a gynecological tumor that is ranked as the fifth leading cause of
death in women. The incidence of ovarian cancer is less than 6/100000 in most of the
Arab region, and only Lebanon has a high incidence (>10/100000). Infertility and
nulliparous are risk factors of ovarian cancer, whereas multiparty, breastfeeding, and
use of oral contraceptives are protective factors (Salim et al. 2009; Nassar et al.
2016). The management of ovarian cancers is a combined approach of surgery,
radiology, and chemotherapy, depending on the type and availability of the treatment
(Nassar et al. 2016).
• Other gynecological cancers such as cancer of the vulva or vagina are rare and
typically present in old age. Management of cancer of the vulva or vagina is by
trained gynecologists in regular national healthcare services (Sankaranarayanan
2006; Arab et al. 2014)
Reproductive Health and Genetic Disorders
The epidemiological profile of genetic disorders of many Arab countries is not clear,
as many families and ethnic groups are descended from a limited number of families,
with some conditions confined to specific areas and ethnic groups. This leads to an
unusual burden of genetic diseases in such communities. However, the prevalence of
congenital and genetic disorders in Arab countries is high (>69.9/1,000 live births)
in comparison with worldwide ratio (<52.1/1,000 live births) (Hamamy and Bittles
2009; Tadmouri et al. 2009). The Catalogue of Transmission Genetics in Arabs
(CTGA) Database indicates the relative geographic distribution of some common
genetic disorders in the Arab world and is shown in Table 9 (Tadmouri 2006).
Table 9 Geographical distribution of common genetic disorders in the Arab region
(Tadmouri 2006)
Genetic disorder Countries
Glucose-6-phosphate Algeria, Sudan, Egypt, Palestine, Syria, Jordan, Lebanon, Iraq,
dehydrogenase deficiency KSA, Kuwait, Qatar, Bahrain, UAE, Oman, and Yemen
Sickle cell anemia Palestine, KSA, Kuwait, Qatar, Bahrain, UAE, Oman and
Yemen, Sudan, and Algeria
Beta-Thalassemia Morocco, Algeria, Tunisia, Sudan, Egypt, Palestine, Syria,
Lebanon, Iraq, KSA, Kuwait, Qatar, Bahrain, UAE, Oman, and
Yemen
Alpha-Thalassemia Mauritania, Morocco, Algeria, Tunisia, Sudan, KSA, Kuwait,
Bahrain, and UAE
Anencephaly Morocco, Tunisia, Palestine, KSA, Iraq, Bahrain, and UAE
Familial Mediterranean fever Morocco, Libya, Palestine, Syria, Jordan, Lebanon, Iraq, KSA,
Kuwait, and Bahrain
32 M. A. Abdelbaqy
The main reasons of the high prevalence of genetic disorders are (1) high rate of
consanguinity among Arab families and (2) low awareness level of genetic and
hereditary issues by families and most healthcare providers. One common mis-
conception is that referral to a genetics counsel will result in either an avoidance
of the marriage or advice of abortion of an affected fetus (Hamamy and Bittles 2009;
Ben Halim et al. 2013).
The Prevention and Management of Genetic Disorders in Arab

Countries
There is a great need to develop a genetics counselling service at a national level; this
should be culturally sensitive and staffed by locally trained personnel. This could be
achieved by increasing public awareness and, in particular, reaching out to remote
communities, specific ethnic groups, etc. (Hamamy and Bittles 2009; Tadmouri
et al. 2009).
Reproductive Healthcare Services After the Arab Spring
The shortage of reproductive healthcare services remains a leading cause of mortal-

ity and morbidity for women and girls in the region, and this was made more severe
by the Arab Spring and the many armed conflicts (particularly in Syria, Yemen, Iraq,
and Libya) (Patel et al. 2016). This created challenges for providing health services
in neighboring countries such as Lebanon, Jordan, and Egypt (UNHCR 2014;
UNFPA 2016; Dejong et al. 2017).
The armed conflict in Libya negatively impacted the quality of healthcare services
and pregnancy outcomes. There was an increase in the rate of preterm births and
low-birth-weight infants compared to data obtained prior to the conflict (Bodalal et
al. 2011). There were great efforts underway to fill the gap between the lack of the
skilled health workers and the need for services in countries such as Yemen.
Unfortunately, this situation continues to deteriorate, particularly affecting the
rural-urban distribution, where 42% of healthcare workers serve only 25% of the
total population in urban areas, leaving a critical need for services in other areas of
the country (Wahed et al. 2012).
The conflict in Syria started in 2011, and the healthcare system remains
severely impacted. In particular, vaccination coverage has decreased by
almost 50% – which further increases epidemic-prone diseases. There is an
increased infant mortality coupled with reduced utilization of the perinatal ser-
vices (particularly antenatal care). Birth attendance by skilled personnel is limited
not only in Syria but in neighboring countries as well (Gilbert et al. 2013; Dejong
et al. 2017).
Conclusion
Healthcare services, particularly reproductive healthcare, in the Arab countries have a

special concern. Especially, many Arab countries are in transition, and there is an urge
to establish sensitive mechanisms to provide reproductive health services and meet
emerging needs in affected areas. The wide variation of the region reflects the difference
in the situation between each country, but still, a common area makes reproductive
health profile unified. The availability and accessibility of healthcare services depend
mainly on traditions and cultural issues as well as integration of reproductive healthcare
services with other healthcare services and political prioritization. It comes clear in
topics like family planning and maternal healthcare services.
Despite the fact that the unmet need for family planning is considerable in the
region, the utilization is generally increased in most countries. This helps close the
gap by increasing the awareness level and providing more friendly services. The
same situation is observed in maternal healthcare services, especially in countries
that suffer from an unstable situation recently.
Female genital mutilation is a unique topic in the region, where there are
legislations and awareness activities to eliminate the phenomenon, which are effec-
tive to some extent.
There is a need for more policy-level engagement and legislation to provide better
regulations for specific services like fertility services, abortion, and cesarean section
in order to increase patient safety and provide high-standard services.
Sexual and reproductive health for the adolescent and young population is a very
critical issue in the region, especially with traditional taboos about sexuality and in a
male-dominated culture. Access to information and friendly sexual and reproductive
healthcare services are a top priority to increase the health well-being of the new
generation.
The marriage character changes in the last period, but still consanguinity and
early marriage are the characteristic features in the region. Reflecting on social and
health aspects, especially genetic disorder, premarital services need more improve-
ment and advocacy.
Gynecological cancers as a part of reproductive health gained special concern in
the Arab region recently. However, early detection and tertiary services are still in
need of more improvement.
After the Arab Spring, the shortage of healthcare services, particularly reproduc-
tive health, increased in the affected area. That increased mortality and morbidity for
women and girls in the region, which highlights the urge to establish sensitive
mechanisms to provide reproductive health services and meet emerging needs in
affected areas immediately. As a current situation, many neighboring countries took
the burden of providing healthcare services including SRH for refugees.
As a conclusion, reproductive health services are a multidisciplinary approach,
where many sectors need to work together including service consumers themselves.
Political welling is fundamental as well as social and individual participation to
34 M. A. Abdelbaqy
address the actual needs and provide high-standard services that can answer
improvement in the population well-being of the Arab region.
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Arab Women’s Health Care: Issues and
Preventive Care 2
Primary Healthcare
Jamila Abuidhail, Sanaa Abujilban, and Lina Mrayan
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Specific Health Conditions Affecting Women in the Arab World . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Women’s Obesity in the Arab World . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Smoking (Tobacco and Waterpipe) by Women in the Arab World . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Family Planning (FP) by Women in the Arab World . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Menopause in the Arab World . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Osteoporosis in Women in the Arab World . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Child Marriages in the Arab World . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Domestic Violence in the Arab World . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Female Genital Mutilation (FGM) in the Arab World . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Breast Cancer in the Arab World . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Cervical Cancer in the Arab World . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
HPV in Arab Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Abstract
Women’s health issues in the Arab world need to be studied so as to fully
understand the health status of Arab women in general and more specifically to
improve the quality of care for their children. This chapter focuses on the most
common women’s health issues in the Arab world from a primary healthcare
perspective and discusses some approaches to reducing complications that arise.
The most common women’s health issues existing in the Arab world discussed in
this chapter are obesity, smoking (tobacco and waterpipe), family planning (FP),
menopause, osteoporosis, child marriage, breast cancer, domestic violence,
female genital mutilation (FGM), and cervical cancer.
J. Abuidhail (*) · S. Abujilban · L. Mrayan

Faculty of Nursing, Hashemite University, Zarqa, Jordan
e-mail: jamila302000@yahoo.com; jabuid@hu.edu.jo; abujelban@yahoo.co.uk;
lina285@gmail.com

https://doi.org/10.1007/978-3-030-36811-1_3
42 J. Abuidhail et al.
Keywords
Women’s health · Arab world · Smoking · Family planning · Breast cancer ·
Violence
Introduction
Women’s health issues in the Arab world seem to be neglected, which lead to
exacerbate such issues to be major problems and complications in Arab society. It
is a priority to understand the health status of Arab women to improve the quality of
care for theirselves and their children. This chapter focuses on the most common
women’s health issues in the Arab world from a primary healthcare perspective. The
most common women’s health issues existing in the Arab world that are discussed in
this chapter are obesity, smoking (tobacco and water pipe), family planning (FP),
menopause, osteoporosis, child marriage, breast cancer, domestic violence, female
genital mutilation (FGM), and cervical cancer.
Specific Health Conditions Affecting Women in the Arab World
Women’s Obesity in the Arab World
Obesity is defined as a body mass index (BMI) of 30 kg/m2 or more and is

considered a serious epidemic public health problem in the Arab world, as reflected
by the increases in the incidence of chronic diseases associated with overweight/
obesity (Abuyassin and Laher 2016). However, obesity is a serious health concern
for Arab women because obesity is more prevalent in women than men in the Arab
world (Jahan 2016).
According to the most recent statistics, Kuwait ranks 9th in the world and first
among Arabic-speaking countries in female obesity. The rank order in Arabic-
speaking countries for obesity in females is Kuwait (55.2%), Egypt (48%), and the
UAE (42%), similarly Bahrain (37.9%), Jordan (37.9%), Saudi Arabia (36.4%), and
Lebanon (27.4%) (Jahan 2016). It is difficult to find more recent data regarding the
incidence of obesity in women in other Arab countries, as there is a significant lack
of data in most Arab countries regarding obesity and its health consequences since
very few Arab countries focus on the health of Arab women.
Women in the Arab world commonly have traditional roles which may contribute
to them becoming obese. Such roles may include that of being cooks and maids,
which adds to a sedentary lifestyle where watching television is the main leisure
activity. Lack of information on healthy eating choices, little motivation to eat a
healthy diet, not having time to prepare or eat healthy food, and lack of opportunities
for physical exercise seem to be the main factors that have increased the prevalence
of obesity among Arab women (Jahan 2016).
2 Arab Women’s Health Care: Issues and Preventive Care 43
Changes to a modernized lifestyle and improved living conditions in Arab

countries have led to further increases in consumption of unhealthy foods, particu-
larly of fast foods as family meals. Further, decreases in the physical activity level by
Arab women have led to increases in the prevalence of obesity (Abuyassin and Laher
2016). There are significant cultural barriers that appear to affect the incidence of
obesity among Arab women such as managing diets during pregnancy and the
postpartum period and the lack of exercise and physical activity facilities for
women (Jahan 2016). Furthermore, perceptions of beauty and a preference for
plumpish women also influence the increased prevalence of obesity in Arab women.
Intervention programs and strategies are needed to prevent obesity and its related
complications such as chronic noncommunicable diseases in women in the Arab
world. These programs should provide solutions to overcome the barriers that
prevent weight control. Healthcare providers should counsel all women about the
negative effects of obesity and the importance of controlling weight to prevent
negative outcomes. Health awareness campaigns regarding the causes and compli-
cations of obesity should be conducted to motivate women on achieving a healthy
weight loss. Cohort studies are needed to adequately investigate the influence of
culture on women and their eating habits and its impact on obesity in the Arab world.
Smoking (Tobacco and Waterpipe) by Women in the Arab World
It has been estimated that tobacco smoking annually causes 6 million deaths
worldwide and is expected to increase to more than 8 million deaths by 2030
(WHO 2011). Tobacco smoking causes morbidity and mortality in the developing
world, especially in the Arab world (Maziak et al. 2014).
The prevalence of cigarette smoking by Arab men is high (Abdulrahim and Jawad
2018). Available data on tobacco smoking in Arab countries show three major
trends: (1) higher rates of cigarette smoking by Arab men compared to Arab
women, (2) waterpipe smoking as a common method of tobacco use by Arab
youth, and (3) the failure of government policies to control the tobacco epidemic
(Maziak et al. 2014).
The tobacco epidemic in the Arab world is in a transitional stage, where cigarette
smoking by men continues to be the main threat to the health and well-being of local
communities, but waterpipe tobacco smoking (WTS) is spreading fast among the
youth and women (Maziak et al. 2014). Even though WTS is now common among
Arab women, there are limited studies related to WTS use by Arab women, and in
general, there are only a few studies on the smoking habits of Arab women. A study
from Jordan showed that the prevalence of cigarette smoking among Jordanian
women remained constant over a 10-year period (around 10%) between 2002 and
2012 (Jawad et al. 2016). Another study conducted by Al-Houqani et al. (2018) in
United Arab Emirates (UAE) aimed to a better estimate of the prevalence of smoking
in the country using a population-based survey. The results of Al-Houqani et al.
(2018) indicated that self-reported smoking rates by women in the study were higher
than previously reported. Moreover, measurements of cotinine, an alkaloid found in
tobacco and which is the predominant metabolite of nicotine, confirmed that women
are exposed to tobacco smoke at higher rates than previously reported (Al-Houqani
et al. 2018). Another study by Abdulrahim and Jawad (2018) examined the inci-
dence of cigarette smoking in four Arab countries (Jordan, Lebanon, Syria, and
Palestine) with inequality in education and wealth. The prevalence of cigarette
smoking by Arab women was 8.4% in Syria, 10.9% in Jordan, and 24.3% in
Lebanon, while the prevalence in Palestine was not reported, suggesting that the
incidence of cigarette smoking is higher where there is inequality in education
(Abdulrahim and Jawad 2018).
Some of the causes of smoking by Arab women can be attributed to their low
levels of education, lower levels of household income, low socioeconomic status,
women entering the labor force, influence of the media, and the relatively low cost of
cigarettes.
Culture has a key role in the smoking rates of Arab women. For example, the low
rates of female smokers in Syria and Jordan may reflect cultural differentiation by
social class where cigarette smoking for women remains acceptable only among
“westernized” social groups who also tend to be wealthier. However, in Lebanon,
where tobacco use by women enjoys cultural acceptability, there is a relatively high
rate of smoking by women of all social classes in urban and rural areas (Abdulrahim
and Jawad 2018).
On the other hand, even if Arab women are not smokers, they are very likely to be
secondhand smokers as most of their husbands are smokers (Azab et al. 2013).
Although there is a lack of studies on secondhand smoking (SHS) in Arab countries
generally and particularly in Arab women, the exposure rates of Arab women to
cigarette and waterpipe smoke are high. For example, nearly 50% of women in
Jordan reported that the most common place where they were exposed to cigarette
and waterpipe smoke was in their houses followed by public places. Their husbands
were the main source for exposure to cigarette and waterpipe smoke (Azab et al.
2013). About 82.4% of women reported that they were exposed to cigarette smoke
and 32.8% reported that they were exposed to waterpipe smoke (Azab et al. 2013).
Tobacco use and exposure in the Emirate of Abu Dhabi is relatively high, with nearly
30% of women reporting exposure to tobacco smoke at home (Al-Houqani et al.
2018). Research on exposure to SHS is not well studied in Arab countries or in the
Eastern Mediterranean Region (EMR), in spite of the very high rates of cigarette and
waterpipe smoking.
Most of the literature in the Arab world has focused on the smoking habits of men
as a public health problem, with smoking by Arab women being only of recent
interest. There is a lack of research targeting the new phenomenon of smoking and
SHS by women in the Arab world, and more studies are needed on its causes and its
consequences for both the health of the smokers and their families.
Although many Arab countries participate in the Global Tobacco Surveillance
System, only a few of them use this data to plan and prioritize any tobacco control
initiatives or increase taxes or the price of tobacco. Future public policies should aim
to decrease the prevalence of smoking by Arab women. Further studies are required
to investigate this growing problem among Arab women.
Family Planning (FP) by Women in the Arab World
The number of Arab women in their reproductive ages (between 15 and 49 years)
increased from 69 million in 2000 to 93 million in 2012, and this is expected to grow
to 94 million by 2025. Therefore, the need for family planning is increasing
throughout the region. The growth in the number of women (40–60%) who use
contraception and family planning services has led to expansion of these services to
meet the increased demand. Unintended pregnancies are widespread in the region
(25%). Effective contraception planning is needed to avoid unwanted pregnancies,
bearing in mind cultural and religious concerns (United Nations Population Fund
(UNFPA) and Population Reference Bureau (PRB) 2012).
Generally, it is expected that using family planning is the responsibility of women
in Arab countries. Arab men are not using contraceptive methods, although their
attitudes affect their wives’ intention to use contraception and the choice of FP
methods. Using condoms by Arab men is rare (about 1% in Arab countries). Men
accept and support their wives’ needs regarding fertility, but they have their own
perceptions regarding contraceptive knowledge, approval, and use.
Family planning in the Arab world is variable since each country has its own
national family planning program and services. The methods of contraception used
for family planning in Arab countries are different. For example, contraceptive pills
are the most common method in Morocco and Algeria, while IUD is the most
common method in Egypt, Tunisia, Palestine, and Jordan (UNFPA and PRB
2012). However, female sterilization is on the rise in countries such as Morocco
and Jordan.
Discontinuation of contraception use can be due to their inherent health risks,
concerns of failure, pressure from the in-laws or the husband’s desire to have more
children (preferably boys), lack of detailed information and counselling, and the
inability to choose a suitable method of choice. Family planning services and infor-
mation should be expanded and improved. This can be achieved through cooperation
between governments and local NGOs to support and provide community-based
healthcare. Encouraging a discussion between husbands and wives about contracep-
tion methods should also be promoted. Collaboration in projects aimed at empowering
women to be well informed about their roles in family planning choices should be
encouraged.
Menopause in the Arab World
Menopause is the cessation of women’s menstruation and can be determined retro-

spectively 1 year after the last menstrual period (Lund et al. 2018). The age of
menopause differs from one woman to another. The median age of menopause in
Europe is 52.8 years, 51.4 years in North America, 53 years in South America, and
49.5 years in Asia (Palacios et al. 2010). Arab women experience menopause
differentlyfrom women in Western societies as they enter menopause earlier than
women in other parts of the world (AlDughaither et al. 2015; Obermeyer et al. 2007).
For example, the median age at menopause in Saudi Arabia and Jordan is 49 years
(Al-Qutob 2001; Rizk et al. 1998).
Frequently reported symptoms of menopause in Arab women include joint and
muscle pains, physical and mental exhaustion, hot flushes, and sweating. Perimen-
opausal women reported that there are also increases in higher somatic and psycho-
logical symptoms with mild severity (AlDughaither et al. 2015). Furthermore, a lack
of emotional support exacerbates vasomotor, psychosocial, and physical symptoms.
In addition, women who work are likely to be obese, live in rented accommodations,
do not exercise regularly, and are more likely to suffer from severe symptoms of
menopause (AlQuaiz et al. 2014, 2017). Women experiencing menopause suffer
from an appreciable level of morbidity including urinary incontinence, urinary tract
infections, reproductive tract infections, and genital prolapse.
In general, women’s education related to menopause and its social, psychological,
and biological impacts is quite limited in the Arab world (Al-Qutob 2001). Meno-
pausal education and services should be improved in the primary care sector in the
Arab world. For example, a quick and short assessment for menopausal symptoms is
needed to guide treatment choices within primary care (Goldstein 2017). Further-
more, primary care providers need training in managing menopausal symptoms in
a sensitive and evidence-based approach. Moreover, healthcare providers should
encourage menopausal women to develop a supportive network with other women
with whom they can share their concerns (Lowdermilk et al. 2012).
Osteoporosis in Women in the Arab World
Osteoporosis is an age-related disease that is characterized by reduced bone mass

and micro-architectural deterioration that results in increased bone fragility and a
greater propensity to fracture (Rodrigues et al. 2018). It can be prevented or
minimized with lifestyle changes and medication (Lowdermilk et al. 2012). Arab
populations have higher rates of fractures than those reported in the West. The
incidence of fragility fractures increases by up to four times as the population ages
in some Arab countries (International Osteoporosis Foundation 2011). The Middle
East and Africa registered the highest rates of rickets worldwide despite having an
abundance of sunshine throughout the year. There are a limited number of DXA
machines in most Arab countries, in addition to the lack of general education or
lifestyle programs on osteoporosis, making awareness of osteoporosis and its com-
plications limited (El-Tawab et al. 2016). It is important to note that only a few Arab
countries consider osteoporosis as a health priority, and there is a lack of published
national guidelines for managing osteoporosis (International Osteoporosis Founda-
tion 2011).
Efforts should be combined by all national institutions to start taking positive
actions in order to improve osteoporosis awareness, screening, prevention, and treat-
ment in the Arab world (Alwahhabi 2015). Furthermore, increased international and
national collaborative research projects on osteoporosis will improve research output
and improve efforts in osteoporosis prevention and treatment (Sweileh et al. 2014).
Child Marriages in the Arab World
Marriage at an early age is common in the Arab region. Nearly 700 million (or 14%)
of Arab women living today were married when aged under 18. Women and girls
make up 70% of all known human trafficking victims. Adult women constitute 50%
of the total number of trafficked people, and more than half (2 in 3) of human
trafficking are young girls.
Child marriage or early marriage is defined as a formal marriage or informal
union before the age of 18, for both boys and girls but more commonly for girls.
Child marriage is common in many parts of the world, including Arab countries. It
can lead to a lifetime of concerns, the most serious of which are the deprivation from
formal education and becoming pregnant at an early age, which results in higher
maternal and infant mortalities (Alsaidi 2015). It is estimated that 1 in 4 women in
the world are married before the age of 18, but this number increases significantly in
sub-Saharan Africa, where nearly 4 in 10 young women are married before the age of
18 (UNICEF 2019). Syrian refugee populations also have higher rates of child
marriages; some estimates show that child marriage rates currently are four times
higher in Syrian refugees compared to lower rates of 13–15% before the conflict
(UNFPA 2017).
According to Alsaidi (2015), poverty, religion, tradition and culture, and laws in
some Arab countries such as Egypt, Yemen, and Jordan are factors that drive child
marriages, with poverty as the main driver for this practice. Governments need to
reduce poverty with the cooperation and support of international communities,
especially from wealthy countries. Other considerations are to create programs that
generate employment opportunities for the poor and provide funds that would allow
young boys and girls to remain in school for longer periods. This could help change
the pervasive attitude in some Arab cultures that marriage, even at a young age, is the
only option for women.
Domestic Violence in the Arab World
Violence against women and girls is an egregious violation of human rights that
leads to several consequences ranging from immediate to long-term multiple dis-
abilities in physical, sexual, and mental health in women and girls and can ultimately
also be a cause of death. In addition to negatively affecting a woman’s health,
gender-related violence also prevents women from fully participating in society.
Violence against women also has tremendous costs, from increased healthcare and
legal expenses to losses in productivity, and can impact national budgets and overall
development. Violence against women costs billions of dollars annually in direct and
indirect costs in various parts of the world.
Domestic violence is not yet considered a major concern in Arab countries,
despite its increasing frequency and serious consequences. Surveys in Egypt, Pal-
estine, Israel, and Tunisia show that at least one out of three women is beaten by her
husband. Violence is considered a private matter and, usually, a justifiable response
for misbehavior on the part of the wife. In Arab countries, the subject of violence
against women and girls is a culturally sensitive topic. Negative stereotypes and
social stigma pose a fundamental challenge for women in seeking protection or
support. More than 6 in every 10 women who are survivors of violence refrain from
asking for support or seek protection of any sort. Women who do admit to being
physically attacked at home seek support from family and friends. Unfortunately this
approach entrenches impunity and also leads to a general lack of statistical data,
which in turn impedes the creation of effective programming to combat violence
against women.
Sadly, rapists are often shown leniency or even acquitted in most of the Arab
region if they marry their victims. In Morocco, Article 475 of the penal code, which
allows rapists to avoid prosecution if they marry their victims, was repealed in 2014
following the suicide of a rape victim who was forced to marry her rapist. Tunisia
ended a law that allowed a rapist to escape punishment if he married his victim, and
some other Middle Eastern countries are also making efforts to protect victims of
rape and violence.
Unfortunately, selected excerpts from the Koran are used to justify the actions of
men who beat their wives. These religious justifications, and the importance of
preserving family honor, lead abusers, victims, police, and healthcare professionals
to join in a conspiracy of silence.
Finally, government legislations in the region often fall short in covering all forms
of violence against women and in many cases lack effective enforcement mecha-
nisms. First responders and paramedics, including law enforcement and healthcare
practitioners, often lack the training required to recognize and also deal with cases of
violence against women.
Female Genital Mutilation (FGM) in the Arab World
According to the World Health Organization (WHO), female genital mutilation

(FGM) – also referred to as female genital cutting and female circumcision –
includes “all procedures that involve partial or total removal of the external female
genitalia, or other injury to the female genital organs for non-medical reasons”
(WHO 2018). It is estimated that more than 133 million women living today have
experienced FGM. Egypt has the highest population of any country in the Arab
world (95 million people), and about 92% of ever married women and girls between
15 and 49 years of age have experienced FGM.
The types of procedure performed also vary, mainly with ethnicity. Current estimates
(from surveys of women older than 15 years old) indicate that around 90% of FGM
cases include either Types I (mainly clitoridectomy), II (excision), or IV (“nicking”
without flesh removed) and about 10% (over 8 million women) are Type III (infibula-
tion). Infibulation, which is the most severe form of FGM, is mostly practiced in the
northeastern region of Africa: Djibouti, Eritrea, Ethiopia, Somalia, and Sudan. In West
Africa (Guinea, Mali, Burkina Faso), the tendency is to remove flesh (clitoridectomy
and/or excision) without sewing the labia minora and/or majora together.
High Prevalence of FGM in the Horn of Africa

The practice of FGM is concentrated in poorer Arab countries on the African
continent, particularly in Somalia, Djibouti, Egypt, and Sudan. According to
UNICEF, Somalia has the highest prevalence of FGM of any predominantly Arab
country, with an estimated 98% of females between 15 and 49 years having
undergone the practice. In Egypt, an estimated 87% of girls and women 15 to
49 have also undergone FGM. Among girls aged 0 to 14 years, Mauritania has the
highest percentage of FGM practice, with 54% having been circumcised. Yemen
then follows, with 15%, and Egypt with 14%.
Historical, Cultural Perceptions Shape Practice

The reasons cited for carrying out FGM are complex. According to the WHO, FGM
in some communities is “associated with cultural ideals of femininity and modesty,
which include the notion that girls are clean and beautiful after the removal of body
parts that are considered unclean, unfeminine and male.” The WHO also claimed
that some communities believe that the practice “reduces a woman’s libido and
therefore [is] believed to help her resist extramarital sexual acts.”
But is the practice a cultural or religious one? FGM is an African practice and
certainly not an Islamic one. The majority of Muslims around the world do not
practice any form of FGM. It is very rare in North African countries such as Algeria,
Libya, Morocco, and Tunisia which have Muslim majorities, although it is common
among sub-Saharan immigrants. The sole exception is Egypt because of the strong
and historic influence of African culture.
Yet the consequences of the practice can be devastating: excessive bleeding,
unbearable pain, and urinary problems are among the immediate complications.
Long-term consequences can include vaginal and urinary infections, increased risk
of cysts, menstrual complications, childbirth complications, chronic pain, absence of
sexual pleasure, and long-term psychological damage.
Due to increasing activism from civil society and international organizations
devoted to eradicating FGM, it has now been banned in Egypt, Sudan, and Djibouti.
In Yemen, the practice is banned in medical facilities but not in homes. In Mauritania
there are legal restrictions, but not an outright ban. Meanwhile, in Iraq, the practice
has been banned in the Kurdish Region in the North but remains legal in central Iraq.
Unfortunately, governments usually only pass laws to fight this phenomenon, but
they do not enforce the law – likely because these laws require extensive education
of the society first. Governments must work harder to change these attitudes,
customs, and inhumane practices targeting women. Change in societal values and
practices starts with education, and it is the role of national governments and civil
society organizations to stop these practices that have not shown to improve the lives
and happiness of Arab women.
Breast Cancer in the Arab World
Breast cancer is the most common form of cancer in Arab women and, importantly,
presents at an earlier age and at a more advanced stage than in Western countries
(Donnelly et al. 2013). It appears in Arab women a full decade earlier than in women
in Western countries. Najjar and Easson (2010) suggest the reason for this may be
that Arab women are a much younger population compared to women in Western
countries. This means, if breast cancer presents at a younger age, it will have more
aggressive cellular features, and the prognosis is poorer. This results in more
aggressive treatment strategies, which often include surgery, chemotherapy, and
radiation (Najjar and Easson 2010).
In the Arab world, there is another important concern that affects women with
breast cancer: the very low rates of breast cancer screening. Furthermore, screening
programs are limited, opportunistic, and relatively new to the region, making it
difficult for all women to access such programs (Donnelly et al. 2013).
Studies undertaken in the Arab world show improvements in the last decade.
However, it will be very beneficial for higher education institutions and research
centers in Arab countries to build new bridges by collaboration with their interna-
tional counterparts to promote breast cancer research (Sweileh et al. 2015). Breast
cancer screening and management strategies should receive far greater attention in
order to help women in the Arab world. Furthermore, studies should focus on
identifying the ideal age at which a rigorous cancer screening program should start
(Najjar and Easson 2010).
Cervical Cancer in the Arab World
A woman dies of cervical cancer every 2 min, and there are an estimated 570,000
new cases diagnosed in 2018, representing 6.6% of all female cancers (WHO 2018).
The incidence of cervical cancer is lower in Arab countries compared to the rest of
the world, but unfortunately most cases of cervical cancer are detected at a late stage.
Only a small number of women in the Arab region are tested annually in spite of the
well-known benefits of the Pap smear test; most testing is through opportunistic
screening during a regular gynecological examination. Therefore, it is crucial for
healthcare providers to advise women on the importance of prevention in terms of
doing regular and consistent screening and possible vaccination against HPV.
Studies from Arab countries indicate an absence of organized, systematic,
population-based cervical cancer screening and a lack of knowledge about cervical
screening.
The impact of cervical cancer on a woman’s life is multifaceted. First, cervical
cancer and its treatments often profoundly affect overall mental and physical health
through changes in infertility, morbidity, and mortality. In this respect, women bear
the greatest burden if diagnosed at younger ages and at a more advanced stage of the
disease. Additionally, many patients experience negative psychosocial reactions
such as fear, shock, denial, anxiety, depression, anger, and shame. Unfortunately,
these concerns are rarely addressed as patients often feel uncomfortable and
embarrassed to discuss changes in their well-being as a result of the complications
of cervical cancer.
HPV in Arab Countries
HPV-related infections are less common in Arab countries compared with the rest of
the world, though the exact prevalence of HPV in the Arab world is not as well
determined as it is for other countries. Several recent studies have attempted to study
the prevalence of HPV in the general population in the Arab world. A study
presented by Seoud et al. at the American Society of Clinical Oncology (ASCO)
in 2010 utilized a large literature survey to specifically determine HPV prevalence,
rather than just the prevalence of cervical cancer in the Middle East and North Africa
(MENA) region. Using data available from the literature to 2009, the authors
suggested that the prevalence of HPV is around 5–12% in the general population
and, moreover, that 60–90% of cervical cancers in the MENA region are positive for
HPV, with HPV 16 as the most predominant type.
A recent study by Al-Thani et al. in Qatar examined the prevalence of different
types of HPV in 95 women living in Qatar and reported a prevalence of up to 70% of
high-risk HPV types in women with gynecological problems. However, it must be
emphasized that this study was carried out on women with preexisting gynecolog-
ical problems, and the results do not represent the general population of Qatar
(Al-Thani et al. 2010). A systematic review to assess the prevalence of genital HPV
infection in women of the Middle East was presented at the International Human
Papillomavirus Conference and Clinical Workshop in July 2010 by Akhtar from
Kuwait University. The results of this review suggested that the prevalence of HPV
infection ranged from 5% to 31% in the general population and prevalences of 80%
in women with cytological abnormalities and almost 100% in women with cervical
carcinoma. The prevalence of HPV infection in different regions of the Arab world
ranged from 4.9% in Lebanon, 13% in Palestine, to 31.6% in Saudi Arabia. Women
with cytological abnormalities had much a higher prevalence of HPV of about 80%
in Turkey and almost 100% in Saudi Arabia in women with cervical cancers. The
predominant HPV subtypes were HPV 16/HPV 18 (Malary et al. 2016). More
country-specific studies were published between 2010 and 2011 by Al-Awadhi
et al. and include a study of 3011 Kuwaiti women where 40.8% of all HPVs
occurred in women aged 30–39 years, and the incidence was 29.6% in women
aged 40–49 years, 19.7% in women over 50 years, and 9.9% in women aged less
than 34 years old. A prevalence of 5.5% of positive HPV findings was also shown in
a cohort of 402 females in Iran.
A 2010 WHO publication reported that every year, an estimated 48 women are
diagnosed with cervical cancer and that 2 die from the disease (an incidence rate of
9.9 per 100,000 women). Cervical cancer ranks as the fourth most frequent cancer in
women in the United Arab Emirates and the third most frequent cancer in women
between the age of 15 and 44 years.
Studies investigating the prevalence of cervical cancer/HPV in the Middle East from
1998 to 2010 reveal that the average annual reported substantial increases in cervical
cancer cases and HPV incidence in the region, although the rates are lower compared to
the rest of the world. This alarming increase emphasizes the need for awareness and
prevention screening, with the use of conventional Pap smear, HPV DNA testing, and
vaccination programs in the region. Indeed, the variation in the prevalence of HPV
infection in the Middle East compared to the rest of the world may itself be a
manifestation of the lack of routine screening programs in the region as well as a
reflection of societal disapproval of extramarital sexual activity. The scarcity of data
regarding the burden of HPV infection in the Middle East demonstrates the need for
more studies to illustrate the HPV infection load in the female population of the region.
Conclusions
This chapter focused on the most common women’s health issues in the Arab world.
There is a clear shortage of primary healthcare services, and where these services do
exist, there are important shortcomings in the services provided to Arab women.
Only some Arab countries provide primary healthcare services. Issues related to
women’s health are major public health issues that need extensive investigation.
Healthcare policy makers need to develop actionable strategies that can be efficiently
delivered to bring about clear and measurable improvements in primary healthcare
services for all women in the Arab world. Cultural practices that negatively impact
the physical and psychological health of Arab women are fairly entrenched in the
region, and greater educational activities are needed.
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Social Determinants of Perinatal Health
in Morocco 3
As. Barkat, M. A. Radouani, and A. Barkat
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Systematic Literature Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Neonatal Deaths . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Perinatal Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Perinatal Health in Arab Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Perinatal Health in Morocco: Example of Rabat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Perinatal Health in Souissi Rabat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Example of an Obstetrical Instrumental Technique: Episiotomy in Current Practice . . . . . . . 62
Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Assumptions of the Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
A Perspective to Improve Perinatal Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Abstract
Socioeconomic development and improved health of the population require a
consideration of all interfering determinants4. This chapter discusses the socio-
economic determinants of perinatal health based on research at the Maternity
Souissi in Rabat, Morocco. We also attempt to extrapolate these findings to a
national level.
As. Barkat
Equipe de recherche en santé et nutrition du couple mère enfant, Faculté de médecine et de
pharmacie de Rabat, Université Mohammed V, Rabat, Morocco
M. A. Radouani (*) · A. Barkat
Equipe de recherche en santé et nutrition du couple mère enfant, Faculté de médecine et de
pharmacie de Rabat, Université Mohammed V, Rabat, Morocco
Service de médecine et réanimation néonatales, Centre National de Néonatologie et Nutrition,
Hôpital d’Enfants, Centre hospitalier Ibn Sina, Rabat, Morocco
e-mail: dr.med.radouani@gmail.com

https://doi.org/10.1007/978-3-030-36811-1_4
56 As. Barkat et al.
Based on a sample of 1000 parturient women (women about to give birth),

with a response rate of 98%, our study shows that: (1) The level of education of
women in labor is closely related to recorded complications, so that a higher level
of education is associated with decreased complications of perinatal health.
(2) Women living in poor neighborhoods have a greater percentage (57%) of
gestational complications compared to women from middle-class neighborhoods
(29%). Women from more affluent neighborhoods were not studied in this
investigation. (3) Income and the working conditions also impact perinatal health.
(4) Access for monitoring of pregnancy also positively impacts the quality of
maternal and newborn health. (5) Social exclusion negatively impacts perinatal
health.
Keywords
Perinatal health · Socioeconomic conditions · Households · Women in labor ·
Neonatal · Primipara · Paucipare · Multiparous · Social exclusion · Education ·
Household income · Housing · Care during pregnancy · Labor conditions
Introduction
The literature on perinatal health reveals that health care, education, sociocultural
practices, employment, income, food, and sanitation are important determinants of
maternal health in all parts of the world. Almost all studies on maternal health in
Africa suggest a lack of women’s decision-making ability regarding their marriage,
contraceptive use, family planning, birth spacing, and health-care choices. This lack
of personal freedom is linked to lower levels of education for women, patriarchal
traditions, and weak social infrastructures and services in most African countries.
The notion that social determinants impact maternal health is well established in
the literature. Several studies suggest that health determinants have either a direct
impact on maternal health or are mediated by other determinants. Health-care
services including health promotion, disease prevention, treatment facilities, and
the presence of skilled health personnel directly impact perinatal health. In addition,
there is much evidence supporting a direct health effect of local sociocultural
practices, such as childhood marriage and pregnancy, unwanted sexual activity,
physical abuse, and the need to obtain permission to access health services. Unde-
sirable social conditions such as lack of proper shelter, lack of potable water, and
poor waste management also negatively influence perinatal health (Organisation
mondiale de la santé 2014; Pesenti and d’Etat 2010; Préambule à la Constitution
de l’Organisation mondiale de la Santé 1946).
On the other hand, improvements in women’s education tend to advance the
social status of women in the family and also in the society in general; this alters
undesirable and health-deteriorating sociocultural practices and thus improves
maternal health. Improved transportation systems such as paved roads and avail-
ability of emergency vehicles, for example, provide easy access to health services,
3 Social Determinants of Perinatal Health in Morocco 57
improve health service utilization, and so improve maternal health. Employment,

income, and wealth also influence health through access to health-care facilities.
In general, many women who are employed are also better educated.
The issue of maternity without risk is no longer of primary concern to interna-
tional organizations. In fact, new guidelines are in place under the aegis of the
proclamations to the right to reproduction in light of the alarming figures related to
maternal mortality. This has helped to lower deaths as a result of pregnancies in a
number of countries, so that between 1990 and 2010, global maternal mortality rates
were reduced by half (Organisation mondiale de la santé 2014; Pesenti and d’Etat
2010).
It is unrealistic to propose that only health conditions are at the root of high rates
of perinatal morbidity and mortality in any country. In fact, the developed countries
consider good health of their citizens to stem from wise policy choices in economy,
education, environment, and social cohesion.
Atypical lifestyles and precarious living conditions are often underreported, and
consequently many studies provide little information on the nature and magnitude of
health problems and maternal and perinatal outcomes of marginalized groups (Orga-
nisation mondiale de la santé 2014; Pesenti and d’Etat 2010; Préambule à la
Constitution de l’Organisation mondiale de la Santé 1946). Our goal is to address
this issue by describing the vulnerability of Moroccan females and the serious risks
they face as a result of an ever-increasing maternal mortality rate (Pesenti and d’Etat
2010; Dahlgren 1995).
Systematic Literature Review
Over 130 million babies are born every year in the world, and more than 10 million
infants die before their fifth birthday, with almost 8 million dying before their first
birthday.
Many countries have set goals for reductions in under-five and maternal mortality
as key developmental goals, as suggested by international conferences such as the
World Summit for Children in 1990, the United Nations Millennium Declaration,
and the United Nations Special Session on Children in 2002. In preparing child-
mortality-reduction strategies, it is important for countries to know the magnitude of
perinatal and neonatal mortality so that they can better assess needs and develop
appropriate programs to reduce avoidable child deaths more quickly. However,
national indicators of the health of mothers and newborn infants are often not readily
available, especially in countries that lack systematic registration systems.
Neonatal and perinatal mortality rates in different countries have differences and
similarities in what is listed. However, analyzing and comparing mortality rates
between countries is also fraught with pitfalls, as minor differences or similarities
may be the result of real distinctions in mortality levels or may be due to diverging
definitions and reporting systems, sources of data, or levels of accuracy and com-
pleteness (Préambule à la Constitution de l’Organisation mondiale de la Santé 1946;
Dahlgren 1995).
Neonatal Deaths
Babies die after birth either because they are severely malformed, are born very
prematurely, suffer from obstetric complications before or during birth, and have
difficulty adapting to extrauterine life or because of harmful practices after birth that
lead to infections. Nearly 1% of infants have a major congenital anomaly. These
anomalies, especially those caused by diseases such as syphilis, neural tube defects,
and cretinism, caused by nutrient deficiencies are more common in developing
countries. Low birth weight is associated with the death of many newborn infants
but is not considered a direct cause. Complications during birth, such as obstructed
labor and fetal malpresentation, are common causes of perinatal death in the absence
of obstetric care. Birth asphyxia and trauma often occur together, and it is, therefore,
difficult to obtain separate estimates (Préambule à la Constitution de l’Organisation
mondiale de la Santé 1946).
Infections are the main cause of neonatal death after the first week of life in many
cases. These are commonly acquired either in the hospital as a complication of
treatment for other perinatal conditions or at home. Preterm infants are at greatest
risk of becoming ill and dying. Harmful cord care practices cause neonatal tetanus if
the mother is not immunized; poor feeding practices cause diarrhea and poor growth;
an unhygienic environment causes sepsis.
Perinatal Mortality
The term “perinatal mortality” has been used for the last 50 years to include deaths
that could be attributed to obstetric events, such as stillbirths and neonatal deaths in
the first week of life. The perinatal mortality indicator plays an important role in
providing the information needed to improve the health status of pregnant women,
new mothers, and newborns. Such information allows decision-makers to identify
problems, track temporal and geographical trends and disparities, and assess changes
in public health policy and practice. Perinatal mortality is an important indicator of
maternal care and of maternal health and nutrition, as well as reflecting the quality of
obstetric and pediatric care available although social factors exert the main influence.
The highest perinatal mortality rates and rates of stillbirth occur in sub-Saharan
Africa, followed by Asia and Latin America. In countries where the mortality is
highest, almost 10% of babies do not survive more than 1 month. The proportion
attributable to each cause varies: in areas where neonatal mortality is lower, preterm
birth and malformations play a larger role; where mortality is higher, the contribu-
tions of asphyxia, tetanus, and infections are greater.
Maternal health and nutrition are important for neonatal health, and maternal
infections contribute to adverse outcomes. But the real causes of adverse outcomes
are untreated or poorly treated maternal complications in Africa and Asia, inade-
quate neonatal care, and harmful home care practices, such as the discarding of
colostrum, the application of unclean substances to the umbilical cord stump, and the
failure to keep babies warm. The risk of death for a pregnant woman with severe
preeclampsia, for example, is 0.5%, and the risk of perinatal death for her child is
13%. If the condition remains untreated and eclampsia develops, the risk of death
increases to 5% for the mother and 28% for the baby (Organisation mondiale de la
santé 2014; Préambule à la Constitution de l’Organisation mondiale de la Santé
1946).
Perinatal Health in Arab Countries
Most studies looking at childbirth in the Arab region focus on the traditional aspects
of the birthing process, on maternal mortality rates, or on emergency obstetric
complications while ignoring the ever-increasing number of women who experience
uncomplicated vaginal births in hospital settings. The reproductive health agendas in
many developing countries, including those of the Arab region, tend to use a
“reductionist approach” in their development activities which are either geared
toward promotion of family planning, reduction of maternal mortality, or universal
uptake of prenatal care. In the great majority of countries, uncomplicated childbirth
is not a priority of the research or policy agendas.
In 2009, the infant mortality rate in the Arab world ranged from 7/1000 to
109/1000 live births. In 1990, it ranged from 13/1000 to 133/1000 live births.
There was a decline in infant mortality rates in all countries. The reduction of the
infant mortality rate during the period 1990 to 2009 ranged from 7.40% to 66.70%,
with the greatest decrease of infant mortality rates in Egypt, while the lowest
decreases were in Mauritania. Education has the largest role on infant mortality.
Despite the significant progress made in adult education, the Arab region is still far
from international standards. There is great awareness in Arab countries at the
governmental and organizational levels of the seriousness of this situation (Organi-
sation mondiale de la santé 2014; Préambule à la Constitution de l’Organisation
mondiale de la Santé 1946).
Perinatal Health in Morocco: Example of Rabat
As a prerequisite for socioeconomic development in a country, the role of interfering

determinants on health needs to be considered.
The determinants which are registering at the socioeconomic context as demon-
strated across studies and researches adopted in this investigation. Indeed, based on
the positive results of researches carried out in different contexts, in terms of the
impact of socioeconomic conditions on health in general and perinatal health in a
specific way, this investigation has raised a number of factors influencing perinatal
health at the Maternity Souissi in Rabat or even at national level, with the possibility
of extrapolation on many regions of the Arab world.
Based on a sample of 1000 parturients (women about to give birth), with a
response rate of 98%, our study shows that:
– The level of education of women in labor is closely related to perinatal compli-

cations, and rates of complications decrease with improvements in education
levels.
– The place of residence is also important in influencing the quality of maternal
health. Women living in poorer neighborhoods have more than the half of the
gestational complications recorded 56.97%, while those from middle-class neigh-
borhoods had only 28.84% of the complications noted. Women from rich neigh-
borhoods were not part of this investigation.
– Income levels and working conditions impact perinatal health.
– Monitoring of pregnancy and the location of the monitoring facility impacts the
quality of maternal and newborn health.
Through various data, social exclusion has an impact on maternal and neonatal
health.
Suggestion Through various data, social exclusion has an impact on perinatal
health. Women in disadvantaged areas are lacking prenatal care because they are
commonly exposed to poor conditions of nutrition and personal hygiene; they are
torn between housekeeping, family duties, and their work. Besides, working women
in precarious conditions are usually victims of stress, extensive working hours, and
abusive dismissal because of pregnancy or do not fully enjoy maternity leave as
guaranteed in the labor law.
Perinatal Health in Souissi Rabat
The results obtained via the measurement tool used in this study are discussed in the
light of the published literature. We first collected data of the parturients to this
research and their newborns. Respondents were aged between 18 years and 35 years
with 97% of them being married, and nearly half (46.5%) were primiparous women
(giving birth for the first time). Nearly a third of the women (29%) have a low
income (less than 2 $ per day); 25% of them were Multiparous (more than one child).
Most (78.3%) were of urban origin. The majority (53.7%) achieved full-term
deliveries, while 30.5% birthed premature infants, and 15.8% were post-term neo-
nates (baby born after the normal 40-week gestational period).
Just over half (53.4%) of the newborn participants in this investigation were male,
and the remainder were female. Apgar scores (of the newborns overall health) were
favorable in 74.2% of babies. Their weights at birth were normal in 70.4% of cases,
20.5% were hypotrophic, and 9.1% were macrosomic. Their examination at birth
was abnormal in 188 births or 18.8% of cases.
Another important factor is the education level of the parturients and its effects on
perinatal health, as shown by others that education influences the quality of health by
ensuring its improvement and promotion (Ronson 2009; UNICEF 2005). These
findings were reaffirmed in our study where we determined that the level of
education of pregnant women positively impacts their health.
The place of residence also influences perinatal health. In effect, the report of the
World Health Organization and the studies by Wilkins on health and housing in
Canada proclaimed that the quality of housing impacts health (Green 2005).
According to the report of the World Health Organization, the exposure to risks
related to unsanitary conditions is at the heart of many physical health problems,
trauma, as well as diseases and preventable deaths. Moreover, the study by Wilkins
reports that women in wealthier areas of Canada live on average 2 years longer than
those living in poorer neighborhoods. This study demonstrated that those living in
the poorest neighborhoods had a mortality rate that was 28% higher (Green 2005;
Wilkinson 2002). The results of our empirical study are in agreement with the study
by Wilkins. We observed that women who live in poorer neighborhoods represent
more than half of the gestational complications and only 6.67% of pregnancies
without complications, while parturients from middle-class neighborhoods had
only 29% complications with more than 86% of these parturients not having any
health problems in their pregnancy or during childbirth. Women living in the slums
represented only 6% of parturients who had no complications and 14% of cases with
gestational problems such as infections, preeclampsia, miscarriage, preterm labor,
etc. Similarly, our study demonstrates that parturients from rural areas represent only
5% of pregnancies without complications.
Income level is among the determinants that influence the quality of perinatal
health, as initially reported in other studies (Raphael 2009; Auger and Alix 2009;
Black 1988; Suhrcke 2008). These studies have shown that low income is associated
with material and social deprivation, heart attacks, diabetes, and perinatal compli-
cations and that a higher income allows for the development of a framework of life
that promotes better health (Raphael 2009; Auger and Alix 2009; Black 1988;
Suhrcke 2008). Unemployment influences negatively the quality of health of
women and children (Pesenti and d’Etat 2010; Préambule à la Constitution de
l’Organisation mondiale de la Santé 1946). Our study evaluated the impact of
working conditions on perinatal health. Half of the gestational complications
occurred to women who stated that they have a difficult job (38% of total) or one
that represents a risk to their health (20% of total) (Organisation mondiale de la
santé, 2014; Dahlgren 1995).
Poverty is widely accepted as a factor influencing the quality of health mostly
because the poor have limited access to basic health care. In this context, a study by
the World Bank of 56 developing countries affirms that among other things, access to
primary health care and the use of perinatal care increase with the social status of the
household, while that the poorest quintile did not enjoy the same follow-up oppor-
tunities during pregnancy (Gwatkin 2007). Women who did not closely monitor their
pregnancies accounted for only 5% of uncomplicated pregnancies and 70% the
gestational complications recorded.
Social exclusion is associated with deterioration of health (Pesenti and d’Etat
2010; Ronson 2009; Auger and Alix 2009). The study by Bynner demonstrated that
social exclusion is accompanied by significant morbidity, early mortality, and several
other health concerns (Bynner 1995). Moreover, those that are socially excluded are
more vulnerable to many perinatal conditions because excluded families may have
difficulty in accessing social and health services (Cour de compte française 2012;
Département des activités médicales 2005; Institut Scientifique de recherches
économiques et sociales 1989). Our study is in agreement with these observations;
our data indicates that the poorly educated presented with 37% of complications
recorded and that the women of rural origin were only 5% of cases without
complications. Moreover, those from low-income households had the highest rates
of maternal complications, and parturients from poor neighborhoods presented with
half of the gestational complications, with only 7% of parturients from poor neigh-
borhoods having no gestational complications. Similarly, neonates of women who
did not have follow-up visits after their pregnancy had the highest rates of neonatal
complications 56% (Hulchanski 2007; Rutstein 2004).
Example of an Obstetrical Instrumental Technique: Episiotomy

in Current Practice
Definition
Episiotomy is the voluntary incision of the perineum, performed by the midwife or
obstetrician to enlarge the vagina to facilitate the delivery. It has been used since the
seventeenth century to prevent perineal injuries and to facilitate and accelerate delivery.
It is an operation that consists of cutting the perineum from the posterior com-
missure of the vulva. It interests the skin, the mucous vaginal membrane, superficial
muscles of the perineum, and the entire puborectal bundle (Graham et al. 2005;
Cleary-Goldman and Robinson 2003).
Indications of Episiotomy
Fetal Indications
They are the most important. The need to accelerate the fetal head exit or to protect
the skull of a fragile fetus against the perineum during the period of expulsion
explains the major indication of episiotomy in fetal distress and delivery of the
prematurity. Thus, episiotomy will limit the forceps introducing to the vulva.
Maternal Indications
They relate either to the condition of the perineum or to the presentation of the fetus
during delivery.
Perineal Anomalies
The narrowness of the vulva, atresia of the perineum, and excess length may require
episiotomy. A serious tear of the perineum, particularly threatening in the following
cases, can be avoided by episiotomy: short and tense perineum as found in the pelvis
dislocated and fragile or edematous perineum.
Certain Fetal Presentations

– Macrocrania
– Occipito-sacral release
– Presentation of the face or bregma
– Presentation of the seat
– Dystocia of shoulders
Disadvantages of Episiotomy
This intervention has disadvantages. It doesn’t always avoid the tear of the perineum
and then makes repair more difficult.
When it is done early enough, in the presentation of the seat, on a perineum not
still distended, it can bleed noticeably. Finally, the oblique episiotomy, if not repaired
carefully, may have an unsightly scarring that leaves the vulvas somewhat asym-
metrical. The scar can remain painful and cause dyspareunia (Comité éditorial de
l’UVMaF 2011).
Situation in Morocco
According to literature, there is A large geographical variation of the episiotomy
percentage in the country, between countries, and between regions. However, it is
difficult to define what is the “universal” episiotomy rate (Bakkali et al. 2014).
The rate of episiotomy ranges from 9.7% (Sweden) to 100% (Taiwan). The rate of
episiotomy ranges from 9.7% (Sweden) to 100% (Taiwan). It tended to be lower in
England, France, and Germany. Whereas in many parts of the world 327 (Latin
America, South Africa, and Central Asia), episiotomy rates remained very 328 high.
In Morocco the rate is 61%.
The age group between 20 and 35 and teenage girls accounted for 94.26% cases
of episiotomy during our study.
The extreme ages of the deliveries were 16 and 43 years old, and the average age
was 25.88 years old.
Our results are comparable to those of Algeria and Tunisia who reported a rate of
98.32% and 96.96% for the same age group (Bakkali et al. 2014; Wildman et al.
2003).
Medical history was absent in 72.13% of cases.
Anemia accounted for 13.93% of parturients, 58.85% of whom had insufficient
expulsive efforts and 11.76% had prematurity. These situations may lead to an
episiotomy and/or instrumental extraction (23.53% of patients with anemia received
instrumental extraction by suction cup).
Congenital arterial hypertension accounted for 4.19% of cases. It increases the
risk of prematurity, intrauterine growth retardation, and death in utero and therefore
increases the rate of episiotomy.
Diabetic patients accounted for 2.46% of cases. This diabetes, which is a risk
factor for obesity, can increase the episiotomy rate in case of macrosomia (33% of
neonates born to diabetic mothers had macrosomia).
In Morocco, 16.39% of patients had a scarred perineum; the causes were not
specified. We could not conclude if it was a scar following a simple episiotomy or a
perineal tear.
The primiparous were the most represented in our study with 59.83% versus
40.17% for Multiparous. In our study we found 80.33% of term pregnancies.
The delivery of a term pregnancy was, in 70% of cases, accompanied by an
episiotomy to protect the already fragile fetus.
Fetal presentations were cephalic in 98.36% of cases and seat in 1.64%.
Mediolateral episiotomy was exclusively practiced in our study; it has fewer
disadvantages than lateral and medial episiotomies.
In our study, primiparity was the major indication with 54.10% of cases. In our
study, primiparity was the major indication with 54.10% of cases. The perineum of
the primiparous was less flexible because it hasn’t yet been distended. In our study,
25.4% of women who received an episiotomy delivered by suction cup and 1.60% by
forceps to facilitate instrumental maneuvers and clearance of the fetal presentation.
Macrosomia accounted for 10.66% of patients who received episiotomy, 30.77%
of which were associated with primiparity and perineum scar.
Fetal distress was accounted for 3.28% of cases. It was morbidity during the
expulsive phase which required an emergency extraction of the fetus; 0.82% of cases
required instrumental extraction.
In our study, 95.90% of newborns had a good Apgar score (>7), and 83.06% of
women gave birth to a newborn; birth weight was between 2500 and 3999 g.
In our study, 7.38% of patients who received an episiotomy have had complica-
tions (pain, hemorrhage, scar) (Wildman et al. 2003; OMS.OMS 2005).
Recommendations
In light of the results of this work, we recommend:

To the health and political authorities
– Adapt the training of the medical profession and midwives to facilitate a more
restrictive use of episiotomy.
– Publish episiotomy rates, to inform women and encourage institutions to improve
their practices.
– Extend the studies on episiotomy and particularly studies.
– Define a maximum allowable rate.
To health staff
– Act on maternal and fetal risk factors that are preventable by early treatment
throughout the period of prenatal consultation.
– Respect the indications and the conditions of the episiotomy so to reach the
episiotomy rate recommended by the WHO.
– Assimilate the techniques of deliveries.
– Know how to practice and repair an episiotomy incision.
– Improve practices associated with instrumental extraction in order to reduce the
use of episiotomy.
– Provide local hygiene and care advice, and maintain dry suture to fight pain in
patients who benefited from an episiotomy.
– Ensure the proper maintenance of obstetric files.
In general
– Raise awareness of the importance of prenatal consultations and short and long-
term postpartum follow-up.
– Systematize the follow-up of the pregnancy especially in rural areas.
Assumptions of the Study
Our empirical result embraces three main concepts:
• There is a correlation between socioeconomic conditions of households and the

health of mothers and their newborns.
• Improved perinatal health requires the intervention of a team.
• The strategic actions carried out in the framework of the perinatal health require
reformulation.
The results of our study demonstrate that maternal health directly related to the
living conditions of pregnant women. The place of provenance, urban or rural, is also
associated with the outcomes of perinatal health. There is a significant association
between work conditions and gestational complications. Similarly, income levels of
households and the place’s residence of the women surveyed were predictors of the
complications recorded.
Limited visits to medical centers during pregnancy impact the quality of mater-
nal health. The location of the facility for follow-up visits also impacts the quality of
maternal health and perinatal health. The number of ultrasounds made during the
pregnancy and the number of antenatal consultations correlate with the complica-
tions recorded. These different socioeconomic variables indicate a clear relation-
ship between maternal health and socioeconomic conditions of households. The
correlation between these conditions with perinatal health also requires a review of
neonatal health, which indicates that the maternal pathologies related to neonatal
complications. These findings suggest that socioeconomic conditions that influence
maternal health impact health of their newborn babies. The correlation between the
perinatal health and socioeconomic conditions of households confirms that health

care of pregnant women and their newborns also depends on socioeconomic
determinants.
A Perspective to Improve Perinatal Health
After studying the situation of perinatal health in Rabat and the socio-economic
conditions of households that impact perinatal health, it might be useful to identify a
set of social determinants of perinatal health within the framework of health policy,
to improve health results of mothers and their newborns. These policies can be
applied at both regional and national levels.
A rigid and carefully planned model of governance is urgently needed. This will
assist in reducing social inequalities of perinatal health by identifying clear policies
on perinatal health and monitoring of maternal health during pregnancy.
It is also important to strengthen democratic and participatory process and then
implement the strategies on different social determinants of health. The needs of the
population in general should be based on an understanding of the regional charac-
teristics of households. Particular attention should be given to marginalized seg-
ments of society (Direction de la Maternité Souissi de Rabat 2013; Haut-
Commissariat au Plan 2008a, 2010a).
These policies should target a greater understanding of social inequalities in
perinatal health conditions. Public health policies in the Arab region should include:
– Greater understanding of social determinants of health when considering

improvements in perinatal health outcomes
– Implementing a multidisciplinary health-care team that includes social workers
(Haut-Commissariat au Plan 2008b, 2010b)
– Targeting those factors known to predict poor perinatal health, such as the level of
education, housing conditions, and access to health care
Conclusion
Health determinants include socioeconomic factors that influence health quality.

Several studies confirm the importance of socioeconomic factors in determining
perinatal health outcomes. Several organizations (such as the World Health Organi-
zation, the World Bank, the National Institute of Health of the USA, the French
Medical Research, the Scientific Institute of Public Health of Belgium, and the
Organization for Economic Cooperation and Development) confirm a relationship
between the socioeconomic condition of pregnant mothers and perinatal health.
Important factors to be considered include levels of education of parturients, places
of residence, places of provenance, working conditions, and household income. The
health care as the heart of social development can be argued forcefully. this is also
true for maternal socioeconomic factors influencing perinatal results.
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An Overview of Women’s Health in the
Arab World 4
Al Johara M. AlQuaiz and Ambreen Kazi
Contents
Women’s Health Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Lifestyle-Related Diseases in Arab Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Prevalence of Chronic Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Lack of Physical Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Overweight and Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Sitting Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Low Vitamin D and Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Sexual Education and Health of Arab Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Menopause and Arab Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
Psychosocial and Mental Health Issues of Arab Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
Violence Against Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Anxiety, Depression, and Self-Esteem of Arab Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Breast Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Ovarian and Cervical Cancers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
Other Cancers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
Conclusion and Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Abstract
The Arab world comprises of 22 countries with a population of more than 350
million people. Nearly half of the population are women, most of whom are
young and middle-aged. Women’s health has made some remarkable progress in
A. J. M. AlQuaiz (*) · A. Kazi

Princess Nora Bent Abdullah Chair for Women’s Health Research, College of Medicine, King Saud
Department of Family and Community Medicine, College of Medicine, King Saud University,
e-mail: jalquaiz@yahoo.com; akamran@ksu.edu.sa

https://doi.org/10.1007/978-3-030-36811-1_2
70 A. J. M. AlQuaiz and A. Kazi
the context of the rights of women in accessing the health-care system and in the
control of maternal diseases. However, the Arab world is experiencing a signif-
icant increase in hypertension, diabetes mellitus, cardiovascular diseases, and
cancers. The major contributor is an unhealthy lifestyle due to low physical
activity, unhealthy diets, smoking, and prolonged sitting times. Information on
sexual health is not openly available and women, especially adolescents, lack
knowledge of sexual health and related problems. There is lack of information on
exposure to environmental hazards and their associations with newly emerging
health issues such as various types of cancers and immune-related diseases.
Hence, the majority of common health problems in women can be discussed
under the following broad headings: lifestyle diseases, reproductive health/hor-
monal problems, psychosocial and behavioral problems, and common cancers in
women. Future policies targeting women’s health should focus on the determi-
nants of health related to the environmental and social factors prevailing in the
Arab world.
Keywords
Women · Health · Arab world, · Lifestyle · Sexual health · Menopause · Vitamin
D deficiency · Violence · Self-esteem
Women’s Health Definition
Women’s health is devoted to facilitating the preservation of women’s wellness and

prevention of diseases in women. This includes screening, diagnosis, and manage-
ment of conditions which are unique to women; are more common and serious in
women; or have manifestations, risk factors, or interventions that are different in
women. Women’s health also recognizes the importance of the study of gender
differences and includes the diversity of women’s health needs over the life cycle
(Donohue and the National Academy on Women’s Health Medical Education 1996).
Women’s health concerns begin at birth and early childhood, and as they grow
older, their health needs change. General health depends on proper nutrition, phys-
ical activity, and immunizations. During their reproductive ages, education is needed
on contraceptive use, prenatal care, postnatal services, and breastfeeding education.
As they reach menopause, management of cardiovascular and other chronic diseases
becomes vital, as does screening for and knowledge about breast cancer, ovarian
cancer, diabetes, and a variety of other conditions. Mental health service throughout
a woman’s lifespan is greatly needed for her overall health as well.
The Middle-East and North African (MENA) region comprise of 22 Arab coun-
tries. According to a 2012 World Health Organization (WHO) report, these countries
have a total population of 358 million, around half of which are women. The Arab
countries have different economical classes; however, they are similar in terms of
religion, culture and language, and share common factors affecting women’s health.
4 An Overview of Women’s Health in the Arab World 71
Women’s health in the Arab world no longer revolves around traditional issues
that are limited to maternal mortality and reproductive health concerns. As else-
where, the majority of Arab countries have achieved a significant reduction in
maternal and infant mortality; however, there is a significant rise in chronic diseases
and associated risk factors (United Nations Development Program 2016). In agree-
ment with a WHO report, the top ten issues of women’s health can be grouped into
four categories based on the determining factors: lifestyle diseases; reproduc-
tive health/hormonal problems; psychosocial and behavioral problems; and com-
mon cancers in women.
Lifestyle-Related Diseases in Arab Women
Prevalence of Chronic Diseases
The majority of the chronic diseases such as hypertension, obesity, diabetes, and
cardiovascular diseases are closely associated with lifestyle choices. International
and regional studies report an increased rate of all cardiovascular diseases in Africa
and the Middle East in comparison to other regions of the world (Almahmeed et al.
2012; World Health Organization 2011). A systematic review on hypertension in the
Arab countries by Tailakh et al. found the overall prevalence was not only higher in
comparison to the USA, but was more prevalent among women (Tailakh et al. 2014).
However, a recently conducted national survey from Jordan reports that the age-
standardized prevalence for cardiovascular diseases was 33.8% in men and 29.4% in
women (Khader et al. 2019). Similarly, a large-scale study from Saudi Arabia found
that men are at greater risk for cardiovascular diseases than premenopausal women,
but that the risk is almost similar for both genders once the females become
postmenopausal (AlQuaiz et al. 2019). The results are in consensus with many
findings that concluded the onset of menopause marks a decline in the cardiovascular
protective effects due to declining levels of estrogen (World Health Organization
2011).
The Arab population has a high prevalence of diabetes mellitus, smoking,
hyperlipidemia, physical inactivity, overweight, and obesity (AlQuaiz et al.
2014a; AlHabib et al. 2009). Despite the similarity in the prevalence for cardio-
vascular diseases, gender differences occur in the individual risk factors; for
example, smoking is more frequent in men, diabetes mellitus and high-density
lipoprotein levels are lower in men compared with women, and hypertension is
reported to be greater in women aged 65 years or more (AlQuaiz et al. 2015). The
prevalence of diabetes mellitus is currently near 30% and is predicted to increase to
96% by 2035 (Abuyassin and Laher 2016; Boutayeb et al. 2012), almost half of
whom will be women. Several factors such as unhealthy lifestyles comprising of
low physical activity, unhealthy eating habits, and rapid urbanization are associ-
ated with the rapid increase in the prevalence of chronic diseases (AlQuaiz
et al. 2015).
Lack of Physical Activity
The Arab countries have higher rates of physical inactivity than most all other world
regions (AlQuaiz et al. 2015; Mabry et al. 2016). About 50% of women and more
than a third of men are inactive. The WHO defines physical activity (PA) as “any
bodily movement produced by skeletal muscles that requires energy expenditure”
and recommends that “Adults aged 18–64 should do at least 150 minutes of
moderate-intensity aerobic physical activity throughout the week or do at least 75
minutes of vigorous-intensity aerobic physical activity throughout the week or an
equivalent combination of moderate- and vigorous-intensity activity” (World Health
Organization 2010). Several studies report that women, especially in Arab countries,
lead sedentary lives with minimal physical activity and consumption of unhealthy
diets (World Health Organization 2010; Al-Hazzaa 2007; Al-Nozha et al. 2007).
More than 80% of the Arab women have sedentary lifestyles. The WHO defines
sedentary behavior as “any waking activity characterized by an energy expenditure
1.5 metabolic equivalents while in a sitting, reclining or lying posture” (Al-Nozha
et al. 2007).
In the pre-oil discovery era, majority of the Arab women used to be busy with
household errands, including indoor and limited outdoor activities including farm-
ing. However, this is no longer the case, as the economic boom has replaced simple
living with more convenient and luxurious lifestyles, both within and outside the
home (Al-Zalabani et al. 2015). In addition, sociocultural norms, safety and security,
and unfavorable weather conditions (very high temperatures and dry conditions)
make regular exercise challenging in this region (AlQuaiz and Tayel 2009a; Amin et
al. 2012). There are several benefits associated with physical activity including
improved regulation of blood pressure, blood sugar, cholesterol, clotting factors,
weight, etc. Physical activity protects against heart disease, diabetes, cancer, osteo-
porosis, and depression with the most profound effect being on cardiovascular
diseases (Li and Siegrist 2012; Al-Otaibi 2013; Al Alhareth et al. 2015).
Performing regular exercise can often be challenging for Arab women. Apart
from lack of resources, there are several other barriers to physical activity, including
lack of self-motivation, unwillingness and low social support (AlQuaiz and Tayel
2009a), excessive television viewing, absence of physical education programs, and
attitudes toward exercise (Amin et al. 2012). An important factor is that the health
benefits associated with household activities are generally underappreciated and
unnoticed. Important forums and papers, while discussing treatment of chronic
diseases through physical activity, do not consider the important role of regular
household activities (Bull and Dvorak 2013). The role of household activities in
optimizing the health should be highlighted, as women unable to follow an outdoor
exercise program due to a variety of barriers should nonetheless engage in household
work to keep them healthy and physically active (Amin et al. 2012). However, this is
an opportunity that will largely be missed due to the widespread availability of cheap
migrant labor.
Overweight and Obesity
The main factor contributing to overweight and obesity in the Gulf Countries in
general is the industrial and economic revolution introduced by the discovery of oil.
Consequently, urbanization and adoption of Western diets and lifestyles have con-
tributed to the obesity epidemic in both genders, which is accompanied by a reduced
rate of communicable disease but with increases in noncommunicable diseases.
A common feature in overweight and obese individuals of all ages in all Arab
countries is their unhealthy lifestyles.
The regional data for people aged 15 years and above indicates that the highest
levels of overweight are in Bahrain, Kuwait, United Arab Emirates, and Saudi
Arabia, where the prevalence of overweight/obesity is reported to be over 70%,
particularly among women (World Health Organization 2017). Obesity is a global
health concern due to its associated risk in causing chronic diseases such as type 2
diabetes mellitus, ischemic heart diseases, and some type of cancers (such as
postmenopausal breast cancer, colon and rectum, esophageal, kidney, and pancreas)
in addition to its effects on the quality of life (World Health Organization 2017;
Kanter and Caballero 2012). A systematic meta-analysis of the global, regional, and
national prevalence of overweight and obesity reported in 2013 that while men have
higher rates of overweight and obesity in developed countries, women have higher
rates in developing countries such as in Middle East and North Africa, where this
relationship persists over time (Kanter and Caballero 2012; Ng et al. 2014). The
general pattern of gender disparity regarding obesity affects almost all countries
around the world including the countries of the Gulf Cooperation Council (GCC),
where Qatar and Kuwait are among the top 10 countries worldwide for the preva-
lence of overweight and obesity (World Health Organization 2017; AlNohair 2014).
Based on WHO statistics, Qatar stands at the top of the list for the prevalence of
overweight and obesity (>70%) among the GCC countries followed by Kuwait,
United Arab Emirates, Saudi Arabia, Bahrain, and Oman (World Health Organiza-
tion 2017). Data from the late 1980s through mid-1990s show a prevalence of
obesity averaging about 20%, ranging from as low as 13.1% in men to as high as
26.6% in women. However, all prevalence estimates from 1995 and beyond are
above 35% (Memish et al. 2014). In 2014, a survey of Saudi women aged
30–70 years reported that the prevalence of overweight was 33.5% and obesity
60% (AlQuaiz et al. 2015).
Gender disparity on the prevalence of obesity has always existed. A study by
Memish et al. in 2014 explored the factors associated with obesity among 10,735
adult Saudis, and indicated that obesity among men was associated with marital
status, diet, physical activity, diagnoses of diabetes and hypercholesterolemia, and
hypertension, while, in women, it was associated with marital status, education,
history of chronic conditions, and hypertension (Memish et al. 2014). Besides these
factors, food preferences also lead to obesity. Excessive intake of energy-dense
foods (heavily loaded with sugar), increased portion sizes, and sedentary lifestyles
contribute to obesity (Kanter and Caballero 2012). In developed countries, it is

evident that sociocultural factors related to dietary habits have a greater influence
on gender disparities in overweight and obesity, while in Arab countries, changes in
physical activity patterns and nutrition shift with the consumption of energy-dense
food are the leading factors; importantly, women in these countries are more
vulnerable to such effects (Kanter and Caballero 2012; Ng et al. 2014; AlNohair
2014).
A meta-analysis by Hallam et al. investigated gender disparity related to the
prevalence of obesity from another perspective: food craving. They documented the
existence of gender differences in food craving which may underlie documented
gender differences in obesity and obesity-related health outcomes (Hallam et al.
2016). Gender differences were reported in the kinds of food craved (where men
tended to crave savory food such as meat and fish, while women tended to crave
sweets such as chocolate and ice-cream), the intensity and frequency of craving
(women tend to exhibit cue craving, “induced by environments as advertisement”
more than men), and the ability to regulate craving (where generally women find it
harder to control) (Hallam et al. 2016).
Sitting Time
Sedentary lifestyles or sitting times are independently associated with deleterious

health consequences regardless of other anthropometric parameters and physical activ-
ity (Hallam et al. 2016). A study of sitting epidemiology involving data from 20
countries revealed that Portugal, Brazil, and Colombia are among the countries with
the lowest sitting times in adults (with a median 180 min/day), while Taiwan, Japan,
Norway, Saudi Arabia, and Hong Kong report the highest in sitting time among adults
(with a median of 360 min/day) (Owen 2012). Moreover, individuals who report low
levels of physical activity are likely to also report high sitting times. A study by Al
Hazza et al. on the prevalence of physical activity and sedentary behaviors in Saudi
adolescents found that females were more sedentary (91.2% vs. 84%) and less phys-
ically active than the males, and that 75% of females and 50% of males do not meet the
daily physical activity guidelines (Al-Hazzaa 2018). The major reason for prolonged
sitting times is similar to those for low physical activity, with most spending large
periods watching television/computer screens (Al-Hazzaa 2018).
Low Vitamin D and Osteoporosis
In addition to chronic diseases and associated risk factors, the majority of the Arab
population suffers from low vitamin D levels. While individuals in almost all regions
of the world suffer from vitamin D deficiency (25-hydroxy vitamin D (25(OH)D)
<75 nmol/L), extreme deficiency (<25 nmol/L) was highly prevalent in regions of
South Asia and the Middle East (Mithal et al. 2009). A recent study from the United
Arab Emirates (UAE) found that 82.5% of patients had vitamin D deficiency/
insufficiency (25–<75 nmol/L), with 26.4% of females and 18.4% of males

exhibiting severe deficiency (<25 nmol/L) (Haq et al. 2016). Several studies from
Saudi Arabia suggest that the prevalence of vitamin D deficiency ranges from 40% to
more than 80% in the Saudi adult population (Kanan et al. 2013; Hussain et al. 2014;
Ardawi et al. 2011).
A major consequence of having low levels of vitamin D is low bone density,
which leads to osteopenia or osteoporosis. The American National Health and
Nutrition Survey (2005–2008) found that 50% of women aged 50 years and above
suffer from low bone mass density (Looker et al. 2012). In the Arab world, the
prevalence of lumbar and femur osteopenia ranges from 7% to 43% and for
osteoporosis it ranges somewhere from 2.5% to 47% (Ardawi et al. 2005; Maalouf
et al. 2007). The recent recommendation for screening women for low bone mass
density in the Arab countries is around 65 years (Maalouf et al. 2007); however, it is
highly recommended to reduce this to 60 years to prevent serious complications such
as fractures and falls. Hence it is important to educate the women on the complica-
tions related to vitamin D deficiency.
The high prevalence of low bone mass density can be attributed to factors such as
sedentary life styles, sun-exposure, obesity, unhealthy diets, and lack of dietary
supplements and vitamin D deficiency; however, the results are complicated by the
methodological differences between the studies (Kanan et al. 2013; Hussain et al.
2014; Ardawi et al. 2005, 2011; Looker et al. 2012). The Arab countries report
contradictory results for the association between seasons during the year and serum
vitamin D levels (Al-Daghri et al. 2012). In addition, there are other factors such as
nutritional status, clothing preferences, and geographical location that can affect sun
exposure during any particular season. Low levels of serum vitamin D during the
summer months can be explained by the avoidance to sun exposure due to intense
sunrays and hot temperatures in Arab countries (Mithal et al. 2009). Sun exposure is
the best source of vitamin D; however, the majority of the Arab population tends to
avoid sun exposure. There are recommendations for the best times for exposure
to the sunlight: in summer it is 8.00 am–4:00 pm and in winter between 10.00 am to
2:00 pm (Alshahrani et al. 2013). We recommend that the Arab population should
follow the above timings for sun exposure to derive maximum benefits.
Recent findings associate vitamin D deficiency with unhealthy lifestyles, includ-
ing consumption of fast foods and carbonated drinks (Olson et al. 2012; Karonova
et al. 2018). The fructose, caffeine, and phosphoric acid in cola drinks may be
responsible for decreasing the absorption of 25(OH) vitamin D from dietary sources
(Olson et al. 2012; Karonova et al. 2018). Secondly, intake of unhealthy foods, such
as sugar-sweetened cola and other drinks, increases calories consumed and thus
results in weight gain (Abbas 2017). A study by Ardawi et al. reported that serum 25
(OH) vitamin D was significantly lower in individuals in the upper quintiles of body
mass index (BMI) and waist-to-hip ratio (WHR) (Ardawi et al. 2011). The associ-
ation can be explained on the sequestering effect of a high quantity of subcutaneous
fat, which reduces circulating 25 (OH) vitamin D levels (Abbas 2017).
The Arab culture encourages the consumption of several healthy foods, including
“laban” (fermented yogurt). Bone health is strongly associated with diets rich in
calcium and vitamin D such as milk, cheese, and yogurt. Several therapeutic benefits
have been associated with fermented milk including reduction or decrease in bone
deterioration, geriatric osteoporosis, skin ulcers, gastrointestinal symptoms, and
aging (Caroli et al. 2011). A community-based study from Saudi Arabia found an
association between consumption of laban and bone mineral density (AlQuaiz et al.
2014b). Regular intake of laban is recommended as a preventive strategy against low
bone mass density. Another preventive strategy is the regular intake of vitamin D
supplements. The Ministries of Health in most Arab countries have made the
prescription of vitamin D supplements mandatory, especially for females aged
40 years and above. However, a recent study by AlQuaiz et al. found that only
27% (547 out of 2029) of females consume vitamin D supplements (AlQuaiz et al.
2018). The public at large, and women in particular, need to be educated on the
importance of sun-exposure and healthy lifestyles, and the potential complications
arising from vitamin D deficiency and the importance of vitamin D supplements.
Encouraging the consumption of healthy foods along with food fortification is
one of the strategies to improve vitamin D levels in humans. However, in the
majority of cases, there is inadequate fortification of food items and so does not
help to fulfill daily requirements. A study by Sedat and colleagues found inadequate
fortification of milk with 25(OH) vitamin D in Saudi Arabia, which may be the
reason for persistent vitamin D deficiency (a liter of milk contains 40 IU of vitamin
D3, which is around only15% of the daily requirement) (Sadat-Ali et al. 2013). We
recommend a comprehensive policy for the Arab world related to the screening,
prevention, and treatment of vitamin D deficiency.
Sexual Education and Health of Arab Women
Sexual health and associated topics are not openly discussed in the Arab world.
Topics covered under sexual health encompass information related to sexuality,
reproductive and sexual health-care problems, the related services available, auton-
omy over choice of partner, and decisions regarding family planning (World Health
Organization 2006). Incorrect and inappropriate information on sexual health could
lead to various types of health risks and complications, especially in young women
(Neal et al. 2012). Health risks may include acquiring sexually transmitted diseases
including HIV infection, unrequired procedures, early pregnancies, unsafe abortions,
adverse birth outcomes due to consanguineous marriages, maternal morbidity, and
mortality (Neal et al. 2012).
Cultural taboos hinder the discussions related to sexual health. The majority of
females in the Middle East region are at greater risk of misinformation as they have
less access to reliable information sources outside their homes, and whatever
information they receive is mostly through their maids, friends, or the social media
(Roudi-Fahimi and El Feki 2011). The school/college curriculums in Arab countries
do not contain any formal education on such topics, and there are no separate
grooming schools for women. Saudi Arabia informally introduced sexual health
topics in school curricula some time ago. A study was conducted to assess sexual
health knowledge, attitudes, and resources by adolescent girls from public and
private schools in Riyadh, Saudi Arabia. This study identified that 42% of students
discussed sexual topics with their friends, 16% with their parents, and 17% with their
household servants (Al-Quaiz et al. 2012). Mostly similar findings were reported in
the rest of the countries in the Middle East region (Population Council 2010). This
suggests the long-standing lack of basic information on women’s sexual health
(AlQuaiz et al. 2013a), despite of the fact the Quranic teachings support the correct
dissemination of knowledge related to sexual health.
Results from the abovementioned study highlight the importance of parental
education in improving their children’s knowledge on sensitive topics such as sexual
health (AlQuaiz et al. 2013a). The study reports that in situations where both parents
are uneducated, there is almost a ten times higher risk of poor sexual health
knowledge. Educated parents (especially mothers) tend to follow a constructive
communicating style which helps in developing trustworthy relationships with
their adolescent children (AlQuaiz et al. 2013a). If mothers perform their roles
positively, children consider them not only as guardians but also as role models
and a guide, teacher, and friend.
Various studies from the Arab world suggest that adolescent girls have
unhygienic practices during their menstrual cycles. Hence, it may be assumed that
their mothers, sisters, or friends must be uneducated or unaware of the adverse health
consequences associated with such unhygienic practices. This increases the need for
interventions targeted towards building the sexual health knowledge of women
based on education, training, and involving the parents from the beginning. Several
health education programs are currently in place in the Middle Eastern countries
(Roudi-Fahimi and El Feki 2011); these programs should work closely with parents
as no change is possible until parents and families are engaged.
Studies from Egypt, Morocco, and Turkey have identified friends as the most
important source for adolescents in building their knowledge on sexual health
(Roudi-Fahimi and El Feki 2011). No matter how close these friendships may be,
they remain unreliable sources of information because many friends may only have
partial knowledge. Therefore, it is important for mothers to know who their chil-
dren’s friends are, as peer influence is identified as a risk factor for negative health
behaviors. Surveys of school children in Lebanon identified the role of schools and
community to be even stronger influencers than the parent’s role (Global School-
Based Health Survey 2005). Studies from Morocco and Egypt suggest that female
students not attending schools are at higher risk of early marriage and pregnancy (as
early as 15 years), suggesting that apart from the school curriculum and the teacher’s
role, the act of attending school can by itself help in improving the health of
adolescent girls.
House maids can be important sources of health education in Arab culture.
House-keepers/maids are from diverse backgrounds and majority of them are
uneducated, making receiving health-related information from such sources some-
what unreliable. The internet and public media sources are convenient ways of
accessing information on any topic; however, they often may not offer culturally
appropriate information with a respect to religious traditions and can at times prove
to be harmful rather than beneficial for young adolescents. Morocco, Lebanon, and
Egypt and some other Arab countries have taken initiatives in launching educational
websites providing free, safe, and correct information on sexual knowledge. It
should be the responsibility of Health and Education Ministries to launch and
monitor websites providing correct information on this topic. It will prevent mis-
information and will also help in disseminating information to parents and other
adult family members as well. The age for puberty for girls is decreasing worldwide
(Okasha et al. 2001), that is negatively associated with weight and body mass index
but not height (Okasha et al. 2001). Hence in Arab countries, delivery of specific,
culturally oriented, and relevant sexual knowledge at a family and school level
should be initiated from a younger age. We recommend that Government agencies,
with the help of all stake holders [adolescents, parents, health-care providers, and
educators], should develop policies and programs for implementing and evaluating
integrated and comprehensive sexual educational programs throughout educational
institutes in all Arab countries. Committees at the school level comprising of parents,
health-care providers, and teachers should design a culturally acceptable curriculum
and adopt practical ways of disseminating it. Similarly, religious leaders through
special classes for girls and boys and in the presence of parents can discuss core
sensitive topics and correct misconceptions held by the adolescents, and also help in
clarifying any myths associated with sexual health in the light of religious teachings.
Such steps will help not only in reducing the health risks associated with mis-
information but will help in building a healthy nation.
Menopause and Arab Women
The aging female population, in addition to being vulnerable to chronic diseases,

also suffers from mental and social health problems. An important factor for this is
the hormonal changes associated with peri- and postmenopausal periods. Meno-
pause is a natural physiologic event of midlife women and is defined by 12 months
of amenorrhea after the final menstrual period due to aging of the ovaries, leading to
a decline in ovarian estrogen and progesterone secretion (World Health Organization
1996). Menopause is associated with various somatic, vasomotor, sexual, and
psychological symptoms that often impairs the overall quality of life (QoL) of
women and disturbs their lives and health (World Health Organization 1996). Arab
women experience physical, vasomotor, and sexual symptoms frequently, but less so
the psychological symptoms in comparison to rest of the world, possibly due to
support from the close family and other elderly women (World Health Organization
1996; Rigg 2012).
The average age of menopause reported from the Arab world is ~49–51 years
(AlQuaiz et al. 2017a). The increase in life expectancy of Arab women (76.16 years)
indicates that women are spending two to three decades potentially experiencing
menopausal symptoms (Jassim and Al-Shaboul 2008). Regional studies from Qatar,
Egypt, Bahrain, Turkey, and Saudi Arabia suggest that a high proportion (80–90%)
of postmenopausal females report physical symptoms (World Health Organization
1996; Rigg 2012; AlQuaiz et al. 2013b, c, 2017a; Jassim and Al-Shaboul 2008;
Shakhatreh and Mas’ad 2006; Loutfy et al. 2006; AlDughaither et al. 2015; Karaçam
and Seker 2007; Gerber et al. 2014). The most common symptoms reported were
physical symptoms (57%), followed by vasomotor (41%), psychosocial (14%), and
sexual symptoms 13% (AlQuaiz et al. 2017a). It is likely that the cultural taboo
associated with the word “sexual” in Arab countries may lead to underreporting of
sexual symptoms (Elavsky 2010).
The reporting of physical symptoms is similar to that reported in the USA, where
there is also a high prevalence of joint aches and stiffness during the menopausal
transition (Avis et al. 2009). Apart from aging, there is a direct linear relationship
between menopausal symptoms, unhealthy lifestyles, and obesity in Arab women
(AlDughaither et al. 2015). The results of a hospital-based study indicated that
housewives, women of low socioeconomic status, and women who were obese
and physically inactive are likely to experience more severe menopausal symptoms
(AlQuaiz et al. 2013b, c).
The reported prevalence rates for vasomotor symptoms of menopause vary
widely in the literature, with the lowest prevalence noted in Asian women and the
highest in Western women, especially African Americans (Gold et al. 2006;
Thurston and Joffe 2011). The most frequent explanation for the occurrence of
vasomotor symptoms is reduced estrogen and higher follicle stimulating hormone
levels. However, because not all women experience vasomotor symptoms, addi-
tional explanations based on an imbalance (narrowing) of the thermoneutral zone or
the role of genetic predisposition may also have important roles (Bauld and Brown
2009). In addition, vasomotor symptoms during menopause have been associated
with disrupted sleep and may occur due to changes in the thermoregulatory system
and mood disorders (Cohen et al. 2006). The prevalence of obesity can increase as a
result of changes in body fat composition and changes in dietary habits during
menopause. That may be one explanation for hot flushes being reported twice as
frequently by overweight women as compared to normal weight women (Bauld and
Brown 2009; Cohen et al. 2006).
The prevalence of depressive symptoms in postmenopausal women from the
Arab world varies widely, ranging from 5% to 53%. Elderly women in the Arab
culture usually have strong religious beliefs, allowing them to be positive and
confident, in addition to the support from their extended families (Bauld and
Brown 2009). Regional studies report a high prevalence (87%) for depressive
symptoms in elderly females in the Arab world (AlQuaiz et al. 2013b, c, 2017a;
Jassim and Al-Shaboul 2008; Shakhatreh and Mas’ad 2006; Loutfy et al. 2006;
AlDughaither et al. 2015; Karaçam and Seker 2007). Diagnosis of depression can
be 2.5 times more likely to occur in women in the menopausal transition
compared to premenopausal women (Roudi-Fahimi and El Feki 2011), a finding
similar to that reported by the Harvard Study of Moods and Cycles (Cohen et al.
2006).
Female sexual dysfunction after menopause is a complex problem with many
etiologies. Nearly 11–55% of women report some form of sexual dysfunction
(AlQuaiz et al. 2017a). The variation in the prevalence of sexual symptoms could
be due to the frequency and severity of symptoms (which change during different
stages of menopause) or could be related to lifestyle, genetic, and ethnic differences.
In comparison to the Arab world, studies from the West report that the prevalence of
any type of sexual dysfunction ranges from 42% to 88% during the various stages of
menopausal transition (Avis et al. 2009; Gold et al. 2006). One study reported that
98% of perimenopausal women presenting for annual gynecologic examinations
reported one or more sexual concerns. More than 50% of these women wanted to
discuss their sexual concerns; however, in 19% of these cases, it was the physician
who initiated the topic (Nappi and Lachowsky 2009).
Menopause in Middle Eastern women is recognized as a phase in life in which
they have mostly accomplished their goals (Al Alhareth et al. 2015). The general
impression in Middle Eastern countries is of a close-knit family system, with
constant support from relatives and families. The formal and informal support
from the husband, children, siblings, etc., is very important at this time of life, as
shown by the increase in the severity of symptoms by elderly women who lack social
support (AlQuaiz et al. 2013b, c). Social support has been identified as a “mediator”
between menopausal symptoms and depression (AlQuaiz et al. 2017a). Women with
social support have more positive attitudes toward menopause and experience less
severe stress, psychological distress, menopausal symptoms, and better physical
health (AlQuaiz et al. 2017a). A qualitative study from Jordan on the perceptions
of women regarding menopause highlighted the importance of social groups in
reducing the impact of menopausal symptoms (Shakhatreh and Mas’ad 2006).
Understanding by relatives, especially from spouses, of the effect of menopausal
symptoms on women’s lives could help in improving their symptoms. Based on
religion and cultural aspects, social support from friends, family members, and
spouses should be encouraged in Arab communities, which are in some cases,
considered very conservative Muslim communities.
Arab women, as elsewhere, are burdened with household responsibilities. The Al
Quaiz study reported that women in the perimenopausal age group may suffer from
retired husband syndrome, in which women begin to show signs of physical illness
and depression as their husbands retire, a widely recognized condition in Japan and
other societies with traditional gender roles (Bertoni and Brunello 2014). All symp-
toms of retired husband syndrome are stress-related, and the retirement effects are
stronger for employed women, who may already be stressed in their workplace
(Bertoni and Brunello 2014). Counselling programs for women and their immediate
family members may improve their emotional and social support and hence help in
controlling/preventing the menopausal symptoms.
Psychosocial and Mental Health Issues of Arab Women
The major psychosocial issues of Arab women include violence, suppression,

anxiety, depression, and stress (Aldosari 2017). Several factors including individual,
societal, and regional are associated with the high prevalence of anxiety and depres-
sion (Aldosari 2017).
Violence Against Women
In almost all Muslim countries, the term intimate partner violence is equivalent to
violence against women by the husband, father, son, or brother. Exploring violence
against women was a taboo in Arab countries until the 1990s. The actual extent of
violence against women is not known; hence, population-based surveys may provide
the most accurate estimate of prevalence of domestic violence in Arab countries. A
recent analysis by the WHO reported that 30% of women from 80 different countries
suffer from intimate partner violence (physical and/or sexual) (World Health Orga-
nization 2016). Studies from the Middle East and North Africa region (MENA)
report that the prevalence of ever experiencing violence ranges from 23% in Syria
and to as high as 65% in Turkey (Boy and Kulczycki 2008). Similar to the
worldwide prevalence, reports from MENA countries also indicate that at least one
out of three women is a victim of intimate partner violence in Egypt, Palestine, and
Tunisia (Douki et al. 2003). The first study reporting domestic violence in Saudi
Arabia was in 2004 and reported that 58% of women reported lifetime prevalence of
abuse (Tashkandi and Rasheed 2009). Other large-scale studies from Saudi Arabia
report the prevalence for lifetime domestic violence as ranging from 20% (AlQuaiz
et al. 2017b) to 43% (Barnawi 2015).
The theoretical framework explaining domestic violence identifies both social
conditions and social relations as being associated with violence (World Health
Organization 2016). The common factors associated with violence against married
women include age, husband being a smoker/alcoholic, low levels of education,
types of occupation, financial dependency, health, temperament and childhood
history of observing abuse (specially pertaining to those who saw their mothers as
victims of domestic violence (Somach and AbouZeid 2009; Yüksel-Kaptanoğlu
et al. 2012; Fageeh 2014).
The majority of the Arab countries still do not openly report violence against
women, and they acknowledge this as a weakness in the system and society.
However, younger aged women being more vocal are open to discuss violence
against women. Studies from the Arab region provide contradictory results on the
prevalence of intimate partner violence, which could be due to methodological
differences in the studies. Amongst the different types of violence, controlling
behavior (37%) is the most common, followed by emotional violence (22%), sexual
violence (13%), and physical violence (9%) (AlQuaiz et al. 2017b). It may be that by
controlling behavior, the male partner is able to bestow his authoritative nature
without leaving any traces of physical marks of violence; this helps him satisfy his
ego and giving the impression that all is well. In Islam, it is forbidden to beat any
women, hence Arab men claim to follow of teachings of Islam but at the same time
allow their commanding nature take control of their emotions (Somach and
AbouZeid 2009; Almosaed 2004). This greatly impacts the mental and psycholog-
ical well-being of Arab women. The high reporting of controlling behavior suggests
a great variation in the degree to which such severe controlling behaviors are
acceptable normative behaviors in patriarchal cultures. Violation of women’s basic
human rights, such as prohibiting seeking health care or meeting one’s family
members, is a serious act against the teachings of Islam (Kposowa and Aly Ezzat
2019).
In comparison to controlling behavior, studies by Tashkandi & Rasheed and
AlQuaiz et al. found that physical violence was reported by 9–50% of women
(Tashkandi and Rasheed 2009; AlQuaiz et al. 2017b). Domestic violence is consid-
ered a private matter in Arab societies, and women tend to underreport any injury
resulting from it (Kposowa and Aly Ezzat 2019; Al-Badayneh 2012). The frequency
of violent acts may be low but the severity is high; hence, it is important to report
even a single act of violence, as this will help in avoiding similar acts in the future. In
addition, a “threatening attitude” becomes a normal way for men to get their
demands fulfilled, and they get accustomed to it (Almosaed 2004). Both proper
awareness and education are required to help in understanding the long-term health
risks associated with “threatening attitudes” when seeking short-term gains (World
Health Organization 2016).
Several studies associate poor health with violence (Abramsky et al. 2011; Dillon
et al. 2013; VanderEnde et al. 2012). In a study by the WHO, women reporting
physical and/or sexual partner violence were more likely to report poor health than
women who had never experienced partner violence (Abramsky et al. 2011), a
similar finding also being reported for an association between violence and lack of
social support (AlQuaiz et al. 2017b). A recent report by the United Nations
Organization found that the majority of women suffering from domestic violence
tended to seek help from their families and friends (United Nations Organization
2015). This may be because the support and understanding from families/friends is
available all the time irrespective of any formalities and disclosures. We recommend
that formal social support services for women should be made available in the Arab
world. In the context of threatening behavior by husbands, we recommend that
health-care providers inquire about the physical, mental, and sexual health of the
couple as this maybe the underlying cause for frustration and violence (Somach and
AbouZeid 2009). Other factors associated with violence are polygamy or extramar-
ital relationships. Again, it is difficult for the women to disclose and talk about these
issues in public. The wife of a husband having 2 wives reported more physical
(13% vs. 8%) and controlling behaviors (AlQuaiz et al. 2017b). The fact that
polygamy is associated with intimate partner violence is of concern, because this
practice is frequent in Islamic societies; however, the prerequisites and conditions of
polygamy as required by Islam may not be fulfilled by the husband. Hence, it is
important to explore this association in depth before reaching any conclusion.
Young women in regional and global studies have higher rates of victimization
compared to older women (Kposowa and Aly Ezzat 2019; Abramsky et al. 2011).
This pattern may indicate that violence is more likely to begin early in many
relationships and marriages. In addition, with increasing knowledge and access to
information and services, younger women are likely more aware that intimate
partner violence is unacceptable and therefore are more likely to report it (Abramsky
et al. 2011). We recommend that women in Arab countries should organize a
national strategy on domestic violence and an action plan for prevention and
intervention. The example set by Saudi Arabia can be followed, where newly
approved national legislation is being enacted; the Law on Protection from Abuse
(August 2013) criminalizes domestic abuse. However, the law does not provide any
details on enforcement mechanisms.
Anxiety, Depression, and Self-Esteem of Arab Women
Depression is the leading cause of disease-related disability in women, who are twice
more likely to suffer from depression and anxiety than men (Kessler 2003). Small-
and large-scale studies from the Arab world are available on depression and anxiety.
The prevalence rates of depression and anxiety in a recent Saudi national study (sex
unspecified) were 6% and 12%, respectively (Saudi Mental and Stress Survey 2019).
Depression correlated with poor education, unemployment, divorced or widowed
status, old age, meagre living conditions, low income, and female gender. Cases of
depression correlated positively with the severity of disease conditions and extent of
medication use, loss of a close relative, living alone, poor health, dependency, and
urinary incontinence (Al-Shammari and Al-Subaie 1999). Females tend to seek
treatment for depression from both the medical doctors as well as the faith healers.
Mental health concerns (stress, anxiety, and depression) are associated with low
self-esteem. Self- esteem is multidimensional as it affects psychological and psy-
chosocial processes, identity development, and intergroup relations (Allen and
Sherman 2011; Orth and Robbins 2013). The majority of Saudi women have high
self-esteem, and education levels are one of the factors associated with self-esteem
(Kazi et al. 2015). There are a number of other factors such as age, gender, level of
education, physical appearance, physical activity, past adverse experiences, and
personal accomplishments that are also associated with self-esteem (Hamaideh and
Hamdan-Mansour 2014; Armin 2012; AlKhatib 2012) Women with low self-esteem
give little value to themselves and their accomplishments, and hence are considered
as “weak”: they are more frequently prone to negative self-talk, have a regretful
attitude, need constant reassurance, and remain lonely (Mokdad et al. 2014).
It is a common belief that women in Arab countries have a passive role in
comparison to rest of the world (Al Alhareth et al. 2015). Men are the decision
makers and lives of women are centered on their husbands, in-laws, children, and
parents. Findings from the Arab world report high levels of depression and anxiety
(Mokdad et al. 2014; Abdel-Khalek et al. 2012) that are often associated with
changes in physical appearance. Obese individuals suffer from low self-esteem
compared with normal weight individuals; importantly, there is significant improve-
ment in self-esteem (from 16 to 25) and quality of life scores (from 63 to 76) 1 year
after surgical treatment for obesity (Aldaqal and Sehlo 2013). This study clearly
demonstrates the association between physical appearance and self-esteem. Another
study from Jeddah, Saudi Arabia, found that academic achievements, motivation,
mother’s education, depression, gender, and aptitude test are associated with depres-
sion (Al-Dabal et al. 2010). There is a significant association between physical
activity and health beliefs (self-efficacy and health locus of control) in Saudi
university students, underscoring the importance of physical activity in improving
the self-confidence of women (Al-Eisa and Al-Sobayel 2012). The majority of

females in Arab countries are physically inactive and obese due to the many social
and cultural barriers to physical activity (AlQuaiz and Tayel 2009b). Various rec-
ommendations have been made to overcome these barriers, but with little success
achieved.
Multiple direct and indirect pathways can explain the association between phys-
ical activity and mental health (Esteban-Cornejo et al. 2014). Physical activity
stimulates the process of brain plasticity, and two factors important in this process
are brain-derived neurotropic factor and catecholamines (dopamine and epinephrine)
which improve the cognition and leading to better mental health (improving self-
esteem) (Winter et al. 2007). Secondly, involvements in physical activity tend to shift
the focus from stressors to being a relaxer. Indirect pathways may include support
from family, neighborhood, and peers to prevent mental health problems such as
depression by providing support and encouragement to engage in physical activity
(Cheng et al. 2014). In addition, a longitudinal study reports that the effects of
physical activity, self-efficacy, and BMI on physical self-worth and global self-
esteem were mediated by changes in self-perceptions rather than physical conditions
(Sonstroem et al. 1994). This study included a wide range of mental health condi-
tions, including cognition, depression, anxiety, satisfaction with life, quality of life,
self-efficacy, and self-esteem.
The concept of multilevel and multidomain contributions to global self-esteem
has improved our understanding considerably. Among these domains, physical
activity has gained much attention by social scientists. A study by Sonstroem et al.
using an exercise and self-esteem model tries to explain how perceived physical
competence predicts more generalized self-competence (Sonstroem et al. 1994).
According to the exercise and self-esteem model, positive changes in physical
parameters (e.g., a decrease in weight) are associated with increases in self-efficacy,
which in turn leads to increases in self-esteem in various physical subdomains
(sports competence, physical conditions, strength, and appearance) and finally in
improving the global self-esteem. Changes in physical parameters (e.g., fitness)
mediate or moderate the impact of physical activity on self-esteem and physical
self-content (Daniali et al. 2013; Ibrahim et al. 2013). Improved looks are supposed
to be important for building self-confidence, especially if a person is rejected
because of physical appearance (Nestler and Egloff 2013). Improvement in self-
esteem is important for the development of the country, as women with high self-
esteem are more confident, perform better, have positive coping attitude, and become
more productive members of the society.
Cancer
Currently, the burden of cancer in the Arab countries is lower than in European
countries and the United States; however, it is predicted to almost double by the year
2030 (Salim et al. 2009). There was dearth of information on cancers from the Arab
world for many years, but this is no longer the case, as several countries have
initiated the national registry system, and several publications are available on the
prevalence, risk factors, treatment, and prevention of cancers (Hamadeh et al. 2017;
Saudi Health Council 2015; World Health Organization: Information Agency for
Research on Cancer 2018a). The oldest cancer registry systems were from Kuwait,
Oman, Algeria, Bahrain, Egypt, and Tunisia (Salim et al. 2009). However, other
Arab countries have now also established national registries and are publishing
regular data (Salim et al. 2009; Hamadeh et al. 2017; Saudi Health Council 2015;
World Health Organization: Information Agency for Research on Cancer 2018a, b;
Hashim et al. 2018; Donnelly et al. 2013; Fearon et al. 2019; Sancho-Garnier et al.
2013; Elmi et al. 2017; Nasser et al. 2017). The most common cancers in females
reported from the Arab world are breast, thyroid, ovarian, cervical/uterine cancers,
colorectal cancer, lymphomas and leukemia, and stomach and liver cancers (Salim et
al. 2009; Hamadeh et al. 2017). The Saudi national data (after stratification for
different age groups) suggests the following: leukemia, brain (CNS), and connective
tissue as the most frequent ones for ages 0–14 years; thyroid, Hodgkin’s disease, and
breast as the top three common cancers for ages 15–29 years; breast, thyroid, and
colorectal as the common three cancers for ages 30–44 years; breast, colorectal,
and thyroid as the common cancers for ages 45–59 years; and breast, colorectal, and
non-Hodgkin lymphoma as the common cancers among women aged 60 and 75 years
(Saudi Health Council 2015).
Breast Cancer
Breast cancer is the leading cause of cancers in Arab women (as it is elsewhere in the
world), however with a lower prevalence than elsewhere (Hashim et al. 2018).
Research from the last decade reports that the incidence of breast cancer ranges
between 20 and 30/100,000 in the majority of the countries from the Arab world;
however, these cancer rates have now increased (Hashim et al. 2018). The Saudi
national registry reports that the median age at diagnosis of breast cancer was
50 years (range between 14 and 108 years) (Saudi Health Council 2015). According
to the WHO factsheet for 2018, both Saudi Arabia and the United Arab Emirates
(UAE) lead in breast cancer prevalence, with the UAE having 39.9% new cases and
Saudi Arabia having 29.7% new cases of breast cancer (Hamadeh et al. 2017; Saudi
Health Council 2015).
Common risk factors associated with breast cancer include; a positive family
history of breast cancer, young age at menarche, obesity, hormonal treatment, and
unhealthy lifestyle (Hashim et al. 2018). Early screening programs initiated by some
countries helped in early detection and referral for treatment. However, cultural
barriers do not allow the women to access health care in some countries – to the
extent that by the time women arrive at the health facility, the cancer has advanced
with metastasis to other parts of the body (Donnelly et al. 2013; Fearon et al. 2019).
In addition to cultural barriers, a lack of appropriate knowledge and awareness
regarding the screening and treatment of breast cancer also contributes to the
prevalence and associated complications of breast cancer (Al Alhareth et al. 2015;
Donnelly et al. 2013). It is high time that the importance of routine self-breast
examinations, and regular screenings and follow-ups after treatment should be better
promoted. Breast cancer has a profound effect on the quality of life of women,
although females belonging to the Islamic faith tend to cope by keeping themselves
strong and determined (Fearon et al. 2019).
Ovarian and Cervical Cancers
The prevalence of cervical cancer is thought to be lower in Arab countries in

comparison to Western countries (Sancho-Garnier et al. 2013), likely due to the
strict rules and regulations pertaining to social mingling and behaviors. The recent
increases in the reporting of HPV 16 and 18 associated with cervical cancer from
various Arab countries have forced some of them to announce mandatory vaccina-
tions against HPV (Sancho-Garnier et al. 2013). In addition, it is important to also
detect changes occurring at the cellular level so that correct treatment and prevention
strategies can be initiated (Elmi et al. 2017). According to the WHO Globocan
survey from 2018, the prevalence for uterine and cervical cancer was 7.1% and 4.1%
in the UAE, whereas the prevalence of cervical cancer was more at 8.8% in Saudi
Arabia.
Cervical cancer is the one of common cancers in females aged 15–44 years in
Saudi Arabia (Saudi Health Council 2015). A retrospective observational study from
Saudi Arabia reports that women aged >60 years and having 2 episodes of
postmenopausal bleeding were at increased risk (OR = 4.5; 95% CI = 1.6–11.8)
of uterine cancer (Nasser et al. 2017). The recent increasing trends in the prevalence
of cervical cancer indicate early screening and reporting of such cancers. In addition
to cultural factors, lifestyle factors such as physical inactivity, unhealthy diet, and
obesity are associated with ovarian cancers. The risk factors associated with uterine
cancer include number of abortions, diabetes, hypertension, endometrial thickening,
and postmenopausal bleeding. In addition, prior infection with HPV (high risk
strains), young age at time of first coitus and increasing number of sexual partners
are some other factors associated with cervical cancer (Elmi et al. 2017).
A cervical screening study conducted in Abha and Western Saudi Arabia reported
abnormal pap smear findings with a prevalence of 4.7%. Only a small percentage of
Saudi women undergo screening for cervical cancer (Nasser et al. 2017). Therefore,
a regional program for diagnosing cervical precancerous lesions should be
established in all countries of the Arab world. Further research is needed in low-
income Arab countries to determine the risk factors.
Other Cancers
There is an alarming increasing incidence of leukemia and lymphoma in Arab

countries. For example, the prevalence is 5.2% in Saudi Arabia. The tradition of
getting married within the family (consanguineous marriages) is a major factor in
this trend; however, other environmental factors cannot be ruled out. Further
advanced cancer research is required, especially in vulnerable groups so that com-
prehensive strategies can be designed.
The prevalence of thyroid cancer among Saudi females is significant compared to
other Arab countries, suggesting that an environmental cause cannot be ruled out.
Thyroid cancer has increased in prevalence and is the second commonest cancer in
females in Saudi Arabia. The WHO cancer statistics from 2018 reports that the
prevalence of thyroid cancers in Saudi Arabia and the UAE was 14.1% and 10.6%,
respectively (World Health Organization: Information Agency for Research on
Cancer 2018a, b). Some advanced forms of thyroid cancer are associated with
different environmental factors but further research is required to establish the
definite causes.
Similarly, an increasing trend has also been observed in colorectal cancers. An
unhealthy diet, especially one low in fiber, is associated with colon cancers. The
prevalence of colorectal cancers in Saudi Arabia and the UAE have a prevalence of
9.5% and 8.5%, respectively (World Health Organization: Information Agency for
Research on Cancer 2018a, b). Some other cancers, such as skin cancers, have been
reported from Sudan and is associated with sun exposure; similarly, oral cavity
cancers in Yemen is associated with tobacco chewing, even in females (World Health
Organization: Information Agency for Research on Cancer 2018a, b).
Conclusion and Recommendations
Women’s health in the Arab world is rapidly evolving despite many challenges faced
by women in the Arab world. Some of these challenges include adopting an active
lifestyle that includes healthy diets and increased physical activity. Policy makers in
the Arab world should explore opportunities to improve women’s health by initiating
health policies aimed to prevent and/or reduce chronic health conditions, and also
promote the wellness of women of all ages. Ensuring that women have access to
quality care will undoubtedly improve not only their own health but also the health
for their children and families.
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Maternal and Neonatal Mortality in
Mauritania 5
Mohamed Lemine Cheikh Brahim Ahmed
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Maternal and Neonatal Mortality in Mauritania . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
Abstract
Maternal and neonatal mortality are global challenges and a major public health
issue facing developing countries. The highest rates of neonatal and maternal
deaths occur in sub-Saharan African countries. Reducing neonatal death to 12
deaths per 1000 live births is a sustainable developmental goal for 2030.
All Arab countries, except Somalia and Sudan, report a significant reduction in
maternal and neonatal mortality, and all Maghreb Arab countries, with the excep-
tion of Mauritania, report increased life expectancies.
This chapter describes the current situation of maternal and neonatal mortality
in Mauritania.
Keywords
Maternal · Neonatal · Mortality · Mauritania
M. L. C. B. Ahmed (*)
The Mauritanian Association for Scientific Research Development (AMDRS) and Unity of
Molecular Epidemiology and Diversity of Microorganisms, Department of Biology, Faculty of
Sciences and Techniques, University of Nouakchott El-Asriya, Nouakchott, Mauritania
Research Unity on Public Health and Epidemiology (URSPE), Faculty of Medicine, University of
Nouakchott Al-Assriya (UNA), Nouakchott, Mauritania
e-mail: lemine1987@hotmail.fr

https://doi.org/10.1007/978-3-030-36811-1_7
96 M. L. C. B. Ahmed
Introduction
Maternal mortality rate is defined as the death of the mother during pregnancy or
within 42 days after childbirth. In 2015, the World Health Organization estimated
that 303,000 women died either during or following pregnancy and childbirth
(WHO and UNICEF 2015). As a result, one million children will die within
1–2 years of their mothers’ death (WHO and UNICEF 2015).
Neonatal mortality is defined as the death of a live-born baby within 28 days of
life. It is estimated that about 2.8 million neonatal deaths occurred in 2013 (Yego
et al. 2013). Of these, 99% occurred in developing countries, with the highest rates in
sub-Saharan Africa (35 deaths per 1,000 live births in 2013) (Moyer et al. 2013;
Yego et al. 2013). The new target set by the Lancet Commission on Investing in
Health and the Sustainable Development Goals (SDGs) for decreasing neonatal
deaths is defined as 12 neonatal deaths per 1,000 live births by 2030 (WHO and
UNICEF 2015).
The United Nations Millennium Development Goals (MDGs) seek to reduce
these deaths by 75% in women and by 33% in children (Lozano et al. 2011).
Mortality rates are decreased but do not meet the MDGs in most developing
countries (WHO and UNICEF 2014; Wang et al. 2016).
There were about 13,000 female deaths in the Arab region when the MDGs were
announced; about 20% of these deaths occurred in four countries: Egypt, Iraq,
Morocco, and Yemen (Roudi-Fahimi 2003). Infant mortality rates ranged from 12%
to 95%, maternal mortality ratios ranged from 3 per 100,000 to 550 per 100,000, and
access to adequate sanitation facilities ranged from 51% to 99% in 16 the Arab
countries of the Eastern Mediterranean (Bahrain, Egypt, Iraq, Jordan, Kuwait, Leba-
non, Libya, Morocco, Oman, Qatar, Saudi Arabia, Sudan, Syria, Tunisia, Emirates,
and Yemen) (Shawky 2001). However, a number of Arab countries have now
achieved their maternal and neonatal health-care goals; this includes the six Gulf
countries (Rahman et al. 2010; Akseer 2015). All Arab countries, except Somalia and
Sudan, show a significant reduction in maternal and neonatal deaths that are in line
with MDGs (Salam et al. 2015).
Maternal and Neonatal Mortality in Mauritania
Mauritania is in the northwest of Africa and has borders with the Western Sahara (to
the north/northwest), Atlantic Ocean (to the west), Algeria (to the northeast), and
Mali (to the east and southeast). About 90% of Mauritania lies in the Sahara, and the
majority of the population (of ~4.3 million) is in the southern parts of the country.
Nearly 40% of the population is under 15 years of age.
Mauritania implemented an obstetric risk insurance policy in 2002 with the aim of
increasing the quality and access to both maternal and perinatal health care
5 Maternal and Neonatal Mortality in Mauritania 97
(Renaudin et al. 2007). Despite all the efforts invested since 1990, the country
still has high morbidity and mortality rates, especially for mothers and children
(Table 1).
For example, neonatal mortality rates are practically unchanged over the last
30 years, from 41 per 1,000 live births in 1990 to 35 per 1,000 live births in 2015,
with the most important causes of death being prematurity (37%), birth asphyxia and
birth trauma (24%), and sepsis and other infectious conditions (21%) (WHO and
UNICEF 2015). However, the maternal mortality rate was reduced from 40% in
1990 to 27% in 2015 (WHO and UNICEF 2015). In 1990, there were about 859
maternal deaths per 100,000 live births; these levels decreased to 813 deaths per
100,000 live births (in 2000) and 602 deaths per 100,000 live births (in 2015) (WHO
and UNICEF 2015). This high mortality rate reflects the extremely low use of skilled
birth attendants. In 2007, 48.4% of Mauritanian women gave birth in a health-care
center, where 61% of live births were attended by a skilled provider; however, 91%
of women who delivered at home did not receive any postnatal care visits (ONS,
Mauritania 2008).
The neonatal mortality rates in rural areas are 32 deaths per 1,000 live births and
25 deaths per 1,000 live births in urban areas (Table 2). In rural areas, 54% of women
made at least four antenatal care visits, compared to 73% in urban areas (ONS,
Mauritanie 2015). According to the results of a study conducted in two rural districts
of South Mauritania, most pregnant women attended at least one antenatal care visit
during their pregnancy (Vallieres et al. 2013). This high access to antenatal care
visits was attributed to the multiple access low-cost centers. An earlier study of
patients in Nouakchott also reported increased rates of hospital and postnatal care
visits (Fall-Malick et al. 2010). Annual rate of reduction in both neonatal and
maternal mortality since 1990 is reported in Table 3.
Table 1 Maternal mortality in 1990–2015

Maternal
mortality ratio
(MMR)a Number of Proportion of maternal deaths
per 100,000 live maternal Live birthsb in females of reproductive age
Year births deaths (Thousands) (PM %)
1990 859 (566–1230) 710 83 40.4
1995 824 (590–1120) 760 92 39.7
2000 813 (596–1100) 850 104 38.9
2005 750 (551–1050) 870 116 35.3
2010 723 (505–1080) 910 126 33.5
2015 602 (399–984) 810 134 27.4
a
MMR and PM are calculated for women 15–49 years (WHO and UNICEF 2015)
b
Live birth data from World Population Prospects (2015 revision)
98 M. L. C. B. Ahmed
Table 2 Neonatal mortality associated to maternal characteristics (between 2011 and 2015)
Neonatal mortality (%) Post neonatal (%)
Maternal characteristics 2011 2015 2011 2015
Urban 34 25 19 13
Rural 33 32 17 15
Education
No 37 31 18 18
Intermediate 25 23 15 9
Socioeconomic
Low 28 33 16 16
Intermediate 32 31 24 13
High 30 18 15 12
Ethnicity
Arab 35 29 17 15
Polar 33 31 20 11
Soninke 25 25 25 17
Wolf 17 21
(Office National de la Statistique (ONS)- Mauritanie, 2008 and 2015). * No data
Table 3 Annual rate of reduction in maternal and neonatal deaths (%)

Maternal mortality Neonatal mortality
Year Annual rate of reduction (%) Annual rate of reduction (%)
1990–2015 1.4 0.17
1990–2000 0.6 0.10
2000–2015 2 0.07
2005–2015 2.2 0.01
Data sources: (WHO and UNICEF 2015)
Conclusion
Maternal and neonatal mortality remain a major challenge in Mauritania. Most of

these maternal and neonatal deaths can be prevented by improving the quality of
services and implementing a management protocol. Maternal education is a key to
achieving sustainable developmental goals in health care by 2030.
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preventable mortality among mothers and children in the eastern Mediterranean region: new
initiatives, new hope. East Mediterr Health J 21(5):361
Fall-Malick FZ, Bara AO, Lam M, Mint Beibacar M, Ba K, Ba H, Ould Ghady I, Ould Horma A,
Toure-Kane NC, Mboup S (2010) Surveillance Sentinelle Du VIH Chez Les Femmes Enceintes
5 Maternal and Neonatal Mortality in Mauritania 99
En Mauritanie Entre 2001 et 2007HIV Sentinel Surveillance of Pregnant Women in Mauritania

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maternal and child mortality: an updated systematic analysis. Lancet 378(9797):1139–1165
Moyer CA, Phyllis Dako-Gyeke, Adanu RM (2013) Facility-based delivery and maternal and early
neonatal mortality in sub-Saharan Africa: a regional review of the literature. African Journal of
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Office National de la Statistique (ONS)–Mauritanie (2008) Enquête par Grappe à Indicateurs
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Shawky S (2001) Infant mortality in Arab countries: sociodemographic, perinatal and economic
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World Health Organization, and Unicef (2014) Trends in maternal mortality: 1990 to 2013:
estimates by WHO, UNICEF, UNFPA, The World Bank and the United Nations Population
Division.
Vallieres F, Cassidy EL, McAuliffe E, Isselmou SO, Hamahoullah MS, Lang J (2013) Where are the
gaps in improving maternal and child health in Mauritania? The case for contextualised interven-
tions: a cross sectional study. Pan Afr Med J 14:97. https://doi.org/10.11604/pamj.2013.14.97.2292
Wang H, Bhutta ZA, Coates MM, Coggeshall M, Dandona L, Diallo K, Franca EB, Fraser M,
Fullman N, Gething PW (2016) Global, regional, national, and selected subnational levels of
stillbirths, neonatal, infant, and under-5 mortality, 1980–2015: a systematic analysis for the
global burden of disease study 2015. Lancet 388(10053):1725–1774
World Health Organization, UNICEF (2015) Trends in maternal mortality: 1990–2015: estimates
from WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division
Yego F, Williams JS, Byles J, Nyongesa P, Aruasa W, D’Este C (2013) A retrospective analysis of
maternal and neonatal mortality at a teaching and referral hospital in Kenya. Reproductive
Health 10(1)
Hormone Replacement Therapy
The Plight of Aging Women in Arab Nations
6
Wendelyn Inman, Alexis Heaston, Revlon Briggs, and
Rosemary Theriot
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
Physiology of Aging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Solutions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Abstract
The challenges for an aging woman in the Arab world are complex and encom-
pass many facets. Some of the health issues are focused on the aging process,
which considers a cultural and religious perspective to effectively and success-
fully improve the health of the aging woman. One of the biggest dilemmas faced
by the aging Arab woman is the end of childbearing years and the beginning of
menopause. The changes and challenges that accompany menopause are often
addressed by considering hormone replacement therapy for the diminishing
hormone levels present during childbearing years. The status of hormone replace-
ment use, the pros and the cons, and other considerations, such as complementary
and alternative therapy to address the aging process, especially in the Arab world,
are discussed in this chapter.
Keywords
Hormone replacement · Menopause · Perimenopause · Hormone therapy ·
Estrogen · Female aging
W. Inman (*) · A. Heaston · R. Briggs · R. Theriot

Department of Public Health, Health Administration, and Health Sciences, Tennessee State
University, Nashville, TN, USA
e-mail: winman@tnstate.edu; aheaston@tnstate.edu; rbriggs@tnstate.edu; rtheriot@tnstate.edu

https://doi.org/10.1007/978-3-030-36811-1_8
102 W. Inman et al.
Introduction
As women begin the aging process, changes occur that are clinically related to
differences in their hormone levels. One significant sign of aging in women occurs
when menstrual cycles cease permanently. The cessation in the menstrual flow is
known as menopause. Menopause is part of the aging process in women, and it
occurs as a result of decreased hormone levels. The time period before menopause is
called perimenopause, and it is characterized by infrequent periods, changes in the
duration of the period, and physical changes in the reproductive tract. While
menopause is a normal part of the aging process for women, it usually occurs
between the ages of 45 and 55 years. One of the most significant components of
menopause is that the ovaries stop producing two hormones, estrogen and proges-
terone. As these hormone levels decrease, the menstrual cycle stops; ovaries stop
releasing eggs; the vaginal walls become thinner, dryer, and less elastic; and the risk
of yeast infections increases. Other physiological occurrences that are separate from
the reproductive tract include hot flashes, moodiness, headaches, and insomnia (Katz
et al. 2012). Women also face decreases in breast tissue, short-term memory prob-
lems, and lowered libido (sex drive) and responsiveness. In addition, the urinary tract
is affected. There frequency and urgency in urination increases. Muscle tone in the
pubic area could also be affected. The vagina, bladder, and uterus could fall out of
position or prolapse. These changes are inherent in the reduction of estrogen and
progesterone. Therefore, it is important to examine why these hormones should be
replaced. Hormone therapy with estrogen and/or progesterone may help with the
symptoms of menopause, especially vaginal dryness, hot flashes, and pain during
intercourse. However, hormone therapy also has several risk factors associated with
the use of them.
More than 50 years of experimental studies have focused on improving the health
status of women as they age by examining the potential of replacing the estrogen lost
as women age. Hormone replacement therapy (HRT) focuses on replacing estrogen
to decrease mortality, cardiovascular disease, osteoporosis fractures, urogenital
atrophy, colon cancer, dementia, and much more (Shoupe 2011). Hormone replace-
ment therapy research is conclusive in some areas with substantiated positive and
negative outcomes. However, in many other areas, HRT outcomes are glaringly
inconclusive, so clinicians seek more substantial evidence that hormone replacement
therapy is the best approach for the aging woman.
Background
Hormone replacement therapy, or HRT, for health issues affecting aging women has
been considered as a treatment option for more than 30 years. HRT, as a form of
clinical treatment, has been considered for several other conditions for more than
90 years (Rymer et al. 2003). HRT is defined as any form of therapy that provides a
patient with a hormone that is either a replacement for a naturally occurring hormone
or as a supplement for a naturally occurring hormone. HRT can serve as a
6 Hormone Replacement Therapy 103
replacement or substitute for natural biological substances. The common hormones

for replacement therapy include thyroid replacement hormones (Jonklaas et al.
2014), testosterone replacement (Giannoulis et al. 2012), and growth hormone
(Park and Cohen 2005) supplementation.
Physiology of Aging
A significant event for women that is governed by hormones is menopause, which

typically occurs at age 50 or older. The natural production of the hormone estrogen drops
significantly in women during menopause. The most common menopausal symptoms
include hot flashes that disturb sleep at night and interfere with activities during the day;
vaginal dryness that causes discomfort and interferes with sexual activities; and changes
in reproductive ability. Hot flashes cause the skin to appear flushed or red and are
followed by sweating and shivering. The decrease in estrogen levels causes vaginal and
urinary tract changes that make normal sexual activity painful.
As females age, significant physiological changes take place that affect the natural
production of two female hormones, estrogen and progesterone. Estrogen and pro-
gesterone are important in regulating the menstrual cycle and supporting pregnancy.
The hormones are produced by the ovaries, which are two small oval-shaped organs
found on either side of the uterus. During the years before menopause, known as
perimenopause, the ovaries begin to shrink. At this time, the levels of estrogen and
progesterone fluctuate which result in irregular menstrual cycles along with
unpredictable episodes of heavy bleeding. Perimenopause can last several years
before the menstrual cycle eventually stops. The actual beginning of menopause is
marked by the last menstrual cycle. Menopause does not begin until 12 consecutive
months have occurred without a period and without being pregnant, breast-feeding,
or subject to pharmacological interruptions (some medicines may interrupt the
menstrual cycle). Menopause has not occurred if there is any spotting or bleeding
between the menstrual cycle. It occurs naturally for most women between the ages of
45 and 55. Surgical procedures such as a hysterectomy, which is the removal of the
uterus, can terminate menstrual cycles. Although the menstrual cycle ends, and the
ovaries remain, menopause still occurs naturally. On the other hand, menopause will
occur immediately if both ovaries are removed. Whether menopause occurs naturally
or if is surgically induced, the symptoms include a decrease in estrogen levels that
vary greatly in women. Women can have multiple symptoms or very few symptoms,
if any, while the symptoms may last for years and others may last for several months.
Solutions
To relieve the symptoms of menopause, physicians may prescribe hormone therapy.

This can involve the use of estrogen alone or in conjunction with progesterone or
progestin (the synthetic form). Together these hormones help to regulate the men-
strual cycle. The addition of progestin prevents the hyperplasia (increased growth) of
104 W. Inman et al.
the cells that line the uterus. Therefore, women who have had a hysterectomy do not
receive progestin as a part of their hormone therapy. HRT can be continuous (daily
use) or cyclic (periodic within a month). The therapy depends upon the purpose. For
example, women who suffer from vaginal pain may receive a cream to relive dryness
and urinary leakage. On the other hand, women who experience hot flashes may be
prescribed an oral medication, a patch, or a vaginal ring (a slow release hormone).
Menopausal women have other physiological changes that affect their health and
can be accelerated or affected by HRT. The health risks associated with menopause
includes an increased incidence of heart disease and osteoporosis. Many scientists
believe that these health risks are associated with estrogen levels and that estrogen
replacement could help protect against these conditions while relieving the symp-
toms of menopause.
Medical research has focused on two types of studies to investigate the benefits of
HRT, observational studies and clinical trials. These studies were significant. Obser-
vational studies followed the medical history and lifestyle activities of women but
provided no interventions. The objective was to determine possible relationships
(benefits or the harm) that resulted in illness or health. The research tracked
individuals over time to determine if the women on HRT versus women who were
not on HRT had different outcomes in specific areas. The other factors that
influenced outcomes may or may not have been examined conclusively. On the
other hand, clinical trials were more rigorous and controlled and compared specific
medical interventions such as the use of HRT. Under experimental conditions,
researchers attempted to control all of the experimental conditions so that the two
groups were compared based upon the HRT intervention. In observational studies,
women who were on HRT were often healthier, had better access to healthcare, and
were more willing to follow the prescriptive regimen. The observational studies
looked for predictors and biological markers for disease. On the average, in the
clinical trials, the researchers had more reliable information since the women had
similar backgrounds (age, education, health, and other factors). Clinical trials were
designed to test for the effects of HRT on menopausal risk factors, which included
heart disease, osteoporotic fractures, and breast and cervical cancer. The researchers
who participated in each study attempted to determine a causal link (a specific
medical outcome).
While these intensive medical research activities were ongoing, women received
HRT for menopausal symptoms. The studies included women from diverse back-
grounds such as whites, blacks, and Hispanics; ages 50 through 79; continuous
hormone use and sporadic hormone use; and normal to high BMI, tobacco use and
nontobacco use, and hypertension. Some studies found improved outcomes of these
health risks while improving, reducing, or eliminating the menopausal symptoms.
Other studies found a direct link to a higher incidence of risk cancer, cardiovascular
disease, and osteoporosis. The increased risks were so evident that the clinical trials
(of estrogen alone and/or estrogen-progestin) were terminated. The researchers
found an obvious link between HRT and the risk of heart disease, high blood
pressure, diabetes, obesity, and more. Estrogen plus progestin increased the risk of
stroke by 41% while decreasing the risk of hip fractures by 34%. Women on this type
6 Hormone Replacement Therapy 105
of HRT had twice the incidence of dementia and reduced cognitive function, and the
symptoms of incontinence became worse. The risks for the population outweighed
the benefits. Studies of estrogen alone found that there was an increased risk of
stroke and pulmonary disease events such as deep vein blood clots, with risk of
breast cancer lowered. For the clinical trials, the risks outweighed the benefits.
Conclusion
Because of increased life spans, women are spending more time in their menopausal
years. Many clinical providers prescribe and closely monitor hormone replacement
therapy (HRT) treatment for women over 50 (Kuh et al. 1997). Synthetic HRT
includes estrogens and progesterone that are not bioidentical but bioequivalent.
Synthetic hormone replacement may produce side effects that are clearly evident
in clinical trials. The controversy may not be resolved or eliminated for years. While
clinicians continue to prescribe HRT (Rossouw et al. 2002), there are some basic
findings that are evident. HRT can improve the quality of life for women with hypo-
estrogenic symptoms (Rymer et al. 2003). Long-term HRT is not a good risk for
women with a family history of breast cancer or osteoporosis. The observational and
clinical trials both identify restrictions for the use of hormone therapy. HRT should
not be considered as a therapy to reduce or prevent heart disease. It may actually
increase the chances of a heart attack and breast cancer.
Benefits: Women benefit from HRT for menopausal symptoms. However, there is
little evidence that the benefits outweigh the risks for other types of therapy.
Menopausal symptoms vary considerably and are related to social class (Gold
et al. 2000), ethnicity (Avis et al. 2001), and culture (Lock 1993). Clinical and
observational studies demonstrate that HRT can provide relief of menopausal symp-
toms, especially vasomotor and urogenital symptoms (hot flashes and incontinence).
The research of the risks and benefits of HRT is ongoing. The Women’s Health
Initiative (WHI) continues to explore the extent of efficacy, safety, and tolerability of
HRT in a number of ways.
References
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Giannoulis MGMartin FC, Nair KS, Umpleby AM, Sonksen P (2012) Hormone replacement
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demographic and lifestyle factors to symptoms in a multi-racial/ethnic population of women
40–55 years of age. Am J Epidemiol 152(5):463–473. https://doi.org/10.1093/aje/152.5.463
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woman: endocrinology, consequences of estrogen deficiency, effects of hormone replacement
therapy, treatment regimes. In: Comprehensive gynecology, 6th edn. Elsevier Mosby,
Philadelphia
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pause, social factors, and health in earlier life. BJOG Int J Obstet Gynaecol 104:1419. https://
doi.org/10.1111/j.1471-0528.1997.tb11016.x
Lock MM (1993) Encounters with aging: mythologies of menopause in Japan and North America.
University of California Press, London. Retrieved from http://hdl.handle.net/2027/heb.04079.
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Park P, Cohen P (2005) X insulin-like growth factor I (IGF-I) measurements in growth hormone
(GH) therapy of idiopathic short stature (ISS). Growth Horm IGF Res 15:13–20. Retrieved from
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(2002) Risks and benefits of estrogen plus progestin in healthy postmenopausal women:
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(3):321–333
Rymer J, Wilson R, Ballard K (2003) Making decisions about hormone replacement therapy. BMJ
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and benefits. Womens Health 7(4):475–485. Retrieved from https://doi.org/10.2217/whe.11.42
Tobacco Use by Arab Women
7
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Cigarette Smoking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Smokeless Tobacco . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
Midwakh (Dokha) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
E-Cigarettes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
Waterpipe Smoking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Health Risks of Tobacco Use in Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Cancer in the Smoking Woman . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Cardiovascular Effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
Respiratory Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
Endocrine Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
Genitourinary Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
Breastfeeding Mothers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
Pregnant Women and Their Offspring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
Barriers to Smoking Prevention and Cessation Among Arab Women . . . . . . . . . . . . . . . . . . . . . . . . . 123
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
Abstract
Tobacco use by women has increased over the past century, and this is also the
case of women in the Arab world. This has led to dramatic increases in smoking-
related diseases such as cardiovascular and respiratory diseases, cancers, and also
diseases peculiar to women’s health. It is widely accepted that women are more
susceptible to the health complications of smoking than men. Although tobacco
use in the Arab population mostly occurs with males, up to 31% of women use
one or more tobacco forms and products in Arab countries. Arab women use
N. Dar-Odeh (*) · O. Abu-Hammad

School of Dentistry, University of Jordan, Amman, Jordan

https://doi.org/10.1007/978-3-030-36811-1_10
108 N. Dar-Odeh and O. Abu-Hammad
different forms of tobacco such as cigarettes, e-cigarettes, water pipe, midwakh,

and smokeless tobacco. They are subjected to the various health risk hazards
associated with these forms of tobacco use. Epidemiological evidence on the
prevalence of tobacco use by females in Arab countries is still insufficient; this
chapter discusses the available data and the reported tobacco smoking complica-
tions in women. Increased awareness of the expected health hazards will help to
enhance smoking cessation programs specifically directed to women.
Keywords
Tobacco · Smoking · Arab · Women · Waterpipe · Midwakh · E-cigarettes ·
Shammah · Toombak · Shisha
Introduction
Tobacco smoking is the most important preventable cause of death globally, as it

constitutes the main cause of morbidity and mortality in any population compared to
any other risk factor. It is estimated that the mortality rate associated with tobacco
smoking is approximately six million deaths annually, with an expected increase to
eight million per year by 2030 (U.S. National Cancer Institute and World Health
Organization 2016). One in every 20 deaths in women older than 30 years is
attributed to smoking. Tobacco smoking is an important risk factor for cardiovascu-
lar diseases, cancer, respiratory diseases, and other adverse health outcomes (Carter
et al. 2015). Tobacco use in Arab countries is believed to nearly double cancer-
related deaths by 2020, an increase of 181% compared to a 26% increase in
industrial countries; this is important to consider as 80% of current smokers live in
middle- and low-income countries (U.S. National Cancer Institute and World Health
Organization 2016).
The final decade of the twentieth century has witnessed many rapid transforma-
tions involving not only major developments in information technology and Internet
communications but also major changes in tobacco use habits across the globe, with
a noticeable resurgence of old habits such as waterpipe smoking and the emergence
of new habits such as the smoking of e-cigarettes. It is well recognized now that
female smoking rates are expected to accelerate in the twenty-first century, particu-
larly in low- and middle-income countries including the Arab countries. Gender
differences in smoking rates are expected to be sevenfold in developing countries
compared to twofold in developed ones. The true rate may be underestimated, with
estimated smoking rates being lowest in Morocco (1.4%) and highest in Lebanon
(47.3%). Other Arab countries with high smoking rates include Jordan and Syria
(Khattab et al. 2012).
Tobacco is mostly used for smoking cigarettes, cigars, pipes, kreteks, bidis, and
waterpipes. Although Pipe smoking is considered to be more common by males, its
popularity is decreasing over time. In some parts of the world, smoking cigars is
more popular, although it contains higher concentrations of toxic substances and
7 Tobacco Use by Arab Women 109
carcinogens compared to cigarettes. Smokeless tobacco is used at lower rates;

smokeless tobacco is inserted in the mouth and includes, but is not limited to,
tobacco leaves, betel quids, snus, and snuff. Betel quid uses tobacco, areca nut,
lime, and spices that are wrapped in the leaf of the betel vine, while snuff is moist
ground tobacco. Smokeless tobacco is thought to carry less disease risk compared to
smoked tobacco, where burning produces an extensive list of toxic substances.
Complications from using smokeless tobacco depend on the quantity of tobacco
intake, the composition of tobacco blend used, and the presence of other synergistic
risk factors.
Although types of tobacco used differ in various parts of the world, Arab
countries have maintained certain types: some of these are used by both males and
females and a few are peculiar to women. There are five types of tobacco use by Arab
women: cigarettes, waterpipe, e-cigarettes, smokeless tobacco, and midwakh. The
following sections describe the types of tobacco use by Arab women.
Cigarette Smoking
Cigarettes were introduced in Western countries in the 1840s, and men were the
primary users. Women later also started to use cigarettes likely at the beginning of
the twentieth century. Despite passing a law in the United States to prohibit women
from smoking, cultural and social acceptance encouraged more women to smoke in
public. Cigarette smokers are at greater risk for developing several diseases: they are
2–4 times more likely to develop coronary heart disease, at twice the risk for
developing a stroke, and 10 times to more likely develop peripheral vascular disease
than nonsmokers. Nearly 20% of mortalities due to heart disease are attributable to
smoking. Further, cigarette smoking is associated with 90% of all cases of lung
cancer according to the WHO. Moreover, the WHO linked the habit to stomach,
uterus, liver, and kidney cancers and myeloid leukemia. Studies from the Maghreb
indicate that cigarette smoking was responsible for 2.0% of deaths and 7.6% of
smoking-related disease deaths among women (Tachfouti et al. 2014).
Smoking is linked to several adverse changes in women’s health: adverse preg-
nancy outcomes include higher rates of miscarriage, premature abruption (i.e., early
detachment of placenta), placenta previa (abnormal location of the placenta near
cervix), premature rupture of membranes, stillbirth, premature birth, and low birth
weight (Bauld et al. 2017). While smoking is known to accelerate menopause, it also
adversely affects postmenopausal women with subsequent increased risk of osteo-
porosis and increased susceptibility to hip fractures and premature aging of the skin
(Yang et al. 2015).
Arab societies are becoming more modernized, so that the major causes of
mortality and morbidity are now associated with noncommunicable diseases.
While rates of cigarette smoking are increasing in Arab men, this habit has not
gained similar popularity among Arab women partly due to the social taboo associ-
ated with women who smoke. The unacceptability of this habit by society may also
contribute to underreporting, so masking the true prevalence of this behavior. With
the widespread use of social media and globalization, many Arab societies became
more westernized and social constraints on women smoking diminished. However,
the image of female smoking cigarettes in Arab communities is still rejected as it is
contrary to the modest personality required of the Arab woman.
The overall prevalence of cigarette smoking by women in the Levant is the
highest in the Arab world. It is estimated to be 8.4% in Syria, 10.9% in Jordan,
and as high as 24.3% in Lebanon (Abdulrahim and Jawad 2018). Smoking is more
prevalent in older, ever-married, and urban women compared to young, single, and
rural women. Wealthier Syrian and Jordanian women, along with the least educated
Jordanian women, have the highest prevalence of tobacco use. Wealthy and educated
(at least have secondary education or more) women in Lebanon have the lowest
smoking rates. A lower prevalence (3.6%) and a different pattern occur in Palestinian
women, where cigarette smoking shows no association with wealth, indicating that
the lengthy political turmoil negated the influence of wealth. On the other hand,
Palestinian men continue to smoke irrespective of wealth, probably as a coping
mechanism against the adverse political atmosphere, with smoking rates being
approximating nine times higher than in women (Tucktuck et al. 2017). Similar to
Palestinian women, relatively low cigarette smoking rates were reported for women
in Morocco (3.1%) and Tunisia (5.2%) (Nejjari et al. 2009; Fakhfakh et al. 2002).
Cigarette smoking prevalence in the Arab Gulf region was reported to be 24% for
adult men and <1% for women (Al-Houqani et al. 2012). The prevalence of cigarette
smoking by women in the United Arab Emirates (UAE) is also estimated to be 1.9%
(Al-Houqani et al. 2018), with previous studies reporting a higher percentage of
8.9% in university students (Mandil et al. 2007). Although Oman does not investi-
gate tobacco use among its people thoroughly, current data shows a relatively low
rate (4.6%) of tobacco use in adults when compared to other developing countries,
with smoking prevalence rates being 8.7% for men and 0.1% for women, with
cigarettes smoking being the only type of smoking in women.
Cigarette smoking by Egyptian women is reported to be as low as 0.2% (Fouda et
al. 2018). There is no recent literature on the prevalence of cigarette smoking among
women in Sudan; however, studies conducted two decades ago reported a low
prevalence of 0.9% (Idris et al. 1998). A higher prevalence was reported among
female university students in Yemen (2.7%) (Nasser et al. 2018). While a low
prevalence was reported from Saudi Arabia for the age range 25–64 years, there
was a large gap between males (28.8%) and females (1.9%) (Moradi-Lakeh et al.
2015). However, for those aged 15–24 years old, smoking rates were 16.1% for
males and 0.8% for females (Moradi-Lakeh et al. 2015). Although this prevalence is
considered quite low in Saudi women, there is a tendency of an increasing preva-
lence over the years, with studies reporting that smoking by young Saudi women
increasing from approximately 5% in the late 1990s to 14% in the early 2000s in
some regions of the Kingdom (Koura et al. 2011). Regional differences in smoking
prevalence occur in Saudi Arabia, with the southern regions having a low prevalence
(~2%) compared to eastern areas (10%) (Mahfouz et al. 2014). Studies conducted in
Western regions among female university students showed a cigarette smoking
prevalence of 5% in Jeddah (Merdad et al. 2007), and an overall prevalence of
15% in the holy city of Al Madina, with approximately 60% of the study sample
smoking cigarettes (unpublished data).
Smokeless Tobacco
Chewing tobacco was the primary form of tobacco used in the western world in the
early 1800s. It was used predominantly by men, although many women used snuff.
Smokeless tobacco in the Arabic countries comes in the form of shammah (local
name in Saudi Arabia) and toombak (local name in Sudan). While this type of
tobacco use may be popular in Yemen, Sudan, and some areas of Saudi Arabia, it is
replaced by other forms of tobacco use in other Arabic areas.
Shammah is probably the most commonly reported form of smokeless tobacco in
Arabic countries (Quadri et al. 2019). This powdered tobacco is placed as a quid
against the buccal or labial mucosa of the oral cavity for a long duration and the
extracted juice is swallowed (Idris et al. 2016). Shammah consists of tobacco powder
mix, carbonate of lime, ash, black pepper, oils, and flavoring. While oral application
is the most common form, nasal application was also reported (Allard et al. 1999).
There is a variation for use of shammah in Saudi Arabia, where it is more frequently
used in Jazan province (in the south), probably due to its close proximity to Yemen,
another country with a high use of shammah. The oral use of shammah in Jazan can
begin in children as young as 10–13 years of age; in fact, some parents use shammah
as a remedy for relieving teething pain in infants and toddlers. The prevalence of
shammah use in Saudi Arabia is thought to be high, although accurate numbers are
not available as shammah is considered an illegal habit (Allard et al. 1999). Further-
more, the prevalence of use by females is likely to be underreported due to cultural
and social restrictions.
Toombak is the common name used for smokeless tobacco in Sudan. The mix is
prepared by finely grinding dried leaves of Nicotiana rustica (strong tobacco) and
used as an oral snuff. About 10 g of the material (called saffa) is formed as a small
ball and then placed into the lower labial vestibule or sometimes into buccal
vestibule or on the floor of the mouth under the tongue (Idris et al. 1998). It is
believed that toombak has a high nicotine concentration, and contains large amounts
of carcinogens (i.e., tobacco-specific nitrosamines and nicotine-derived nitrosa-
mine). This material contains around 100 times more ketone levels than any other
tobacco products in other parts of the world. Adverse effects on teeth and oral
mucosa are shown in Figs. 1 and 2. The habit is associated with a higher incidence
of dental caries, periodontal disease, and eventual tooth loss and oral cancer in many
users (Hassanin and Idris 2017).
Use of toombak has also been linked to potentially malignant oral lesions such
as leukoplakia, as well as systemic diseases namely cardiovascular diseases,
and nicotine dependence (Alsanosy 2014). Apart from risks on the oral cavity,
systemic health hazards of smokeless tobacco are underreported and not well
documented. This is probably due to the variability in composition of smokeless
tobacco mixes among countries reporting the use of this type including western
Fig. 1 Intraoral photograph of a 38-year-old female using smokeless tobacco for 25 years. To quit
smokeless tobacco, she started using a mixture of tea, black pepper, ginger, and cloves. The habit is
associated with severe gingival recession, periodontal attachment loss, and mobility of teeth
Fig. 2 Tooth discoloration

and wear in 65-year old
women who uses smokeless
tobacco
countries, south East Asia, and few Arab countries. However, its contributory role
in the development of heart disease, peripheral vascular disease, hypertension,
peptic ulcers, and fetal morbidity and mortality should not be overlooked (Cullen
et al. 1986).
Although toombak smoking prevalence is greater in males (40%) than females
(10%) (Idris et al. 1996, 1998), females tend to place toombak quids into buccal
vestibules for longer periods than males. Therefore, the habit places women at
increased risk for exposure to carcinogens for longer periods of times. Moreover,
Sudanese female toombak users tend to be older than males, as most users are
postmenopausal women who may have other confounding health problems such
as nutritional deficiency (Hassanin and Idris 2017). There are no cultural restrictions
on the use of toombak in Sudan (in contrast to Saudi Arabia), which allows for more
accurate epidemiological data. An alarming finding is the increased use of toombak
by younger generations in Sudan. The prevalence of use of toombak by secondary
school Sudanese male students was 74.3% and 25.7% for female students (Almahdi
et al. 2017a). Apart from Sudan and Saudi Arabia, smokeless tobacco use also occurs
in women in Egypt but at a lower prevalence (0.3%), although the type of tobacco
was not specified (Fouda et al. 2018).
Midwakh (Dokha)
A new public health concern is the spread of midwakh, which is used in Lebanon and
some Gulf countries. Midwakh is also called dokha, the Arabic term for “dizzy” or
“drowsy.” Its use requires a narrow pipe to smoke a mixture of dried tobacco leaves,
herbs, and spices. Smoking will consequently lead to “dokha” or “dizziness.” The
main types of dokha blends commonly available are categorized based on their
“strength” (or concentration of tobacco in the mix) into cold (light), warm (medium),
and hot (strong) according to the extent of dizziness produced. About half a gram of
dokha blend is placed in the midwakh, followed by one or two deep inhalations
taken to burn the dokha. The popularity of midwakh as an alternative to cigarettes
and waterpipe smoking is probably due to the intense dizziness associated with
transient brain hypoxia caused by nicotine. The habit is being promoted by social
media describing it as odorless, associated with rapid satisfaction of nicotine
craving, production of less second-hand smoke, relatively low cost, and convenient
use compared to the more complicated instrument of the waterpipe (Vupputuri
et al. 2016).
Midwakh has a high nicotine content and is associated with numerous pathologic
effects. The immediate effects are mainly on the cardiovascular system, including
increased systolic blood pressure, tachycardia, and tachypnea (Shaikh et al. 2012).
Long-term use of midwakh leads to sympathetic stimulation of the heart and damage
to blood vessels. Seizures and adverse respiratory effects were also reported
(Vupputuri et al. 2016). The smoke generated by midwakh contains harmful
amounts of toxic metals such as cobalt, cadmium, chromium, and lead, as well as
irritants, toxic organic compounds, carcinogens, and central nervous system depres-
sants, among others (Elsayed et al. 2018).
Most data on midwakh use comes from the Gulf region where midwakh origi-
nated, although recent data also emerged from Lebanon where 4.6% of students were
current midwakh users, with an estimated 6.7% use in males compared to 2.7% use
in females (2.7%) (Afifi et al. 2018). Use of midwakh is second in popularity to
tobacco use in the UAE, and is increasing in popularity by young adult males in
particular. In the UAE, 27% of males and 24% of females use tobacco. Tobacco
products used are mainly cigarettes, waterpipe, and midwakh. Most tobacco users
start their habits around the age of 17 years. Among university medical students in
the UAE, 30% of males and 5% of females reported the use of midwakh
(Jayakumary et al. 2010). Another study among adolescents in the UAE reported the
prevalence of current midwakh users to be 9.0%, of which 15.9% smoked midwakh
daily (19.6% among males and 4.8% among females) (Jawad et al. 2019). Reasons
given for smoking midwakh included stress management, better concentration,
improved mood, and peer pressure (Elobaid et al. 2019).
E-Cigarettes
Electronic cigarettes (e-cigarettes) deliver a solution containing nicotine, propylene

glycol, vegetable glycerin, and flavors in an aerosol form. The solution is placed in a
cartridge, and an electronic atomizer then converts the mix into aerosol that is
inhaled through a mouthpiece. A battery provides the atomizer with heat necessary
to convert a solution into vapor. Since their invention in China in 2003, e-cigarettes
have become more popular among young age groups, in the mistaken view that
e-cigarettes have fewer health hazards than cigarettes and to avoid governmental
legislations against conventional smoking.
E-cigarettes have been marketed as a healthier alternative to conventional
smoking, so increasing its popularity. However, e-cigarettes are still not yet
approved by the FDA for smoking cessation. It appears that peer and family
influences, in addition to appeal of using new technologies, attract females to the
habit more than males, possibly because of females’ high tendency to use social
media (Rodríguez-Bolaños et al. 2020). The potential health hazards of e-ciga-
rettes are underreported. Pregnant users of e-cigarettes have nearly the same risk
of preterm birth as nonusers, but have an increased risk for restricted fetal growth
(Wang et al. 2020). Recent reports indicate potential lung injury associated with
e-cigarettes (Itoh et al. 2018). The associated nicotine use by the youth can lead
to adverse cognitive effects that could persist into adulthood (Nguyen et al.
2018).
Scarce data are available on e-cigarette use by females in Arab countries. In Saudi
Arabia, the prevalence of e-cigarette smoking was 27.7% among health sciences
university students, which is about double the prevalence of conventional smoking
(Qanash et al. 2019). The increasing popularity could be due to several reasons
including being a source of entertainment, the opportunity to try something new, and
as a cigarette cessation method.
A study from Egypt reported that e-cigarette smoking was nine times higher in
females (27.8%) than males (3.1%), with the prevalence of e-cigarette smoking
among female waterpipe smokers being 12 times higher than males (40.3% and
3.3%, respectively) (Mostafa et al. 2018).
The prevalence of e-cigarette use in Qatari males is 2.5% compared to 0.5% in
females (Palipudi et al. 2016). In Lebanon the prevalence in males was much higher
than females (58% versus 1.7%), with males showing better awareness and positive
attitude toward e-cigarettes use (Aghar et al. 2020). In other countries like Oman no
data were reported on e-cigarettes use (Al-Lawati et al. 2017).
Waterpipe Smoking
Water pipe smoking probably started about 400 years ago in India. The term “water
pipe” is a modern name, as local terms for this type of smoking include argileh or
shisha. Waterpipe use was mainly part of the culture of the Eastern part of the world,
and was an experience that tourists would not miss when visiting the Middle East,
India, and other countries. Waterpipe smoking has now gained more charm and
appeal not only among tourists but also by large sectors of populations across the
globe. Epidemiological studies report that waterpipe smoking is a popular habit
among all age groups, particularly the young generations including school and
university students, in almost all continents.
Contrary to the use of cigarettes, which mostly occurs in males, waterpipe
smoking in Arab countries is prevalent in both genders, and is considered a gateway
or a substitute to smoking other forms of tobacco such as cigarettes. This is largely
due to cost savings and mistaken perceptions of less associated health risks. The
habit appears to be popular in females who cite a number of factors that encourage
such behavior including pleasure, curiosity, independence, and freedom to make
their own life decisions. Increased popularity is enhanced by the fact that females are
targeted by advertisements that emphasize a sense of sophistication, freedom and
independence, power, weight control, and stylishness, all of which are characteristics
being linked to the open-minded, modern woman.
In contrary to cigarettes, the lax family and social attitudes toward waterpipe smoking
has greatly encouraged females to practice the habit in public without concerns of being
judged or blamed. The habit seems to have gained more popularity among adolescents,
or even worse, among children. The passive role of society that shows acceptance and
encouragement of females to smoke waterpipe seems to override religious beliefs that
are strongly linked to Arabic culture (Dar-Odeh et al. 2013). The majority of Arabs
practice Islam, where the basic belief is that one’s soul is a gift that should be cherished
and preserved, and which regards any action that endangers health, wellness, and safety
as a violation of its teachings. Cigarette smoking is not socially accepted for girls in
conservative Arabic societies, and is considered an inappropriate and impolite behavior
that may tarnish their reputation, or even jeopardize their opportunities to get a proper
marriage proposal. Consequently, cigarette smoking is practiced in secret, particularly
by unmarried girls. However, it is not uncommon to see females (whether single or
married) practicing the habit of waterpipe smoking in the open without feeling
embarrassed or ashamed (Dar-Odeh and Abu-Hammad 2011).
The use of waterpipe is encouraged in female smokers by the trendy presentation
of the instrument and the habit. The attractiveness of its smell and taste, availability
of pre-prepared moistened tobacco mixes (Maassel), and the availability of a wide
range of fruity and similarly attractive flavors contribute to the powerful resurgence
of this habit in the Arab world among the female population.
Endorsement of official authorities in several countries to grant licenses for
waterpipe coffee shops has contributed to the increased popularity of this type of
smoking by reinforcing the feeling of a safe, social atmosphere for youth of both
genders to enjoy without much (if any) parental supervision. A random visit to one
of these coffee shops constitutes an invitation to start this habit when watching others
smoking the waterpipe and apparently enjoying the exotic experience.
Before the COVID-19 pandemic that first appeared in China in winter 2019,
family members (including youth) would share a single waterpipe during the
smoking session. This behavior usually reflected hospitality and the generous nature
of the Arabs. When sharing a waterpipe, smokers would use the same hose tip while
transferring the whole equipment from hand to hand and from mouth to mouth. Even
before the COVID-19 epidemic, this behavior was potentially risky and constituted a
means for cross-infection with skin and oral pathogens. Elite coffee shops used to
provide disposable pieces like plastic hose-tips or plastic hoses (ironically called
hygienic hose) at an extra charge. However, many customers would prefer not to use
them due to extra costs or because the hygienic hose provides a rough smoking
sensation due to its narrower diameter when compared to traditional hose. Further-
more, the plastic hose is nonporous in nature which may lead to delivery of more
toxic substances than the porous traditional leather hose. The emergence of the
COVID-19 outbreak in 2020 has caused many countries to implement quarantine
practices including closure of waterpipe coffee shops. As a result, people shifted to
practicing the habit of waterpipe smoking mainly at their homes. Whether this has
influenced epidemiological aspects of waterpipe smoking, and increased second-
hand smoke exposure among family members remain to be further investigated.
Although waterpipe was displayed as a “healthier” alternative to other tobacco
smoking methods, many studies report several adverse health effects. However,
interpreting the results of these studies is complicated as some of these studies
were conducted on dual smokers (waterpipe and cigarette smoking) and not exclu-
sively on waterpipe smokers. Aldehyde compounds in waterpipe smoke are toxic,
carcinogenic, and hazardous. Waterpipe smoking releases great amounts of formal-
dehyde, and acetaldehyde particularly with fruit-flavored tobacco which exposes
café customers and employees to many health risks like cancer (Naddafi et al. 2019).
Some studies report increased urinary levels of tobacco-specific nitrosamines and
polycyclic aromatic hydrocarbons following waterpipe smoking (Radwan et al.
2013). The plasma levels of nicotine after one session of waterpipe smoking are
estimated to be equivalent to smoking 2–3 cigarettes (Jacob et al. 2011). Waterpipe
smoke, which is produced at about 450 °C compared to about 900 °C for cigarettes,
contains charcoal combustion products that include substantial amounts of carbon
monoxide, and is a frequent cause of carbon monoxide poisoning (Veen 2016).
Waterpipe smokers had about twofold higher expired CO levels than cigarette
smokers (Shafagoj et al. 2002). The affinity between hemoglobin and carbon
monoxide is approximately 210 times stronger than the affinity between hemoglobin
and oxygen (Blumenthal 2001). Carboxyhemoglobin does not have the ability to
carry oxygen thus reducing its availability to tissues. This preferential binding of
hemoglobin to carbon monoxide starves organs of oxygen, leading to an increased
risk of ischemic events (Kadhum et al. 2014). Long-term carbon monoxide exposure
elevates total red blood cells mass in smokers as a result of loss in oxygen carrying
capacity, leading to increased blood viscosity. Increased levels of carbon monoxide
in the body can lead to detrimental effects such as nausea, vomiting, confusion,
shortness of breath, and memory loss (Kadhum et al. 2014). Waterpipe smoking is
associated with elevated levels of carboxyhemoglobin, and can sometimes progress
to acute syncope and intraoperative toxic levels during anesthesia. The problem is
clearly manifested in waterpipe cafés where patrons had more than three times the
level of carbon monoxide as did traditional bar patrons (Barnett et al. 2011).
Nicotine, the addictive substance in tobacco smoking, was found to be about
threefold higher in plasma of waterpipe smokers than cigarette smokers (Shafagoj
et al. 2002).
Waterpipe smoking significantly increased urine excretion of tobacco-specific
nitrosamines and polycyclic aromatic hydrocarbons (Jacob et al. 2013). Waterpipe
smoking is also associated with decreased pulmonary function leading to increased
risk of chronic obstructive airway disease. It has been suggested that waterpipe
smoking does not affect pulmonary functions as seriously as is the case with
cigarette smoking, which was attributed to the relatively long periods of time
between waterpipe smoking sessions, which allow healing of inflamed airways.
However, this difference may be insignificant in smokers who smoke waterpipe on
a daily basis or more than once during the day. Waterpipe smoking affects the
pulmonary system directly by reducing aerobic capacity and lung cell proliferation,
and accelerating lung aging (Hawari et al. 2017).
Only a few studies have reported the effects of waterpipe smoking in the oral cavity.
The habit is known to promote periodontal bone loss, halitosis, and increased suscep-
tibility to acute osteitis (dry socket) after dental extractions (Al-Humaidi et al. 2017).
A few studies investigated the association between waterpipe smoking and oral
candidiasis, but with conflicting results (Dar Odeh et al. 2016; Akram et al. 2018).
The association between waterpipe smoking and potentially malignant lesions such as
oral leukoplakia is still weak and where it has been reported, there were obvious
confounders such as cigarette smoking and betel quid chewing (El-Zaatari et al.
2015). Current thinking suggests that the increased incidence of oral cancer reflects
changes in the patterns of exposure to some risk factors. The disease is primarily
associated with tobacco and alcohol, which act synergistically. It is thought that the
development of oral cancers in waterpipe smokers is attributed to exposure to carcino-
genic chemicals, mechanical trauma (irritation by the bamboo or plastic tubes used in
the mouth piece), the heat generated from the smoke, and chronic infection associated
with the use of one waterpipe by several individuals. The link between waterpipe
smoking and oral cancer is of interest because there is a popular belief that the filtration
of the tobacco smoke through water removes potential carcinogens. A recent systematic
review found that waterpipe tobacco smoking was significantly associated with respi-
ratory diseases, bronchitis, wheeze in passive smokers, oral cancer, lung cancer, low
birth weight, metabolic syndrome, cardiovascular disease, and mental health (Waziry
et al. 2017). Although there are reports of an association between waterpipe smoking
and some cancers including esophageal carcinoma, bladder cancer and pancreatic
cancer, the link seems to be weak (El-Zaatari et al. 2015).
Smoking one or more waterpipes a day during pregnancy is associated with at
least a 100 g reduction in the adjusted mean birth weight of babies (Nuwayhid et al.
1998). Further, the risk of having babies of low birth weight almost doubles in those
who smoke waterpipes (Nematollahi et al. 2018). Babies born to women smoking
waterpipe during pregnancy have a higher proportion of other health concerns
such as neonatal respiratory distress, and increased risk of reductions in anthropo-
metric measurements such as mean newborn length and mean newborn head
circumference.
Statistics for the prevalence of waterpipe smoking by Arab women especially the
young age group are disturbing particularly in countries such as Lebanon, Jordan and
Syria, Egypt, Palestine, and Gulf regions. Data from more conservative societies such
as those of the Gulf are scarce as studies are mostly conducted on male populations
(Baboor et al. 2014). The prevalence of waterpipe smoking by young Arab women was
lowest in the Maghreb and Gulf areas, and highest in Lebanon where it ranged from
0.2% to 38%. Men in Palestine were about three times more likely to be current
waterpipe tobacco smokers compared to women (36.4% vs. 12.9%) (Tucktuck et al.
2017). Approximately 1.3% of Emirati women indulged in waterpipe smoking (Al-
Houqani et al. 2018), with a much higher prevalence of 26.2% among university
students (Mandil et al. 2007). Waterpipe smoking increased from 3.34% to 7.35% in
Saudi men between 2005 and 2015, and from 0.5% to 1.28% in women aged 15–
64 years, suggesting increases in this habit in all age groups and for both sexes (Moradi-
Lakeh et al. 2015). A recent study among female Saudi students in Jeddah, Western
Saudi Arabia, showed that students were more inclined to use the waterpipe (8%
prevalence) when compared to cigarettes (5% prevalence) (Merdad et al. 2007).
Young adult females were more likely to smoke flavored waterpipe tobacco (76.7%)
than older females (65.1%) or their male counterparts (12.4%) (Mostafa et al. 2018). In
the 2005 and 2009 Global Youth and Global Adult Tobacco Surveys, Egyptian
Tobacco use by Arab women
Cigarettes Waterpipe E cigarettes Smokeless

A common form (Shisha, The most recent tobacco
of tobacco use form spreading (Shammah, Midwakh
among Arab
Argileh) Toombak)
among Arab
women A popular form of women Limited to specific
Limited to areas including
Prevalence is tobacco use particularly the Specific areas
among Arab youth the United
thought to be including Yemen, Emirates and
underestimated women Insufficient data South Saudi Lebanon
due to social Popularity is on prevalence Arabia and Sudan
taboo encouraged by: and associated Associated with
Mainly used rapid adverse
Is thought to be 1. social factors due to the among
limited number of cardiovascular
most prevalent in acceptance postmenopausal effects leading to
the Levant and studies women with
2. misconception dizziness and
least prevalent in More data is increasing contributing to its
of its safety
Maghreb, Egypt, needed on reports on its popularity
Sudan and Gulf 3. the fashionable prevalence and use among
region looks and exotic associated health adolescents of
tobacco mixes risks both genders
Fig. 3 Different forms of tobacco use and factors contributing to their prevalence
adolescent girls were 11 times more likely to smoke waterpipe tobacco than adult
women and reported a higher prevalence of overall use of any tobacco product (3.8%)
than older females (0.3%) (El Awa et al. 2013). Yemeni university female students also
showed a preference of waterpipe smoking when compared to cigarette smoking with a
prevalence of 13% (Nasser et al. 2018). It was also found that as high as 15% of
pregnant women in Jordan and 21% in Lebanon smoke the waterpipe (Azab et al. 2013;
Chaaya et al. 2003). The different forms of tobacco use and their characteristics are
illustrated in Fig. 3.
Health Risks of Tobacco Use in Women
Ailments caused by tobacco use in women are similar to those affecting men, such as
cardiovascular diseases, respiratory diseases, cancer, and infertility. Women are also
subjected to adverse pregnancy outcomes, and their offspring are at risk as well
(Samet and Yoo 2001). Tobacco use in women is associated with premature meno-
pause, delayed conception, and menstrual abnormalities, miscarriage, preterm deliv-
ery, intrauterine growth restriction, sudden infant death, and others. The health
hazards of tobacco use among women are summarized in Fig. 4.
Cancer in the Smoking Woman
Tobacco smoking is a risk factor for lung cancer which claims the lives of many women
in the world. Moreover, it is also a risk factor for the following types of cancer: kidney,
nasal cavity, bladder, paranasal sinuses, lips, tongue, larynx, pharynx, esophagus,
stomach, uterine cervix, liver, pancreas, colorectal, vulvar, ovarian cancers, and acute
myeloid leukemia (Kjellberg et al. 2000; Madsen et al. 2008; Tsoi et al. 2009).
Lung cancer is the leading cause of death attributed to cancer in women world-
wide (Lombardi et al. 2011). Increased risk of lung cancer has a genetic and
biochemical basis. It is speculated that nicotine induces gastrin-releasing peptide
receptor, a receptor which is expressed more frequently in women, and which is
linked to lung cancer (Shriver et al. 2000). Smoking women are also thought to
metabolize nicotine more rapidly, and produce more tobacco-specific nitrosamines
than men (Benowitz 2008).
The association between breast cancer and smoking remains controversial; how-
ever, more evidence is emerging that documents an association between breast
cancer and tobacco smoking. This is explained by the mutagenic potential of
carcinogens found in tobacco smoke such as polycyclic hydrocarbons, aromatic
amines, and nitrosamines (Egan et al. 2002). The association is further confirmed by
several meta-analyses, systematic reviews, and epidemiologic studies which found
that the risk of developing breast cancer is 70% higher in smoker women (Nagata
et al. 2006), and that this risk is dose- and time-dependent (Reynolds et al. 2004).
The risk of developing cervical cancer triples in smoking women and is dose-
dependent (Kjellberg et al. 2000). Moreover, it seems that smoking increases the risk
Fig. 4 Health hazards of tobacco use by women
of progression to cervical intraepithelial neoplasia for women who have human

papillomavirus (Collins et al. 2010).
Oral cancer presents mostly as squamous cell carcinoma. Although this cancer
can affect nonsmokers, the patients are predominantly smokers. An increased risk to
oral squamous carcinoma in smoker women was found to be higher than smoker
men (Muscat et al. 1996). On the other hand skin cancer can present as melanoma or
nonmelanoma cancers, the latter presenting as basal cell carcinoma and squamous
cell carcinoma. Smoker women have a threefold increased risk to develop skin
squamous cell carcinoma (Rollison et al. 2012).
Cardiovascular Effects
Women who smoke are susceptible to similar cardiovascular problems encountered

by men but the risk of developing a stroke increases in women consuming oral
contraceptives (Teo et al. 2006). Even in women who do not consume oral contra-
ceptives, studies have shown that there are greater relative risks for stroke and
coronary heart disease from smoking for women than men (Woodward et al.
2005). In the case of oral contraceptive consumption, the interaction between
products of tobacco smoke with oral contraceptives accelerates their metabolism
and decrease their serum levels, hence increasing the risk of thrombotic events
(Reichert et al. 2009). In general, smoking may produce an antiestrogenic effect in
addition to the thrombogenic effect which could increase the risk. Women who
smoke as few as four cigarettes a day are three times more likely to die from coronary
heart disease than nonsmokers (Bjartveit and Tverdal 2005).
Further, smoker women with polycystic ovary syndrome had increased insulin
resistance and increased susceptibility to cardiovascular disease probably due to
increased fasting insulin, free testosterone, and free androgen index (Cupisti et al. 2010).
Respiratory Diseases
It is estimated that the likely death from chronic obstructive pulmonary disease
(emphysema and chronic bronchitis) among smoker women is 22 times more than
nonsmokers (United States Department of Health and Human Services 2014).
Gender differences in deterioration of lung function due to smoking are controver-
sial. However, men and women may have variable susceptibility due to differences
in lung morphology that may modify the dispersion and deposition of cigarette
smoke, or the differences in homeostatic processes controlling lung clearance and
recovery after smoking cessation (Kim and Hu 1998).
It was also found that women who smoke have higher rates of asthma regardless
of their weight (Chen and Mai 2011). Within this context, females were found to be
more susceptible to the effects of smoking than men with the risk of asthma being
significantly related to active smoking in women but not in men (Piipari et al. 2004).
Osteoporosis
Another effect of smoking is the development of osteoporosis and bone fractures

regardless of bone mineral density. Women who smoke have lower estrogen concentra-
tions, lower body mass index, increased bone turnover, decreased calcium absorption,
and decreased bone mineral density with an 80% higher risk of fracture (Rigbi et al.
2011). In particular, women who smoke the waterpipe were found to have a decreased
bone mass density and an increased risk of new fractures (Ardawi et al. 2013).
Endocrine Disorders
The relationship between smoking and levels of sex hormones has been explored
particularly that there is a potential of developing chronic diseases like cancer and
cardiovascular diseases (Benson et al. 2010). Heavy smoking women and those who
start smoking as early as adolescence are at a higher risk for premenstrual syndrome
and irregular, shorter menstrual cycles than nonsmokers (Bertone-Johnson et al.
2008). Tobacco use in women is associated with premature menopause, delayed
pregnancy, menstrual abnormalities, and other adverse health outcomes (Fréour et al.
2013). Smoking is a factor that doubles the risk for the development of ectopic
pregnancy because of interference with ovulation and fallopian tube function
(Reichert et al. 2009). An increased risk to diabetes was also observed in smokers
of both genders; however, this risk seems to be greater in women (Liu et al. 2018).
Genitourinary Disorders
An unexplained finding in smoker women was the higher rates of urinary incontinence.
This disorder was related to years of smoking and was associated with higher levels of
urinary cotinine, and worse self-reported cough (Hannestad et al. 2003). Chronic cough
associated with chronic obstructive pulmonary disease is thought to induce anatomic
changes and pressure leading to incontinence (Bump and McClish 1992). Smoking is
the most important risk factor of bladder cancer. Approximately 33% of bladder cancer
cases in women affect smokers (La Vecchia et al. 1991). It is also estimated that 15% of
kidney cancer cases in women are associated with smoking (Parkin 2011). Each puff of
smoking exposes the body to an estimated 60 types of carcinogens, many of them can
be identified in smokers’ urine (Mobley and Baum 2015).
Interstitial cystitis is a chronic bladder disorder characterized by pain and is
considered of unknown etiology. Smoking is blamed to be an aggravating factor in
this disorder (Temml et al. 2007).
Breastfeeding Mothers
Nicotine is detected in the breast milk of women who smoke during breastfeeding,
and children of nicotine using mothers who smoke during breastfeeding may be at a
higher risk of becoming smokers in the future. It is estimated that the amount of
nicotine detected in breast milk is more than double that detected in the mother’s
serum (Mennella et al. 2007). It is also reported that smoking impairs nutritional
value of breast milk by lowering its iodine content (Laurberg et al. 2004). While
nicotine reduces the amount of milk produced and results in shorter lactation periods,
it also impairs the taste of milk and suppresses the baby’s appetite (Napierala et al.
2016). Babies who are breast fed by smoker mothers were found to have sleeping
disturbances (Mennella et al. 2007).
Pregnant Women and Their Offspring
As high as 25% (Bachir and Chaaya 2008) and 15% (Azab et al. 2013) of pregnant
women in Lebanon and Jordan smoke tobacco. A lower rate of 4–18% was reported
in Tunisia (Fakhfakh et al. 2011). Pregnant women may choose to smoke the
Fig. 5 Health risks of tobacco use for pregnant women and their offspring
waterpipe more often than cigarettes due to the misconception that water has a
filtering action and hence is associated with less harm than cigarettes. However,
waterpipe smoking was found to affect fetal health in several ways. It is associated
with low birth weight, low Apgar score, pulmonary complications at birth, and infant
mortality (Akl et al. 2010; El-Zaatari et al. 2015).
More recently, studies suggest that exposure to e-cigarettes during pregnancy could
cause fetal respiratory and neurological disorders (Li et al. 2018). On the other hand,
fetus exposed to tobacco is susceptible to obesity (Behl et al. 2013). Recent evidence
suggests that parental smoking during pregnancy is associated with increased risk of
diabetes mellitus independent of body mass index (La Merrill et al. 2015). Several
adverse pregnancy outcomes have been reported: miscarriage, preterm delivery, intra-
uterine growth restriction, and sudden infant death (Lombardi et al. 2011). High blood
carbon monoxide levels and compromised placental blood flow are associated with
fetal hypoxia and intrauterine growth restriction which subsequently lowers intellectual
attainment in children (Burstyn et al. 2012). In addition, children born to smoker
mothers are susceptible to impaired lung development and asthma (Castro-Rodriguez
2014). Smokeless tobacco was also reported as a risk factor for increased rates of fetal
morbidity and mortality (Zhou et al. 2014). The health risks of tobacco use in pregnant
women and their offspring are presented in Fig. 5.
Barriers to Smoking Prevention and Cessation Among

Arab Women
Tobacco use by Arab women is associated with many confounding factors including
social status, education, age, employment, income level, marital status, psycholog-
ical status, and religious beliefs. Women generally face specific challenges and risks,
such as harassment, domestic violence reproductive problems, unwanted pregnan-

cies and unsafe abortions, family rejection, financial pressures, and legal issues.
Other obstacles are related to healthcare systems, where there is limited access to
healthcare facilities and the presence of many coexisting morbidities (Abu-Hammad
et al. 2018; Dar-Odeh et al. 2019). Further, there is a high prevalence of tobacco use
among healthcare professionals, thus undermining organized and robust tobacco
cessation efforts on the national levels (Dar-Odeh et al. 2016; Alajmi et al. 2017).
Since most Arab women start tobacco use during early years of life including
university years, it may be beneficial to target female students in high school and
university. Tobacco cessation efforts need to be tailored to accommodate the cultural
and social beliefs of female smokers, especially that male smokers had more
knowledge about smoking cessation services than females (Jaghbir et al. 2014).
Many women smoke in secret, and many would avoid tobacco cessation activities
to avoid social embarrassment. A common belief is that women appear to be more
motivated to smoke after watching thin celebrities, indicating a perception of self-
image among female smokers (Sweis 2018). Women consistently show less confi-
dence in their ability to quit smoking, have lower levels of quitting motivation, and
feel more stress during the cessation period. Women involved in smoking cessation
therapy also report more tobacco withdrawal symptoms, such as anxiety, depression,
and irritability, compared to men. Furthermore, nicotine replacement therapy may
not be as useful in women, implying that nicotine is not the only reinforcing agent in
female smokers. Women seem to be more sensitive to the non-nicotine components
of tobacco, such as sight, smell, and the sensation of smoking, the so-called
behavioral dependence. In the case of waterpipe smoking, there is the lure of the
unconventional materials and the variations in the tobacco mix, drugs added to this
mix, that may be appealing to women. An aspect of smoking cessation therapy
unique to women is the effect of the menstrual cycle on success rates. Premenstrual
symptoms are associated with higher relapse rates in women attempting smoking
cessation, suggesting that quitting during the follicular phase (estrogen-dominated)
may be associated with a higher relapse rate as estrogen may be associated with the
reinforcing effects of addictive drugs.
It was noticed that women may gain weight during tobacco cessation. Hence, it is
advisable to practice exercise during this critical period, and this is expected to
improve cardiovascular health, reduce post-cessation weight gain, and improve
important factors related to inflammation, namely white blood cells, prothrombotic
factor, cholesterol profiles, and maximum oxygen consumption (Korhonen et al.
2011).
Another factor that may represent an obstacle to tobacco cessation efforts is the
issue of substance use among Arab women. Khat is another popular substance for
chewing particularly in the Arabic peninsula. It was found that approximately 14%
of women of different educational and social backgrounds are khat chewers in Jazan,
Southern Saudi Arabia (Mahfouz et al. 2015). More research is emerging from
Lebanon to report on the issue of substance abuse among women. This is probably
attributed to the less conservative nature of the Lebanese society and willingness of
women to talk about their social habits. In Lebanon a recent study among university
students found that the top five substances used by female students include alcohol
(38%), tobacco (25.5%), tranquilizers (11.1%), cannabis (8.5%), and stimulants and
solvents (4.7%) (Salameh et al. 2015). Although the previous study reported a high
prevalence of alcohol consumption among female students, this practice is not often
associated with Muslim students who regard this as “haram” or prohibited (Salam et
al. 2013). However, it was noticed that rates of alcohol consumption among women
in Lebanon are increasing, and once an alcohol drinker, the influence of religion
almost fades (Karam et al. 2004).
Reports on cannabis use among women in other Arab countries are scarce, and a
number of countries have no reports on the prevalence of its use. One study from Iraq
reported that a number of 106 females younger than 17 years are registered with drug
or alcohol use problems.
Conclusions
There are five forms of tobacco use among Arab women: cigarettes, e-cigarettes,
waterpipe, midwakh and smokeless tobacco. Perhaps the most popular forms of
these are cigarettes and waterpipe smoking which are used by females in many Arab
countries. On the other hand, smokeless tobacco and midwakh are localized to
particular areas of the Arab region; smokeless tobacco (shammah, toombak) is
used in Sudan, Saudi Arabia, and Yemen, while midwakh is used in Lebanon and
Arab Emirates. The most recent form of tobacco use to emerge is e-cigarettes, which
have not yet gained much popularity among the female Arab population. The
statistics on prevalence of tobacco use among Arab women should be interpreted
with caution because of underestimating the true prevalence among the female
gender particularly in conservative Arab societies. Social restrictions cause many
Arab women to smoke in secret. This is complicated by other contextual issues that
could contribute to women’s tobacco use in the Arab region, such as political
turmoil, education, family role, trauma, violence, poverty, social media, and
women empowerment. Arab countries have strong cultural and psychosocial values
which limit women’s smoking behaviors as such activities were thought to reflect
disrespect, masculinity, and disobedience. The tobacco industry has succeeded to
change this attitude so that smoking by Arab women is now perceived as positive
images of liberation, triumph, well-being, and dignity.
Empowerment of women is occurring in most Arabic countries, meaning that
Arab women can now enjoy a number of privileges such as higher education, better
career opportunities, and as a result an increased spending power. The numbers of
women judges, ministers, and members of parliament are on the rise. Unfortunately,
health risk behaviors such as smoking and sedentary life styles are not being
addressed. Younger generations, particularly female adolescents, are adopting liberal
attitudes including smoking. Social pressure and antismoking campaigns are
directed mainly against cigarette smoking, and although they have been relatively
successful in limiting cigarette smoking by females in Arabic countries, there is a
need for other tactics to address alternative smoking methods such as waterpipe
smoking. Laws banning smoking in public premises have reduced the numbers of
cigarette smokers; however, laws should be implemented to regulate water pipe
coffee shops and ensure proper hygienic practices, and establish minimum age limits
of their customers.
According to the WHO smoking cessation interventions raising tobacco taxes,
banning tobacco marketing, and cessation support have been shown to be highly
effective; however, they are underutilized. Significant tobacco tax and price
increases are the most cost-effective of these interventions (U.S. National Cancer
Institute and World Health Organization 2016).
It is important to involve family values when considering tobacco prevention and
cessation for Arab females, since smoking is mostly practiced after approval from a
male figure in the family such as a father or husband. Unfortunately, the family role in
combating smoking seems to be lacking. On the contrary, a family member such as a
father, a sister, a brother, or a mother could be responsible for introducing tobacco to
the young adolescent female relative. The lack of awareness of tobacco hazards,
particularly related to recent types of tobacco use habits such as waterpipe smoking,
adds to the role model of smoking mothers. The role of schools in tobacco prevention
is particularly invaluable as this is a critical period of adolescence and peer pressure;
fortunately female school workers in parts of the Arabic world understand their roles
in the use of tobacco by their young learners (Almahdi et al. 2017b).
The role of the family in influencing health behaviors of women may be
counteracted by social networking and information technology, which create rather
permissive and more lenient attitudes. The World Health Organization, in collabo-
ration with the ministries of health, delivers educational programs not only to school
students but also to their parents. Since peer pressure is an important aspect in
tobacco use, it is also important to involve youth in the fight against tobacco use and
encourage them to play a proactive role in prevention and cessation campaigns.
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Epidemiology of Mental Health Problems in
the Middle East 8
Nahla Khamis Ibrahim
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
Overview of Global Mental Health Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
Classifications of Mental Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
Mental Health in the Middle East . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
Magnitude of Mental Health Problem in the EMR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
Common Problems in Mental Health Management in the Region . . . . . . . . . . . . . . . . . . . . . . . . . 137
Common Mental Disorders in EMR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
Determinants of Mental Disorders in the EMR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Recommendations for Improving Mental Health in the Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
Abstract
This chapter provides reviews on mental health in the Middle East, with an
emphasis on the magnitude, common presentations, determinants, and suggested
solutions for disorders of mental health in the region.
All electronic databases were searched for studies on mental health in the
Middle East region, and publications from 1990 to 2018 were searched, scrutinized,
and summarized.
The data indicates that the Middle East has high rates of mental health disorders,
and the rates are predicted to increase due to ongoing wars and conflicts. Large
community-based studies reported that the prevalence of mental illness ranges from
15.6% to 35.5%, with the higher rates being in nations with complex emergencies
N. K. Ibrahim (*)
Community Medicine Department, Faculty of Medicine, King Abdulaziz University, Jeddah,
Saudi Arabia
Epidemiology Department, High Institute of Public Health, Alexandria University, Alexandria,
Egypt
e-mail: nahlakhamis@yahoo.com

https://doi.org/10.1007/978-3-030-36811-1_12
134 N. K. Ibrahim
such as war and famines. Mental illness is associated with 11.9 million disability-
adjusted life years (DALYs) during the period from 1990 to 2013, with Palestine,
Djibouti, and Somalia recording the highest DALYs in the region.
The most common mental disorders in the region are depression and anxiety,
particularly in vulnerable groups such as females, the poor, unmarried, elderly,
those suffering from chronic illnesses, victims of conflicts or violations of human
rights, and refugees. The stigma attached to mental disorders is a common reason
for not seeking for mental health care, and this leads to negative health outcomes.
Important is the inverse association between religious belief and some mental
illnesses, especially in cases of depression.
Suggestions for improving the mental health programs and services are
recommended in the region. Decreasing the stigma attached to mental illnesses
can be achieved through mass media, schools, universities, etc. Conflict resolution
is required. More researches in mental health are needed across the Arab world.
Keywords
Mental illnesses · Middle East · Distribution · Determinants · Conflicts and
solution
Abbreviations
ADHD Attention deficit hyperactivity disorder
BDI Beck Depression Inventory
DSM–5 Diagnostic and Statistical Manual of Mental Disorders-5
DALYs Disability-adjusted life years
EMR Eastern Mediterranean Region
GBD Global Burden of Disease
HADS Hospital Anxiety and Depression Scale
HIV Human immunodeficiency viruses
ICD-10 International Classification of Disease-10
KSA Kingdom of Saudi Arabia
MDE Major depressive episode
PTSD Post-traumatic stress disorder
UAE United Arab Emirates
WHO-AIMS WHO-Assessment Instrument for Mental Health Systems
Introduction
Overview of Global Mental Health Problems
Mental health was newly defined in 2015 as “a dynamic state of internal equilibrium
which enables individuals to use their abilities in harmony with universal values of
society” (Galderisi et al. 2015). Mental illnesses are complicated, multifactorial
disorders that occur due to the interaction of personal, cultural, religious, and biolog-
ical factors with environmental conditions (Adawi et al. 2018). Mental disorders was
8 Epidemiology of Mental Health Problems in the Middle East 135
ranked as the ninth cause of global burden of disease in 2017 (Mokdad 2017) and
accounted for about 15% of the global burden of diseases, with their burden being
higher than from all cancers (Zender and Olshansky 2009). The commonest three
mental illnesses in the world are depression, anxiety, and somatic complaints. These
disorders affect approximately one-third of the world’s population, with a female
predominance (Hamdan 2009). Mental illnesses affect approximately 25% of adults
yearly (Zender and Olshansky 2009). The results of a meta-analysis of studies between
1980 and 2013 suggest a prevalence of common mental illnesses in adults as 17.6%
during 12 months preceding the studies and 30% throughout life (Steel et al. 2014).
Global mental health is a growing concern, with increasing benefits from world-
wide efforts for sustainable development of mental health programs (O’Donnell and
O’Donnell 2016). The epidemiology of mental disorders is well studied in high-
income countries, but there is a need to study these disorders in lower income
countries (Allen et al. 2014).
Classifications of Mental Disorders
Psychiatric disorders are classified based on both the International Classification of

Disease-10 (ICD-10) and the Diagnostic and Statistical Manual of Mental Disorders-
5 (DSM–5). This is done using a diagnostic hierarchy, which divides the psychiatric
disorders based on presentations:
1. Personality disorders
2. Anxiety disorders: generalized anxiety, panic, obsessive compulsive, post-trau-
matic stress, and adjustment disorders
3. Mood disorders such as bipolar affective disorders and psychotic depression
4. Psychotic disorders such as schizophrenia
5. Organic disorders such as delirium, dementia, and disorders related to drug and
alcohol abuse (Katona et al. 2015)
All electronic databases of “PubMed, Clinical Key, Google, Google scholar & the
World Health Organization” were extensively searched for the period 1990–2018.
Furthermore, all documents and books were also investigated. The keywords used
were: mental health, mental health problems, mental illnesses, mental disorders,
psychiatric problems, Arab countries, Middle East, Eastern Mediterranean Region
(EMR), mental stigma, conflicts, morbidity, mortality, and burden.
The collected references were then scrutinized and summarized. The most impor-
tant studies are discussed in this chapter.
Mental Health in the Middle East
The Middle East or the EMR region consists of 22 countries which include the Arab
countries and also Pakistan, Afghanistan, and Iran (Charara et al. 2017). Sixteen out
of these countries are classified as low- and middle-income nations (Mokdad 2017).
136 N. K. Ibrahim
These countries differ in their income, socioeconomic levels, health indicators,

health system capabilities, and health coverage (Jefee-Bahloul et al. 2015).
The vast social variations, cultural transitions, and globalization in Arab nations
have affected the attitudes, beliefs, and behaviors of their youth (Hamdan 2009;
Bener et al. 2015). There have been rapid demographic changes and epidemiological
transitions in the region, with improvements in health status resulting in increased
longevity and decreased childhood deaths. The EMR experiences a considerable
burden of chronic diseases, including mental disorders (Charara et al. 2017; Al-
Hamzawi et al. 2015; Liu 2017), and this is predicted to further increase due to
ongoing unrest in the region (Charara et al. 2017). Most countries in the region are
prone to struggles, wars, and terrorism. Furthermore, cultural beliefs and the influ-
ence of the “magic” or “evil eye” can impact mental symptoms (Okasha 2012;
Charara et al. 2017).
Magnitude of Mental Health Problem in the EMR
Mental illnesses – though difficult to measure – usually contributes to disability,

morbidity, mortality, and increased rates of other associated medical illnesses (Jaju
et al. 2009; Hamdan 2009).
All EMR countries have a relatively greater burden of mental disease than global
levels, imposing an ever-escalating burden of concern (Mokdad et al. 2016). If such
illnesses are not suitably addressed, mental health concerns will increase even more
in the region. According to the Global Burden of Disease (Charara et al. 2017), and
based on the “Diagnostic and Statistical Manual of Mental Disorders and the
International Classification of Diseases,” it is estimated that mental disorders were
responsible for 5.6% of the total disease burden in the EMR. It was estimated that
more than 100 million persons suffer from mental illnesses in the region. In 2013,
mental disorders contributed to 5.6% of the total disease burden in the EMR (1894
DALYs/100,000 population): 2519 DALYs/100,000 population (2590/100,000
males, 2426/100,000 females) in high-income countries, 1884 DALYs/100,000
population (1618/100,000 males, 2157/100,000 females) in middle-income coun-
tries, 1607 DALYs/100,000 population (1500/100,000 males, 1717/100,000
females) in low-income countries. The DALYs due to mental disorders increased
from 1726 DALYs/100,000 population in 1990 to 1912 DALYs/100,000 population
in 2013 (10.8% increase). Within the mental health disorders in the EMR, depression
accounted for most DALYs and this was followed by anxiety disorders. Regarding
countries, Palestine carries the largest burden of mental health disorders in the
region. This may be attributed to the presence of more than 50 years of conflicts.
Djibouti and Somalia had the next highest DALYs, based on the age-standardized
rates of mental disorders by countries and gender (Charara et al. 2017).
Regarding the prevalence of mental disorders, large community-based studies in
the region found that the prevalence of psychological distresses ranges between 15.6%
and 35.5%, with higher rates in nations with complex emergency circumstances
(WHO 2011). The 1-year prevalence of mental illnesses in the region ranges from
11.0% to 40.1% (Charara et al. 2017). The 30-day prevalence of psychiatric disorders
is 26.1% among Lebanese adolescents (Maalouf et al. 2016).
A nationwide household survey, 2009, done among 15,000 Egyptian persons aged
18–64 years revealed that 17% of adults had mental disorders. Mood disorders,
anxiety, and multiple disorders were the commonest types (Ghanem et al. 2009). On
the other hand, there are inconsistent results on mental health disorders in different
Gulf countries. This may be due to the benefits of an extended family, religion, under-
representation of female samples in different studies, and care of mental disorders
outside hospitals (Hickey et al. 2016). A study of 1475 persons aged 18–65 years who
attended the Qatari Primary Health Care Centers revealed presence of at least one
psychiatric diagnosis among 20% of the study sample (Bener et al. 2015).
The WHO estimated that persons with major depression and schizophrenia have a
40–60% increased risk of premature death compared to control subjects. This may be
attributed to other associated diseases that are usually left untreated, such as cancers,
cardiovascular diseases, diabetes, human immunodeficiency viruses (HIV) infection,
and suicide (WHO 2013).
Common Problems in Mental Health Management in the Region
Low Health Expenditure on Mental Disorders in the EMR

According to the Charara et al. (2017), and the WHO-Assessment Instrument for
Mental Health Systems (WHO-AIMS), money allocated to mental health services in
the region is inadequate. The mental health expenditure in the EMR is 0.15 US
dollars/person, which is half of what is spent in other parts of the world. Countries
such as Qatar, Egypt, Palestine, and Morocco assigned 1%, <1%, 2.5%, and 4% of
their health expenditure to mental health, respectively. On the other hand, Afghan-
istan, Pakistan, and Somalia allocate a very small/negligible budget on it (Charara
et al. 2017).
Lack of Access to Mental Management in Region

Many people in region with mental health disorders can’t access management of
their cases. This can be attributed to inadequate resources, lack of sufficient knowl-
edge, and a stigma of mental illnesses. The first choices for mental health patients in
the EMR are traditional healers, religious leaders, or other respected community
members (not physicians or mental health specialists) (Okasha 2012; Sabry and
Vohra 2013). The increasing number of conflicts and ongoing instability in the
region adds to the burden of mental health disorders (Charara et al. 2017).
Stigma Attached to Mental Illnesses in the Region

The stigma attached to mental disorders (discrimination and social inequity) is one of
the commonest reasons for not seeking care in the EMR (Okasha 2012; Stuart 2016).
This delay can lead to further negative health outcomes (Dardas and Simmons 2015).
It is important that patients with mental disorders in the region receive ethical,
acceptable, and effective management for their illnesses (Sabry and Vohra 2013).
138 N. K. Ibrahim
Common Mental Disorders in EMR
Depressive disorders and anxiety are the most frequent mental illnesses in the EMR
(Mokdad 2017; WHO 2017). Here, we discuss anxiety, depression, somatization,
and eating disorders related to mental health disorders in the EMR.
Depression
There are many types of depressive disorders, including major, dysthymic, psychotic
post-partum depression, and seasonal affective disorders (Zender and Olshansky
2009). Depression presents with sadness, anxiousness, hopelessness, feelings of
guilty, worthlessness, restlessness, loss of interests, fatigue, difficulty in concentra-
tion, reduced memory, insomnia or hypersomnia, eating disorders, suicidal feelings,
or suicidal attempts. Furthermore, patients can have persistent pains, headaches,
cramps, or gastrointestinal complaints that are difficult to treat (WHO 2017; Zender
and Olshansky 2009). Mood disorders are classified into bipolar affective disorders
and psychotic depression (Katona et al. 2015). Mood disorders can cause premature
mortality and morbidity by restricting the usual quality of life for months or years
(Zender and Olshansky 2009).
The prevalence of depression in the EMR varies from 6% to 32% (Hamdan and
Tamim 2011). Depression is the most common mental illness experienced by women
(Zender and Olshansky 2009). In Kingdom of Saudi Arabia (KSA), Ibrahim et al.
reported that prevalence of morbid depression was found to be 14.7%, and the
borderline depression was 21.8%, among female medical students enrolled in King
Abdulaziz University, Jeddah. It was measured using the Hospital Anxiety and
Depression Scale (HADS) (Ibrahim et al. 2013). Furthermore, it was found that
40% of Bahraini medical students have symptoms of depression (Mahroon et al.
2018). A study from Taibah University, Medina, Saudi Arabia, reported that the
overall prevalence of depression in a student population was 28.3% (Sultan et al.
2016). Mood disorders are the commonest mental illness in Egypt, with a point
prevalence of 6.4% (Ghanem et al. 2009). The prevalence of any mood disorder was
found to be 12.6% in Lebanon and 7.5% in Iraq (Okasha 2012). A mental health
survey of 4,332 Iraqi adults aged 18 years found that lifetime and 12-months
prevalence of major depressive episode were 7.4% and 4.0%, respectively. Further-
more, about one-half of them (46%) had severe or very severe forms (Al-Hamzawi
et al. 2015). The prevalence of major depressive disorders in Morocco was reported
to be 26.5%, while a study in a rural area of Pakistan reported a prevalence of
depressive disorders as 44.4% (Husain et al. 2000).
A study of Arab women (aged 18 years) who attended the Primary Health Care
Centers in Sharjah, United Arab Emirates (UAE), reported that about one-third of
females had either moderate (14.7%) or severe (18.0%) depression, based on the
Beck Depression Inventory (BDI) (Hamdan et al. 2008). Another study from
the UAE reported that depression during the post-partum period was related to the
number of children, religion, and use of formula for feeding (Hamdan and Tamim
2011). About 10% of females in the UAE are diagnosed with post-partum depression
(Hamdan and Tamim 2011). The prevalence of mood disorders in Lebanon is
estimated at 6.6% (Karam et al. 2006), while it is estimated to be 4.8% in Dakahlia,

Egypt (El-Wasify et al. 2011). One-fifth of patients presenting to primary healthcare
centers in KSA are thought to suffer from depression (Becker 2004).
Anxiety
Anxiety presents as fear accompanied by unwanted physical manifestations. Anxiety
is a normal response to stress but becomes abnormal when it is disproportionate
relative to the severity of the stress and persists after the stressor ends or when it
occurs in the absence of any external stressor (Davies and Craig 2009). It has a
negative impact on daily functions, and anxious persons can also have high levels of
comorbidities with other depressive disorders and drug abuse (Hamdan 2009).
Anxiety is the most prevalent mental disorder, with a lifetime prevalence of 16.7%
in Lebanese adolescents (Maalouf et al. 2016). Furthermore, the 30-day prevalence
of anxiety in Lebanese and Iraqi adolescents is about 13.0% (Okasha 2012;
Alhasnawi et al. 2009).
The prevalence of the generalized anxiety in Morocco is about 10.0% (Okasha
2012), and 5% in Egypt (Ghanem et al. 2009). A study of 810 adults aged
15–65 years from Dakahlia, Egypt, revealed a 1-year prevalence of anxiety of
4.3% (El-Wasify et al. 2011).
Ibrahim et al. reported that about one-third of female medical students in Jeddah,
KSA, had morbid anxiety, and almost another one-third had borderline degree
(Ibrahim et al. 2013). The situation in Bahrain is similar, where anxiety symptoms
were measured in 51% of medical students (Mahroon et al. 2018).
Somatization
Patients with mental health problems in Arab countries usually present with physical
symptoms to avoid the stigma attached with such an illness. They also tend to
underutilize (and having negative emotions toward) mental health services. They
also have a great reliance on spiritual leaders when dealing with mental illnesses (Al-
Krenawi 2005). Nearly 70–80% of psychiatric patients in developing countries tend
to present their feelings as physical complaints to avoid the stigma attached to mental
illness: depressive symptoms, for example, may be expressed as pain in the chest or
abdomen, and the patient may not be aware of feelings such as sadness or hopeless-
ness (Okasha 2003). Furthermore, 19% of patients attending primary healthcare
centers in Saudi Arabia were diagnosed with somatization, with the majority
(70%) being females; women were over twice as likely to experience somatization
(Becker 2004).
Eating Disorders
Eating disorders such as anorexia and bulimia nervosa often occur during adoles-
cence (Davies and Craig 2009). There are not many studies on eating disorders in the
EMR, even though such disorders represent an emerging problem affecting females
in the region. Atypical eating attitudes and an obsession about weight gain is fairly
common in young females from KSA, UAE, Oman, Egypt, Jordan, and Qatar. About
a quarter of a sample of 500 adolescents from the UAE were above the suggested
140 N. K. Ibrahim
cutoff-point on the Eating Attitudes Test, indicating widespread abnormal eating

attitudes and practice (Hamdan 2009). The Charara et al. (2017) reported high Years
of Life Lost (YLL) due to eating disorders in UAE, Qatar, and Kuwait (Charara et al.
2017). Another study from UAE reported that one-third of participants had moderate
to severe binge eating disorders, where that emotional eating and guilt related to the
body image were the strongest predictors of binge eating (Schulte 2016).
Some Determinants of Mental Disorders

Determinants of mental health illnesses include interactions between individual
attributes, social, cultural, economic, political, and environmental factors (policies,
social protection, living standards, working conditions, and community social sup-
ports) (WHO 2013). People vulnerable to mental illnesses include the poor, those
with chronic illnesses, abused children, drug abusers, minority clusters, older pop-
ulation, persons exposed to discrimination or violations of human rights, transgender
persons, prisoners, persons exposed to conflicts, natural disasters, or other emergen-
cies (WHO 2012). Mental illnesses also frequently involve genetic factors (Reardon
2017).
Determinants of Mental Disorders in the EMR
There are many factors associated with mental illnesses including the following.
Gender and Mental Health

Females in Arab countries are at greater risk of mental health disorders (Al-Krenawi
2005). According to the Charara et al. (2017), women in the region had a greater
burden attributed to the mental illnesses compared to men of the same age, except for
those aged <15 years (Charara et al. 2017). Women are more prone to disorders such
as depression, anxiety, somatization, and eating problems (Hamdan 2009). The
female to male ratio in mental health conditions was reported to be 1.5–2.0 (Bener
and Ghuloum 2011). The prevalence of depression and anxiety in females is about
twice that in males; gender variations occur in the rates of mental illnesses, their
associated factors, onset, diagnosis, treatment, and adjustment to other chronic
diseases (Mokdad 2017).
Studies Revealed Gender Differences in Mental Illness in the EMR

Studies from Egypt reported that young women had worse mental health status
compared to men in the same age group (Liu 2017), and that women were nearly
twice more vulnerable to mental disorders compared to men, with an odds ratio of
1.8 (El-Wasify et al. 2011).
Similar data were also reported in Qatar, where the prevalence of the commonest
psychiatric disorders was more prominent in women. This gender difference applied
to generalized anxiety, panic disorder, social phobia, depressive disorders, etc.
Nearly 20%, 12.0%, 9.7%, and 4.3% of participants suffered from 1, 2, 3, and 4
psychiatric diagnoses, respectively (Bener et al. 2015).
Females have much higher rates of anxiety disorders compared to males and have
much higher rates (more than 90%) of obsessive-compulsive disorders, generalized
anxiety, and agoraphobia compared to males (less than 10%).
It was estimated that 80% of people affected by violent conflicts, disasters, and
displacement in the world are women and children, which increases the risk of
developing post-traumatic stress disorder (PTSD) (WHO 2006; Hamdan 2009).
Two-thirds of patients with depression who attended primary healthcare centers in
KSA were females, suggesting a significant association between gender and depres-
sion (Becker 2004). The prevalence of depressive symptoms in Kuwaiti attendees of
public health centers settings was 21.7% in females and 15.3% in males (Al-Otaibi et
al. 2007). An older study from Al-Ain, UAE, indicated that lifetime depression rates
were much higher in females (10.3%) than in males (2.8%) (Daradkeh et al. 2002). A
large study about depression in Arab and Islamic countries revealed significant
gender differences in eight countries (Iraq, Syria, Egypt, Algeria, Oman, Qatar,
Morocco, and Kuwait), with rates always being higher in females (Hamdan 2009).
About one in five females and one in ten males in a study from Lebanon were
predicted to have depression during their lifetime (Karam et al. 2006). Similarly,
both anxiety and depression are higher in females (Mahroon et al. 2018). Females
were twice more prone to unipolar depression, a disorder that is projected to be the
second leading cause of worldwide disability by 2020 (Hamdan 2009). A study from
rural Pakistan also reports that females had a higher prevalence of depressive
disorders (57.7%) compared to males (25.5%) (Husain et al. 2000). Females are
prone to more severe forms of mental illnesses and are more liable to depression and
to have more relapses (Zender and Olshansky 2009).
The causes of such sex differences in mental illnesses may be related to global-
ization, and urbanization in most of the countries in the EMR. Females are exposed
to several stressors, and stress experienced by females can affect all family members,
especially children (Mokdad 2017). In addition, stresses related to the expectations
from females, family duties, along with the relatively fewer social and economic
resources, can impact their mental health.
Discrimination is also strongly associated with sex differences in mental illnesses
in the EMR. Females react differently to stress. In Western countries, women are
more willing to ask for help when she has mental illnesses. Accessibility to
healthcare providers, awareness of mental illnesses, stigma toward mental disorders,
socioeconomic levels, and cultures all contribute to the probability of visiting mental
health facilities (Bener and Ghuloum 2011).
The other causes of predominance of mental disorders in females may be
attributed to biologic variations in hormonal profiles. Such biologic differences
may be related to the risks, symptoms, the course, and recovery from mental
disorders. Female sex hormones effect the stress response and lead to higher rates
of stress among females. Women also show an increased vulnerability to depression
during times of reproductive endocrine changes such as during premenstrual, post-
partum, and peri-menopausal periods (Zender and Olshansky 2009).
Another cause of gender variation in mental illnesses may be related to the size
and structure of the brain. Males have larger brains, while females have
142 N. K. Ibrahim
proportionately larger frontal lobes (lobe for socialization, judgment, memory, and
language), and this could also contribute to the different presentations in women
(Zender and Olshansky 2009).
In addition, females are also more vulnerable to the effects of PTSD than males.
About 80% of individuals exposed to violence, disasters, and displacement are
females and children, and this increases their susceptibility to PTSD (WHO 2006).
Violence against females is a plague around the world, including in the EMR.
Violence can be in the form of domestic violence, rape, murder, forced marriage,
etc. Violence can predispose the victims to other mental disorders (Pocock 2017).
Females are so more liable to violence in the region, as shown by a study where
approximately 70% of students enrolled in the King Abdulaziz University, Jeddah,
reported exposure to some form of maltreatment during childhood (Ibrahim et al.
2008).
Age
Older people are more vulnerable to mental illnesses (WHO 2012). According to the
analysis by the Charara et al. 2017, the highest proportion of DALYs in the region
occurred in persons aged from 25 to 49 years, with a peak in the 35 to 39-year range.
Half of mental illnesses start at an age younger than 14 years. In the EMR, Attention
deficit hyperactivity disorder (ADHD) was more frequently reported in boys less
aged than 14 years (Charara et al. 2017). A study done between secondary school
students in KSA showed that feeling so sad or hopeless and feeling worried were
significantly more prevalent among older adolescents (Abou Abbas and AlBuhairan
2017).
Marital Status
Inadequate social interactions can lead to loneliness, which in turn can lead to mental
illness (Mushtaq et al. 2014). A study from Egypt reports that more than a quarter of
older men experienced worsening mental health due to failure to marry (Liu 2017).
An Iraqi study indicates that that Major Depressive Episode (MDE) was more
common in those who were previously married, separated, divorced, or widowed
(Al-Hamzawi et al. 2015). Similarly, a study of the elderly in the UAE showed that
single, separated, divorced, or widowed people were more prone to mental disorders
(Ghubash et al. 2004).
Another older study from KSA reported that unmarried elderly people had a
higher prevalence of depression (Al-Shammari and Al-Subaie 1999).
Genetic and Familial Factors

Many studies have tried to detect the map of the susceptibility genes for the major
mental disorders. The concept of a single causative gene has changed into a more
complex relationship between multiple genes interacting with environmental factors.
Such interaction increases the susceptibility to mental illness (Hyman 2000). It was
found that autism, attention deficit hyperactivity disorder, bipolar disorder, major
depression, and schizophrenia are more likely to have genetic variations at the same
four chromosomal sites. These included risk versions of two genes (Burmeister et al.
2008). On the other hand, a moderate-to-sizable percentage of genetic effects related

to personality disorders is not shared with the area constructs of the “Big 5”
personality traits: experience, conscientiousness, extraversion, agreeableness, and
neuroticism (Czajkowski et al. 2018).
Family, twin, and adoption studies have provided evidence for the role of genetics
in a few psychiatric disorders, including obsessive-compulsive disorders, panic
disorder, major depressive disorders, bipolar disorder, schizophrenia, and
Alzheimer’s disease (Shih et al. 2004). There is a lack of similar studies in the
EMR on the genetic causes of mental illnesses. Of note is that one-third of PTSD in
Syrian refugees in Turkey occurred in women exposed to 2 traumatic attacks, and
who had a personal or family history of mental disorders (Al-Nuaimi et al. 2018).
Caregivers of Persons with Mental Illnesses

Professional caregivers or family members of persons with mental health disorders
are at increased risk for developing similar symptoms (Hamid and Musa 2017).
Socioeconomic Conditions
Income
Mental illnesses are usually associated with poverty (WHO 2012). A study of the
elderly in the UAE revealed an association between mental illnesses and the low
income (Ghubash et al. 2004). The Global Burden of Disease (2013) indicates that
countries with low incomes had an increasing burden of mental illnesses between
1990 and 2013 (Charara et al. 2017).
Occupation
Some occupations can increase the prevalence of mental illnesses, with examples
being managers, teaching staff, and service providers such as nurses and doctors
(Stansfeld et al. 2011). A study of 412 nurses working in five different hospitals from
Alexandria, Egypt, using the General Health Questionnaire revealed that more than
one-fifth of the sample as having moderate to severe psychological manifestations
(Arafa et al. 2003). Another study also from Egypt reported that more than a quarter
of their study group of older males as having experienced worsening mental health
due to unemployment (Liu 2017).
Education
There is a positive association between higher educational levels and positive mental
health status (Halpern-Manners et al. 2016). A lower educational performance is
associated with mental illness in young Egyptian males, and more than a quarter of
younger females experience worsening mental health due to failure to complete
school education (Liu 2017).
Cultural Factors and Social Support

There is a dominating influence of culture on mental illness (Koenig et al. 2014).
Cultural factors can predispose to mental illnesses in the EMR. For example,
144 N. K. Ibrahim
polygamy is more common in the region, and females in polygamous marriages

report an increased rate of depression and psychotic illnesses. The first wife has a
higher prevalence of mental illness compared to the following wife/wives, in a
phenomenon called “the first wife syndrome” (Charara et al. 2017).
Regarding the social support, a study from Qassim, KSA, showed that lower
social support increased depression in persons with type-2 diabetes. Diabetics who
received moderate support were about 2.5 times more prone to depression, while
those with low levels of support were about seven times more liable to depression
(Al-Mohaimeed 2017).
Religion
There is an inverse association between religiosity and depression, as shown by a
meta-analysis of 147 studies involving nearly 100,000 persons that revealed an
inverse association between involvement in religious activities and depression.
Such a relation was also increased in stressed populations. Religion is thought to
stimulate remission of depression in vulnerable persons. Attending religious
events is associated with decreased suicidal attempts in both the general population
and in those with mental disorders (Dein 2010), a finding that also extends to
Korean immigrants in Dubai, UAE (Kim et al. 2015). Muslims who utilized
spiritually modified cognitive therapy for anxiety and depression have a quicker
response compared to treatment which is not Islamically modified (Sabry and
Vohra 2013).
Chronic Diseases
Mental illnesses occur more frequently in patients with chronic diseases such as
cardiovascular diseases (WHO 2012; Chaddha et al. 2016), diabetes mellitus (Al-
Mohaimeed 2017) and cancers. Anxiety and depression were the commonest mental
disorders in those affected by chronic medical conditions (Al Sayah et al. 2014).
War and Conflicts

The commonest cause of mental illnesses in the EMR currently is the plague of war
and conflict, especially in Syria, Iraq, Yemen, South Sudan, and Palestine. War can
cause mental illnesses such as depression, anxiety, PTSD, childhood behavioral
problems, and violence against others, and can lead to suicide (Pocock 2017).
Domestic violence is an important source of mental illness after the civil conflicts
in Palestine and Lebanon (Amawi et al. 2014).
Syrian refugees have high prevalence of psychotic illnesses and PTSD. Hospital
admissions due to psychosis and suicide increased when the war in Syria started
(Jefee-Bahloul et al. 2015). This is made worse by the failure of medical services,
due to the many health workers who left the country (Maziak 2018). A study of
PTSD in Syrian refugees in Lebanon found that the lifetime and the point prevalence
of PTSD to be 35.4%, and 27.2%, respectively. Those from the Aleppo region
reported higher lifetime PTSDs compared to those from the Homs region, due to
the greater impact of the war and subsequent exposure to trauma (Kazour et al.
2017). The prevalence of psychiatric morbidity in injured Syrian refugees in Turkey
is also very high, with the commonest diagnoses being major depression, adjustment
disorders, and PTSD (Al-Nuaimi et al. 2018).
Revolutions also victimize people (especially young) through killing; wounding
(purposively or accidentally); deprivation from home, education, or other life oppor-
tunities; loss of loved persons; mental trauma; and distress (Moussa et al. 2015). The
EMR has recently witnessed financial and political instability, which is yet another
trigger for mental distress (Mokdad 2017). A cross-sectional study of 515 school
children enrolled in different types of primary schools who had witnessed the
political violence in Tahrir Square during the Egyptian Revolution of 2011 found
high rates of depression, PTSD, and anxiety symptoms in these children (Moussa
et al. 2015).
Infection and Mental Illnesses

Neurodegenerative psychiatric diseases such as Alzheimer’s disease have clear
neuroimmune mechanisms which may be important factors for their management
in the future (Herron et al. 2018).
Mental Health Disorders in Students

Academic difficulties (condensed course and academic failure), emotional problems,
and major life events are among the predictors of anxiety and depression in medical
students from Jeddah. Nationality can also play a role, as non-Saudis have a
significantly higher prevalence of both anxiety and depression (Ibrahim et al.
2013). Another study from KSA reports that having very sad or anxious feelings
were associated with poor relations with parents, negative body image, and the
presence of chronic diseases (Abou Abbas and AlBuhairan 2017). A study from
Taibah University, KSA, showed that participants with other medical diseases, and
those with fewer sleeping hours, were more susceptible to depression. Furthermore,
those who ate 1 meal/day and consumed energy drinks and stimulants had a
significantly higher prevalence of depression (Sultan et al. 2016).
Conclusions
This chapter reviewed the research on mental illness in the EMR that has been
published over the last three decades and discusses gender and other determinants of
mental illnesses in the region, such as wars and conflicts. There are relatively few
community-based studies to determine the distribution and determinants of mental
health diseases in the region.
There are many mental health problems in the region and the rates of such
illnesses are expected for further increase due to the instability in the region. The
estimated prevalence of mental illnesses in the Arab world ranges from 15.6% to
35.5%. The commonest mental disorders in the region are depression, anxiety, and
somatization. There are problems related to lack of adequate mental care services –
due to low expenditure on mental health care in the region, lack of access to the
services, and stigma against mental illnesses.
146 N. K. Ibrahim
Recommendations for Improving Mental Health in the Region
1. Establishing and improving programs for mental health promotion in all coun-
tries of the EMR
2. Expanding mental health services, with increasing expenditure on mental health
3. Scaling up mental health services and addressing barriers to care of patients
4. Surveillance and continuous monitoring of mental health diagnoses, including
PTSDs, in countries of the EMR
5. Ensuring that all patients with mental disorders in the region receive ethical,
acceptable, and effective management for their illnesses
6. Decreasing the stigma attached to mental illnesses by providing educational
programs, for example, at schools, universities, occupational settings, and malls
7. Collaborating with schools, universities, religious leaders to advocate for better
mental health
8. Utilizing press, television, and other media for decreasing the stigma of mental
illnesses and improving access to mental health services
9. Screening for mental health problems invulnerable groups such as those
exposed to wars, refugees, females especially in the postpartum period, elderly,
and persons with chronic diseases
10. Collaborating with nongovernmental organizations (NGOs) for preventing,
treatment, and rehabilitating cases of mental illnesses
11. Caring for family members with chronic mental illness
12. Conflict resolution in war-torn countries, aimed at decreasing mental illnesses
related to trauma
13. Helping countries with conflicts and those with low incomes to increase their
capacity in mental health with help from agencies such as WHO and UNICEF
14. Increased training for mental health professionals
15. Conduct more conferences and workshops on mental disorders in the region
16. Increase research in mental health including the genetic components of mental
illnesses
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Achieving Sexual and Reproductive Health
Equity in the Arab Region: A New Role for 9
the Health Sector
Hoda Rashad, Sherine Shawky, Zeinab Khadr, Shible Sahbani, and

Mohamed Afifi
Contents
The Sexual and Reproductive Health Landscape: A Success Story . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
The Engagement and Response from the Arab Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
Progress and Shortfalls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
Progress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
Shortfalls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
A New Role for the Health Sector . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
Improving Performance and Adopting a Fairness Lens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
Playing a Stewardship Role . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
Concluding Remarks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
Abstract
The sexual and reproductive health landscape in the Arab region is a manifesta-
tion of the success of the development discourse and the international consensus
in impacting positive change. This chapter demonstrates how the strategy and
performance of the health sector in the Arab region have positively changed and
contributed to the improved reproductive health of women. The chapter also
discusses a number of shortfalls in the progress achieved. In particular, we
highlight the inequity shortfall and argue that addressing this shortfall requires
H. Rashad (*) · S. Shawky

The Social Research Center, The American University in Cairo, Cairo, Egypt
e-mail: hrashad@aucegypt.edu; shshawky@aucegypt.edu
Z. Khadr
The Social Research Center, The American University in Cairo, Cairo, Egypt
Faculty of Economics and Political Science, Cairo University, Cairo, Egypt
e-mail: zeinabk@aucegypt.edu
S. Sahbani · M. Afifi
United Nations Population Fund - UNFPA, Arab States Regional Office, Cairo, Egypt
e-mail: sahbani@unfpa.org; afifi@unfpa.org

https://doi.org/10.1007/978-3-030-36811-1_156
152 H. Rashad et al.
departure from “business as usual” approach. Such a departure demands a

significant paradigm shift as well as knowledge and action shifts. The nature of
the departure needed was articulated by the Commission of Social Determinants
of Health, but has not received the attention it deserves in the Arab region. The
positive achievements on the reproductive health front provide an opportunity to
address the reproductive health challenge to ensure leaving no one behind and can
serve as a gateway of reform of health policies. The health sector particularly
should spearhead a major policy reform movement.
Keywords
Sexual and reproductive health · Health sector · Arab region · Inequalities and
inequities · Social determinants of health
The Sexual and Reproductive Health Landscape: A Success Story
The landscape of sexual and reproductive health has many dimensions, including the
identification of sexual and reproductive health as a public health priority, the
content of the sexual and reproductive health agenda, the vision and approach
guiding sexual and reproductive health policies and actions, as well as the leadership
of the agenda.
This section describes the roles played by the development actors and the
international community in shaping a very different, and much improved, landscape
of sexual and reproductive health. It also highlights the key features of this new
sexual and reproductive health landscape.
The cornerstone for shaping the new landscape of sexual and reproductive health
can be traced to the vision and consensus of the International Conference of
Population and Development (ICPD) held in Cairo during 1994 (UNFPA 2004).
ICPD 94 is one of the most influential intergovernmental conferences on popu-
lation, health, and development. The conference made visible the interdependency
between health, population, and development issues. It placed the achievement of
improvements in the lives of individuals, particularly for women, as a central
measure of development. The focus on individual well-being and respecting
human rights and freedom of choices reflected itself in the specifications of what
constitutes development priorities and also on how these priorities are addressed.
Sexual and reproductive health in particular holds a special position in ICPD. It
was defined as “a state of complete physical, mental and social wellbeing and not
merely the absence of disease or infirmity, in all matters relating to the reproductive
system and its functions and processes” (UNFPA 2004). The definition of sexual and
reproductive health is not confined to pregnancy and birth but also encompasses
other aspects of women’s health beyond reproduction, such as mental and social
well-being. Importantly, sexual and reproductive health also applies to men and to all
age groups in matters related to the reproductive system.
It should be emphasized that sexual and reproductive health cannot be separated
from the package of rights and freedom of choices as well as gender equality. This is
9 Achieving Sexual and Reproductive Health Equity in the Arab Region . . . 153
explained by the fact that sexual and reproductive health is both a measure of health
and an approach to improved well-being. Sexual and reproductive health as an
approach recognizes the inferior position of women and emphasizes the implications
of that reality on how women experience sexuality and reproduction. The approach
is a liberating and human rights ideology that advances the necessity of empower-
ment of women to achieve their reproductive rights. Indeed reproductive rights and
gender equality in this new approach cannot be considered as just social determi-
nants of sexual and reproductive health. They are important ends in themselves and
central to sexual and reproductive health goals.
The key features of the new sexual and reproductive health landscape include:
– Sexual and reproductive health became a priority measure of developmental

success and not just an expression of one dimension of health.
– Sexual and reproductive health moved from its focus on physical aspects of
health dominated by the agenda of high fertility to a much broader consideration
of social challenges affecting the reproductive health of individuals.
– The expansion of the sexual and reproductive health agenda was driven by the
goal of individual well-being, respecting reproductive rights and informed
choices. This is very different from the traditional pursuit of macro goals and
the prevailing tendency to sacrifice individual rights for the sake of societal good.
– The pool of actors on sexual and reproductive health were no longer confined to
the health sector alone. Indeed sexual and reproductive health became the man-
date of the many actors in fields of population, gender, as well as social
development.
The Millennium Development Goals (MDGs 2000–2015) reflected the newly

acquired status of sexual and reproductive health. Among the small list of eight
carefully chosen priority development goals, two goals on “Promote Gender Equal-
ity and Empower Women” and “Improve Maternal Health” were specified
(UN 2003).
The Sustainable Development Goals (SDGs 2015–2030) are currently the blue-
print for development adopted by governments of the world (UN 2015). The SDGs’
agenda expanded to include 17 interconnected goals. The attempt is to finish the
remaining agenda of MDGs and to tackle challenges that became more visible.
These goals express the cumulative experience and the lessons learned from the
implementation of MDGs. The political leverage of these goals is unprecedented, as
partly reflected by the anchoring of the international partnerships around these goals.
Two SDGs features stand out and are very relevant to sexual and reproductive
health. The first is that the SDGs manifest a more conscious expression of the vision
and approach of ICPD. The second is the explicit recognition of the challenge of
inequality and the importance of “leaving no one behind.” This recognition was
shaped by the implementation experiences and also by the appreciation of the equity
anchor for development. The implementation lessons, particularly for sexual and
reproductive health, while confirming that the ICPD has contributed to substantial
improvement, continue to highlight the uneven and unfair distribution of these gains.
The SDGs goals continued to prioritize the sexual and reproductive health goal.
This goal did not explicitly appear as a separate one. However, goal five, “Achieve
gender equality and empower all women and girls,” pursues a central component of
the sexual and reproductive health goal. Also, goal three, “Ensure healthy lives and
promote well-being for all at all ages,” incorporates two relevant targets:
By 2030, ensure universal access to sexual and reproductive health-care services, including
for family planning, information and education, and the integration of reproductive health
into national strategies and programs (Target 3.7).
Ensure universal access to sexual and reproductive health and reproductive rights as agreed
in accordance with the Program of Action of the International Conference on Population and
Development and the Beijing Platform for Action and the outcome documents of their
review conferences (Target 5.6).
In brief, the development discourse succeeded in pushing sexual and reproductive

health to the forefront of attention, expanded on the topical concerns that comprise
sexual and reproductive health and the pool of actors, as well as the concern of
inequality. It also embraced the life cycle consideration, the centrality of gender, and
the pursuit of well-being as well as individual human rights. These important
changes implied that sexual and reproductive health can no longer be confined to
the physical aspects of health and to the confinement of the health sector.
The Engagement and Response from the Arab Region
The Arab region and all its members have actively participated and engaged in all
international forums related to sexual and reproductive health. They contributed to
the formulation of the agenda and participated in the many global and periodic
reviews of the implementation of the ICPD program of action.
In particular, the Arab region held a conference during 2013 to reflect on its
efforts and on regional specificities of the region. The 2013 Cairo Declaration (LAS
et al. 2013) adopted by representatives of member states of the League of Arab States
(LAS) represents the consensus of the Arab countries on the way forward. The input
of various Arab countries was merged into the “Framework of Actions for the
follow-up to the Program of Action of the ICPD Beyond 2014” (UN 2014). This
framework is the culmination of the United Nations review of progress, gaps,
challenges, and emerging issues in relation to the ICPD Program of Action.
Five years following the 2013 Cairo Declaration, a regional review report was
prepared (ESCWA et al. forthcoming) as mandated by the UN General Assembly
(resolution 65/234). The review was based only on the responses of 13 governments
to a standard questionnaire. A summary of this review (Rashad 2018) noted that
despite the turmoil (Occupation, armed conflicts, civil unrests, terrorism, forced
displacement, as well as political instability) and development challenges, significant
implementation efforts were implemented.
In relation to sexual and reproductive health and gender equality, which are the
cornerstones of ICPD, the review report was particularly favorable. It referred to the
ratification of international frameworks, the establishment of high-level councils,
the changes in the legal framework, and the formulation of strategies and programs
for protection of women.
In terms of reproductive health-care services, the report stated that some of these
services were integrated within the primary health-care system. The report also
showed that there were expanded and improved services related to maternal health,
family planning, and prevention and treatment of sexually transmitted infections
including HIV/AIDS in all countries that answered the questionnaire. The majority
of these countries invested in human resources, upgrading their skills or improving
their geographic distribution. In addition, in most of the responding countries, there
exist programs that provide accessibility to sexual and reproductive health care for
all, without discrimination based on gender, nationality, displacement status, or
marital status.
More detailed illustration of measures adopted by Arab countries is summarized
in Table 1. The large number of measures, notwithstanding the diversity and
variations among Arab countries and among specific measures investigated, are
quite evident.
Other sources of information provided by independent scholars do not contradict
the reporting by governments that many efforts were made. These sources, however,
clarified the many impediments and proposed specific recommendations.
Two relevant studies in this regard are summarized here. The first study provides
the findings of a recent regional study based on 11 Arab countries (DeJong and
Bashour 2016). The study developed and applied a mapping tool to assess the sexual
and reproductive health laws and policies in the selected Arab countries.
The study confirmed almost universal ratifications of international agreements.
Reforms on the legal front in a number of countries and in important areas of
reproductive rights were noted. (These included removing all reservations to
CEDAW (Tunisia); explicit guaranteeing of the right to health (all countries but
two) and the right to decide on the number and spacing of children (Morocco); the
right of women to pass their nationality to their children (except six countries), many
reforms in personal status law (particularly prevention of child marriage); protection
against rape; and legal measures to address female genital cutting in countries where
practice is prevalent (Egypt, Sudan).) Other positive changes included articulation of
special family planning policies, increased services for the treatment of infertility,
and improvement in the information base. (The study referred, in particular, to the
formal comprehensive policies for the notification of maternal mortality.)
The second study on the integration of sexual and reproductive health services
(UNFPA and MENA Health Policy Forum 2018) states that integration is specified
in the two targets of the Sustainable Development Goals (3.7 and 5.6). The study
states that “Integration of sexual and reproductive health services and primary health
care means that people who are seeking information or health care for a specific
sexual or reproductive health concern can have their other needs met simulta-
neously—preferably at the same time in the same location, or otherwise by effective
Table 1 Selected policies, strategies, and program measures on reproductive health
156
Measures to address newborn and maternal mortality

Expanded Expanded Expanded coverage Expanded Expanded access to Expanded Government
coverage of coverage of of essential access to safe abortion care, recruitment or support for
Country comprehensive obstetric postpartum and effective including post- training of skilled family
name prenatal care care newborn care contraception abortion care birth attendants planning
Algeria • • • • ○ ○ Direct
support
Bahrain ○ ○ ○ ○ ○ ○ Direct
support
Comoros • • • • ○ • Direct
support
Djibouti • • • • • • Direct
support
Egypt • • • • • • Direct
support
Iraq • • • • ○ • Direct
support
Jordan • • • • • • Direct
support
Kuwait ○ ○ ○ ○ ○ ○ Direct
support
Lebanon • • • • • • Direct
support
Libya ○ ○ ○ ○ ○ • No support
Mauritania • • • • ○ • Direct
support
Morocco • • • • ○ • Direct
support
Oman • • • • • •
H. Rashad et al.
9
Direct
support
Palestine • • • • • • Direct
support
Qatar ○ ○ ○ ○ ○ ○ Direct
support
Saudi • ○ • ○ ○ ○ No support
Arabia
Somalia • • • • • • Direct
support
Sudan • • • • ○ • Direct
support
Syria • • • • ○ • Direct
support
Tunisia • • • • ○ ○ Direct
support
UAE ○ ○ ○ ○ ○ ○ No support
Yemen • • • • ○ • Direct
support
Measures on reproductive and sexual
health of adolescents Policy on restricting access to contraceptive services
Expanded
Raised or girls’ Provided Level of
enforced secondary school Parental concern
Achieving Sexual and Reproductive Health Equity in the Arab Region . . .
minimum school based consent Emergency about

age at enrolment or sexuality Minimum Marital (for contraceptive Sterilization Sterilization unsafe
Country marriage retention education age status minors) pills of women of men abortions
Algeria • • ○ ○ ○ ○ ○ ○ ○ Not a
concern
Bahrain • • • ○ ○ ○ ○ ○ ○
157
(continued)
Table 1 (continued)
158
Measures on reproductive and sexual

health of adolescents Policy on restricting access to contraceptive services
Expanded
Raised or girls’ Provided Level of
enforced secondary school Parental concern
minimum school based consent Emergency about
age at enrolment or sexuality Minimum Marital (for contraceptive Sterilization Sterilization unsafe
Country marriage retention education age status minors) pills of women of men abortions
Comoros • • • ○ ○ ○ ○ ○ ○
Djibouti • • • ○ ○ ○ ○ ○ ○ Major
concern
Egypt • • • ○ • ○ ○ ○ ○ Minor
concern
Iraq • • ○ ○ • ○ ○ ○ • No
official
position
Jordan • • ○ ○ • • • ○ • No
official
position
Kuwait ○ ○ ○
Lebanon • • • ○ ○ ○ ○ ○ ○ Minor
concern
Libya ○ ○ ○
Mauritania • • ○ ○ ○ ○ ○ ○ ○ Major
concern
Morocco • • • ○ • ○ ○ ○ ○ No
official
position
Oman • • • ○ ○ ○ ○ ○ •
H. Rashad et al.
9
Not a
concern
Palestine • • • ○ • ○ ○ ○ ○ Major
concern
Qatar • ○ ○
Saudi ○ • ○
Arabia
Somalia • • ○ ○ ○ ○ ○ ○ ○
Sudan ○ • ○ ○ ○ ○ ○ ○ ○
Syria • • ○ ○ ○ ○ ○ ○ ○
Tunisia • ○ ○ ○ ○ ○ ○ ○ ○
UAE ○ ○ ○
Yemen ○ • ○ ○ ○ ○ ○ ○ ○
Source: United Nations (2017). Reproductive Health Policies 2017. Data Booklet. (ST/ESA/ SER.A/396)), by (Department of Economic and Social Affairs), ©
(2017) United Nations. Reprinted with the permission of the United Nations. http://www.un.org/en/development/desa/population/publications/pdf/policy/
reproductive_health_policies_2017_data_booklet.pdf. Accessed 27 September 2018
•
Indicates that policies and strategies are adopted or concrete measures were taken
○
Indicates that no policies were adopted nor measures were taken
A blank cell indicates that data are not available
Achieving Sexual and Reproductive Health Equity in the Arab Region . . .
159
Table 2 Essential sexual and reproductive health services offered at primary health-care facilities
Services Egypt Jordan Morocco Palestine KSA Sudan
Family planning ✓ ✓ ✓ ✓ ✓ ✓
Antenatal care ✓ ✓ ✓ ✓ ✓ ✓
Labor and delivery ✓ ✓
Postnatal care ✓ ✓ ✓ ✓ ✓ ✓
Newborn and child health ✓ ✓ ✓ ✓ ✓ ✓
Prevention of unsafe abortion and ✓ ✓
post-abortion care
Emergency contraception ✓a ✓ ✓ ✓
STI/RTI screening, diagnosis, ✓ ✓ ✓ ✓
and treatment
Cervical cancer screening ✓ ✓
Breast cancer screening ✓ ✓b ✓ ✓
Prevention and management of ✓c ✓ ✓
gender-based violence
Source: United Nations Population Fund (UNFPA) Arab States Regional Office (ASRO) and
Middle East and North Africa Health Policy Forum (MENA HPF), 2017. Assessment of Sexual
and Reproductive Health Integration in Selected Arab Countries: Regional Report
a
Private facilities only
b
Diagnosis and treatment only
c
Management only
referral”(Warren et al. 2017). A wide range of services to be included were also

noted. (These include family planning; maternal and newborn health care; clinical
management of sexual and gender-based violence; post-abortion care; and preven-
tion and management of HIV/AIDS, other sexually transmitted infections, cancers of
the reproductive system, and infertility.)
Table 2 summarizes the essential sexual and reproductive health services offered
at primary health-care facilities in selected Arab countries, with Morocco being the
only country that offers all the specified services. However, several countries provide
many of these services.
Progress and Shortfalls
Progress
The commitment, strategies, increased efforts, and the expansion of health-care

services are expected to translate into the realization of sexual and reproductive
health for all. This section takes note of the household acquired wisdom: “The proof
of the pudding is in its taste.” The progress in the realization of sexual and
reproductive health impact measures and health risk factors is discussed below.
18% 45 9%
1000 50
820 41
800 676 40 28%
27% 31 48% 29
600 30
66% 63% 20 40% 21
400
50% 358
20 16 62%
244 261 12 13
188
200 64 92 10 5
30 15
0 0
Fig. 1 Selected sexual and reproductive health impact measures during 1990 and 2010. (Source:
United Nations and League of Arab States (2013). The Arab millennium development goals report:
Facing challenges and looking beyond 2015)
As shown in Fig. 1, there was a 27% decline in the maternal mortality ratio in the
Arab region over the past two decades (1990–2010). Remarkably, the GCC countries
(the Cooperation Council for the Arab States of the Gulf: Bahrain, Kuwait, Oman,
Qatar, Saudi Arabia and the United Arab Emirates ) halved their already relatively
low maternal mortality ratio to 15 per 100,000 livebirths in 2010. A decline of over
60% occurred in Mashreq countries (Egypt, Iraq, Jordan, Lebanon, Palestine and the
Syrian Arab Republic) and the Maghreb countries (Algeria, Libya, Morocco and
Tunisia) reaching 64 and 92 per 100,000 livebirths in same period. The least
developed Arab countries (the Comoros, Djibouti, Mauritania, Somalia, the Sudan
and Yemen) showed modest declines of 18%, with an unacceptably high MMR of
676 per 100,000. The decline in maternal mortality ratio continued during this period
reaching 261 per 100,000 for the Arab region (UN and LAS 2013).
Another impact measure of sexual and reproductive health is the neonatal mor-
tality rate, which is closely related to pregnancy and delivery. It is generally believed
that more than 50% of neonatal mortality is related to preterm birth complications
and complications during birth. Figure 1 shows appreciable progress in reducing
neonatal mortality rates, with a diversity in the speed of progress and levels of
challenge across the region.
The trend in other impact measures of sexual and reproductive health is more
difficult to establish, given the paucity of data. In terms of progress in sexual and
reproductive health risk factors, there is some progress in selected sexual and
reproductive health risk factors between 1990 and 2010, as shown in Fig. 2. In
terms of indicators related to fertility, the rate of decline from 1990 to 2010 has
slowed or even halted during more recent periods (Table 3).
Additional information on other measures of sexual and reproductive health risk
factors is needed to confirm the picture of improvement (these include, but are not
limited to, female genital cutting, risky birth intervals, women’s autonomy, mental
violence, etc.). Furthermore, progress across time should not conceal an unfinished
agenda.
100 93 98
79 82 96 99
70 100 82 83
80
60 80 69
60 49 53 58
39 40 60 46 52
40 32 34
40
20 20
0 0
Fig. 2 Sexual and reproductive health risk factors during 1990 and 2010. (Source: United Nations
and League of Arab States (2013). The Arab millennium development goals report: Facing
challenges and looking beyond 2015)
Table 3 Levels and trend of fertility related indicators

1990 2000 2010 2015
Contraceptive prevalence rate 33.7 45.2 49.8 51.5
Unmet need for family planning 24.7 19.0 17 16.6
Proportion of demand for contraception satisfied 57.8 70.4 74.6 75.6
UNFPA (2016). Universal access to reproductive health: Progress and challenges. https://www.
unfpa.org/sites/default/files/pub-pdf/UNFPA_Reproductive_Paper_20160120_online.pdf.
Accessed 12 September
Shortfalls
There are many shortfalls including an incomplete health sector agenda as well as
issues of inequity.
Incomplete Health Sector Agenda

The broad definition of sexual and reproductive health is not fully captured in the
health sector agenda. The neglect of sexual and reproductive health issues of a social
nature that undermine the quality of life as well as the shortage of data is not
surprising. Indeed, the neglect of social dimensions of health and the weakness of
information system are common features of the highly medicalized health care in
developing countries. What is less expected is the absence of many issues that
undermine the physical aspects of health. Such issues are those related to puberty,
menopause, as well as infertility, reproductive cancers, and sexually transmitted
diseases. The absence of these issues can be grouped under two types of
impediments:
1. Not adopting the life course trajectory.
Puberty and menopause are two key benchmarks in the sexual and reproductive
health life cycle trajectory but are not visible in the agenda of the health sector in
Arab region.
Puberty is a benchmark for young adolescents’ sexual and reproductive health.

The lives of youngsters involve profound biological, cognitive, emotional, and
social changes associated with the passage through puberty. These formative
years offer an ideal window of opportunity for building the foundations of sexual
and reproductive health in young adolescents (WHO 2010). While almost all
Arab States currently have strategies (such as the creation of special agencies) to
tackle issues related to the youth, health-care programs and services are generally
small in scale and not well-advertised. There are currently insufficient nationwide
health-care services to monitor the adolescents’ growth and development. There
is also no scientific evidence on the biological, cognitive, emotional, and social
needs of both girls and boys during puberty.
Menopause is a second key benchmark in the life cycle trajectory. It involves a
physiological “Change of Life” that transforms a woman’s life. There are some
interventions to promote the health of the elderly in the Arab States, yet women’s
sexual and reproductive health during menopause and beyond the reproductive
health age are not sufficiently addressed. A large majority of menopausal women
experience negative physical, emotional, and social impact. Menopause is asso-
ciated with decreases in hormone production by the ovaries that can lead to hot
flushes, mood swings, anxiety, irritability, feeling of sadness, difficulties with
memory and concentration, and even depression. Women are at increased risk of
developing significant depressive symptoms after they enter menopause, even if
they do not have a history of depression. The term used for menopause in Arabic
is “age of despair,” reflecting the value placed on women’s reproductive roles.
Menopausal support and care are the concerns that are not sufficiently prioritized
in Arab States.
2. Not paying adequate response to socially grounded and culturally sensitive
issues.
Infertility or even just delayed conception is a major crisis in a couple’s life in the
Arab region. The failure of a woman to become pregnant after 1 year of regular,
unprotected intercourse is a proxy of infertility. This has many potential causes,
which could be related to either the man, the woman, or both partners. While men
and women are equally likely to be infertile, women are the ones stigmatized in
Arab societies. An inability to conceive or bear children can result in women
being socially shunned or divorced and carries with it economic, mental, or other
health implications.
Infertility in the Arab States is an understudied concern, with little information on

the magnitude of infertility and its underlying causes. In Egypt, for example, delayed
primary fertility for more than 2 years occurs in 2.4% of married women (Shawky et
al. 2018). It is difficult, however, to estimate from the data if the delayed fertility is a
planned choice or not. These results can be taken either as a rough estimate of
physical primary infertility or a planned delay of pregnancy pending further inves-
tigation. There are other indirect indications of the magnitude of the problem from
the increasing number of in vitro fertilization (IVF) clinics in the Arab States (Inhorn
and Gurtin 2012).
Infertility care is not part of the sexual and reproductive health services in Arab
States despite the known links between reproductive tract infections and subsequent
infertility. Services for IVF are mostly available in the private sector and in big cities
and thus only accessible to couples who can afford treatment. Furthermore, the
processes are not regulated. For example, the types of infertility treatments allowed,
the number of embryos that can legally be implanted, and the sex selection/identity
of the embryo are not adequately covered (Shawky et al. 2018).
Reproductive cancers are another serious reproductive health concern. In women,
these are cancers in the breast, cervix, uterus, vulva, endometrium, or ovaries.
Despite the increased awareness of this elsewhere in the world, there is no nation-
wide evidence on their magnitude in the Arab world, and their screening remains a
low priority and is practiced on a limited scale (Shawky et al. 2018).
Cervical cancer is one of the most preventable of all cancers. It is caused by types
of the human papillomavirus (HPV). Although HPV vaccination is now
recommended in many countries worldwide, insufficient attention has been given
to this in the Arab States (e.g., by making the HPV vaccine widely available)
(Gamaoun 2018).
Sexually transmitted diseases (STDs), including HIV/AIDs, are other harmful
infections. For example, ever married women aged 15–49 years self-reported rates of
32.0% in Egypt (Ministry of Health and Population [Egypt] 2015a) and of 12.2% in
Morocco of sexually transmitted infections (STIs) or their symptoms (Ministry of
Health [Morocco] 2012). Several efforts exist to halt such infections have been made
in the Arab Region, but many countries do not report their incidence or the
effectiveness of their efforts to control the spread.
The Inequity Shortfall

This section differentiates between inequalities and inequities and describes positive
changes on the inequality fronts that have not managed to adequately address the
concern of “leaving no one behind.” The level of inequality remains quite high, and
its trend over time is a cause of concern. Also, the health sector is not alleviating the
inequalities and in fact appears to be contributing to them.
The issue lies in not framing inequalities as inequities and in applying a proximate
social determinants frame instead of the structural determinant frame of social
inequalities as called for by the Commission on Social Determinants of Health
(CSDH 2008). The following details refer to the discussion above.
Positive Changes on Inequalities Front

Positive changes have occurred in relation to the challenges of inequalities. First, the
visibility of these challenges has improved considerably. Second, the appreciation of
the role of social determinants in shaping them has benefited from improved
conceptualization. As a result, these changes have resulted in a flurry of actions
and initiatives targeting the disadvantaged groups of society by adopting an empow-
erment model.
The recognition of health inequality in social groups is not new. Disparities within
countries, and the fact that they are shaped by different social conditions, are well
known and even implicitly normalized as part of socioeconomic realities. What is

new is that health inequalities have moved from being presented as anecdotal
information to being centrally placed as the focus of concern. This is evident from
the recent increases in the number of studies investigating inequality, with a flagship
among these being the UNFPA state of the world population 2017 report: “Worlds
Apart: Reproductive Health and Rights in an Age of Inequality” (UNFPA 2017).
Similarly, the recognition of the social determinants of health dates back to the
early 1970s. The Alma Ata (1978) established that health is a social phenomenon
and that its promotion invites action on more than one social front (WHO 1978).
What is new is the move away from an exaggerated focus on behavioral changes and
from the adoption of socially sensitive interventions and simplistic awareness
campaigns. The lessons from practice demanded changing the context that governs
high-risk behaviors. These lessons called for greater empowerment of the disadvan-
taged and “making healthy choices easy choices.” All Arab countries can now list
major programs for poverty alleviation and improved socioeconomic conditions of
disadvantaged communities. Many targeting and empowerment initiatives, in col-
laboration with the civil society, were adopted.
Significant Inequalities That Are Increasing

Despite the positive changes cited earlier, the increased concern and efforts have not
managed to tackle the challenge of inequalities. Many examples of inequalities
across social stratifiers are available (Khadr et al. 2012; Khawaja et al. 2008; Shawky
2018). They mostly describe the distribution of sexual and reproductive health
across social groups to create a visual impact and emphasize the gap between the
most and least advantaged as a summary measure. They also mainly use two
traditional stratifiers of geographic residence (rural/urban) and socioeconomic status
(wealth and education). The findings show that these stratifiers always demonstrate a
gap that tend, with very few exceptions, to be quite large. Such a gap occurs in all
countries regardless of their economic levels.
The following provide examples of disparities for recent periods (between 2012
and 2017) that exist across and within countries: A child born in Lebanon or Qatar
today can expect to live at least 15 years more than one born in Comoros or Somalia,
and the risk of dying due to a pregnancy for a woman living in Yemen is 64 times
higher than it is for a woman living in United Arab Emirates (UNDP 2018). These
disparities are explained by the differences in socioeconomic development and
health system performances. Disparities in health within countries are less well
documented and more difficult to justify; national averages mask significant dispar-
ities within population groups. For example, infant mortality rate among the poorest
20% of the population in Egypt is double that in the richest 20% (Ministry of Health
and Population [Egypt] 2015b). In Qatar, where achievements on the health front are
well documented, female children under 5 years of age experience twice the risk of
not receiving any treatment for diarrhea compared to male children (Ministry Of
Development Planning and Statistics [Qatar] 2014).
A more systematic regional comparative investigation of the distribution of
sexual and reproductive health inequality has recently been completed. This
investigation draws on the findings of five national studies (Al Hinai 2018; Lfarakh
2018; Mohamed 2018; Shawky et al. 2018; Zoubi and Elmoneer 2018). The regional
report (Rashad et al. forthcoming) provided a broad list of sexual and reproductive
health impact and health risks indicators and investigated their social distribution. It
introduced two new social determinants that were not studied previously. The first
speaks on the distribution of gender norms and the second on the social inequalities
in the health system components. The recent regional report replaced the gap
measure, that is more commonly used, by the index of dissimilarity. The latter
provides an assessment of inequality across the whole distribution of stratifiers. It
is also a measure that is not affected by actual values of the phenomenon being
studied and hence allows a comparison of levels of inequality, and the ordering of
inequality, across countries. The cutoff point for classifying inequality as severe was
set at ten following the recommendations from the literature.
Despite the many constraints related to the availability, comprehensiveness,
accessibility, as well as periodicity of the data sets, a number of significant findings
can be summarized:
First, there is a concerning level of inequality across all countries, regardless of
the stratifier used. Jordan is an exception, where the geographic inequalities are low,
while other social inequalities are generally high.
Table 4 illustrates that the dimension of health that suffers from high inequality is
not similar in the countries studied and that the severe levels of inequality range from
as low as 10.0 to as high as 27.2.
Second, the priority sexual and reproductive health challenges are not necessarily
the priority sexual and reproductive health inequality challenges. Table 5 illustrates
this finding for Egypt. Similar findings also apply to other Arab countries.
Third, improvements over time do not guarantee improvements in the inequality
distribution. Figures 3 and 4 show that the decline in sexual and reproductive health
measures (except for infant mortality) for different geographic region in Egypt was
accompanied by an increase in the dissimilarity index of inequality.
Inequalities in the Performance and Capacities of the Health System

The regional study, referred to earlier (Rashad et al. forthcoming), investigated the
social inequalities in the health system components using the WHO Operational
Health System Strengthening (HSS) Monitoring Framework . The framework
(WHO 2009) brings together indicators and data sources across the results chain
and its entirety and is composed of four major indicator domains: (1) system inputs
and processes, (2) outputs, (3) outcomes, and (4) impact. System inputs and pro-
cesses reflect health system capacity. Outputs, outcomes, and impact reflect health
system performance. Monitoring of health system performance needs to show how
inputs to the system (resources, infrastructure, etc.) are reflected in outputs (such as
availability of services and interventions) and eventual outcomes and impact,
including use of services and better health status. The analysis investigated the
fairness of the distribution of the components of health system within the two
common social stratifiers of geographic location and wealth to monitor the health
Table 4 Geographic sexual and reproductive health inequalities (Index of Dissimilarity) for
different measures in selected Arab countries
Egypt Jordan Morocco Sudan

2014 and o Morocco
Impact 2012 2011 2014
2015
Neonatal mortality 10.0 4.6 14.3 7.7
Infant mortality 11.4 4.8 19.6 9.7
Delayed primary fertility (>24months) 7.6 1.7 8.4 17.0
Hepatitis B infection in males (1–59 years) 17.7
HBV infection in females (1–59 years) 15.4
Self-reported STIs 2.6 3.0
Social and psychological risk factors
Female genital cutting (1–14 years) 17.3 27.2
Consanguinity 13.8 1.5 7.0
Early marriage among ever married women
14.0 1.1 7.4 7.3
(<18years)
Adolescent child bearing (15–19) 19.5 3.9 19.0 6.9
Multiparity (5+ children) 23.5 2.0 10.3 6.5
Risky birth interval (<24months) 6.3 0.5
Marital violence 3.0 1.8
Marital physical violence during pregnancy 7.5 2.6
Biological risk factors
Anemia among women in reproductive age 8.2 1.9
Low birthweight (<2.5 kg) 4.8 2.4 17.7 8.6
Source: Rashad et al., forthcoming. Reproductive health equity in the Arab region: Evidence and
policy implications. To be published by SRC and UNFPA. http://schools.aucegypt.edu/research/src/
Documents/SRH-Inequities/Reproductive-Health-Equity-in-the-Arab-Region.pdf
ID% 10% indicates high magnitude of inequality
system as a social determinant of health influencing the sexual and reproductive

health and their uneven distributions.
The regional study documented an uneven distribution of health sector compo-
nents within countries. In terms of health system performance, for example, in
Egypt, Morocco, and Sudan, the poorest populations are the least served and are
not sufficiently served by sexual and reproductive health services such as antenatal
care and skilled birth attendance. There is also evidence that the health system
capacity is still unevenly distributed. The report showed that the poorest women
were those were the most likely to have distant health-care facilities and unaffordable
health care.
The index of dissimilarity as a measure for the magnitude of geographic inequal-
ities is shown in Table 6. Geographic inequalities in health system components exist
within Arab countries. Similarly, there are also geographic inequalities in health
system capacity, notably distant health-care facilities, unavailable female health-care
providers, and unaffordable health care.
Table 5 Summary of priority sexual and reproductive health and priority inequality challenges in
Egypt 2014 and 2015
Priority
Priority inequality challenges
challenges
Geographic Wealth Gender
National level
(ID% ≥ 10%) (rCI%≥10%) (rCI%≥10%)
Impact
Maternal mortality Not available Not available
Most
Neonatal mortality Rural Upper Egypt
conservative
Most
Infant mortality Rural Upper Egypt
conservative
Delayed primary fertility (> 24months)
Urban gov.
Hepatitis B infection in males (1– 59
Urban Upper Rich
years)
Egypt
HBV B infection in females (1–59 years) Urban gov.
Self-reported STIs
Risk factors
Female genital mutilation/cutting Most
pt Poor
(1–14years) conservative
Most
Consanguinity Rural Upper Egypt Poor
conservative
Most
Early age at marriage (<18years) Rural Upper Egypt Poor
conservative
Rural Upper Egypt Most
Adolescent child bearing (15–9 years)
Rural Lower Egypt conservative
Most
Multiparity (5+ children) Rural Upper Egypt Poor
conservative
Risky birth interval (<24months)
Marital violence
Marital physical violence during
pregnancy
Biological risk factors
Anemia among women in
reproductive age
Low birthweight
Source: Shawky et al., 2018. Reproductive health inequalities in Egypt: Evidence for guiding
policies. National study. http://schools.aucegypt.edu/research/src/Documents/SRH-Inequities/
Egypt-Report.pdf
Note: Priority challenges appear as dark boxes
ID%: Index of dissimilarity percent
rCI%: Concentration index redistribution need percent
From Inequalities to Inequities

Inequalities are differences in health between social groups of a population regard-
less of any assessment of their systematic patterns, the cause of their occurrences,
and the fairness of these causes. Inequities, on the other hand, are differences that
exhibit systematic pattern, are produced by social forces, and are unfair.
Unfairness could simply be a value judgment since denial of health that could be
avoided is also a denial of human rights. The unfairness here is not linked to the
cause of differences but is couched in a moral value judgment. The role of the state in
addressing inequalities becomes a part of its normal responsibility as a duty bearer.
a ID%= 12.8% ID%= 11.4% b ID%= 4.7% ID%= 10.0%

60 60
50 50
40 40
30 30
20 20
10 10
0 0
Infant Mortality (per 1,000 live births) Neonatal Mortality (per 1,000 live births)
Urban gov. Urban Lower Egypt Rural Lower Egypt
Urban Upper Egypt Rural Upper Egypt Frontier gov.
Fig. 3 Infant mortality and neonatal mortality in five geographic regions and dissimilarity index
during 2005 and 2014 in Egypt. (Source: Shawky et al. (2018). Reproductive health inequalities in
Egypt: Evidence for guiding policies. National study. http://schools.aucegypt.edu/research/src/
Documents/SRH-Inequities/Egypt-Report.pdf)
a ID%= 15.0% ID%= 19.5%

b ID%= 17.0% ID%= 23.5%
20 40
15 30
10 20
5 10
0 0
Adolescent Childbearing (%) Multiparity 5+children (%)
Urban gov. Urban Lower Egypt Rural Lower Egypt
Urban Upper Egypt Rural Upper Egypt Frontier gov.
Fig. 4 Adolescent childbearing and multiparity in five geographic regions and dissimilarity index
during 2005 and 2014 in Egypt. (Source: Shawky et al. (2018). Reproductive health inequalities in
Egypt: Evidence for guiding policies. National study. http://schools.aucegypt.edu/research/src/
Documents/SRH-Inequities/Egypt-Report.pdf)
Health equity framed by social justice adds an additional value judgment by

explicitly linking the denial of human rights to the unfairness of governance and
policies. Systematic health inequalities are reflective of the unfair distribution of
resources and opportunities and are strongly linked to “unfair economic arrange-
ments, bad policies, and politics,” as noted in the Commission of Social Determi-
nants report (CSDH 2008).
The Commission of Social Determinants report articulates that a social position is
central to understanding distribution of health and well-being. But the framework
Table 6 Geographic inequalities in health system components
Index of dissimilarity expressed in percent (ID%)

Egypt Jordan Morocco Oman Sudan
Health system performance
No contraceptive method used 7.6 0.1 5.6 3.5 2.9
FP unmet need 10.0 2.6 3.7 5.6
No antenatal care ( one visit) 21.0 2.4 17.3 24.4 14.3
No regular ANC ( visits) 17.0 3.9 9.0 15.9 8.3
Birth not protected against tetanus 8.2 1.8 6.6
Home delivery 24.8 2.8 15.4 29.4 9.3
Birth not attended by skilled provider 30.6 6.2 16.1 28.6
Caesarean section delivery 4444444
6.8 1.7 13.7 29.6
No postnatal care 4444444
22.4 10.1 6.3 6.1
4444444
No HIV/AIDS comprehensive knowledge in 1.2 0.3 27.8 2.0
4444444
No HIV/AIDS comprehensive knowledge in 0.9
4444444
Never had clinical breast examination 0.6
4444444 0.7
Health system capacity 444444 0.
Distant healthcare facility 6
10.7 0.7 15.3
Difficult transportation 9.7 0.7
Unavailable provider 7.7
Unavailable female provider 7.2 3.8 12.2
Unavailable medication 6.5
Unaffordable healthcare services 17.2 2.3 7.1
Source: Rashad et al., forthcoming. Reproductive health equity in the Arab region: Evidence and
policy implications. To be published by SRC and UNFPA. http://schools.aucegypt.edu/research/src/
Documents/SRH-Inequities/Reproductive-Health-Equity-in-the-Arab-Region.pdf
ID% 10% indicates high magnitude of inequality
moves beyond the proximate determinants defined by daily living conditions and
their material conditions, psychosocial support, and behavioral options, into struc-
tural root causes of inequities such as politics and governance, policy, and cultural
and societal forces. Root causes may operate at the global and the national levels.
Social inequalities in public services institutions, such as health-care systems, play a
role in modifying or producing health inequities.
The conceptual framework for social determinants of health inequities is shown
in Fig. 5. The proximate subcomponent of this framework focuses the attention to
changing living conditions and behavior, while the upstream components call for
addressing the causes of causes. These are the structural forces and their manifesta-
tions in inequitable services, contexts, and norms (such as the health-care system,
other public services, as well as enabling environments and norms, particularly
gender norms).
The CSDH called for reconsidering our approach to health and to health care. The
new approach to health requires looking to the causes of inequities through a lens of
Proximate SDH Frame
Inequitable
living conditions
l Socioeconomic status
Structural forces l Access to health care
l Governance l Access to schools and
l Policy education Systematic Distribution

(macroeconomic, l conditions of work and differences of health and
social and health) leisure in behaviors well being
l Cultural and l homes ,communities
societal forces and cities
Inequitable services
contexts and norms
l Health care system
l Other public services
l Enabling environments
l Gender norms
Social determinants of health inequities frame
Fig. 5 Social determinants of health inequities framework
social justice. Such an approach moves the action beyond the confinement of the
health sector. In other words, the health equity approach is not confined to a remedial
welfare approach solely responding to the health gap between the most and least
disadvantaged groups. It instead entails the provision of fair opportunities that
prevent the systematic differences in health across the hierarchies of social distribu-
tions. The new approach to health care recognizes that health care is a central social
institution that can play a role in responding to health inequities and, unfortunately,
can also contribute to producing such inequities).
The approach adopted entails integrated and intersectoral actions by the state
and invites the participation of several other players. It also establishes health
equity as a performance indicator and a benchmark for a just and fair society. Health
equity should be a central policy goal and used as a measure of societal success.
Furthermore, the approach adopted requires the health sector to improve its perfor-
mance with particular emphasis on fairness, as well as play a very much needed
stewardship role.
As previously discussed, the call of the Commission on Social Determinants of
Health has not yet been embraced in the Arab region. The approach adopted is
confined to the proximate social determinants frame.
The recent regional report referred to earlier (Rashad et al. forthcoming), and the
five national studies on which it is based, may be the only ones to systematically
investigate the structural frame of inequities and adapt it to the social determinants of
sexual and reproductive health. The systematic investigation of structural determi-
nants and their role in causing health inequalities is a step that is overdue and one that
produced two key findings. The first is that evidence of the unfairness of the
distribution of the social stratifications is abundant. The second is that significant
advances are needed in knowledge and research to address such unfair distributions.
An improved evidence base is required to influence governance reform and guide
programs to fully adopt the equity lens.
A New Role for the Health Sector
Improving Performance and Adopting a Fairness Lens
The discussion above suggests that policy reforms needed to achieve equity in health
and in sexual and reproductive health is a complex and difficult process. It also stated
that the health sector cannot continue to be assigned sole responsibility. However,
prior to inviting other partners to the table, the health sector must put its house in
order.
The health sector is the one to be called upon to prevent and address the high
levels of maternal and infant mortality, to respond to the many morbidity challenges
of sexual and reproductive health (infertility, sexually transmitted diseases, cancers
of reproductive organs, etc.), and to engage with the many social risk factors of
sexual and reproductive health (harmful traditional practices, early marriage, vio-
lence, etc.). The health sector is also required to include a broader list of sexual and
reproductive health-care services and to ensure that these services cater for the needs
of special groups (particularly unmarried women and adolescents). The universal
coverage of the services and inequality challenges are new components that are now
capturing greater attention from the health sector.
These expanded responsibilities place additional demands on an already
constrained health sector. The financing and effectiveness of services are no longer
the only impediments to the health sector performance. The health sector is now
called upon to:
– Demonstrate impact on an expanded list of sexual and reproductive health. These

incorporate mental and social aspects in sexual and reproductive health, as well as
health risk determinants that are mainly shaped by social forces (early age at
marriage, violence, denial of reproductive rights, etc.).
– Partner with other social sectors to address risk determinants of sexual and
reproductive health that are shaped by social forces.
– Broaden health-care services and integrate key services within primary health
care, as well as address the specific needs of groups that face cultural constraints
in accessing sexual and reproductive health services.
– Rely on a much broader information and knowledge base to guide monitor and
evaluate their work.
More importantly, the health sector needs to adopt a fairness lens in its provision
of services and in its evaluation of performance. Section III of this chapter (Progress
and Shortfalls) described not only the failures of the health system in responding to
differentiated needs but also that increased sexual and reproductive health needs are
met with worse health system components (performance and capacities) when
catering for these needs.
Playing a Stewardship Role
Another new role of the health sector is its stewardship role, which is directed to
other social agencies. The WHO speaks to three dimensions of this role: advocacy,
partnership, and leadership (WHO 2009).
– The advocacy dimension assigns the health sector the responsibility of providing
and disseminating evidence to support integrating an equity lens into social
policies impacting sexual and reproductive health. This requires a health infor-
mation system able to systematically measure and monitor inequality in sexual
and reproductive health. The health information system should allow tracing and
linking of sexual and reproductive health inequalities to their structural root
causes and to the fairness of these causes.
– A partnership dimension requires the health sector to engage with the other social
partners and other stakeholders in society to support equitable integrated and
intersectoral actions for improved health.
– The leadership dimension demonstrates the role of the health sector in supporting
good governance and a governmental approach to sexual and reproductive health
equity. It also demonstrates how the health sector adopts the visionary well-being
equity approach in prioritizing and in addressing sexual and reproductive health
inequities, as well as the successful demonstration of participatory integrated
models that manage to achieve sexual and reproductive health equity.
Concluding Remarks
The Arab region has actively participated in the international movement to promote
sexual and reproductive health. The expressed commitment, the adoption of strate-
gies, and the increased efforts did translate into improvements for a number of health
impact measures and risk factors. Such improvements should not conceal the
unfinished agenda and the many challenges that need to be addressed.
This chapter emphasizes the urgency of addressing the inequity shortfall. It calls
for a new approach to health and health care in the Arab region. Such an approach
while recognizing that the health sector cannot be assigned the sole responsibility for
“health and well-being for all,” calls on it to spearhead a very much needed policy
reform movement, a movement that is anchored on social justice and entails fairness
in the distribution of reassures for health and in the responsiveness of social services
(including health sector services) to differentiated needs. Such a movement places

health equity as a measure of social success and meets the aspirations of the Arab
population for a better future for all, a future anchored on justice, nondiscrimination,
and inclusiveness.
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Cultural Barriers to Breast Cancer Screening
in Arab Women 10
Manal Alatrash
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
Breast Cancer Incidence and Status in the Arab World . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
Prevalence of Breast Cancer Screening in Arab Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
Cultural, Religious, and Social Barriers to Breast Cancer Screening . . . . . . . . . . . . . . . . . . . . . . . . . . 187
Spirituality and Belief in Predestination in Breast Cancer Screening . . . . . . . . . . . . . . . . . . . . . . . . . . 193
Embarrassment, Fear, and Fatalism in Breast Cancer Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
Influence of Selflessness, Emphasis on Children and Family, and Social Factors in Breast
Cancer Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196
Implications for Public Health, Healthcare Policy, and Oncology Settings . . . . . . . . . . . . . . . . . . . 197
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
Abstract
Breast cancer is the most common type of cancer in the world and also in Arab
countries. Despite the fact that its incidence and mortality rates in the Arab world are
on the rise, preventive care is not practiced by Arab women. Breast cancer screening
is highly recommended to detect the disease early, promote health, and reduce
mortality rates. Several barriers were found to influence views, beliefs, attitudes,
and behaviors of Arab women toward breast cancer screening. Addressing barriers
related to the Arab culture, religion, and spirituality, in addition to social and
personal barriers, is a critical element that must be well-understood to reinforce
the importance of breast cancer screening and improve related practices.
This chapter discusses the incidence and current status of breast cancer
screening in the Arab world. It also examines and analyzes sociocultural, reli-
gious, and spiritual barriers to breast cancer screening that must be integrated into
culturally congruent awareness programs to enhance their effectiveness. Intensive
M. Alatrash (*)
School of Nursing, California State University, Fullerton, CA, USA
e-mail: malatrash@fullerton.edu

https://doi.org/10.1007/978-3-030-36811-1_160
178 M. Alatrash
efforts are much needed to achieve early detection of breast cancer since screen-
ing is perceived as unnecessary among Arab women. Although recent years have
shown a slight increase in breast cancer studies, research is still scarce. This
chapter identified several research areas to help cover the gap in breast cancer
screening practices and improve screening rates in Arab women.
Keywords
Breast cancer · Arab women · Cultural barriers · Religious barriers · Breast cancer
screening · Mammography · BSE · CBE · Breast cancer incidence · Breast cancer
prevalence
Introduction
Breast cancer is the most common type of cancer in Arab countries and the world
(World Health Organization [WHO] 2019). Breast cancer incidence and mortality
rates in the Arab world are on the rise (Donnelly et al. 2014; WHO 2019). Breast
self-examination (BSE), clinical breast examination (CBE), and mammography
screening are recommended to detect breast cancer early (American Cancer Society
[ACS] 2019). With the widespread of primary healthcare aiming at wellness pro-
motion and disease prevention, breast cancer screening is highly recommended to
detect breast cancer early and reduce its mortality rates. Mammography has been
identified as a valuable tool to decrease morbidity and mortality from breast cancer
(ACS 2019). According to the ACS (2019), mammograms should be continued as
long as the woman is in good health and is expected to live for at least 10 more years.
Despite the well-known benefits of breast cancer screening and the fact that Arab
women present with advanced stages and late presentations of breast cancer, screen-
ing rates have been reported to be low in Arab women (Assaf et al. 2017; Baider and
Goldzweig 2016; Donnelly et al. 2014; Ermiah et al. 2012; Fares et al. 2019; Komen.
org 2019; Mamdouh et al. 2014; Stapleton et al. 2011). Several factors were found to
influence views, beliefs, attitudes, and behaviors of those women toward breast
cancer screening. Although recent years have shown a slight increase in breast
cancer-related studies, research is scarce, and much work to achieve early detection
of breast cancer is still to be done since screening remains unpracticed and is
perceived as unnecessary among the vast majority of Arab women.
This chapter will discuss the incidence and current status of breast cancer
screening in Arab countries and examine barriers related to the Arab culture, religion
and spirituality, and personal and social factors which are critical factors that must be
considered to effectively increase breast cancer screening rates.
Breast Cancer Incidence and Status in the Arab World
Breast cancer has been ranked as the leading cancer in all of the Arab countries
except for Mauritania in which it is recognized as the second most common behind
cervical uterine cancer (International Agency for Research on Cancer 2019),
10 Cultural Barriers to Breast Cancer Screening in Arab Women 179
indicating that this cancer is a major public health problem in Arab countries that
requires special attention. The statistics from the WHO’s International Agency for
Research on Cancer (IARC), Globocan 2018, revealed that the incidence of breast
cancer has been increasing rapidly in the Arab world. Figure 1 presents
age-standardized incidence and mortality rates per 100,000 of women affected by
breast cancer in the Arab world in 2018 (IARC 2019).
Although breast cancer incidence in the Arab world may be lower than global
averages (Hashim et al. 2018), Lebanon is one Arab country in which breast cancer
is significantly more prevalent compared with other Arab countries followed by
Syria, Jordan and the West Bank, and Gaza. Breast cancer incidence in Lebanon was
55.4/100,000 in 2008, compared to 97.6/100,000 in 2018 (IARC 2019), suggesting
the rapid increase in incidence in this country. Complied breast cancer data for the
years 2005–2015 from the National Cancer Registry of Lebanon revealed that
Lebanon has the second highest breast cancer incidence behind Denmark when it
was compared with other countries in the region and selected countries from
different parts of the world (Fares et al. 2019). Breast cancer-related mortality rate,
however, is found to be the highest in Comoros, 39.8/100,000, compared to Leba-
non, 25.3/100,000. This can be attributed to the fact that Lebanon has recognized the
urgent need to fight this cancer and has been emphasizing the importance of
increasing knowledge about breast cancer and overcoming barriers to its screening
(Abu-Helalah et al. 2015; Asmar et al. 2018; Doumit et al. 2017; El Ermiah et al.
2012; Mamdouh et al. 2014; Othman et al. 2015). In addition, lack of technology and
screening programs was reported in nonindustrialized countries, hence the high
mortality rate in Comoros (Charalabos 2011).
Despite the availability of these statistical data, the status of breast cancer
screening in the Arab world still requires more clarity and scientific evidence as
Age-Standardized Incidence and Mortality Rates per 100,000

120
100
80
60
40
20
0
Jo ia
W n
S ...
Le yria
or n
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Tu ria
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i A pt
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an
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m it
os
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ira i
s
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ud gy
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oc
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a
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hr
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ab jib
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au
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a
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G
Fig. 1 Incidence and Mortality Rates of Breast Cancer in Arab Countries– Globocan 2018
(International Agency for Research on Cancer 2019)
180 M. Alatrash
the majority of the related literature, although scanty, came from a few Arab
countries, such as Qatar, Lebanon, and Jordan. In other Arab countries, such as
Comoros and Mauritania, research studies examined barriers to screening were hard
to find. Arab women come from 22 diverse countries in the Arab world (Batniji et al.
2014), ranging from rich countries, such as oil states of the Persian Gulf that have
longer life expectancy, to poor countries characterized by poor health indicators,
such as Yemen and Somalia (Batniji et al. 2014).
A vital issue that may potentially influence screening practices in the Arab world
is the presentation of breast cancer which significantly differs from the Western
world. Arab women with breast cancer got diagnosed at significantly younger ages
with an average age of 46–48 years (Arkoob et al. 2010; Boder et al. 2011; Makoukji
et al. 2016) and presented with advanced stages (Chouchane et al. 2013; Corbex and
Harford 2013; Doumit et al. 2017). Data about newly diagnosed women obtained
from the Jordan Cancer Registry and hospital records during 1997–1998 indicated
that half of these women were diagnosed between the ages of 40 and 59 years
(Arkoob et al. 2010). About two thirds of women diagnosed with breast cancer are
younger than 50 which can be attributed to the fact that the entire populations of
Arab countries are relatively young (Corbex and Harford 2013).
Identifying potential risk factors that may have contributed to the increasing
incidence of breast cancer is paramount (Saggu et al. 2015). Makoukji et al.
(2016) indicated that different gene expressions were noted in Lebanese women
when compared to women in the West; therefore, the early breast cancer occurrence
in Lebanese women may be due to exposure to unique environmental and genetic
factors. These findings were supported in Arab women in North African countries,
such as Libya, who were found to have predominantly premenopausal types of
breast cancer with unfavorable characteristics such as large tumor sizes, high
histological grade and stage, and frequent lymph node metastases, whereas in
Europe, breast cancer is predominantly postmenopausal (Boder et al. 2011). This
suggests that population differences may be involved due to known variations
regarding the distribution of genetic markers although environmental impact cannot
be excluded (Boder et al. 2011). Tumor stage was found to be the most imperative
epidemiological factor which significantly influenced survival analysis after control-
ling for other factors in Jordan (Salem et al. 2013). These epidemiological findings
encourage further future studies to focus on exploring and analyzing epidemiolog-
ical and genetic profiles of Arab women since these factors may contribute to high
mortality rates (Arkoob et al. 2010; Fares et al. 2019; Makoukji et al. 2016; Saggu
et al. 2015).
Increased incidence of breast cancer in the Arab world can be credited to
improved diagnostic testing in addition to environmental risk factors including
changes in reproductive patterns, use of birth control, high mean marital age, lack
of exercise, diet, and higher obesity and smoking rates (Badr et al. 2018; Fares et al.
2019; Hamadeh et al. 2014; Horn and Vatten 2017). When Lebanese women were
compared with their Lebanese-American counterparts, Badr et al. (2018) found that
Lebanese women had significantly higher risk factors especially smoking cigarettes
and hookah regularly. Hookah is composed of water chamber, tobacco chamber, and
water pipe used to smoke flavored and sweetened tobacco. Smoking, exercise,
duration of breastfeeding of more than 6 months, and eating fruits were found to
be predictive factors to mammography and CBE screening (Badr et al. 2018).
The Arab nation has a rising incidence of breast cancer, while it is characterized
by lack of screening and health promotion campaigns, variations in ethnic and
religious groups, social and economic inequities, sociodemographic changes, and
political turmoil forcing migration, increasing the vulnerability of some populations,
and limiting access to healthcare services and quality of care (Batniji et al. 2014;
Doumit et al. 2017; Jordan Department of Statistics and ICF International 2019).
Breast cancer is especially feared among women; having a better understanding of
and integrating incidence, prevalence rates, histopathologic presentation, and risk
factors into national awareness programs can motivate Arab women to engage more
in breast cancer screening.
Prevalence of Breast Cancer Screening in Arab Countries
Breast cancer screening is highly recommended to decrease morbidity and mortality

from breast cancer and to improve survival rates (ACS 2019). Cancer screening and
health promotion are generally not practiced in Arab populations due to perceived
barriers to screening and lack of knowledge, awareness, and screening resources in
Arab countries, hence the low breast cancer screening participation rate
(Abu-Helalah et al. 2015; Al Rifai and Nakamura 2015; Alshahrani et al. 2019;
Arevian et al. 2011; Chouchane et al. 2013; Doumit et al. 2017; El Asmar et al. 2018;
Elobaid et al. 2014; Mamdouh et al. 2014; Othman et al. 2015). Additionally, there
are significant variations in the Arab region in regard to access to healthcare,
affordability of the services, presence and quality of screening programs, and
national cancer registries (Bowser et al. 2017). Low breast cancer participation
rates have been reported by the current literature from various Arab countries
(Abolfotouh et al. 2015; Al Rifai and Nakamura 2015; Arevian et al. 2011; Donnelly
et al. 2013, 2015b; El Asmar et al. 2018; Elias et al. 2017; Elobaid et al. 2014;
Haddad et al. 2015; Hamadeh et al. 2014).
Despite the fact that women should start mammography screening between ages
40 and 44 (ACS 2019), and that Arab women got diagnosed with breast cancer at
younger ages, several studies showed older Arab women had more participation in
breast cancer screening. Younger women felt that screening was unnecessary since
they were too young to get breast cancer and believed that they did not need it before
age 50 (Al Dasoqi et al. 2013; Al-Rifai and Loney 2017; Elobaid et al. 2014; Jordan
Population and Family Health Survey 2019; Haddad et al. 2015). This supports the
notion that since older women are more likely to visit healthcare providers for having
more health issues, they receive more education about breast cancer screening than
younger women. A consistent increase in utilizing mammography screening was
reported in women in their 50s compared with younger women (Haddad et al. 2015).
Arab women generally failed to seek medical help or get a mammogram until
they had symptoms such as pain or inflammation, it was recommended by the
182 M. Alatrash
physician, or they had an advanced cancer (Elobaid et al. 2014; Jordan Population
and Family Health Survey 2019; Mamdouh et al. 2014; Othman et al. 2015).
Lebanon, however, has recently begun to promote knowledge about breast cancer
and its screenings considering the overwhelming increased incidence of breast
cancer in this country (Doumit et al. 2017). Therefore, participation rates in mam-
mography screening appear to have increased among Lebanese women. Current
studies reported 72.8% and 69.4% of ever having mammography screening (Badr
et al. 2018; El Asmar et al. 2018), whereas 59.1% reported having regular yearly or
biennial mammograms (El Asmar et al. 2018). Another study showed that although
many Lebanese women practiced mammography screening properly, less than 25%
practiced CBE per guidelines, which was not congruent with the high level of
knowledge about breast cancer screening found in those women (El Asmar et al.
2018). In support of these results, BSE was reported to be practiced every month by
less than 25%, and only 37.7% of Lebanese women reported having both CBE and
BSE although they demonstrated satisfactory knowledge about breast cancer screen-
ing practices (Doumit et al. 2017). A 2014 survey that recruited 2400 women, about
50 years of age, living far from the central capital district of Greater Beirut, and
mostly socioeconomically disadvantaged, from all areas of the country showed that a
very small proportion (44%) had never heard of mammography screening. Only
45% of those women had ever obtained a mammography, indicating that the
prevalence is still low compared to developed countries (Elias et al. 2017). These
results are consistent with a previous survey conducted nationally between 2005 and
2013 in Lebanon which found that 43% reported ever-having mammography
screening compared to 20% reported having recent mammography by 2013 (Haddad
et al. 2015). In 2011, although the majority of women reported having heard of BSE
and mammography, only 14.9% performed BSE on a regular basis, and 79.6%
reported never having a mammogram done (Arevian et al. 2011).
In Jordan, national surveys and studies confirmed the low breast cancer partici-
pation rate and even lower adherence (Abu-Helalah et al. 2015; Al Rifai and
Nakamura 2015; Jordan Population and Family Health Survey 2019; Othman
et al. 2015; Taha et al. 2014). The Jordan Population and Family Health Survey
2017–2018 (2019) showed that 17% of ever-married women, between ages 15 and
49, performed BSE in the past 12 months, 14% had CBE, and only 9% had a
mammogram. Women from the highest socioeconomic status had higher rates of
BSE (27%), CBE (24%), and mammography (16%). Only 39% of ever-married
women reported undergoing a breast examination, CBE or BSE, in the previous year
with 19.3% and 31.5% having CBE and BSE, respectively (Al Rifai and Nakamura
2015). Participation rates of 34.9%, 16.8%, and 8.6% were reported in another
survey for BSE, CBE, and periodic mammography screening, respectively
(Abu-Helalah et al. 2015). Women resided in the city showed higher odds of
undergoing mammography than those who lived in villages or towns
(Abu-Helalah et al. 2015; Al-Rifai and Loney 2017). Othman et al. (2015) reported
a higher BSE rate of 50%, whereas low participation rates were reported for CBE
(28%) and mammography (7%), although 54% of women who underwent CBE had
it only once in their lifetime. In 2012, 12.4% of the Jordanian women reported ever
having a mammography at least once in their lifetime (Al Nsour et al. 2012). The
screening pattern over the past few years addressed in those studies indicates that
screening has not been increasing despite the awareness campaigns conducted in
Jordan which urgently calls for continuous and rigorous efforts to improve these
rates. Similarly, breast cancer screening rates remain low in the Gulf countries, such
as Saudi Arabia, Bahrain, Qatar, and the UAE, despite the availability of breast
cancer screening resources and health insurance (Abolfotouh et al. 2015; Donnelly
et al. 2013, 2015a; Elobaid et al. 2014; Hamadeh et al. 2014). In Bahrain, only
12.7% of all breast cancer cases were detected by screening (Hamadeh et al. 2014).
There are very few published studies about breast cancer screening from North
African Arab countries, such as Egypt, Libya, and Algeria and Morocco. The
literature found that Arab women in the North African region had very low breast
cancer screening rates due to a lack of knowledge about its screening in addition to
some other factors related to cultural and financial barriers and lack of physician
recommendations (Al-Rifai and Loney 2017; Bowser et al. 2017; Mamdouh et al.
2014). Insufficient knowledge of BSE was reported; thus, there is a special need to
spread awareness about breast cancer and its screenings in those countries (Assaf
et al. 2017; Taher et al. 2016). Boder et al. (2011) found that although mammography
has been practiced in Libya, it has not succeeded in improving early diagnosis
because it was not performed for screening purposes.
Similarly, breast cancer screening rates among Arab women in the West Bank and
Israel were reported to be low (Azaiza et al. 2010; Cohen et al. 2012). When
compared to Jewish ultra-Orthodox women in Israel, Arab women had more adher-
ence to mammography and CBE, which was associated with lower levels of reli-
gious beliefs (Freund et al. 2019). Wilf-Miron et al. (2011) reported 61% of
mammography screening among Arab women in Israel. However, over 70% of
women in the West Bank never participated in mammography screening or CBE,
whereas 62% performed BSE (Azaiza et al. 2010). In support of these results, only
20% of Arab women in Israel had accurate mammography although 51% reported
ever having it (Soskolne et al. 2007). Table 1 presents more details about partici-
pants’ sociodemographic characteristics and screening rates in various Arab
countries.
Delayed detection and fatalism have mostly influenced Arab women with low
socioeconomic status and educational levels indicating variations within Arab
groups (Al Rifai and Nakamura 2015; Donnelly et al. 2013; Doumit et al. 2017;
Taha et al. 2014). However, even when screening services were offered for free by
some facilities and widely covered by health insurance in some wealthy and well-
resourced Arab countries in the Middle East, participation rates were still generally
low (Elobaid et al. 2014, 2016; Jordan Population and Family Health Survey 2019).
Interestingly, screening rates are also still low despite the national awareness pro-
grams conducted in some Arab countries (Al Rifai and Nakamura 2015; Elobaid
et al. 2014, 2016; Sosklone et al. 2007). In addition, several studies showed that
although the level of knowledge about breast cancer screening was found to be
higher in educated women, they were not adamant about having mammography
screening (Arevian et al. 2011; Doumit et al. 2017; El Asmar et al. 2018; Elobaid
184 M. Alatrash
Table 1 Participation rates in mammography, breast self-examination, and clinical breast exam-
ination in Arab women
Author(s)
and year Arab country Sample description Screening rates
Abu-Helalah Jordan A random sample of Breast self-examination, doctor
et al. (2015) women aged 40 to examination, and periodic
69 years. A total of mammography screening were
507 participants reported by 34.9%, 16.8%, and
8.6% of study participants
3.8% underwent breast cancer
screening at least once but not
periodically, while 87.6% had
never undergone mammography
screening
In the absence of regular
systematic screening for breast
cancer in Jordan, the uptake of
this preventive service is very low
Al Rifai and Jordan 11,068 ever-married Generally, over 39% of ever-
Nakamura women (women who married Jordanian women
(2015) had ever-married) reported having undergone a
aged 15–49 years breast examination during the
previous year. In the previous
year, the rate of performing BSE
was 31.5% and that of CBE was
19.3%. The odds of performing
BSE and CBE were higher among
women in the highest wealth-
index quintile as compared to
those in the lowest quintile
Taha et al. Jordan 2363 women, aged Out of 625 women who received
(2014) 20–79 years, a voucher for free mammography
participated during screening, 73% attended the
breast health mammography unit, while only
awareness home visits. two women without a voucher
625 women aged went for mammography
40 years or older were screening at the assigned unit
referred to free
mammography
screening
Badr et al. Lebanon and 105 Lebanese- Both groups had almost similar
(2018) United States American and rates of undergoing a
(cross- cultural 250 Lebanese women mammography screening, with
comparison aged 40–75 years old 74.3% for Lebanese-American
between the women and 72.8% for Lebanese
West and the women
East) Lebanese-American women had a
higher rate of having CBE within
a year, 84.8% vs. 58.4%
BSE was not significantly
different between the two groups,
(continued)
Table 1 (continued)
Author(s)
48.6% for Lebanese-American
women vs. 46.0% for Lebanese
women
The Lebanese-American
participants had a
significantly better understanding
of the effectiveness of the
mammogram, BSE, and CBE
El Asmar Lebanon 371 Lebanese women Self-examination,
et al. (2018) aged 18–65 with no mammography, and clinical
history of breast examination practices were
cancer 42.3%, 36.5%, and 45.5%,
respectively
Doumit et al. Lebanon A total of 1200 women 83.5% of the women heard of
(2017) participated in this BSE; however, only 63.7% of
study, 73% of which them conducted BSE. 71.1%
aged 40 to 59 years. reported knowing about CBE,
More than half were and 71% of them conducted
Muslim (53.6%) it. Overall, only 37.7% reported
having had both CBE and BSE
Elias et al. Lebanon A sample of 2400 105 women (4.4%) had never
(2017) women was selected heard of mammography as a tool
aged 40 and older for early breast cancer detection.
Of the remaining 2295, 45% had
ever used it. 67% of 926 women
who had the time opportunity
were repeaters
Haddad et al. Lebanon Women aged 40 and Ever utilization of mammography
(2015) older from all areas of reached 43% with recent
Lebanon. The sample utilization of 20% nationwide.
size has increased Utilization was significantly more
incrementally from in the age group 50–59 compared
1200 in 2005 to 2400 with the age group 40–49 or 60.
in 2013 While recent rates have increased
nationwide, they have reached a
plateau of about 25%
Arevian et al. Lebanon 94 women. More than 80.9% of women heard of BSE,
(2011) 64.8% were over 41 while 76.6% heard of
mammography. However, 53.2%
never practiced breast self-
examinations, and 79.6% never
underwent mammography
Donnelly Qatar 1063 (87.5% response 28.9% were aware of breast self-
et al. (2015b) rate) female Qatari examination and 41.8% of
citizens and clinical breast exams, while
non-Qatari Arabic- 26.4% knew that mammography
speaking residents, was recommended by national
screening guidelines. Only 7.6%
(continued)
186 M. Alatrash
Table 1 (continued)
Author(s)
35 years of age or had knowledge of all three BCS
older activities
Less than one third practiced BCS
appropriately (13.9% of
participants performed BSE
monthly, 31.3% had a CBE once
a year or once every 2 years, and
26.9% of women 40 years of age
or older had a mammogram once
every year or 2 years)
Abolfotouh Saudi Arabia 225 adult female 91.2% of women heard about
et al. (2015) employees, working at BSE; however, only 41.6%
King Abdulaziz reported ever practicing BSE, and
Medical City and their only 21% performed it regularly
non-working adult
female family
members (n = 208),
aged 45 and younger
Elobaid et al. UAE 247 women were Screening uptake was 48.6% for
(2014) randomly selected BSE, 49.4% for CBE, and 44.9%
from 4 out of for mammography
12 cultural and 44.8% of women who never had
religious community CBE and 44.1% who never had
centers in Al Ain City mammography expressed a lack
of knowledge about the existence
of these screening techniques.
Nearly one third of the
participants interpreted the
presence of a breast lump
incorrectly
Azaiza et al. The West Bank 397 women, aged Greater than 70% of the women
(2010) 30–65 years, residing had never undergone
in the Palestinian mammography or clinical breast
authority, and a examination (CBE), whereas
stratified sample 62% performed self-breast
method was used examination (SBE)
et al. 2014; Sosklone et al. 2007), indicating that participation in breast cancer
screening is multifaceted especially that it is influenced by sociocultural and reli-
gious values and beliefs. Arab women’s behaviors toward breast cancer screening
are not well-understood; therefore, raising awareness and increasing knowledge
about breast cancer screening alone may not be sufficient to increase participation
rates in Arab women. This is a multifold public health problem that requires
multifold tailored interventional programs.
Disparities in breast cancer screening rates between Arab women in the Western
world and their counterparts in the Arab world are evident and should be examined
(Alatrash 2019; Badr et al. 2018). The current literature reported higher rates in Arab
women living in Western countries (Alatrash 2019; Badr et al. 2018). This may be
attributed to the acculturation factor since length of stay and integrating into the
Western culture provide women an opportunity to become more familiar and
knowledgeable about breast cancer screening (Badr et al. 2018; Padela et al.
2015). Additionally, living longer in an advanced country, such as the United States,
may increase proficiency in English which provides an opportunity for these women
to navigate and access healthcare services more easily (Ayyash et al. 2018). Accul-
turation, length of stay, and English proficiency were found to be significant vari-
ables in managing health in Arab women living in the Western world (Ayyash et al.
2018).
Cultural, Religious, and Social Barriers to Breast Cancer Screening
Several barriers to breast cancer screening and contributing factors to the general
low participation rates in breast cancer screening in the Arab region have been
identified by the current literature. Consistent and significant barriers included
cultural and religious barriers, level of education, family and social influences,
low socioeconomic status, lack of knowledge and awareness about breast cancer
screening, lack of physician’s recommendations, fatalism, fear, shame, and embar-
rassment (Alagraa et al. 2015; Al Dasoqi1 et al. 2013; Al-Khasawhen et al. 2016;
Assaf et al. 2017; Azaiza and Cohen 2008; Baider and Goldzweig 2016; Donnelly
et al. 2013, 2015b; Doumit et al. 2017; El Asmar et al. 2018; Haddad et al. 2015;
Taha et al. 2012).
In the Arab region, breast cancer practices are heavily reliant upon cultural,
religious, and social factors that may act as barriers or facilitators. A growing body
of evidence, although still scanty, has revealed the great extent to which Arab
women’s views and health practices are influenced by unique cultural, religious,
and traditional customs in addition to social and family structures. All of which are
highly interrelated and overlapping factors that significantly impact breast cancer
screening. These factors must have a special attention especially that differences in
socioeconomic status, access to care, and levels of knowledge and education failed
to sufficiently explain underutilization of breast cancer screening tests in Arab
women (Al Dasoqi et al. 2013; Donnelly et al. 2015b; El Asmar et al. 2018; Jordan
Population and Family Health Survey 2019; Sosklone et al. 2007). Table 2 presents
research findings related to facilitators and barriers to breast cancer screening in the
Arab world.
Understanding the different meanings of health concepts within various cultural
and social structures of Arab and Muslim populations can be one of the most
important challenges facing healthcare professionals (Baider and Goldzweig 2016;
Hwang et al. 2017).
188 M. Alatrash
Table 2 Reported facilitators and barriers regarding breast cancer screening

Author(s) Facilitators and barriers to
and year Arab country Sample description screening
Alshahrani Saudi Arabia Simple random Only 18.8% had good general
et al. (2019) sampling of 1046 knowledge
male and female Poor knowledge about breast
participants aged cancer, risk factors, signs, and
12–80 years symptoms or early detection
procedures
Abolfotouh Saudi Arabia 225 adult female Poor knowledge and negative
et al. (2015) employees and attitudes toward BSE
208 of their
non-working adult
female family
members aged
45 and younger
Al-Rifai Egypt A representative Lack of knowledge of performing
and Loney population-based BSE
(2017) sample of 7518
women aged
15–59 years
Mamdouh Egypt 612 Egyptian 81.8% would not seek care until
et al. (2014) women were they were ill, 77% were unwilling
randomly selected to have a mammogram until it
to understand the was recommended by the doctor,
possible personal, 71.4% blamed the lack of privacy,
economic, and 69.2% thought that medical
systems barriers to checkups were not worthwhile,
BC screening and 64.6% blamed the cost of
services
Stapleton Egypt 343 women with 46% had presented at late stage.
et al. (2011) breast cancer Women without any pain were
more likely to present at later
stage
Knowledge of breast self-
examination increased the
likelihood of women to present in
early stages
El Asmar Lebanon 371 Lebanese Fear of learning bad news, pain,
et al. (2018) women, aged cost, and staff unpleasantness
18–65 years
Elias et al. Lebanon A sample of 2400 Older age, higher socioeconomic
(2017) women, aged status (SES), and living in the
40 and older urban area of Greater Beirut
(GB) were significantly
associated with mammography
ever-use
Within GB, psychosocial factors
such as perceived susceptibility
and benefits were most strongly
associated with ever-use. Outside
(continued)
Table 2 (continued)
GB, socioeconomic advantage
seemed to mostly affect ever-use
Opposition from husbands to
their mammography. Husband’s
support was significant for
adherence to mammography
guidelines mostly outside GB
Ermiah Libya 200 women, aged Fear and shame prevented women
et al. (2012) 22–75 years from seeking medical help when
they felt symptoms
Diagnosis delay is a very serious
problem in Libya
Assaf et al. United Arab Qualitative data (1) Protecting one’s self from
(2017) Emirates (UAE) collected from stigma, (2) facing uncertainties
20 Arab women and prayers, and (3) getting on
following a recent with life
diagnosis of breast Arab women with breast cancer
cancer experienced a myriad of social,
cultural, psychological, and
relationship difficulties that
impacted their overall health and
well-being
Bener et al. UAE 41 women, aged Social and cultural barriers
(2002) 25–45 years related to breast cancer and its
screening included fear,
embarrassment, and mistrust of
healthcare, belief in
predestination, anxiety and fear
leading to denial, and lack of
knowledge about cancer and the
screening program
The facilitators included feelings
of susceptibility, high levels of
knowledge in some women,
attitudes and beliefs about
personal responsibility for health,
and a supportive social milieu
Othman Jordan 1549 population- Lack of knowledge about breast
et al. (2015) based randomly cancer screenings. Only 13%
selected women stated correctly that women
aged 18 to 95 years should start doing CBE at the age
of 20 years, but 53% of the
women reported the correct
answer that women should have a
CBE every year. Only 37.6% of
women correctly reported that
mammography screening should
start at the age of 40 years, but
(continued)
190 M. Alatrash
Table 2 (continued)
60% knew that mammography
screening should be performed
every year
Al Dasoqi Jordan Qualitative data (i) Young women should not
et al. (2013) collected from think about it, (ii) absence of a
45 young educated role model, (iii) cultural shame of
women, aged breast cancer, and (iv) cancer
20–25 years, about means death and disability
their breast cancer High levels of apprehension and
views and screening ambiguity related to breast cancer
practices
Othman Jordan 626 women aged Absence of health problems, lack
et al. (2013) 40 years and older of knowledge of the significance
of mammography, pain, and
embarrassment
Those who reported absence of
health problems as a barrier for
mammography were significantly
less likely to have higher
education. Those who had routine
medical checkups were more
likely to report lack of physician
recommendation as a barrier
Bowser The Middle East A systematic (1) Access to insurance,
et al. (2017) and North Africa review using the (2) physician recommendations,
(MENA) region PRISMA (3) physician gender, (4) provider
(with a specific methodology. characteristics, (5) having a
focus on Egypt, 55 studies from regular provider, (6) fear of the
Jordan, Oman, January 1, 2000, system or procedure, and
Saudi Arabia, UAE, until September (7) knowledge of the health
and Kuwait) 1, 2016, were system
included
Donnelly Qatar Qualitative data Gender-related issues as men
et al. (2017) collected from were adamant that any
50 Arab men to examination must be done by a
examine their female healthcare professional,
perceptions about social stigma and anticipated
breast cancer negative consequences of a
screening for diagnosis of breast cancer, and
women educational and financial barriers
Hwang Qatar Qualitative data Three major factors influenced
et al. (2017) collected from breast cancer screening practices:
50 women and (a) beliefs, attitudes, and practices
15 healthcare regarding women’s bodies,
practitioners health, and illness; (b) religious
beliefs and a culturally sensitive
healthcare structure; and
(c) culturally specific gender
relations and roles
(continued)
Table 2 (continued)
Donnelly Qatar 1063, aged 35 years Education level, occupation,
et al. and older, nationality, years of residence in
(2015a) participants. The the country, level of social
majority of the activity, self-perceived health
participants were status, and living area influenced
married, had income indicating that financial
children, and stress, unemployment, and
resided in urban unfavorable social conditions
areas for at least may impede women’s
30 years. 52.1% participation in breast cancer
were Qatari activities in well-resourced
citizens, whereas Middle East countries
47.9% were
non-Qatari citizens
from the Greater
Middle Eastern
region
Donnelly Qatar 1063 Qatari citizens Lack of a doctor’s
et al. (2013) and non-Qatari recommendation, fear, and
residents embarrassment
Women who engaged in breast
cancer screening were those who
received a doctor’s
recommendations and believed
cancer can be prevented
Freund Israel 598 participants, Lower level of religious beliefs
et al. (2019) aged 40–60, and gaining a better
randomly selected understanding of the importance
from two faith- of screening were significant
based communities predictors of performing breast
in Israel. 331 of awareness practice and
these participants undergoing CBE in both groups
were Arab women,
and 267 were ultra-
Orthodox Jewish
women
Cohen et al. Israel and the West A random sample Higher fatalistic perceptions,
(2012) Bank of 697 Arab traditional beliefs, barriers to
women, 300 from bodily exposure, and social,
Israel and 397 from environmental, and personal
the West Bank aged barriers to screening were
30–65 years reported
Lower likelihood of attending
screening was associated with
higher fatalism, more traditional
beliefs and higher barriers to self-
exposure, higher perceived
personal barriers, and lower
perceived benefits
(continued)
192 M. Alatrash
Table 2 (continued)
Lower likelihood of CBE
attendance was predicted by
younger age, higher religiosity,
and higher social barriers
Azaiza et al. The West Bank 397 women, aged Women were more likely to
(2010) 30–65 years, undergo mammography if they
residing in the were less religious and if they
Palestinian expressed lower personal barriers
Authority, and a and lower fatalism
stratified sample A higher likelihood for CBE was
method was used related to being Christian and
being less religious, perceived
higher effectiveness of CBE, and
perceived lower cancer fatalism
Women were more likely to
perform BSE if they were more
educated, resided in cities, were
Christian, were less religious, had
a first-degree relative with breast
cancer, perceived higher
effectiveness and benefits of SBE,
and perceived lower barriers and
fatalism
Azaiza and Israel Qualitative data Birth and breastfeeding were
Cohen were collected from perceived as protective factors.
(2008) 51 women Integrating modern views with
traditional concepts of
motherhood as a woman’s
principal role in society emerged
Other major themes include:
(1) who or what was responsible
for one’s health emerged, opinions
ranging across fate and God’s will,
physicians and health services, or
taking personal responsibility for
one’s health; (2) the perception of
cancer as either a punishment or as
a test devised by God; (3) fears of
stigma related to breast or
gynecological examinations;
(4) worries about the spouse’s
reaction once a lump is detected;
and (5) worries regarding the
violation of religious and cultural
requirements of modesty
(continued)
Table 2 (continued)
Soskolne Israel A random sample Limited knowledge about breast
et al. (2007) of 510 Muslim cancer and mammography and
Arab women aged the rate of mammography
50–69 years screening behavior (at the
recommended interval) was only
20%
The women who were
significantly more likely to
undergo mammography were
those who received a
recommendation from a healthcare
professional or from family/
friends, perceived themselves as at
risk for breast cancer, perceived the
test as efficacious and not painful,
and were more educated
Spirituality and Belief in Predestination in Breast Cancer

Screening
Spirituality is essential and deep-rooted in Arabs despite any fundamental variations

(Hall and Breland-Noble 2011). Women from cultural, ethnic, and faith-based
communities in Arab countries have been identified for their significant underutili-
zation of breast cancer screening services (Azaiza et al. 2010; Donnelly et al. 2013;
Freund et al. 2019). Spirituality and belief in predestination are imperative factors
influencing Arab women’s health behaviors and attitudes (Abu-Helalah et al. 2015;
Assaf et al. 2017; Azaiza et al. 2010).
In the Islamic theism, the major and fastest-growing religion in the Arab world,
right and wrong judgments depend upon the teachings of the Quran interpreted by
the schools of law (Sire 2009). Therefore, following God’s commandments and
accepting what He sends without asking why is the best choice for a Muslim; saying
the phrase “inshallah or God willing” and “Qadaa Wa Qadar or destined” to
accompany any statement of intentions to express honest reliance on God is encour-
aged (Azaiza et al. 2010; Sire 2009). Muslims believe that human holiness and
spirituality come from the soul of God being inside all of us, regardless of religion, as
God breathed into us from his own soul. The Quran says “I am going to create a man
(Adam) from sounding clay of altered black smooth mud, so when I have fashioned
him completely and breathed into him the soul which I created for him, then fall
down prostrating yourselves unto him” (15: 28–30).
These beliefs have impacted health behaviors of Arab women. Qualitative and
quantitative cancer screening data have identified the role of God in health. Muslim
194 M. Alatrash
participants showed a very strong sense of thankfulness to God for good health and
referred it to predestination and recognized God as the supreme protector
(Abu-Helalah et al. 2015; Assaf et al. 2017; Azaiza et al. 2010; Hwang et al.
2017; Padela et al. 2015; Taha et al. 2012). Believing that breast cancer is Qadaa
Wa Qadar (destined) and that there was no cure were identified as barriers to
screening (Abu-Helalah et al. 2015; Cohen et al. 2012; Hwang et al. 2017). Both
Muslim and Christian participants mentioned God when discussing their health and
relied on religion, the holy books, prayers, and spiritual practices to find solace and
cope with a diagnosis of breast cancer (Assaf et al. 2017). Spirituality greatly
influenced participants’ health beliefs about cancer which was considered by many
a punishment from God, or that a cure was only known by Him (Baider and
Goldzweig 2016; Hwang et al. 2017; Freund et al. 2019).
Interestingly, higher participation and adherence to CBE and mammography were
found to be associated with lower levels of religious beliefs (Azaiza et al. 2010;
Cohen et al. 2012; Freund et al. 2019). Generally, health status has a spiritual aspect
among Arabs, regardless of religion, as illness is often perceived as a divine test to
purify the soul. However, keeping healthy habits and taking care of the body and
seeking medical help are required by the religion since the body has rights that
should be respected (Hwang et al. 2017). These beliefs should motivate Arab women
to increase their participation in breast cancer screening; however, it is well
documented that screening is underutilized by this population perhaps because
these women felt safe from breast cancer as they accepted it as a test from God
and believed that examinations were not necessary since the issues of illness, life,
and death should rather be left to God (Abu-Helalah et al. 2015; Azaiza et al. 2010;
Hwang et al. 2017; Padela et al. 2015; Shah et al. 2008; Taha et al. 2012) and that
once the woman was diagnosed with breast cancer, there would be no cure
(Abu-Helalah et al. 2015; Hwang et al. 2017). Some women, however, would seek
medical help to take care of themselves like Islam instructed them to do and because
God will cure them since He gave it to them (Hwang et al. 2017).
Cancer is a disease that has its negative connotation and remains a taboo in Arab
women; therefore, women refused to mention its name or discuss it publicly
(Alagraa et al. 2015; Al-Khasawhen et al. 2016; Assaf et al. 2017; Donnelly et al.
2017). Furthermore, the Muslim woman needed to perceive a medical necessity;
otherwise, she would have mixed feelings regarding privacy and religious beliefs.
Misconceptions and misunderstanding of religious views can cause these women to
have lack of self-care and become passive about their treatment (Hwang et al. 2017).
However, perceiving more benefits of breast cancer screening significantly increased
Arab women’s participation in screening (Abu-Helalah et al. 2015; Saca-Hazboun
2018).
Both Arab women and men reported gender-related barriers to screening. They
preferred a female provider to examine the woman (Bowser et al. 2017; Donnelly
et al. 2017; Cohen et al. 2012; Hwang et al. 2017). The physician’s gender was
reported as a significant issue especially in relation to CBE. Arab men insisted that
the physician who performed the test must be female. For women, the fear of
exposing breasts and being palpated by a male doctor can be a contributing factor
to their reluctance to obtain the man’s approval and support which is required in the
Arab culture (Donnelly et al. 2017). Also, the fact that Muslim men are permitted to
have more than one wife can be further discouraging to women to engage in breast
cancer screening (Al Dasoqi et al. 2013; Baider and Goldzweig 2016; Bowser et al.
2017; Cohen et al. 2012; Donnelly et al. 2017; Hwang et al. 2017).
The aforementioned barriers support the notion that it is necessary to understand
breast cancer screening within the cultural and religious context.
Embarrassment, Fear, and Fatalism in Breast Cancer Screening
Spirituality, religion, and culture have been identified as major determinants of feelings
of embarrassment, modesty and shame, fear, and fatalism regarding breast cancer
screening. Research addressed embarrassment and shame, due to exposing the body,
as frequently reported cultural perceptions that negatively influenced utilization of
breast cancer screening in Arab women (Al Dasoqi1et al 2013; Arevian et al. 2011;
Cohen et al. 2012; Donnelly et al. 2013, 2017; El Asmar et al. 2018; Elobaid et al. 2014;
Ermiah et al. 2012; Hwang et al. 2017; Mamdouh et al. 2014). In the Arab and Islamic
cultures, the intimate parts of the human body must not get exposed (Al-Kawthari 2009;
Assaf et al. 2017). Awra, which refers to everything in the body that causes embarrass-
ment if exposed, must be covered with proper clothing, and breasts must be covered
even from other women (Al-Kawthari 2009). Modesty is rigorously maintained by
women in the traditional Arab society, and violating it, by exposing breasts during the
exam, arouses feelings of discomfort, embarrassment, and guilt, contributing to the lack
of participation in breast cancer screening especially with perceived lack of privacy
(Assaf et al. 2017; Cohen et al. 2012; Elobaid et al. 2014; Hwang et al. 2017; Mamdouh
et al. 2014). Clinical breast examination was found to have caused greater feelings of
embarrassment which might explain why religious women avoided it more than
mammography (Azaiza et al. 2010; Cohen et al. 2012). Modesty is one of the numerous
factors that clearly demonstrates how religious and cultural beliefs can overlap as
modesty is the religious and cultural expectation.
In Arab countries, cultural conceptualizations kept people from talking about
cancer openly; it is perceived as contagious or a stigma in someone’s life (Arevian
et al. 2011; Assaf et al. 2017; Azaiza and Cohen 2008; Hwang et al. 2017). Feelings
of shame were found to be associated with the disease, so it was kept a secret and hid
from others to save the family from the embarrassment, pity, and ridicule. Women
were afraid of gossip and isolation as a result of a positive diagnosis of the disease if
they participate in breast cancer screening (Ermiah et al. 2012; Hwang et al. 2017).
Women who got diagnosed with the disease felt that they were no longer able to
fulfill their roles in their families, leading to feelings of being worthless and getting
isolated and divorced (Al Dasoqi et al. 2013; Assaf et al. 2017; Azaiza and Cohen
2008; Donnelly et al. 2017; Hwang et al. 2017).
In addition to modesty and embarrassment, fear and fatalism have also greatly
influenced breast cancer screening behaviors leading to delayed detection of breast
cancer (Al Dasoqi et al. 2013; Assaf et al. 2017; Baider and Goldzweig 2016; Donnelly
196 M. Alatrash
et al. 2013; Doumit et al. 2017; Elobaid et al. 2014; Haddad et al. 2015; Jordan
Population and Family Health Survey 2019). Perceived inevitable fatal consequences
of the disease and that breast cancer cannot be prevented by screening and early
detection have led to negative attitudes about breast cancer and its screenings in the
Arab culture (Al Dasoqi et al. 2013; Azaiza et al. 2010; Cohen et al. 2012; Freund et al.
2019). Fear of having cancer, fear of pain or the screening examination, and fear of
radiation causing cancer have been identified as significant barriers in Arab women
(Abu-Helalah et al. 2015; Al Dasoqi et al. 2013; Bowser et al. 2017; Elobaid et al. 2014;
Ermiah et al. 2012; Mamdouh et al. 2014). A few studies found that higher participation
in breast cancer screening was associated with lower fatalism, but with more fears
related to potential losses (Azaiza et al. 2010; Cohen et al. 2012; Freund et al. 2019).
Influence of Selflessness, Emphasis on Children and Family,

and Social Factors in Breast Cancer Screening
Arab women are frequently intimately connected with their families and communi-
ties. Food and family are the foundation of Arab culture in which the family is the
single most important social and economic institution. Illness intensifies the affilia-
tion needs of Arabs; a person seeking medical care may be accompanied by one or
more persons who expect to attend the examination or interview for support.
Supportive social milieu was recognized as one of the most significant facilitating
factors for women to perform breast cancer screening (Assaf et al. 2017; Baider and
Goldzweig 2016; Bener et al. 2002; Donnelly et al. 2017). Arab women’s lack of
participation was indicated to be mostly due to the way these women prioritized their
health needs as they put the needs of their children and families first in addition to
their reliance on the support of men in the family, husband, father, or brother
(Donnelly et al. 2017; Elobaid et al. 2014; Taha et al. 2012). The marital status
and being ever-married were found to be significantly associated with perceiving
lower rates of barriers to BSE and higher rates of confidence and benefits to
mammography than single participants (Arevian et al. 2011).
In the conservative Arab society, patriarchal customs govern common attitudes,
perceptions, and behaviors; reliance on male family members’ support and protec-
tion influenced women’s decision about their health and engagement in breast cancer
screening (Baider and Goldzweig 2016; Donnelly et al. 2017; Elobaid et al. 2014).
Many men felt that it was their job to support their wives and take them to the
hospital if needed as their religion, Islam, calls for it since she is the foundation of the
society (Donnelly et al. 2017). Lack of men’s approval and their negative perception
of the importance of breast cancer screening were found to be significant barriers to
woman’s participation in screening (Donnelly et al. 2017; Hwang et al. 2017; Jordan
Population and Family Health Survey 2019).
Fear of losing their husbands and inability to fulfill their responsibilities as wives
and mothers are important social barriers in the Arab culture (Al Dasoqi et al. 2013;
Assaf et al. 2017). To Arab women, breasts are not just related to their femininity;
they are a big part of their ability to give birth and breastfeed (Arevian et al. 2011;
Hwang et al. 2017). Therefore, breast cancer and its treatment can be congruent with
fertility and loss of their role in the family and society (Hwang et al. 2017) and with
poor self-image and negative repercussion on daughters in the family. Fear of being
abandoned by the husband may be indicative of the significant interpersonal influ-
ence that the male figure in the family has on the woman’s decision to participate in
screening. According to Baider and Goldzweig (2016), Arab women live within a
system of religious and moral values and perceptions defined within a context of an
intergenerational family structure and clear family roles that influence these
women’s attitudes and behaviors toward breast cancer screening.
Additionally, personal barriers, such as perceiving more important issues, having
children with lack of childcare, forgetting to schedule, and lack of advice and role
models from family and friends, were all reported as critical barriers to screening in
these women (Abu-Helalah et al. 2015; Al Dasoqi et al. 2013; Al-Rifai and Loney
2017; Azaiza et al. 2010; Cohen et al. 2012; El Asmar et al. 2018; Elobaid et al.
2014; Jordan Population and Family Health Survey 2019). A family role model can
play an important part in motivating Arab women to engage in screening. Donnelly
et al. (2015a) indicated that Arab women from the highest-income families partic-
ipated in a wider social activities and integration than other women, supporting the
vital role social factors have on health and screening behaviors.
Physician’s recommendation was frequently reported as an imperative factor
influencing women’s behaviors regarding breast cancer screening (Bowser et al.
2017; Mamdouh et al. 2014; Donnelly et al. 2013; Freund et al. 2019). Arab women
who received physician’s recommendation, mostly during a visit for another health
issue, were more likely to perform and adhere to breast cancer screening especially
that preventive care is not practiced and is perceived as unnecessary in this popula-
tion (Abu-Helalah et al. 2015; Bowser et al. 2017; Donnelly et al. 2015b; Freund
et al. 2017; Mamdouh et al. 2014; Othman et al. 2013). Physician’s recommendation
may also have increased women’s self-efficacy which was found to increase the
likelihood of performing breast cancer screening (Othman et al. 2013; Sosklone et al.
2007). However, Hwang et al. (2017) suggested that despite the physician’s recom-
mendations, some women believed no doctor or screening can help them since the
disease is coming from God to test their strength.
These research findings may be indicative of the physicians’ power that rests on
the willingness of these women and the society to trust their health-related judgments
unconditionally; and therefore, the role of the physician in facilitating breast cancer
screening cannot be underestimated and must be considered when designing tailored
outreach programs to increase screening rates in this hard-to-reach population.
Implications for Public Health, Healthcare Policy, and Oncology

Settings
Sociocultural and religious factors may be the foundation to cultivate tailored

interventions and culturally congruent programs to reach out to this unique popula-
tion. Such factors must be understood, analyzed, and incorporated in interventional
198 M. Alatrash
programs to improve participation rates and promote adherence to breast cancer

screening in these women.
Efforts must be intensified to improve breast cancer screening rates in this
population especially that this issue has multiple dimensions that greatly influence
behaviors and decisions of these women. To raise awareness effectively, intensive
health education should be conducted for these women at a young age using
appropriate language and a variety of methods, such as media, social networks,
and physicians and healthcare providers, to reach out to these women in a conser-
vative society (Al-Rifai and Loney 2017; Assaf et al. 2017). Families, especially
men and role models, must get involved in the breast cancer screening education to
provide women with the necessary social support to make an informed decision
about their participation.
Since increasing knowledge about breast cancer and its screenings alone may not
be an adequate strategy to encourage Arab women to engage and adhere to screening
practices, culturally congruent interventions are vital to developing an effective
awareness program to change women’s attitudes, beliefs, and views toward breast
cancer screening. Exploring cultural and religious taboos and misconceptions,
perceived fatalism, fears, and feelings about screening is necessary to integrate in
outreach programs at the local, national, and regional levels in the Arab world.
Furthermore, including effective strategies, such as home visits, may improve
women’s knowledge about breast health and their perceptions of BSE and mam-
mography (Taha et al. 2014) as this helps women perceive more benefits. It was also
suggested that such awareness campaigns for early screening should overcome the
stigma associated with cancer in the conservative Arab society (Assaf et al. 2017).
Over the past few years, population-based cancer registries, global organizations,
and public policy initiatives have arisen in the Arab region to develop awareness
programs (Komen.org 2019). The Susan G. Komen Breast Cancer Foundation is an
organization in the United States working with Arab governmental, such as the
Saudi Ministry of Health, and nongovernmental agencies, such as the King Hussein
Cancer Foundation, to increase awareness and enhance women’s empowerment in
countries like Saudi Arabia, Jordan, Egypt, and Israel. This includes outreach pro-
grams such as Breast Health Awareness Expansion Program, Breast Cancer Out-
reach and Awareness Among Arab Bedouin Women in the Negev, Celebrating Life:
Building Healthy Relationships between Palestinian and Israeli Cancer Patients and
Professionals, Make it Matter, and Comparative Baseline Needs Assessment for
Breast Cancer Awareness and Management in Middle East and North Africa
(Komen.org 2019). Nationwide systematic programs were implemented in some
Arab countries such as Egypt and Jordan (Jordan breast cancer program 2007;
Mamdouh et al. 2014; Taha et al. 2014). When implementing such programs, a
referral system and screening of no- or low-cost and access-enhancing strategies
must be incorporated to overcome economic and health insurance barriers that may
exist (Arevian et al. 2011). Collaboration with local agencies to increase the number
of community-tailored outreach programs to include every single country in the
Arab region is much needed considering the continued low screening rates. Spread-
ing awareness may not be sufficient with the presence of socioeconomic burdens
(Donnelly et al. 2015a). With the development of these national, community-based

programs, policy makers and healthcare professionals must acknowledge the impact
socioeconomic status has on health behaviors (Donnelly et al. 2015a), and therefore,
overcoming it in these programs increases the focus on sociocultural and religious
barriers which may be much harder to resolve.
Awareness programs must be followed by a comprehensive evaluation of their
effectiveness in accomplishing the ultimate goal of raising breast cancer screening
rates to save lives. In Jordan, for instance, the Jordan Breast Cancer Program was
implemented to offer mammography screening services in multiple healthcare
facilities since 2007. In 2010, phase III of the program was launched to spread
awareness about breast cancer screening nationwide. Upon evaluating the program
through the Jordan Population and Family Health Survey (2012), the results con-
firmed that screening rates in all of the three breast cancer screening tests, mam-
mography, BSE, and CBE, were still significantly low despite all of the efforts made.
When women were asked about the reasons for not having the screening done, they
reported “no need for it,” “weren’t sick,” and “didn’t have any symptoms” in
addition to “fear of the results” and “having no support from family or husband”
(Jordan Department of Statistics and ICF International 2019).
Similarly, the Breast Cancer Foundation of Egypt has launched multiple national
health campaigns aimed to reduce stigma and fear related to breast cancer, increase
knowledge about how to navigate early detection services, and teach about BSE to
raise awareness of breast cancer among Egyptian women from different socioeco-
nomic and social status since 2004 (Cancer Foundation of Egypt 2019). Although
more studies are required to evaluate the effectiveness of this program, Al-Rifai and
Loney (2017) found that the strategies followed to teach Egyptian women about
BSE needed to be reviewed and modified to maximize their effectiveness as those
strategies need to empower women especially in the rural areas of the country.
In Morocco, a national breast cancer screening program was launched in 2010 for
women between 40 and 69 years of age by the Ministry of Health, the Lalla Salma
Foundation for Cancer Prevention and Treatment, and the United Nations Population
Fund. This program used CBE as the screening test at the primary health centers.
Upon evaluating the program for the years 2015 and 2016, an acceptable screening
rate of 60% was achieved indicating an increase in screening rates ever since the
program has been conducted as the evaluation between 2009 and 2011 showed that
the participation rate was only 35.7% (El Fakir et al. 2015). However, a low
detection rate was indicated in the most recent program evaluation suggesting the
need to review the quality of screening and diagnostic tests in addition to compliance
of the women who were screened positive with further testing and evaluation (Basu
et al. 2018). It was recommended to further train healthcare providers to adhere with
screening and assessment protocols and continue the community recruitment activ-
ities around the year and use computerized database (Basu et al. 2018).
This situation of low screening rates in Arab women calls for an urgent need to
use continuous and intensified culturally congruent strategies and religious-based
services in such to empower women by addressing cancer-related taboos and
rectifying misconceptions, such as cancer is contagious, and to acknowledge cultural
200 M. Alatrash
and religious concerns related to beliefs in predestination, the status of health and
body in religion including modesty, feelings of embarrassment and shame, cancer-
related fatalism, and fear. Arab women have a profound trust in their religious
leaders and can be more empowered to practice screening if they are encouraged
and supported by them. Providing privacy in doctor’s clinics and screening centers,
increasing the number of female physicians, and collaborating with religious leaders
can be some of the effective strategies to reach out to this population (Assaf et al.
2017; Donnelly et al. 2017; Mamdouh et al. 2014). Availability of privacy is
fundamental to further enhance screening practices (Mamdouh et al. 2014).
Considering the influence of physician’s recommendations on Arab women’s
screening behaviors, it is imperative to educate healthcare providers about their
major role in educating and empowering women to engage and adhere to breast
cancer screening (Elobaid et al. 2014; Mamdouh et al. 2014). Elobaid et al. (2014)
found that Arab women gained significant breast cancer knowledge from their
healthcare providers. Therefore, inviting women by healthcare agencies to perform
the screening and to educate them about the importance of screening in the absence
of symptoms can be effective strategies to address the low prevalence of breast
cancer screening (Othman et al. 2015). Employing physicians; family support,
especially the man figure in the family; as well as support of social networks and
influential community members can help resolve personal and social barriers.
Utilizing public figures and influential women who have experiences with breast
cancer and its screenings can contribute to the empowerment of those women to take
charge of their own health (Donnelly et al. 2017).
Effective communication by healthcare professionals is vital for Arab women to
be able to make an informed decision about having a screening test. This implicates
the importance of training healthcare professionals in oncology settings and the
community to conduct culturally sensitive communication and counseling tech-
niques that demonstrate respect to these women’s dignity and modesty (Baider and
Goldzweig 2016; Mamdouh et al. 2014). Furthermore, healthcare professionals need
to challenge policy makers and authority in healthcare to offer more possibilities,
opportunities, and increased funding to provide all Arab women, regardless of
socioeconomic status, with equal and ample opportunities to engage in this lifesav-
ing screening. Policy makers and healthcare providers should consider revising the
Western screening recommendations, such as the American Cancer Society’s rec-
ommendations, to better fit the needs of the Arab women population that gets
affected by the disease at a significantly younger age than the Western world
(Othman et al. 2015). Understanding younger women’s perceptions about screening
is imperative, and based on this, health promotion campaigns should be designed to
incorporate age-appropriate interventions and education that address the fact that
breast cancer can affect younger women and that they are not protected from it
(Al Dasoqi et al. 2013). Campaigns may also use awareness posters on street
billboards which were found to be effective in Qatar (Donnelly et al. 2017).
In the Arab region, there is a need to establish more regional and national cancer
registries for reliable sources of data about breast cancer which helps with develop-
ment of more informed screening recommendations customized for Arab women.
Bahrain, Jordan, Kuwait, Oman, Algeria, Egypt, Tunisia, Libya, Palestine, Saudi
Arabia, and Qatar are some of the countries with national registries (Chouchane et al.
2013). In addition, there should be consistency in screening awareness programs in
Arab countries followed by sufficient evaluations of their effectiveness (Hamadeh
et al. 2014). According to the WHO (2019), comprehensive cancer prevention plans
are needed, especially in low-income and middle-income countries to promote a
healthy lifestyle.
Future research must focus on analytical studies to better understand risk factors
and their multifaceted role in the high incidence of breast cancer in the Arab region
(Hamadeh et al. 2014). Such research can help identify the reasons why Lebanon, for
instance, has the highest breast cancer incidence in the Arab region and one of the
highest worldwide. More research is also needed to evaluate regional awareness
programs and their effectiveness in increasing screening rates. Diverse culturally
congruent interventions to spread awareness and address sociocultural and religious
issues are still necessary to be developed, not only to increase participation in breast
cancer screening in a diverse population but also to sustain it. Interventional studies
are also needed to assess cost-effectiveness and long-term sustainability of health
promotion programs (Donnelly et al. 2017).
Conclusion
Breast cancer is a major public health problem on the rise in the Arab nation where
screening rates are still significantly low despite the high rates of late presentation of
the disease. Future endeavors are much needed to overcome cultural, religious,
personal, and social barriers to motivate these women to make a decision of
participating and adhering to breast cancer screening. Influences of religion and
culture must be addressed when educating Arab women about breast cancer screen-
ing. Religious, ethnic-based, and younger Arab women especially in rural areas
require special attention when cultivating breast cancer awareness and health pro-
motion programs as even lower screening rates were reported in these groups.
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Violence Against Women in the Arab World:
Eyes Shut Wide Open 11
Saïda Douki Dedieu, Uta Ouali, Rym Ghachem, Hager Karray, and
Ilhem Issaoui
Contents
Introduction: The Gap Between Reality and Awareness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
Eyes Wide Open: Facts and Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210
Typology of Gender-Based Violence (GBV) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210
Domestic Violence (DV): So Many Duties, So Few Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
Extra-Domestic Violence: The “Politics of Invisibility” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
Women with Disabilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
Eyes Shut: A Troublesome Tolerance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
What Violence Are We Talking About? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
The Look of Society: No Right of Interference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
The Look of Justice: An Incomprehensible Leniency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224
The Cultural Roots of Violence Against Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
A Culture of Honor and Shame . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226
A Misinterpretation of Islam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
A Woman’s Subordinate Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
A “Great Fear” of Female Power . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
The Heavy Toll . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234
Fighting Violence Against Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
Addressing the Causes and Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
The Present Situation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
The Way to Go . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240
Education Matters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
Role of the Healthcare System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248
Concluding Remarks: Shame Must Change Sides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
S. Douki Dedieu (*)

Faculty of Medicine of Tunis, University Claude Bernard, Lyon, France
e-mail: sdoukidedieu@gmail.com
U. Ouali · R. Ghachem · I. Issaoui
Hôpital Razi, La Manouba, Tunisia
H. Karray
CHS Annecy, France

https://doi.org/10.1007/978-3-030-36811-1_169
208 S. Douki Dedieu et al.
Abstract
Violence against women and girls is a global phenomenon that is not confined to
any particular geographical region, race, ethnicity, society, culture, age group, or
socioeconomic status. Recent reviews have emphasized that it has reached
epidemic proportions and that it has major negative consequences, not only for
the victims, but for the whole society. However, it remains a socially accepted and
hidden issue in many parts of the world including the Middle East and North
Africa region. Despite the scarcity of scientific data and the systematic under-
reporting, consistent findings show that in Arab countries, as well as worldwide,
at least one out of three women has been exposed to domestic violence, which is
the most prevalent form that affects women of all social strata across the world.
As well as traditional forms of violence such as wife-battering and sexual
abuse, Arab women suffer, throughout their lives, from specific types of domestic
violence: carelessness, female genital mutilation, lack of education/access to
education, confinement at home, sexual abuse, child marriages, forced marriages,
temporary and polygamous marriages, repudiation, honor-related violence
directed at both married and unmarried women, and abuse by other family
members (such as in-law, parents, and brothers). Outside the home, they experi-
ence many forms of sexual violence and commercial exploitation. Moreover, the
risks of violence have increased with the crises sweeping the region (war, armed
conflicts, and uprisings) and the rise of Muslim extremism.
Violence against women is not only tolerated but also often justified, and this
discourages the victims from disclosing it and withholding punishment from the
perpetrators. Violence stems from deep cultural roots in a “shame-honor” society
that fosters a culture of violence against women, through the crucial importance
attached to the “kinship spirit,” through the subordinate status of women, and
through a misinterpretation of Islam. However, arguably the most important
factor currently underpinning violence against women was expressed by Hannah
Arendt, when she stated: “The reign of pure violence starts when power begins to
be lost.”
As a consequence, fighting violence against women and girls is of the highest
priority as it comes at a very high cost, at the levels of human rights, public health,
and financial expenses and is an impediment to development and democracy. It
should be based on two pillars: legislation to adequately repress the offenses and
crimes and to protect the victims, along with the promotion of gender equality.
But, as said by Mao Tse-tung: “Obviously, in matters of women’s rights, we must
begin with laws, but since then, all remains to be done.” This means that
legislation is necessary to debunk the myth that domestic violence is a “private
affair,” but insufficient to win the fight. Legislation must be accompanied by
access to education for all females to change the mentality of a patriarchal society.
The challenge in combating gender-based violence is that most governments
deny there is a problem. Such a challenge cannot be met without a strong political
will and the adhesion of the civil society.
11 Violence Against Women in the Arab World: Eyes Shut Wide Open 209
Keywords
Violence against women and girls · Arab world · Specific features of violence ·
Cultural issues · Tolerance towards violence
List of Abbreviations
BWS Battered woman syndrome
CEDAW Convention on the Elimination of All Forms of Discrimination
Against Women
CRC Convention on the Rights of the Child
CSW Commission on the Status of Women
FGM Female genital mutilation
GBV Gender-Based Violence
MDG Millennium Development Goal
NGO Non-governmental organization
UNDP United Nations Development Programme
UNFPA United Nations Fund for Population Activities
UNICEF United Nations Children’s Fund
UN-Women United Nations Entity for Gender Equality and the Empowerment
of Women
VAW/G Violence against women/girls
WHO World Health Organization
Introduction: The Gap Between Reality and Awareness
In spite of growing international awareness of the problem and the declared will-
ingness of states to fight gender-based violence, women and girls continue to suffer
disproportionately from violence (both in peacetime and in the context of armed
conflicts), at the hands of close relatives or strangers as well. Moreover, violence
against women and girls (VAWG) is not only frighteningly common but also highly
tolerated within many societies in developing countries in general and in Arab and
Islamic countries in particular, under the garb of “cultural values.” Thus, very little is
known about the topic, in these parts of the world, at least from the scientific
literature which is very limited. Nevertheless, existing research shows consistently
that domestic violence, especially, is as prevalent as in Western countries, but highly
under-reported. International news coverage, however, is far more informative and
has been reporting for years the many kinds of violence suffered by Muslim and
non-Muslim women in these geographical areas. Moreover, it seems that the risk
keeps steadily growing, because of the various conflicts that are devastating the
Middle-East and North-Africa. Despite these alarming facts, both the governments
and civil society do not seem to be really concerned about addressing the problem.
So, while this phenomenon is largely addressed in Western countries and adequate
policies formulated to deal with it, in Arab and Islamic societies, gender-based
violence (GBV) is not yet considered of major concern despite its increasing
frequency and its tragic consequences. We are going to report some data about the
magnitude of the problem and its characteristics, and then address the issue of its
under-recognition and the impact of “cultural roots,” in order to propose some
appropriate recommendations to fight it.
Eyes Wide Open: Facts and Figures
Research data is scarce but sufficient enough to provide a fairly accurate picture of
the situation.
Typology of Gender-Based Violence (GBV)
The Declaration on the Elimination of Violence Against Women (DEVAW), adopted

by the United Nations General Assembly in 1993, defines Violence against women
as “any act of GBV that results in, or is more likely to result in physical, sexual or
psychological harm or suffering to women, including threats of such acts, coercion
or arbitrary deprivation of liberty, whether occurring in public or private life.” It can
affect women at any time of their life span and may be carried out by individuals,
familiar or not, as well as “states” or “criminal organizations.” Thus, it can fit into
several categories. WHO (1997) has proposed a typology according to the life cycle
(Table 1).
We are not going to refer to this classification since it does not reflect some
specificities of the Arab world. For example, the elderly are generally much
respected. High regard for older individuals is a value that can be traced directly to
the Koran. In addition, we think that it is very important to distinguish between
Table 1 Typology of VAWG throughout the life cycle

Phase Type of violence
Pre-birth Sex-selective abortion; effects of battering during pregnancy on birth
outcomes
Infancy Female infanticide; physical, sexual, and psychological abuse
Girlhood Child marriage; female genital mutilation; physical, sexual, and
psychological abuse; incest; child prostitution and pornography
Adolescence and Dating and courtship violence (e.g., acid throwing and date rape);
adulthood economically coerced sex (e.g., school girls having sex with “sugar
daddies” in return for school fees); incest; sexual abuse in the workplace;
rape; sexual harassment; forced prostitution and pornography; trafficking
in women; partner violence; marital rape; dowry abuse and murders;
partner homicide; psychological abuse; abuse of women with disabilities;
forced pregnancy
Elderly Forced “suicide” or homicide of widows for economic reasons; sexual,
physical, and psychological abuse
domestic and extra-domestic violence which do not occur in the same background
and imply different aggressors: indeed, within the family, women are supposed to be
protected while outside, especially during periods of conflicts, women are exposed
to the worst kinds of violence.
Domestic Violence (DV): So Many Duties, So Few Rights
According to the UN Commission on the Status of Women, domestic violence

remains the most prevalent form of violence that affects women of all social strata
across the world. Indeed, women are far more likely to be abused in the private
sphere of life: “only” 10% of women reported having been assaulted in the public
space, in the Tunisian National Survey (Zemni 2014).
Specific Features
Types: As well as traditional forms of violence such as wife-battering and sexual
abuse, women in the Arab countries are also exposed to specific types of domestic
violence: honor-related violence directed at both married and unmarried women,
forced and temporary marriages, polygamy and repudiation, and abuse by other
family members (such as in-laws, parents, and brothers). As for girls, they still suffer
from carelessness, female genital mutilation or cutting (FGM/C), early veiling, lack
of education, confinement at home, physical, psychological, and sexual abuse,
including incest or child marriages.
Victims: DV affects all females including wives, daughters, sisters, cousins, and
nieces, since the men in the family feel responsible for watching over them and
controlling their behavior. Only mothers are spared because they enjoy a very high
status in Islamic culture. Indeed, “Paradise is in under the feet of mothers,” according
to a saying of the Prophet. Moreover, mothers may support the aggressor and commit
violence against their daughters-in-law. Apart from family members, maidservants
too may be enslaved and experience physical and sexual assaults.
Arab women are exposed to discrimination and violence throughout their lives,
from birth until menopause, which means that violence is essentially related to their
sexuality!
The Original Curse and the Disputed Right to Live

Discrimination and violence against women begin very early, from birth, because
preference for sons is readily expressed in many countries where being born a girl is
still a misfortune. In these cultures, like the Arab one, male offspring are desired in
order to inherit property, carry on the family name, and provide support for parents in
their old age. Besides, there is the common myth that women are the only ones who
can bring the dishonor on their families.
Consequently, their right to live remains disputed, even if they are no longer
buried alive, as in the period before the advent of Islam. “Discrimination against
girls is actually a matter of life and death,” stated UNPFA in 2000. As a matter of
fact, girls are more likely to die than boys are in parts of the world, as reflected by
unusual patterns of child death and distorted sex ratios at birth in some countries.
Since 1990, Sen Amartya, Nobel Prize in Economic Sciences 1998, reported that
these effects are concentrated in countries typically in Asia, the Middle East, and
northern Africa. At least 100 million girls who would otherwise be expected to be
alive are “missing” from various populations as a result of sex-selective abortions,
infanticide, or food and care neglect. According to a dispatch from the French Press
Agency dated the 17 January 2011, “Infanticide continues to grow in the conserva-
tive Islamic Republic of Pakistan [. . .]. 1,210 babies were abandoned or killed in the
country in 2010, compared to 999 in 2009 and 890 in 2008 [. . .]. Most are less than a
week old. 90% of the children found dead are girls.” In the same country, in Aftab
2000, Aftab observed that 25% of new-born females were at risk to be undernour-
ished at birth and exposed to the consequent risk of weak development and poor
immunity to infection. When these girls survive and marry, they could become some
of the 30,000 women who die each year as a result of pregnancy or childbirth. In
2015, the World Bank reported rates of maternal mortality reaching 178 for every
100,000 live births in Pakistan, 311 in Sudan, 732 in Somalia, whereas in Western
countries, these rates are below 10!
As for the fortunate survivors, they will be brought up under close surveillance to
become a “good woman,” namely submissive and chaste. Families have to prevent
their daughters from being exposed so as not to lose their precious virginity and
bring dishonor upon them. Furthermore, various violent methods are applied to serve
this purpose, since girls are primarily considered a liability until they are married off.
The Duty of Virginity and Related Violence
FGM/C and Other “Chastity Belts”

The exact number of women and girls who have undergone FGM/C remains
unknown, but at least 200 million girls and women in 30 countries have been
subjected to this practice. Of these 200 million, more than half live in three countries:
Indonesia, Egypt, and Ethiopia. Annually, about three million of them are at risk of
being mutilated. This practice has been documented in 28 countries in Africa, in
Asia, and in several Arab countries, such as Somalia (98%), Djibouti (93%), Egypt
(91%), Sudan (89%), Mauritania (69%), but also in Saudi Arabia, Yemen, the United
Arab Emirates, Bahrain, and Oman.
FGM remains widespread despite its health-threatening consequences, which are
both immediate and long-term. The Egypt 2008 DH Survey revealed that nearly 50%
of female respondents believed that FGM was a religious requirement and needed to
be continued. Support for FGM is higher in men, reaching 70% (IMAGES 2017).
FGM is performed to reduce girls’ sexual desire and enforce their premarital
chastity, in order to protect their virginity which remains a must-have obligation.
Virginity is “a social rule to be maintained” for 87% of women in Tunisia (Belhadj
1993). And the loss of virginity is the main cause of suicidal behavior in adolescents
in societies where a young woman’s worth is equated with her virginity (Saif El
Dawla 2001). But FGM is above all performed to contain woman’s sexuality which,
in that culture, is supposedly overflowing. So, despite the religious encouragement
of married women’s sexual fulfillment, sex remains a man’s prerogative. In that

respect, FGM reinforces established gender roles and supports a priority for male
over female sexual satisfaction. It means that women have also the duty to be frigid!
Frigidity is the best guarantee for chastity, isn’t it? . . . In a survey among
347 Tunisian women aged from 15 to 59 (Belhadj 1993), 78.4% of them had
never been informed about sexuality before their marriage, 71.2% didn’t have any
knowledge about the anatomy of genital organs, 61.2% considered sexual inter-
course a “religious and social duty,” and one woman out of two was indifferent to
sexual abstinence. Similarly, in Morocco, Kadri reported a prevalence of 43% of
sexual disorders in a representative sample of 728 women (Kadiri and Moussaoui,
2001). For the Egyptians surveyed in the IMAGES 2017, FGM is a necessary
procedure to curb female sexual desire. Both genders agreed on its effect on female
sexuality: more than two-fifths believed that FGM reduces women’s sexual pleasure,
and more than half of women and two-thirds of men believed that it makes women
less sexually demanding.
Contrary to common beliefs, FGM is not a religious requirement. Nor is the early
veiling of prepubescent girls (as early as 2 years!) which is a kind of “psychological”
mutilation serving the same purpose, namely, protecting the “sacred” virginity and
preventing any abuse, even though it is contrary to any religious prescriptions. In
countries where “sharia (Islamic) law” is harshly applied, even the dress code can be
a matter of life and death. As a matter of fact, adolescent women have been
assassinated for unveiling.
Unfortunately, little girls are not spared from sexual abuse, especially incest. “The
notion that child sexual abuse and neglect are rare in Arab countries is a myth that
can no longer withstand the strength of evidence” (Al-Mahroos and Al-Amer 2011;
Al-Madani et al. 2012).
For the same reasons, too many girls are not sent to school or are removed early so
that they can be confined at home. In Yemen, only 53% of girls finish primary school
even though the Prophet of Islam recommended seeking knowledge “from the cradle
to the grave.”
That is because education and freedom are not yet vested rights, while virginity
and chastity are the main pillars of the honor of the family at large. “In our traditional
societies, the status of a family depends on the honour of a female member whereby
anything that happens to a woman dishonours the whole family,” said the journalist
Rana Husseini to The Arab Weekly (2015). They justify the honor-related violence
against young women.
Honor Killings: A Crime in the Name of “Family Honor”

The so-called “Honor killing” is an act of “cleansing the family honor” by eliminat-
ing the woman believed to have tarnished the family’s reputation. In 2000, the
United Nations estimated that there are approximately 5000 honor killings every
year (Chesler 2010). The number of honor killings is routinely underestimated, and
most estimates are little more than guesses that vary widely. Definitive or reliable
worldwide estimates of honor killing incidence simply do not exist. But, what we do
know is that, worldwide, the majority of victims (93%) were women and the
perpetrators Muslims. They were 91% in a study reported by Chesler in 2010.

Although Sikhs and Hindus do sometimes commit such murders, honor killings
are mainly Muslim-on-Muslim crimes.
The Arab Weekly reported, on 8/5/2015, that Suha was stabbed to death by her
teenage brother who suspected she was dating a neighbor. She was one of 23 women
killed in Jordan in 2014 in what are widely called “honor crimes,” namely, killings
committed by male relatives against women for being raped, losing their virginity,
having a relationship out of wedlock, or for simply dating. The crimes are committed
to “wash the family shame,” even on the slight suspicion or rumor that the woman
knows a man. According to a Thomson Reuters Foundation report on women’s
rights in the Arab world (Kehoe 2013), Jordan ranked second-worst, after Egypt, in
the category of honor killings. The phenomenon is not limited to Jordan but extends
also to other male-dominated countries where men have the final say in all family
matters.
That is why, families are so eager to get their daughters married as soon as
possible. A Tunisian proverb states: “If your tooth hurts, tear it out, if your daughter
grows up, marry her.”
Child Marriage: At the Age of Playing with Dolls

Let us remind that the Convention on the Rights of the Child (CRC) defines a child
as any person under the age of 18 (Article 1). Early marriage of girls is another
common type of VAW in the Arab world, which can occur at age 9 in Yemen or
Somalia, 10 in Sudan, and 15 in Kuwait. Seven hundred million women, living
today, have been married under the age of 18 and 14% of Arab girls still marry under
age 18. The highest rates are observed in Mauritania, Sudan, and Yemen. But it is
mostly not perceived as such by people. It implies, however, two major risks. The
first is related to the absence of choice and the high probability of marital discord and
wife abuse. The second is associated to premature childbearing and its many
complications. Findings documented in Egypt’s DHS 2014 (Nossier 2015) indicate
that the overall level of teenage childbearing is 11%. Teenage mothers face a higher-
than-average risk of maternal death and their children have higher levels of morbid-
ity and mortality; the risk of maternal death among pregnant women aged 15 to 19 is
four times higher than among 25 to 29 year-olds. Early marriage and childbearing
also impede young woman’s educational and employment opportunities.
However, even marriage in general may carry its fair share of violence.
Marriage-Related Violence: The Duty of Obedience and Chastity

Marriage is presumed to promote a woman’s status and protect her from many
difficulties of life. Many studies (marripedia.org) have shown that married people
are least likely to have mental disorders and least likely to commit suicide. They
have higher levels of emotional and psychological well-being than those who are
single, divorced, or cohabiting. Married mothers enjoy greater psychological well-
being. Marriage also has a wide range of benefits for physical health. Unfortunately,
in Arab society, marriage may be a major threat to women’s physical and mental
health, as Rezaeïen (2010) concluded: “It is very agonizing to realize that for Muslim
females, especially the younger ones, marriage acts as a risk factor that may lead to
an increase in the likelihood of committing suicide using violent methods.”
When Marriage Itself May Be Violence

It is the case of forced or arranged marriages, where the future bride has no say or
choice. Forced marriages are all the more damaging as they involve very young
women. According to the teachings of the religion, women, even minors, cannot be
married without their consent. This contrasts sharply with the situations prevailing in
many countries, where forced marriage is still common and associated with a high
risk of marital discord, divorce, mental disorders, and wife abuse. Indeed, in a survey
in Tunisia (Bouasker 2003), forced marriage was a major cause of marital violence.
In a literature review undertaken in 2010, Rezaeien showed an increasing rate of
suicide or attempted suicide among young Muslim females in the Middle East.
According to his study, “Four M” are among the most important interrelated reasons
that could explain this increase: the violent method chosen for suicide (self-
immolation), mental disorders (depression), marriage (forced), and masculine role
(male domination). He reported that one of the main causes of the doubling of
the number of female self-immolation cases in just one year in some parts of
Afghanistan for example is forced child marriage.
It is the case of unregistered marriages. According to the ESCWA (2013), there
are indications that unofficial marriage is on the increase in various Arab countries,
with adverse implications for women’s welfare and a corresponding increase in
female vulnerability to domestic violence.
It is also the case of polygamous marriages on which weighs the threat of
repudiation, which makes them all precarious and insecure. Polygamous marriage
has been outlawed in Tunisia, since 1956; however, other Arab countries (Algeria,
Egypt, Iraq, Jordan, Kuwait, Lebanon, Morocco, Sudan, and Syria) allow women to
include a clause prohibiting polygyny in marriage contracts.
Prevalence rates vary markedly among practicing societies. For example, in
sub-Saharan countries, the percentage is estimated between 17 and 30, and in
Arab countries, from 2 to 12 (Al-Krenawi and Graham 2006). Even if it has become
uncommon, women suffer disproportionately from the practice. Indeed, research has
shown that polygamous marriage remains a highly tensioned situation which favors
domestic violence and triggers many mental disorders (Douki et al. 2007). Its
psychiatric impact has been documented by many authors; Al-Issa (1990) cited
polygamy as one culturally specific family stress that is associated with mental
illness among Algerian women. Chalaby (1985) reported a significantly higher
percentage of co-wives in the inpatient psychiatric population than in the general
population of Kuwait. In a subsequent study of traditional marriages in Saudi Arabia,
in Chalaby 1988, the same author concludes that polygamy is definitely a stress on
women. In a community sample study, Ghubash (2001) showed that polygamy
seems to increase vulnerability to psychiatric disorders in the wife; of those in
monogamous marriages, 17.8% presented with a psychiatric disorder in contrast to
39.1% of women in polygamous marriages. The difference was significant
( p = 0.0037). The “first wife syndrome” has been reported by many Arab
psychiatrists (Al-Sherbiny 2005; Al-Krenawi 2013) as a specific condition, charac-

terized by multiple somatic symptoms that do not respond to treatment. The stress of
polygamy is closely related to the threat of repudiation.
Repudiation was likewise banned in Tunisia in 1956 and judicial divorce
established, granting both spouses the right to request it. Repudiation in classical
Islamic law refers to the husband’s right to dissolve the marriage by simply
announcing to his wife that he repudiates her. It is actually the paramount of these
severe life events that cause a sense of loss, inferiority, humiliation, or entrapment
that can predict depression. Brown et al. (1995) found that when marital separation
was initiated by the woman, only about 10% of such women subsequently developed
depression. When the separation was almost entirely initiated by her partner, around
half the women developed depression.
After marriage, women have the duty to obeying the husband and even the
in-laws and to be faithful.
The Duty of Obedience and Related Violence: Wife Abuse

Although very scarce, whatever research is available on domestic violence in some
Arab countries has provided evidence to debunk the myth that wife-battering affects
only few women. The most reliable evidence is the amazing similarity of the figures
reported by different studies, in different countries, in different samples, and at
different times, as shown in Table 2.
Similarly, in Jordan, the Population and Family Health Survey of 2007 revealed
that one in three women aged 15–49 years who were or had been married reported
being subjected to physical violence (ESCWA 2013). More recently, the first global
systematic review (WHO 2013) on the prevalence of intimate partner violence (IPV)
finds the same result: almost one-third (30%) of all women who have been in a
relationship have experienced physical and/or sexual violence by their intimate
partner. In the WHO review, the prevalence was highest in African, Eastern
Mediterranean, and South East Asia regions (37%). Likewise, the rates seem
very stable over time. As an example, the prevalence of DV in Egypt across various
Demographic and Health Surveys (Nossier 2015) does not appear to have changed
over these two decades (Nossier 2015). Finally, it is interesting to observe that the
figures are similar worldwide since one in three women have experienced physical or
sexual violence at least once in her lifetime – mostly by intimate partners.
Table 2 Studies on the lifetime prevalence of wife physical abuse

Country Author Date Sample Rate (%)
Palestine Haj Yahia 1994 National random sample of 2410 34
Palestine Haj Yahia 1995 National random sample of 1334 37
Egypt El Zanaty 1996 National random sample of 14,770 35
Tunisia Belhaj 1998 500 women attending a PHCC 33.8
Tunisia Bouasker 2002 423 women in PHCC 34.2
Tunisia ENVEFT 2010 National random sample of 3873 31.7
However, prevalence rates are higher when one considers all forms of wife abuse,
namely, physical, psychological, sexual, and economic. Indeed, the national survey
in Tunisia reported a prevalence rate of 47.6%. In Morocco, a national survey
estimated the prevalence of violence at 62% with nearly 9% of sexual violence,
while in Jordan, 44% of women who have been married have at some point in their
lives experienced physical violence at least once since age 15, and 9% sexual
violence, as reported by the deputy regional director of the Arab states at UN
Women (Kadi 2017).
On the other hand, we have to take into account the systematic under-reporting of
DV in the traditional societies. An indicator of under-reporting is that studies
conducted in health settings tend to yield higher prevalence rates. Authors explained
that this high rate was also due to strict assurance of confidentiality, privacy, and
using women for data collection; all encouraged women to disclose more informa-
tion to the primary care physician. Nevertheless, considerable percentages of wives
refrained from disclosing the real causes of violence, as the social norms in this
culture forbid disclosure of marital conflicts.
Violence against pregnant women is also worrying, as shown by Nossier (2015)
who reported a rate of 30.6% among pregnant women attending the largest Univer-
sity Hospital in Egypt. In a survey carried out among a representative sample of
475 pregnant women in Turkey, Sahin and Sahin (2003) found a rate of 33.3% of
physical and sexual abuse since the victims had become pregnant.
Finally, we did not include marital rape because it is not recognized even by the
victims (except in Tunisia), given the fact that sexual intercourse is considered a
religious duty.
The Duty of Fidelity and Death Penalty

In Arab countries, female adultery is the worst crime that deserves nothing less than
the death penalty. The sentence can be executed by the family itself, without much
risk, because “honor killings” enjoy quasi-impunity. The perpetrators are indeed
rarely prosecuted, on the grounds that this is a form of private violence that has to do
with personal family and honor matters.
In many Arab and Islamic countries, the culprits enjoy immunity or leniency
under the guise of extenuating circumstances. They also benefit from the
community’s sympathy.
It should be noted that, in general, Arab penal legislation treats a wife’s adultery
more harshly than a husband’s. Frequently, an adulterous husband is only liable for
punishment if the act takes place in the marital home, whereas women’s adultery is
penalized no matter where it takes place.
Extra-Domestic Violence: The “Politics of Invisibility”
Outside the family, women are no longer spared anymore from violence even in
peacetime.
In Peacetime: The Duty of Invisibility

Relatively little attention was paid to extra-domestic violence. Maybe it is because
the presence of women in the public space is still considered unwarranted!
According to a Maghrebian saying, “The woman only goes out three times in her
life: a first time from her mother’s womb, a second time to go to her husband’s home
and a third time to be taken to the cemetery.”
Sexual Harassment
Sexual harassment in public and places of work or education is extremely prevalent
in all Arab countries, but poorly documented except in Egypt. A United Nations’
study (2013) showed that 99.3% of Egyptian women experienced sexual harass-
ment. Abbas et al. (2010) investigated harassment in a large University Hospital in
Gharbeya, Egypt, and reported very high levels of workplace harassment (70.2%).
Most of the harassed nurses, despite claiming adverse psychological impact due to
harassment situations, did not take action or lodge an official complaint for fear of
being dismissed, losing their reputation, or facing social stigma in the workplace. As
a matter of fact, the victims are often blamed for having been harassed. In Egypt,
more than three-quarters of male respondents cited a woman’s “provocative” dress
as a legitimate reason for harassment. Women held even more conservative views
than did their male counterparts, pinning the responsibility for harassment firmly on
women for tempting men into such acts (IMAGES 2017).
Rapes
Rapes are not documented because victims very often do not report it, not even to the
family, fearing they will be accused of adultery. A study of female homicide in
Alexandria, Egypt, found that 47% of all women killed were murdered by a relative
after they had been raped (UNFPA 2000). If they escape the family sentence, they
run the risk to be tried and exposed to the violence of the “sharia.” In some Arab
countries, such as Sudan, the distinction between rape and adultery tends to be
blurred, since a woman needs four witnesses to prove rape, failing which she is
criminalized as an adulteress (Abbas 2010).
But some figures, reported by The Reuters Foundation (Kehoe 2013), indicate the
magnitude of the phenomenon: 412 rapes were recorded in Mauritania in 2012. And
half the inmates of Moroni prison, in Comoros, were jailed for sexual aggression.
Commercial Exploitation
Commercial exploitation may concern even children for sexual purposes or bonded
labor. In many countries of the region, girls from poor families are often sent away
from home to work as servants or to beg on the street. In both cases, they become
subject to physical and sexual abuse. Their isolation makes them more vulnerable to
violent attacks, kidnappings, and trafficking. Women and girls make up 70% of all
known human trafficking victims. Adult women constitute 50% of the total number
of trafficked people. Two in three child victims of human trafficking are young girls.
The Violence of the Islamic Justice

Women face disproportionate and very cruel sentences for “crimes” or “offenses”
considered venial in the Western world: stoning to death in public for “zina” (illicit
sexual relationships before or after marriage), flogging for transgressing the Islamic
dress code (unveiling, wearing men’s clothes). In Somalia, girls as young as 13 have
been stoned! In her book “Forty lashes for a Pair of Trousers,” Lobna Husssein,
a Sudanese journalist describes her struggle with sharia law that culminated in her
arrest in a Khartoum restaurant for wearing slacks, in 2009. She was tried and
sentenced to flogging, for breaching decency laws. Thousands of girls and women
suffer the same fate regularly. Like these young students in Saudi Arabia, who died
“unnecessarily because of extreme interpretations of the Islamic dress code,”
according to the Executive Director of the Middle East and North Africa division
of Human Rights Watch (Kingdom Arab News 2002). This tragic example illustrates
the violence of the Islamic justice against women. In 2002, a fire broke out at a girls’
school in Mecca. As a result of the fire and ensuing rush to escape, 15 young girls
died, and more than 50 were injured. According to at least two reports, members of
the CPVPV (Committee of the Promotion of Virtue and Prevention of Vice), also
known as Mutaween, would not allow the girls to escape or to be saved from the fire
because they were “not properly covered,” and the mutaween did not want physical
contact to take place between the girls and the civil defense forces for fear of sexual
enticement, and variously that the girls were locked in by the police, or forced back
into the building (Newsweek 2002).
In Time of Crisis: A Weapon of Mass Destruction

In recent years, the Arab world has experienced many crises: wars, armed conflicts,
popular uprisings, which have seriously deteriorated the security of the population
and their living conditions. These crises, compounded with the rise in Muslim
extremism and a push for adherence to Islamic law have increased risks of violence
against women, including striking forms of sexual violence. As everywhere, women
are the most impacted, because of their extreme vulnerability. But, in these honor
societies, they become a weapon of mass destruction to defeat men without fighting
them. So, according to the survey of the Reuters Foundation (Kehoe 2013), women
and girls suffer from kidnappings, rapes, trafficking, early and forced marriage in
these countries, especially in refugee camps. Thousands of displaced women have
been forced to work as prostitutes in neighboring countries including Syria, Jordan,
and United Arab Emirates. There are reports of government forces and armed militias
sexually abusing women and girls during home raids and in detention centers.
Women with Disabilities
All women are targets of violence, but certain groups are even more vulnerable; it is
women with disabilities, whether the disability is physical or mental. We can add as
well the social handicap of divorced women or women held in institutions or in
prison which is highly stigmatized in the Arab societies.
Because women with disabilities are more isolated than most underrepresented
groups, their plight typically has not been addressed. Women with disabilities therefore
warrant unique attention when examining abuse and violence in the world. Perpetrators
of abuse against disabled women include family members, intimate partners, care-
givers, teachers, and peers, and the range of abuse perpetrated is staggering.
In the absence of specific studies, we will illustrate the subject with two testimo-
nials from these “voiceless” women.
The voiceless is unheard of because quite often it is perceived as the passive,

the mad, the unfinished, the showy, and the sentimental. The voiceless is the
other who is willing to speak only if we decide to hear. The voiceless is the
female long mired in her equanimity.
One of these voices in the Tunisian society is the divorced woman. The
divorced woman talked about in this example and kept anonymous is from the
center of the country. It should be noted that there is a stigma around the word
divorce, particularly in relation to women. Divorced women are perceived as
the double burden: a burden for being the female who is incapable of trans-
mitting her father’s name, and a burden for being the no-longer virgin, that is,
the used, and the unwanted. Violence is always thought to be on the physical
level only. Emotional abuse is still discredited because it cannot be seen, yet
the impact of it on the victim can be a matter of life and death. This Tunisian
woman was subjected to emotional abuse by her own family for being thought
of as the one who caused the divorce. Repeatedly called by her mother as “the
abandoned” and perceived as the unwanted by her own ex-husband and family
members, this woman took her own life by drinking rat poison.
In another case, a recent case in relation to women with disabilities, a
female student on a wheelchair, due to systemic disability, was denied her
right to be registered at the Higher Institute of Languages. This is a clear cut
example of emotional violence against disabled women and their right to
dignity as well as education. Furthermore, it is a conspicuous example of
breaching of the 48th chapter of the Tunisian constitution. It is noteworthy that
disabled women are still struggling in institutions that prefer “normalcy” over
disability. Emotionally speaking, they are perceived by their teachers as less
intelligent, as someone to be set aside from the rest of the class. In certain
cases, females with disabilities are incapable of reporting their traumatic
experience, and this leaves the floor for teachers to even physically abuse
them in front of their peers. Incidents as such can lead to the widespread of
bullying among children and can further ostracize and traumatize females with
a disability. As semi-disabled, she was subjected to violence by her own
teachers. Trauma made her unable to open up to her family until recently.
A third voice (and certainly not the last) is that of the woman suffering from a
mental disorder. To our knowledge, there have been no systematic studies in the
Arab world on violence against mentally ill women. However, they face, more than
men, high stigma and discrimination that limit their access to care. Some studies
have systematically found fewer women than men in the psychiatric settings. In a
Tunisian psychiatric outpatient clinic, less than 40% of patients were women,
although the clinic was predominantly dealing with common mental disorders
known to be twice as frequent in women (Ouali et al. 2007). The same picture is
found in emergency and inpatient settings: Women represent only 29.5% of the 1030
patients attending the psychiatric emergency service at Casablanca, Morocco, during
10 months (Louzi 1988). Women also represented only 38% of the total psychiatric
population at the psychiatric hospital in Libya (Avasthi et al. 1991). Two major
reasons prevent women from being cared for a mental disorder. First of all, the
cultural taboo of consulting or, worse, being hospitalized in a psychiatric setting,
carries the risk of non-marriage, risk which could attain even the female relatives. If
the disease develops after marriage, they are far more likely than men to be divorced
and to lose their children’s custody. Secondly, there are irreplaceable in their role of
housewives, mothers, and caregivers and cannot leave their home for long periods.
So, as long as they continue to look after household and children, they will not
benefit from treatment. It is only when they become unable to do her housework that
they are allowed to seek care. And, in this case, the family keeps pushing to speed up
the discharge. And, at home, treatment is discontinued in 30.2% of women compared
to 6.5% of men, given the sedative effects (Ouali et al. 2007). Very often, families
prefer consulting traditional healers who are more accepted culturally, but the
practices of some of them may be violent, if not harmful. However, systematic
review has shown that stigma and discrimination of mental patients were consis-
tently linked to worse outcomes such as higher rates of depression, more social
anxiety, withdrawal as coping strategies, along with lower quality of life, lower self-
efficacy, lower self-esteem, lower social functioning, less support, and less mastery
(Gerlinger et al. 2013). Thus, there is considerable evidence that mentally ill women
do not have the same right to care as men. It clearly means that their mental health is
regarded as being of low priority compared to their care giving role.
Despite this dark picture, which is actually not exhaustive, the eyes remain closed
and the mouths too!
Eyes Shut: A Troublesome Tolerance
What Violence Are We Talking About?
The meaning of violence varies from one culture to another, and sometimes within
the same culture. Women from Arab cultures are brought up in a belief system that
stresses the greater importance of the family than that of individual members. So, all
forms of violence are not treated in the same way. Some of them are not considered
as such and performed, because they belong to the tradition and culture and
considered as protection for young girls against sexual abuse and temptation:
FGM, early veiling, confinement at home, or early marriage. As a matter of fact,
FGM is publicly celebrated, like the circumcision of boys and sometimes even
claimed by the young girls. Wife battering is recognized as abuse but accepted as part of
the order of things, and regarded by many, including the victims, as private and often
legitimate. Consequently, it is highly condoned and largely under-reported. On the
other hand, sexual assaults (from harassment to rapes) are not tolerated at all but should
never be disclosed, because they bring shame and dishonor on the family. Indeed, they
implicate the victim as guilty somewhere; at worst, she was consenting, at best, she
provoked her aggressor, by being unveiled, for example. Finally, what is recognized as
violence is at the same time defined as private and locked in family secrets.
The Look of Society: No Right of Interference
Wife Abuse Is a Private Affair

In Arab societies, the tendency is to view wife abuse as a private, personal, and
family affair rather than a social and criminal problem requiring external interven-
tion. For 80% of the 625 men and the women participating in Haj-Yahia’s study (Haj
Yahia 1998), “marital violence doesn’t justify reporting the husband to the legal
authorities.” Two decades later, this mentality has not changed much. In Morocco,
60% of men consider that wives should tolerate violence to keep the family united,
and that number goes up to 90% in Egypt (IMAGES 2017).
Wife Abuse Is “Justified”

DV is above all widely justified. In Tunisia, only 60% of women and 51% of men
considered marital violence intolerable (Belhadj et al. 1998); in another study
(Aouidj 2001), wife abuse was acceptable or sometimes acceptable for 77.6% of
Tunisian women! In the Tunisian National Survey (Zemni 2010), 55% of the victims
accepted violence as part of the order of things because of shame and fear of
aggravating the situation. In Palestine (Haj Yahia 2000), only 41% of respondents
strongly agreed or agreed that “there is no excuse for a man to beat his wife.”
However, 60% of men and 50% of women strongly agreed or agreed that “a violent
husband is not solely responsible for his behavior.” Marital violence is justified by:
• The wife’s misbehavior
Nearly, 49% of men and 43% of women in Palestine strongly agreed or agreed
that “a battered woman is solely responsible for being beaten because she obviously
did something that irritated her husband.” In Tunisia, 32.3% of men and 21.6% of
women consider that “the husband is sometimes obliged” to beat his wife! Battered
women are to blame for violence against them under different circumstances (Douki
et al. 2003): if the husband believes she is sexually unfaithful, if she refuses sex to
her partner, if she challenges her husband’s masculinity, chatters, talks too much,
nags, complains too often, disobeys and undermines his authority, interferes with her
husband’s social life, and does not respect his parents and siblings. The Egypt 2008
Demographic and Health Survey revealed that around 30% of women in the sample
who were or had been married believed a husband was justified in beating his wife if
she went out without his permission, neglected her children, or refused to have
sexual intercourse with him (IMAGES 2017).
• The conditions of the husband’s daily life
Some respondents (13% in Palestine) expressed support for the husband; they
strongly agreed or agreed that the husband is justified in beating his wife, based on
his personal and life conditions: work pressure and debt, and the feeling that no one
understands or helps him.
• The religious commandment
“Men are the maintainers of women [. . .]. the good women are therefore obedient,
guarding the unseen as Allah has guarded; and for those who show rebellion, you
shall FIRST enlighten them, then desert them in bed, AND THEN beat them; once
they obey you, do not seek a way against them; surely Allah is High, Great.” (Koran,
IV, 34). It is on the basis of this verse that violent husbands claim the right to
discipline their wives as they see fit.
The perception that domestic violence in general, and wife-abuse in particular, is
a family issue rather than a criminal act requiring a sanction, has a strong impact on
the decision of the wife and her family to keep the problem to themselves. Indeed, all
the protagonists in this drama are partners in a real conspiracy of silence.
The Conspiracy of Silence
The Victims
More than 6 in every 10 women survivors of violence refrain from asking for support
or protection of any sort and remain silent rather than seek protection or support.
They were 73% in the ENVERT who did not seek help from anyone.
Women are reluctant to report marital violence because of the risk of facing social
isolation and ostracism. Battered Arab women who use the law to remove violent
husbands from the home or issue a protection order against them may be ostracized
by their community and blamed for undermining family stability and unity. This can
be attributed to the prevailing belief that the children’s best interests, the woman’s
personal reputation, and the reputation of her family of origin take precedence over
her own well-being and safety.
Under-reporting of spousal violence is also common as a result of shame, fear of
retaliation, lack of information about legal rights, lack of confidence in, or fear of, the
legal system, and the legal costs involved. Also, as everywhere, women often feel
guilty, believing that they deserve the beatings because of some wrong action on
their part. Although women in traditional societies are probably most inclined to
believe that men are justified in beating their wives, in all settings, in developed and
developing countries, abused women tend to hold more beliefs which justify vio-
lence against them. Under-reporting is highest in the case of sexual violence as it
remains highly stigmatized in all settings (UNICEF 2000)).
The remaining ones who do speak up mostly turn to family and friends for
support or protection. In Tunisia, only 3.8% turn to the police station and 2.3% to
the health services. However, in the majority of cases, even if violence is disclosed,
family, police, and even health professionals are not of great help, given the
importance attached to maintaining the marital link.
The Environment
For the family, the marital bond must be preserved at all costs. The family is viewed
as a highly important social institution whose unity and cohesiveness should be
maintained. Battered women are generally advised to forgive their husbands in order
to protect their children and their home.
The police generally use (especially when they know the husband) the same
arguments to deter the woman from filing a complaint. Law enforcement authorities
routinely dismiss domestic violence as “private” disputes. Female victims
attempting to register complaints of abuse are often turned away and advised, or
pressured, by the police to reconcile with their abusive spouses.
Physicians also collude in this conspiracy. The lack of abuse detection by health
professionals is alarming. Women’s reports of abuse are often denied, minimized,
interpreted as delusional, or ignored. Women in relationships with violent men are
often labeled as “masochistic” and “self-defeating.” Frequently, victims of wife-
assault, incest, rape, and other forms of abuse are not addressed in individual
treatment, marital and family interventions, or discharge plans. There is also a
systematic underrating of the health consequences and the traumatic injuries that
occur.
If the victims do manage to break the silence, they will confront justice that is as
blind as deaf and dumb!
The Look of Justice: An Incomprehensible Leniency
“The law is in favour of men, not women” declared Lubna Taweel, a Jordanian
lawyer, to The Arab Weekly, on 05/08/2015. Indeed, the leniency of justice on this
subject reflects the general tolerance of the society at large, especially in countries
implementing Islamic laws and rules. The perpetrators of violence against women
often escape punishment and its victims rarely receive reparation. Rare are the Arab
countries, where laws condemning violence against women are legislated.
First of all, many forms of VAW are not considered crimes or offenses and
consequently are allowed, if not encouraged. This is the case with FGM, child,
temporary and polygamous marriages, repudiation, or domestic violence, in partic-
ular marital rape, in most countries.
As for wife abuse, according to Islamic law, many countries recognize the
husband’s right to discipline his wife for disobedience and consider that a refractory
wife has no legal right to object to her husband’s exercising his disciplinary
authority. However, even when a repressive law exists, it is rarely used to charge
violent partners. In Tunisia, the law on violence against women has been amended
for the first time to increase the sentence against the offender when he was a spouse
but, at the same time, it offered the possibility for the victim to withdraw her
complaint. Thus, about 6000 complaints for marital violence were lodged every
year but most of them were withdrawn and only 0.3% referred to a court! This clause
has been repealed in 2017, under pressure of the women’s and human rights
organizations. Likewise, Tunisia became the first Arab country, and up to the present
time, the only one, to recognize and punish marital rape.
Muslim scholars and jurists argue that Islam does not set limits on the freedom of
man in the practice of sex with his wife without her consent. They base their opinion
on the Koranic verse which says: “Women are the land which is yours to plough –
you may therefore plough them wherever you wish.” (II: 22). On the other hand,
Islamic teachings forbid women to desert their husbands in bed. According to the
Hadiths (sayings of the Prophet), a woman is sinful if she refuses sex, without a
reasonable cause, to her husband. Among these sayings, are the followings: “If a
man invites his wife to sleep with him and she refuses to come to him, then the
angels sends their curses on her ‘til morning.” Or, “When a man calls his wife to
satisfy his desire, she must go to him even if she is occupied at the oven” (Mishkat
1, p. 691).
Muslim scholars explained later that all these commands were made for the
security of the social order, to prevent men satisfying their sexual needs with
prostitutes. The same explanation has been used to justify the practice of polygamy.
Regarding sexual violence, the perpetrators are often shown leniency or even
acquitted! For example, rapists can escape being sentenced if they marry the victim!
In Morocco, article 475 of the penal code which allowed rapists to avoid prosecution if
they marry their victims was only repealed in 2014 following the suicide of a rape
victim who was forced to marry her aggressor. Similarly, honor killings enjoy exten-
uating circumstances and run the risk of 3-year imprisonment, at worst. The example of
Jordan is very eloquent, in terms of cultural barriers. The Arab Weekly (Nahhas 2015)
reported that King Abdullah II and his wife, Queen Rania, fought an uphill battle to
impose harsher punishments on rapists and those who commit honor killings. Parlia-
ment argued that sentences longer than the prevailing 6 months in jail would encourage
women to commit “vice.” But the King wanted honor killings to be considered the same
as other murders, punishable by a minimum of 10 years in prison. It took at least 3 years
to amend the penal code, specifically Article 98, and even then not quite as much as the
King had sought. Article 98 obliges judges to give high regard to extenuating circum-
stances, such as male fits of rage, when handing down sentences.
It is time to question this intolerable tolerance!
The Cultural Roots of Violence Against Women
Gender-based violence seems to stem from cultural roots, including sociological and
psychological factors, which foster violence and its acceptance, and contribute to the
perpetuation of this problem. It is of crucial importance to identify these factors in
order to fight them appropriately.
A Culture of Honor and Shame
Cultural anthropology distinguishes three types of societies: the guilt society, the
honor-shame society, and the fear society. This classification sorts the different
cultures, according to the emotions they use to control individuals (especially
children) to maintain the social order, guiding them towards norm obedience and
conformity. The Arab society is typically an honor-shame culture, where the means
of control are the inculcation of shame and the complementary threat of ostracism.
Shame is a matter between a person and others, unlike guilt which is a matter
between a person and his conscience. As Raphael Patai wrote in The Arab Mind
(1973, p. 113), “A hermit in a desert can feel guilt; he cannot feel shame. [. . .] What
pressures the Arabs to behave in an honourable manner is not guilt but shame, or,
more precisely, the psychological drive to escape or prevent negative judgment by
others.” Shame cultures are based on the concepts of pride and honor and appear-
ances are what count.
Patai emphasizes the strong correlation between honor and group survival. Honor
and shame, for an Arab family/or tribe, are seen as a key survival factor. Honorable
behavior is that which is conducive to group cohesion. This imperative explains the
preference for endogamy, to nurture the kinship spirit. He notes that the marriage of
cousins “serves as a fail-safe protective device to secure collective family honour,”
and links the honor-based function of inbreeding to a broader appreciation of
in-group solidarity as a social strategy. As a matter of fact, in Iraq, as in many
countries of the region, nearly half of all married couples are first or second cousins
to each other. In most European countries, cousin marriage does not exceed 1%, and
is under 10% in the rest of the world outside a corridor linking Morocco to Southern
India. Endogamy is, actually, one of the building blocks of Arab Muslim cultures, by
fostering intense family loyalties and strong nepotistic urges.
Jason Pappas explains however that inbreeding curbs the development of a civil
society. “Extended families that are incredibly tightly bound are really the enemy of
civil society because the alliances of family override any consideration of fairness to
people in the larger society.” The practice has little to do with Islam and has been a
prevalent cultural norm before Islam. On the contrary, in the early days of the spread
of Islam, marriages outside the clan were highly encouraged to increase religious
expansion. Endogamy which feeds the group-spirit prevents, above all, the emanci-
pation of the individual from the group. It is absolutely opposite to the guilt society,
which emphasizes the individual conscience. Thus, the group’s interest will always
surpass that of its members.
Patai also described the “substituting words for deeds” as an Arab way of living.
“The intention of doing something, or the plan of doing something, or the initiation
of the first step toward doing something—any one of these can serve as a substitute
for achievement and accomplishment.” [p. 67]. That is why so many women have
been killed based on the faith of a saying! Did not the Prophet say: “Deeds are
[a result] only of the intentions [of the actor], and an individual is [rewarded] only
according to that which he intends”? This is an example of the common misunder-
standing of the prophetic message.
A Misinterpretation of Islam
The “alibi of religion” is often used to legitimize violence against women. However,
we aim to demonstrate that this “alibi” is in reality a misinterpretation of the Islamic
teachings.
The Son Preference

The son preference is definitely condemned by the religion. Islam prohibited female
infanticide which was practiced before its advent, during the “Jahiliyah” (ignorance)
period and also mocked the fathers who viewed the birth of girls with contempt:
“When news is brought to one of them, of the birth of a female, his face darkens and
he is filled with inward grief! With shame does he hide himself from his people
because of the bad news he has had! Shall he retain her on contempt or bury her in
the dust? Ah! What an evil choice they decide on” (Koran, XVI: 58–59). And the
Prophet added, more explicitly: “Whosoever has a daughter and does not bury her
alive, does not insult her, and does not favor his son over her, God will enter him into
Paradise.”
Female Genital Mutilation

FGM is not a religious requirement and violates the women’s right to a full sexual
achievement, according to the Islamic teachings. It is an ante-Islamic practice which
has never been performed in some Islamic countries (e.g., North-Africa and Iran),
whereas it is widespread in many non-Islamic countries or communities. We can also
recall that “clitoridectomy” was practiced in Western countries to “treat” hysteria up
to as late as the nineteenth century! After the “Jasmin revolution” in Tunisia, in 2011,
a famous Qatari preacher tried to introduce the practice into the country, ruled at that
time by a religious conservative party, arguing that it was an “aesthetic operation”!
He provoked a general indignation.
FGM is a typical example of the weight of tradition that may prevail over religion.
While the religion stresses the importance of mutual sexual satisfaction between
married partners, negative cultural factors can prevent such an outcome. The Islamic
position on sexual behavior is clear. Both men and women are required to be chaste
and to seek fulfilling relationships within wedlock. The most explicit discussions of
sexual relations with respect to fulfilling the wife’s needs are found in the Book on
the Etiquette of Marriage, part of Abu Hamid Al-Ghazali’s larger work, Revival of
the Religious Sciences (Ihya Ulum al-Din), written in the eleventh century. Al
Ghazali quotes the Prophet as saying: “Let none of you come upon his wife like an
animal, let there be an emissary between them.” When asked what the emissary is,
he replied: “The kiss and sweet words.” In another hadith, the Prophet points out that
one of the deficiencies of a man is that “he approaches his wife and have sexual
contact with her before exchanging words and caresses, consequently, he sleeps with
her and fulfils his needs before she fulfils hers.” Al-Ghazali further elaborates on the
importance of a woman achieving orgasm by stating: “Congruence in attaining a
climax is more gratifying to her because the man is not preoccupied with his own
pleasure, but rather with hers.”
The Marriage-Related Violence

Concerning wife abuse and the right to beat one’s spouse, we cannot deny that it is
written in the Koran in the verse IV, 34. However, if we want to have a fair interpretation
of this “recommendation,” we must take into account the historical context and the
other sources of the “sharia,” namely, the sayings of the Prophet and the Sunna (the
Prophet’s behavior), as well as the explanations of the religious authorities.
In Islam, the divine allowance to beat one’s wife can be considered a real progress
compared to the status of women before Islam when husbands had the right of life and
death on their many partners and daughters. The Koran severely condemned the old
customs of ill-treating women (XVI, 58/59, and LXXXI 8/9) and protected their rights
in one of its longest chapters (IV) entitled precisely “Women.” According to the famous
scholar Badawi (1971), the fact that violence is permissible does not mean that it is
desirable. Just like divorce which is allowed but greatly discouraged. Indeed, the
Prophet said: “The most hateful of all lawful things, in the sight of Allah, is divorce.”
Beating should always be seen as a last resort, preferable to divorce, a “lesser of two
evils” which may be used to save a marriage, “threatened by a wife’s misconduct.”
Similarly, many sayings of the Prophet formally condemn violence against women:
“The most perfect believers are the best in conduct. And the best of you are those who are
best to their wives”; “It is the generous who is good to women, and it is the wicked who
insults them”; “Do not beat the female servants of Allah.” Actually, to be a Muslim is to
follow the example of the Prophet Muhammad, who never resorted to that measure,
regardless of the circumstances. Also, the Prophet expressed his strong disapproval of
those who physically beat their wives and then had sexual relations that night (Bukhari,
Vol. 7, No. 132, Vol. 9, 81–82; Riyadh us-Salaheen, No. 274).
Even the scholars do not justify violence; according to their interpretation,

“beating” is more a symbolic measure than a punitive one and they consider
permissible only a light striking which leaves no mark on the body (“dharban
ghaira mubarrah,” as said the Prophet). They suggest the use of a “miswak,” a
small natural toothbrush. The Prophet was even more delicate in advising to beat
them “with a flower.”
Wife beating was intended to discipline the rebellious and potentially unfaithful
spouse as physical sanctions were until recently largely accepted as a way of educating
children! But nowadays, it largely overcomes these limits and can be considered a
transgression of religious commandments. As a matter of fact, wife beating must be
considered a rare exception to the repeated exhortation of mutual respect, kindness, and
good treatment between spouses advocated in all the Islamic teachings. Among the
most impressive verses in the Koran about spouses are the following:
He created mates for you from yourselves that you may find rest, peace of mind in them, and
He ordained between you love and mercy. Lo, herein indeed are signs for people who reflect.
(Koran 30:21)
But consort with them in kindness, for if you hate them it may happen that you hate a thing
wherein God has placed much good. (Koran 4:19).
When the continuation of the marriage relationship becomes impossible for any
reason, men are still taught to seek a gracious end for it. “When you divorce women,
and they reach their prescribed term, then retain them in kindness and retain them
not for injury so that you transgress (the limits)” (Koran II: 231). Repudiation is
considered by the Islamic religion as the most reprehensible means of divorce, and
many measures are provided to deter men from resorting to it.
Honor-Related Violence
Death penalty for “Zina,” whether it is executed by a family member or the justice system,
by stoning to death, is wrongly ascribed to Islam. “Zina” is an Islamic legal term referring
to unlawful sexual activities, namely, adultery (of married parties) and fornication
(between two unmarried persons). Stoning or lapidation is a method of capital punishment
whereby a group throws stones at a person until the subject dies. It is today considered a
form of execution by torture. However, it is still included in the laws of some countries like
Saudi Arabia, Sudan, Somalia, and Yemen as punishment for adultery. It is practiced on
the basis of sayings held by the Prophet whose veracity is problematic for many exegetes.
During the life of the Prophet, stoning was only applied to those who accused themselves
of adultery and claimed for their execution to be “purified” before death.
In fact, the Koran never mentioned the act of stoning for any crime, contrary to
the Torah, where lapidation is the method of execution most frequently reported. The
punishment for “Zina,” in the Holy Book, is flogging with a 100 lashes, if the accuser
can provide four witnesses to the act. If the accuser cannot do it, he himself will be
punished by flogging with 80 lashes. “The woman and the man guilty of fornication/
adultery, flog each of them with a hundred stripes: Let not compassion move you in
their case, in a matter prescribed by Allah, if ye believe in Allah and the Last Day:
and let a party of the Believers witness their punishment” (Koran, XXIV: 2). “And
those who accuse chaste women then do not bring four witnesses, flog them, (giving)
eighty stripes, and do not admit any evidence from them ever; and these it is that are
the transgressors. Except those who repent after this and act aright, for surely Allah
is Forgiving, Merciful” (Koran, XXIV: 4–5). Besides, the flagellation is not sup-
posed to cause death, since the same verse adds: “ The fornicator will only marry a
fornicator or a polytheist. And the fornicator will be married only by a fornicator or
a polytheist; such a thing has [been] forbidden to believers” (Koran, XXIV: 2–3).
Finally, GBV and its acceptance cannot be attributed to Islam but to the patriar-
chal ideologies, as stated by Badawi (1971): “It is also true [. . .] that in many so
called “Islamic” countries, women are not treated according to their God-given
rights. But this is not the fault of Islamic ideology [. . .] many of these practices are
based on cultural or traditional customs.” The same goes for the subordinate status
of women that is wrongly ascribed to Islam.
A Woman’s Subordinate Status
The United Nations General Assembly, in its 1993 Declaration on the Elimination of
Violence against Women, stated that violence is a manifestation of historically
unequal power relations between men and women. Obviously, gender inequality is a
key factor that underpins violence against women, arising from their subordinate
status and lack of empowerment. If women are so maltreated, it is because they have
the status of “minor” who needs to be disciplined and have no power or means to
defend themselves. The occurrence of violence in the region is shaped by discrim-
ination against women and the persistence of negative stereotypes conveyed about
them, in order to belittle them and legitimize their subordination.
Certainly, at all times and in all places, women have suffered from the worst
prejudices and a subordinate legal status. In Hindu scriptures, a good wife is
“a woman, whose mind, speech and body are kept in subjection.” Athenian
women were always minors, subject to some male kin. A Roman wife was described
as “a babe, a minor [. . .], a person continually under the tutelage and guardianship of
her husband.” As late as the nineteenth century, in his essay “The Subjection of
Women,” John Stuart Mill wrote: “We are continually told that civilization and
Christianity have restored to the woman her just rights. Meanwhile the wife is the
actual bondservant of her husband; no less so, as far as the legal obligation goes,
than slaves commonly so called.” The Indian essayist Pankaj Mishra (The Guardian,
17 March 2018) recalls in an article entitled “The crisis in modern masculinity,” that
even Napoleon, the child of the French Revolution and the Enlightenment, believed
women ought to stay at home and procreate; his Napoleonic Code, which inspired
state laws across the world, notoriously subordinated women to their fathers and
husbands; likewise, Thomas Jefferson, America’s founding father, commended
women, “who have the good sense to value domestic happiness above all other.”
However, the Arab States are among the last ones to keep on translating these
negative stereotypes in discriminatory laws which allow the exercise of violence
against women. According to the Economic and Social Commission for Western
Asia, in its report of 11 October 2013, “the unequal status of women in the Arab
region owes largely to discriminatory legislation in personal status laws, criminal
codes, labor regulations and other policies. These laws officially designate a subor-
dinate status for women in society, a status that undermines the ability of the law to
confront violence against women.” And, a recent report on achieving the MDGs by
2015 concludes: “The Goals have not been entirely successful in eliminating social
and legal constraints and discriminatory behaviour against women in the Arab
world” (Sika 2011).
No Arab country grants equal rights to women and men. Furthermore, some states
continue to deny any link between gender inequality and violence against women
and claim for evidences to be shown to illustrate that connection. This correlation is
obvious, in the Arab region, where, in addition to the negative social stereotypes
towards women, law itself fosters violence against them. Let us list some of these
discriminatory laws that perpetuate violence against women.
Duty of obedience towards the husband and his family is prescribed by law in
most Arab countries and justifies wife abuse and the leniency of justice towards the
violent husband. Iraq’s amended penal law permits husbands to punish their wives.
In the United Arab Emirates, penal law decrees the male guardian’s right to use
physical violence against female kin, including wives. Apart from Tunisia, no Arab
country explicitly refers to spousal rape as a criminal offense, which constitutes a

lapse that indirectly encourages the impunity of perpetrators.
When the age at marriage is set at less than 18 years for girls (it is 9 years in
Yemen) and not for boys, should we denounce child marriage or the law that allows
it? The same question could be raised concerning polygamous marriage and
repudiation.
Repression of women’s sexuality, outside wedlock, is an incitement to “honor’
crimes, as well as the quasi-impunity of the perpetrators.
In all Arab countries, rape is a criminal offense. However, in several countries, the
male rapist escapes punishment if he marries the victim. Similarly, the “rapists-
marriage laws” can be considered an encouragement to rape.
In some Arab countries (Saudi Arabia, Sudan), a dress code is imposed on
women, who are exposed in case of an offense, to a sentence of public flogging,
and, on the street to various assaults, from acid throwing on the face to murder.
We must add the lack of empowerment, with females less educated, less inte-
grated in the working world (The MENA region has some of the lowest rates of
women’s economic participation in the world), unable to marry the person they want,
unable to transmit their citizenship to their children, unable to move without
permission of a male kin amongst other things. Women face discrimination in
matters dealing with marriage, divorce, guardianship, custody, and inheritance.
These forms of inequalities severely marginalize women and girls, curtail their
equal opportunities to education and employment, restrict their access to healthcare
and make it difficult for women to seek judicial remedies when their rights are
violated.
However, a question remains that asks for an answer. Why do not policies fighting
GBV seem effective, in Western countries, despite the promotion of women’s status
and their empowerment? Certainly, they have broken the wall of silence and allowed
thousands of women to disclose their suffering. Nevertheless, in France, for exam-
ple, a woman is killed every 2 or 3 days by an intimate partner! This seems to suggest
that achievement of gender equality is not sufficient, by itself, to eradicate violence
against women and that there are other psychological drivers that maintain this high
level of violence. It is necessary to obtain these drivers of violence against women
from the men themselves. There is always hope when people are forced to listen to
both sides, said John Stuart Mill.
A “Great Fear” of Female Power
For the first time, a study on male attitudes towards gender equality and GBV was
conducted in the Middle-East and North-African region (MENA), including some
10,000 men and women in four countries: Egypt, Lebanon, Morocco, and Palestine.
IMAGES MENA 2017 (International Men and Gender Survey) was rightly entitled
“Understanding Masculinities.” The study revealed that a majority of the men
surveyed in the four countries supported a wide array of inequitable, traditional
attitudes. In addition, strong majorities of men believed it was their role to monitor
and control the movements of the women and girls in their households, a practice
starting in childhood. Men are expected to control their wives’ personal freedom,
from what they wear and where they go to when the couple has sex. Two-thirds to
90% of men reported exercising these various forms of control, with women
affirming that their husbands sought to control them in these ways. Too many men
in the region continue to uphold norms that perpetuate violence against women or
confine women to traditional roles. Women are still widely defined – by men and
women alike – as wives and mothers first, rather than by professional or workplace
achievements.
Men in Arab countries do not seem ready to give up their power to control
women, as is the case for many men worldwide, since the beginning of the “feminist
revolution.” The problem might lie precisely in the shift of power balances between
genders. The answer was identified by Hannah Arendt, well known for her work on
power and violence, when she stated that “the reign of pure violence is established
when power begins to be lost.” After centuries during which the male supremacy has
never been challenged, men are losing this privilege and their power over women.
Actually, issues of gender and power, rather than ethnicity and culture, may be more
important in creating and maintaining the occurrence of violence against women.
Indeed, most men feel threatened by the “murderous equity doctrine,” espoused
by feminists, as bemoaned by the Canadian writer J.B. Peterson. And, “luridly retro
ideas of what it means to be a man have caused a dangerous rush of testosterone
around the world [. . .] and have gone mainstream, even in so-called advanced
nations,” observes Pankaj Mishra (2018) who published” The age of anger: A
History of the Present.” And he added to explain: “As manly virtues arose, attacks
on women, and feminists in particular, in the west became nearly as fierce as the
wars waged abroad to rescue Muslim damsels in distress.” Many examples illustrate
that “frenetic pursuit of masculinity.” Harvey Mansfield, in “Manliness” (2006),
denounced working women for undermining the protective role of men. The histo-
rian Niall Ferguson deplored that “girls no longer play with dolls” and that feminists
have forced Europe into demographic decline. In Sexual Anarchy: Gender and
Culture at the Fin de Siècle (1990), Elaine Showalter already described the great
fear induced among many men by the very modest gains of feminists in the late
nineteenth century, namely, “fears of regression and degeneration.”
It is certainly true that historically privileged men tend to be profoundly disturbed
by perceived competition from women. Many men feel besieged by women with the
destruction of “the traditional household division of labour.” Since the 1950s,
historian Arthur Schlesinger Jr was warning of the “expanding, aggressive force”
of women, “seizing new domains like a conquering army.”
But they fear above all a reversal of the power balance at their expense. They fear
to lose the power of mastery in giving equal rights to women. Men through the ages
have both loved and dreaded them. Actually, if men hold power, women possess
potency, and male power aims to channel female potency. Indeed, women have the
unique potency of giving life and until recently, to appoint the new-born’s father. A
Tunisian proverb says: “It’s your father, if your mother said true.” The Romans said
it otherwise: “Mater certissima, pater semper incertus.” That is why chastity was
required to guarantee to the husband his paternity. Female potency is also sexual, in
male fantasies that credit women with an insatiable sexual appetite and an endless
pleasure. That is why female sexuality threatens males’ virility and honor and has to
be permanently under control.
Even worse, women’s sexuality threatens the social order. From centuries ago,
women were considered as “empty headed blabbers” causing all the chaos of
mankind. Men have the duty to prevent her from sowing disorder. Domestic violence
is thus seen as a means of maintaining and reinforcing “social order” threatened by
the “fitna” (social disorder) that only females are able to provoke with their uncon-
trollable sexuality and their infinite cunning. Arab men are delighted to quote this
sentence of the Koran addressed by her husband to Zulaikha who attempted to
seduce Prophet Yusuf: “It’s a trick of women! Your tricks are very huge!” (Koran,
XII: 28). Even the Prophet Mohamed would have said, according to Bukhari: “After
I have left, there will be no greater menace to my nation more liable to create anarchy
and trouble than women.”
However, the feminist revolution has completely changed the gender relationship
by freeing women from the guardianship of men. How to manage a woman who
conquered the right to move without him or his permission in mixed settings? How
to guard against the risks of loss of virginity or infidelity? How to be obeyed?
These new prospects seem intolerable, especially in societies where a man is
worth his control over women. If they are deprived of power, they are deprived of
masculinity, “castrated.” They face a real problem of identity, their self-image
depending on despising and excluding women. As Mishra explains, “It is as though
the fantasy of male strength measures itself most gratifyingly against the fantasy of
female weakness. Equating women with impotence and seized by panic about
becoming cucks, these rancorously angry men are symptoms of an endemic and
seemingly unresolvable crisis of masculinity.”
This helplessness generates violence against women who are still considered
potentially guilty, according to the popular saying: “Beat your wife every morning;
even if you do not know why, she knows it”! They do not know obviously the more
precious advice of the Prophet: “If you have to beat your wife, do it with a flower.”
However, Arab women are no more willing to accept their subordination. Brave
women and girls defy daily the restrictive norms and expectations under which they live
to speak up, stand up, and push forward for their rights. In the face of tremendous
societal pressure to conform to a very narrow definition of femininity, women and girls
persist, counting small victories along the way. As it has been recalled by Mohammad
Naciri, Regional Director, Arab States UN Women, “We have seen progress. Govern-
ments in the region have pushed for equality; particularly in the last few years, they
have adopted legislation to ensure equal rights, they have criminalized violence against
women, and some have lifted all reservations on CEDAW.”
John Stuart Mill wrote to Auguste Comte, in 1869: “there is no question of
governing society by women but to know if it would not be better governed by men
and women.”
It becomes evident that to put an end to the “war of the sexes,” we need to
reassure men in order to disarm them. It is necessary that gender relationships evolve
towards equality, mutual respect, and cooperation because this undue conflict
spreads an exorbitant cost that is borne by all.
The Heavy Toll
Arab countries are paying a very heavy price for gender-based violence in terms of
human rights, public health, economic development, and democracy.
Violence against women is indeed the most pervasive yet least recognized human
rights abuse in the world. Numerous international and regional treaties and conven-
tions recognize violence as a fundamental violation of girls’ and women’s rights. It
prevents women and girls from living a life free from harm; compromises their
dignity, security and autonomy; and contributes to grave health consequences.
Indeed, it is also a “priority health issue” as declared, since 1997, by WHO which
added further in 2013 “a global public health problem of epidemic proportions.”
A growing body of evidence shows that women’s experience of violence has
direct consequences not only for their own well-being but also for that of their
families and communities. Worldwide, it has been estimated that violence against
women is as serious a cause of death and incapacity among women of reproductive
age as cancer, and a greater cause of ill-health than traffic accidents and malaria
combined (WHO 1997).
Victims are at risk for serious injury and death. In addition to various bodily
injuries (broken bones, third-degree burns), abuse can have long-term mental health
consequences, including depression, suicide attempts, substance abuse, and post-
traumatic stress disorder (PTSD). A specific form of PTSD has been described as
“battered woman syndrome” which results from long-term domestic abuse. Vio-
lence, including sexual assaults may also cause sexually transmitted diseases,
unwanted pregnancies, and other sexual and reproductive health problems. Abused
pregnant women are exposed to many obstetrical and perinatal complications as are
the new-born. For girls, the health consequences can carry on into their adult life.
Finally, violence against women is a profound health problem, sapping women’s
energy, compromising their physical and mental health, and eroding their self-
esteem.
VAW can also have repercussions on subsequent generations. Children of
battered women may suffer from injury themselves and later develop substance
abuse, problems at school, violent behavior, enuresis, sleep disorders and chronic
somatic diseases, or even suicide. For example, boys who witness their mothers
being beaten by their husbands are more likely than other boys to use violence to
solve disagreements in their adult lives. Girls who witness the same sorts of violence
are more likely than other girls to be involved in relationships in which their partners
abuse them. Thus, violence tends to be carried over from one generation to the next,
thereby creating a culture of brutality. IMAGES (2017) presented evidence that one
of the root causes of gender-based violence was found in highly violent childhoods.
In all four countries surveyed, half to three-quarters of men reported having expe-
rienced physical violence in their homes growing up, and two-thirds or more
reported having experienced physical violence by teachers or peers in school. The

violence men and women experienced as children turns into violence against their
own children. Across all four countries, 29% to 50% of men and 40% to 80% of
women reported using some form of physical punishment or other violence against
their own children.
Violence against women incurs tremendous costs, from greater health care and
legal expenses to losses in productivity, impacting on national budgets and overall
development (WHO 2012). On the one hand, violence negates women’s autonomy
and undermines their potential as active members of society. On the other hand, the
cost going into services for victims and lost productivity could have been directed
into projects and other activities that benefit everyone in society. Estimation of the
cost of the violence is viewed as an important tool to bring about constitutional
reform and push forward for implementing laws and enforcement. Day et al. (2005)
affirm that “Economic development is limited as long as violence against women
exists. The sooner countries bring in effective policies and programmes to end
violence against women, the sooner they will begin to reduce the economic cost of
that violence to their society and benefit in the long run [. . .]. While it is recognised
that VAW represents a loss to the State in terms of the cost of service provision, the
loss of productive work by women suffering from the effects of violence also
represents a loss to GDP.”
Globally, the total direct and indirect costs of violence against women are
estimated to be as high as 1–2% of Gross National Product. At the global level,
this amounts to millions of dollars. With some exceptions, Arab countries do not
generally focus on the economic cost of neglecting the grave issue of violence
against women and girls. According to the ESCWA report, among Arab countries,
only Egypt, Morocco, and Qatar appear to pay attention to this issue. In Egypt, the
cost of violence that women and their families experienced was estimated to be at
least $208 million in 2015 and possibly as high as $780 million, according to the
Egypt Economic Cost of Gender Based Violence Survey 2015 (http://egypt.unfpa.
org). The 2009 Violence Against Women Costing Study in Morocco revealed that
the cost of women seeking help from the justice system may total around $6 million
annually; health providers indicated that the cost of tending to each female victim of
violence amounted to $196 (Barker et al. 2009; UN Women 2013a). In Qatar, the
2011–2016 National Development Strategy explicitly refers to the social and eco-
nomic costs of violence against women and children, “which includes physical,
emotional and sexual abuse that directly undermine Qatar’s goal of providing social
care and protection for all its citizens” (Qatar, General Secretariat for Development
Planning, 2010, p. 170).
Finally, violence against women, which is rooted in gender inequality, power
imbalance, and human rights’ violations, is an absolute impediment to democracy.
“Democracy is as much about citizenship rights, participation and inclusion as it is
about political parties, elections, and checks and balances,” wrote Valentine
Moghadam (2008). (Valentine M. Moghadam is director of women’s studies and
professor of sociology at Illinois State University. Dr. Moghadam is the author of
“Modernizing Women: Gender and Social Change in the Middle East” (Boulder,
CO: Lynne Rienner Publishers, 2003, second ed.)) It means that empowerment of
women and establishment of gender equality are crucial to democracy. Everywhere,
the expansion of women’s rights has gone hand-in-hand with the establishment of
democracy, and women have played a key role in the transition from authoritarian-
ism to democracy. They have proved it again during the recent “Arab Spring.”
Therefore, fighting violence against women is fighting for democracy. It was beau-
tifully said by John Stuart Mill stating: “Whatever crushes individuality is despo-
tism, by whatever name it may be called and whether it professes to be enforcing the
will of God or the injunctions of men.”
Fighting Violence Against Women
Women’s right to live free from violence is upheld by international agreements such
as the Convention on the Elimination of All Forms of Discrimination against Women
(CEDAW), especially through General Recommendations 12 and 19 and the 1993
UN Declaration on the Elimination of Violence against Women. Besides this, there
are a number of internationally agreed norms and standards related to ending
violence against women. Fighting violence against women, as advocated by “UN
Women,” needs the adoption of comprehensive legislative and policy frameworks
that are aligned with international standards. A comprehensive legislative approach
would encompass the criminalization of all forms of VAW, the effective prosecution
and punishment of perpetrators, and the support and protection of survivors, along
with the promotion of gender equality and the strengthening of women’s empower-
ment. Gender-based violence is closely connected with discrimination against
women. Violence against women and girls is not only a consequence of gender
inequality but reinforces women’s low status in society and the multiple disparities
between women and men (UN General Assembly 2006).
However, to fight a problem which affects health and security, in the whole
society, it is not enough to talk about repression; we must also recommend solutions
and bring hope for a better life for women and men. Furthermore, any strategies must
be conducive to its own environment and circumstances and must address the
specific causes and risk factors which feed violence against women.
Addressing the Causes and Risk Factors
A variety of factors have been shown that interact to increase the risk of violence
against women and girls (UN WOMEN 2010).These factors include:
• Witnessing or experiencing abuse as a child (associated with future perpetration

of violence for boys and experiencing violence for girls)
• Substance (including alcohol) abuse (associated with increased incidences of
violence) (World Bank 1993)
• Women’s membership in marginalized or excluded groups
• Low levels of education (for boys associated with perpetrating violence in the
future and for girls, experiencing violence)
• Limited economic opportunities (an aggravating factor for men associated with
perpetrating violence; and as a risk factor for women and girls, of experiencing
domestic abuse, child and forced marriage, and sexual exploitation and
trafficking)
• The presence of economic, educational, and employment disparities between
spouses
• Conflict and tension within an intimate partner relationship or marriage
• Women’s insecure access to and control over property and land rights
• Male control over decision-making
• Attitudes and practices that reinforce female subordination and tolerate male
violence (e.g., dowry, bride price, child marriage)
• Lack of safe spaces for women and girls that allow free expression and commu-
nication; a place (physical or virtual) to develop friendships and social networks,
to seek advice, if needed, from a supportive environment
• Normalized use of violence within the family or society to address conflict
• A limited legislative and policy framework for preventing and responding to
violence
• Lack of punishment (impunity) for perpetrators of violence
• Low levels of awareness among service providers, law enforcement, and judicial
actors
On the other hand, there are protective factors that can reduce women and girls’
risk of violence against them, including:
• Completion of secondary education for both girls and boys

• Delaying age of marriage to 18
• Women’s economic autonomy and access to skills training, credit, and
employment
• Social norms that promote gender equality
• Quality response services (judicial, security/protection, social and medical)
staffed with knowledgeable, skilled, and trained personnel
• Availability of safe spaces or shelters
• Access to support groups
It seems that all the risk factors are prevalent while the protective factors are
lacking in the region and need to be addressed.
The Present Situation
The Legal Framework

The situation is very different from one country to the other, but none of the Arab
countries until now grants equal rights to both genders. Likewise, none of them have
a comprehensive legislative framework to address VAW. When there is a constitu-

tional reform, it is not transformed into law. If there is a law, there is no policy and if
there is policy, there is no budget.
The Economic and Social Commission for Western Asia (ESCWA 2013)
conducted a study in 18 Arab countries to examine the legal framework in place.
The analysis of national constitutions and basic laws, penal legislation and personal
status laws indicates that laws and regulations pertaining to violence against
women are not only dispersed among various sources but may also be contradictory.
Faith-based personal status laws may contradict other sources of legislation uphold-
ing women’s rights. For example, Tunisia which is the most advanced Arab country
regarding women’s rights is still combating the last inequality related to inheritance
and fiercely defended by sharia supporters.
Even when legislation combating violence against women exists, it often fails to
comprehensively address all forms of violence (like child marriage, spousal rape or
FGM) and enforcement mechanisms are frequently inadequate or ineffective.
Similarly, harmonization of national legislation with international human rights
instruments on gender equality remains a key challenge. With the exception of the
Sudan, all the countries in the Arab region have ratified CEDAW. However, the
majority of Arab countries have raised reservations about certain articles that call for
equal rights for women and men. Most countries include the caveat that ratification
must not contradict Islamic sharia norms or principles. These contradictions hinder
the ability of Arab countries to address manifestations of violence against women,
especially modes of violence that are socially taboo, such as spousal and sexual
violence in the family.
Many Arab countries do not explicitly cover domestic violence in their penal code.
On the contrary, some allow it. Thus, in Iraq, penal law permits husbands to punish
their wives. In the United Arab Emirates, penal law decrees the male guardian’s right
to use physical violence against female kin, including wives. In Egypt, the judiciary
may consider domestic violence by males against females to be in accordance with
sharia (Human Rights Watch 2004). Even when penal legislation is in place, there are
impediments to implementing the rule of law. For example, in Jordan, the court
requires two witnesses in order to rule in the case of wife battery. In some countries,
such as Bahrain, the court does not accept testimony of relatives in cases of domestic
violence or it may accept testimony of only one female witness. Apart from Tunisia,
no Arab country explicitly refers to spousal rape as a criminal offense.
As for rape, it is criminalized in all Arab countries. However, in Algeria, Bahrain,
Libya, Palestine, Sudan, and the Syrian Arab Republic, the male rapist escapes
punishment if he marries the victim. In some countries, such as Sudan, the distinc-
tion between rape and adultery tends to be blurred and victims have to prove they
have been raped.
Regarding so-called “honor crimes,” with the exception of Tunisia, where such
crimes may entail the death penalty, penal regulations in Arab countries generally
include leniency clauses.
As for gender equality, dispositions like age at marriage, forced, unregistered or
polygamous marriages, repudiation, inheritance, ban on marrying a non-Muslim,
imposed dress code, and duty of obedience to the husband, who is the head of the
family, are clearly discriminatory but are highly defended by the proponents of
sharia, arguing that they comply with the religious prescriptions.
The Service Provision

The lack of essential multisectoral and coordinated services to respond effectively to
survivors of violence also adds to the magnitude of the problem in the region. Many
women and girls who experience physical and sexual violence still lack access to the
core services they need to survive and recover. Nongovernmental organizations
(NGOs) in Arab countries play a crucial role in filling gaps left by the States in
combating violence against women and girls. Through their “counselling and lis-
tening” centers, NGOs help victims of domestic violence cope with their situations
by providing legal, psychological, and social support; they operate hotlines and
shelters; provide health services, including the detection of domestic violence and
group therapy; they organize sensitizing campaigns, training seminars, and follow-
ups for survivors. However, protection services provided by the NGO sector are
generally limited in coverage and dependent on donor funding, a fact that limits their
ability to combat violence against women and girls effectively. There is an urgent
need for increasing shelters, listening centers, and hotlines nationwide.
The Fight Begins, But the Resistance Continues

Some progress has been made, suggesting at least that the culture of silence hitherto
surrounding the subject has begun to be addressed. This was recently illustrated by a
conference held in Tunis in November 2017 by the Coalition of Women MPs from
Arab Countries Combating Violence against women and girls, which gathered
representatives from the 13 Arab States members (Egypt, Lebanon, Jordan, Tunisia,
Morocco, Palestine, Iraq, Djibouti, Sudan, Bahrain, Kuwait, Saudi Arabia, and
Libya) and the Tunisian Ministry for Women, Family and Childhood. The summit
was convened to review efforts to end gender-based violence and a Tunis Declara-
tion listing several propositions was agreed upon.
The coalition is an independent organization established in December 2014, with
the support of the Westminster Foundation for Democracy, formed by Members of
Parliaments from both legislative chambers of different Arab countries that believe
in combating violence against women. In just a few years, it has already registered
some success, such as the development of the draft Arab Convention to combat
violence against women and girls, launched in 2016 with the Arab League. At the
national level, through the Coalition, parliaments in Lebanon, Jordan, Iraq, Tunisia
and Palestine put violence against women and girls on the political agenda. The first
results are very promising. Thus, after Morocco in 2014, Lebanon, Jordan, Tunisia,
and Palestine repealed the “marry your rapist’s law” from their penal code in 2017.
Moreover, Morocco and Tunisia have withdrawn their reservations to CEDAW. And
last, but not least, Tunisia enacted a pioneering “Domestic Violence Bill” which
recognizes domestic violence including marital rape for the first time as criminal
offense and places a responsibility on the state to act in situations previously
considered part of the private sphere. It also established the Arab Day to Combat
Violence against Women to raise awareness about the treatment of women in the
region. It now takes place every year on 12 January.
Since 2012, the Palestinian Cabinet adopted the Arab region’s first national
strategy to combat violence against women. With the support of UN Women,
survivors of violence took part in drafting it. The strategy unifies existing efforts
to end violence against women, covering: improved policing, the application of
forensic science to violence cases, extended social services and better training of
social workers. As one step towards implementation, the Cabinet agreed on a by-law
allowing the Ministry of Social Affairs to require all shelters for survivors of
violence to uphold quality and human rights standards. It draws from good practices
developed at the UN Women-backed Mehwar Centre, a pioneering initiative offering
women a full range of services to recover from violence, seek legal redress and
develop livelihood skills. A new helpline, backed by web-based counselling and
referral mechanisms, has given 18,000 callers access to potentially life-saving
information.
Unfortunately, at the same time, an opposite movement is developing, showing
that the combat is not won in advance. After the Arab Spring, the Woodrow Wilson
Centre (ESCWA 2013) reported an increase of violence against women: “Women are
experiencing physical violence against their persons in the form of rape, beatings,
arrests, prison, and torture. There is more. Women political activists are subjected to
virginity tests. Little girls are forced into marriage. Under the threat of physical
punishment, women are told what to wear and how to behave in public. Women face
a creeping segregation; they are being pushed out of the political arena and the
workplace.” Very recently, according to The Independent (2019-03-14), women
have been arrested in May 2018, subjected to “imprisonment, solitary confinement,
and torture by the Saudi Arabian government as part of its brutal crackdown on
individuals who raise their voices in defence of women’s rights in the Kingdom.”
The writer-activists have publicly spoken out against the government and the
oppressive guardianship system in Saudi Arabia, which restricts women’s travel,
education, and other rights unless a male guardian gives permission. The Woodrow
Wilson report adds: “There are other danger signs. Progressive personal status laws
in the countries of the Arab Spring are under threat. In Egypt, there was a move to
lower the marriage age for girls to nine and to permit female genital mutilation. In
Egypt, Libya, and Tunisia, there is talk of permitting polygamy once again.”
It means that vigilance is necessary and that the fight is just beginning.
The Way to Go
Laws Matter: GBV Is Not a Private Affair

Even though laws are insufficient, by themselves, to eliminate VAW, as shown in
Western countries, they are necessary and of crucial importance to highly affirm that
violence is not a private matter and that the state has the final say. The CEDAW
Committee’s General Recommendation No. 19 on VAW makes clear that “States
may also be responsible for private acts if they fail to act with due diligence to
prevent violations of rights or to investigate and punish acts of violence, and for
providing compensation.” It was recently confirmed by Sayida Ounissi, a Tunisian
minister from the Islamist Ennahda Party, saying: “The state is now being pushed to
acknowledge that even if you [are violent towards women] behind closed doors, you
are accountable to the rest of society for what you are doing because we are together
paying the cost of your actions [. . .] in terms of insecurity, in terms of health, in terms
of violence.” Once laws are in place, they convey a strong message that violence
against women is not tolerated and that it is the right of every woman to live free of
violence. Domestic violence and harmful traditional practices are not “outside
justice.” It was one of the recommendations of the Tunis Summit: “We encourage
States that have not yet adopted legislation and comprehensive frameworks to
eliminate violence against women and girls and domestic violence to work towards
the establishment of national systems in this field that are in conformity with
international standards and are consistent with the contents of the draft Arab
Convention.”
The first step, at the international level, is to ratify the CEDAW or to withdraw the
reservations raised to the articles that call for gender equality. Article 3 of the United
Nations Declaration on the Elimination of Violence against Women (DEVAW)
stipulates that “States should condemn violence against women and should not
invoke any custom, tradition or religious consideration to avoid their obligations
with respect to its elimination.”
At the national level, “the time has come” was the campaign launched in Sudan in
March 2019 to denounce sexism. Actually, it is about time to implement a compre-
hensive policy starting with a Constitutional reform. This is what was done in
Tunisia. Article 21 of the new Constitution (2014) states: “All citizens, male and
female alike, have equal rights and duties, and are equal before the law without any
discrimination [. . .].” Article 46 adds: “The state shall commit to protecting
women’s achieved rights and seek to support and develop them [. . .]. The state
shall take the necessary measures to eliminate violence against women.”
States have to translate this commitment into specific laws. This is how a “Law on
Eliminating Violence against Women” passed in Tunisia on 26 June 2017 which has
been hailed as a “landmark” of progress by human rights groups. The new law,
which came into force in 2018, is the first piece of legislation which recognizes
domestic abuse, “physical, moral, and sexual,” as a crime. The legislation allows
women to seek protection from acts of violence committed by their husbands and
other relatives. It leads the way to the prosecution of abusers and psychological and
practical assistance for victims of domestic violence. It also includes provisions on
harassment in public spaces and abolished the controversial clause that allowed
rapists to escape punishment if they marry their victims.
However, authorities then have to ensure that there is adequate funding and
political will to put the law into effect. Unfortunately, the law does not specify
how the state will fund the programs and policies it brings into being. As an example,
while it requires authorities to refer women to shelters if they are in need, it provides
no mechanisms for funding either governmental or nongovernmental shelters. It also
does not set out provisions for the government to help women with timely financial
assistance to meet their needs or assistance in finding long-term accommodation.

Consequently, a year after Law 58 was implemented, its assessment by NGOs,
government officials, and victims revealed a host of shortcomings, from logistical
barriers that prevent some women from filing complaints to social pressures that
keep others from even trying.
A specific law combating violence against women and girls would be incomplete
and ineffective if it does not put an end to the legal loopholes that contribute to
perpetuating impunity and ineffective enforcement of the rule of the law such as
mitigating circumstances for perpetrators, and if it does not address all forms of
violence. It means that it must be completed by other legal measures to fight the real
sources of gender-based violence, namely, discrimination, gender inequality, and
women’s lack of empowerment.
In Tunisia, before the promulgation of this specific law, many legislative mea-
sures were already brought to prevent violence against women: abolition of the
dowry, postponing the age of marriage for both genders at 18, outlawing of polyg-
amy, unregistered marriages and repudiation, suppression of the clause of obedience
for the wife, co-responsibility of the two spouses in the management of the house-
hold, and compulsory schooling to prevent girls from being withdrawn early from
school.
Maybe the most urgent reform is to promote equality between spouses and to
suppress the “clause of obedience.” Many personal status laws recognize the hus-
band as the head of the household, which is an approach that undercuts the equality
of men and women within the family. A majority of these laws still include an
obedience clause that grants the husband the right to discipline both his wife and his
children. Additionally, these laws also perceive the wife’s “duty” to be to obey her
husband, a fact that further obscures the issue of marital rape. This law is not only
discriminatory but also unsuited to the modern world, where more and more women
are de facto today heads of household, given the frequent migration of men. It
ignores the existence of female-headed households which is an increasing trend,
particularly in conflict and post-conflict countries in the Arab region.
Maybe it is finally time to end criminalizing of women’s clothing or behavior, like
in Sudan, where thousands of women are arrested and flogged every year, according
to article 152 of the Criminal Code which applies to “indecent acts” in public. This
includes wearing an “obscene outfit” (trousers, for example) or “causing an annoy-
ance to public feelings”!
This last question is being debated: must mandatory reporting be introduced?
Some argue that the number of unreported cases of abuse is likely to decrease if
health and legal professionals, educators, social workers, clergymen, and local
community leaders who may witness this violence report it to the police or to the
relevant social institutions. For them, better data about the incidence of domestic
violence will allow to better address the problem. It is the case of the National
Coalition to Protect Women from Family Violence in Lebanon which has lobbied for
a mandatory reporting of violence against women.
Finally, the most perfect laws would be useless if they do not meet the real needs
of the survivors, namely, a “safe environment.” It means that the provision of
services is a crucial piece in the prevention and response to VAWG. The Coalition of
women MPs put their “emphasis on the need to allocate shelter centres for
women and children victims of violence and domestic violence and to monitor the
human and material resources necessary to safeguard the dignity of women and
children,” and on “the importance of ensuring special protection against violence for
women with disabilities.” However, in the region, there is still a wide gap between
the legal commitments for the provision of services for women experiencing vio-
lence and actual country level implementation. Although progress is being made
globally, many victims still lack access to quality multisectoral services. These
services are essential as they provide much-needed support to survivors of violence,
by keeping them safe, providing health care for their injuries, responding to their
sexual and reproductive health needs, including provision of post-rape care and
counselling, and facilitating their access to the police and justice system. Particularly
vulnerable groups – such as migrants, women living with disabilities, or women
living in remote areas – have even more limited options and often lack access to
basic services. The Joint Global Programme for Essential Services for Women and
Girls Subject to Violence (the “Programme”), a partnership by UN Women, UNFPA,
WHO, UNDP, and UNODC, has developed an “Essential Services Package” includ-
ing the essential services to be provided by the health, social services, police, and
justice sectors as well as guidelines for the coordination of Essential Services and the
governance of coordination processes and mechanisms.
This lag between the law and its practical impact lies in the cultural barriers that
curb the enforcement of the law. As has been stated by Mohammad Naciri, Regional
Director, Arab States UN Women, “Still, the biggest obstacle of all is society: you
and me and our neighbours, and the stereotypes and norms we harbour and perpet-
uate. We are all guilty of it.”
Mao Tse-tung used to say: “In matters of women’s rights, we must begin with
laws, but since then, all remains to be done.” It is the role of education, because
combating violence is the responsibility of society as a whole and not only its
institutions.
Education Matters
Violence against women and girls is rooted in gender-based discrimination as well as

in social norms and gender stereotypes that perpetuate such violence. Given the
devastating effect violence has on women, efforts have mainly focused on responses
and services for survivors. However, the only way to end VAWG is to prevent it from
happening in the first place by addressing its roots and structural causes. Violence is
anchored in the persistent social acceptance of discrimination against women among
both males and females in the region. As a matter of fact, IMAGES 2017 showed
that “too many men in the region continue to uphold norms that confine women to
conventional roles [. . .], and they act on these attitudes in ways that cause harm to
women, children, and themselves. There is a long and winding road that must be
travelled before most men – and many women, too – reach full acceptance of gender
equality in all domains.” For example, two-thirds to more than three-quarters of men
support the notion that a woman’s most important role is to care for the household.
Women often internalize these same inequitable views: about half of women across
the four countries surveyed support the same idea. In addition, majority of men
believe it is their role to monitor and control the movements of women and girls in
their households, a practice starting in childhood. In some countries, majorities of
women not only affirm but also appear to accept male guardianship; in others, they
challenge the idea, in theory if not in practice.
To address these cultural factors is the second crucial step in fighting GBV. But
challenging these cultural practices is not the sole responsibility of the State, but of
all of us, everyone. And the only means is education which, according to Nelson
Mandela, is “the most powerful weapon that can be used to change the world.”
Education that aims to change mentalities, attitudes, and behaviors must target the
widest possible audience. We have chosen four priorities to fight and prevent
violence in the short and long term: training of professionals, education of women
to open the way to their empowerment, education of the youth about gender equality,
education of the public to the reality, and the devastating effects of GBV on the
society.
Training Professionals
Many sectors are involved in the struggle against gender-based violence: health care,
judicial, police, and social services. However, those systems are largely ill-prepared
to deal with the consequences of violence. Specialized training must be included in
the education curriculum of all these professionals who have a crucial role to play in
the management of victims. They must learn how to be empathetic, how to listen to a
survivor, how to guard against moral judgment, and how to take care of them
professionally, within their field of expertise.
Educating Women: Open Door to Empowerment

Illiteracy is highest amongst women. Of the 781 million adults over the age of
15 estimated to be illiterate, 496 million, full two-thirds, were women, according to
the World’s Women Report 2015. This proportion has remained unchanged for two
decades. The 2013/2014 Education for All Global Monitoring report highlights that
more than 60% of adult women in Arab states, south and west Asia, and sub-Saharan
Africa are illiterate. The 2015 report points out that illiteracy still affects almost
52 million adults, in the Arab World, most of whom are women. Universal primary
education is far from being achieved in the region. And while there has been
progress towards gender parity in primary and secondary education, gender equality
remains elusive. Despite the parity gap being halved, the region remains one of those
furthest from the target of gender parity. Besides, gender disparities widen as the
level of education increases, although girls tend to perform better than boys. This gap
may be the result of girls’ being early drop-outs from school.
Despite the fact that promoting women’s education is beneficial for all, in terms of
education, health, and development. Rita Levi-Montalcini, winner of the Nobel Prize
for Medicine in 1986 said: “If you educate a boy, you will have an educated man. If
you educate a girl, you will have a woman, a family and a society educated.” Even
Sheikh Abdelaziz Ibn El Baz, who was until his death Grand Mufti of Saudi Arabia,
recognized that “women are half the society and educate the other half.”
According to WHO, closing the gender gap in education is the most valuable
investment a country can make after primary health care (World Bank 1993). The
World Bank came to a similar conclusion when it declared that ensuring girls’ rights
to education and to nondiscrimination within the education system represented one
of the most powerful strategies for improving health in the developing world. The
education of girls is a key factor in improving family health, reducing infant
mortality, and changing reproductive behavior. As a matter of fact, there is a strong
relationship between a higher level of education and a decrease in infant mortality
rates: in developing countries, where access to care is limited, and each additional
year of schooling is associated with a reduction of 5–10% in infant mortality rates
(UNDP 1999).
Education is an open door to empowerment. With education comes increased
confidence and self-esteem; educated women assume responsibility, are more likely
to stand up for themselves, communicate more with their husbands, enjoy a higher
status in the family, giving them more say in all decisions. They may above all
participate in the labor force and contribute to the economic development of their
countries.
However, the right to education without sex discrimination must be confirmed by
law. Thus, in Tunisia, the law of July 29, 1991 instituted compulsory education with
penalization of contravening parents, in order to struggle against discrimination, and
against the dropout phenomenon which affected a large number of girls in rural
areas. This law resulted in a significant increase in girls’ enrolment at all three levels
of education (Table 3).
Today, women outnumber men in the higher education with a rate of 56%
(Table 4).
At the same time, the country targeted adult illiteracy, giving a special priority to
fighting female and rural illiteracy. For example, the national campaign to eradicate
illiteracy, launched in 1993–1994, targeting a population of 67,000 girls and women
Table 3 Evolution of the rate of girls’ enrolment in school

Rate of school % of girls in the % of girls in the % of females in
enrolment at the primary school secondary institutions of
age of 6 population population higher education
1975–1976 38.6 32.4 25.8
1997–1998 99% 47.3 50.2 45
Table 4 Evolution of the rate of girl’s enrolment in school at age 6

% of boys % of girls
1981–1982 97.6% 82.5%
2000–2001 98.8% 99.1%
between the ages of 15 and 29, won the 1994 UNESCO prize for literacy, awarded to
the National Union of Tunisian Women (UNFT) (World Bank 2013).
But money matters too. Tunisia’s investment in education is 19.9% of the State
Budget and 6.2% of GDP; in 2012, amongst 194 countries, Tunisia (preceded only
by Libya) ranked 23, Saudi Arabia 55, Syria 79, Algeria 103, Qatar 114, Oman
121, Egypt 123, and Kuwait 125. According to Mohamed Faour (2008) “Education
is not a priority in many national budgets in the region, with the percentage of the
government budget allocated to education being below 20% in all the nine countries
with data in 2012.” UNESCO concluded that “according to projections, Tunisia will
be the only Arab State likely to achieve universal primary education by 2015,
ensuring that all children who have access to school also complete it.” (2013/14
Education For All Global Monitoring Report)
Educating Young People About Gender Equality

Prevention aims at changing social norms and gender stereotypes. Therefore, it
should start early in life, by educating and working with young boys and girls
promoting healthy, respectful relationships, non-violence, and gender equality.
Working with the youth is a “best bet” for faster, sustained progress on preventing
and eradicating gender-based violence. While public policies and interventions often
overlook this stage of life, it is a critical time when values and norms around gender
equality are forged. Freud warned: “Be careful, [. . .] the child accomplishes all his
evolution in the first five years of his life” (S. Freud, My life and my psychoanalysis,
p. 131).
At Home
This education must begin inside the family. Yet, it is the period when Arab fathers
are virtually absent in the lives of their children. Children are totally raised and
educated by their mothers, as shown by the results of the Tunisian Family Health
Survey, conducted in 2001, as part of the Pan Arab Project for Family Health
(PAPFAM). The study which covered 6083 households revealed that mothers are
two to four times more involved than fathers in the caring and raising of their
children, including disciplining the child!
Figure 1 illustrates the real inequality between genders. Power lies in the hands of
men, certainly, but in that of mothers as well. Herein lies the roots of gender
inequality. Mothers and their sons share power at the expenses of girls and their
fathers. “You will be a man, my son” should be replaced by “You will be a father, my
son.” If we want young boys to become not only men but fathers, we must change
our approach to education. The best means is to bring back fathers (and not women)
at home, from the time of the birth of a child. When men find their place at home,
besides mothers, women will find a place in the public space, besides men. Children
have to be raised by both parents who are father and mother and also man and
woman, in order not to differentiate between “sacred” mothers and demeaned
women! It is in the sharing of responsibilities as a couple that children will learn
that there is no gender hierarchy and will appreciate the importance of dialogue. The
hierarchical nature of human relationships carries in them the seeds of violence.
50% Women
45% Men
40%
35%
30%
25%
20%
15%
10%
5%
0%
Education Schooling Health Sanction
Fig. 1 Distribution of parental roles
Promoting men’s role of caregivers and fatherhood is necessary to alleviate the

highly inequitable burden of unpaid caregiving work that is shouldered by women
and to allow them to participate fully in the work place. This is above all the best
example of equality and complementarity between men and women that one can
give to children.
As a matter of fact, IMAGES showed that young men whose mothers were more
educated and whose fathers carried out more traditionally “feminine” tasks in their
childhood homes were generally most likely to favor gender equality. At the same
time, results affirm that many men appreciate and value their role as fathers and
caregivers, and that men’s involvement in caregiving could become the key driver of
intergenerational change in gender relations in the region.
It is clear, therefore, that promoting equality in the region requires dual, concerted
efforts to promote both women’s participation in the workplace and men’s partici-
pation in domestic chores and caregiving. For these efforts, it is necessary that
education outside the family takes over in the same direction.
At School
Achieving gender equality in education requires not only that girls and boys have
an equal chance to access and participate in education but also that students benefit
from a gender-sensitive learning environment. Unfortunately, this is not the case,
according to Mohamed Faour (2008) who undertook “a review of citizenship
education in Arab nations” and observed that “the state of women’s rights leaves
much to be desired” in the content of programs, and that “Tunisia’s constitution is
unique among all Arab nations in recognizing the rights of women according to
international declarations.” Everywhere else, the reference to sharia prevails. Since
all Arab nations, except for Lebanon and Tunisia, consider Islam to be a reference
source of legislation; they do not endorse laws or declarations that contradict any of
the rules or concepts that are explicitly stated in the sharia. Accordingly, they
disapprove of parts of Article 16 in the Universal Declaration of Human Rights,

which states: “men and women of full age [. . .] are entitled to equal rights as to
marriage, during marriage and at its dissolution.” In the Cairo Declaration, an
alternative article, 5(a), was presented with the word “equal” deleted from Article
16 of the Universal Declaration. Article 5 (a) states that “men and women have the
right to marriage.” According to the Cairo Declaration, gender equality in Islam is
displayed in certain aspects of life such as human dignity, financial independence,
and the right to retain maiden names, but “the husband is responsible for the
maintenance and welfare of the family.” The Arab Charter left the issue of gender
rights in marriage to national law, which gives wide powers to religious courts on
issues related to marriage, divorce, and inheritance.
Furthermore, in Tunisia, a thorough overhaul of children’s textbooks was also
undertaken to affirm the status of women and teach the principles of equality
between men and women and the concept of mutual respect. Empowering the
youth as agents of change for gender equality must go hand in hand with public
education at large.
Public Education: Raising Knowledge and Awareness

It is time to lift the “cloak of silence” about GBV. And all of us are accountable for
disseminating evidence-based information on the violation of women’s human rights
and its tragic consequences for the whole society. There is a terrible situation that
prevails in the Arab world that of confounding identity and equality. Certainly, men
and women are different but why would they have different rights? Condorcet said:
“Or, all humans have the same rights or nobody.” It is the role of community leaders,
academia, and the media to convey the essential message of gender equality through
equal rights and mutual respect.
Role of the Healthcare System
According to WHO, violence is also a health problem and of epidemic proportions. Thus
the health sector has a critical role to play in helping women and girls who experience
violence, although it cannot solve the problem alone. Health workers are often the first
professionals to be in contact with the victims: those working in the community, in
primary care centers or clinics, where women seek treatment for other conditions; those
working in hospital emergency departments, where they may examine injured women;
those working in institutions such as prisons and retirement homes, where they may be
the only qualified witnesses of abuse and sources of help. However, they are ill-prepared
for managing these kinds of situations and often share their society’s prejudices, with a
bias toward the private nature of domestic violence. This is why they need special
training. WHO underlines the importance of training health care workers to recognize
both the obvious and more subtle signs of violence and meet women’s health needs in
this regard. Many authors even recommend including the topic in the curriculum of
medical, paramedical, and nursing studies. They can, however, be very helpful in
identifying, informing, and referring victims of abuse to specialized settings.
Identification
Survivors are also often reluctant to disclose their abuse even to the physician who is
member of the same community, unless they come to get a medical certificate to
support a complaint to the justice system. In those conditions, the primary care
physician is a key-person in detecting violence and providing a culturally sensitive
service to victims (Usta and Taleb 2014). Given the assurance of confidentiality and
privacy, battered women are more likely to confide in them. However, opinions are
divided as to the method. For some, the health professional should only begin their
investigation if they suspect any abuse, observing bruises or scars, anxiety or
depressive symptoms, for example. For others, because of the magnitude of the
problem, all women and girls, especially the pregnant ones, should be routinely
asked about any experience of abuse. Two screening questions have been found to
have a sensitivity of 71% and a specificity of almost 85% in detecting domestic
violence: “Do you ever feel unsafe at home?” and “Has anyone at home hit you or
tried to injure you in any way?” (Eisenstat and Bancroft 1999).
Once the violence is recognized, the physician has to complete his history taking
about it and try to determine what stage of the process the victim is going through in
order to adapt his management approach. Domestic abuse typically follows an
extremely predictable cycle, starting with an abusive relationship and progressing
as follows:
• From the beginning, the potential abuser tries to win over their new partner,
moving quickly into a close relationship with tactics like “love-bombing,” grand
romantic gestures, and pressuring for commitment early. He manages to get her
away from her family, friends and usual activities and leisure, just to “keep her
only for him,” in reality to isolate her and deprive the partner from any support.
• The abuser engages in this way in behaviors that create relationship tension and
becomes emotionally or physically aggressive. This often starts small, like a slap
instead of a punch, or punching the wall next to the partner.
• The abuser will then express feelings of guilt, swearing he will never do it again.
He apologizes, makes amends for his bad behavior, and tries to fix his wrongdo-
ing with romantic declarations, gifts, and beautiful promises. There will be a
temporary “honeymoon” period, where the abuser is on his best behavior, luring
his partner into thinking that she is safe and things really will be different. The
abuse is forgiven. But it is only a respite.
• Abuse occurs, starting the cycle all over again. The trap is in place and it closes in
on her.
A question may be asked. Why do these women not leave their abusers? First of all,
many women think that it is their religious duty and their God-Given destiny to stay
with their husband. Others become trapped in abusive relationships for many reasons,
such as financial dependence on the abuser, which is often manufactured by himself,
willingness to keep a complete family unit for their children’s sake, fear of leaving,
disbelief or denial that the partner is actually abusive, belief that the abuser loves them
and that they can change his behavior, or thinking that the abuse is their own fault.
They have begun to develop a “battered woman syndrome” (BWS) which will
progress in four stages: at first, comes the denial. The woman is unable to accept that
she’s being abused, or she justifies it as “just being that once.” As the cycle
continues, she starts to feel that the abuse is her own fault. That is what we call
“learned helplessness,” when the victim takes responsibility for her own abuse. She
becomes convinced of her helplessness and that the abuse cannot be escaped. Thus is
borne the psychology of BWS. In a third stage, named “enlightenment,” she begins
to realize that she didn’t deserve the abuse and acknowledges that her partner has an
abusive personality. And finally, she accepts that only the abuser holds responsibility
for his behavior. In many cases, this is when she will try to escape the relationship.
It is not too difficult to recognize a BWS. Women suffering from BWS share
certain common characteristics easily observable when one speaks with them
(Walker 1991):
1. She takes full responsibility for the abuse, and finds it difficult or impossible to
blame the abuser himself.
2. She fears for her safety and that of her children.
3. She hides the abuse from friends and family because she irrationally believes that
the abuser is all-powerful and all-knowing. He can see her every movement and
he can hear everything she says. And he will hurt her if she tries to seek help or to
contact the authorities.
Once the signs of BWS are recognized, it is time to set up a safety plan.
However, some warning signals must alert the professionals before the situation
progresses further. These include:
• Withdrawing from family, friends, or activities they used to enjoy (this can be
something the abuser is controlling)
• Seeming anxious around their partner or afraid of their partner, described as easily
jealous or very possessive.
• Having frequent bruises or injuries they lie about or try to hide under clothes, like
long-sleeve shirts in summer or scarves around the neck.
• Having limited access to financial resources or means of displacement.
• Getting frequent calls from the abuser that require them to check in or that make
them very anxious.
Several serious side effects are associated with BWS. Short-term side effects that
may be seen immediately include depression with lowered self-esteem, severe
anxiety, and alcohol or drug abuse. Research has also shown that BWS can result
in long-term health consequences that can last for decades, such as:
• PTSD-like symptoms, including flashbacks, dissociative states, and violent out-

bursts against the abuser
• Health issues caused by stress, such as high blood pressure and associated cardiac
problems
• Health issues from the physical abuse, such as damaged joints or arthritis
• Chronic back pain or headaches
• Increased risk of developing diabetes, asthma, and immune dysfunction due to
long-term stress
Forensic Issues
BWS is often accompanied by legal issues. It is important for every health care
provider to become familiar with the legal reporting requirements for DV. BWS is
serious, which is why it is taken into account when women murder their abusive
partners. Battered woman syndrome (BWS) emerged in the 1990s from several
murder cases in England in which women had killed their violent partners in
response to what they claimed was cumulative abuse, rather than in response to a
single provocative act. Feminist groups challenged the legal definition of provoca-
tion, and in a series of appeals against murder convictions secured the courts’
recognition of BWS. BWS is now recognized in legislation by many countries and
is considered when defending battered wives who kill or injure their abusive
spouses. For the courts, BWS is an indication of the defendant’s state of mind or
may be considered a mitigating circumstance. The courts in Australia, Canada,
New Zealand, the United Kingdom, and the United States have accepted the
extensive and growing body of research showing that battered women can use
force to defend themselves and sometimes kill their abusers because of the abusive
and sometimes life-threatening situation in which they find themselves, acting in the
firm belief that there is no other way than to kill for self-preservation. The courts
have recognized that this evidence may support a variety of defenses to a charge of
murder or to mitigate the sentence if convicted of lesser offenses.
Management by Health Care Professionals

“First, no do harm”: you must be “neutral and caring.” If you suspect that your patient
is trapped in an abusive relationship or suffers from BWS, it is important for you to
withhold judgment Unsympathetic or victim-blaming attitudes can reinforce isolation
and self-blame, undermine a women’s self-confidence and make it less likely that
women will reach out for help. A survivor told us, one day: “I believe that empathy
is the solution to a better world and that listening is the best gift one can give.” Likewise,
you should never force a victim to do something you think is the best solution for her.
They are already being controlled by one person. And if you force them to leave before
they are ready, there is a good chance they will go back to the abuser, putting them in
even more danger. That is why it is very important to determine the stage of the process
she is going through. Even though the abuser is in the wrong, you would like to know
why would she stay? Why would she let this happen? Many women in these circum-
stances feel shame or are afraid to admit what’s been happening. Make it easier for them
to do so, and let them know that you’re always there if they need anything.
The primary role of the physician is to provide appropriate medical care and to
document in the patient’s medical records the instances of abuse, including details on
the effects (physical and mental) and on the perpetrator. It is crucial to maintain the
privacy and confidentiality of patient information and records.
Perhaps, the most important function of the physician is to inform the patient of viable
options for getting help and removing herself from danger. So, she must be informed
about the community resources available. Every health care professional should have a
list of local resources and hotlines available to provide directly to their clients.
The third step depends on their risk assessment and the willingness of the victim.
In case of high risk, when the health professional feels that she is not safe until she
leaves home, it is necessary to get the woman to a safe place away from her abuser. If
possible, help them gain access to resources they don’t have. Help them develop a
safety plan to get away from their abusers. If their patient is not ready yet, refer them
to a psychiatrist to validate the battered woman syndrome and to propose adequate
therapy, after evaluation for other mental health conditions, like anxiety and depres-
sion. The therapist will use a combination of medications and psychotherapies to
help the woman regain control of her life. Various therapies are proposed: interper-
sonal therapy, to help the woman establish stronger relationships with her support
system, which may have been damaged due to isolation caused by the abuse; Trauma
therapy, to identify the trauma triggers and learn how to overcome them and deal
with her situation; STEP (Survivor Therapy Empowerment Program), which helps
women better understand how the violence has impacted their lives.
Concluding Remarks: Shame Must Change Sides
As is the case in the rest of the world, Arab women and girls suffer in their respective
countries from all forms of violence inflicted on them by their family and relatives.
Contrary to their counterparts in other countries, however, they are not sufficiently
protected against abuse since in their culture, the value placed upon honor and shame
forces society to close their eyes and mouths about this private problem. Moreover,
specific social norms and the negative stereotypes conveyed about women contribute to
almost absolve their aggressors. These prejudices fed by the majority of their fellow
citizens prevent enacting or enforcement of a comprehensive legal framework to fight
gender-based violence. Therefore, it is as important to support the victims and punish the
perpetrators as to work for a change in mentalities. Shame and guilt must change sides!
Victims do not have to feel guilty or ashamed to the point of suffering in silence or, worse,
to marry their tormentor. Abusers do have to feel guilty and ashamed and treated as such.
The true sense of honor is to defend the victim and punish the guilty and not the contrary.
This is the Law that allows our life in society, as human beings equal in rights and dignity.
John Stuart Mill said: “The despotism of custom is everywhere the standing
hindrance to human advancement.”
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Spousal Violence in Arab Countries
12
Hamid Yahya Hussain
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258
The Historical Context of Violence in Arab Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
Domestic Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260
Types of Intimate Partner Spouse Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260
Global Reporting of Intimate Partner Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
Spouse Violence in Arab Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262
Spouse Violence in UAE – Dubai . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262
Domestic Violence Against Saudi Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262
Domestic Violence Against Women in Morocco . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267
Spouse Violence in Lebanon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267
Violence Against Women in Iraq . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268
Domestic Violence Against Syrian Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269
Violence Against Women in Tunisia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269
Domestic Violence in Sudan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269
Health Consequences of Intimate Partner Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 270
Spouse Violence in Global Health Contexts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271
Case Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272
Sexual Spouse Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272
Psychological Spouse Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273
Associated Socio-demographic Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 274
Interpretation on Spouse Violence in Arab Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 274
Bridging Gaps in Spouse Violence: The Road Ahead . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275
Strengthening National Commitment and Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275
Promoting Primary Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275
Involving the Education Sector . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 276
Strengthening the Health Sector Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 276
Use Reproductive Health Services as Entry Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 276
Supporting Women Living with Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277
H. Y. Hussain (*)
Faculty of Medicine, University of Baghdad, Dubai Health Authority, Dubai, UAE
e-mail: hussainh569@outlook.com

https://doi.org/10.1007/978-3-030-36811-1_186
258 H. Y. Hussain
Sensitizing Criminal Justice Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278

Support Research on the Causes, Consequences, and Costs of Violence Against Women
and on Effective Prevention Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278
Increase Support for Programs to Reduce and Respond to Violence Against Women . . . . 278
Adopting Family REFORM LAW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279
Abstract
There is a growing recognition among health care professionals that domestic
violence is a major health problem, with devastating effects on individuals,
families, and communities (Groves B, Augustyn M, Lee D, Sawires
P. Identifying and responding to domestic violence consensus recommendations
for child and adolescent health. Family Violence Prevention Fund, US Depart-
ment of Health and Human Services, Administration for Children and Families
and the Conrad N. Hilton Foundation, 7 Dec 2001). Violence against women,
with domestic violence by a spouse or other intimate partner violence as being the
most common form of domestic violence, is widely recognized as a hidden and
pervasive human rights violation and a global public health issue (World Health
Organization (WHO). Violence against women. WHO Consultation, Geneva,
1996; Ellsberg M et al., Lancet 371(9619):1165–1172, 2008). The term “domes-
tic” includes violence by an intimate partner and/or other family members,
wherever this violence takes place and in whatever form (Rajani N, Sandhya
Rani G. Combating domestic violence against women. International conference
on social science and humanity, IPEDR, vol 5. IACSIT Press, Singapore, 2011).
It is well known that no society can claim to be free of such violence; its presence
cuts across boundaries of culture, class, education level, economic status, ethnic-
ity, religion, nationality, and age. It is a global public health crisis. Many studies
estimate that between 20% and 50% of women have experienced physical
violence at the hands of an intimate partner or family member (World Health
Organization (WHO). Violence against women. WHO Consultation,
Geneva, 1996).
Keywords
Spouse violence · Arab countries
Introduction
The World Health Organization (WHO) released a report documenting levels of

intimate partner violence as a major contributor to the ill-health of women; this
report also explored outcomes of violence in terms of mental, sexual, and reproduc-
tive health in ten countries (Heise et al. 1994; United Nations Children’s Fund 2000).
Violence against women has yet to be sufficiently explored in conservative
12 Spousal Violence in Arab Countries 259
communities as it is considered a very sensitive issue. It often goes unrecognized or

unreported and remains substantially underestimated. Only serious cases that go
through legal channels and investigation by legal officials and the justice systems
have the opportunity to be reported. Despite most societies prohibiting violence
against woman, it is allowed to occur under the umbrella of cultural practice and
norms or through misinterpretation of religious tenets. In developing countries such
as Dubai, women are socialized to accept, tolerate, and even rationalize domestic
violence and to remain silent about such experiences. Violence of any kind has a
detrimental impact on the economy of a country through increased disability,
medical costs, and loss of labor hours; however, because women bear the brunt of
domestic violence, they disproportionately bear the health and psychological bur-
dens as well. Victims of domestic violence are abused in what should be the most
secure environment – their own homes – and usually by persons they trust most.
The Historical Context of Violence in Arab Countries
Violence against women is a manifestation of historically unequal power relations

between men and women, which have led to domination over and discrimination
against women by men, so also preventing leading the full advancement of women
in society and the workplace. There is no universally accepted definition of violence
against women. In any case, there is a need to develop a specific operational
definition so that research and monitoring can become more specific and have
greater cross-cultural applicability (Heise et al. 1999; Hindin et al. 2008). The United
Nations Declaration on the Elimination of Violence against Women (1993) (Hindin
et al. 2008) defines violence against women as “any act of gender-based violence
that results in, or is likely to result in, physical, sexual or psychological harm or
suffering to women, including threats of such acts, coercion or arbitrary deprivation
of liberty, whether occurring in public or in private life” (Heise et al. 1999; Hindin
et al. 2008).
Although comprehensive data on the prevalence of violence are lacking in the
region, largely due to under-reporting of violence within marriages, some estimates
are available. Intimate partner violence includes early forced marriages and tempo-
rary marriages, sexual harassment, and female genital mutilation. An estimated 30%
of ever-partnered women in the Middle East and North Africa region have experi-
enced physical violence by intimate partners at some point in their lives, while one in
seven girls is married as a child with the highest rates in Mauritania, Sudan, and
Yemen. While 87% of women and girls aged between 15 and 49 have undergone
female genital mutilation in Egypt and Sudan, an estimated 19% have experienced
the same form of violence in Yemen and 8% in Iraq since 2015. The prevalence of
domestic violence in Egypt has not changed over two decades, with nearly one-third
of married women experiencing a form of physical violence by their husbands. In
Morocco, a national survey estimated the prevalence of domestic violence at 62%
(with nearly 9% being due to sexual violence), while in Jordan, 44% of women who
260 H. Y. Hussain
have been married at some point in their lives have experienced physical violence at
least once since the age of 15 and 9% reported experiencing sexual violence.
The conflicts and violence sweeping the Middle East have increased the risks of
violence against women, including egregious forms of sexual violence. Female
Syrian refugees in Jordan, Lebanon, and Iraq have reported high rates of domestic
violence, sexual harassment, and early and forced marriages. Similar trends were
observed in Yemen and Libya according to the United Nations.
Gender-based violence has a direct and devastating effect on society and consti-
tutes an impediment to progress, development, and democracy. Estimation of the
cost of the violence (~$11.8 billion) is viewed as an important tool to bring about
constitutional reform and for implementing laws and enforcement.
With the exception of Somalia and Sudan, all Arab League countries have signed
and ratified the “Convention on the Elimination of all Forms of Discrimination
Against Women” (CEDAW). However, the ratification did not improve the safety
of women in the region because many countries had reservations about the core
provisions of the convention and did not ratify the optional protocols. Progress in
addressing violence against women is largely fragmented. One finds some countries
that have passed constitutional reform – like Egypt and Tunisia – but this has not been
transformed into law. Alternatively, if there is a law, there is no strategy and if there is
a strategy, there is no budget. So, none of the Arab countries has a comprehensive
framework. These are forms of violence that have existed, for example, in Syria, even
before the current crisis but they have been exacerbated significantly with displace-
ment as a negative coping mechanism for economic and protection purposes. The
family members likely find it more convenient to marry off girls than keeping them in
camp settings where there could be other forms of violence.
Domestic Violence
“Domestic violence” describes acts of violence between family members, including

adult partners, a parent against a child, caretakers, or partners against elders and
between siblings. Intimate partner violence is used to define a range of behaviors
between husbands or another intimate partner (Groves et al. 2001; Heise et al. 1994).
It is a pattern of purposeful coercive behaviors that can include physical injury,
psychological abuse, sexual assault, progressive social isolation, stalking, depriva-
tion, intimidation, and threats. These behaviors are perpetrated by someone who is,
was or wishes to be, involved in an intimate or dating relationship with an adult or
adolescent victim and is aimed at victimizing the partner (Campbell et al. 2004).
Types of Intimate Partner Spouse Violence
Intimate partner violence includes physical abuse such as slapping, beating, arm
twisting, stabbing, strangling, burning, choking, kicking, threats with an object or
weapon, and murder. It also includes traditional practices harmful to women, such as
female genital mutilation and wife inheritance (the practice of passing a widow, and
her property, to her dead husband’s brother). Sexual abuse includes acts such as
coerced sex through threats, intimidation, or physical force, forcing unwanted sexual
acts or forcing sex with others. Psychological abuse includes behavior that is
intended to intimidate and persecute, and takes the form of threats of abandonment
or abuse, confinement to the home, surveillance, threats to take away custody of the
children, destruction of objects, isolation, verbal aggression, and constant humilia-
tion. Economic abuse includes acts such as the denial of funds, refusal to contribute
financially, denial of food and basic needs, and controlling access to health care,
employment, etc. Acts of omission is a form of gender bias that discriminates in terms
of nutrition, education, and access to health care. It should be noted that the
categories often occur simultaneously.
Global Reporting of Intimate Partner Violence
Intimate partner violence is a health problem of enormous proportions. One in every

four women will experience domestic violence in her lifetime (Dearwater et al.
1998). About 85% of domestic violence victims are women (“Violence against
Women,” WHO, FRH/WHD/97.8 1999). The levels of violence vary both between
and within countries due to the many differences in the way violence is defined and
measured in different countries, making it difficult to make meaningful comparisons
between studies or make reliable estimates in different settings (Somach and Abou
Zeid 2009). A review of studies from 35 countries indicates that between 10% and
52% of women reported being physically abused by an intimate partner at some
point in their lives, and between 10% and 30% reported that they had experienced
sexual violence by an intimate partner. Between 10% and 27% of women and girls
reported having been sexually abused, as either children or adults (Heise et al. 1994).
The WHO multicountry study on women’s health and domestic violence against
women, which consists of population-based surveys conducted in various countries
using the same methods and definitions, found a prevalence of 15–71% physical or
sexual violence, or both, at some point in the lives of women by a current or former
partner (United Nations Children’s Fund 2000). Women in Japan were the least
likely to have ever experienced physical or sexual violence, or both, while the
greatest violence was reported by women living in provincial (for the most part
rural) settings in Bangladesh, Ethiopia, Peru, and Tanzania. For partner violence, the
figures ranged from 4% in Japan and Serbia and Montenegro to 54% in Ethiopia.
Physical intimate partner violence in pregnancy ranged between 1% in Japan to 28%
in Peru, with the majority reports ranging between 4% and 12% (Heise et al. 1994).
This finding was supported by an analysis of in ten Demographic and Health
Surveys and the International Violence against Women Survey, which found the
range of prevalence of physical or sexual violence experienced by women from
intimate partner violence to be from 75% in Bangladesh to 16% in the Dominican
Republic. The highest reported rates of physical violence were in Bangladesh (71%),
Bolivia (52%), and Zambia (45%). The highest rates of sexual violence were
262 H. Y. Hussain
reported in Bangladesh (26%), Kenya (15%), and Bolivia (14%) (Heise et al. 1994;
Clark et al. 2009). Clinical studies tend to yield higher prevalence rates but often are
the only sources of information available; such studies reported the highest preva-
lence in Egypt (32%) followed by India (28%), Saudi Arabia (21%), and Mexico
(11%) (Boy and Kulczycki 2008). In the United States, it is estimated that an
intimate partner at some point in their adult lives has physically and/or sexually
abused 20 to 30% of women (Emirates 24/7 News 2011).
Spouse Violence in Arab Countries
Violence against women has risen recently in the region which, according to the
World Bank, has the lowest number of laws protecting women from domestic
violence in the world. The UN estimates that 37% of Arab women have experienced
violence, with some indications that the percentage might be even higher (https://
www.arabnews.com/node/1374871/offbeat). About 32% of Palestinian women
reported at least one episode of physical abuse by their partners and 30% reported
sexual coercion by their husbands (Rand 1997). About 35% of Egyptian women
reported being beaten by their husband at some point in their marriage (Rand 1997).
According to the Egypt Demographic and Health Survey, 47% of ever-married
women reported having experienced physical violence since the age of
15 (McCauley et al. 1995). In Egypt and Nicaragua, about one in three ever-married
women reported experiencing domestic violence. The proportion of women in
Jordan who have experienced intimate partner violence at some point during their
marriage reported the most prevalent acts as physical violence (31%) and sexual
violence (19%) (Coker et al. 2000; Hagion-Rzepka 2000). A study by the National
Council of Women found about 1.5 million Egyptian women report being subjected
to domestic violence each year, which translates to an average of 4000 cases per day,
though unreported figures may be much higher.
Spouse Violence in UAE – Dubai
A study carried out in Dubai (Al Serkal 2012) revealed that spouse violence was
significantly identified among study participants, both physical and emotional abuse,
and the study revealed the following figures as reflected in the Tables 1, 2, 3, and 4
below.
Domestic Violence Against Saudi Women
Domestic abuse in Saudi Arabia is gaining public attention. Violence against women
and children in the home was traditionally not seen as a criminal matter in Saudi
Arabia until 2013 (Al Dosary 2016). In 2008, “social protection units,” Saudi
Arabia’s version of women’s shelters, were established in several large Saudi cities
Table 1 Distribution according to lifetime prevalence and types of controlling form of violence
among respondent women to the study (in Dubai 2013) (Al Serkal 2012)
Never Always
Experienced happened Once <5 5+ happened
controlling types No. % No. % No. % No. % No. %
1. Does not allow 440 62.9 41 5.9 117 16.7 102 14.6 260 37.1
dialogue or does not
take your opinion on
issues that affect
you or the family
2. Gets angry if you 448 64 60 8.6 95 13.6 97 13.9 252 36
speak with another
man
3. Expects you to 489 69.9 41 5.9 75 10.7 95 13.6 211 30.1
ask his permission
before seeking
health care for
yourself
4. Insists on 423 60.4 47 6.7 109 15.6 121 17.3 277 39.6
knowing where you
are at all times
5. Restricts your 494 70.6 56 8 93 13.3 57 8.1 206 29.4
ability to visit others
or have visitors in
the home
6. Restricts contact 550 78.6 47 6.7 65 9.3 38 5.4 150 21.4
with your family of
birth
7. Ignores you and 519 74.1 39 5.6 81 11.6 61 8.7 181 25.9
treats you
indifferently
8. Tries to keep you 507 72.4 33 4.7 91 13 69 9.9 193 27.6
from seeing your
friends
9. Restricts your 569 81.3 49 7 58 8.3 24 3.4 131 18.7
movement outside
the home or
physically locks you
in the home
10. Often accusing 550 78.6 4.6 6.5 64 9.1 30 4.3 140 20
you of being
unfaithful
to provide education and awareness against domestic violence (Heise et al. 1994).
Five years later, in 2013, Saudi Arabia launched its first major effort against
domestic violence, when the Saudi cabinet approved a law making domestic vio-
lence a criminal offense for the first time. The law called for punishment of up to a
year in prison and a fine of up to 50,000 riyals (US$13,000) (Al Dosary 2016). The
maximum punishments can be doubled for repeat offenders. The law criminalizes
264 H. Y. Hussain
Table 2 Distribution according to lifetime prevalence and types of physical form of violence by
women (in Dubai 2013) (Al Serkal 2012)
Never Always
happened Once <5 5+ happened
Types of behavior No. % No. % No. % No. % No. %
1. Does not allow dialogue or 440 63 41 6 117 17 102 15 260 37
does not take your opinion on
issues that affect you or the
family
2. Gets angry if you speak 448 64 60 9 95 14 97 14 252 36
with another man
3. Expects you to ask his 489 70 41 6 75 11 95 13 211 30
permission before seeking
health care for yourself
4. Insists on knowing where 423 61 47 7 109 16 121 17 277 40
you are at all times
5. Restricts your ability to 494 71 56 8 93 13 57 8 206 29
visit others or have visitors in
the home
6. Restricts contact with your 550 79 47 7 65 9 38 5 150 21
family of birth
7. Ignores you and treats you 519 74 39 6 81 12 61 9 181 26
indifferently
8. Tries to keep you from 507 72 33 5 91 13 69 10 193 28
seeing your friends
9. Restricts your movement 569 81 49 7 58 8 24 3 131 19
outside the home or
physically locks you in the
home
10. Often accuses you of 550 79 5 7 64 9 30 4 140 20
being unfaithful
Never Always
happened Once <5 5+ happens
Type of physical violence No. % No. % No. % No. % No. %
1. Slapped you or threw 483 69 99 14 85 12 33 5 217 31
something at you
2. Hit you with his fist or with 544 78 79 11 54 8 23 3 156 22
something else that could hurt
you
3. Pushed or shoved you or 554 79 78 11 42 6 26 4 146 21
pulled your hair
4. Kicked you, dragged you, 589 84 42 6 50 7 19 3 111 16
or beat you up
5. Choked or burned you on 617 88 36 5 37 5 10 1 83 12
purpose
6. Threatened to use or 632 90 31 4 24 3 13 2 68 10
actually used a gun, knife, or
other weapon against you
Table 3 Distribution according to lifetime prevalence and types of sexual form of violence by
women (in Dubai 2013) (Al Serkal 2012)
Never Always
1. Does not allow dialogue or 440 63 41 6 117 17 102 15 260 37.
family
with another man
3. Expects you to ask his 489 70 41 6 75 11 95 13 211 30.
the home
family of birth
indifferently
seeing your friends
outside the home or
home
being unfaithful
Never Always
Type of sexual violence No. % No. % No. % No. % No. %
1. Physically forced you to 555 79 54 8 56 8 35 5 145 21
have sexual intercourse when
you did not want to
2. Forced you to do something 577 82 55 8 47 7 21 3 123 18
sexual that you found
degrading or humiliating
3. Had sexual intercourse 543 78 84 12 37 5 36 5 157 22
when you did not want to
because you was afraid of
what partner might do
psychological and sexual abuse, as well as physical abuse. It also includes a

provision obliging employees to report instances of abuse in the workplace to their
employer (United Nations Children’s Fund 2000). The move was followed by a
Twitter campaign.
266 H. Y. Hussain
Table 4 Number of women who suffered physical violence by a current or previous husband, and
the percentage who reported having been injured as a consequence of an assault by a partner
(in Dubai 2013) (Al Serkal 2012)
Never Always
1. Does not allow dialogue or 440 63 41 6 117 17 102 15 260 37
family
with another man
3. Expects you to ask his 489 70 41 6 75 11 95 13 211 30
the home
family of birth
indifferently
seeing your friends
outside the home or
home
being unfaithful
Report (n ¼ 700) Number of women affected %
No physical violence 483 69
Mild-to-moderate physical violence 61 8
Severe physical violence 156 22
Total physical violence 217 31
Variables out of physically abused women (n ¼ 217) Numbers %
Consult health professional or been in a hospital 70 32
Had loss of consciousness 48 22
Frequency of injuries
1–2 times 61 28
3–5 times 44 20
More than 5 times 23 11
Types of injuries
Bruises 140 65
Cuts, bruises, and abrasions 70 32
Fractures 20 9
(continued)
Table 4 (continued)
Report (n ¼ 700) Number of women affected %
Burns 5 2
Ear injury or problems 1 0.5
Abortions 1 0.5
Nervous breakdowns 1 0.5
Saudi women’s rights activists welcomed the new laws, although some
expressed concerns that the law could not be implemented successfully without
new training for the judiciary and that the tradition of male guardianship would
remain an obstacle to prosecutions (Al Dosary 2016). A multivariate logistic
regression analysis showed a lifetime prevalence for any type of violence as
43.0% (n ¼ 810). The most frequent type was controlling behavior (36.8%),
followed by emotional violence (22%), sexual violence (12.7%), and physical
violence (9.0%). The analysis also revealed that the following were associated
with greater odds of reporting domestic violence: younger age 30–40 years
(adjusted odds ratio [aOR] ¼ 1.9, 95% confidence interval [CI] ¼ [1.3, 3.0]),
41–50 years (aOR ¼ 1.6, 95% CI ¼ [1.1, 2.5]); lack of emotional support
(aOR ¼ 1.7, 95% CI ¼ [1.2, 2.5]); lack of tangible support (aOR ¼ 1.4, 95%
CI ¼ [1.1, 1.9]); and perceived poor self-health (aOR ¼ 1.7, 95% CI ¼ [1.0,
3.0]), husbands’ poor health (aOR ¼ 1.9, 95% CI ¼ [1.2, 2.0]), and polygamy
(aOR ¼ 1.6, 95% CI ¼ [1.5, 2.6]). Domestic violence occurs frequently in Saudi
Arabia. Both social conditions and social relations are significantly associated
with domestic violence against Saudi women. Furthermore, improvement in the
implementation of the local policies and multispectral protection services can
prevent women from domestic violence (Al Dosary 2016). Many studies in
Saudi Arabia revealed the following figures as reflected in the below Tables 5
and 6.
Domestic Violence Against Women in Morocco
The rate of violence against women in urban areas is 55.8%, while the rate of
domestic violence in rural areas was slightly lower at 51.6%. The ministry conducted
its nationwide survey between January 2 and March 10 (2019).
Spouse Violence in Lebanon
Domestic violence is a prevalent yet underrated problem in Lebanon, which has

witnessed several high-profile cases of husbands beating their wives to death. KAFA
(enough) Violence and Exploitation is the leading Lebanese NGO advocating for
women’s rights and receives 2600 calls in its domestic abuse helpline each year. They
268 H. Y. Hussain
Table 5 Socio- Characteristics No. %

demographic
Age 421 women
characteristics of Saudi
women surveyed for Mean SD 29.88 8.82
domestic violence Min–max 14–55
Marital status
Single 179 42.5
Married 203 48.2
Divorced 34 8.1
Widow 5 1.2
Educational level
Elementary 2 0.5
Intermediate 5 1.2
High school 68 16.2
University 346 82.2
Residency
Urban 397 94.3
Rural 24 5.7
Housing type
Own house 292 69.4
Rental house 129 30.6
Working status
Working 178 42.3
Not working 243 57.7
Monthly income (in Saudi riyals)
<5000 84 20.0
5000–<10,000 149 35.4
10,000–<15,000 83 19.7
15,000–<20,000 52 12.4
20,000 and above 53 12.6
report that nearly 44% of the population personally knows of someone subject to
domestic violence, with higher rates in Bekaa (66%) and Northern (52%) residents
(https://www.hrw.org/news/2014/04/03/lebanon-domestic-violence-law-good-incom
plete, cited on 18/11/2019, (1) o’clock Pm).
Violence Against Women in Iraq
Violence against women in the home is a major problem that prevents a women’s full
participation in society. One in five women (21%) in Iraq aged 15–49 has suffered
physical violence at the hands of their husbands. About 14% of women who suffered
physical violence were pregnant at the time; 33% of women suffered emotional
violence and 83% were subjected to controlling behavior by their husbands (Al-Ali
and Pratt 2011).
Table 6 Frequency of violence reported by survey participants by country, n ¼ 385

Total sample (n ¼ 385) Jordan (n ¼ 200) Lebanon (n ¼ 185)
Type of violence Number Percentage Number Percentage Number Percentage
Emotionala 105 27.3 57 28.5 48 26.0
Physicalb 37 9.6 20 10.0 17 9.2
Sexualc 39 10.1 23 11.5 16 8.7
Economicd 11 2.9 5 2.5 6 3.2
a
Insulted her or made her feel bad about herself, belittled or humiliated her in front of others, done
things to scare or intimidate her on purpose, threatened to hurt her, or threatened to force her to go
back to Syria
b
Slapped, hit with a fist, thrown something at her that could hurt her, pushed or shoved her, kicked,
dragged or beat her up, threatened to use or actually used a gun, knife, or other weapon against her,
hit, slapped, kicked or done anything else to hurt her while she was pregnant
c
Made sexual advances toward her or sexually harassed her, made her feel threatened with some sort
of retaliation for not being sexually cooperative tried to fondle or kiss her when she did not want
him to, or she engaged in sexual intercourse when she did not want to because she was afraid of
what another person might do
d
Pressured her to do house work or other types of work for housing or basic necessities like food
Domestic Violence Against Syrian Women
Domestic violence has risen sharply among Syrians forced to flee their homeland.
While many aid programs target women, some groups are putting new focus on men,
hoping to address the problem at the source (Al Rosary 2016).
Violence Against Women in Tunisia
Violence against women in Tunisia is widespread and systemic. Within the country,
there are high levels of domestic violence, physical violence, and sexual violence
and currently lack comprehensive legislation to combat violence against women. It
was reported in 2010 that “one in six married women has faced sexual violence at
least once in her life, mostly by her intimate partner.” In the same year, 48% of
Tunisian women aged 18–64 were subjected to at least one form of violence in their
lives. Legal, cultural, and social norms often result in inadequate law enforcement
response in cases of violence against women, by refusal to file complaints or, if the
perpetrator is a spouse, pressuring the victims to reconcile privately with the offender
rather than take legal action (Alquaiz et al. 2017).
Domestic Violence in Sudan
The limited amount of data from Sudan regarding domestic violence against women,
which was submitted to UN agencies, shows concerns with child marriage (34%)
and female genital mutilation/cutting (87%). The prevalence of sexual coercion,
psychological violence, and verbal insult was 17%, 30.1%, and 47.6%, respectively.
In the majority of cases, violence was experienced as repeated acts, that is, more than
270 H. Y. Hussain
three times per year. Acts of verbal insult (20.1%) and 27.5% yelling and shouting
(27.5%) were common (Safaa Kasraoui 2019).
Health Consequences of Intimate Partner Violence
Physical Health Effects

Physical violence is usually accompanied by psychological abuse and in many cases
by sexual assault as well. Despite this variability, there is agreement that battering
has significant short-term and long-term physical health effects. Intimate partner
violence is one of the most common causes of injury in women (The Ripple Effect
2002). Battered women were more likely to have minor injuries (bruises, abrasions,
cuts, punctures, and bites) in the head, eyes, ears, face, neck, thorax, breasts, and
abdomen than women injured in other ways (Ludermir et al. 2008).
There are significant associations between women reporting violence and poor
general health or self-reported specific health problems. These women have trouble
with walking or carrying out daily activities and experience pain, memory loss,
dizziness, and vaginal discharge. Prevalence of injury in ever-abused women ranged
from 19% (Ethiopia) to 55% (Peru). In Bangladesh and in Peru, at least half of ever-
injured women reported that they had lost consciousness because of a violent
incident. The highest proportions were recorded in Bangladesh, Japan, Namibia,
Peru, and Tanzania, where over 50% of ever-injured women reported having needed
health care for an injury (Campbell 2002).
These effects can manifest as poor health status, poor quality of life, and high use
of health services. The injuries, fear, and stress associated with intimate partner
violence can result in chronic health problems such as chronic pain (e.g., headaches,
back pain) or recurring central nervous system symptoms including fainting and
seizures. Abused women frequently (10–44%) report choking – incomplete stran-
gulation – and blows to the head resulting in loss of consciousness, both of which
can lead to serious medical problems including neurological sequelae (https://www.
alianzaporlasolidaridad.org/wp-content/uploads/GBV-Against-Women-and-Girl-Syri
an-Refugees-in-Lebanon-and-Jordan-FINAL.pdf). Higher than average self-reported
gastrointestinal symptoms (e.g., loss of appetite, eating disorders) and diagnosed
functional gastrointestinal disorders (e.g., chronic irritable bowel syndrome) are asso-
ciated with chronic stress (https://www.theadvocatesforhumanrights.org/uploads/tuni
sia_upr_april_may_2017_review.pdf). Also, self-reported cardiac symptoms such as
hypertension and chest pain are also associated with intimate partner violence. The
stress of being in an abusive relationship suppresses the immune system, causing
mental-health disorders such as depression, and leads to higher reporting colds and
influenza (http://evaw-global-database.unwomen.org/fr/countries/africa/sudan). Long-
term effects observed in adult victims of domestic violence include intense startle
reactions, tension, nightmares, chronic fatigue, disturbed sleeping and eating patterns,
and a variety of other medical symptoms (United Nations 1989).
Mental Health Effects of Spouse Violence

Intimate partner violence results in more than 18.5 million mental health care visits
each year (Back et al. 1982). Depression and post-traumatic stress disorder, which
have a substantial co-morbidity, are the most prevalent mental-health squeal of
intimate partner violence. A comprehensive meta-analysis from the United States
shows that the risk for depression and post-traumatic stress disorder associated with
intimate partner violence was even higher than that resulting from childhood sexual
assault (Alquaiz et al. 2017). A recent study of women who had been victims of
long-term emotional abuse identified PTSD symptoms, along with depression and
dissociative forms of coping (Beusenberg et al. 1994) along with the increased use of
tranquilizers and antidepressants (Al-Subaie et al. 1998). Domestic violence is
strongly associated with depression, anxiety, panic disorders, phobias, somatization,
insomnia, and social dysfunction, attempted suicide, and chemical abuse (alcohol
and drug). These mental health problems are directly attributable to the abuse
suffered by women. In developing countries such as Nicaragua, 70% of cases of
emotionally distressed woman were exposed to intimate partner violence, while
depression and anxiety was also reported in battered women in Pakistan (Secretariat
of the Pacific Community 2010). Based on studies in both developed and developing
countries, suicide is 12 times as likely to have been attempted by a woman who has
been abused than by one who has not. In the United States, as many as 35–40% of
battered women have attempted suicide. In Sri Lanka, the number of suicides by girls
and women aged 15–24 years old is 55 times greater than the number of deaths due
to pregnancy and childbirth (Frieze and Browne 1989). Common mental disorders
(assessed by using the Self Reporting Questionnaire SRQ-20) were significantly
higher for women who had experienced abuse than that for nonabused women.
Spouse Violence in Global Health Contexts
Intimate partner violence against women is an important global public health

problem with severe adverse consequences. This study presents the results of the
cross-sectional study of intimate partner violence against women in Dubai (2012–
2013) among a sample of 700 women who were randomly selected from DHA clinic
attendees. It was conducted according to an internationally developed standard of
measurement (WHO domestic violence questionnaire) which was modified to rep-
resent major forms of suffering from women throughout the Middle East region and
beyond (Clark et al. 2009). The study was designed to investigate the problem of
intimate partner violence against women was it aimed to determine its prevalence
among women attending PHC in Dubai, and to uncover the pattern, frequency, and
severity, to identify some that violence risk factors and to assess the extent to which
intimate partner violence is associated with a range of health outcomes.
272 H. Y. Hussain
Case Studies
The rates of intimate partner violence found for Dubai are not as high when compared
with data from other countries (Al-Subaie et al. 1998; Naing et al. 2006; World Health
Organization 2013). A large proportion of ever-partnered women in Dubai (aged
15 to 49 years) have experienced intimate partner violence at some point during their
marriage. Of the 700 women respondents, 31% reported that they had experienced
one act of physical violence by an intimate partner in their lifetime, with reported
levels of severe violence (22%) and moderate violence (8%). The most prevalent
form of physical violence was being slapped or being the target of a thrown object
(31%). This was followed by being struck with a fist (22%). The most lethal form of
violence included being threatened to use a gun, knife, or another weapon (9.7%).
Repeated episodes were noted, as 20% of women experienced injury because of
violence at a frequency from three to five times. Most ever-injured women reported
minor injuries (bruises, abrasions, cuts, punctures, and bites), but more serious
injuries were also reported. About 32% of ever-injured women needed health care
for an injury resulting from intimate partner violence. The findings of our study on
injury are consistent with research elsewhere that established partner violence is a
common cause of injury to women. The high occurrences of loss of consciousness is
especially alarming. Further qualitative research is needed to fully understand these
findings because the term “loss of consciousness” might have different meanings in
different cultural contexts and individual perceptions by women. Collectively, the
weight of this evidence supports the view that the life experience of intimate partner
violence is a major contributor to women’s ill health, and may underpin a broad range
of health outcomes. Furthermore, when combined with the information that approx-
imately 32% of women with a lifetime experience of physical intimate partner
violence had presented to a healthcare provider (usually a general physician/family
doctor or the Emergency Department) within the previous 4 weeks, these findings
have considerable implications for healthcare delivery. The prevalence of intimate
partner violence in Dubai is within the range of most of the 15 localities studied with
the same methodology in a multicenter study investigated in the WHO multicountry
study. Ranked according to prevalence, there was a range of physical violence from
13% (Japan) to 61% (Peru). The most common act of violence experienced by women
(slapping a partner) ranged from 9% in Japan to 52% in Peru. This was followed by
being struck with a fist (11–21%). The percentage of ever-partnered women
experiencing severe physical violence ranged from 4% of women in Japan to 49%
in Peru, with most countries falling between 13% and 26%. A pattern of continuing
abuse was noted in most sites (Garcia-Moreno et al. 2005).
Sexual Spouse Violence
At least 22.4% responding women experienced one of three forms of sexual violence
in their lifetimes. Our results are within the range of most sites investigated by the
WHO multicountry study with a range from 6% (Japan and Serbia/Montenegro) to
59% (Ethiopia) (Garcia-Moreno et al. 2005). In most settings in the WHO study,
about half of sexual violence was a result of physical force rather than fear. However,
a larger proportion of women (22.4%) in our study reported having sex because they
were afraid of something their partner might do, similar to the findings in Ethiopia
and Thailand. These findings are likely related to a culture of a dominant gender and
the low perception of such duress within relationships largely of a conjugal nature.
Psychological Spouse Violence
Psychological violence is the most frequent abuse, and is reported by approximately

half of the respondents (41%). Nearly 40% of women reported experiencing at least one
form of control when using the WHO questionnaire items. The most frequently
reported form of control was when the husband insists on knowing where the respon-
dent is at all times. For emotional violence, 41% of the respondents reported experienc-
ing at least one form. When restricted to only the items included in the WHO
questionnaire, this dropped to 36%; the most prevalent experiences of psychological
violence included being blamed for things that happened to her husband or to the
household followed by being insulted or made her feel bad about herself. The results of
our study were within the range of the WHO study. Across all countries, the proportion
of women reporting one or more controlling behaviors by their partner varied from 20%
to 75%. Emotional abuse was reported as a low in Japan (21%) to 90% in Tanzania
(Garcia-Moreno et al. 2005). This suggests a great variation in the degree to which such
behaviors are seen as acceptable (normative) in different cultures.
The magnitude of lifetime intimate partner violence in women attending Govern-
mental health facilities in Dubai city is 41%, including psychological (41%), physical
(31%), and sexual (22%) violence; these events mostly occurred over a lifetime rather
than just in the previous year. The prevalence of intimate partner violence in this study
is within the range of most of the 15 localities studied with the same methodology in the
multicenter study investigated in the WHO multicountry study. Thus, Dubai was in an
intermediate or low position within this range except for sexual violence, which is more
common internationally. However, the prevalence in Dubai is higher than in Saudi
Arabia and lower than in Egypt and Pakistan. Overall, the results indicated that a large
proportion of ever-partnered women (15–49 years of age) in Dubai have experienced
intimate partner violence at some point during their marriage.
The majority of physical violence of a severe type was reported by 22% of
participant’s women. Moreover, the most prevalent form of physical violence was
a moderate type of severity, being slapped, or being the target of thrown object
(31%) This was followed by severe abuse, for example, being struck with a fist
(22%). Most of the cases were recurrent (3–5 times). For sexual violence, all of the
women who experienced sexual violence also experienced other forms of violence,
with it being rare to experience sexual violence in isolation. Furthermore, overlap
between physical and sexual violence 17%. In addition, the most conmen form
(22.4%) of violence was women having sex because they were afraid of something
their partner might do. This could be due to the male-dominant gender concept in the
274 H. Y. Hussain
Arab culture. Psychological violence most frequently reported lifetime intimate

partner violence against women. When restricted to only the items included in the
WHO questionnaire, the most frequently reported form of control was the husband
insists on knowing where the respondent is at all times (39.6%). For emotional
violence, the most prevalent experiences of psychological violence included being
blamed for things that happened to her husband or to the household (36%).
Associated Socio-demographic Characteristics
Some socio-demographic factors could explain the risk for lifetime experience of
intimate partner violence against women. These include the male partner’s lower
level of education and use of alcohol and drugs, while it is possible that women
(especially of a low socioeconomic status) become dependent on the husband in
long-term marriages. There are significant associations between lifetime experiences
of physical/sexual/psychological violence (or a combination) by a male intimate
partner and a wide range of self-reported physical and mental health problems in
women. The vast majority of violence has health consequences long after the actual
violence has ceased. Physical violence has the greatest effects on mental and
physical health. The most common self-reported experiences of symptoms of ill
health that occur within 4 weeks and significantly associated women with life
experiences of intimate partner violence and includes being unable to perform
usual activities. Many report unable to walk, due to moderate/severe/extreme pain
or discomfort. Physical injuries include bruises, abrasions, cuts, punctures, and bites,
with some more serious injuries also reported.
Psychological violence and the combination of physical and psychological vio-
lence are common factors affecting the mental health women after intimate partner
violence. The commonest symptoms of mental health reported by such women were
symptoms of emotional distress followed by suicidal attempts. There is increased use
of medication to reduce depressions.
Interpretation on Spouse Violence in Arab Countries
Many women-accessing healthcare in the Arab region have been exposed to

violence from family members or intimate partners. Domestic violence affects
Arab women. Our findings are of interest to clinicians and policy makers in the
Arab region. Contact with a healthcare professional provides an opportunity to
identify survivors of violence and offer support and referral to specialist services
(Secretariat of the Pacific Community 2010; Naing et al. 2006). The WHO has
called for a healthcare response to violence against women but much of the current
evidence comes from high-income settings. The results from our review provide
regional evidence, which could be used to inform the development of healthcare
interventions and policy in the Arab world. Interventions with an evidence from
high-income or other regional settings need local adaptation and evaluation, by
taking into account not only the cultural context but also the healthcare system
resources and infrastructure and national policy and legal framework in the Arab
world. We recommend further research in the Arab region to establish what a
suitable healthcare response to domestic violence might look like. Intimate partner
violence against women and its health effects on women highlight the need for
urgent action by a wide range of actors, from local health authorities and community
leaders (including religious leaders) to national governments and international
donors. Clearly, violence against women is widespread in the region and is deeply
ingrained; it seriously impacts women’s health and well-being. Yet no other prob-
lem of public health has – until relatively recently – been so clearly ignored and yet
remains poorly understood.
Bridging Gaps in Spouse Violence: The Road Ahead
Strengthening National Commitment and Action
1. Promote gender equality and women’s human rights.

Improving women’s legal and socio-economic status is likely to be, in the long
term, a key intervention in reducing women’s vulnerability to violence. This
includes awareness of their rights and measures should ensure women’s rights
related to owning and disposing of property and assets, access to divorce and
child custody following separation. Women’s access to education – in particular
keeping girls enrolled through secondary education – and to safe and gainful
employment are key (World Health Organization 2013).
2. Implement and monitor multisectoral action plans.
The prevention of violence against women should rank high on national public
health, social, and legal agendas. Governments should publicly acknowledge that
the problem exists and make a commitment to act, plan, and implement national
programs.
3. Enlist social, political, religious, and other leaders to address violence against
women
4. Enhance capacity and establish systems for data collection to monitor vio-
lence against women, and gather data on the attitudes and beliefs that perpetuate
it. Surveillance is a critical element of a public health approach as it allows trends
to be monitored and also assess the impact of interventions (Garcia-Moreno et al.
2015).
Promoting Primary Prevention
Develop, implement, and evaluate programs aimed at primary prevention of

intimate-partner violence, which requires changing gender-related attitudes, beliefs,
and values of both women and men, at a societal as well as at an individual level.
Prevention efforts should include multimedia and other public awareness activities
276 H. Y. Hussain
to challenge women’s subordination and to counter the attitudes, beliefs, and values –
particularly by men – that condone partner violence as being normal (Bacchus et al.
2012).
Involving the Education Sector
Make schools safe for girls. Primary and secondary school systems should be
heavily involved in making schools safe by eradicating teacher violence, as well
as engaging in broader antiviolence efforts. There should be greater community
actions to reduce violence and promote nonviolent behavior. These programs should
begin early, involve both girls and boys (although probably with different informa-
tion and key messages, and with a balance of single-sex and mixed-sex discussions),
and apply age-appropriate learning.
Strengthening the Health Sector Response
Develop a comprehensive health sector response to the impact of violence against

women. Empower women in situations of violence at the service level: responses
to violence against women should be integrated into all areas of care (e.g.,
emergency services, reproductive health services such as antenatal care, family
planning, and postabortion care, mental health services, sexually transmitted
infections related services). It is necessary to improve access to nonstigmatizing
mental health services for women and recognize the associations between violence
and mental health, in particular depression and suicide ideation. Health providers
should work with other sectors, particularly the police and social services with
formal referral procedures and protocols. These measures should ensure that: (a)
women who have experienced violence are not stigmatized or blamed when they
seek help from health institutions, (b) women will receive appropriate medical
attention and other assistance, and (c) their confidentiality and security will be
ensured. Training providers to be sensitive to issues of abuse, treat women with
respect, and maintain confidentiality and not to reinforce women’s feelings of
stigma or self-blame, as well as being able to provide appropriate care and referral
as needed.
Use Reproductive Health Services as Entry Points
For identifying and supporting women in abusive relationships and for delivering
referral or support services. Clinics could be a woman’s only point of contact with
formal institutions and structures of support. The importance of reproductive health
programs to women at risk of intimate partner violence is further underscored by the
fact that women’s utilization of reproductive health services has been increasing
globally, while their use of other institutional services (e.g., police, social services)
in response to intimate partner violence continues to be limited. Indeed, framing

violence prevention as an integral part of reproductive health promotion is likely to
be a safer and more acceptable strategy than one focused exclusively on violence
prevention.
While health care providers in reproductive health and primary care clinics
cannot end intimate partner violence, they can however address its health conse-
quences. Health care providers in family planning clinics should be trained to
screen for specific reproductive health risks associated with intimate partner
violence rather than merely screening for acts of physical, sexual, and psycho-
logical violence and then take concrete steps to reduce the health risks and
improve women’s health outcomes. Screening combined with the offer of
longer-acting contraceptives and resources for domestic and sexual assault assis-
tance can reduce a woman’s risk of being coerced into pregnancy; this can also
help to end unhealthy and unsafe relationships. The simple assessment of abuse
followed by referrals increases safe behaviors and the use of community
resources.
Broad changes in the health system necessitate a number of actions, including
(1) creating a supportive environment within the system for clients to discuss
intimate partner violence and for physicians to screen patients for intimate partner
violence, (2) displaying informational material in clinics, (3) focused training for all
health care providers with mechanisms for continuous feedback and evaluation as
staff practice their new skills, (4) on-site referral services, (5) strong linkages
between the health sector and community agencies, (6) commissioning an indepen-
dent task force within the organization to develop and promote an integrated intimate
partner violence response system, and (7) ensuring inter-departmental collaboration.
Women experiencing intimate partner violence should receive health care and
justice. This needs governments to develop national policies outlining the role of
health care providers to address intimate partner violence, and then widely dissem-
inate these policies.
Supporting Women Living with Violence
Lack of support from formal services or institutions (e.g., social workers, counselors,
shelters) is of great concern. Women exposed to intimate partner violence lack
confidence in existing services and that authorities would listen with sensitivity or
impartiality or could even make a difference to their situation. This highlights the
need for better and more accessible support services where women can safely
disclose their experiences of violence. Formal services offered by health or justice-
related institutions should be expanded or improved. There is also a need to educate
religious and other local community leaders to the conditions experienced by women
exposed to intimate partner violence. Since abused women are most likely to seek
help from an informal network of friends, relatives, and neighbors, strengthening
these networks through the popular media (TV, radio, etc.) is important so that when
278 H. Y. Hussain
women do reach out to friends and family, they are better able to respond in a
sympathetic and supportive manner.
Sensitizing Criminal Justice Systems
This includes sensitizing legal and justice systems (police, investigators, medico-
legal staff, lawyers, judges, etc.) to the needs of women victims of violence. They
should be trained in using medico-legal evidence-gathering techniques and use this
as a part of a comprehensive package of care, including counseling and relevant
treatment. The safety and confidentiality of women exposed to intimate partner
violence is of paramount importance.
Support Research on the Causes, Consequences, and Costs

of Violence Against Women and on Effective Prevention Measures
More research on the magnitude and nature of the problem of violence against
women, and its costs, settings, the causes of violence against women in the Arab
world, is long overdue. It is important to understand both the risk and protective
factors related to violence, so as to provide a stronger basis for advocacy and action.
Increase Support for Programs to Reduce and Respond to Violence

Against Women
Donors and international organizations should support efforts to carry out research
on this sensitive issue and foster increased collaboration across countries and
regions. International donors, development agencies, and nongovernmental organi-
zations should be prepared to provide financial and technical support protecting the
rights of women exposed to intimate partner violence in the Arab world.
Adopting Family REFORM LAW
Why is family law reform so significant, especially in the MENA region? How does
family law relate to Islam? What would it take to reform these laws in this region in
particular? These questions cannot be answered without an understanding of the
development of legal systems across the MENA region.
Conclusion
Spouse violence in Arab world is deep-rooted structural and behavioral phenomenon

which needs big social change advocacy and movement.
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Cultures of Resistance: The Struggle
Against Domestic Violence in Arab Societies 13
Lisa Hajjar, Eduardo de Leon Buendia, Patrick Fairbanks,
Emma Kuskey, Sasha Misco, and Ada Quevedo
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282
Religion, the State, and Women’s Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284
Domestic Violence and Shari’a . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288
Rights, Wrongs, and the Role of the State . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291
Arab States, Religion, and Women’s Rights in Comparative Perspective . . . . . . . . . . . . . . . . . 293
Communalization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293
Nationalization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295
Theocratization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 298
Liberalization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301
Conclusion: The Role of Healthcare in Treating the “Hidden” Epidemic . . . . . . . . . . . . . . . . . . . . . 308
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310
Abstract
Domestic violence is a global phenomenon that affects an estimated 30% of all
females worldwide. The health impacts of physical or psychological violence
within the home include depression and other mental health issues, reproductive
problems, injuries, and even death. While this problem is common to almost all
societies, it is not the same everywhere. The focus of this chapter is Arab
countries. Understanding domestic violence demands an understanding of the
sociocultural context in which it occurs. The most important sociocultural factors
in the Arab region are the culture of religion, specifically religious family law, and
L. Hajjar (*)
University of California – Santa Barbara (UCSB), Santa Barbara, CA, USA
Department of Sociology, UCSB, Santa Barbara, CA, USA
e-mail: lhajjar@soc.ucsb.edu
E. d. L. Buendia · P. Fairbanks · E. Kuskey · S. Misco · A. Quevedo
University of California – Santa Barbara (UCSB), Santa Barbara, CA, USA
e-mail: deleonbuendia@ucsb.edu; pcfairbanks@ucsb.edu; emmakuskey@ucsb.edu;
sashamisco@ucsb.edu; aquevedo@ucsb.edu

https://doi.org/10.1007/978-3-030-36811-1_201
282 L. Hajjar et al.
the politics of the state. We present a comparative framework that emphasizes the
interplay among family law, state power, intrafamily violence, and women’s
rights. Given cultural and political resistance to combatting domestic violence,
the field of healthcare can be the most effective site for obtaining more and better
data and for developing national policies to redress this problem.
Keywords
Women’s rights · Gender · Shari’a · Family law · Islam · State power · Islamist
politics · Human rights · Communalization · Nationalization · Theocratization ·
Liberalization
Introduction
Women and girls are more at risk of domestic violence – that is, violence perpetrated
by family members and intimate partners – than any other form of violence. This
phenomenon affects an estimated 30% of all females worldwide (Garcia-Moreno
et al. 2005). Among the many adverse consequences of domestic violence, the
implications for women’s health and wellbeing are alarming (Hawcroft et al.
2019). Statistically, the health impacts of those subjected to or threatened by
domestic violence include the following: they are twice as likely to experience
depression, posttraumatic stress disorder, suicidal thoughts, or other mental health
issues; they are 16% more likely to have a low birthweight baby; 42% have been
injured as a result; and 38% of the murders of women and girls globally are at the
hands of family members or intimate partners (Fig. 1).
Violence perpetrated in the context of the family may involve “a single incident or
pattern of incidents which can take multiple forms including physical, sexual,
psychological, emotional, financial and control violence” (Hawcroft et al. 2019).
For the purpose of this study, the categories of domestic violence include beatings,
Fig. 1 Some determinants of health consequences for women. (Taken from https://www.who.int/
reproductivehealth/publications/violence/VAW_health_impact.jpeg?ua¼1)
13 Cultures of Resistance: The Struggle Against Domestic Violence in Arab. . . 283
battery, murder, marital rape, and forced marriage, as well as psychological abuse,
including behavior intended to intimidate and persecute, such as threats to abandon,
divorce, or take away custody of children; confinement and surveillance; and verbal
aggression and humiliation. (Not addressed in this article are domestic or gendered
violence in the context of armed conflict, forced migration, or pandemic; abuse of
non-family members within homes (i.e., domestic workers); and female genital
mutilation/cutting (FGM/C).)
Because domestic violence occurs within the family and/or among people with
familial relationships, making it visible as a first step to making it redressable is
exceedingly difficult. The very intimacy of domestic space and relationships makes
intrafamily violence difficult to document, and the importance of the family in every
society makes the formulation of strategies to protect women from abuse difficult or
even controversial. Conceiving of strategies to redress domestic violence requires
identifying those legal structures that maintain forms of familial relations, and those
social norms and cultural discourses about gender, sex, and family that foster
toleration or, even worse, endorsement of violence against women and girls.
The problem of domestic violence is common to almost all societies, but it is not
the same everywhere (Fig. 2). The focus of this chapter is Arab countries: Bahrain,
Egypt, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Palestine and Arab com-
munities in Israel, Oman, Qatar, Saudi Arabia, Sudan, Syria, Tunisia, United Arab
Emirates, and Yemen. Although data from this region is limited, the World Health
Organization estimates that 37% of women from the Arab countries where there is
national data (Egypt, Iraq, Jordan, and Palestine) have experienced physical or
sexual violence by a family member or intimate partner (Garcia-Moreno et al. 2013).
Understanding domestic violence demands an understanding of the sociocultural
context in which it occurs (Haj-Yahia 2000; Hajjar 2004). The most important
sociocultural factors in the Arab region are the culture of religion, specifically
religious family law, and the politics of the state. Islam is the dominant religion
across the region and the demographic majority of Arabs are Muslims. Islamic law
(i.e., shari’a) is a major factor in the governance of family relations and personal
status issues (marriage, divorce, custody and inheritance), albeit this varies from
country to country and across time. In general, shari’a functions both as specific legal
rules and a religio-cultural framework for Islamic norms and values. Therefore,
understanding the vulnerability of women and girls to intrafamily violence in this
region must take account of the role of shari’a, but this accounting must be done in a
comparative rather than generalizing way.
The other major factor is the state because states (everywhere) are ultimately
responsible for the regulation, restriction, and punishment of violence within society,
including – in principle – that which occurs within the domestic sphere. The prospect of
prohibiting and punishing domestic violence depends on the state’s willingness and
capacity to reform criminal and family laws in ways that provide greater protections for
women. The possibility of state-sponsored reform is strongly affected by prevailing
social beliefs and cultural ideologies about religion, gender, and family relations. The
comparative analytical framework that we present emphasizes the interplay among
religion, state power, intrafamily violence, and women’s rights in the Arab region.
Fig. 2 Global patterns of violence against women. (Taken from https://www.who.int/

reproductivehealth/publications/violence/VAW_Prevelance.jpeg?ua¼1)
Religion, the State, and Women’s Rights
Violence against women occurs with regularity in the Arab world, as shown in Fig. 3
and Table 1. While shari’a fosters some commonalities in gendered rights and family
relations in Arab societies, there are marked variations in the ways in which shari’a is
interpreted and applied. Many factors contribute to interpretative variations, including
different schools of Islamic jurisprudence ( fiqh), the histories and politics of religious
institutions, and the legacies of conversions, reforms, and education. These variations
should deter overgeneralizing about Islam or adopting biased presumptions that “Islam
itself” is inherently bad for women. As we elaborate in greater detail below, some
Qur’anic verses and hadith on which shari’a is based emphasize different roles and
rights for men and women within the family, whereas others propound their equality
before God and pietistic virtues of compassion and fairness. These seeming contra-
dictions lend themselves to multiple readings, claims, and counter-claims about what
Fig. 3 Violence against

women in the Arab world
Table 1 Frequency of violence against women in the Arab world (on a yearly basis). (Adapted
from https://www.arabbarometer.org/wp-content/uploads/Sexual-Harassement-Domestic-Violence-
Arab-Citizens-Public-Opinion-2019.pdf)
Country Frequency of domestic violence (%)
Palestine 75
Libya 73
Iraq 72
Yemen 68
Jordan 62
Morocco 57
Sudan 55
Tunisia 53
Lebanon 50
Egypt 48
Algeria 48
Islam prescribes for women and are prominent themes in the scholarly literature
about women and Islam (Engineer 1992; El-Solh and Mabro 1994; Mernissi 1991;
Mir-Hosseini 1996; Moghissi 1999; Yamani 1996).
Shari’a lays claim to timeless, transcendental ideals, but it does not actually
operate in a timeless, transcendental way. Rather, to understand how shari’a actually
operates in any Arab society and how it figures in the political landscape, the most
important consideration is the state and state-society relations.
The history and politics of Arab states include the specific experiences of colonial
rule; the trajectories of national independence, societal integration, and develop-
ment; any coups or engagements in wars and armed conflicts; and the type of regime.
These country-specific experiences inform state projects and agendas in all spheres,
including those affecting family relations and gendered rights. “In particular, the
state mediates gender relations through the law. . . in its attempts to foster or inhibit
social change, to maintain existing arrangements or to promote greater equality for
women in the family and the society at large” (Charrad 1990, 20).
The relationship among religion, the state, and women’s rights can be framed and
compared using four categories. In countries where the population is religiously
diverse, the state communalizes religion by according religious authorities and
sectarian family laws semi-autonomy from the national legal regime. While family
law is communalized in religiously diverse Palestine, Israel, Syria, and Iraq, we
highlight the example of Lebanon because the entire political structure and not just
family relations is based on religious diversity and the semi-autonomy of religious
authorities of the country’s 18 ethno-religious communities (Mikdashi 2018).
In countries where the vast majority are Sunni Muslims and Islam has status as the
official religion but the state itself is secular, governments have nationalized religion
by incorporating shari’a principles into the national legal regime (Agrama 2012). We
focus mainly on Egypt as a clear example of the nationalization of religion. In a few
countries, the state theocratizes religion by declaring itself Islamic and basing the
national legal regime on overtly theological paradigms. Today Saudi Arabia offers
the clearest example of theocratization in the Arab world because the state claims to
rule according to shari’a and its constitution is the Qur’an (Al-Rasheed 2015). North
Yemen was a theocratic state prior to the reunification of the country in 1990.
(Theocratization also characterizes non-Arab Shi’i Iran.) The fourth model which,
at present, only applies to Tunisia manifests when the state liberalizes religion by
promoting gender equality and egalitarianism as a rubric for family laws.
Alongside these country-specific variations, two transnational discourses and
movements have been particularly influential politically and culturally to contesta-
tions over the relationship among religion, the state, and women’s rights: political
Islam and human rights. Since the 1970s, Islamist movements have mobilized or, in
the case of older organizations like the Muslim Brotherhood, intensified their
demands for a (re)turn to Islam. Notwithstanding ideological variations among
contemporary Islamist movements, common aspirations include a transformation
in the system of government to elevate the role of religion in society and to use
the full power of the state to enforce shari’a principles (Al-Arian 2014; Stork and
Beinin 1997). The political agendas and influence of Islamist movements and their
relations to state governments vary, but there is a generally shared commitment

between Islamists and most Arab regimes to preserve patriarchal family relations
(Zubaida 2001). Indeed, even in national contexts where Islamists constitute a
hostile opposition, states have accommodated their demands on matters of gender
and family relations as a means of placating them (Halliday and Alavi 1988;
Kandiyoti 1988).
Since the 1970s, there also have been mobilizations across this region to promote
international human rights. Organizations have been established in every country,
leading to greater awareness of the discourse of universal rights and principles of
international law. A major breakthrough for women’s human rights was passage of
the Convention on the Elimination of All Forms of Discrimination against Women
(CEDAW), which was adopted by the UN General Assembly in 1979 and came into
force in 1981. CEDAW, often described as the international bill of rights for women,
clearly establishes the “indivisibility” of women’s rights in public and private life.
Every Arab government except Sudan is a party to CEDAW, although many of them
submitted reservations to articles that call for gender equality in family life. While
CEDAW recognizes the importance of culture and tradition in shaping gender and
family relations, it imposes on states the obligation to take “all appropriate mea-
sures” to modify social and cultural patterns of conduct that are discriminatory or
harmful toward women. It also makes clear that states are responsible for violations
of the rights of women, even those perpetrated by private individuals. However,
CEDAW does not explicitly identify violence against women as a human rights
violation.
In the 1980s, a worldwide campaign was launched to end violence against women
and to demand international recognition of domestic violence as a human rights
violation. In 1993, the United Nations adopted the Declaration on the Elimination of
Violence against Women which prohibits “any act of gender-based violence that
results in, or is likely to result in, physical, sexual or mental harm or suffering to
women, including threats of such acts, coercion or arbitrary deprivation of liberty,
whether occurring in public or private life.” It explicitly includes violence occurring
in the family, including wife battering and marital rape. In 1994, the UN established
a position for a Special Rapporteur for Violence against Women.
In the Arab region, the role of religion and the status and rights of women have
been central concerns to both the human rights and Islamist movements, albeit in
often contradictory and even adversarial ways (Halliday 1995). Both movements
seek to influence or even transform the state itself in accordance with their political
and legal agendas. The critical – and debatable – question which directly implicates
the state is whether Islam and human rights offer compatible worldviews and, if not,
which should prevail in national policymaking. This is not an abstract philosophical
matter; it is a deeply charged political concern that informs national debates and the
strategies that local actors pursue to institute their visions and goals, whether their
priority is to promote women’s rights in accordance with international law, to
promote an “authentically Islamic” social order (however that is interpreted), or to
reconcile religious laws and beliefs with women’s rights (Afary 1998; Afkhami et al.
1998; Afkhami and Vazeri 1996; Ali 2000; Hajjar 2004; Svensson 2000).
Domestic Violence and Shari’a
Domestic violence is distinguished from other forms of gender violence by the

context in which it occurs (the domestic sphere) and the relationship between
perpetrators and victims (familial). Domestic violence can be defined as “violence
that occurs within the private sphere, generally between individuals who are related
through intimacy, blood or law. . . [It is] nearly always a gender-specific crime,
perpetrated by men against women” (Coomarswamy 1996, 53). In a comparative
study of 90 societies (Levinson 1989), four sociocultural factors, taken together,
were shown to be a strong predictor of spousal abuse: (1) gendered economic
inequality, (2) a pattern of using violence for conflict resolution, (3) male authority
in the home, and (4) divorce restrictions for women.
Across the Arab region, male authority in the home and women’s limited access
to divorce are largely dictated by shari’a or other ecclesiastical courts that are
empowered to interpret and enforce family laws. However, even where divorce is
a legal option, it does not constitute an adequate protection from violence for many
women. Myriad factors discourage, impede, or prevent women from even contem-
plating leaving a violent relationship (see Adelman 2000), including a lack of
resources or support to establish alternative domestic arrangements and powerful
social expectations and pressures to maintain family relations at any cost.
Violence within the context of the family raises questions about the laws and legal
administration of family relations. Is intrafamily violence proscribed by criminal
law? In practice, is it tolerated or penalized by state authorities and/or family law
authorities? Are civil remedies available to victims (e.g., right to divorce, restraining
orders)? In contexts where intrafamily violence is not prohibited (i.e., criminalized),
perpetrators enjoy legal impunity. In contexts where it is prohibited but the laws are
not enforced, perpetrators enjoy social impunity.
Impunity reflects a reluctance or resistance to recognize and deal with intrafamily
violence as violence. By imagining and referring to beatings, confinement, intimi-
dation, and insults as “discipline” or “punishment” for an ostensibly misbehaving
female rather than “battery” or “abuse,” the nature of harm to women and girls is
obfuscated. Moreover, if prevailing sociocultural beliefs about family relations
include the idea that men have a right or obligation to punish and discipline female
family members, then the tactics used to do so can be seen – and even lauded – as
“necessary” to maintain order at home and in society at large. The problem of
impunity is exacerbated by popular perceptions of male power (including to dom-
inate and aggress against women) as normative.
Although shari’a is a critically important factor in understanding family relations,
it does not constitute an explanatory device for the problem of domestic violence.
The notion that Islam (or any religion) can explain social relations is a hallmark of
orientalist scholarship, including orientalist trends in some Western feminist schol-
arship about Muslim women (Abu-Lughod 2013; Mohanty 1991). Rather, explana-
tions must be sought by analyzing how the actual interpretation and enforcement of
shari’a in any given society bear on the permissibility or prohibition of violence
within the family and the rights of women.
The global phenomenon of domestic violence is strongly and directly related to

social-structural inequality between men and women. But the contested legitimacy
of gender equality, especially in the context of the family, impedes or complicates
efforts to deal with domestic violence as a social problem. In the Arab region,
cultural resistance to the principle that men and women should be equal, especially
in the context of the family, is pervasive. The corollary is the belief that domestic
relationships are legitimately (i.e., naturally and/or divinely) hierarchical. This belief
is both derived from and reinforced by shari’a, which tends to be interpreted to give
men power over female family members. Thus, gender inequality is acknowledged
and justified in religious terms on the grounds that God made men and women
“essentially” different; that these differences contribute to different familial roles,
rights, and duties, which are complementary, and that this complementarity is crucial
to the cohesion and stability of the family and society.
Dominant interpretations of shari’a accord men the status as heads of their
families with legal guardianship over female relatives. The complement to this is
the expectation that women have a duty to obey their guardians. (For a country-by-
country survey of Islamic family law, see https://scholarblogs.emory.edu/islamic-
family-law/home/research/legal-profiles/.) This hierarchical and overtly patriarchal
relationship is based on the Qur’anic principles of qawwama (authority, guardian-
ship) and ta’a (obedience), from which gender-differentiated rights and duties are
derived (Al-Hibri 1997: 18–21; Sonbol 1998). The primary source of the Qur’anic
principles of qawwama and ta’a is Sura 4, Verse 34. This verse also contains the
most commonly cited reference that men have a prerogative to beat disobedient
spouses. Engineer (1992, 47) reports that the historical origin of this verse is the case
of a man (S’ad bin Rabi’) who slapped his wife (Habiba bint Zaid) because she had
disobeyed him. She complained to her father, who complained to the Prophet
Muhammad. Sympathizing with the woman, the Prophet told her that she was
allowed the right to qisas (a form of legal retribution. Men in the community
protested that this would give women advantages over them. Fearing unrest, the
Prophet sought and received a revelation from God (4:34) that effectively reversed
his earlier ruling giving women the legal right to retaliate.) Although this verse is
translated in a variety of ways (An-Na’im 1996, 97; Engineer 1992, 46; Hassan
1987, 98–105; Stowasser 1998), a standard English translation, which captures
dominant understandings about authority, (dis)obedience, and punishment, states:
Men have authority [qawwama] over women because Allah has made the one superior to the
other, and because they [men] spend their wealth to maintain them [women]. Good women
are obedient [ta'a]. They guard their unseen parts because Allah has guarded them. As for
those [women] from whom you fear disobedience [nushaz], admonish them and send them
to beds apart and beat them. Then if they obey you, take no further action against them. Allah
is high, supreme. (Dawood 1974, 370)
There are several ways to draw interpretative meaning from this verse. Because
the Qur’an is revered by devout Muslims as a revelation from God, the verse lends
itself to interpretations that God sanctions beating disobedient wives. But because
beating women was quite common in the time period and locale where Islam
emerged, the verse also lends itself to interpretations that God intended to transform
the practice of beating into a symbolic act that should be used minimally if it could
not be avoided entirely. Al-Hibri (2001, 75–81) supports this reading by pointing to
the Prophet’s declaration to men: “The best among you are those who are best toward
their wives.” Other Qur’anic verses and hadith condemn violence between spouses
as contrary to the marital ideal. For example, Sura 30, Verse 21, describes marital
relations as tranquil, merciful, and affectionate, and the relationship itself as based on
companionship, not service or tyranny. In this vein, Riffat Hassan writes, “God, who
speaks through the Qur’an, is characterized by justice, and. . .can never be guilty of
‘zulm’ (unfairness, tyranny, oppression or wrongdoing). Hence, the Qur’an, as
God’s word, cannot be made the source of human injustice” (1995, 12). The notion
that beating women constitutes a God-ordained right available to men also runs
contrary to the Qur’anic right of both men and women to dissolve a failed marriage,
which would seemingly override the notion that women have a duty or obligation to
submit to violence. Yet because there is a mention of beating in the Qur’an, Islamic
jurists and scholars have grappled with the question of whether hitting constitutes a
de jure right under shari’a or a de facto last-resort option (Eissa 1999). For example,
some jurists have proposed that men should be prohibited from hitting women in the
face or hard enough to cause pain (Badawi 1995).
Marital rape is another form of domestic violence. Although rape is a punishable
crime in every Arab country, nowhere except Tunisia (as of 2017) is the criminal
sanction extended to rape within marriage because sexual access is deemed elemen-
tal to the marriage contract. One Qur’anic basis for men’s unabridged sexual access
to their wives is Sura 2, Verse 223 which stipulates that “your wives are ploughing
fields for you; go to your field when and as you like.” Under dominant interpretations
of shari’a, there is no harm – and thus no crime – in acts of sex between people who
are married which makes marital rape literally uncriminalizable. Although other sura
and hadith instruct men not to force themselves sexually upon their wives, this can
be undermined by the principle of female obedience (El Alami 1992; El Alami and
Hinchcliffe 1996). Indeed, a wife’s refusal to have sex with her husband can be
construed as disobedience, thereby triggering justification for beating.
Forced marriage is a form of psychological and emotional violence. Although the
Qur’an does not expressly sanction this practice, the principles of male authority and
female obedience create conditions that enable men to impose their will on matters
of marriage. While the Qur’an recognizes “mature” (postpubescent) women’s right
to enter freely into marriage, their status as legal minors can undermine their ability
to assert this right in the face of male opposition.
There is a selective adherence to the shari’a laws in many Arab countries, as
illustrated in Fig. 4. In many Arab societies, there is a popular belief that demands for
greater rights for women are un-Islamic or even anti-Islamic because they contradict
and conflict with shari’a. The societal strength and influence of these beliefs has
emboldened those holding more conservative positions on gender issues to oppose
women’s rights and to propound the strict maintenance of hierarchical family
relations and male power over women as “authentically Islamic.” Indeed, the
discourse of “Islamic authenticity” has condensed around opposition to women’s
Fig. 4 Women’s decision

making abilities in the Arab
world. (Taken from https://
www.unescwa.org/sites/www.
unescwa.org/files/event/
images/english_page_02.jpg)
rights. According to Deniz Kandiyoti (1991, 8), “Islamic authenticity may therefore
be evoked to articulate a wide array of worldly disaffections, from imperialist
domination to class antagonisms. This opens up the possibility of expressing such
antagonisms in moral and cultural terms, with images of women’s purity exercising a
powerful mobilizing influence.”
Because this chapter focuses specifically on domestic violence, we bracket the
question of whether shari’a is supportive of or opposed to equality for men and
women writ large. Mainstream feminist discourses tend to regard gender inequality
as causal for domestic violence (Dobash and Dobash 1980, 1992) and prioritize the
struggle for equality as the most efficacious means of combating it (Connors 1994;
Coomarswamy 1999). This is premised on the idea that if women were equal to men
and had equal protection under the law, men would not be able to get away with
perpetrating violence against them without consequence. While this is a valid
assumption, it neglects or ignores the power of religious beliefs and cultural ideol-
ogies that provide justifications for inequalities. By foregrounding violence, we
pursue a somewhat different line of inquiry: Is the practice of family law in various
contexts interpreted to construe violence against women and girls by family mem-
bers as a harm or a right. Our point is that interpretations of religion are social
constructions and have a history.
Rights, Wrongs, and the Role of the State
The role of the state is of central importance to any discussion of rights because
states are the arbiters of law with sovereign responsibilities to prohibit and punish
violent crimes that endanger and harm their citizens and subjects. But sociocultural
resistance or refusal to regard domestic violence as a criminal offense can deter states
from fulfilling this responsibility. Even in societies with robust state-enforced legal
rights for women, the prevalence of domestic violence signals an enduring difficulty
to activate criminal law solutions. Thus, the global scope of domestic violence and
the pervasiveness of impunity, whether de jure or de facto, is an important rejoinder
to cultural stereotypes that Arab women are uniquely or exceptionally vulnerable.
To analyze and compare how states deal with domestic violence, the most
important issues are the administration and laws governing gender and family
relations, and official commitment (or lack thereof) to women’s rights (Htun and
Weldon 2012). The kinds of questions that this raises include the following: Has the
state signed and ratified CEDAW, and if so, has it registered any reservations
applicable to family relations? Is there a constitutional authority guaranteeing
equal protection of law for women, and if so, is this authority used effectively to
protect women from domestic violence? Are there national laws and/or administra-
tive sanctions prohibiting domestic violence? What measures, if any, has the state
taken or authorized to deal with domestic violence and the protection of victims
(e.g., provision of social services and health care, public education campaigns)?
Over the last few decades, conflicting demands on Arab states to demonstrate
their Islamic authenticity, on one hand, and obligations to protect women from
violence, on the other hand, have played out on the legal terrains in many countries.
One clear manifestation of the former occurred in 1990 when the Organization of
Islamic Cooperation, to which all Muslim-majority countries belong, issued the
Cairo Declaration on Human Rights in Islam which asserts that all national laws
must comport with shari’a principles. This declaration was a collective statal
response to anxieties about cultural imperialism and a rejoinder to the ostensible
“Islamic inauthenticity” of indivisible, universal, and equal human rights. What it
demonstrated most clearly was how implicated and responsive states are to cultural
resistance to women’s rights. However, this resistance rarely manifests as an open
defense of violence against women as a cultural value or end in its own right (Mani
1989; Walley 1997). More commonly, resistance is framed as servicing other values
or ends, including social stability, male authority, respect for tradition, and adherence
to religion.
And indeed, the specific problems of domestic violence, rather than gender
inequality writ large, have yielded some notable national legal reforms in recent
years (UNDP 2018). Six Arab states and one regional government have enacted
domestic violence laws: Bahrain (2015), Iraqi Kurdistan Region (2011), Jordan
(2017), Lebanon (2014), Morocco (2016), Saudi Arabia (2013), and Tunisia
(2017). Algeria, in 2015, reformed its penal code to criminalize domestic violence.
But even in countries that have instituted legal reforms, the protections are limited
(ESCWA 2017). For example, in Jordan, women must present two or more witnesses
to prove battery and in Bahrain, relatives cannot serve as witnesses. Other govern-
ments remain resolute in their failure to enact laws designed to protect women. In
Egypt and Syria, some forms of domestic violence may be punishable under the
penal code but, in Egypt, only if the abuse exceeds the accepted limits of discipline
decided by the judge and if the injuries are apparent when filing the complaint at the
police station and, in Syria, only if there is evidence that the violence has caused
physical injury. In Iraq, a provision in the penal code grants husbands a legal right to
punish their wives.
What these seemingly conflicting trends illustrate is that struggles over women’s
rights and the role of religion in society being waged on national legal terrains
involve sociopolitical contestations over legal jurisdiction – can criminal law go
“into the house?” – and disputes over which legal standards will prevail to guide
state policy. Whether a government will or will not reform its laws to better protect
women from domestic violence depends ultimately on the country-specific histories,
politics, and agendas of states and state-society relations.
Arab States, Religion, and Women’s Rights in Comparative

Perspective
One way of engaging a comparative approach to domestic violence in Arab countries

is to highlight variations in the relationship between religion and the state and to
reflect on how this bears upon women’s rights. This relationship can be divided into
four categories: (1) communalization in which religious laws, institutions, and
authorities are accorded semi-autonomy from the state; (2) nationalization in con-
texts where religious laws and jurisprudence are incorporated into the state’s legal
regime; (3) theocratization in which the state bases its own authority on religious law
and jurisprudence; and (4) liberalization in which citizens’ rights and religious laws
are subject to constitutional principles.
Communalization
In countries where society is religiously (and/or ethnonationally) diverse and where

that diversity is built into the national legal architecture, members of the different
communities are subject to separate systems of family laws. This system of
communalization, which has roots in the Ottoman era, has been adopted by modern
states. In such countries, there are two tiers of law: Communal laws govern the
personal status affairs of the community and national laws are under the direct
control of the state whose character is “nonreligious.” The communal laws and
institutions that govern family relations are not only legally separate from the state
but also are regarded ideologically as outside the state’s domain. Palestine and Israel
(Hajjar 1998, 2004, 20–21), Syria and Iraq are all characterized by such diversity
because the various religious authorities and institutions have semi-autonomy from
the state over their own communal affairs. But Lebanon offers the clearest example
of communalization because the entire political system is built around the manage-
ment of communal diversity.
The French established the communal political system in Lebanon during the
Mandate era and it was retained after the country became independent. It was
reinforced in the 1990 Taif Accord that brought an end to Lebanon’s 15-year civil
war. Under this communalized arrangement, the highest national political offices are
reserved for people along communal lines and the rights of citizens are mediated
through their communal identity. The Lebanese state is technically neutral on matters
of religion and all of the 18 legally recognized communities are defined as minorities.
As Maya Mikdashi (2018) explains, “Lebanese citizenship and statecraft are
constituted along two axes of political difference: sectarian and sexual difference”
which she describes as “sextarian.” Under this communalized arrangement, “sect
and sex are mutually constitutive modes of political difference.” The whole nation-
ally communalized structure is overtly patriarchal because “Lebanese law states that
citizens are born into the jurisdiction of different personal status laws depending on
their father. . . [and] sectarian belonging itself is defined through sexual difference
and patriarchal kinship regulations.” Individual male and female Lebanese citizens
are registered according to their patriarchal family serial numbers. For this reason,
female citizens cannot be recognized legally as “head of household.” This circum-
scribes women’s rights to be recognized as the legal guardians of their own children
or to pass on citizenship to non-Lebanese husbands and the children born to these
marriages. In state registries, women are registered as daughters of their fathers or
wives of their husbands. Consequently, the constitutional principle of equality
between the sexes is contravened by the country’s nationality law which defines
who and how people can become citizens. “Structurally, sexual difference is as
foundational to Lebanese law as sectarian difference, and the management of sexual
difference is as productive of Lebanese sovereignty as that of sectarian difference”
(Mikdashi 2018).
There are 15 different sets of personal status laws in Lebanon and all aspects of
“family affairs” are governed by them. (Some Christian denominations (i.e., Cath-
olics, Orthodox, Protestant) of different ethnic communities (e.g., Armenians and
Copts) are subject to the same family laws.) To varying degrees, all are discrimina-
tory toward women but the communalized structure differentiates the gendered
experiences of inequality. For example, because of Lebanon’s specific history of
state-building and national integration, “there are important differences between the
ways that Christian personal status courts and Muslim personal status courts are
incorporated into the state. Christian courts. . .are institutionally separate and enjoy a
greater measure of independence from the state. . .[which] can leave Lebanese
Christians [i.e., women] in a more vulnerable position than their Muslim counter-
parts” (Mikdashi 2018).
In recent decades, women’s rights activists in Lebanon have demanded national
measures to protect women from domestic violence. This pressure led, in 2014, to
the passage by parliament of Law No. 293 which criminalizes the perpetration of
physical and psychological violence within the family, with the exception of marital
rape unless there is proof of physical harm; this marital rape exception was
demanded by religious communal leaders and supported by their political allies.
The 2014 Family Violence Law delineates procedures and obligations on the
judiciary and the police over how to respond to domestic violence and grants
wives the right to file restraining orders against violent spouses. The country’s
criminal laws have penal sanctions against rapists although until recently, there was a
loophole allowing a rapist to avoid punishment if he married his victim. In 2017,
parliament repealed this marry-your-victim provision, although it retained a loop-
hole “relating to sex with children between the ages 15–17 and seducing a virgin girl
into having sex with the promise of marriage” (Begum 2017).
These recent developments in Lebanon suggest – not only for this country but for
others characterized by communalization – the strategic importance of targeting the
national government and pressuring state institutions to produce national legislation
that prohibits family violence and attaches criminal sanctions for perpetrators. But
the partiality and loopholes in these recent Lebanese legal reforms also suggest the
durability of patriarchal norms that communal leaders use their power to preserve.
When the very fabric of the state and society is communalized, leveraging the state to
protect and enhance the rights of women can be seen and protested as an impinge-
ment on the semi-autonomy of communal authorities and laws. These challenges are
exacerbated when the national government is politically incompetent at managing
the economy or otherwise unable to provide for the welfare and security of its
citizens. Failures on the part of the state can reinforce or elevate the significance of
communal relations and institutions as sources of solidarity, protection, and social
welfare for the community.
Nationalization
The nationalization of religion describes countries in which Islam is the official

religion but the state does not derive its own authority from religion per se. Many
Arab governments’ constitutions have clauses decreeing that shari’a is the main
source or basis of all national legislation. This nationalization of religion blurs the
boundaries between shari’a and state power. States have pursued this approach in
order to consolidate a Muslim national community and to promote their own
legitimacy among sectors of society who are inclined to see a commitment to
Islam as a marker of “good government” in the form of an “Islamic social contract.”
Egypt exemplifies the nationalization of religion. Article 2 of the Constitution
affirms Islam as the state religion, and in 1956 shari’a courts were integrated into the
national court system. In 1981, under pressure from Islamists, the constitution was
amended to provide that the principles of shari’a would constitute the main source of
legislation and the Supreme Constitutional Court was authorized to determine
whether new legislation conforms to these principles.
In the practice of family law in Egypt, shari’a is interpreted to maintain male
authority and female obedience. Therefore, women’s legal disadvantages and vul-
nerability to domestic violence are sanctioned by the state because of the privileged
role of shari’a in the national legal regime. Shari’a-based restrictions on women’s
right to divorce illuminate this vulnerability. Until 2000, a woman’s only recourse to
try to end a marriage because of violence was to apply to a shari’a court judge, and in
the interim she could not refuse to be obedient while continuing to cohabit the
marital home. If she fled the home and then returned later, the judge could assess this
return as a demonstration that “life could continue between them, which does not
constitute grounds for divorce later” (Tadross 1998, 18). Because the practice of
shari’a prioritizes the preservation of marriage rather than the safety of women,
judges tended to grant a divorce only if the wife could provide sufficient proof of
physical harm, and only if efforts to reconcile the couple proved fruitless (Tadross
1995, 57).
In January 2000, a new divorce law was passed in Egypt as a direct result of a
lengthy campaign by women’s rights activists (Zaki 2017), although the version that
passed was a watered-down version of the one they had proposed. One of its
provisions allows for “judicial khul,” a type of no-fault divorce relieving women
of the obligation to prove any harm so long as they refund their dower and forfeit all
financial claims from the marriage. This new law provided recourse for battered
women who might not be able to obtain a divorce through litigation in shari’a courts,
but the ability to take advantage of it is limited to women with the financial ability to
meet the repayment demands and renounce their financial claims (Negus 2000).
Moreover, if women’s families refuse to support their desire to divorce and/or are
unwilling to take them in, establishing separate homes for themselves is economi-
cally unfeasible for the vast majority, not to mention that it would be a socially
frowned upon option. But over time even women who might not actually be able or
willing to seek divorce have used the very existence of this law as leverage against
husbands for better marital conditions and treatment.
Political demands for state legal reforms to better protect women have yielded
some results. In 2000, the government established the National Council for Women
with a state-feminist mandate to ensure that Egyptian women enjoy equal treatment
in terms of political, economic, social, and cultural rights in keeping with the
CEDAW paradigm. The NCW has worked with government agencies and non-
governmental organizations to institute measures to reduce violence against
women, to provide safety resources for victims, and to press for legislative reforms
to criminalize domestic violence. In 2002, the Ministries of Justice and Interior set
up units to combat violence against women. In 2004, family courts were established
where women were allowed to demand their rights and seek legal protection from
domestic violence (Reda 2015). In 2008, personal status law was reformed to enable
women to keep legal custody of children up to 15 years of age. In 2009, NCW began
devising a framework for a national strategy for combatting all forms of violence
against women, noting that it must be “based on a commitment to genuine Egyptian
morals and values, and on promoting religious awareness as a basis for combating
violence against women” (National Council on Women 2015, 8). To garner the
support of religious leaders, this process incorporated representatives from the
Ministry of Waqfs, al-Azhar, and the Orthodox Coptic Church.
During the tumultuous period of Egyptian politics from the uprising in 2011 that
ended the dictatorship of Hosni Mubarak through the election of a Muslim Broth-
erhood-led government to its overthrow by a military coup and the installation of a
new dictator, Abdel Fattah el-Sisi, the most rampant forms of violence against
women have been street harassment and political violence. The human rights
situation in Egypt has deteriorated dramatically in recent years and the state remains
highly authoritarian. However, there have been some reformist gestures to

recalibrate the relationship between state power and women’s rights. In 2014, the
Sisi regime amended the constitution to incorporate articles prohibiting domestic
violence and to authorize the preparation of a National Strategy for Combatting
Violence against Women, which was unveiled in 2015.
Notwithstanding these national legal reforms and developments, rates of domes-
tic violence are high and have remained relatively steady. In 1995, the National
Population Council conducted a demographic and health Survey among a represen-
tative sample of the national population which included questions about domestic
violence and attitudes toward it. The survey reported that one out of every three
“ever-married Egyptian women has been beaten at least once since marriage” (El-
Zanaty et al. 1996, 208). Of those, 45% were beaten at least once in the past year, and
17% were beaten three or more times (El-Zanaty et al. 1996, 208). The study found
that the frequency of beating varies along lines of social, economic, and regional
differences. In terms of findings about attitudes, most women who were ever married
agree that husbands are justified in beating their wives at least sometimes. This
indicates a high degree of tolerance for domestic violence, even among women.
However, factors such as being older, married longer, married to a relative, having
consented to the marriage, living in urban areas, higher levels of education, and wage
employment all reduce the probability that a woman would agree that a husband has
the right to beat his wife under any circumstance. Among those factors, higher
education and employment are the most statistically significant. But even among the
most educated women, around 65% agreed that a husband is justified in beating his
wife at least sometimes (El-Zanaty et al. 1996, 206–207). In 2005, another demo-
graphic and health survey was conducted which gathered data on family violence.
The statistical findings were similar to the 1995 survey: 47.4% of married women
had been victims of violence by their husbands and 45% had been victims of
violence by other male family members, including fathers on daughters (53%) and
brothers on sisters (23%).
In 2015, the NCW in cooperation with the UN Population Fund and the Central
Agency for Public Mobilization and Statistics conducted a national survey in Egypt
to assess the economic and other social costs of gender-based violence (UNFPA
2015). Statistics about the rates of domestic violence were similar to the previous
surveys: 46% of ever-married women experience some form of spousal abuse, 24%
had experienced it recently, and 35% of victims were injured as a result. The findings
of this study indicate that 5.6 million women are exposed to domestic violence
yearly, and this has broad socioeconomic ramifications that affect far more than
direct victims: children from 113,000 families regularly missed school; one million
women fled their marital homes to escape violence; abused women are at higher risk
of miscarriages and stillbirths; and over two million women suffered injuries or
emotional problems. The economic impact includes the loss of half a million
working days with an estimated cost to women and their households at close to a
billion dollars annually.
The empirical findings from the various surveys conducted in Egypt verify claims
made by women’s rights activists throughout the world: that women’s rights and
empowerment within the family are correlated to female literacy and education,
employment opportunities, financial security, and the availability and accessibility of
social services. Thus, the role of the state in directing, pursuing, and prioritizing
social and economic development on a national scale is critical to reducing women’s
vulnerability to domestic violence. Conversely, combatting domestic violence is
critical to improving the health and wellbeing of society as a whole. But the
difficulties and failures of governments to develop the country economically have
contributed to the vulnerability of women to domestic violence, not by mandating
violence per se but by creating conditions in which it can be perpetrated with relative
impunity.
As the case of Egypt demonstrates, the challenges to instituting and enforcing
legal measures to combat domestic violence are inextricable from national struggles
over the state power, priorities, and laws and cultural struggles over the relationship
between religion and women’s rights. The nationalization of religion strengthens the
importance of religious law but also opens space for national debates over the
relationship between shari’a and other bodies of law. On matters of women’s rights
in general and domestic violence in particular, there is room for maneuver to seek
state intervention and legal reform of criminal and constitutional laws. Hind Ahmed
Zaki (2017, 17), reflecting on the campaign that led to the change in the nation’s
divorce law, explains:
The. . .battle between women’s rights activists and conservative religious leaders did not
result in a clear winner, yet it did shift the ideological terms of the debate significantly. This
new shift in discourse constituted an important ideological advance for women’s rights
advocates. . .By shifting the focus of the debate on women’s rights from a purely religious
perspective to one that focused on divorce as a social issue, women’s rights advocates
managed to change the terms of the debate radically. Furthermore, they forced their
opponents for the first time to recognize and address the real-life consequences of the doubly
pluralistic family law system. This tactic forced the issue of women’s rights onto the national
agenda as a social problem that necessitated immediate remedies. The success of such a
tactic suggests the importance of the cultural dimension of legal campaigns as a tool in
renegotiating new legal subjectivities for women, ones that are based on an equal under-
standing of the contractual relation between two spouses.
Through the process of reframing women’s rights in this way, Egyptian activists’
reform-seeking tactics enabled them “to use to their advantage the very tool used
against them: culture” (Zaki 2017, 22). Some of the campaign strategies for legal
reforms in Egypt have been emulated by women’s rights activists in other Arab
countries where religion is nationalized, including Jordan, Morocco, and Algeria.
Theocratization
Countries where the state defines itself as Islamic and religious law is the law of the
state are theocracies. In such contexts, defense of religion can be conflated with
defense of the state, and critiques or challenges can be regarded and treated as heresy
or apostasy, which the state authorizes itself to punish. Saudi Arabia is an example of
theocratization.
Saudi Arabia is an absolute monarchy governed by the dynastic Al-Saud family.
According to the country’s Basic Law: “Governance in the Kingdom of Saudi Arabia
derives its authority from the Book of God Most High and the Sunnah of his
Messenger, both of which govern this Law and all the laws of the State.” The king
is both the head of state and the imam of the faithful and obedience to the regime is
propounded as a religious duty. The national Shura Council functions as an advisory
body which can propose laws and submit them to the king, but he has the absolute
power to decide whether to pass or enforce them.
Shari’a is law of the land and is interpreted in accordance with the ultra-conser-
vative Sunni-sectarian Wahhabi tradition. Wahhabism, a variant of Salafism, origi-
nated in central Arabia as a puritanical movement with an agenda to advance “the
literal interpretation of religious texts, and the return to the early tradition of the
pious companions of the Prophet” (Al-Rasheed 2007, 3). In the eighteenth century,
the Wahhabi movement entered into a pact with Al-Saud tribe which resulted in a
power sharing arrangement that has endured; Al-Saud rule and Wahhabi jurists and
scholars have a monopoly over the interpretation of religion and considerable
influence over the state’s domestic policies in the social sphere, including family
relations. Madawi Al-Rasheed (2007, 4) explains this syncretic religio-political
relationship: “From its early eighteenth-century history, [Wahhabis] developed reli-
gious interpretations to legitimise political power which led to deep grounding in
authoritarianism, and even despotism, within Islam.”
Saudi Arabia has no constitution other than the Qur’an, and no penal code. This
vests judges and prosecutors with discretion to determine what are “Islamic crimes,”
which include “breaking allegiance with the ruler” or “trying to distort the reputation
of the kingdom.” Wahhabi interpretations of shari’a advocate and legitimize the
regime’s use of “Islamic punishments,” including beheading, flogging, and crucifix-
ion. They also legitimize religious persecution or even repression against anyone
who is not Sunni Muslim, including Shi’i citizens who are concentrated mainly in
the Eastern Province. Personal status law, although based on shari’a, is not codified,
either. Gender inequality and segregation are construed as a religious mandate and
national virtue. “The exclusion and confinement of women have become a symbol
for the piety of the Saudi state” (Al-Rasheed 2007, 4).
Saudi society as a whole and familial relations are rigidly patriarchal because of
the country’s guardianship system. Women are legal minors under the authority of
male guardian family members. They do not have a unilateral right to divorce and
they are sorely disadvantaged in terms of custody. Until recently, women and girls
required their guardian’s permission to marry, travel, study, work, or even undergo
certain medical procedures.
Saudi Arabia’s brand of politically authoritarian conservative piety faced new
challenges in recent decades. A number of events and crises, including the rise of al-
Qaeda and other violent jihadi groups and the regional upheavals of the Arab spring,
altered the national discourse about the role of religion in domestic political and
social affairs. The dominating concerns in public debate in the second half of the
twentieth century over how to modernize the country while remaining committed to
a Wahhabi vision of Islamic authenticity have given way to new debates featuring
“more complex and focused questions relating to increasing political participation,
social justice, the rights of women and minorities, freedom of speech, an indepen-
dent judiciary and other urgent issues which many Saudis feel are neither properly
addressed nor fully applied by the current regime” (Al-Rasheed 2007, 15).
In 2003, a National Dialogue Forum was established by royal decree, but because
it was state-controlled, the forum functioned mainly as a public-relations maneuver
to try to offset domestic political frustration and international criticism of the regime.
Another kind of national dialogue is occurring within Saudi society.
An integral part of public debate is the question of the status of women. A distinction is
beginning to emerge between the shari’a position on gender issues and what is referred to as
tarasubat wa tarakumat ijtima’iyya (social norms). Some Saudis call for a clear distinction
between what Islam allows women to do and what social norms dictate. For the first time
Saudis are making a public distinction between the religious field and social tradition. In
short, today they no longer shy away from discussing important religious principles and
interpretations, to the extent that some are openly reconsidering the heritage of Muhammad
ibn Abd al-Wahhab, whose message has held hegemonic status for almost 250 years. (Al-
Rasheed 2007, 15–16)
In furtherance of state-led gestures toward reform, in 2013, King Salman

appointed women, for the first time, to serve as members of the Shura Council.
According to the royal decree, these female representatives must be “committed to
Islamic Shariah disciplines without any violations” and “restrained by the religious
veil.” Within the council, females are segregated from male members. In August of
that year, the council introduced a new law criminalizing domestic abuse. However,
this law does not delineate any enforcement mechanisms to ensure investigations or
prosecutions nor did the regime operationalize a national policy to enforce it.
The regime’s current position on gender issues is two-faced. Royal leaders, most
visibly Crown Prince Muhammad bin Salman (MBS), have expressed desires to
introduce more liberal policies toward women at the same time as Saudi authorities
have continued to repress, arrest, and prosecute women’s rights and human rights
activists and independent clerics because they challenged the state by calling for
greater rights for women and an end to the discriminatory guardianship system. In
2018, “Saudi authorities began arresting prominent women’s rights activists and
accused several of grave crimes such as treason. . .Saudi interrogators tortured at
least four of the women, including with electric shocks and whippings, and had
sexually harassed and assaulted them” (Human Rights Watch 2019).
In 2019, at a time when the regime was facing unprecedented international
criticism of its human rights record, the Council of Ministers issued several land-
mark amendments to eliminate some elements of the guardianship system; this
occurred even as those who had championed such reforms remained in jail
(Human Rights Watch 2019). Saudi women now can obtain passports, register the
births of their children, and travel abroad without the prerequisite of a guardian’s
permission. The reforms also ended the requirement that women must live with their
husbands. However, Saudi women still must obtain a male guardian’s approval to get
married or obtain certain forms of healthcare and many discriminatory aspects of
family law remain intact in regard to marriage, divorce, and child custody. And men
can still file cases against female relatives under their guardianship for “disobedience.”
Recent developments in Saudi Arabia indicate the possibilities that even in an
authoritarian theocracy, reform is possible and the terms of religious authority over
women’s rights is fluid and debatable. But the actual nature of Saudi reforms
preserves most elements of the guardianship system and this, in turn, maintains
women’s vulnerability to domestic violence (Alquaiz et al. 2017) and impunity for
perpetrators.
Liberalization
From the beginning of its postcolonial existence in 1956, Tunisia enacted liberal
state policies on family law and women’s rights. Liberalism is defined by principles
that citizens deserve equality, individual autonomy, and nondiscriminatory political
and social rights. The liberalization of gender in Tunisia did not, however, mean that
the country’s polity as a whole was liberalized. Rather, Tunisia’s gender liberalism
has been used on many occasions by the state (prior to 2011) to shore up support for
itself and to assail or repress opponents, especially Islamists (Marks 2013). The
principle of gender egalitarianism in particular and the relationship among religion,
state power, and women’s rights in general have been durable and recurring points of
contention, including since the 2011 revolution. Therefore, the Tunisian case offers a
particularly rich example of all the key issues in this chapter.
Tunisia’s culture, history, demography, and kin-based society resembled its
Maghrebi neighbors, Morocco and Algeria. According to Mounira Charrad (2001),
Tunisia was able to chart a distinct liberalizing path on gender by establishing
relative autonomy for the state from tribal kin groupings in the aftermath of inde-
pendence and this was made possible because in the first political struggle for power,
the faction of modernizing reformers defeated the faction of socio-religious
conservatives.
One of the first major acts of the new government was to pass a Code of Personal
Status that deviated sharply from conventional interpretations of shari’a. Polygamy
and men’s right to terminate a marriage at will (i.e., repudiation) were abolished and
divorce rights for men and women were made equal. Gender-differentiated inheri-
tance rights and men’s status as heads of families remained unchanged, however.
[F]amily law reform in Tunisia was a part and a by-product of a larger project to build a
modern nation-state by dismantling the foundation of kin-based solidarities. Occurring as it
did in the absence of a feminist movement, the expansion of women’s rights that followed
from the new family law can be understood only as the outcome of a reform from above by a
reformist leadership intent on encouraging social change and on marginalizing what was left
of tribal communities. At the same time, it was the autonomy of the national state from kin-
based tribal groups that made the transformation of family law possible. . .To this effect, the
winning faction, under the leadership of Habib Bourguiba, made reforms that attacked
various traditional institutions such as the collective ownership of tribal lands, the indepen-
dent power of Islamic courts, and the predominance of the extended patrilineage in matters
of marriage, divorce, and inheritance. The moves accomplished two goals at once. They
enforced the vision of a modern nation-state held by the victorious urban-based, reformist,
nationalist faction. The moves also weakened or undermined the social bases of support of
the defeated rival conservative faction. (Charrad 2001, 201, 202)
In the new regime’s pursuit of its agenda to consolidate state power and modern-
ize the country by transforming society, expanding the rights of women was a critical
move. Given the ways in which women, family, and tradition are so often culturally
conflated, in the Tunisian case, women’s rights were instrumentalized not only to
benefit and liberate women from “backward” (a term Bourguiba often used) religio-
cultural norms but to undermine conservative religious bases of power and even to
emancipate men from tribal-kinship ties. But unlike the Turkish model in which
Kemal Ataturk sought to banish Islam as contrary to modernity, the new Tunisian
code was touted “as the outcome of a new phase in Islamic thinking” that was
inspired by shari’a and therefore was “faithful to the Islamic heritage” (Charrad
2001, 221). Thus, Tunisia forged a path to liberalize the interpretation of shari’a that,
officials claimed, could rejuvenate tradition and innovate religion in a modern and
more gender-egalitarian way. The code was presented to the Tunisian public as a
national achievement and it became a source of national pride as something that
distinguished the country from its Arab neighbors as the most progressive on
women’s rights.
Bourguiba consolidated state power into a one-party system which he dominated
as head of government, head of state, and party leader, turning Tunisia into a
“presidential monarchy” (Perkins 2014, 137). His political popularity as an inde-
pendence leader and the institutional power he accrued, combined with his agenda to
reform the role of religion led to significant transformations in government and
society. The country’s shari’a courts were absorbed into the national judicial system
and religious education was placed under the supervision of the Ministry of Educa-
tion. In order to entrench these religio-cultural changes more broadly, the govern-
ment launched a campaign to discourage all forms of traditional dress, including the
veil which Bourguiba publicly condemned as an “odious rag” that demeaned
women, had no practical value, and was not necessary to demonstrate Islamic
modesty and piety (Perkins 2014, 142).
Because it was the government rather than a grassroots women’s movement that
pressed an agenda to improve women’s rights and equalize their status in society,
what developed in Tunisia was a very strong brand of state feminism. Feminist
organizations that were established later aligned themselves closely with the state
because they supported its agenda to achieve greater gender egalitarianism and raise
the status of women. As a result of state programs and investments to socialize
education and healthcare and invest in industrial projects, rates of female (and male)
literacy rose and fertility rates fell while demands for new forms of labor brought
rising numbers of women into the workforce.
Religious conservatives were disgruntled about these changes and their own
marginalization in national politics. In 1970, students at the Zaituna mosque-
university formed the Association for the Preservation of the Qur’an to “express
their anguish over the diminishing Muslim identity of Tunisia and the parallel
deterioration of moral standards, both of which they attributed to government
policies of secularization and Westernization” (Perkins 2014, 162). One of their
leaders was Rachid Ghannouchi.
By the 1970s, the government’s ambitious but poorly designed and underfunded
socialist projects could not stave off rising unemployment and other forms of
socioeconomic distress. There was also rising political resentment over Bourguiba’s
personal grip on power and the dominance of favored allies. Tunisian discontent
spawned two kinds of mobilization: human rights and Islamist politics.
In 1977, political liberals opposed to the undemocratic aspects of one-party
governance established the Ligue Tunisienne des Droits de L’Homme (LTDH;
Tunisian Human Rights League), which was the first human rights organization in
the Arab region. In 1981, religious conservatives, led by Ghannouchi, established
the Mouvement de la Tendance Islamique (MTI; Islamic Tendency Movement),
which was inspired ideologically by the Muslim Brotherhood and motivated polit-
ically by the rise of Islamist politics elsewhere in the region. MTI resurrected earlier
calls “for individuals to embrace the moral and ethical values of religion in their
personal lives, but went on to demand that the government reverse its ruinous
economic policies and craft a more representative political structure” (Perkins
2014, 169). MTI began gaining popularity, especially among the poor as well as
among some political dissidents.
When an economically weakened Tunisia sought financial aid from the IMF and
the World Bank, the government was impelled to institute neoliberal structural-
adjustment policies which, like neoliberalism everywhere, intensified inequalities.
To deal with rising unrest, Bourguiba anointed General Zine ben Ali to suppress
disturbances. In the landscape of dissidence, MTI was the group most heavily
repressed. But persecution added to the organization’s popularity among economi-
cally disaffected sectors of society. In 1985, MTI called for a national referendum on
the Code of Personal Status and pitched the claim that the transformation of women’s
status, including their labor market participation, was depriving men of scarce jobs
and immiserating society. In response, the government, women’s organizations, and
even oppositional secular political parties rallied in defense of the code.
When it became clear that Bourguiba was no longer mentally capable of ruling,
he was removed from power in 1987 and succeeded by Zine ben Ali who inherited
all the executive powers that his predecessor had accrued. Initially, ben Ali made
gestures to political opponents, including MTI, to solidify a fractured polity. In 1988,
he announced a National Pact and promised a new era of political pluralism. MTI
was given the first chance to enter national politics, but with the caveat that it must
change the religious terminology in its name. The organization rebranded itself Hizb
Ennahda (Renaissance Party).
Ennahda did not, however, achieve the foothold in national politics to which it
aspired, and ben Ali responded to its demands and popularity with a new surge of
anti-Islamist repression. In 1992, several hundred members of Ennahda were pros-
ecuted, including Ghannouchi who was tried in absentia, and given life sentences.
This crackdown had broad appeal because, among other reasons, Tunisians were
horrified by the catastrophic clash between Islamists and the regime in neighboring
Algeria that caused over 200,000 deaths. The only sector protesting the harsh
treatment of Tunisia’s Islamists was the LTDH.
State feminism thrived under ben Ali and nongovernmental women’s rights
organizations, “including the Association of Tunisian Democratic Women (ATFD)
and the Center for Arab Women Training and Research (CAWTAR) rose to prom-
inence during the early 1990s, largely to safeguard women’s gains against the
perceived threats of Islamist fundamentalism and extremism” (Marks 2013, 229).
However, unlike Bourguiba’s political sincerity as a modernizing gender liberalizer,
Ben Ali’s manipulation of women’s rights proved transparently self-serving. . .little more
than a smokescreen—an illusion of modernity that distracted many secular leaning Tunisians
and some foreign observers alike from scrutinizing the country’s numerous human rights
abuses. Propping himself up as a defender of women’s rights gave Ben Ali a bully pulpit for
suppressing the Islamist resistance, which he portrayed as regressive, violent, and staunchly
opposed to Tunisia’s “modern” way of life. . .Manufacturing a Manichean conflict between
Islamist terrorists and women’s liberation helped Ben Ali convince many international
observers and a broad swath of the Baldī-Ṣaḥeli [bourgeois coastal] class, including many
women’s rights activists, that he was the sole guarantor of their rights and privileges. (Marks
2013, 229)
To capitalize on the support of feminists and burnish its own gender-liberal

credentials, in 1993, the government instituted a new round of legal reforms,
including giving women greater custody rights and the ability to pass nationality
onto their children, and eliminating the clause in the Code of Personal Status
stipulating that wives must obey their husbands. “It is important to note that only
secularly oriented women’s organizations were allowed to form and operate under
Ben Ali” (Marks 2013, 229). Indeed, one of the paradoxes of Tunisian politics was
that as women achieved greater rights, the state was becoming increasingly
repressive.
In 1991, Tunisian feminists began working in earnest on combatting domestic
violence, which was rife in society. ATFD formed a commission to identify strategies
to tackle domestic violence and then created “a counseling center and hotline for
women victims of domestic violence, an initiative that spread to Algeria and
Morocco and eventually elsewhere in the Arab region” (Arfaoui and Moghadam
2016, 638). In 1998, as a result of feminist activism, a law was passed criminalizing
so-called “honor crimes” and the penal code was amended to make family violence a
criminal offense with punishments double that of other kinds of criminal offenses,
although feminists complained that enforcement mechanisms were weak (Moghadam
2018, 7).
With Ennahda largely out of the way because its members were in prison, in exile,
or underground, the government turned its repressive attention to outspoken secular
opponents and human rights activists who demanded a more participatory political
environment and opposed the government’s economic policies. As in many other
contexts around the world, Tunisian political authoritarianism was a means of
squelching social unrest arising from the adverse effects and unpopularity of neo-
liberalism. Because the regime took a hard line on Islamists and was complying with
the demands of the IMF and the World Bank, Western governments were inclined to
look the other way or even subtly approve of political repression. Women were not
spared; the regime targeted those suspected of affiliation or even family ties with
banned political parties, and the most rampant form of gender violence under ben Ali
was perpetrated by state agents.
By the end of the 1990s, ben Ali’s government had evolved into a full-blown police
state. By 2004, he had become, for all intents and purposes, “president for life” in a
country where growing numbers of people were living in poverty and unemployment,
especially among the young, was skyrocketing. These political and socioeconomic ills
were exacerbated by rampant corruption; the president and his family and entourage
were amassing vast fortunes as the country spiraled downward economically and
bribery was the cost of doing even the most mundane business. These were the sparks
that ignited a revolution in December 2010. Tunisians of all political stripes took to the
streets demanding an end to ben Ali’s rule. In a little more than a month, they succeeded
in bringing down the regime and forcing ben Ali into exile.
Tunisia’s “Jasmine Revolution” inspired uprisings in Egypt and other Arab
countries over the following months. Inside Tunisia, the rapid collapse of the regime
precipitated a dramatic transformation in the country’s political culture over the
months and years to follow. The interim government made several political gestures
to try to assuage public anger and build a postrevolutionary basis for solidarity and
optimism; in addition to dissolving the ruling party, it legalized Ennahda and
allowed its exiled leader, Ghannouchi, to return, and to accommodate long-held
demands of feminists, it withdrew all of Tunisia’s reservations to CEDAW.
In the unsettled postrevolutionary environment as Tunisians began to prepare for
election, Ennahda had two distinct advantages: it had broad name recognition and de
facto credibility for having been the organization targeted most viciously by the ben
Ali regime. But it had two disadvantages: having been suppressed for so long, most
Tunisians knew little about what it stood for and it had been thoroughly demonized
by the former regime as a terrorist organization and a national menace – especially to
Tunisia’s modern, secular women.
Ennahda sought to convey to the public how their ideology had evolved from the
past; they presented themselves as “Muslim democrats,” lauded Turkey’s Justice and
Development Party (AKP) as a model they sought to emulate, and denounced Saudi
theocracy (Marks 2017, 35–36). Their main opponents were Tunisian feminists and
secularists who were intent on defending women’s rights and were inclined to regard
Islamists as inherently threatening to them (Marks 2017, 34–35). At the same time,
however, feminists were seen by many to be tainted by their long and strong associa-
tions with the deposed regime. The significance of women’s rights, both symbolically
and materially, became a dominating theme in postrevolutionary public debates.
Women’s rights stood out as one of the most fiercely contested issues in the campaigning that
preceded Tunisia’s October 23, 2011 elections, a somewhat surprising development given
that economic malaise, corruption, and police brutality—not suppression of women—
provided the impetus for. . .the revolution itself. For competing political parties, however,
women’s rights represented a useful wedge issue—one that could deflect attention from
hastily constructed economic programs and isolate electoral opponents as either “too
secular” or “too Islamist” to please the population at large. (Marks 2013, 224)
When Tunisia held its first multiparty election in the nation’s history, almost 90%
of registered voters turned out for the electoral competition for seats in the National
Constituent Assembly (NCA). Ennahda won 37% of the popular vote, over three
times more than any of the hundreds of other parties competing in the election.
“Ironically, 42 out of the 49 women elected to the 217-member Constituent Assem-
bly represented Ennahda, in part because it was the only major party to fully respect
the gender parity rules for electoral lists, and because it mobilized many female
activists to win over undecided voters and get people to the polls” (Marks 2013,
225). To counter secularists’ anxieties that the country was about to be “democrat-
ically Islamized,” Ennahda formed a coalition government with the two largest
secular parties and affirmed that the nation’s sacrosanct principles, including
women’s rights and human rights, would be maintained. Only Tunisia’s hardline
Salafis objected.
When the NCA released the first draft of the new constitution in August 2012, Article
28 used the term “yetekaamul” which many interpret to mean “complementary” (or
“complémentaires” in French) to describe the relationship between women and men.
This relational terminology reflects Ennahda’s bedrock philosophy concerning community

and human rights. Instead of viewing human rights in atomistic, individualized terms,
Ennahda—like many Islamist movements, and traditional Muslim societies in general—
prefers to see persons as interconnected within an umma, or faithful community, comprised
of different but equal components. Male and female representatives of Ennahda generally
believe that while the two sexes were created equal under God, they nevertheless remain
distinctive in terms of their biological roles and familial obligations. These views echo those
of numerous Christian conservatives, many of whom agree that while women can and often
should work outside the home, they are naturally oriented toward motherhood and more
nurturing responsibilities within the nuclear family unit. (Marks 2012, 2–3)
The religiosity embedded in the draft language of that article ignited public
protests led by feminists and spawned national debates. An online petition opposing
any language of gendered relationality as inimical to equality garnered over thirty
thousand signatures. “The semantics are the surface expression of profound differ-
ences over women’s place in contemporary Tunisian society” (Charrad and Zarrugh
2014, 231). The controversy and protests
could have led to mass resignations within the NCA and the government’s collapse, but civil
society organizations stepped in to ease tensions democratically. The National Dialogue
Quartet, consisting of the trade union UGTT, the employers’ organization UTICA, the
Tunisian League for Human Rights, and the lawyer’s association, served as mediators
between the opposition and the government, and negotiated an agreement whereby the
government would step down and hand over power to a transitional nonpartisan government
following the finalization of the new constitution. . .For its role in the peaceful transfer of
power following a very fraught summer, the Quartet was awarded the Nobel Peace Prize in
2015. (Moghadam 2018, 11)
As a result of this negotiating process, Ennahda compromised some of its long-

held ideological positions; it agreed to omit the term “complementary” and to
abandon efforts to include shari’a as a source of national legislation (Marks 2017,
47). These concessions over the text of the constitution demonstrated Ennahda’s
capacity for political pragmatism and transactional political considerations in order
to legitimize its role in Tunisia’s transition to democracy and to attract voters in the
next election (Meddeb 2019). That Ennahda was impelled by political realities to set
aside its historical mission to Islamize society was a testament to the breadth of
public support for gender equality in Tunisia.
The constitution that went into effect in January 2014 guaranteed equality in all
spheres and “a neutral state that is neither Islamist nor secular, but instead the
champion of freedom of thought, belief, and religion” (Meddeb 2019, 8). It also
contains an article stipulating that the state “shall take all necessary measures to
eliminate violence against women.” Feminists had demanded this language in order
to commit the state to redressing domestic violence. According to a 2010 study
conducted by the National Office of Family and Population, approximately 47% of
women between the ages of 18 and 64 have been victims of violence at least once in
their lives (Arfaoui and Moghadam 2016, 642).
Now with constitutional backing, feminists intensified efforts, which had been
going on for more than 20 years, to criminalize all forms of gender violence,
including that which occurs in the family. In July 2017, those efforts paid off.
Parliament, with unanimous approval, adopted a new Organic Law on Elimination
of Violence against Women, making Tunisia the first Arab country and the 19th in
the world to adopt such legislation (Belhassine 2017).
The most significant contribution of this new law is widening and deepening the definition of
violence to include sexual, physical, psychological, economic, and other forms of gender-
based violence. This constitutes an unprecedented and comprehensive level of acknowl-
edgement of violence and all its different forms, which, subsequently, provides an unprec-
edented and comprehensive level of protection against these multiple forms of violence. It
also criminalizes discrimination based on gender in all spheres. By doing so, this law moved
the notion of violence out of the private and into the public sphere by showing that violence
against women is a phenomenon that concerns all of society, including the workplace and
political participation. This increases the acknowledgement, recognition, and visibility of
these multiple forms of violence and compels society to take them more seriously. (Khamis
2017)
What makes this law so exceptional is both that it garnered unanimous approval
even by Ennahda and other religiously conservative members of parliament, some of
whom had been registering their opposition prior to the vote, and that its wording
prohibits marital rape without explicitly naming it; the law defines sexual violence as
any nonconsensual sexual act “regardless of the perpetrator’s relationship with the
victim.”
Previously, women who raised this sensitive and controversial issue were denied a hearing in
court, on the basis that this is their marital obligation and their husbands’ marital right. Based
on a strict interpretation of Shariah law, judges were able to say that marital rape was not
actually rape and, therefore, not a crime. Thanks to this new law, marital rape will always be
criminalized and unambiguously treated as rape, but also with no direct clash with the
religiously conservative camp which believes that a man’s sexual acts inside marriage are a
right not to be impeded. (Khamis 2017)
The key to the success in passing this landmark legislation was the wording;
Ennahda was willing to support it not only because doing so might enhance the
party’s reputation among the secular public (which could have implications in the
next election) but also because the wording does not overtly clash with language in
Islamic texts (Khamis 2017).
Tunisia has not solved the problem of domestic violence. But it has achieved a
legal framework and heightened public awareness that this is a problem that warrants
redress. In doing so, the basis for impunity has been significantly weakened.
Conclusion: The Role of Healthcare in Treating the “Hidden”

Epidemic
Domestic violence is a global epidemic that affects millions of women annually. But
it is also a hidden problem because of the dearth of reliable information. The reasons
for this include: the inability or disinclination of victims to report violence; refusal or
failure of authorities to document reports or make reports publicly available; official
and/or social acceptance of certain forms and degrees of intrafamily violence; and
lack of consensus on how to define domestic violence.
In the Arab world, available data about domestic violence is limited and uneven
(Boy and Kulczycki 2008). Only in a few countries in the region have national
studies that focus on or include domestic violence even been undertaken. For some
countries, there is virtually no statistical information. Much of the information that
does exist comes from local and international organizations, including women’s and
human rights organizations, and certain bodies of the United Nations with mandates
that focus on or include women’s rights.
As this chapter has argued, disrupting tacit tolerance for practices that constitute
domestic violence requires efforts to make such practices visible as violence. In
countries where this has succeeded to greater or lesser extents, it has been the result
of concerted efforts to delegitimize justifications for the use of violence by bringing
culturally relevant arguments to bear. In order to further the cause of combatting
domestic violence in the Arab region, given the durability of cultural resistance in
many countries, one way to proceed is to make the defense of women’s health and
safety the centerpiece of arguments and demands for changes in laws, jurisprudence,
and ideologies. This health- and healthcare-centered approach has come to define the
agenda of many international organizations. Focusing on the health and wellbeing of
women as vital to the greater good of society as a whole may be an efficacious means
of disentangling the issue from cultural views about women, family, and religion that
sustain impunity. Failure to protect women on the grounds that measures to do so
would contravene religion or culture literally sacrifices women’s health and safety to
some other culturally cognizable “social good.”
Because of the adverse health impacts of domestic violence, healthcare providers
are an important source of information because they are the ones – often the only
ones – abused women may turn to when they are injured or hurt. In a recent study
focused specifically on the relationship between domestic violence and health in Arab
countries, the researchers combed databases in Arabic, English, and French to conduct
“the first systematic review and meta-analysis of the prevalence and health outcomes
of domestic violence in clinical settings” (Hawcroft et al. 2019). They found that
“approximately one in two women experienced psychological violence, one in three
physical violence and one in five sexual violence from an intimate partner during their
lifetime, with over 70% experiencing any form of violence. . .This may indicate a
higher prevalence of DV [domestic violence] amongst women seeking healthcare.”
According to their findings, “Many women accessing healthcare in the Arab region
have been exposed to violence from family members or intimate partners. In some
settings, the majority of women were affected. We have demonstrated that the adverse
health outcomes of DV, well documented internationally, also affect Arab women”
(Hawcroft et al. 2019). These researchers also offer recommendations about how
information drawn from medical professionals and healthcare settings can advance
the fight against domestic violence: “Contact with a healthcare professional provides
an opportunity to identify survivors of violence, offer support and refer to specialist
services” (Hawcroft et al. 2019). The WHO has called for a healthcare response to
violence against women, but on an aggregate global scale, much of the data and
analysis comes from high-income countries.
Two conclusions can be drawn from these findings and recommendations. The first
is to further engage and coordinate people working in fields of health across the Arab
region to probe and document when injuries or other adverse health effects are the result
of domestic violence. This information “could be used to inform the development of
healthcare interventions and policy” (Hawcroft et al. 2019). The second, which brings
the role of the state directly into focus, involves translating findings about domestic
violence from healthcare settings into demands for changes in national policies and
laws in ways that will prioritize the health and wellbeing of women and girls.
Making women’s health the tip of the spear in the battle against domestic violence
may be the most effective way to beat this scourge. “This suggests that frame
alignment may be needed, including the judicious use of global frames on women’s
rights in a way that resonates with different local publics. . .The ultimate goal is to
help construct a women-friendly polity, one founded in large measure on women’s
dignity” (Arfaoui and Moghadam 2016, 649). Framing the problem of domestic
violence as a health crisis can offer a culturally relevant and persuasive means of
overcoming or undermining culturalist arguments that condone or tolerate
intrafamily violence. Indeed, one universal truism that transcends all social differ-
ences, including sex, gender, culture, and religion, is the fact that all human beings
have frail human bodies. Protecting those frail bodies is one important way of
dignifying human beings. Emphasizing health and dignity may be the frame for
the next phase in the struggle against domestic violence.
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Part II
Health Needs of the Displaced and Refugee
Population
Maternal Health Care in a Multiethnic
Setting with Examples from Sweden, 14
Scandinavia, and Europe
Pernilla Ny and Atika Khalaf
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318
Maternal Health Care in Sweden, Organizational Forms Compared to Scandinavia
and Europe: Access to Care as a Migrant in Different Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 320
Foreign-Born Women’s Experiences of Maternal Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 322
Health-Care Organizations, Health Literacy, and the Future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325
Health-Care Organizations: Different Experiences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 330
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331
Abstract
Women immigrating with their children are a vulnerable group often exposed to
ill health and a bad environment. In Europe, women from the Middle East have a
complex situation, but immigrant women from low socioeconomic status back-
grounds are at highest risk, also with regard to the perinatal period in life. In
Sweden, all women independent of their immigrant status are offered free high-
quality perinatal care performed by midwives free of charge and nearly 100% use
this care, though differently than the nonmigrant population. Often care is sought
late in pregnancy, and problems with regard to communication affect the situation
as well as care-seeking patterns. However, experiences from families originating
from the Middle East show their high trust in midwives in Sweden. This trust
must be handled with care since it is a great challenge for the health-care
P. Ny (*)
Kristianstad University, Kristianstad, Sweden
e-mail: pernilla.ny@hkr.se
A. Khalaf
Faculty of Health Science, Kristianstad University, Kristianstad, Sweden
College of Nursing, Sultan Qaboos University, Muscat, Oman
e-mail: atika.khalaf@hkr.se

https://doi.org/10.1007/978-3-030-36811-1_13
318 P. Ny and A. Khalaf
organization in Sweden as well as in other countries to host large migrating

populations, reaching out and communicating in a satisfactory way.
Keywords
Women · Immigrants · Reproductive health care · Perinatal period · Families ·
Staff · Socioeconomic status
Introduction
Every day, even in the twentieth century, about 830 women die due to complications
of pregnancy and child birth settings, and most could have been prevented (WHO
2018a). Between 2016 and 2030, as part of the Sustainable Development Goals, the
World Health Organization (WHO) is aiming to reduce the global maternal mortality
rate to 70 per 100,000 live births. The sad part is that most deaths are preventable
since management of these complications is well known: “All women need access to
antenatal care in pregnancy, skilled care during childbirth, and care and support in
the weeks after childbirth” (WHO 2018b).
Worldwide, migrants are extremely vulnerable groups due to conflicts, underly-
ing diseases, and their experience. All this, put into a gender perspective, make
women and children even more exposed. The majority of migrants are from low- and
middle-income countries, about 135 million people, mostly living in high-income
countries. Many of these women are often in the reproductive periods of their lives
and in many countries these women represent more than 20% of the birthing
population (Merry et al. 2016).
Women in their reproductive age are vulnerable to different exposures and risks,
for both them and their children. The stress of the migration process might also lead
to psychological problems such as depression and postpartum depression, which
also affect not only the woman but also her children and family negatively. Even
more severe situations such as posttraumatic syndrome and schizophrenia can occur
in these exposed groups (Moreira Almeida et al. 2013).
The migrant population in different high-income countries consists of a widely
diverse group of families and individuals. This leads to a challenge in the ability of
offering suitable services in the health-care sector. Therefore, it is of great impor-
tance to understand the behavior of migrants seeking health care. Studies undertaken
in Sweden show how different groups went to different health-care providers during
pregnancy, even though it was not the “normal” way of seeking health care.
Immigrant women from eastern European countries sought more unplanned health
care at the delivery ward, instead of planned care at the midwifery clinics, as an
example (Ny 2007; Phillimore 2015; Moreira Almeida et al. 2013).
Results from a systematic review investigating the perinatal health of migrants to
industrialized countries indicates that migrants were described primarily by geo-
graphic origin and that other relevant aspects (e.g., time in country, language
fluency) were rarely studied (Gagnon et al. 2009). Another important finding of
14 Maternal Health Care in a Multiethnic Setting with Examples from. . . 319
the review by Gagnon et al. (2009) is that preterm birth, low birthweight, and health-
promoting behaviors among migrants were as good or better as those for host
country’s women in 50% of all cases. They reported that North African migrant
women are among those with greater risk of feto-infant mortality than most of the
receiving populations. The authors concluded that although the migration literature
is extensive, it is heterogeneous in the design and definition of migrants, which limits
the conclusions that can be drawn. Thus, research that uses clear, specific migrant
definitions adjusts for relevant risk factors and includes other aspects of migrant
experience is needed to confirm and understand these associations.
Factors that prevent women from receiving or seeking care during pregnancy and
childbirth are not only practical reasons such as distance to maternal health-care
centers, but also lack of information, cultural practices, and suppression in the family
where they live. Therefore, it is important to improve maternal health and identify
barriers that limit access to quality maternal health services (WHO 2018b). This is
also supported by newer data from the UK (Phillimore 2015) where researchers
interviewed the most vulnerable immigrant women without any or little support in
the new country. They identified multiple factors associated with an inappropriate
health-seeking pattern such as lack of skilled interpreters, miscommunication, use of
family members as interpreters, and lack of understanding from the health-care staff.
In Sweden, the use of professional interpreters and the nonuse of family members are
stressed. Women coming from other cultures may find it difficult adapting to the
primary health-care system if they are used to hospital-based care. Therefore, they
face some difficulties in understanding the gatekeepers as well as the procedures
used, at least in the beginning of their stay in the country.
The immigration process makes adaptation of the new immigrant women difficult
since they can also face a complex family situation being dependent on the family of
the father to-be for example and thereby becoming disempowered. They might
experience homelessness or fear of immigration services together with economic
difficulties such as having no income to buy clothes for the colder climate for
themselves or their babies making income a higher priority instead of seeking health
care. It is nearly impossible to reach the maternity health-care setting when suffering
from financial difficulty for transport expenses, which, is a fact that some migrant
women, especially illegal migrants, suffer from (Firth and Haith-Cooper 2018).
These factors among others are important for the professional to get an understand-
ing of the pressure that immigrant women are facing in the immigration process.
In the area of reproduction, immigrant women do show a higher risk of low birth
weight and preterm birth, and some groups do have higher risks of worse outcomes
than the native population (Merry et al. 2013). An unequal burden of harm has been
reported in different studies, which highlights the importance of understanding
immigrant women’s experiences as well as their care-seeking patterns (Phillimore
2015). As shown in Finland, immigrants have less access to good quality care (Malin
and Gissler 2009). In Scandinavia, research shows that certain groups of immigrant
women are at risk of giving birth to small gestational age children, similar to women
born in the Middle East, North Africa, and South Asia (Skøtt Pedersen et al. 2014).
Also in Europe, migrant women are at a higher risk of maternal mortality, than other
women. There are different kinds of deaths as well due to different reasons. Sub-
standard care might cause death in these groups, but women’s health status might be
the cause of indirect deaths.
Furthermore, lack of connection, communication, and cultural understanding
does impact the health and well-being of migrant women’s experience of childbirth.
A qualitative analysis of asylum women’s experiences of childbirth in Ireland (Tobin
et al. 2014) showed that inadequate and poorly organized maternity services were
complicated by lack of training in cultural understanding. In addition, sporadic
access to interpreter services had an unfavorable impact on the care provided to
immigrant women during the antenatal period. Furthermore, health-care providers
appear to lack insight into the specific needs of this vulnerable group as shown in
evidence of traumatization related to pre- and post-migration stressors. This could
result in lack of effective connection and communication, which could worsen
immigrant women’s experiences of alienation, loneliness, and isolation (a.a.). The
authors want to emphasize that some of the most important implications for practice
should be a focus on “how” providers can meet the maternity care needs of asylum-
seeking women. Examples of such practical knowledge could be community-based
services, training in cultural competence, 24-h access to skilled interpreters, and
information leaflets in several languages.
Noteworthy, not all migrant women have higher risk factors. A British study
showed less risk for preeclampsia for women from the Middle East as an example
(Urquia et al. 2014). The effect of migration on risk factors for cesarean section is
still lacking, but there seem to be a combination of different factors where length of
time since migration seems among others to be an important contributing factor
(Merry et al. 2016). This was also reported in a German study where women have
free access to maternal health care independent of residential status (David et al.
2017). Similarly, in other international studies, the differences found were not due to
immigration only but to socioeconomic status as well. Women with lower levels of
education were more at risk even if they were of German origin. However, a possible
limitation introduced in this study could be the fact that the authors defined women
as immigrants putting both first- and second-generation immigrants in the same
analysis group. Using the information we have that a lack of knowledge about the
health-care system and the need for interpreters when encountering the system are
risk factors associated with probably first generation immigrants, this might have
affected the outcome of the calculations and risk associations between German and
non-German women (David et al. 2017).
Maternal Health Care in Sweden, Organizational Forms

Compared to Scandinavia and Europe: Access to Care as a Migrant
in Different Settings
Maternal health care in Sweden is free, is handled by registered midwives and

available for everyone. The coverage in Sweden is very high; almost 99% of all
pregnant women use maternal health care. However, the pattern of use is different in
different groups depending on country of origin. Use of interpreters and having

the clinics out in the communities are a norm (Affinity for obstetricians, midwives,
and psychologists; Merry et al. 2016).
The midwife in the maternity health-care clinic out in the municipality can be the
first contact with Swedish society that the foreign-born family gets. Through the
midwife, the woman and her family develop an understanding of how the health-care
system in Sweden works and how Swedish family life works, how it is organized and
also regulated. This is a challenge both for the family as well as for the organization.
Being a professional in these circumstances puts exceptional demands on: offering
special treatment such as provision of more visits than the national recommendations
(normally 7–9 times including the post-partum visit at 6–8 weeks after birth), using
interpreters, and working together with other public institutions such as social
services, primary schools, and child health care. Further, maternal health-care pro-
fessionals could put demands on an organizational level where every health-care
organization should be expected to develop its accessibility to meet the new chal-
lenges. To organize health care so that every person in the society gets an equal
chance to access care independent of one’s background and language skills is a
human right and a way to secure better health. The organization of health care
considering these issues might include more flexible visiting hours, information
guides in different languages leaflets, and when communicating on the phone
(Ny 2016).
The Swedish maternal health-care system is affected by the global situation. In a
pluralistic society such as Sweden today demands that health-care providers offer
good quality care independent of the care seekers’ ethnic origin, belief, skin color, or
sexual orientation. As discussed above, the origin and the social class of people does
affect their health, health behavior, and future health. Therefore, a professional
organization needs to be updated about exposed groups and their specific needs.
Sweden has a long tradition in providing promotional and preventive health care.
Thus, conducting this together with the positive status and good reputation of the
midwife has led to one of the lowest maternal and child mortality rates globally
(Ny 2016).
In Sweden, the general health status has not developed during the last 20 years.
Meanwhile, the population’s diversity introduces new challenges to the health-care
system in form of different health statuses among the different social groups. The
fact that immigrants have poorer health than the Swedish born population is evident
especially in the segregated areas. Further, people who have immigrated to Sweden
have a greater risk of developing ill health than the Swedish-born population, and
utilization of health and medical care by the immigrant population is higher in
general. Yet, the utilization of the Swedish perinatal care services remains sub-
optimal. It has also been shown that women born outside Europe immigrating to
Sweden have reported poorer experienced health in comparison to other immigrant
women, due to both pre immigration as well as post immigration factors (Stockholm
County Council 2014). Furthermore, not only health-related differences have been
observed, but also the immigrant women’s labor situation could be affected,
depending on their level of education and the reason for immigration. A doctoral
thesis research undertaken in the southern region of Sweden (Essén 2001) showed
that immigrant women from the Horn of Africa had an increased risk of perinatal
mortality due to pregnancy strategy practices in combination with suboptimal
utilization of Swedish perinatal care services. Therefore, time is a crucial factor in
improving the health status and the ability to and chances of engaging in the work
force for many immigrants, especially women. The longer the time in a country the
better chances according to the Swedish Migration Office ( 2018). Consequently, the
Swedish Parliament made a decision about new goals for public health in 2003
(2002/03:35 Mål för folkhälsan (Goal for the health of the public)) stating that
integration is an important political area and needs to be considered in the field of
health care as well.
Foreign-Born Women’s Experiences of Maternal Health Care
Globally, the midwife is the most cost-effective and appreciated caregiver for low-
risk women during pregnancy and birth (Khan-Neelofur et al. 1998). By providing
good antenatal care, dealing with unwanted pregnancies, and improving the way
society looks after pregnant women, it is possible to make pregnancy and childbirth
safer. WHO concluded, however, that inappropriate perinatal care and technology
continues to be practiced widely throughout the world. Therefore, they have pro-
posed principles for antenatal care (WHO 2018b) that recommends, in detail, what
activities should be abandoned and what forms of care can reduce the negative
outcome of birth (“too little too late, too much too soon”). The care for a normal
pregnancy and birth should be de-medicalized and that less, rather than more,
technology should be applied. Likewise antenatal care should be supported by the
best available research where possible and appropriate. Increased use of antenatal
care will not only increase public expenses but the avoidance of the possible
negative physiological effects of the medicalization of a normal life event may be
more important. If the general attitude prevails that pregnancy is a dangerous period,
this will set the stage for unnecessary medical examinations and interventions with
the potential for iatrogenic injuries. Established procedures should be implemented
that are right for the individual person and at the right time (WHO 2018b).
Sexual and reproductive health is an integral part of basic human rights. Thus,
access to sexual and reproductive health care is the gateway to health; because not
only it is vital for our survival as mammal species but it also represents the most
important steps toward gender equality. At the World Conference on Human Rights,
in 1994, 179 countries came to an agreement that empowerment of women and
achievement of people’s individual needs for health including reproductive health
was accepted as essential for sustainable economic, social, and environmental
development. The purpose of maternal health care is to enable the birth of as
many healthy babies as possible to well-prepared parents and should consist of a
number of scheduled visits to health-care services in order to detect symptoms such
as hypertension and deviation from normal fetal growth as well as offering psycho-
social support and health education. The history of success in reducing maternal and
new-born mortalities shows that skilled professional care during and after childbirth
can be the difference between life and death, and have impact postpartum. In reality,
it is often not so that the medical checkup can prevent a complication from happen-
ing, but may reduce the damage by early intervention. The purpose is also to deliver
effective and appropriate screening or prevention, or treatment intervention, to
ensure and maintain continual improvement in a high level of health care and to
avoid outdated and possibly harmful interventions (Ny 2007).
In the strategic approaches from Making Pregnancy Safer, WHO highlights the
need for empowerment of individuals, families, and communities to increase
the control of maternal and neonatal health, but there are few studies focusing on
the views of immigrant women in general and women from the Middle East
specifically on maternal health care in Sweden. One study showed that women
from the Middle East stated that they felt safe when they had knowledge of the
Swedish health-care system. Being able to ask the professional and knowledgeable
staff made the women feel safe since most of them did not have a female network in
Sweden. Being prepared created a sense of security for the women and they were
positive toward participating in the parental education offered. Furthermore, they felt
positive about the fact that the husband was invited to participate (Ny 2007).
In the UK, in 1996, a reduction of the number of visits (from 13 visits to 6–7
including low-risk pregnant women) was introduced in an ethnically diverse area.
The visits were still as clinically effective, but the reductions lead to reduced
psychosocial effectiveness and dissatisfaction from the woman’s point of view
(Sikorski et al. 1996). A study in Middle Eastern women in Lebanon revealed
women’s satisfaction in both rural and urban settings (Kahakian-Khasholian et al.
2000). The most important thing, for the women in the Lebanese study, was the time
spent and the communication, empathy, and skills the staff provided both during
their pregnancy and during delivery. Being cared for by health-care personnel they
trusted, they experienced a significant reduction of their fears.
Few studies have focused on immigrants’ views of the maternal health care in
Sweden and their views on becoming parents in a foreign country such as Sweden.
The foreign-born parents, or parents to be, will encounter a very different worldview
regarding parenthood and gender equality in Sweden. The formal attitude in Swedish
society is that men should take equal responsibility for the household and the
upbringing of the children, as well as the woman/mother is expected to work in
paid employment after having children (Ny 2007). Another group of immigrants
living in Sweden expressed both positive and negative feelings about being an
immigrant. The reasons for the father to be entering the female arena of pregnancy
and childbirth were because the woman did not speak the new language, she was
lonely. Some said it was because he wanted to, motivated by responsibility toward
his family. He acted as the spokesperson for the woman. Globally, women seem to
share the attitude of the importance of having the partner present in pregnancy and
birth. Many women also mentioned the importance of the psychosocial support
provided by the husband during pregnancy (Wiklund et al. 2000).
Studies show that the foreign-born woman is grateful that the male partner is
included in her care in the perinatal period. She is glad about the increased
involvement in what was formerly a woman’s world. The lack of her former female
network opens up new areas for men to be involved (Ny 2007; Wiklund et al. 2000).
Many men are also positive to step into this female arena thereby supporting their
families also by making them more independent in this new society: “you have to be
strong to be independent” (Ny 2007). By including the men in the world of women
and children, he can offer support, a sense of safety for the women, and a greater
involvement in his children which together also makes the risk of domestic violence
less likely. Also important is that the health-care organization can also support the
independence of women by offering interpreters and not using family members as
such. A patient has the right to their anonymity even within the family. This is,
especially important in the area of reproductive and sexual care (Singh and Newburn
2003).
The rates of cesarean section have been discussed in different contexts and
whether the Middle Eastern female population has a higher rate of cesarean births
compared to other populations, especially host populations. A literature review and
meta-analysis of 33 studies comparing cesarean birth rates of migrants by region/
country of origin to nonmigrants living in high-income countries showed that
women from among other regions of North Africa and Middle East consistently
show higher rates of emergency cesarean (Merry et al. 2016). The authors wish to
draw attention that the risk factors causing cesarean births need to be investigated
further but they are likely to involve both migration-related factors as well as the
quality of their maternity care.
Maternal adverse events in Middle Eastern women in Germany were different
from the host population as reported in van den Akker and van Roosmalen (2016).
They had for example an increased risk of sepsis (OR 2.2 (1.6–3.1)) but lower risk of
peripartum hysterectomies (a.a.). Furthermore, women from Middle East and North
Africa were among those with higher prevalence of early and late preterm birth
(9.3%) compared to Swedish-born mothers (Khanolkar et al. 2015) but had lower
odds of preeclampsia compared to women from six industrialized countries (Urquia
et al. 2014). They also have the highest proportions of overweight and obesity
(Khanolkar et al. 2015).
Compared to Swedish mothers, women from the Middle East had a higher risk of
delivering low birth weight babies (OR 1.63) and preterm child birth (OR 1.16), but
lower risk of delivering large for gestational age babies (OR 0.26), and post-term
delivery (OR 0.96) (Juárez and Revuelta-Eugercios 2016). On the other hand,
women from North Africa were found to have increased risk of delivering large
for gestational age babies (OR 1.48), and have post-term delivery (OR 1.36), but
decreased risk of delivering low birth weight babies (OR0.79) and preterm child
birth (OR 0.99) (Table 1).
Studies have shown that even though free health care in Europe exists for all
women, immigrant women, women with foreign backgrounds, and those with lower
incomes are more likely to receive inadequate care. The best care for low-risk
women is offered by midwives since they are commonly available and known by
the women (Delvaux et al. 2001). In Sweden, health care for pregnant women
including sexual and reproductive care is offered by midwives and regulated by
Table 1 Risk for adverse outcomes in Middle Eastern and North African women compared to
diverse Western populations
North
Middle Africa RR/OR (95%
Study Risk for East (n) OR (95% CI) (n) CI)
Juárez and Low birth 20,570 1.45 (1.13–1.85) 1657 0.79 (0.57–1.09)
Revuelta- weight
Eugercios Macrosomia 0.26 (0.08–0.81) 1.48 (0.94–2.33)
(2016) Preterm 1.16 (0.93–1.44) 0.99 (0.78–1.25)
Post-term 0.96 (0.79–1.16) 1.36 (1.15–1.60)
Urquia et al. Preeclampsiab 13.8 per 1000 deliveriesa 0.75 (0.71–0.79)
(2014)
Khanolkar et al. Early preterm 3,985a 0.73 (0.43–1.24)
(2015) Late preterm 3,985a 0.90 (0.74–1.06)
Ekéus et al. Stillbirth 65,937 1.37 (1.22–1.55)
(2011)
a
Both Middle Eastern and North African populations
b
Total (n) with preeclampsia = 3,031,399
national recommendations (Affinity for obstetrician, midwives and psychologists’

et al. 2016).
Health-Care Organizations, Health Literacy, and the Future
The expression “super diversity” implies that there is a large diversity both within
groups as well as between groups based on their migration status. Such variation can
be due to gender and associated rights and entitlements, different beliefs, reasons for
migration, socioeconomic status, educational levels, and more, leading to a demo-
graphic complexity. This will have an effect on the need to restructure public
services in the light of diversification, which can introduce challenges on both social
and political levels (Phillimore 2015).
Health-Care Organizations: Different Experiences
Many of the immigrant women coming from the Middle East and Central Africa
sometimes have a limited experience of preventive health care in general. Further-
more, access to health-care facilities is also dependent on the organizational forms of
the health care provided in the respective country and can affect the experience of
interventional health care. However, compared to the public health priorities in
European countries in general, health promotion and preventive actions are not
well developed and fully accessible to all members in Middle Eastern countries.
Few of these counties have the economic capacity and health infrastructure to serve
the population with a preventive health-care program, since this demands a
functioning state and governmental economic support. Therefore, there is often also
a lack in national guidelines with regard to health care for pregnant women and the
curative attitude is more prevalent (Kahakian-Khasholian et al. 2000).
Preventive health care requires an interaction between many factors. The first
factor is related to the patient and his or her possibility of understanding the advice
given. This in turn requires that health-care staff have knowledge as well as an
understanding of the value base and a wish to provide preventive health care for each
individual. Preventive health-care actions also require that health-care personnel
have the knowledge about how to communicate in a supportive manner using a
positive and nonjudgmental attitude. This is the fundamental in a society where the
patient has the right to make informed choices and become involved in his or her
health care and the decisions made.
Migration has become one of the most important determinants of global health
and social development. Reproductive health is one of the most important and often
unmet public health challenges in relation to migration. At the same time, the
migration process can lead to new customs for the parents to-be, such as the greater
participation of the male partner during pregnancy and birth which is the case in
Sweden when asking fathers from the Middle East who had become fathers while
living in Sweden. Being able to take part in the delivery situation, sharing their
wives’ struggle through delivery, and meeting with health professionals, together
with their child, was considered as a very deep and profound experience (Ny 2007).
The background of the individuals matters in the meeting with the health-care
organization since earlier experiences affect the individuals’ care-seeking pattern.
Those women who have left their social network behind can experience social
isolation and worse health since they have now lost their previous knowledge and
support base. Globally women seek knowledge from professionals as well as
the female network (Barclay 1998). The experience a woman has from her home
country is usually brought to the new country (Ny 2007), but independent of the
woman’s background and previous experiences, access to a midwife-led health-care
facility during pregnancy is a key to security, support, and knowledge within
perinatal care.
To understand health care-seeking behavior, it is important to understand migra-
tion. It is a process of social change and within this change process, a group selects
portions of a dominant or contributing culture that fits their original worldview and at
the same time strives to retain what is left of their traditional culture. Any such event
that means leaving the social networks behind creates a sense of dislocation,
alienation, and isolation. There are both physical and psychological aspects related
to health, but experiencing a sense of coherence is of great importance for health.
Migration in itself adds to a loss of coherence. One reason for this can be discrim-
ination regarding both housing and the labor market. Other reasons can be, how one
lives, the reasons for migration, experiences from a traumatic background, and
earlier conditions when living in the native country. At a sociocultural level,
transnational immigration has created significant economic, health, and social–psy-
chological problems in societies and nations where similar problems have not been
seen earlier. Immigrants have left their communities of origin in search for change as
they look for acceptable political climates, improved economic conditions, and the
protection of their beliefs and values. How individuals and groups deal with this is an
important research question and acculturation has become an important concept in
trying to explain the different experiences of minorities, such as international
migration, in the creation of multicultural societies. Adaptation and change are
important components and instead of assimilation, one should consider that there
are many options available to individuals interacting with a new culture, also linked
to the experiences of received health care (Ny 2007).
Different models have been criticized for “pathologizing” ethnicity due to the
often poor outcome, but providers in Scandinavia, the United Kingdom, and the
Netherlands have seen that providing different specialist services, such as midwifery
clinics, is a good way to go (Phillimore 2015). Being a foreign-born woman and
multiparous, they have more pregnancy-related risk factors which might result in
negative health outcomes and experiences postpartum. Therefore, the country that
hosts them needs to address their psychological and biological factors while caring
for them (Malin and Gissler 2009). It is not only the physical factors that affect the
health of foreign-born women, they also have less access to care, use health care less
compared to other populations, and get or use less optimal care. All these factors
might result in a higher incidence of adverse outcomes, which is a challenge for the
countries that host them and the health-care providing organizations (Moreira
Almeida et al. 2013).
Physical factors such as anemia, being malnourished, grand multipara, having
several cesarean sections, and hypertension are factors that might have fatal conse-
quences for women often from subtropical Africa and having just arrived to the host
country (Skøtt Pedersen et al. 2014; Urquia et al. 2015). The health outcomes are
better the longer they stay in the new country, which also occurs in Sweden. Other
factors of importance are being from a higher-middle income or higher-income
country, having developed a better health status and having a better possibility to
get access to the health care in the new country. Furthermore, an understanding of the
different procedures may improve foreign-born women’s health-seeking behavior
and prevents them from seeking care in time (a.a.). This together with communica-
tion difficulties in the host country’s language might introduce an increased risk of
adverse health effects. Overcoming all these barriers is both a political as well as
professional dilemma (van den Akker and van Roosmalen 2016), but should be a
major priority of the host communities.
Due to a pregnant women’s vulnerability, policy makers should prioritize access
to care as well as the quality of care given to these often high-risk groups. At the
same time, increasing literacy about the existing health-care systems could help
women and families on an individual level. The right to access to the highest level of
care is a human right and governments who are signatories to the Universal Decla-
ration of Human Rights and the International Covenant on Social, Economic and
Cultural Rights should strive toward progressive realization of this standard. Failure
to do so could result in governments being held responsible for cases of maternal
mortality and severe morbidity among foreign-born women (Skøtt Pedersen et al.
2014).
Studies performed on sexual health determinants among migrants in Europe show

that level of education has a crucial importance in maintaining the health and well-
being of women (Keygnaert et al. 2014). The lower the level of education, the less
importance is placed on health care. Women and girls use friends and media more
often as well as different educational and religious settings to seek medical advice,
instead of seeking health care advice from professionals. Knowledge about this
phenomenon is important when trying to deliver health care advice to exposed
groups and getting it across to them (a.a.).
Migrants cover a diverse population, as in Belgium, for example, where two
thirds of new mothers are migrants who are well-off workers from nearby counties.
However, the migrant population is more often dominated by women from low- and
middle-income countries and from war zones (Keygnaert et al. 2014).
In most European countries, maternal health care is free – as is the case in
Sweden. This free health care has been a cornerstone in maternal health care for
decades. Regardless of the immigration status of pregnant women (i.e., if they
belong to a low socioeconomic level, and have had emotional strain due to isolation,
hostility, or discrimination), PTSD in the household has to be considered. It is
important with regard to public health to begin antenatal care early in pregnancy,
to inform people about risk factors of stillbirth and improve the health literacy for
women and their families in perinatal care. This makes it possible to reach more
women and families with more significant information at stages when the informa-
tion is most effective. In a study performed in Sweden most of the immigrant
women’s death was due to suboptimal care, but may also be that the women used
the existing health care in a suboptimal manner, which complicated the use of the full
potential of the care provided. Therefore, it is recommended for clinicians to acquire
more insight into these groups in order to build a better understanding and thereby
make it possible to guide the patients/women through their health-care needs with as
few risks as possible (Esscher et al. 2014).
As stated in Miller et al. (2016), there are two extreme situations in maternal health
care worldwide: too little, too late (TLTL) and too much, too soon (TMTS). The
former (TLTL) describes care with inadequate resources, below evidence-based stan-
dards, or care withheld or unavailable until it is too late to help. This is a risk factor for
maternal mortality and morbidity. The latter (TMTS) describes the routine of over-
medicalization of normal pregnancy and birth. This means an unnecessary use of non-
evidence-based interventions, but also use of interventions that normally are life-
saving when used appropriately, but harmful when overused. Therefore, it is of utmost
importance that a global approach is taken to support the implementation of evidence-
based care for all women but especially for immigrant women because of all the
factors described above. As previously mentioned, preventable maternal morbidity
and mortality is associated with the absence of timely access to quality care, and
women immigrating from poor to rich countries are at the greatest risk. Therefore,
clinicians and the systems that guide them need to make sure that all women receive
high quality, evidence-based, equitable and respectful care. It is important that it be the
right amount of care at the right time and delivered in a respectful way that protects and
promotes the human rights of every single woman (a.a.).
It is important that we follow the path that was set during the United Nations
General Assembly 2015, in New York. UN Secretary-General Ban Ki-moon
launched the Global Strategy for Women’s, Children’s and Adolescents’ Health,
2016–2030. This strategy describes the Sustainable Development Goals and seeks to
end all preventable deaths of women, children, and adolescents and creates an
environment in which these groups do not only survive, but also thrive.
As part of the Global Strategy and goal of Ending Preventable Maternal Mortal-
ity, WHO is working toward:
• addressing inequalities in access to and quality of reproductive, maternal, and

newborn health care services;
• ensuring universal health coverage for comprehensive reproductive, maternal,
and newborn health care;
• addressing all causes of maternal mortality, reproductive and maternal morbid-
ities, and related disabilities; and,
• strengthening health systems to collect high quality data in order to respond to the
needs and priorities of women and girls; and,
• ensuring accountability in order to improve quality of care and equity (WHO
2018c).
Greater effort is needed to improve the quality of the health-care service offered to
all women during their antenatal period. In addition, increased attention is required
to ensure that particular groups of women, especially those living in rural areas, the
poor, and the less educated, obtain better access to antenatal services (Löf 2006),
which is of importance in all countries. Antenatal care has the advantage of enabling
the creation of a long-lasting relationship with both of the parents to-be and that can
lead to empowerment, a feeling of respect and participation; not only in the setting of
parenthood and women’s health, but also the feeling of being an accepted and
worthy member of society as a whole.
Foreign-born women in general have limited knowledge about their rights, which
might affect their health-seeking behavior in the new country. Questions regarding
expectations, how the communication with caregivers worked, if the parents expe-
rienced support from health-care personnel, and if the partner felt engaged as well as
the parents’ feeling of affirmation all affect the pregnant women’s experiences to a
great extent.
As a professional, the health-care personnel have to be aware that a woman’s
behavior is not only a result of her own priorities. As for an example, women who
gain support from their significant others with regard to breastfeeding do breastfeed
longer. Many women who come from families with traditional values might find it
difficult to adapt to the new country’s norms and traditions. For example, Sweden is
a country where the society expects that the woman will take part in the workforce
and play an active part in the society’s development besides being a mother. This
way of looking upon women and society can have obvious results for breastfeeding
(less than other nations), expectations on the father’s involvement during the whole
antenatal period, having the opportunity of paid parent leave to care for the child, etc.
On the other hand, the foreign-born women do not have the same priorities, for
example, they in general not take part in the perinatal education groups together with
their partners. These educational sessions are offered free of charge to expecting
couples to prepare them for their new role as parents, and they have a strong tradition
among the Swedes. Being seen as a good father, partners need to take part in the
preparation and planning phases of pregnancy to show that they are going to take an
active part in their role as supporting partners as well as fathers to the unborn child.
This example clarifies that the health-care organization must work in a different
way in order to reach foreign-born families. Sarkadi and Bremberg showed already
in Sarkadi and Bremberg (2005) that reaching families from low socioeconomic
levels was more satisfactory if health-care providers could communicate via Internet
for example. Another simple way to spread information is by using places where
immigrants feel comfortable such as in cultural and religious settings. Other com-
munication channels could be inviting people from different cultures to get access to
different groups via significant others, such as trusted leaders.
How can the health-care organization and the health-care professionals encounter
the immigrant family? A kind and compassionate encounter and an understanding
from the professionals were the most important aspects in the sense of preventing ill
health. That is the result from a Swedish study with material from the child health-care
setting (Samarasinghe and Arvidsson 2002). To communicate about one’s health
together with someone the woman and the family know and with someone whom
the health-care seeker feels safe with can make the person understand facts much
better, as shown in a Swedish study including immigrants from the Middle East, both
fathers and mothers (Ny et al. 2006). Therefore, as a professional, it is of importance to
be aware of one’s own attitudes and feelings toward others (Akhavan 2012). By
communicating compassionately, the woman and her partner have a greater chance
of experiencing support and thereby feeling safe (Halldórsdóttir and Karlsdóttir 1996).
Conclusions
There are various causes of suboptimal outcomes of the antenatal period for women
from the Middle East and Africa. Some of these causes are strongly influenced by the
health-seeking behavior of the women and their partners. Consequently, a multifaceted
approach needs to be taken in order to improve these outcomes with a focus on early
access to antenatal services and enhanced medical screening and surveillance for
detection and optimization of comorbid conditions. Providing information and trans-
lation services are important components in the improvement of standards of care.
In addition, a critical study of the norms applied to white middle-class women
needs to be undertaken in order to address the needs of migrant women. Further
research looking specifically at antenatal care and childbirth education for ethnic
minority women is also needed. There is also an urgent need for further investigation
of the barriers to using information and translation services which are critical
components in the improvement of the standards and provision of effective care
ethnic minority women.
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Mental Health and Well-being of Refugees
15
Muhammad Ilyas, Ammar Ahmed Siddiqui, Freah Alshammary,
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334
The Plight of Refugees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335
Impacts on the Mental Health of Refugees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337
Impact of Mental Disorders on Family and Relatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 338
Impact on General Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339
Cardiovascular Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339
Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339
Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339
Oral Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 340
Issues Faced by Refugees and Refugee-Hosting Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 340
Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 340
Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341
Social Integration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342
The Influx of Refugees and Their Cultural Acceptance in Host Countries
(Sociocultural Adversity) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343
M. Ilyas (*)
Department of Management and MIS, College of Business Administration, University of Ha’il, Ha’il,
Saudi Arabia
A. A. Siddiqui
Division of Dental Public Health, Department of Preventive Dental Sciences, College of Dentistry,
F. Alshammary
Division of Pediatric Dentistry, Department of Preventive Dental Sciences, College of Dentistry,
A. S. Al-Enizy
College of Dentistry, University of Ha’il, Ha’il, Saudi Arabia
M. K. Alam
Orthodontic Division, Preventive Dentistry Department, College of Dentistry, Jouf University,
Sakaka, Al Jouf, Saudi Arabia

https://doi.org/10.1007/978-3-030-36811-1_14
334 M. Ilyas et al.
Mental Health and Well-being of Refugees with Psychosocial and Psychological

Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 348
Abstract
Refugees and displaced people are often victims of mental stress and psychological
trauma that starts with facing the conditions causing them to leave their home
countries, families, and loved ones and continues with the migration to a new host
country and the complications of resettlement. The stress and anguish they face are
often related to experiencing the atrocities of wars and persecutions. Financial
difficulties further add to the trauma and increase the mental stress in refugees.
Integrating into the new host country, facing linguistic and cultural barriers and
challenges due to their unidentified legal status and with limited or no job oppor-
tunities, exacerbates stress levels of displaced people. Stigma of mental health
issues further deteriorates their mental health. The living conditions of refugees,
food insecurity, poor quality services and health, poverty, and suffering from sexual
and gender-based violence increase the risk of mental health issues and psycho-
logical trauma. More welcoming interventions and practices can reduce mental
stress of refugees, and providing them with rights and services can positively
impact their mental health and psychosocial well-being. This chapter reviews the
literature on the mental health and psychosocial well-being of refugees. The influx
of refugees in host countries and the attitude of host nations integrating refugees are
also reviewed. Mental health issues are related to poverty, marginalization, lack of
access to education and health care, and poor community support. Inconsistent
practices, policy gaps, restrictions on cross border movements, insufficient financial
resources, poor coordination among governments, and lack of commitments are the
main reasons associated with increased stress levels in refugees. Recommendations
that can ease the lives of refugees are provided so that policy-makers can change
conditions to improve the well-being of refugees.
Keywords
Refugees · Asylum · Mental health · Stress · Psychological · Psychosocial ·
Social integration · Linguistic and cultural barriers · Stigma
Introduction
The current global refugee crises are at its most critical point in history (Ashfaq et al.
2020). The last three decades have seen devastating wars and ferocious conflicts in
the Middle East, Africa, Eastern Europe, Central America, and Central Asia that
have increased the refugee crisis in many countries. The United Nations High
Commissioner for Refugees (UNHCR 2019) reports that at least 79.5 million people
have been forced to flee their homes due to violence, persecution, conflict, and
human rights violation. Among them are nearly 26 million refugees (UNHCR 2019).
15 Mental Health and Well-being of Refugees 335
There are currently 45.7 million internally displaced individuals and 4.2 million
asylum-seekers refugees. These refugees are at great risk of facing social, economic,
environmental, political, and mental health difficulties (Kazandjian et al. 2020;
Walther et al. 2020). Among others, armed conflicts cause psychological distress,
behavioral disorders, and increased prevalence of mental illnesses and disabilities
such as post-traumatic stress disorder, depression, and anxiety.
The mental disorders in refuges can be classified according to their occurrence
before the flight, during the flight, and after their resettlement (Fazel et al. 2012;
Buchmüller et al. 2020). In the preflight phase, organized violence disrupts public
infrastructure and limits access to school and health facilities. The children and their
caregivers face severe adversities associated with violence, such as torture,
witnessing violence, or losing family members due to conflict and war. Likewise,
during their flight, refugees might seek shelter in mass camps, where they can
experience malnutrition and disease, limited access to medical care and clean
water, and lose their privacy (Moss et al. 2006). These experiences create a sense
of deprivation and severe mental disabilities at large.
The last decade witnessed many upheavals in the Middle East and Arab region
amidst many wars, which greatly increased the number of refugees and forced their
migration to other countries. For example, the recent wars in Syria, Yemen, and Iraq
have greatly increased the number of refugees. Refugees from failed states such as
Libya, Afghanistan, Somalia, Yemen, and Sudan are among the largest groups of
displaced people. The burden in accommodating them in North African states and
Turkey remains a hefty challenge for the host countries, and some have even become
transit hubs for onward migration to Europe.
This chapter aims to answer the following questions: What are the main challenges
faced by refugees? How do refugees cope with these challenges? The chapter then
examines the implications of these questions. Firstly, the chapter has theoretical
significance in identifying the mental, social, economic, environmental, and cultural
challenges faced by refugees. Secondly, the study tries to provide recommendations
for overcoming these challenges. Thirdly, the study has practical implications for host
countries who are trying to cope with the influx of refugees by helping to improve the
mental, social, economic, environmental, and cultural challenges they encounter.
The plight of refugees and the dilemmas they face in different countries related to
mental health disorders occurs during the three stages of a refugee’s journey. The
impact of mental health on refugees and their families, their general health, the issues
faced by the refugees and refugee hosting countries, cultural acceptance of refugees
in host countries, and their psychological and psychosocial well-being are discussed
in separate sections. The risk and protective factors with interventions for well-being
are discussed throughout in the chapter.
The Plight of Refugees
An immigrant leaves his homeland to find greener grass. A refugee leaves his homeland
because the grass is burning under his feet. (Barbara Law)
336 M. Ilyas et al.
A well-defined explanation of who is considered to be a refugee is provided by the

United Nations High Commissioner for Refugees (UNHCR) that states that refugees
are individuals who flee their countries due to war, violence, terrorism, or fear of
persecution. These individuals are in danger due to the attributes attached to them
such as ethnicity or race, different political opinions, nationality, religion, and
specific social groups. There has been a dramatic increase in the number of refugees
around the globe, with 79.5 million displaced worldwide, 45.7 million internally
displaced, and 26 million refugees (UNHCR 2019). The plight of the growing
numbers of refugees has several root causes such as wars, humanitarian crises,
political disagreements and victimization, religious extremism, ethnic orientation,
and tribal violence (Oda et al. 2017). Apart from psychosocial obstacles, these
refugees also face economic, environmental, psychological, emotional, and social
hardships (Porter and Haslam 2005; Silove et al. 1998; Fazel et al. 2005; Haaken and
O’Neill 2014). These issues stem from forced displacement, violence in their
respective regions, and exposure to wars and terrorism, all of which negatively
impact the physical and mental well-being of refugees (Fazel et al. 2005).
European countries receive large numbers of immigrants and refugees, where a
quarter of the refugees are children. Recent wars around the globe targeted civilians
in large numbers, based on the basis of religious or ethnic cleansing (Fazel and Stein
2002). Refugees in such crises are trying to relocate to different countries to save and
improve their lives. Article 1A (2) of the 1951 convention forwarded by UNHCR on
the rights of refugees states:
Owing to well-founded fear of being persecuted for reasons of race, religion, nationality,
membership of a particular social group or political opinion, is outside the country of his
nationality and is unable or, owing to such fear, is unwilling to availing himself of the
protection of that country; not having a nationality and being outside that country of his
former habitual residence as a result of such events, is unable or, owing to such fear, is
unwilling to return to it.
Compared to economic-based migration or asylum seekers, refugees are forced to

leave their countries of permanent residence involuntarily due to persecution and
constant fear of being killed on returning (Lustig et al. 2004).
According to some critics (Fazel and Stein 2002; Berman 2001; Pumariega et al.
2005; Lustig et al. 2004), the plight of refugees and their experiences can be
categorized into three different phases. The first phase is pre-migration, where
refugees are still in their own home countries before escaping elsewhere. They and
their families remain under threat during this time due to conflicts, social upheavals,
and chaos in the country they live in. Limited or no access to schools affects children,
and if forced to participate in the conflicts, children become victims of war injuries,
torture, substance abuse, rape, anxiety, and suicidal ideation attempts. The second
phase is an uncertain period for refugees where they search for a location to resettle.
Some harsh realities of this migration phase include families being separated from
their loved ones, resulting in behavioral, emotional, and mental stress. Unaccompa-
nied refugee minors who become separated from their families, and women without
their male family members, suffer in the camps while fleeing to unknown locations.
In the post-migration phase, the refugees might find solace in the peace of
resettlement and leaving a war-torn zone or persecution, but soon a sense of grief
results from leaving their homeland, family, friends, and material possessions.
A fourth phase has been suggested to be related to the refugees’ trauma
(Papadopoulos 2001). The plight of refugees and their experiences when fleeing
has not only traumatizing effects in the country of their origin, but they also face
psychosocial, psychological, and mental health issues in the host countries for
various reasons, i.e., cultural isolation, social integration, economic uncertainty,
and acculturation in the host society (Papadopoulos 2001).
Impacts on the Mental Health of Refugees
The impact of mental health issues on individuals, and on the society in general,
should not be neglected. Refugees are one of most affected groups by mental health
issues. There are numerous risk factors that are associated with the development of
mental health disorders in refugees (Table 1) (Laban et al. 2004, 2005; Silove et al.
1997; Steel et al. 1999, 2006).
Mental health issues in refugees are usually linked to their traumatic experiences
during and after leaving their homes and also to the reasons for their displacement
such as wars and political conflicts. Post-migration issues are associated with new
mental health issues. Some studies report that risk factors in the post-migration
situations have a stronger association with psychological morbidity than the trau-
matic experiences of the refugees (Gorst-Unsworth and Goldenberg 1998; Laban
et al. 2004; Lie 2002).
A study of Iraqi asylum seekers suggests a strong relationship between lower
support levels and psychological distress, but was less influential for PTSD (Table 2)
(Gorst-Unsworth and Goldenberg 1998).
It is difficult to know exactly how much refugees are affected by mental health
disorders, as this varies greatly depending on the experience and sufferings of
individuals or a specific refugee population. However, studies of settled refugees
estimated that PTSD ranges from 10% to 40% and major depression from 5% to 15%
(Fazel et al. 2005; Turner et al. 2003).
Table 1 Risk factors associated with mental health disorders in refugees

The scale of the refugees traumatic experiences Detention
The numbers of traumas Loss of their culture
Delayed asylum application process Loss of support systems
Taken from: Laban et al. 2004, 2005; Silove et al. 1997; Steel et al. 1999, 2006
Table 2 Common mental health disorders associated with refugees

Generalized anxiety Panic attacks
Major depression Post-traumatic stress disorder (PTSD)
338 M. Ilyas et al.
Several reviews documented a variety of mental health signs and symptoms

experienced by children, indicating that the younger the refugee, the greater the
impact of these disorders. Children and adolescents have higher tendency to develop
PTSD (ranging from 50% to 90%) and major depression (ranging from 6% to 40%)
(Barenbaum et al. 2004; Lustig et al. 2004).
A systematic review by Slewa-Younan et al. (2015) explored the prevalence of
PTSD and depression in Iraqi refugees who settled in Western countries and reported
that Iraqi refugees have a high prevalence of PTSD (8–37%) and even higher rates of
depression (28.3–75%). Similar studies of Syrian refugees in refugees camps in the
Middle East and neighboring countries such as Lebanon (Kazour et al. 2017; Naja
et al. 2016), Iraq (Ibrahim and Hassan 2017), and Turkey (Chung et al. 2017;
Acarturk et al. 2018; Alpak et al. 2015) reported a high prevalence of PTSD (ranging
from 27% to 83%) and depression (ranging from 37% to 44%). Syrian refugees in
the USA also experience increases in anxiety (40%), PTSD (32%), and depression
(47%) (Javanbakht et al. 2019).
Impact of Mental Disorders on Family and Relatives
Mental disorders are also public health issues, as mental disorders affect not only
afflicted individuals but also their families and caregivers. People with mental
disorders were hospitalized as a routine approach to manage and treat these disorders
in most countries until the 1950s, after which, the management of people with
mental disorders shifted from institutions to community health-care centers (Thomp-
son Jr and Doll 1982). This shift strongly impacted the families of people with
mental disorders since the family members then also became caregivers, even though
they were usually not equipped to take on that responsibility (Thornicroft and
Knudsen 1996). The burden on caregivers has been researched intensively in
Western countries, but there are a limited number of studies from the Middle East.
Family burden is seen as a non-mediated consequence on family members who are
living with and giving the care needed by their relatives with the mental disorder
(Zahid et al. 2010). The burden on caregivers are classed as either subjective or
objective burdens (Table 3) (Jungbauer et al. 2004).
The burden of caring for people with mental disorders includes displeasure with
relatives, disturbance of everyday routines, financial issues, stigma, and blame
(Evensen et al. 2017). Stigma not only causes harm to people with mental disorders,
but it is also damaging to family members of these individuals, as often spouses and
siblings are blamed for mishandling their illness (Corrigan and Miller 2004).
Table 3 Types of burden on caregivers

Objective Observable such as money and time that the caregiver spent for the mentally
burden affected person
Subjective The caregiver perception on how burdensome giving the care for the mentally
burden affected person
Taken from Jungbauer et al. (2004)
Impact on General Health
The Surgeon General’s report about mental health (Rockville 1999) states that
mental health is linked with both the general well-being of people and also their
physical health. Many studies report a relationship between mental health disorders
and other health issues and chronic diseases (Strine et al. 2008; Zhao et al. 2009).
Cardiovascular Disease
Depressive conditions and mental disorders are linked with risk factors associated
with cardiovascular disease. Examples of these risk factors include smoking and lack
of physical activity (Hayward 1995). Persons suffering from depression are at a
greater risk of developing coronary heart disease (Nemeroff et al. 1998). A meta-
analysis reported that the relative risk for developing heart disease in an individual
with depression is higher than in non-depressed persons (Wulsin and Singal 2003).
Depression is a predictor for stroke (Jonas and Mussolino 2000) and is associated
with increased risk for stroke mortality and morbidity (Ramasubbu and Patten 2003).
A person with severe depressive symptoms is more likely to have a stroke within
10 years than a person with less severe symptoms (Ohira et al. 2001). Depression
also appears to be related to heart attacks and myocardial infarction; a person with
major depression has a four times greater risk of having a myocardial infarction
(Ziegelstein 2001).
Diabetes
Depressive symptoms are linked with diabetes (Peyrot and Rubin 1997). A meta-
analysis indicates that depressive symptoms are twice as prevalent in diabetic
patients (Anderson et al. 2001). Some studies suggest that depression could be
considered as a risk factor for developing diabetes. However, this relationship is
more evident at higher levels of depression and, interestingly, was only noticed in
people with education levels lower than high school levels (Carnethon et al. 2003) –
as is often the case with underprivileged minorities such as refugees. These results
indicate that factors associated with lower socioeconomic status can increase the
chance of developing diabetes in people suffering from severe depressive symptoms.
Obesity
Several studies reported an association between depression and obesity. However,

the association between obesity and depression is not similar in males and females.
Women with a higher body mass index (BMI) are at increased risk of major
depressive symptoms, especially in women with a BMI exceeding 30 (Becker
et al. 2001). Centrally obese males suffer from depression (Rosmond and Björntorp
340 M. Ilyas et al.
2000) and increased use of antidepressants (Rosmond et al. 1996). Children and
adolescents with major depressive disorders are at higher risk of becoming over-
weight (McElroy et al. 2004).
Oral Health
Depression is anticipated to be one of the leading causes of the global burden of

diseases by 2020 as assessed by the “disability-adjusted life years” (Murray et al.
1996). The oral health of persons with mental health disorders has been studied by
several groups, who reported a relationship between periodontal diseases and
depressive symptoms (Rosania et al. 2009; Genco et al. 1999). Some studies
documented an association between depression and higher lactobacillus bacteria
counts, which can increase dental decay in people experiencing depressive symp-
toms (Anttila et al. 1999). Antidepressant medications have been linked with an
increased risk for developing dental carious lesions (Hunter and Wilson 1995;
Peeters et al. 1998). Other oral health side effects of antidepressant medications
include xerostomia, bruxism, and dysgeusia (D’Mello 2003).
Issues Faced by Refugees and Refugee-Hosting Countries
The refugee crisis will have several long-term effects on hosting countries, including
economic, social, and political outcomes. And as for the refugee, there are many
issues that they face throughout their long, burdensome, and unpredictable journey.
Some studies report that higher trauma rates increase the severity of mental health
issues (Kinzie et al. 1990). Thus, the stresses during the preflight period are most
likely to affect the mental health of both adult and young refugees due to the
uncertainty and fear of family separation, detention centers, and refugee camps.
The last 20 years has witnessed increasing numbers of refugees in many parts of
the world. For all refugees, the process of migration is stressful both mentally and
physically. It involves leaving their homes and trying to adapt to a different society
with new languages, customs, and laws. Stressful events occur before, during, and
after their travel, and refugees experience significant challenges in integrating in
their new host countries (Carta et al. 2005; Bhugra et al. 2014). Major issues faced by
refugees include the fear of deportation and detention (Assembly 2015).
Education
Refugees are usually considered an underprivileged minority who face many

inequalities. A common issue that Syrian refugees encounter is access to education
(Saleh et al. 2018). Chronic absenteeism from school for many days, including both
excused and unexcused absences, can result in suspension from school. Refugee and
immigrant children are more likely to have at least one (often more) risk factor of
poor school outcomes, including exposure to major trauma and poverty (Porche et al.
2011; Block et al. 2014). Children who live in poverty are more likely than other
children to be chronically absent from school (Carlson et al. 2014; Chang and
Romero 2008). The most common factors related to chronic absenteeism are poor
overall health (Hughes and Ng 2003; Bloom and Dey 2006), exposure to violence
(Ramirez et al. 2012), and unstable housing conditions (Rafferty 1995).
High-quality education is an essential issue facing refugees everywhere (Arabacı
et al. 2014). Approximately half the Syrian population were forced to move to other
countries after the civil war (Trends 2015). Syrian refugees are the second biggest
populace of refugees after Palestinian refugees (Nebehay 2015). Only 40% of Syrian
refugees have the opportunity of being enrolled in the education system of their host
countries. This will affect the future and the stability of both the Syrian migrants and
their host countries (Culbertson and Constant 2015; Nebehay 2015).
Education for refugee groups has multifactorial concerns such as discrimination
and difficulty in integration and language barriers (Bourgonje 2010; Nonchev and
Tagarov 2012; Dryden-Peterson 2016). These issues can hinder the academic pro-
cess and lower their performance compared to other non-immigrant students
(Hachfeld et al. 2015). Schools and education systems are ideal places for the
early detection and treatment of mental health disorders in refugee children and
adolescents, and such individuals can then be referred to specialized mental health-
care centers (Guruge and Butt 2015).
Accessibility to health centers that provide mental health care is an essential element
of resettlement care, especially in young refugees (Murray et al. 2010). There are
multiple factors that impact the mental health of young refugees, including their living
environments, language barriers, and racism (Fazel et al. 2005, 2012; Reed et al. 2012).
Other reasons that can hinder identifying mental health disorders relate to the
competency of school staff in recognizing the symptoms related to mental health
disorders in refugee students. (Rothì et al. 2008). This is usually due to a lack of
training in recognizing such symptoms (Bostock et al. 2011) as well as the fact that
some symptoms of mental disorders are difficult to distinguish from other normal
adolescent behaviors (Rothì et al. 2008; Vieira et al. 2014).
Although mental health concerns are usually caused by previous trauma during
the preflight phase, neglecting current and ongoing stressors should also be seriously
considered. School staff should recognize the effects of current and the ongoing
issues, such as physical or financial health challenges, that refugee likely experience
on a daily basis (Ellis et al. 2013; Chen et al. 2017).
Health Care
The Syrian civil war is a tragic humanitarian crisis, with rampant malnutrition, poor
hygienic environments, and a lack of medical care in camps (Cookson et al. 2015). A
study on the burden and cost of neuropsychiatric disorders in Iraqis and Syrian refugees
suggested governments and companies invest in primary and public health programs to
reduce neuropsychiatric disorders among the refugees (McKenzie et al. 2015).
342 M. Ilyas et al.
Chronic and acute health issues of asylum seekers from the Middle East are
usually related to their asylum seeker status, including but not limited to their living
conditions and to their cultural backgrounds (Pfortmueller et al. 2016). Refugees
suffer from a variety of mental issues and can seek help from professional mental
health centers; however, accessing care for mental health is usually complicated for
refugees (Lindert et al. 2008).
Telepsychiatry is a useful tool to provide greater accessibility to mental health
care for underserved minorities such as refugees (Rohland 2001; Rohland et al.
2000). However, telepsychiatry is underutilized in war-torn areas in the Middle East.
Telepsychiatry could be particularly useful to serve the needs of refugees as it uses
low-cost technology that can be utilized by mental health providers to provide
supervision, consultation, and education on mental health disorders, particularly
for people still in original war-torn countries like Syria (Jefee-Bahloul 2014).
Social Integration
The WHO emphasizes that health inequalities are primarily caused by social,
political, and economic factors, which collectively are considered the social deter-
minants of health. If these social determinants are disproportionately distributed,
they create or reinforce existing social inequalities in health. Psychiatric disorders
are linked with social adversity (Muntaner et al. 2004). Mental health disorders are
influenced by social, physical, and economic conditions; these mental health disor-
ders are strongly linked to social inequality (WHO 2014).
In the resettlement phase, most issues are related to the social integration of the
refugees and their children in a new society and affect their culture and language and
forces them to adapt to their new environment (Murray et al. 2010). There are
multiple difficulties in diagnosing and treating mental health disorders in refugees,
including cultural and language barriers, for both the health-care provider and the
refugee (Sue et al. 2009).
Social integration helps to develop self-confidence and decreases or prevents
mental health concerns (Priebe et al. 2016). Reduced social integration, whether
related to social isolation or lack of jobs, is linked to poor socioeconomic conditions
in refugees (Bogic et al. 2015; Steel et al. 2009). Factors related to poor opportunities
for housing, shelter, education, and employment have long-term negative effects.
Numerous studies found that there is an increased chance for developing depressive
symptoms due to poor socioeconomic conditions after migration (Bogic et al. 2015;
Bell and Zech 2009; Hollander 2013).
Unemployment is a risk factor for mental health disorders (Crumlish et al. 2010). A
lack of jobs will prevent the full integration into a newer society and environment (Ryan
et al. 2008). A study exploring young Middle Eastern refugees whose parents were
unemployed in their host country reported that these young refugees suffered from peer
hostility that included demeaning and offensive comments (Montgomery and Fold-
spang 2008). It is estimated that there are at least half million of Syrian refugees
displaced in Jordan (UNHCR). Most Syrian refugees have very limited opportunities
to work and frequently work in informal sectors (Wells et al. 2016). Integration can be
facilitated by developing and improving programs in asylum policies, employment,

shelter settings, and education (Priebe et al. 2016). Another issue in Western countries
that host refugees from Arab countries is that Muslim refugees are often linked with
terrorism since the terrorist attacks of 9/11 (Eid 2014). The majority of mainstream
media providers portray Muslims in a negative way, resulting in distorted public
perception of them (Christensen 2006). There is often a mismatch between the skills/
qualifications of a refugee and the employment available in a host country.
The Influx of Refugees and Their Cultural Acceptance in Host

Countries (Sociocultural Adversity)
Social or cultural integration means integrating with the host culture by bringing a
balanced connection between refugees’ own cultural heritage and the host culture.
Separation is opposite to integration, where refugees rigidly cling to their cultural
heritage with no intention of adopting aspects of the dominant society of the host
country. Assimilation means adopting into the mainstream culture, although it does
not improve the well-being of refugees.
Refugees fleeing to different countries face sociocultural and acculturation issues
in host countries, leading to mental disability and acute stress (Ahmed et al. 2011).
Cultural differences and the attitude of refugees on the culture of the hosting country
increases stress and mental health issues, while the interplay between the immi-
grants’ culture and the culture of the host country causes sociocultural adversity
(Berry 2003). Adopting the four basic modes of acculturation, i.e., social integration,
separation, marginalization, and assimilation, can help refugees to better adopt the
host culture (Berry 2003).
There are also other sociocultural challenges such as racism, discrimination, and
some social stratification mechanisms which negatively impact refugees. Likewise,
treatment based on race, ethnicity, religion, social class, or gender significantly impacts
the mental health of refugees. Such stress may also be ignited during the transition and
adapting to new experiences such as linguistic difficulties, pressure to assimilate,
separation from family, experiences with discrimination, and intergenerational family
conflicts; these challenges are associated with the greater likelihood of suicide ideation
and increased depression and anxiety (Ahmed et al. 2011; Walker et al. 2008). Likewise,
perceived discrimination is also present during sociocultural adversity. The integrative
developmental model highlights the importance of social stratification mechanisms
based on race, prejudice, discrimination, and oppression (Walker et al. 2008).
Mental Health and Well-being of Refugees with Psychosocial and

Psychological Interventions
Practitioners use many explanations and terms to describe the psychological and
psychosocial well-being and mental health of refugees, often leading to confusion.
Mental health is often described by terms such as PSTD (post stress traumatic
disorder), emotional literacy and intelligence, emotional and behavioral difficulties,
344 M. Ilyas et al.
emotional health and well-being, mental health problems and disorders, and psy-
chological well-being and distress (Weare 2004). These terms usually refer to the
paradigms to which these practitioners belong. It is important to highlight the main
terms related to well-being and mental health.
There are elements which promote or demote mental health, while the interac-
tions between these paradigms influence mental health (MacDonald and O’Hara
1998). If the organic factors (stress and exploitation) are decreased, and coping skills
and social support and self-esteem are increased, mental illness can be prevented
(MacDonald and O’Hara 1998) as shown in Table 4.
Risk and protective factors identified in observational studies can be used to
measure mental disorders and identify interventions for treatment (Ottisova et al.
2016; Porter and Haslam 2005; Giacco et al. 2014). A comprehensive report by the
World Health Organization (WHO 2018) combined data from various studies to
summarize factors that affect mental health in refugees is shown in Fig. 1.
Studies by Giacco et al. (2014) and Priebe et al. (2016) on how refugees and
migrants encounter mental health issues proposed some interventions for promoting
improved mental health care in refugees (Giacco et al. 2014; Priebe et al. 2016). It is
important to identify strategies to overcome barriers to mental health, increase social
integration and acculturation, and facilitate treatment of the refugees with manifest
mental disorders (Priebe et al. 2013).
As advanced nations are better equipped with modern methods, European host
countries treat manifest disorders, pharmacological and psychological, based on
evidence-informed treatments. Refugees are not treated in host countries using
current mental disorders guidelines, as most suffer from anxiety and depression
disorders. It is important to use the same guidelines for mental disorders in refugees
as would be used for the treatment of such disorders in the host population. Social
integration will help the refugees to promote their mental health and will reduce not
only physical health concerns but also help in overcoming mental disorders. Such
efforts in a new country will save refugees from marginalization issues and lack of
productivity and prevent criminal activities. Only 10% of refugees are diagnosed
with PTSD (post-traumatic stress disorder), though this number varies in different
studies (Turrini et al. 2017).
Social integration interventions reduce mental disorders in refugees as the prev-
alence of such mental issues are often due to poor social integration (Bogic et al.
2015). Social care services, employment support agencies, and participation in
community activities can improve mental health, although some studies reject this
notion (Johnson et al. 2006; Patel et al. 2019).
There is a scarcity of studies providing reliable and specific evidence-based
interventions for the facilitation of access and engagement with care for refugees
(Giacco et al. 2014; d’Ardenne et al. 2007). On the other hand, the treatment of
PTSD and treatment of mental disorders may benefit from randomized psychological
interventions (Turrini et al. 2017; Bogic et al. 2015).
Practitioners attached to MHPSS (mental health and psychosocial support ser-
vices) consider it of utmost importance to provide direct mental health and psycho-
social support according to the settings of the refugees. According to the World
Table 4 Elements of mental health
Health Organization (2014), countries that provide MPHSS can overburden them-
selves with the increased demand, which in turn becomes a barrier for refugees to
access these care facilities (WHO 2014). Many international and national organiza-
tions provide mental health and psychosocial support services for refugees (Akoury-
Dirani et al. 2015; Hijazi and Weissbecker 2015). For example, there are 47
organizations in Jordan and 36 in Lebanon involved in MPHSS interventions to
346 M. Ilyas et al.
Fig. 1 Risk factors and protective factors for mental health in refugees and migrants (source:
WHO 2018)
assist displaced Syrian refugees, while these governments also made efforts (with the
help of external funding agencies) to integrate mental health in the general health-
care systems (El Chammay and Ammar 2014; Hijazi and Weissbecker 2015;
Ommeren et al. 2015).
Several factors act as access barriers for refugees wishing to benefit from the
services of MHPSS. Some important barriers are language barriers and stigma
associated with seeking mental health care. It is important that a professional
interpreter equipped with mental health terminologies and jargon be used. On the
other hand, using a family member or ad hoc interpreter can cause ethical and
practical challenges for refugees already suffering from mental health issues
(Jefee-Bahloul 2014). It is imperative that the practitioners should use interpreters
that are properly trained and aware of the stresses and traumatic disorders
the refugees experience (Holmgren et al. 2003; Tribe and Morrissey 2004; Ciftci
et al. 2013).
Stigmatizing mental illness and psychological distress is an important barrier for
refugees in general and in the Arab world in particular. The recent refugee displace-
ment in Syria and neighboring countries puts many under mental distress. Although
emotional suffering is considered by some as an aspect of life, mental health
concerns in the Arab world are often interpreted differently as many consider such
patients very negatively and lead shame and embarrassment in both the victims and
their families. Avoiding psychiatric labeling and jargon will reduce stigmas and
improve the mental health of refugees and bring comfort to their families.
Conclusion
This chapter discusses the various dilemmas faced by refugees, their internal dis-
placement, or fleeing from disasters, wars, and persecution to relocate for reasons of
safety and improved opportunities. The trials and tribulations faced by refugees
impact their mental health and the mental health of their families and adversely
impact the psychological and psychosocial health of their children. The refugee
crises have destabilized the Arab world and caused the displacement of millions of
people around the globe. Although the issues faced by host countries and interven-
tions for the psychological and psychosocial well-being of refugees are considered in
this chapter, it is also important to have some policy recommendations for the
betterment of the lives of refugees:
• Integrated action plans are needed by host countries to deal with the influx of
refugees by recruiting the help of academia, press, civil society, and private
organizations and by collaboration with international organizations; this will
help to safeguard the well-being of refugees, protect their basic rights, positively
impact the economy, and promote social integration.
• Local governments should be given authority to help in socioeconomic integra-
tion of the refugees.
• Municipalities and mental health clinics in public and private sectors should be
given financial incentives to treat mental health and social issues faced by
refugees, as implemented by Germany and Canada, for example.
• In the wake of new developments in Syria as the regime imposes property and
mobility laws, it is unlikely that displaced Syrian refugees will return to their
homeland. It becomes important to safeguard the right of return of refugees by
introducing an international legal framework giving rights to the refugees to
safely return to their homelands whenever peace prevails. It is necessary to
advocate for the legal empowerment of refugees and allow/increase cross-border
348 M. Ilyas et al.
mobility. Such measures will not only reduce mental health issues but will also
safeguard the well-being of refugees by providing them access to education,
employment, and social integration in the communities where they choose to
live after leaving their homelands.
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Healthcare Among Immigrant and Refugee
Arab Americans in the United States 16
Sara Alosaimy, Bashayer Alshehri, Raniah Aljadeed, Rana Aljadeed,
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Contents
Arabs in the United States . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 357
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 357
History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 357
Composition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 358
Acculturation and National Identity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 360
Healthcare Among Arabs Outside the Arab World . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 361
Urgent Care Centers in the US . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 361
Chronic Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 361
S. Alosaimy
Department of Pharmacy, Brigham and Women’s Hospital, Boston, MA, USA
College of Pharmacy, Wayne State University, Detroit, MI, USA
e-mail: Sarah.alosaimi@gmail.com
B. Alshehri
Department of Pharmacy, Brigham and Women’s Hospital, Boston, MA, USA
e-mail: alshehriba2@gmail.com
R. Aljadeed
Department of Pharmacy, University of Arizona/Northwest Medical Center, Tucson, AZ, USA
e-mail: raaljadeed@gmail.com
R. Aljadeed
Department of Pharmacy, University of Arizona/Northwest Medical Center, Tucson, AZ, USA
Department of Pharmacy, Houston Methodist Hospital, Houston, TX, USA
e-mail: rana.aljadeed@gmail.com
D. Alnahas
Department of Pharmacy, University of Kalamoon, Deir Atiyah, Syria
e-mail: deema.nahas@hotmail.com

https://doi.org/10.1007/978-3-030-36811-1_15
356 S. Alosaimy et al.
Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 362

Social Norms and Health Behaviors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363
Tobacco Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363
Alcohol Consumption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363
AA Mothers and Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 364
Allergies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 364
Disasters and Conflict . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 364
Birth Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365
Infant Feeding Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 366
Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367
Medication Utilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367
Medication Safety and Adherence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367
Preventive Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 368
Cervical Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 368
Breast Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 369
Prostate Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 370
Colorectal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 370
Vaccines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371
Barriers to Medications and Healthcare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371
Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371
Barriers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371
Conclusion and Prospective View . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 372
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 373
Abstract
Arab immigration to the United States (US) began as early as the eighteenth
century. Despite living in the US for many years, there is limited comprehensive
information about Arab health and healthcare. This chapter aims to focus on the
healthcare of Arab immigrants and refugees in the US. We will evaluate here
chronic diseases, mental health issues, tobacco and alcohol use, health of mothers
and children, use of prescribed medication, and preventive care practices among
the population. We have compared these health practices to the general popula-
tion in the US and, in some cases, to Arabs in the Middle East. In addition, we aim
to discuss potential barriers and factors that contribute to impediments in good
health and well-being in this population.
N. Alsuhebany
Department of Pharmacy Systems, Outcomes and Policy, University of Illinois College of
Pharmacy, Chicago, IL, USA
e-mail: nalsuhebany@gmail.com
D. M. Qato (*)
Program on Medicines and Public Health, School of Pharmacy, University of Southern California,
e-mail: dimaqato@uic.edu
16 Healthcare Among Immigrant and Refugee Arab Americans in the United States 357
Keywords
Arab American · Acculturation · Immigrant · Refugee · Arabs · Healthcare
AA Arab Americans
AAI Arab American Institute
ACA Affordable Care Act
CDC Centers for Disease Control and Prevention
CRC Colorectal cancer
HDL High-density lipoprotein
IgE Immunoglobulin E
MCC The Michigan Cancer Consortium
NHIS National Health Interview Survey
PCPs Primary care physicians
PSA Prostate surface antigen
PTSD Post-traumatic stress disorder
US United States
Arabs in the United States
Introduction
Arab immigrants started moving to the US in considerable numbers in the early

eighteenth century. By the beginning of the twenty-first century, approximately 3.5
million Arabs were scattered across the US (Talaat 2015). According to the Arab
American Institute (AAI), most Arabs with US citizenship reside within the urban
areas of ten states. The states with the highest Arab population growth are California,
Michigan, New York, Florida, Texas, New Jersey, Illinois, Ohio, Pennsylvania, and
Virginia, respectively (AAI 2014).
History
Arabs started coming to the US in three waves of migration (Hammad et al. 1999).
The first stream of recorded Arab immigrants was from the Greater Syria and
Lebanon and was mostly Christians rather than Muslims escaping the Ottoman
Turkish empire and seeking better economic opportunities. It is estimated that half
of today’s AA descend from immigrants who arrived in the US during that wave.
This group has been incorporated smoothly in the American society. The second
wave occurred after World War II when the US changed its immigration policies.
Then, most immigrants were Palestinians who were forced to migrate following
Israel’s occupation of Palestine. Additionally, Egyptians, Syrians, Moroccans,
Tunisians, and Yemenis also arrived in notable numbers (AAI 2014). The third
and largest wave of Arab immigrants occurred in the 1960s after immigration laws
were reformed and the US started accepting immigrants of all nationalities on
a roughly equal basis (Hammad et al. 1999). Several of them emigrated because of
the Persian Gulf War and Lebanese Civil War. A large number of this wave of
immigrants follow the religion of Islam and were highly educated with higher level
degrees. One may speculate that these groups may have different health behaviors
due to their different backgrounds, primary reasons for immigrating, and the number
of years lived in their new environments.
Before we define who Arab Americans (AA) are, it is important to explain the
concept of ethnicity, race, and ancestry. Ethnicity is derived from the Greek word
ethos, meaning “tribe, race, national, and people”; however, this term had been
associated recently with customs and cultural patterns rather than a biological
difference (Edelman et al. 2014). Race is a biological term referring to a group
with distinct physical features like color or facial characteristics. Finally, ancestry
refers to the ethnic origin, descent, roots, heritage, or place of birth of a person or of
the person’s ancestors (Brittingham and de la Cruz 2005). Arabs have variable
ancestries ranging from Middle Eastern to North African with ties to over 20 coun-
tries each with a distinct background. As the reader may gather, these concepts have
their own characteristics that strengthen a person’s national identity.
A major obstacle when conducting research on AA is how the US Census Bureau
defines ethnicity and race. Individuals from the Middle East and North Africa are
currently classified as “White,” a racial group which also combines Irish, Italians, and
European immigrants, leading to imprecise quantification. Therefore, Arabs have been
considered as “White” subjects in the US population record system rather than a unique
racial group. Another issue is that not all AA phenotypically pass as White subjects
because Arabs have various skin tones (e.g., Black Arabs like Sudanese or White Arabs
like Syrian). Even when physically similar to a White individual, AA live markedly
distinct lives which can influence their health practices.
Arab race and ethnicity are ambiguous and complicated and should be further
defined to facilitate research among large national databases. Since AA as a group do
not fit into a racial category, for the purpose of this chapter, we shall define AA as
individuals living in the US who self-identify their country of origin as a country
located in the Arab world, whether it was in the Middle East or North Africa unless
indicated otherwise in the literature presented.
Composition
To date, 1.5 million AA live in the US. The eight countries of origin with the
highest Arab populations in the US are presented in Table 1 (Asi and Beaulieu
2013). The highest population of Arabs in the US is from Lebanon accounting for
roughly half a million people. The 2000 US Census estimated that the Arab
population was less likely to be female accounting for roughly 40% (Brittingham
and de la Cruz 2005). In addition, nearly 70% were adults between the ages of
18–64, followed by younger Arabs under the age of 18, and older adults over
65 years of age at approximately 9%.
Table 1 Eight ancestry Country of origin Number

groups of Arab
Lebanese 485,917
population: 2006–2010.
(Adapted from US Egyptian 179,853
Census Bureau, Arab Syrian 147,426
Households in the Palestinian 83,241
United States: Moroccan 74,908
2006–2010)
Iraqi 73,896
Jordanian 60,056
Yemeni 29,358
90
80
70
60
50
40
30
20
10
0
High school diploma or more Occupation Poverty rate
Total population Arab
Fig. 1 Socioeconomic profile of Arabs vs. the total population. (Adapted from US Census Bureau,
Census 2000 Special tabulation)
Certain socioeconomic characteristics comparing AA with the general US popu-

lation are highlighted in Fig. 1. As of 2000, around 85% of Arabs were high school
graduates, and at least 80% of those had completed a higher educational degree. AA
men were more likely to have jobs compared to the general US population of men,
while Arab American women were less likely to be employed compared to women
in the general US population (Brittingham and de la Cruz 2005). This emphasizes
that AA men often take the lead in providing family income. Interestingly, AA have
a higher household income than the general US population, $56,433 and $51,914,
respectively (Asi and Beaulieu 2013). This demonstrates that the socioeconomic
profile of AA is more favorable than other immigrants. Having said that, although
AA have a good income profile, a higher proportion of them suffer from poverty
compared to the total population suggesting a possible growing gap between wealthy
and poor AA families (Brittingham and de la Cruz 2005). The poverty threshold in
the US is determined annually through the US Census. In 2005, when the data about
AA came out, the threshold was $9,973 per person per year. The threshold has
significantly increased since then to $12,448 in 2017; it remains unclear how this
now compares to the average AA.
The US Census indicates that Arabs were more likely to be married compared to the
overall US population (Brittingham and de la Cruz 2005). Only 12% of Arabs ever
divorced or were without spouses. This suggests the potential influence family and
marriage may have on Arab American healthcare, specifically on women and children.
Acculturation and National Identity
Immigrants face unique challenges as they go through personal and ethnic identity
formation (Edelman et al. 2014). The characteristics of the acceptable and desirable
identity are different between the dominant culture and the culture of origin. Therefore,
achieving acceptance in both cultures could be an arduous experience. The literature on
immigrant health has frequently used the Acculturation Model as a framework to
describe the integration of immigrants into the mainstream culture. Acculturation is
defined as a multifaceted process through which individuals acquire the language,
customs, beliefs, attitudes, and behaviors of American society (Lopez-Class et al. 2011).
The ability to strike a balance between one’s sense of ethnic and religious identity
and adaptation to a foreign culture can pose a significant challenge, especially for
someone accustomed to living a conservative lifestyle marked by a strong reliance
on cultural tradition and religious dogma. The precise role of religion and culture on
mental health especially is not well defined; however, marginalization and less
integration are known to be linked to depression and dysfunctional families
(El-Sayed and Galea 2009a). One study assessed sociodemographic differences in
acculturation among AA using best available validated tools to assess religiosity,
acculturation stress, depression, and family dysfunction. Researchers found distinct
differences based on religious beliefs; specifically, less religious values were asso-
ciated with depression among Muslim AA, but the opposite is true among Christian
AA. This may be due to different acculturation models between religious Christians
and Muslims, which ultimately affects their mental health.
Jaber et al. (2003a) assessed the influence of acculturation on blood sugar instability or
dysglycemia among immigrant AA. They evaluated 206 men and 314 women who were
born in the Middle East and have immigrated to the US. Among the population studied,
105 participants had diabetes and 118 had either impaired fasting glucose or impaired
glucose tolerance. Compared to men with normal glucose tolerance, diabetic men were
older at immigration (mean age 34 vs. 24 years), more likely to speak Arabic with friends
(95% vs. 76%, p = 0.0097), and tend to consume Arab food (92% vs. 82%). Similarly,
women with diabetes were compared to those with normal glucose tolerance and were
found to be older upon immigration (40 vs. 26 years), more likely to be raised in rural
communities in the Middle East (20% vs. 9%) and had longer lengths of stay in the US
(15 vs. 9 years). However, none of these relationships were statistically significant. The
authors concluded that less acculturation could be a risk factor for diabetes in AA.
In another study, Abdulrahim and Baker (2009) examined the impact of accul-
turation on the health of AA by utilizing data from the 2003 Detroit Arab American
Study. Participants were asked to describe their overall state of health to assess self-
rated health, which is an independent predictor of mortality (Abdulrahim and Baker
2009). The results showed that AA who were born in the US were less likely to rate
their health as fair/poor 4.66%, while 11.03% of English-speaking Arab immigrants
and 27.47% of Arabic-speaking immigrants did so. Such findings suggest an
improvement in self-rated health of AA with greater acculturation into American

society (Abdulrahim and Baker 2009). Language preference and immigrant status
were used in this study as indicators of acculturation.
Moreover, a cross-sectional correlational study assessed the physical and mental
health of 297 AA adults living in Southern California (Jadalla and Lee 2012). Data
suggest that exhibiting a greater level of acculturation is associated with better
mental health ( p = <0.001). Additionally, individuals who moderately identified
themselves with both Arabic and American cultures had better physical health
( p = <0.01). While those who were strongly identified to either culture reported
worse physical health.
Finally, it is important to note that the Acculturation Model is a one-dimensional
measure commonly influenced by immigration-related variables such as nativity,
generational status, age at migration, and language use. However, other structural
factors contribute to acculturation, such as class, gender, and social hierarchies
(Viruell-Fuentes et al. 2012).
Healthcare Among Arabs Outside the Arab World
Urgent Care Centers in the US
In the US, urgent care centers have grown widely to efficiently reduce low- to
mid-acuity emergency room patients (Weinick et al. 2009). Urgent care centers
provide immediate same day medical care for ill patients. Most facilities are run
by family physicians and operate for about 10 h every weekday, along with one
weekend day. Compared to the emergency department, these centers are more cost-
effective for patients and hospitals and flexible in their wait time and appointments
and resemble a clinic rather than an emergency room.
Primary care centers in the US are a universal health provision that serves daily
healthcare needs (Bates 2010). They are staffed and managed by primary care
physicians (PCPs). These physicians act as the principal point of contact for the
current and continuing care of each patient present in their respective systems. PCPs
(including family physicians, internists, and medical students) in the US earn a 10%
bonus from the Affordable Care Act (ACA). In contrast, Arab countries seldom have
urgent care clinics. Instead, they have ambulatory healthcare clinics that offer
primary care services (Paulo et al. 2017). Hence, many AA are not familiar with
the concepts of urgent care and primary care centers; therefore, they do not access
such services. Instead, they may choose to disregard their health needs or choose to
go the emergency department in a hospital, which can be costly and time-consuming.
Chronic Diseases
A high prevalence of chronic diseases such as diabetes mellitus, depression, and

hypertension among AA was suggested from multiple surveys by health and social
community centers in the US. Diabetes mellitus, particularly type II, is known to be
common among Arabs in their homeland (Jaber et al. 2003b). To determine the
prevalence of diabetes among AA adults, a study was conducted in Michigan during
2003 based on factors like age, obesity, and family history. The prevalence of
diabetes among AA was as high as 33% (Jaber et al. 2003b; El-Sayed and Galea
2009a). This high percentage exceeds that of African Americans, Hispanics, and
non-Hispanic Whites. However, studies by the National Health Interview Survey
(NHIS) and Jamil et al. showed more reassuring prevalence of diabetes that is as low
as 4% and is therefore comparable to other ethnic groups, such as non-Hispanic
Whites and African Americans.
Regarding cardiovascular disease, there seems to be limited data about the burden
and risk factors relative to other groups. Notably, the prevalence of hypertension lies
in the range of 13–20% among AA and is comparable to that of non-Hispanic
Whites, but higher than African Americans (El-Sayed and Galea 2009a).
Metabolic syndrome is a major risk factor for both diabetes and cardiovascular
disease (Shara et al. 2017). Although prevalence of metabolic syndrome among AA in
Michigan was comparable to the general population, the condition manifests differ-
ently. Specifically, AA demonstrate lower HDL levels compared to the general popu-
lation (48% vs. 24.7%). Interestingly, this prevalence is comparable to Arabs in the
Middle East, which suggest genetic as well as cultural factors related to dyslipidemia.
When comparing life expectancy and age-adjusted mortality risk of AA to other
ethnic groups, a study among individuals in Michigan revealed that AA have higher
age-adjusted mortality risk (El-Sayed et al. 2011). Life expectancies for non-Arab
and non-Hispanic Whites were 2.0 and 1.4 years higher when compared to AA,
possibly due to chronic diseases such as cardiac, diabetes, and chronic respiratory
disease. The review of the literature suggests that feelings of discrimination and
stress in AA, as well as specific cultural features such as less healthy diet habits,
higher fat intake, and lower physical activities, may explain this disproportion.
Mental Health
Perceived discrimination and the psychological effect of adapting to a different

culture, also known as “acculturative stress,” are associated with an increased risk
of mental illness among ethnic and racial minorities in the US (Torres et al. 2012).
Immigrants face numerous challenges ranging from discrimination to racism to
marginalization. In addition, they face difficulties in adaptation, as they come from
drastically different backgrounds. There, they may have been accustomed to a
certain socioeconomic “status” or way of life. These hurdles vary according to the
immigrant’s level of fluency in the foreign language, length of time he/she has been
in the new country, and the extent of any trauma experienced before and during the
transition (Abu-Ras and Suarez 2009).
In war-stricken regions, women and children are faced with a plethora of chal-
lenges. Left with the burden of providing support for a family often without a male
breadwinner household, they must deal with psychological burdens such as trauma,
stress, and anxiety that can be destructive if left untreated. Refugees face additional
trauma – the stress of moving from one place to another is compounded by the
necessity to survive. A female Arab refugee or immigrant in the US can suffer
serious trauma and stress when adjusting to her new life. Consequently, these
struggles make Arab women more vulnerable to mental health conditions. A retro-
spective study in Michigan that assessed the mental health of Arab immigrants
reported more post-traumatic stress disorder (PTSD) and physical complaints
among immigrants from Iraq compared to other Arab countries (Jamil et al. 2002).
Another study found medical complaints among Iraqi refugees to be relatively high
compared to other AA immigrants overall (Jamil et al. 2005). Specifically, PTSD
occurred in 28.4% and depression in 22.4% of Iraqi refugees. Around 70% reported
at least eight medical complaints, primarily irregular sleep, loss of interest, and
difficulty remembering.
Social Norms and Health Behaviors
Tobacco Abuse
Tobacco abuse is a common cultural habit in many Arab countries (Maziak et al.
2014). The prevalence of cigarette smoking can be as high as 50% of the male
population. Water pipe smoking is a more culturally acceptable form of tobacco
smoking for Arab women and youth than cigarettes. The use of water pipe on the
other hand can range between 15% and 18.9%, depending on the country. Despite
these reports, there is lack of specific data from the Center for Disease Control and
Prevention and health promotion (CDC) regarding smoking in AA (El Hajj et al.
2017). There is a mistaken view that using of the hookah has reduced risk in
comparison to smoking cigarettes (Golbidi et al. 2018). However, until more studies
are conducted to explore the difference, the safety outcomes of cigarettes can be
reasonably assumed as that of the water pipe. In a small cross-sectional study of
100 AA immigrants living in Colorado, 19% identified themselves as current
cigarettes smokers and 21% as hookah smokers. Predictors of tobacco abuse in the
AA community include being more integrated into Arab culture and having family
and friends who also use tobacco products. Another study examined risk factors for
hookah smoking by AA and found that higher income, male sex, younger age, and
having health insurance are potential risk factors for hookah use (Jamil et al. 2014).
Alcohol Consumption
The magnitude and patterns of alcohol consumption by immigrant AA in the US are

influenced by religious prohibition and social norms (Arfken et al. 2013). These
factors could potentially lead to underreporting of alcohol consumption, as individ-
uals may tend to deny alcohol usage because of the social stigma (Abu-Ras et al.
2010). In Islam, consumption of alcohol is forbidden, which would be expected to
influence the reporting of alcohol use by Muslim AA.
Abu-Ras et al. (2010) explored alcohol drinking habits in Muslim college stu-
dents in the US using the 2001 Harvard School of Public Health College Alcohol
Study data. They found that 46.6% of Muslim college students had consumed
alcohol within the past year compared to 80.7% of non-Muslim students. Of the
Muslim students who did not drink, 90% were lifetime abstainers. The authors
reported that Muslim students who drank alcohol were less likely to participate in
religious activities (18% vs. 45.6%) and more likely to have parents who approved
of alcohol drinking (44.3% vs. 7%) compared to Muslim students who don’t drink.
A much lower percentage of alcohol drinking by Muslim college students was
reported in a survey by Arfken et al. (2013). Only 9.1% of Muslim undergraduate
college students had ever consumed alcohol, compared to 63.9% of full-time college
students. Another study found that speaking English fluently significantly increased
alcohol consumption (77.3%) (Arfken et al. 2014). Additional factors associated
with a higher lifetime alcohol consumption in AA include being male, older, and
non-Muslim and having a higher educational level.
The discrepancies in reporting alcohol use by AA could be a result of several
factors such as denying alcohol use when asked (as drinking is a stigmatized
behavior in Arab community), excluding non-English speakers from surveys that
did not offer an Arabic version, and utilizing poor sampling methods and small
sample sizes (Arfken et al. 2011, 2013). Therefore, more research is needed to better
identify changes in the pattern of alcohol use and abuse by AA.
AA Mothers and Children
Allergies
Despite having their own unique genetic makeup and special environmental expo-
sures, AA children were rarely studied as a separate group in allergy research
(Havstad et al. 2017). Only one study investigated the sensitization rates and total
immunoglobulin E (IgE) in AA children. Researchers found that AA children differ
tremendously at baseline compared to White children; they tend to have younger
mothers, similar parenteral history, and are more likely to be breastfed. Regarding
allergen exposure, AA children were significantly less likely to hold pets, specifi-
cally dogs, possibly due to cultural and religious reasons. Therefore, the risk of early
life sensitization was twice higher for AA children. In addition, total IgE was also
higher than in White children. Disparities in allergic sensitization by race may be due
to environmental and cultural factors rather than genetic predisposition alone (Yang
et al. 2008; Havstad et al. 2017).
Disasters and Conflict
The association between trauma, maternal mental health, and perinatal health out-
comes is inevitable (Harville et al. 2010). Pregnant and postpartum women may be
more vulnerable to negative outcomes of disasters such as terrorist attacks and

natural disasters. Such outcomes include, but are not limited to, low birth weights,
preterm delivery, and spontaneous abortion.
Events of September 11 have placed pregnant AA women at a higher risk of
harassment and discrimination (Lauderdale 2006; Eskenazi et al. 2007; El-Sayed
et al. 2008). One study found that Arabic-named women in California had a higher
incidence of lower birth weight and preterm birth in the 6-month period following
the terrorist events compared to the period prior (Lauderdale 2006). Similarly, a
study among AA women in New York City found that the events of September
11 were associated with an increase in birth of low-weight infants and delayed
decreased preterm delivery which can be linked to stress (Eskenazi et al. 2007). In
contrast, a similar study conducted in Detroit, Michigan, found no association
between September 11 and birth outcomes among AA women (El-Sayed et al.
2008). In fact, they found that self-reported AA ethnicity is associated with lower
risk of adverse events. This can be attributed to the higher ethnic density in Michigan
compared to California (0.82% vs. 0.48%) as strong social connection is known to
positively impact the health of ethnic minorities.
Birth Outcomes
Although White Americans have a better socioeconomic status, and generally better
health, AA women are 16% less likely to have negative birth outcomes compared to
women of White ethnicity (El-Sayed and Galea 2011). Several factors were found to
affect risk for birth outcomes among AA mothers (Table 2) (El-Sayed and Galea
2009b). Marital status, smoking tobacco, and having a foreign birthplace may be the
most critical factors for negative birth outcomes, such as low and very low birth weight.
Table 2 Factors affecting birth outcomes among Arab American mothers

Age when giving Age of less than 16 years and over 35 years is associated with increased risk
birth of maternal complications. Arab American mothers are less likely to have
children at those age groups compared to White American mothers
Parity Parity is inversely related to positive birth outcomes. Women of minority
groups, including Arab American women, are less likely to be older and
primiparous than White American women
Maternal Maternal education was associated with better birth outcomes. Arab
Education American women are more likely to be educated than White mothers
Marriage Not being married at the time of pregnancy was associated with higher risk
of negative birth outcomes. Arab American women are more likely to be
married than White mothers
Smoking Tobacco use increases risk for adverse birth outcomes. Arab American
women are less likely to use tobacco during their pregnancy than White
mothers
Birth outside the Foreign maternal birth had been linked to lower risk of negative birth
US outcomes. Arab American women are more likely to be foreign born than
White mothers
One study explored the relationship between interracial mating and birth out-
comes among AA women (El-Sayed and Galea 2011). The researchers interestingly
concluded that AA mothers with a paternal non-Arab ethnicity are at higher risk of
negative birth outcomes, including preterm birth and late preterm birth compared to
paternal Arab ethnicity.
Infant Feeding Practices
Breastfeeding has been linked to numerous favorable outcomes for infants and
mothers, including but not limited to improved cognitive development, decreased
risk of allergy and infections, and stronger bonding between mother and child (Jessri
et al. 2013, 2015).
AA children are more likely to be breastfed compared to White American
children (94% vs. 76%); however, they are less likely to being exclusively breastfed
for the first month of their lives (16% vs. 29%) (Havstad et al. 2017). While no
studies have been conducted among AA to investigate factors that led to such
favorable breastfeeding practices, researchers in Canada have explored potential
considerations that can be applied to AA immigrants. One study explored
breastfeeding patterns among Arabs in Canada after immigration (Jessri et al.
2013). Determinants of an Arab mother’s decision to breastfeed were religion,
employment status, privacy concern, social impact, maternal characteristics, and
cultural beliefs. Details of these determinants are summarized in Table 3.
Notably, Arab mothers are more likely to introduce solid food at a younger age,
typically rice, dates, and tea (Jessri et al. 2013, 2015). In another study also
conducted in Canada, Arab mothers were asked about their main considerations
Table 3 Determinants of an Arab mother’s decision to breastfeed after immigration

Religion There is a general belief that breastfeeding until 2 years of age is
recommended in the Quran. Moreover, adaptation of a non-Muslim wet
nurse is not favorable due to the general belief that a non-Muslim would
“influence” the child
Employment Compared to conditions in the Arab world, employed Arab mothers lack
amenities to support lactation, such as private nursing rooms and paid
nursing breaks
Privacy Social stigma associated with public breastfeeding, lack of positive
breastfeeding policies, and nursing family rooms that allow male parents to
enter influences Arab mothers’ ability to breastfeed
Social impact Arab mothers tend to trust their friends and husband’s advice when it comes
to breastfeeding more than healthcare providers’ advice. Young immigrant
women with little social support were concerned about their breastfeeding
competency
Maternal Arab mothers view breastfeeding as a positive, relaxing, cost-effective,
characteristics practical, and nutritious practice
Culture Arab culture in general encourages the introduction of solid food at a young
age, such as dates, milk, and yogurt
when choosing their children’s formula (Jessri et al. 2015). Results show that Arab
mothers care considerably about the food being “Halal” (i.e., permitted religiously)
rather than inquiring about allergies.
Medications
Medication Utilization
Medication prescribing is a process that authorizes patients to get medications from

pharmacies. Physicians or other qualified healthcare practitioners are the main
purveyors of prescription medication. The healthcare delivery system in the US is
complex and has several distinct layers which are challenging for immigrants to
understand (Edelman et al. 2014). It has been called “multiplicity of health systems
or subsystems” because of its complicated nature involving private and public
sectors providing services to consumers. The system is further complicated by its
three-dimensional model involving local, state, and national sectors.
Self-medication on the other hand can be defined as obtaining and consuming
drugs without a physician to manage self-reported medical concerns (Khalifeh, et al.
2017). This is a common practice among adolescents in certain parts of the Arab
world, which suggests possible autonomous health behavior among AA. In the Arab
world, individuals tend to get drugs advice from pharmacists in community phar-
macies because many drugs that can only be obtained through a prescription in the
US are sold over the counter in Arab countries. Friends and parents are also a
common source of self-medication.
Most Arab refugees in the US prefer to get their medications from Arab pharma-
cies because they feel more comfortable dealing with individuals who speak the
same language, have the same background, and are from the same culture (Hammad
et al. 1999). This is particularly convenient for recent refugees with little adaptation
to the US.
Data regarding volume and patterns of medication usage among AA is limited
and outdated. Several factors such as the Internet, globalism, social media, and
access to knowledge can lead to improvement in collection of new data. While it
could be extrapolated from healthcare practices in their homeland, further research in
these aspects is warranted.
Medication Safety and Adherence
Medications are safe in general when patients use them as prescribed by a healthcare
practitioner or as mentioned in the label description. Arab immigrants may have
insufficient awareness of medications safety because they can buy most of the
medications without prescriptions in their home country’s (Khalifeh et al. 2017).
Some American physicians reported non-compliance with medication among immi-
grants and refugees (Hammad et al. 1999).
Table 4 Characteristics of Arab American immigrants’ medication use

Medication discontinuation upon feeling Arab immigrants use their medications on an “as
better needed basis” and save the “leftover” pills for future
diseases that are more serious and complicated. For
example, there is a tendency to stop antibiotic
regimens prior to course completion. There is lack of
knowledge that such practices may lead to worse
outcomes
Fasting Ramadan with no knowledge of Fasting could affect medication safety because of
optimum medication US practices complete discontinuation of long-term medications
or doubling of doses after breaking the fast. Thus, it
is crucial to discuss medication regimens while
honoring religious and cultural beliefs
Social influence Family members and friends who have the same
condition can influence Arab immigrants’
medication regimens. They tend to change and adjust
without consulting their providers
Herbal and traditional medicine Herbal and traditional medicine is often used when
Western medications do not make them immediately
feel better. Healthcare providers are often unaware
about such practices which may influence outcomes
Medication adherence is one of the important factors leading to successful

treatment plans. Non-compliance could be a consequence of several characteristics
related to the AA culture and belief. Characteristics are summarized in Table 4
(Alzubaidi et al. 2015a; AlRawi et al. 2011).
Preventive Health
Cervical Cancer
Cervical cancer is one of the most common cancers among women worldwide, partic-
ularly in developing countries (American Cancer Society 2017). In the US, cervical
cancer ranks 14th in prevalence due to efforts in prevention and early detection. Lesions
detected by Pap smears can be treated before it progresses into cancer. Therefore,
mortality from cervical cancer in the US is relatively low compared to other types of
cancer. Racial and ethnic disparities can introduce factors that may act as barriers to
utilization of medical services for cancer prevention and ultimately influence mortality
(Matin and Lebaron 2004; Shah et al. 2008; Salman 2012; Gauss et al. 2013; Padela
et al. 2014; Williams et al. 2014; Dallo and Kindratt 2015a, 2015b; Talley and Williams
2015; Abboud et al. 2017).These factors had been extensively studied in the literature;
details and examples are illustrated in Table 5 (Matin and Lebaron 2004; Shah et al.
2008; Salman 2012; Padela et al. 2014; Williams et al. 2014; Dallo and Kindratt
2015a,2015b; Abboud et al. 2017; Roman et al. 2014).
A review (Abboud et al. 2017) thoroughly investigated cervical cancer screening
rates as well as factors that may influence screening among AA women. The authors
Table 5 Factors associated with cervical cancer screening

Factor Findings
Knowledge Arab American women have similar cervical cancer literacy when
compared to Black and Latina women
Arab American women who knew that screening was preventive of
cervical cancer were more likely to obtain screening
Beliefs Religious issues: values in Arab and Muslim cultures empower modesty
and virginity, which may contradict with clinical recommendations to
perform Pap smear testing regardless of sexual activity. The strong
preference for a female provider in those private parts may influence access
Fatalism: fatalism is the belief that events such as cancer are inevitable.
Higher fatalism was associated with lower rates of cervical cancer
screening among Arab American women, but not when adjusted for social
and demographic variables
Pain: the perception that a Pap smear is painful reduces the likelihood of
women regardless of ethnicity to schedule a Pap test. Interestingly, Arab
American women have lower perception of pain at baseline when
compared to African American women or Latina (24.2% vs. 30.3% and
35.5%, receptively). The perception of pain improves as women schedule
and experience their first appointment
Immigration and The ability to understand or speak English and a longer duration of time
nativity living in the US were associated with more Pap smear
Competing Higher competing priorities such as working two or more jobs, need to
priorities schedule appointments, and having a low family income were all
associated with lower cervical cancer screening
Marital status Being married was identified as crucial prior to obtaining gynecological
healthcare. Being single was not associated with fewer odds of receiving a
Pap test in one study but was in another
Health insurance Out-of-pocket costs for healthcare and lack of health insurance were
associated with less frequent Pap smear
Healthcare Arab American women who had a primary healthcare provider were more
providers likely to receive a Pap smear
found that the screening rate in AA women varies considerably among studies,
ranging between 50% and 87%. This is noticeably low in comparison with the
2020 goal of 93%. When compared to other ethnicities, AA women have fewer
Pap smears in their life span compared to European-born and US-born women at
rates of 87% and 95%, respectively. African American women also have higher
screening rates, as high as 85%. Only Latina women had rates of screening ranging
from 68% to 77%, which is similar to AA women.
Breast Cancer
According to the American Cancer Society (2017), breast cancer affects around a quarter
of a million women in the US annually. The Society recommends annual screening for
all women with moderate risk starting at age 45 (Oeffinger et al. 2015). AA women have
less incidents of breast cancer than White women; however, they are more likely to have
an advanced and aggressive form of the disease as well as having the disease at a young
age (Dallo and Kindratt 2015a; Talley and Williams 2015). This is primarily due to late
screening and follow-up. Foreign-born AA women were less likely to receive a breast
exam compared to US-born White women (Dallo and Kindratt 2015a). While no
specific studies have been conducted exploring factors leading to delayed breast cancer
screening among AA women, one can extrapolate from cervical cancer screening studies
factors such as lack of knowledge, language barriers, and cultural and religious beliefs.
One study looked at health literacy as a potential factor in breast cancer among minority
women in the US using the Breast Cancer Literacy Assessment Tool. One of the
findings is that AA women have similar knowledge about prevention and screening
methods for breast cancer, but they lack awareness about breast cancer as a disease
(Talley and Williams 2015).
Prostate Cancer
Prostate cancer is the most common non-skin cancer among American men (American
Cancer Society 2017). Prostate surface antigen (PSA) testing may be able to detect
cancer earlier than other methods of screening. The American Cancer Society currently
recommends prostate-specific antigen (PSA) to detect prostate cancer in men over
40 years of age with certain risk factors. Because preventive care research in AA men
is considerably low compared to AA women, literature discussing prostate cancer
prevention is generally poor because research in immigrants’ preventive care measures,
particularly among AA men, is uncommon. One study found that foreign-born AA men
have similar rates of PSA screening when compared to American White men (Dallo and
Kindratt 2015b). In another study, AA PSA screening was lower than the general
population, but better than some minorities such as Hispanics and American Indians
(Yassine et al. 2010). Little is known about barriers for PSA testing among Arab men.
Possible hurdles with prostate screening in AA men include embarrassment, language
issues, perception of cancer, lack of knowledge about PSA, and preference for taking
medication rather than preventive care (Aboul-enein and Aboul-enein 2010).
Colorectal Cancer
Colorectal cancer (CRC) is the third most common cancer among both men and
women (Talaat and Harb 2013; Talaat 2015). Screening at the polyp stage can prevent
over half of colorectal cancer-related deaths. The Michigan Cancer Consortium
(MCC) reports that Arabs in Michigan had lower CRC screening rates compared to
the general population (45.6% vs. 60.8%) (Talaat 2015). Another survey among AA
over the age of 50 in Michigan confirmed this low percentage (45%), even though over
80% of survey respondents had health insurance and had Arabic-speaking PCP (Talaat
and Harb 2013). This suggests that discomfort and unawareness by the PCP may be
the major factors contributing to lower CRC screening rates rather than access alone. A
study aimed to compare two Arabic countries of origin, Lebanon and Yemen, to
recognize barriers to nonadherence (Talaat 2015). The results showed that Lebanese
immigrants were more likely to be screened compared to the Yemeni (72.2%
vs. 27.9%), possibly due to their increased CRC knowledge (46% vs. 11%). In general,
factors associated with lower rates of colorectal screening include lack of knowledge,
language barriers, financial circumstances, embarrassment, problems in scheduling,
and misconception that CRC screening is not necessary.
Vaccines
The CDC currently recommends that all individuals of 6 months and older receive
the flu vaccine annually to prevent influenza disease and its complications (CDC
2017). In addition, the CDC recommends pneumococcal vaccine to prevent pneu-
mococcal disease, a disease caused by Streptococcus pneumoniae. The CDC rec-
ommends pneumococcal conjugate vaccine for all children younger than 2 years of
age and pneumococcal vaccination for all adults 65 years or older. Two studies have
pooled 12 years of National Health Interview Survey data to compare the prevalence
of receiving flu or pneumonia vaccines among AA. AA women who were of foreign
birth were less likely to be vaccinated with a flu shot or pneumococcal vaccine
compared to US-born White women (Dallo and Kindratt 2015b). Similarly, foreign-
born AA men were less likely to report being vaccinated with the influenza or
pneumococcal vaccine in comparison to US-born White men (Dallo and Kindratt
2015b). No studies have been conducted among AA children. This raises concerns
about the misconceptions that AA families may have about vaccines.
Barriers to Medications and Healthcare
Background
Access to healthcare services is a multidimensional approach that includes avail-

ability, acceptability, affordability, and accommodation (Alzubaidi et al. 2015b).
There is overwhelming evidence that ethnic minority groups underutilize and
delay access to healthcare services when compared to nonimmigrant comparators
(Al abed et al. 2014; Alzubaidi et al. 2015b). Unfortunately, the AA population in
Western countries have been under-investigated, with very few studies conducted
among the AA population (Al abed et al. 2014). Greater understanding of the social
determinants and social inequalities would provide stronger recommendations in
achieving effective healthcare access.
Barriers
The population of noncitizen Arab immigrants in the US is made up of both

undocumented and legally present immigrants. Under the ACA, legal immigrants
were eligible for marketplace subsidies and may also be granted Medicaid coverage
(Hacker et al. 2015). It remains unclear how the repeal of the ACA in 2017 would
influence AA. The remaining proportion of immigrants were ineligible to receive
Medicare or Medicaid coverage due to their illegal presence in the US. Apart from
coverage denial, undocumented Arab immigrants face additional barriers in
accessing healthcare. These barriers include financial status, fears of deportation,
and, most importantly, language barriers (Sarsour et al. 2010; Hacker et al. 2015).
Language barriers often compromise the health and longevity of AA. It is estimated
that over half of AA patients will choose their healthcare provider based on language
considerations. In addition, many undocumented Arab immigrants fail to seek
medical help until a health situation becomes gravely serious because speaking up
could put these individuals at risk of deportation.
Socioeconomic needs create structural barriers to healthcare among immigrants
(Ayash et al. 2018; Jaber 2003). Some examples of those include financial, trans-
portation, health insurance, social support, legal, and food assistance. Because many
immigrants live below the poverty level, financial need is the highest need expressed
among immigrants regardless of background (Ayash et al. 2018). AA have similar
financial housing, supportive care, health, legal, and transportation needs when
compared to Latinos and Caribbean immigrants of African descent.
However, AA are more likely to express the need for health insurance, placing a
huge barrier against access to healthcare. In addition, AA were more likely to express
the need for legal services. This is possibly due to the vulnerable status of most AA
as immigrants or international refugees with various legal needs and experiences
with discrimination, abuse, and harassment. Interestingly, AA were less likely to
express food assistance needs compared to Latinos and Caribbean immigrants of
African descent. It is unclear why this is the case, but can possibly be alluded to the
nature of Arab culture, which can create a sense of shame if food insecurity is
abundant in the family household.
Conclusion and Prospective View
Five general recommendations are offered to guide government agencies and aid
organizations improve healthcare for Arab immigrants and refugees in the US
(Hacker et al. 2015). First, legal changes are necessary regarding healthcare reform
which may impede access to healthcare in immigrant populations. Efforts should
also focus on promoting legislation to protect the rights of immigrants undergoing
treatment in the US and at risk for deportation.
Second, aid agencies could recommend alternatives to healthcare coverage to
support undocumented Arab immigrants by easing their access to healthcare. Such
options include a variety of plans offered at a low-cost and/or expanded care
coverage. This kind of coverage should, however, require that undocumented
immigrants make regular financial contributions to their healthcare plans.
Third, aid agencies should also consider training healthcare practitioners on the
importance of cultural sensitivity and awareness when managing Arab immigrants’
health-related needs. This includes several socio-behavioral barriers to care, espe-

cially financial, legal, and health insurance needs. In addition, numerous providers
fail to understand how current healthcare provision policies apply (or do not apply)
to Arab immigrants and how such policies and procedures can be utilized in favor of
their vulnerable patients.
Fourth, due to the vital differences between their countries of origin and the US, it
is essential to educate Arab immigrants about the health-related options available to
them as residents of the US. Education is crucial to ensure Arab immigrants obtain
access to quality healthcare that they can afford in order to achieve their health-
related goals.
Finally, targeted research studying AA as an independent ethnic group is required
to recognize the unique characteristics and determinants that influence AA health.
More research is required among AA children as well as medication use.
Overall, the outlined recommendations include focused research, policy reviews,
health insurance alternatives, as well as PCP training on cultural competence and
creating awareness of the US healthcare system among immigrant populations.
Advocacy for legislation aimed at improving the status of healthcare for Arab
immigrants in the US is also warranted. Such positive change would undoubtedly
serve as an inspiration for many Arab nations, as they still have a long way to go in
terms of healthcare provisions for their citizens and residents.
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COVID-19 and Refugees’ Status
of Permanent “Out-of-Placeness”: 17
A Necropolitical Neoliberal Construct
Thalia Arawi, Taha Hatab, and Diana Mikati
Contents
Defining “Refugee”: A Historical Evolution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 379
Refugees: A Look into the Present . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 380
Refugees and the Permanent State of Exception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381
Necropolitics, Neoliberalism, and the Emerging Concept of Refugee . . . . . . . . . . . . . . . . . . . . . . . . . 382
Covid-19, Refugees, and the Healthcare State of Exception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 384
Universal Human Rights and the Refugee Crisis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 385
Rights of Refugees in International Laws . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 386
The State of Palestinian Refugee Camps: A Snapshot of Living, Housing, and Health
Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 389
Poor Infrastructure, Housing, and Sanitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 389
The Practical Impossibility of Social Distancing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 390
Deteriorating Economic Conditions and Rising Unemployment . . . . . . . . . . . . . . . . . . . . . . . . . . . 391
Insufficient NGO Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 391
Psychological Distress and Deteriorating Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 392
High Level of NCDs and Comorbidities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 393
Thalia Arawi, Taha Hatab and Diana Mikati contributed equally with all other contributors.
T. Arawi (*)
The Salim El-Hoss Bioethics and Professionalism Program, Department of Internal Medicine,
Head of Division of Plastic & Reconstructive Surgery, American University of Beirut Medical
Center, Beirut, Lebanon
e-mail: ta16@aub.edu.lb
T. Hatab
The Salim El-Hoss Bioethics and Professionalism Program, American University of Beirut,
Beirut, Lebanon
e-mail: tmh13@mail.aub.edu
D. Mikati
The Salim El Hoss Bioethics and Professionalism Program, American University of Beirut Medical
Center, Beirut, Lebanon
e-mail: dm29@aub.edu.lb

https://doi.org/10.1007/978-3-030-36811-1_222
378 T. Arawi et al.
Hindered NGOs Aid and Initiatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 393

Discriminatory Policies and the International Community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 394
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 395
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 396
Abstract
We present the definition of a “refugee” in light of historical and modern
international laws. The dichotomy between the rights that refugees have by virtue
of being human and as stipulated by international regulations, on the one hand,
and what they actually have will be addressed, with special emphasis on the
perception of refugees as an out-of-place population and what ensues from this
reality. We address these issues with references to the state of exception as argued
by Agamben with references to the Foucauldian concept of biopolitics. We will
also address the impact of the above on life in camps in light of the difficult
endeavor to control the spread of the Coronavirus Disease 2019 (COVID-19)
pandemic with emphasis on the particular case of Palestinian refugees. Finally,
we aim to highlight the importance of washing the term refugee from the
neoliberal necropolitical constructs that altered its essential purpose, which will
help such populations in receiving their much-needed rights.
Keywords
Conflict zones · Gaza Strip · Needs · Palliative care challenges · Concerns ·
Healthcare · Necropolitics
Exile is strangely compelling to think about but terrible to experience. It is the unhealable rift
forced between a human being and a native place, between the self and its true home: it’s
essential sadness can never be surmounted. And while it is true that literature and history
contain heroic, romantic, glorious, even triumphant episodes in an exile’s life, these are no
more than efforts meant to overcome the crippling sorrow of estrangement.
– Edward Said, Reflections on Exile
In Men in the Sun (Rijal fil al Shams), Ghassan Kanafani recounts the story of
three undocumented Palestinian refugees and their unsuccessful endeavors to travel
even furtively from country to country in search for a recovered life for them and
their families. Their life in refugee camps was harsh enough to push them to a risky
journey during which they came across smugglers, corruption, abuse, and other
kinds of people and life situations that refugees of this day are well aware of and still
face. It is the story of Palestinians, Syrians, Yemenis, Iraqis, Lebanese, and many
more persons either seeking asylum or running away from the harsh lives refugee
camps impose on them. The novel ends with a poignant statement: “Why didn’t you
knock on the sides of the tank? Why didn’t you say anything? Why?” (Kanafani
1999). A question which solicits many answers and modern interpretations but in
which we will not delve as it is beyond the scope of this manuscript. Would knocking
on the sides of the tank have saved them? Kanafani never tells us.
Similar stories are recounted by Susan Abulhawa in her Mornings in Jenin
(Abulhawa 2010) as the reader travels with Amal and in The Blue between Sky
17 COVID-19 and Refugees’ Status of Permanent “Out-of-Placeness”: A. . . 379
and Water (Abulhawa 2016), a multigenerational saga with the Baraqa family and
recently, the story of Nahr in Against a Loveless World (Abulhawa 2020). These are
stories of refugees, migrants, and displaced people suffering a suffocating infringe-
ment of their basic human rights.
In this chapter, we will present the definition of a “refugee” in light of historical and
modern international laws. The dichotomy between the rights that refugees have by
virtue of being human and as stipulated by international regulations, on the one hand,
and what they actually have will be addressed, with special emphasis on the perception
of refugees as an out-of-place population and what ensues from this. We will tackle
these issues with references to the state of exception as argued by Agamben with
references to the Foucauldian concept of biopolitics. We will also address the impact of
the above on life in camps in light of the difficult endeavor to control the spread of the
Coronavirus Disease 2019 (COVID-19) pandemic with emphasis on the particular case
of Palestinian refugees. Finally, we aim to highlight the importance of washing the term
refugee from the neoliberal necropolitical constructs that altered its essential purpose,
which will help such populations in receiving their much-needed rights.
Defining “Refugee”: A Historical Evolution
First, what does the term “refugee” mean, and in what sense has this naming become
recently equated with imposing a binding state of “out-of-placeness” on the named
population (Said 2000), which appears as a condemnation to what Arendt refers to as
“statelessness” and to a life of pain and indignity?
On the 13th of April 1598, King Henry IV of France gave notable rights, mainly
religious and civil, to the Calvinist Protestants of France, also known as Huguenots,
in the predominantly Catholic state, in what was later known as the Edict of Nantes
(Cavendish 1998). Under the umbrella of civil unity, King Henry wanted his people,
from all different sects, to live in harmony under the gown of a single unified state.
Less than a century later, Louis XIV revoked the Edict of Nantes and ordered the
destruction of Huguenot churches and the persecution of all Protestants, forcing
them to convert into Catholicism. Huguenots found themselves helpless given these
circumstances, and decided to leave France and seek asylum in nearby countries.
Those French Protestants that fled the oppression of Louis XIV were called “réfugié”
(Cavendish 1998). This was the chain of events that gave way to the word “refugee”
in the connotation understood today. The term “refuge” is derived from Latin
“refugium,” a word that had been around for centuries, which denoted a place of
protection, of safety. Technically, it means “the act of taking refuge” or “place of
asylum.” “Refuge” completely retained its Latin senses and original definition,
where it means “sanctuary” and “shelter” (Merriam Webster). The terms “refugee,”
“asylum-seeker,” and “migrant” are often used interchangeably as they all refer to
persons who have left their countries and have crossed borders. Yet, they are not
identical. An asylum seeker is an individual seeking international protection but his
refugee status is yet to be confirmed. On the other hand, an internally displaced
individual is a person who left his home from fear of persecution or insecurity but
has not crossed any borders in the process. Meanwhile, a refugee is an individual
380 T. Arawi et al.
who crossed borders to a new country or state and has been officially recognized as
refugee under the 1951 Geneva Convention Relating to the Status of Refugees
(referred to as the 1951 Refugee Convention) (Phillips 2011). People can also be
refugees in their own country as is the case with Palestinians scattered in different
refugee camps in the Occupied Palestinian Territories (OPT). In this chapter, we will
mainly focus on refugees. So in terms of international laws, who is a refugee?
In modern international terms, refugees are people who have been compelled to
flee their own country, because of a well-founded fear of being persecuted and
oppressed for reasons related to race, religion, nationality, or political affiliation. In
most of the cases, refugees cannot return to their homeland, or are too afraid of the
consequences of doing so. The right to seek asylum is protected by the 1951 Refugee
Convention (United Nations High Commissioner for Refugees 1989).
Refugees: A Look into the Present
It is our contention that the term “refugee” has been for some decades abused and
placed within a static category, as if there were a tacit agreement among white settlers,
colonialists, and neoliberals that refugees are displaced people who will remain
displaced, who will always have to rely on external help for survival, and who suffer
the impact of COVID-19 for reasons mainly beyond their control. There seems to be an
implicit agreement, even acquiescence, that refugees are people who cannot and should
not live beyond what Agamben calls “bare life” under the mandate of a Foucauldian
biopower (a power over life) which controls entire populations. Biopolitics is about
tactics and apparatuses through which human life processes are run by authorities that
govern knowledge and power, thus ensuring subjugation of the populace, going as far
as deciding who gets to live and who gets to die. Foucault argues that “[w]e are, then, in
a power that has taken control of both the body and life or that has, if you like, taken
control of life in general – with the body as one pole and the population as the other”
(Foucault 1976). Thus, refugees are not even allowed to have a rational plan of life nor
to attempt one if they wished, as argued in “Deconstructing the challenges of doing
research in conflict zones and areas of protracted conflict: The case of Gaza” (▶ Chap.
147, “Deconstructing the Challenges of Doing Research in Conflict Zones and Areas of
Protracted Conflict: The Ecology of Life in Gaza”). Refugees are consequently objec-
tified and reduced to “otherness” by biopolitical powers and consequently become
“others” under the gaze of uninformed non-refugees (aka citizens). Refugees are
visualized as objects of policy; this detracts from their rights, and often results in the
unfair treatment of the population which the policy is supposed to protect. Refugees are
not treated as ordinary citizens with normal rights; rather countries of refuge implement
indiscriminate rules and policies, without taking into consideration the dynamic state of
refugees (International Justice Resource Center -IJSR- 2019). Thus, the refugee’s
existential plight is but the outcome of what we will call the “biopolitics of neoliber-
alism” where, as Agamben would argue, all power is biopower, constituted by its ability
to halt itself in a “state of exception” and decides who lives and who dies (Zembylas
2010). The relatively new notions of a global village and globalization, as well as the
North-South divide (Global North vs. Global South), an International Monetary Fund
(IMF) construct, further deepen the divide and enable the “otherness.” This indirectly
confirms that developing countries will never become developed. These terms are
constructs of neoliberalism, which will be addressed shortly to guide our interpretation
of why refugees are actually denied basic human rights.
According to the 2020 United Nations High Commissioner for Refugees
(UNHCR 2020) statistics, there are over 79.5 million forcibly displaced people
worldwide, of which, 45.7 million are internally displaced and 26 million are
refugees. Out of all refugees, 68% hail from only five nations which include Syria,
Venezuela, Afghanistan, South Sudan, and Myanmar. Syria continues to be the
country with the highest displaced people across borders with 6.6 million people.
Since the late 1940s, millions of Palestinians have been displaced, whether in the
occupied Palestinian territory, or in nearby countries, mainly Lebanon, Syria, and
Jordan. The United Nations Higher Commission for Refugees (UNHCR) has described
their situation as “by far the most protracted and largest of all refugee problems in the
world today” (UNRWA 2020). Palestinian refugees are not included in the UNHCR
database because the majority falls under the auspices of the United Nations Relief and
Works Agency for Palestinian Refugees in the Near East (UNRWA). Those included
under UNRWA’s supervision include a striking 5.6 million Palestinian refugees, statis-
tically second only to Syrian refugees, and with more refugees than Afghanistan and
South Sudan combined (UNRWA 2020). But what remains as a concern is that not all
Palestinian refugees are registered with UNRWA, leaving such populations vulnerable
and with no basic rights or financial support whatsoever. Palestinian refugees rely on
UNRWA for substantial financial support and services spanning from “education,
healthcare, relief, social and protection services, infrastructure and camp improvement
works among others” (UNRWA 2019). In Lebanon alone, about 205,000 persons
benefit from UNRWA services every year (UNRWA 2019).
Refugees and the Permanent State of Exception
Agamben first presented the conception of “state of exception” in Homo Sacer:

Sovereign Power and Bare Life and later expanded it in his State of Exception in
which he argued that “[t]oday it is not the city but rather the camp that is the
fundamental biopolitical paradigm of the West” (Agamben 1998). According to
Agamben, the “homo sacer” is basically a person without any political rights
(a non-citizen), who is not protected by law and can even be sacrificed if that serves
power and market, two concepts that are core to neoliberalism. “States of exception”
are used by neoliberal powers to suspend conventional rules for some or all of the
population, and where certain officials give themselves the authority to do whatever
they find necessary to keep their power, including depriving people of their rights.
While initially a state of exception was used in wartimes or emergencies, this state is
quasi permanent for refugees, in particular Palestinian refugees who live in a state of
suspension. They are not killed, yet they are not allowed to live, and thus live in
abeyance between life and death and in between massive carnage, pain and “other-
ness.” Refugees are thus powerless, have no rights, and are bound to live in a “state
of exception” reduced to a concept that originated with Arendt, a “bare life” where
382 T. Arawi et al.
“people who had indeed lost all other qualities and specific relationships- except that
they are still human. The world found nothing sacred in the abstract nakedness of
being human” (Agamben 1998).
Arendt’s The Origins of Totalitarianism talks about oppressors and dehumanizers
and about what hideous governments are capable of doing to those who became
Pariahs and refugees (Arendt et al. 1973). A “stateless” refugee herself, Arendt
presents a description of what it means to be a refugee, namely living in a constant
state of anxiety, eaten by despair, fighting to find optimism against all odds, and
experiencing an abject birth and absurd existence. Refugees, she argues, are people
who are forced to seek protection outside their homeland in another country (though
we can argue that Palestinians in Gaza are refugees in their own homeland),
regardless of whether they plan their stay in the host country to be temporary or
permanent. Refugees contemplate suicide in a Sartrean way, as the final resort to
exert their only remaining freedom, where suicide becomes “the supreme guarantee
of human liberty” (Arendt 1943). Thus, since refugees cannot design the lives they
want, they can “reject it nonetheless” as evidenced recently from widespread suicide
attempts among refugees (Arendt 1943). On the 15th of July of this year, an opinion
piece published in Haaretz reported “[n]early everyone I know in Gaza has contem-
plated suicide more than once. Despite the deep taboo, 2020 is heading toward a
record spike in suicides, and most are young, unemployed and suffocated by
despair” (Shehada 2020); with four suicides reported in 1 week, another published
analysis stated that “in Gaza, suicides are a political message” (Hass 2020). The term
refugee was originally meant to express a temporary state of evasion. What we
witness currently are the consequences of a neoliberal necropolitics (simply under-
stood as power and sovereignty over life and death), condemning refugees to a
permanent state of exception, otherness, and dehumanization.
Necropolitics, Neoliberalism, and the Emerging Concept

of Refugee
Drawn from classical liberal economic philosophy, neoliberal economic policy

essentially attributed to Hayek and Friedeman, which entered mainstream politics
with Reagan and Thatcher, promotes the abolition of trade barriers and relies mainly
on the efficacy of markets to reach a state of well-being without the regulatory
intervention from governments (Bettache and Chiu 2019). The advancement of
neoliberal policy is primarily credited to US economic theory; nonetheless, it is
through foreign economic institutions and policies that the movement to spread these
policies was promoted and pushed around the world (Harvey 2007). In the last
40 years, countries all over the globe have been marked by increased connections
between economies and expanded privatization of markets. This new era, the era of
neoliberalism, has been correlated with elevated levels of socioeconomic inequality,
both inside and among nations. The emergence of neoliberalism is closely related to
globalization mechanisms, so much that terms are sometimes used interchangeably
(Bettache and Chiu 2019). The belief that inequality is normal and inevitable is a
central principle of neoliberal ideology; this allows one to appreciate its role in
keeping the permanent status of developing countries as continuously developing,
and the increasing number of refugees and poverty in poor countries that were
colonized such as the Middle East in particular (Dutt and Kohfeldt 2018). The
irony lies in the comprehension that the global pattern of increasing interconnection,
which presumably aimed to increase communication between people all over the
world, may simply decrease the tendency of individuals to care about people’s lives
beyond their closer circle, as well as lead to a striking rise in individualism (Bettache
and Chiu 2019).
Technology has widened the disparity gap, and we even dare say that it is one tool
created by neoliberalism to attain its goals. According to neoliberalism, personal
interest is a central tenet; people tend to engage with each other if they know there is
some benefit behind it. Refugees are a vulnerable population, both economically and
socially; being at a disadvantage, they require support to adapt to their new envi-
ronment and to establish security, before they are able to give back to their societies.
Accordingly, for a neoliberal state, providing refugees with the needed support could
impose a significant financial toll with limited if not no direct returns on the short
term. This neoliberal approach leads to marginalization of such populations, making
them more vulnerable to apathy and harm (Dutt and Kohfeldt 2018). It is evident that
neoliberal policies have systemic benefits for advantaged groups and individuals
with preexisting power, allowing them to acquire even more power, and thus
widening the gap between them and those with less preexisting power, who in turn
become increasingly oppressed (Chomsky 1999).
A study done in community psychology found a connection between neoliberal-
ism and reduced social interest. Through a longitudinal analysis from 1984 to 2005
of media language in Norway, the authors (Nafstad et al. 2009) observed a reduction
in terms that represented connectivity (e.g., equality and cooperation) and an
increase in terms that represented more individualistic orientation (e.g., right and
privilege). To this day, access to decent health care and proper education remains a
privilege for numerous disadvantaged populations, when in fact, they should be
basic rights for all people living in any specific country, whether locals or foreigners,
irrespective of their race, religion, or social class. Henceforth, neoliberal environ-
ments foster a sense of distance, or “otherness,” from those who are not local
residents, as reflected in ethnocentric values and minimal desire to help asylum
seekers, aka refugees. In Lebanon for example, which contains the highest concen-
tration of refugees per capita, successive governments have emphasized the right of
refugees to be supported until they are safely able to return to their home countries.
Nonetheless, implemented measures and initiatives have not been sufficient and
remained highly reliant on international support to deal with the refugee crisis. In
sum, globalization, which is a main feature of neoliberalism, has encouraged the
development of global problems like that of the refugee crisis. Its indirect outcome,
that is, embraced injustice and individualism, compels countries to consider them-
selves exempt from the obligation of providing assistance to address these problems,
especially among neoliberal countries (Klein 2015). This further exacerbates the
status of refugees, particularly Palestinian refugees, rendering it irresolvable by tacit
384 T. Arawi et al.
consensus. As a consequence, they will remain “undesirable, kept apart from the
world, far from the city,” as per the words of Agier, where “everything is potential
but nothing develops, no promise of life is really fulfilled” (Agier 2008). They are in
the world yet outside it, a form of inclusion through exclusion. This situation
remains unchanged since 1948, with a deafening international silence vis-à-vis the
plight of refugees and a remarkable lack of support for the Occupied Palestinian
Territories and Gaza on behalf of Arab countries, whose support rarely goes beyond
paying lip service for a seemingly lost Arab cause. A clear example is the complete
silence on behalf of the Arab League. Indeed, Palestinian refugees are denied many
of the rights other refugees are bestowed under the office of the United Nations High
Commissioner for Refugees (UNHCR); the reason being that they are defined as
“persons whose normal place of residence was Palestine during the period 1 June
1946 to 15 May 1948, and who lost both home and means of livelihood as a result of
the 1948 conflict” (UNRWA 2020b). As a result, Arab countries consider
Palestinians as a state-less population, with no means of protection by international
laws, nor rights to be awarded by host countries.
Covid-19, Refugees, and the Healthcare State of Exception
Up until the first week of October 2020, there were 49,744 positive cases of COVID-
19 in Lebanon and 439 deaths. UNRWA reported that 1,282 Palestinian refugees had
tested positive for COVID-19, and that 31 Palestinians had unfortunately died since
the epidemic began in Lebanon on 21 February 2020. There are reportedly 54,355
confirmed cases of COVID-19 in the Occupied Palestinian Territories and
412 deaths. A total of 50,604 cases have been confirmed in the West Bank, including
11,099 in East Jerusalem. Here we will touch on some of the difficulties refugees,
mainly Palestinians, had faced over the years and currently exacerbated during the
COVID-19 pandemic (Medical Aid for Palestinians 2020). According to the
UNHCR, the year 2020 witnessed the highest rate of displacement since World
War II with 70.8 million people forcibly displaced (Knudson 2020). Among those
the UNHCR noted “25.9 million refugees, 41.3 million people displaced in their own
country, and 3.5 million asylum-seekers awaiting determination on refugee status”
(Knudson 2020). Ever since the eruption of the COVID-19 pandemic, a major
concern has been the way refugees were assisted (or not) to mitigate the effects of
the pandemic. Among these concerns is the ecology of refugee camps worldwide,
which is often characterized by poor infrastructure, lack of proper sanitation, and
social distancing, as well as the psychological aftermath of the pandemic. The
situation is described by 23-year-old Rayhana, mother of four children who had to
flee Myanmar and live in a refugee camp in Bangladesh: “Living in a refugee camp
is difficult. There is no food, no water, no toilet and no place to bathe. We can’t
afford to eat three times a day. My newborn baby cries for milk but I cannot produce
enough breast milk – maybe because I have not eaten enough over the past weeks”
(Mree 2017). Another article in The Independent shares the pains of 92 year old Fuda
Al-Bareesh who fled war-torn Syria: “Basking in the intoxicating paraffin warmth of
her tent, Fuda Al-Bareesh, 92, spends her days alone. At the arrival of visitors, her
piercing blue eyes sparkle momentarily, catching the light from the open doorway.
Her journey from Syria by donkey was also alone, and to this day she has heard no
news of her children from whom she was separated in the exodus of 2012. Kindly
neighbors fetch her fuel for her, but she often has to go without food to pay for it”
(Dawling 2019). Measures to mitigate the pandemic under such conditions are
practically impossible. A closer look at what refugee camps look like can help the
reader appreciate the difficulty of the situation.
Universal Human Rights and the Refugee Crisis
A prickly discussion in international matters today is refugee status. Every ratifying

state that grants the person in question UN-protected rights also has UN-mandated
requirements. Unfortunately, these measures have been unchanged since 1951 – the
aftermath of World War II. In a world where reasons to leave, reasons to immigrate,
reasons to flee, and reasons to take refuge overlap, intersperse, and blend together, a
clear, updated definition of the word “refugee” and what it entails is needed. The
gray area left by the simple qualifier “fear of persecution” in the 1951 Refugee
Convention leaves a lot – if not too much – open to interpretation in today’s
convoluted, complicated world. People flee their homes, cities, and home countries
because of war, famine, plague, natural disasters, civil unrest, lack of security,
poverty, as well as the clinching political, or religious persecution. Is someone
running away from death by hunger any less deserving of the rights bestowed
upon refugees than someone running away from death by firing squad? Well,
some interpretations of the United Nations’ definition would concur. The thirty-
third article refers to threats to life and freedom of the individual “on account of his
race, religion, nationality, membership of a particular social group or political
opinion.” An understanding of refugees that was suitable for its time; this phrasing,
if not the spirit, has fallen behind in today’s world. Evidence to this are countries
changing their own official understanding of “refugee.” Many African and Latin
American nations have created their own addenda in an effort to encompass the
current meaning of the term “refugee” (Human Rights and Refugees 2017). Other
countries conform to an almost constrictive comprehension of the 1951 definition;
refugee status is not an easily attainable prospect. This is a significant humanitarian
issue; clearly demarcating the line where an economic migrant becomes a refugee
may not be simple (indeed, some argue that it is not possible), but it certainly can be
defined a little more clearly than in the 1951 accord.
An argument about the focus of refugee status is that it is meant to be
implemented in cases where life and freedom are on the line; however, life and
freedom do not exist without a semblance of economic stability. Even if one were to
wave these intricacies aside, the simple definition of human rights entails that,
fleeing from hunger or from bullets, native or foreigner, people are entitled to a
minimum of human rights and an afforded modicum of treatment. The International
Covenant on Economic, Social and Cultural Rights establishes the principle of
386 T. Arawi et al.
nondiscrimination in the context of economic, social, and cultural rights. It commits

states to working progressively to realize rights to an adequate standard of living, to
the highest attainable standard of physical and mental health, and to education,
among others (Nicholson and Kumin 2017). Why should this not apply to people
simply because their reason for flight differs from others’?
What are some international rights refugees are being deprived from?
Rights of Refugees in International Laws
“We reaffirm the 1951 Convention relating to the Status of Refugees and the 1967
Protocol there to as the foundation of the international refugee protection regime. We
recognize the importance of their full and effective application by States parties and
the values they embody. . . . We reaffirm respect for the institution of asylum and the
right to seek asylum. We reaffirm respect for and adherence to the fundamental
principle of non-refoulement in accordance with international refugee law” (United
Nations General Assembly 2016).
The first, and most obvious, of these rights is non-refoulement. One of the
fundamental standards of refugee law, non-refoulement alludes to the commitment
of states not to return, or refoule, a displaced person to “the frontiers of territories
where his life or freedom would be threatened on account of his race, religion,
nationality, membership of a particular social group or political opinion” (United
Nations High Commissioner for Refugees 1989). Non-refoulement is unanimously
recognized as a human right. However, freedom of movement is a more controver-
sial refugee right; the stance on it is largely dependent on the policy of the host
country. Article 26 of the 1951 Refugee Convention mentioned that states must give
refugees the right to pick their place of residence within the country and to guarantee
their freedom of movement. Article 28 requires states to provide refugees with travel
documents allowing them to travel outside the country of refuge “unless compelling
reasons of national security or public order otherwise require” (United Nations
General Assembly 1948). In addition, the Universal Declaration of Human Rights
dictates that “Everyone has the right to freedom of movement and residence within
the borders of each State” (United Nations General Assembly 1948). However, some
countries like Kenya and Ethiopia specify in their laws that the free movement of
refugees in the country is restricted, and that refugees may be required to live in
specific areas, mainly refugee camps.
Lebanon, as a notably recurrent refugee-hosting nation, has – more or less –
abided by the standard regarding non-refoulement; the Lebanese government has not
officially returned refugees to Syria against their will. Despite the fact that there is no
concrete evidence to prove otherwise, the Human Rights Watch has reported that
refugees leaving from Arsal in 2017 were not voluntary, but the consequence of
dismal conditions, largely because of strict Lebanese policies that have made legal
residency, work, and freedom of movement largely difficult (Human Rights Watch
2018). Unfavorable and unstable situation notwithstanding, targeted persecution is a
valid fear for returning refugees: possibilities of arrest, torture, and forced conscrip-
tion are real and recorded. Human Rights Watch has reported on the near-policy
trends of random incarceration, torture, and execution in government custody in
Syria (Human Rights Watch 2018). While Lebanese politicians adopt the “not our
problem” stance when faced with this, using UNHCR as a scapegoat in the light of
Syria’s unlawful detention practices rings particularly hollow. This is, of course, not
to mention the Syrian government’s exploitation of urban planning laws to seize
previously private property without recompense or even notification (Human Rights
Watch 2018).
Another internationally acknowledged right – that also differs in the details – is
the right to liberty and security of the person. The notion is, of course, agreed upon.
The variation in interpretation of this right lies in the context of how refuge seekers
are being dealt with in the country of refuge. Some countries revert to detention of
refugees to allow for further investigation of their situation. Refugee detention is a
controversial current issue due to the rampant conditions in many destination-
countries’ detention centers. In particular, this is a problem in Greece, a nation
overwhelmed by the huge number of refugees it receives, who are using Greece as
a port of entry while attempting to enter other European countries. In Greek
detention centers, human rights groups, including Amnesty International, have
reported on low-hygiene and overpopulated conditions. Furthermore, refugees
have argued that they had no access to a representative of the UNHCR or any sort
of information about how to apply for refuge while in custody. The European Court
of Human Rights (ECtHR) has ruled a breach of basic human rights in Greek
detention centers, violating human dignity rights under the European Convention
on Human Rights. This is a clear violation of one of the tenets of the UDHR which
states, “No one shall be subject to arbitrary arrest, detention or exile” (United
Nations General Assembly 1948).
Moving further down the spectrum comes the right to family life. Regarding
this right, a number of countries provide protection for the dependent relatives of
the refugee. However, the concept of a dependent relative varies according to the
cultural notions of the family in a specific state or country. In the United Kingdom
for example, dependents are identified as “the applicant’s spouse, civil partner,
unmarried or same-sex partner, or minor child accompanying the applicant,”
while in Kenya, dependents include the “applicant’s brother or sister under the
age of 18, or any dependent grandparent, parent, grandchild, or ward living in the
same household as the refugee”. So, discrepancies can be seen in terms of family
life rights between one country and the other, leading to separation in some cases,
and in other cases, it may reach to deportation of the “non-dependent” family
member.
In addition, the 1951 Refugee Convention covers the rights to education, access
to justice, employment, and other basic privileges and forms of freedom; rights that
are constituents of general human rights agreements. Refugees must be ideally
afforded the same minimally humanitarian treatment as other populations in the
host country, with different comparisons drawn about specific tights. Their access to
the judiciary system should be identical to that of natives, while with different rights,
388 T. Arawi et al.
such as paid employment and ownership rights, treatment must at least mirror that of
foreign nationals.
A frequently encountered argument against refugee status being given to the vast
majority of those who ask for it is “economic migration,” that the refugees are in the
host country because of financial reasons. Economical immigrants, according to this
point of view, should not be granted refugee status: direct political persecution is the
internationally listed reason for refugee status. As a result, less than 20% these
people who ask for refugee status are obliged (Shiblak 1996). Judging and measur-
ing an evolving phenomenon by parameters ordained some 70 years ago seems
counterintuitive and outdated. Today’s refugees and their movements are unlike
those fleeing persecution and death in the World War. Furthermore, compare some-
one running away from death by starvation with someone running away from death
by firing squad. Is any one of them more deserving of the protective rights given to
refugees?
As a result of prior policy, refugee conditions have arrived at an all-time low.
Hindrance of rights and, in some cases, outright systematic discrimination have
become the painful norm. For example, presently, refugee document holders or
Palestinians carrying “short-term” Jordanian passports are regularly denied entry
visas to almost all Arab states. In the summer of 1994, and for the very first time,
Syria started denying entry to Palestinians from the occupied territories or to those
holding temporary Jordanian passports. Palestinians in Lebanon are excluded from
many occupations and cannot seek employment without licenses that are difficult to
obtain (Shiblak 1996). This situation pressurizes most Palestinians to illegal works,
where they are subject to all sorts of exploitation. Generally speaking, labor laws in
Arab states discriminate between “nationals” and “foreigners” with respect to equal
opportunity and benefits (Shiblak 1996). This results in a high prevalence of
unemployment among Palestinians, due to job constraints and sluggish economies.
The lack of Palestinian refugees’ access to governmental support and services
only adds to their hardships. Palestinian refugees are treated as foreigners in most
Arab countries, where they are denied access to government facilities, such as
education, health, and social services. This has been the case in Lebanon since
1948 and continues to this day. The same was carried out in Egypt in 1980; Jordan
and Iraq recently followed suit, albeit to a lesser degree (Shiblak 1996). Lebanon
particularly denies Palestinians access not only to health services and schooling, but
also to social security services. This is explained away by the argument that a
tradeoff agreement must be arrived at with the host country. The Egyptian public
school system – free for nationals – imposes tuition fees on Palestinian children; this
has been in place since 1980. Higher education required hard currency in payment;
those in higher education institutions when the ruling came into effect were unable to
graduate if they did not pay (Shiblak 1996). Additionally, Arab states almost entirely
limit Palestinian property ownership. Some limitations are part of generic laws
controlling foreigner access to real estate. For instance, only nationals are allowed
to own property in the majority of Gulf areas. Lebanon has the same attitude toward
ownership but specifically toward Palestinians. In rare cases, a personal residence
may be bought, but the process is costly and may take years (Shiblak 1996).
Although all rights as mandated by international laws and regulations must be

respected and delivered regardless of the country of refuge, some countries refer to
these regulations as recommendations and rather than obligations. For this reason,
we find rampant discrepancies between what should be delivered and what is
actually being provided.
The State of Palestinian Refugee Camps: A Snapshot of Living,

Housing, and Health Conditions
One of the authors visited a number of refugee camps in Lebanon, namely, Sabra and
Chatila, Mar Elias, and Ain el Helweh, among others. Climbing the stairs of one of
these camps unfolds the following scene: a big number of persons clustered in as sate
of deprivation through no fault of their own. The stench of sewage made its
unwelcome way straight through the nostrils and the lungs causing a sudden bout
of dizziness. The mental shock caused by the inhumane sight was inescapable: Quasi
small houses, and at times makeshift tents, were haphazardly scattered all around
with minimum space between them and massive dust settling all around, giving the
camps a shade of brownish sadness. People with scanty clothes ran around in
crowded streets, rendering social distancing an impossible feat. The entire ecology
of the camps was conducive to ill-health and infections, with a few healthcare centers
and at others none at all. In fact, the dire conditions of Palestinian refugee camps
have been documented noting poor living conditions, high rates of extreme poverty,
and compromised health status of camp residents (Chaaban et al. 2010). The
pandemic, the environmental crisis, and the psychosocial determinants of health
have compounded to make life of refugees a nightmare. Below we will highlight
eight essential factors that render mitigating the COVID-19 pandemic in refugee
camps a herculean task: poor infrastructure, the impossibility of social distancing,
unemployment, lack of access to health care, psychological repercussions, rise in
noncommunicable diseases (NCDs), insufficient nongovernmental organization
(NGOs) aid, and the reverberating silence of the international community.
Poor Infrastructure, Housing, and Sanitation
Poor sewage systems, electricity cuts, lack of clean water, and poverty characterize
the refugee camps’ infrastructures of both Syrian and Palestinian refugees in Leba-
non. The majority of Palestinian refugees in Lebanon have had no alternatives except
to live in such decaying camps and informal settlements, in 12 camps distributed
among different regions in Lebanon, that lack basic infrastructure and sanitation.
The amount of land assigned to official refugee camps has hardly changed since
1948, in spite of a fourfold rise in the documented refugee population (Amnesty
International 2007). Governmental laws and regulations have barred inhabitants
from bringing construction materials into those camps, thus prohibiting the renova-
tion, expansion, or reinforcement of housing units (Amnesty International 2007).
390 T. Arawi et al.
Residents who violate property laws are subjected to fines and likely taken into
custody; new buildings and violating structures have been destroyed. In rare cases
where new rooms or structures have been added to existing houses, the alleyways
have become much narrower, most dwellings do not receive direct sunshine, and the
constant smells of garbage and waste are at times unbearable, despite the best efforts
of the occupants (Amnesty International 2007). A number of surveys have revealed
prominent housing problems in Palestinian refugee camps to include water leakages,
pest infestations, structural damages, and lack of proper heating and ventilation
(Habib et al. 2006, Zabaneh et al. 2008).
These refugee camps remain very overcrowded and lacking in basic facilities,
such as clean water and electricity (Sarkis et al. 2020). Deprivation indices have
shown that around 40% of Palestinian refugees residing in these camps are deprived
(Chaaban et al. 2010). More recent studies indicate that about 61,000 Palestinian
refugees in Lebanon are living in life-threatening poverty and earn approximately
$22 a quarter (every 3 months) per person (Sarkis et al. 2020). One can expect that
the impact of a major health crisis such as that of the COVID-19 pandemic would
further strain the already fragile infrastructure. “I think everybody realized that we
are not prepared for a major outbreak. . . especially with the Palestinians because the
medical infrastructure [in the camps] is even behind our own,” says Dr. Firas Abiad,
who heads the government-run Rafic Hariri University Hospital in Beirut – the main
public facility for Lebanon’s response to the COVID pandemic (Sewell and
Chehayeb 2020). “Our best policy is to stay overcautious. . . If the virus finds its
way into this crowded population, then it is very easy for the virus to spread” (Sewell
and Chehayeb 2020). On the other hand, Palestinians elsewhere, such as those in the
Gaza Strip including 76% of the Palestinian refugee population, must endure the
COVID-19 pandemic, as well as the continuing 20-h power cuts, 14 years of Israeli
siege, and a perpetual renunciation of their freedom of movement (UNRWA 2020).
The Practical Impossibility of Social Distancing
One of the major characteristics of refugee camps is overcrowding, as noted in a

number of studies in Lebanon (Habib et al. 2006; Zabaneh et al. 2008). A corona-
virus epidemic in a crowded refugee camp can easily spread with social distancing
unlikely in compromised housing units, and many NGOs working on the ground
have warned that refugees living in such camps are “among the most vulnerable to
contracting the virus” (Zaatari 2020). NGOs have also reported that social distancing
and other required safety precautions to reduce the spread of COVID-19 in
Lebanon’s refugee camps have been difficult to enforce, particularly to convince
people to wear their masks at all times and to remain confined to their already-
crowded homes (Zaatari 2020; Rayes and Chehayeb 2020). In its attempt to curtail
the impact of the COVID-19 pandemic over the past few months, UNRWA has been
taking action to ensure that critical services remained available to Palestinian
refugees and to facilitate social distancing; this included supporting remote learning
programs for students, providing facilities for COVID-19 patients to quarantine or
isolate provided, in addition to allocating additional support to provide their primary
care centers and agency clinics with personnel, personal protective equipment, and
the needed triage systems and telemedicine services (UNRWA 2020).
Deteriorating Economic Conditions and Rising Unemployment
Prior to the pandemic, Lebanon had extended legislative limits on the freedom of
Palestinian and Syrian refugees to work in the country, thus inciting further obstacles
to employment (Sarkis et al. 2020). In the summer of 2019, the Ministry of Labor
introduced new prohibitions on small businesses that often employ foreign workers
without a work license (Sarkis et al. 2020). These restrictions were accompanied by
the lockdown on COVID-19 and the unfolding events in the country. Owing to the
obligatory quarantine and constraints, many refugees are employed as day per day
workers and have not been able to work, further compromising their financial
capabilities and the ability to sustain their most basic needs.
UNRWA claims that camp unemployment has shot up from 65% to 90%, and
acknowledges its limited capacity to provide further needed assistance (UNRWA
2020). Cash assistance still helps about 30,000 Palestinians fleeing the Syrian war:
households received monthly installments of 150,000 Lebanese pounds before March
2020, $100 at the official exchange rate, or around $18 at the current street rate (Sewell
and Chehayeb 2020). Moreover, for food, refugees were previously given 40,000 Leb-
anese pounds per person. As of April 2020, the amount was changed to 320,000 L.L.
(around $216 at the official exchange rate and $37 at the real street rate) in general aid
per family and 81,000 Lebanese pounds (around $9 according to the real street rate) in
food aid per person to account for the devaluation of the currency (Sewell and
Chehayeb 2020). Ultimately, however, they did not receive the promised amount of
$216 per month – just a one-time payment of 112,000 Lebanese pounds that was
postponed during lockdown because financial institutions were closed. “We would love
to do [cash payments] on a monthly basis, but I don’t think it’s realistic,” said Hoda
Samra, UNRWA’s spokeswoman in Lebanon; “I don’t think we will get the funds,” she
added (Sewell and Chehayeb 2020).
Recent surveys on vulnerable refugee populations in Lebanon assessing the effect
of COVID-19 have revealed that almost a quarter were unable to buy medication,
61% lost their jobs, 74% were unable to pay rent, and 77% had trouble purchasing
food (Sarkis et al. 2020). One can expect a similar scenario to apply to Palestinian
refugees as well. The deterioration of the Lebanese economy has been incontestable,
with the rapid devaluation of the Lebanese pound. This has led to a dramatic rise in
the cost of food and other products and has put an even greater pressure on the
country’s refugee families and consequently sounding the alarm on the imminent
hunger and food insecurity (UNRWA 2020).
Insufficient NGO Funding
It took almost 2 months of lockdown for UNRWA to declare cash assistance and the
establishment of a medical isolation center exclusively for Palestinian COVID-19
392 T. Arawi et al.
patients on the campus of a school in southern Lebanon (Sewell and Chehayeb

2020). “For a week, we’ve been coming and going for nothing, and standing in the
sun,” said 82-year-old Fawad Yusef, a Palestinian refugee who left home self-
isolation to join a line of hundreds of people on a Friday afternoon outside a Beirut
money transfer office. “Now, we’ve been here for an hour and maybe there’s
nothing,” Yusef said (Sewell and Chehayeb 2020). UNRWA’s spokesperson Hoda
Samra noted that the agency continues to function at a loss, and is unable to recover
from the impact of a full withdrawal of funding from the United States which began
in 2018. She notes that the agency has so far received less than 30% of the $1.4
billion it has sought for the year after having already entered 2020 with a deficit
(Rayes and Chehayeb 2020). UNRWA appealed for $14 million on 17th of March
for its COVID-19 response, which Hoda Samra said was approximately half-funded.
With such a shortage in financial resources, one could only imagine how difficult it is
to manage the everyday expenses, not to mention medical assistance.
Psychological Distress and Deteriorating Mental Health
The hopes for the future for the inhabitants of the refugee camps in Lebanon
generally, and Palestinians more specifically, are not promising. It is practically
impossible to find a job and most residents suffer from difficult housing conditions
and a fragile socioeconomic status. The distress of enduring such dire conditions and
the difficulty to cope are bound to be significant. Almost one-third of the patients
seen by Médecins Sans Frontières (MSF) from such camps are affected by depres-
sion, while others are affected by anxiety, psychosis, bipolar, and personality
disorders (Forgione 2012). These data date back to 2012, and numbers are expected
to have increased significantly since then, especially with the ongoing economic
crisis Lebanon has been witnessing since late 2019 and the multiple compounding
repercussions, which have led to additional restrictions and burdens on refugees.
The unfolding sequelae of the COVID-19 pandemic have also made matters
much worse, critically aggravating the levels of deprivation and despair among
refugees (Anderson 2020). “Palestinian refugees said they were going to come
into our schools, saying they have nowhere to sleep, nothing to pay the rent, and
no food to eat” asserted Claudio Cordone, UNRWA’s director in Lebanon, pointing
out the current state of mind Palestinian refugees are suffering from (Sewell and
Chehayeb 2020). A clinical psychologist working with Palestinian refugee families
in camps testified “It is already a difficult situation in the camps [. . .].The corona-
virus situation is suffocating them even more” (Anderson 2020). Doctor Rabih El
Chammay, head of Lebanon’s National Mental Health Programme (NMHP) who
until 2018 worked as a consultant psychiatrist in one of the camps, explains that the
NHMP is collaborating with local NGOs providing mental healthcare services inside
camps; however, the prospects and sustainability of these efforts remain uncertain
with no resolution on the horizon (Anderson 2020). Lockdown has led to another
crisis in refugee camps. A surge in already problematic rates of rape and sexual
violence as well as gender-based violence has been reported by local activist groups
and NGOs and ensuing post-traumatic stress disorders (PTSD) have also increased
with lockdown (Shanks et al. 2001; Terre des Hommes 2020; Ryan 2020).
COVID-19 death is also likely to increase the prevalence of PTSD and the already
prevalent psychological distress experienced by the young and old. Thus, it is our
contention that after the specter of COVID-19 is over, a mental health pandemic
consisting of depression, anxiety, and PTSD will upsurge for preemptive measures
must be taken as of now.
High Level of NCDs and Comorbidities
The poor supply of shelter, sanitation, electricity, waste disposal, and other facilities
in Palestinian refugee camps have shown correlation with poor health outcomes and
multiple comorbidities (Habib et al. 2006; Zabaneh et al. 2008; Habib et al. 2013). A
study by Habib et al. conducted in July 2010 on a total of 2575 households chosen
randomly from Palestinian refugee camps all over Lebanon, revealed that up to
one-third of the population selected suffered from chronic illness and up one-fifth
had acute diseases (Zabaneh et al. 2008; Habib et al. 2013). The majority of chronic
illnesses included those of the circulatory system (21.5%), the musculoskeletal
system (18.9%), and the respiratory system (15.2%) (Habib et al. 2013). Many
reported living in harmful health conditions, with sewage water running between
houses with water and hazardous construction material dripping from the roofs;
more housing problems were associated with a higher prevalence of illness with a
cumulative effect (Habib et al. 2013). This only represents the tip of the iceberg
when it comes to what Palestinian refugees have to face during their everyday life.
Hindered NGOs Aid and Initiatives
As if the existential crisis and the deplorable ecology of camps were not enough,
following the COVID-19 crisis, NGOs faced additional difficulties in accessing
refugee camps due to then restrictive lockdown regulations enforced by the govern-
ment (Sewell and Chehayeb 2020). Khalil Dalal, a resident of Jalil camp who leads a
local NGO called the SHAHD Association, said that “civil society organizations
worked a lot more than UNRWA” when it came to both prevention measures and
relief work, distributing food boxes, face masks and disinfectants in the camps
(Sewell and Chehayeb 2020). To a certain extent, UNRWA agrees with its critics.
It admits that, in reaction to COVID-19 and the subsequent economic difficulties, the
organization was late to provide assistance, but claims the delay was due to a
shortage of resources, both in Lebanon and in all the countries in which it operates
(Sewell and Chehayeb 2020).
Prior to this, the Lebanese government had started implementing severe eco-
nomic measures in 2019, including a 7% reduction in the budget of public health
care, which provides funding to NGOs vital to the continuity of financial and
humanitarian aid for millions of Palestinian and Syrian refugees (Rayes and
394 T. Arawi et al.
Chehayeb 2020). Such cuts in budget have had a significant effect on access to health
care for refugees, who are mostly dependent on the public sector. During the
COVID-19 lockdown, night curfews and other limitations made it impossible for
medical agencies to enter refugee camps and, as a result, for refugees to access
medical facilities. This includes Amel Association and Medecins Sans Frontieres
who had reported that their visits to facilities decreased in March 2020 by 30%
(Rayes and Chehayeb 2020). At least 21 municipalities had already enacted curfews
and other limits on freedom of movement until the national lockdown-like limits and
measures introduced in mid-March (Rayes and Chehayeb 2020). These policies
preceded the national curfews implemented by the Lebanese government, which
according to Human Rights Watch, were not only discriminatory in nature, but also
redundant in avoiding the dissemination of the virus (Rayes and Chehayeb 2020).
Lebanon’s economic crisis and sociopolitical instability and the advent of the
COVID-19 pandemic has contributed to a reduction in donor support as well as an
insufficient capability within the health system to address the increasing needs of
Lebanon’s Palestinian and Syrian refugee communities. Consequently, refugees
were condemned to a life of precariousness, under the mercy of an insidious
biopolitics, ultimately expressed by a sovereignty, which decides, albeit tacitly,
who may live and who may die.
Discriminatory Policies and the International Community
The 1948 Nakba, which entered its 71 years anniversary, is not an event in the sense
that it did not occur and end. The first response of the host Arab states to the
Palestinian influx was to provide protection based on the presumption that the stay
of the refugees would be temporary, and that the Palestine Conciliation Commission
would reach some sort of an agreement. It became important to determine the status
of Palestinian refugees when a solution did not see the light. Two approaches were
adopted (Shiblak 1996). The first was to demonstrate solidarity with refugees. This
was exemplified through the willingness of Arab governments, at least in principle,
to grant citizenship to Palestinians, without giving them political rights enjoyed by
their own citizens. The Casablanca Protocol of 1965, which referred to the right of
Palestinian refugees to work and to enjoy freedom of movement and full rights of
residence, encapsulates this policy (Shiblak 1996). Among all Arab countries,
Jordan was the only country which granted Palestinians, who fled the Nakba, its
citizenship.
The second approach was to emphasize the protection of Palestinian identity by
maintaining a refugee status for Palestinians under the presumption that granting
them citizenship would be an indirect assertion on their behalf that there is no “right
to return” nor a need to claim a right to return. Until recently, Arab governments
declined to make an official contribution to the UNRWA budget as a matter of policy.
They formally opposed resettlement or naturalization (Shiblak 1996). Whatever the
policy toward the refugees is, one of the main obstacles to establishing civil rights of
the refugees, in general, and Palestinian refugees, in particular, in host Arab states is
the absence of clear and well-defined legislation regulating their status. By adopting
the second approach, the Arab states doomed vulnerable populations, like refugees,
to tremendous amount of separation and discrimination. Indeed as Simone Weil said,
“to be rooted is perhaps the most important and least recognized need of the human
soul” and “the destruction of the past is perhaps the greatest of all crimes” (Weil
1952). By failing to integrate refugees in the countries of asylum, Arab countries are
not only “destroying” the refugees’ roots and past but also eliminating their present
and future.
Conclusion
Evident throughout the chapter is the denial of rights that refugees are subject to,
particularly in the case of Palestinian refugees. The majority of this discriminatory
and unjust treatment can be attributed to different interpretations and subsequently
different executions of international law. But in specific cases, like those of Arab
country policies, abject unwillingness to host refugees – along with incompetence –
becomes the cause. In either scenario, the refugees themselves are the primary
victims: rights unavailable or denied, opportunities stunted, and an imposed “out-
of-place” stamp on all. Refugee camps have engendered a unique ecology charac-
terized by poor infrastructure, unemployment and poverty, increased psychological
distress coupled with a feeling of abandonment, high level of noncommunicable
diseases with inability of refugees to attain proper health care, or NGOs to access the
camps to provide help during the COVID era.
April third marked the confirmation of the first six cases of COVID-19 confirmed
in one of the refugee camps in Al Bikaa, Lebanon. Ever since, and mainly due to lack
of proper regulations and assistance, the number has increased drastically. Refugee
camps are ticking bombs and the pandemic promises to be a carnage for people
living in refugee camps. The duty of the intellectuals is to bear witness in the hope
that change will 1 day come about. Indeed, as noted by Said in his Representations of
the Intellectual, “the intellectual is an individual endowed with a faculty for
representing, embodying, articulating a message, a view, an attitude, philosophy or
opinion to, as we as for a public” (Said 1993). The issue here is not the term
“refugee” itself; the status quo that accompanies it and the dismissive attitude toward
it are the elements that should be removed. Hopefully it will be a big step in the
journey toward a fairer, more welcoming world. We hope we did that, even if only to
a small extent.
Perhaps the best way to end this article is by quoting the translation of a poem
written by the revolutionary and anti-colonialist poet from Martinique, Aimé
Cesaire:
For it is not true that the work of man is finished,

That we have nothing more to do in the world,
That we are just parasites in this world,
That it is enough for us to walk in step with the world,
396 T. Arawi et al.
For the work of man is only just beginning and it remains to conquer all,
The violence entrenched in the recess of his passion,
And no race holds a monopoly of beauty, of intelligence, of strength, and,
There is a place for all at the Rendezvous of Victory. (Kesteloot 1974)
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Mental Health Care in Syrian Refugee
Populations 18
Kareem Sharif and Ahmad Hassan
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 400
Mental Health of Syrian Refugees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 401
Current Status of Mental Health Services in Syrian Refugee Populations . . . . . . . . . . . . . . . . . . . . . 402
Barriers to Mental Health Care Among Syrian Refugees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 403
Future Directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 405
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 406
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 406
Abstract
Almost a decade into the Syrian Civil War, and with no end in sight, the
humanitarian crisis in the Middle East has reached a tipping point. Syrian
refugees are flooding neighboring countries and struggling to receive basic access
to mental health services, contributing to a mental health crisis in the younger
generation of Syrians. Many host countries for Syrian refugees do not allocate
enough resources to mental health services. Some provide free mental health
services to refugees, but unfortunately many barriers exist that prevent refugees
from benefiting from such services. The current state of mental health care of
Syrian refugees is perilous, and with the refugee crisis worsening every day, it is
vital that Middle Eastern and European countries follow the advice of experts on
reforming mental health services for refugees.
K. Sharif
Department of Neuroscience, Perelman School of Medicine at the University of Pennsylvania,
Philadelphia, PA, USA
e-mail: ksharif@sas.upenn.edu
A. Hassan (*)
Department of Neuroscience, Yale University School of Medicine, New Haven, CT, USA
e-mail: ahmad.hassan@yale.edu

https://doi.org/10.1007/978-3-030-36811-1_224
400 K. Sharif and A. Hassan
Keywords
Syrian refugees · Refugees · Telepsychiatry · Refugee mental health · Mental
health disparities · PTSD · Barriers
Introduction
The world is witnessing the greatest global refugee crisis in history. With nearly 80
million refugees displaced across the world, nations worldwide are experiencing
economic, structural, and political unprecedented turmoil. War and violence con-
tinue to ravage the Middle East, creating new diasporic landscapes in many Euro-
pean countries. Stemming from the ongoing Syrian Civil War, which is entering its
tenth year, Syrian refugees are the largest forcibly displaced population in the world.
Upwards of 13.4 million Syrians are estimated to be displaced by the end of 2020,
accounting for more than half of the original Syrian population (UNHCR). More
than 6.6 million refugees have fled Syria seeking asylum status in surrounding
countries and Europe (UNHCR). Turkey hosts more Syrian refugees than any
other country with an estimated 3.4 million refugees, followed by Lebanon with
around one million refugees, and Jordan with more than 600,000 refugees (Pew
Research Center).
Syrian refugees are often victims of multiple war-related stressors such as torture,
rape, death of close family members, and the complete destruction of their homes
and livelihoods. Additionally, they are often left with no choice but to undertake
dangerous, risky, and stressful journeys to escape their perilous homeland for an
unknown future (Silove et al. 2017). Syrian asylum seekers are at high-risk for
developing mental health disorders as their exposure to adversity and trauma causes
them to be more vulnerable to a range of negative psychological outcomes (Fazel
et al. 2005; Lee et al. 2016). Factors such as war, violence, and poverty affect the
mental health of refugees and predisposes them to several mental disorders (Reavell
and Fazil 2017; Uygun 2020; Sijbrandij et al. 2017). Foreign intervention in the
Syrian Civil war is rampant, contributing to a substantial increase in poverty and
disease due to sanctions on medical supplies, food, and basic goods imposed by the
United States and European Union (Walker 2016). Perhaps the most affected
population amongst Syrian refugees are children below the age of 10, who will
have experienced the full extent of war, poverty, and the rapid deterioration of social
structures (Taleb et al. 2015). It is for this reason that they are commonly referred to
as the “lost generation.”
Syrian refugees are an especially vulnerable population of refugees considering
the extent of the Syrian war, and the current political climate of the Middle East. Not
only are Syrian refugees subjected to war, family separation, and traumatizing
events, but their struggles continue and sometimes worsen as they venture to host
countries in hopes of finding sanctuary. Post-migration variables such as difficulty in
obtaining asylum, entering a new socioeconomic class, language barriers, social
isolation, and difficulty assimilating to the new culture are linked with increased
18 Mental Health Care in Syrian Refugee Populations 401
mental health complications in refugee populations (Demiralay and Haasen 2011;

Schenk 2007; Laban et al. 2004). Furthermore, visa status has been shown to have
predictive value for diagnosis of future psychological distress in migrants (Chou
2007). When considering the plight of Syrian refugees, it is important to take into
account their full experience rather than focusing solely on pre-migration trauma.
Mental Health of Syrian Refugees
Compared to civilian populations, refugees have significantly higher rates of mental

illnesses and mood disorders, most notably depression, anxiety, and post-traumatic
stress disorder (PTSD) (Hynie 2017), with PTSD being one of the most studied
mental disorders among refugee populations (Hendrickx et al. 2019). This is likely
due to the pervasiveness of PTSD among refugees. Depending on the makeup of the
population, 30% to 80% of refugees typically screen positive for PTSD – compared
to 8% for the general population (Suhaiban et al. 2019). Exposure to trauma pre-
disposes refugees to PTSD. Trauma is generally defined as the exposure to death, the
threat of death, violence, injury, disaster, sexual violence, or the threat of sexual
violence. Exposure refers to directly experiencing an event, witnessing an event, or
learning about an event (American Psychiatric Association 2013). About 70% of the
general population has experienced some sort of trauma (Kessler and Ustun 2008).
However, the type of trauma, as well as the frequency and duration, can affect the
likelihood of developing PTSD. It is common for refugees to repeatedly experience
traumatic war experiences, including: displacement, separation from family, starva-
tion, being held in concentration camps, and torture (Suhaiban et al. 2019).
Experiencing these events puts one at risk of developing psychological impairment.
The mental health of refugees is significantly affected by post-migration condi-
tions (Li et al. 2016). The rates of mental illness among refugee populations varies
widely depending on the environment and country. Those living in refugee camps
and low-income countries tend to show the highest rates of anxiety and depression.
Longer duration of displacement is also associated with higher rates of mental
disorders (Bogic et al. 2015). Recently literature on the impact of post-migration
conditions on refugee mental health led experts to call for models to address post-
migration conditions and social determinants of mental health (Hynie 2017). Refu-
gees are at high risk for mental disorders not only because of prior traumatic
exposures but also due to post-migration conditions. Many find themselves on the
lower end of the social gradient post-migration. This may be due to public attitudes
and policies regarding refugees, as well as being stigmatized and thus experiencing
social isolation in their new environment. Instead of focusing only on prior traumatic
experiences, experts now emphasize the importance of post-migration conditions
and social determinants of mental health.
One of the major determinants of refugee mental health post-migration is income
(Hynie 2017). Virtually all refugees leave behind their material possessions when
undergoing forced migration. Many leave behind businesses, life savings, homes,
farms, and documentation regarding their professional qualifications. This causes to
most refugees remain in poverty for several years after migrating to a new country
(Allsop et al. 2014). It is well-documented that income is a powerful determinant of
mental health for the general population (Braveman and Gottlieb 2014). Refugees
are no exception. The relationship between post-migration socioeconomic status of
refugees and incidence of mental illness is well-established (Bogic et al. 2015). The
majority of refugees struggle to find employment opportunities, mainly due to not
being able to speak the official language upon arrival in a new country (Bogic et al.
2012). Moreover, many educated refugees are not able to provide documentation of
their qualifications, and therefore cannot obtain employment in their field of spe-
cialization. This results in a large number of refugees working jobs for which they
are overqualified, further contributing to decreased mental health.
Along with income and employment, another main determinant of refugee mental
health is the level of social support in their new environment. One of the most
studied issues among refugees is social isolation upon arrival to a new country (Chen
et al. 2017). Social isolation in refugees usually results from language barriers,
discrimination, poverty, and separation from family. Familial separation is strongly
associated with decreased mental health (Shishehgar et al. 2017). A lack of social
support likely exacerbates existing mental disorders among refugees upon arrival in
their new environment, which is oftentimes highly discriminatory against refugees
and asylum-seekers. This, coupled with major life-stressors such as poverty, lack of
employment, and uncertainty regarding the asylum-seeking process, creates a situ-
ation in which most refugees remain at the bottom of the social gradient even
decades after migration. By taking into account the post-migration conditions of
refugees, experts are gaining a more comprehensive understanding of refugee mental
health, which will hopefully lead to more successful programs and interventions in
the near future.
Current Status of Mental Health Services in Syrian Refugee

Populations
Most mental health interventions directed towards refugees are specific to treating
PTSD. These interventions typically include components of either cognitive behav-
ioral therapy (CBT) or narrative exposure therapy, as these can reduce symptoms of
PTSD (Slobodin and Jong 2015). These interventions mainly focus on addressing
refugees’ pre-migration trauma. Researchers have argued that this focus on pre-
migration trauma fails to address other aspects of refugee mental health. Refugees
who experience better post-migration conditions tend to have significantly lower
rates of mental illness, and also tend to process their trauma differently. It is for this
reason that experts have recently called for refugee mental health interventions to
shift focus, and to place more emphasis on the daily hardships of post-migration life.
Although our understanding of refugee mental health has improved greatly in recent
years, current mental health interventions do not reflect this advancement. Mental
health interventions should target the main stressors facing refugees (Nickerson et al.
2011). Along with psychotherapy and pharmacotherapy, additional resources should
be provided to assist refugees in practical issues such as seeking asylum, seeking

employment, legal support, language learning, and social support.
Currently, the majority of Syrian refugees do not live in refugee camps, but rather
have settled in cities and villages in neighboring countries such as Turkey, Iraq,
Lebanon, and Jordan (Sijbrandij et al. 2017). Many of these countries were already
experiencing their own hardships before the current humanitarian crisis and were
unable to provide adequate medical and mental health services to their own citizens.
Unsurprisingly, most of the Syrian refugees who have settled in neighboring coun-
tries struggle to access even the most basic medical and mental health services. In the
10 years since the Syrian Civil War began, the health care system in these countries
remain overburdened and are unable to properly adjust to accommodate the influx of
refugees.
Mental health services have historically been neglected in the Middle East. As a
percentage of the government health budget, government expenditure on mental
health services ranges from 2% in Egypt and Syria to 5% in Lebanon. In comparison,
government expenditure on mental health services in European countries such as
Germany and the Netherlands is approximately 11%. The low prioritization of
mental health services in the Middle East may be due to several factors, including
the stigmatization of mental illness in Arab culture. In Jordan and Turkey, refugees
are eligible to receive free mental health treatment, although, considering the lack of
government expenditure on mental health services in these countries, the services are
likely to be inadequate. Some European countries such as Germany allow asylum
seekers and undocumented migrants the right to seek psychotherapy at state-funded
facilities (Mladovsky et al. 2012). Other European countries have various forms of
mental health services offered to refugees and migrants. Unfortunately, a common
characteristic of refugee mental health services in these countries are the many
administrative and practical barriers to access (Bozorgmehr and Razum 2015). For
example, one of the main barriers to accessing mental health services for refugees is
the language barrier between the refugee patient and the mental health professional
(Hassan and Sharif 2019). Training more Arabic-speaking mental health profes-
sionals, as well as allocating more resources for interpreters, could potentially
address this issue. Experts also recommend providing some group-based mental
health services that encourages refugees to form social support networks (Alfadhli
and Drury 2016). This could potentially improve mental health outcomes by reduc-
ing social isolation, increasing social support, and minimizing the stigma associated
with seeking mental health services. However, due to study limitations, there is little
evidence to support the efficacy of this approach.
Barriers to Mental Health Care Among Syrian Refugees
Some form of mental health services is usually available for Syrian refugees living in
host countries. However, the many barriers to accessing these services prevents the
majority of refugees from seeking treatment. Delaying mental health treatment for
trauma is dangerous, especially for children. Early intervention results in much better
outcomes for PTSD patients. Studies report that upwards of 80% of some Syrian
refugee populations screen positive for PTSD (Acarturk et al. 2018; Al Ibraheem
et al. 2017). Additionally, Syrian asylum-seeking populations possess high rates of
depression – between 27.4% and 70.5% (Euteneuer and Schäfer 2018; Fuhr et al.
2019; Ibrahim and Hassan 2017). Syrian refugees are generally receptive to receiv-
ing mental health treatment if the services are readily available. Complicating access
to mental health services puts a whole population at risk of developing complications
from mental illness.
Millions of Syrian refugees are located in impoverished, resource-constrained
host countries such as Turkey, Lebanon, and Jordan where basic access to food,
water, and health care is limited (International Labor Organization). Refugees in
such camps do not have proper access to basic medical attention, let alone special-
ized care such as mental health treatments. Estimates from Turkish government
officials indicate that more than half of the Syrian refugees in Turkish refugee
camps are in dire need of mental health care and psychiatric services, yet remain
untreated due to resource constraints (İçduygu 2015). As such, many refugee camps
throughout Turkey, Lebanon, and Jordan face horrid living environments and spe-
cialized access to medicine is nonexistent (Hassan and Sharif 2019).
Syrian refugee populations in Western countries such as Switzerland and Ger-
many face many structural and sociocultural barriers to mental health care which
further perpetuate poor health outcomes (Kiselev et al. 2020). Limitations in struc-
tural components in many European host countries for Syrian asylum seekers
include lack of knowledge on how the local health system works in the designated
country, issues associated with long waiting times for specialized treatment care, and
language barriers (Kiselev et al. 2020; Byrow et al. 2019). Additionally, as Syrian
refugee enter Western countries with low socioeconomic status, financial difficulties,
the emotional weight of a war-torn homeland, and the complete restructuring of their
way of life. Furthermore, there are limited numbers of specialized health care pro-
viders, including psychiatrists, clinical psychologists, clinicians, and counselors
working in Syrian refugee populations in most host countries, so creating a large
barrier to health care access (Oetterli et al. 2013). Additionally, mental health pro-
fessionals in non-Arab host countries such as Turkey or Germany typically do not
speak Arabic, further adding to the barriers experienced by refugees in receiving
mental health services. In locations that do have specialized access to mental health
treatments, providers are often overworked and under-supplied due to the heavy
influx from the Syrian Refugee Crisis in Europe and refugee populations throughout
Africa (UNHCR).
Sociocultural barriers to mental health access dominate over those of structural
barriers previously elaborated. Sociocultural barriers are composed of differing
cultural systems and ways of life between the country of origin and the host
country. Strong cultural stigmas and lack of mental health awareness associated
with mental health issues are strong components of treatment strategies. Addition-
ally, the cultural mismatch between the patient and medical provider is another
limitation of quality care for refugees (Bartolomei et al. 2016; Jensen et al. 2014;
Omar et al. 2017).
Future Directions
With no end to the Syrian Civil War in sight, it is reasonable to assume further
increases in the number of refugees in the coming years. This will further strain the
ability of health care systems to provide adequate and sufficient care for incoming
Syrian asylum seekers in surrounding countries and Europe. Many approaches have
offered to address the extreme demands of mental health care in resource-
constrained and low-income populations. Approaches have targeted expanding
health care access through minimizing cost and maximizing quality in refugee
communities. Currently, dominating factors that increase health disparities in Syrian
refugee communities include physician and resource shortages, as well as barriers to
mental health services.
Most host countries for Syrian refugees have a shortage of mental health pro-
fessionals, a lack of Arabic-speaking mental health professionals, and a lack of
translation and interpretation services. A frequently recommend measure in refugee
mental health is to produce more mental health professionals, and to focus specif-
ically on training mental health professionals who also speak Arabic. While it is
preferred that the mental health professional speak Arabic so that they better interact
with the patient, it is also as beneficial to have adequate interpretation services
available. Another major barrier to mental health services for Syrian refugees is
the location of the mental health services centers and adequate means of transpor-
tation. Many Syrian refugees live in refugee camps, which typically do not have
mental health professionals on site. Most trained mental health professionals in the
Middle East prefer to work in hospitals or offices rather than at refugee camps. Host
countries should incentivize newly trained mental health professionals to spend
some time treating patients in refugee camps. Another alternative is to implement
telehealth programs, which would allow patients to meet with mental health pro-
fessionals remotely. This could also be a means of resolving issues of a lack of
Arabic-speaking providers, as refugees would be able to meet with providers from
other Arab countries.
Telepsychiatry provides remote access to specialists through video conferencing
and is a cost-effective approach to reducing mental health disparities in
resource-constrained regions. A recent systematic review article on the efficacy of
telepsychiatry services suggests promising potential (Hassan and Sharif 2019).
Telepsychiatry may be one of the only rapidly implementable treatment options
that could yield immediate benefits in the near future. A study evaluating the use of
telepsychiatry in treating PTSD patients found it to be as effective as traditional
modes of receiving care (Maieritsch et al. 2016). More research is needed to
determine the quality and effectiveness of telepsychiatry compared to face-to-face
appointments. With quick and easy implementation of telepsychiatry services in
resource-constrained Syrian refugee communities, especially those located in Tur-
key, Jordan, and Lebanon, structural and sociocultural barriers to health can be
reduced. Telepsychiatry offers a mode of health care delivery that does not further
constrain the existing health system infrastructure, while simultaneously improving
quality of care by connecting patients with Arabic-speaking providers remotely, and
reducing the need of transportation. During the COVID-19 pandemic, medical

providers have become heavily reliant on telehealth to ensure safety in clinical
settings by reducing exposure to the virus. Telehealth is a reliable mode of high-
quality health care delivery to many countries in the world (Calton et al. 2020).
Further implementation of telehealth services, including telepsychiatry, offers an
attractive model to expand health care access and reduce the large demands for
mental health services in Syrian refugee populations.
Conclusion
Syrian refugees are by-products of one of the worst humanitarian crises in recent
history. Half of the population is either internally displaced or currently seeking
asylum in a neighboring country as a result of the Syrian Civil War. Syrian refugees
have experienced countless war related stressors, including, death, trauma, torture,
sexual abuse, rape, the complete destruction of their hometowns, family separation,
and forced migration. In addition, Syrian refugees continue to experience post-
migration stressors, including the complete abandonment of their way of life,
discrimination, seeking asylum status, low socioeconomic status, and language
barriers. The mental health complications related to war plagued populations are
striking. Victims of trauma are much more likely to develop mental health issues,
including depression and PTSD, two mental health illnesses that are prevalent in the
Syrian diaspora communities across the world. As a result, the demand for mental
health care in Syrian refugee populations is immense. Despite the urgent need of
psychiatric attention, Syrian refugees face many challenges and barriers to receiving
needed care. In many surrounding countries such as Turkey, Lebanon, and Jordan,
mental health care is nearly nonexistent due to a lack of resources and specialized
care even though upwards of 80% of some refugee populations is in desperate need
of attention. Syrian refugees in European countries, such as Germany and Switzer-
land, face many structural and sociocultural barriers to health. The biggest barriers to
accessing mental health services for Syrian refugees are language barriers and
location. One of the most promising avenues to improve access to mental health
care is the use and rapid implementation of telepsychiatry. Telepsychiatry has the
potential to alleviate language barriers by connecting Syrian refugees to mental
health providers from other Arab nations. It can similarly alleviate other barriers
such a lack of providers in the area. The efficacy of telepsychiatry compared to
traditional psychiatry is being studied. However, future research should focus on
applying telepsychiatry in the context of the unique needs of refugee populations.
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Part III
Cancer
Cervical Cancer Screening in Arab Countries
19
Osman Ortashi and Moza Alkalbani
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 414
Etiology of Cervical Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 415
HPV Progression and Regression Cycle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 415
Risk Factors for Acquiring HPV Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 416
Risk Factors for HPV Persistent and Progression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 417
Ethical and Legal Consideration When Counselling Women with HPV Infection . . . . . . . . . . . . 418
The Epidemiology of HPV and Cervical Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 418
Epidemiology of Cervical Cancer in Arab Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 420
Milestones in Cervical Cancer Screening and Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 421
Current Strategies for Cervical Cancer Prevention and Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 423
Opportunistic Screening with Cervical (Pap) Smear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 423
Organized Cervical Cancer Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 424
HPV Vaccination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 424
Visual Inspection with Acetic Acid (VIA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 425
Cervical Cancer Screening in Arab Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 426
Practical Approach to Cervical Cancer Screening and Prevention in Arab Countries . . . . . . . . 428
Guidelines for Effective Implementation of HPV Vaccination in Arab Countries . . . . . . . . . . . . 430
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 432
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 432
Abstract
Approximately half million women developed cervical cancer each year, and half
of this number die as a result of this diseases each year. Eighty percent of the
burden of cervical cancer occurs in developing countries with no prevention and
screening cancer programs. Almost all cases of cervical cancer develop secondary
to infection with human papillomavirus (HPV) which does affect 80% of sexually
O. Ortashi (*)
Obstetrics and Gynaecology Department, Sidra Medicine, Doha, Qatar
M. Alkalbani
Sultan Qaboos University Hospital, Muscat, Oman

https://doi.org/10.1007/978-3-030-36811-1_16
414 O. Ortashi and M. Alkalbani
active women at one stage. HPV is the most common sexually transmitted
infection (STI). Most women who get the HPV infection will clear the infection
by themselves; however, the infection might persist in few women. It is the
persistent high-risk HPV infection (mainly HPV 16 and 18) which caused
cervical cancer. There are 14,280 new cases of cervical cancer in the Arab region
in 2018 with 9,354 deaths. There is no single strategy that can be applied across
all Arab countries due to variations in resource, demography, and the burden of
cervical cancer in each country. Arab countries with high resources can adopt
both organized screening program and HPV vaccination; however, in
low-resource Arab countries, HPV vaccination in collaboration with funding
agencies such as Gavi allies might be the best cervical cancer intervention
strategy.
Keywords
Cervical cancer · HPV · Arab countries · Screening
Introduction
The cervix or cervix uteri (Latin, “neck of the uterus”) is the lower part of the uterus
in the human female reproductive system. The cervix is usually 2–3 cm long (~1 in.)
and roughly cylindrical in shape, which changes during pregnancy.
The cervix is a fibromuscular organ that links the uterine cavity to the vagina.
Although it is described as cylindrical in shape, the anterior and posterior walls are
more often ordinarily apposed. The cervix is approximately 4 cm in length and 3 cm
in diameter. In woman with previous pregnancies (parous ladies), the cervix is
considerably larger than that of women without babies (nulliparous). The cervix of
a woman of reproductive age is considerably larger than that of a postmenopausal
woman. The cervix occupies both an internal and an external position. Its lower half,
or intravaginal part, lies at the upper end of the vagina, and its upper half lies above
the vagina, in the pelvic/abdominal cavity. The two parts are approximately equal in
size. The cervix lies between the bladder anteriorly and the bowel posteriorly.
Laterally, the ureters are in proximity as well as the uterine arteries superiorly and
laterally.
The cervix has several different linings. The endocervical canal is lined with
glandular epithelium, and the ectocervix is lined with squamous epithelium. The
squamous epithelium meets the glandular epithelium at the squamocolumnar junc-
tion (SCJ). The SCJ is dynamic and moves during early adolescence and during a
first pregnancy. The original SCJ originates in the endocervical canal, but as the
cervix everts during these times, the SCJ comes to lie on the ectocervix and becomes
the new SCJ. The area between the old and new SCJ is called transformation zone
(TZ) and is formed of metaplastic tissues. The cells in the TZ are in continuous
changes from columnar epithelium to squamous epithelium and vice versa. It is these
continuous metaplastic changes which make these cells very susceptible to infection
19 Cervical Cancer Screening in Arab Countries 415
and later neoplastic changes by human papillomavirus (HPV) which is the main
cause of cervical cancer as we will discuss later.
Etiology of Cervical Cancer
Cervical cancer is caused essentially by persistent infection of the cervix with high-
risk types of human papillomavirus (HPV); almost all cervical cancers are caused by
persistent HPV infection with only a minority of cervical cancers not HPV related
(Walboomers et al. 1999). HPV infection is the commonest sexually transmitted
infection (STI) worldwide where it is estimated that 80% of sexually active men and
women will get HPV infection at one stage of their life and only a minority of women
will develop cervical cancer.
Evidence suggests that HPV infection precedes the development of cervical
cancer by several decades and that persistent infection with HPV is necessary for
the development and progression of precancerous lesions of the cervix, either to
higher grades of precancerous disease or to invasive cancer, a process that can take
10–30 years (Moscicki et al. 2006).
HPV is a quite common sexually transmitted infection that is usually acquired
soon after the initiation of sexual activity. Most HPV infections clear spontaneously
within 1–2 years, but persistent infections with high-risk types of HPV (particularly
HPV16 and HPV18) may progress to precursors of and ultimately to invasive
cervical cancer. High-risk types of HPV are identified in nearly all cancers of the
cervix, and the expression of HPV oncoproteins is necessary to maintain the cancer
phenotype. The International Agency for Research on Cancer evaluated the follow-
ing 12 HPV types as carcinogenic to humans: 16, 18, 31, 33, 35, 39, 45, 51, 52, 56,
58, and 59. HPV16 and HPV18 are responsible for about 70% of cervical cancer
cases worldwide (Schiffman et al. 2007). Little geographical variation has been
found in the prevalence of the predominant HPV types associated with cervical
cancer, but the proportion of cancers associated with types other than 16 and 18 is
higher in high-risk areas (IARC 2012). There are some factors associated with
acquiring HPV infections and others related to the persistent of HPV infection.
HPV Progression and Regression Cycle
As it was mentioned earlier, though 80% of sexually active women and men will get
HPV infection at one stage of their life, only a minority of women who got infected
develop HPV infection. HPV infection progressed to cancer through four steps called
HPV progression and regression cycle. The components of the cycles are HPV
infection, regression, persistent, and progression to precancerous and cancer (Fig. 1).
HPV genital infection occurred with direct sexual contact; condom protects to
some degree but does not offer complete protection. A minority of women get the
infection through methods other than direct sexual contact; to date, we do not have
the exact knowledge about how this can happen.
HPV progression-regression cycles
2 years 3-5 years 5-10 years
Infection Persistent Progression Cancer
Immunity status Immunity status

Age of first intercourse Infection with other microbiomes Smoking
Number of sexual partner High parity Infection with other microbiomes
High parity
Fig. 1 HPV progression-regression cycles
Regression is the clearing of the HPV infection by self-immunity which does

happen in over 90% of women who get the HPV infection.
Persistent happened when the HPV infection is present in the genital tract without
causing cellular changes for over 2 years. During this time, the self-immunity is at an
equilibrium with the virus, where the virus is present but is not able to cause any
cellular changes. Persistent is the main risk factor for progression to precancerous
and cancer in women. Women with persistent HPV infection will have positive HPV
test but negative cervical smear.
Progression happens when the above equilibrium between self-immunity and the
virus ends in favor of the virus. This will lead to cellular changes which pass what is
called cervical intraepithelial neoplasia (CIN). CIN is further divided into CIN1,
CIN2, and CIN3. During progression from CIN1 to CIN3, there is still a chance of
regression specially with CIN1 where regression happens for over 70%; however,
this reduces to less than 30% with CIN3.
Risk Factors for Acquiring HPV Infection
1. Age of first sexual intercourse: This has been shown to be one of the main risk
factors for HPV infection and cervical cancer. Higher incidence of cervical cancer
with earlier onset of disease has been reported in countries with early age of first
sexual intercourse and sexual activities. Of note is that early initiation of sexual
intercourse is also associated with acquiring other STIs as well as having multiple
sexual partners and drug abuse. The link between early age of first intercourse and
higher chance of developing cervical cancer at later age of life is due to higher
chance of getting genital HPV because of the above risk factors.
In the Arab region, marriage at a very young age is not uncommon. Some
countries make it illegal for girls to get married before the age of 18; however, in
some rural and remote areas, it is not uncommon to see girls married at a noticeably
young age. In Arab countries, sexual activity is illegal before marriage; therefore,
sexual activities outside marriage cannot be accurately assessed or estimated. In
countries like the United States, the percentage of women aged 15–19 years who
report having ever had sexual intercourse is 43% (Martinez et al. 2011). Though
cervical cancer screening is not recommended before the age of 21 years, it is very
important to pay special attention to girls who get married at a young age, and it is
good practice to offer them cervical smear 3 years after their marriage.
2. Number of sexual partners: As with all other STIs, the number of sexual partners
is causally related to the chance of acquiring infection. Data published by the
World Health Organization showed a greater number of sexual partners among
men than women in developing countries, while the proportion of multiple sexual
partners was similar between men and women in Australia, Europe, and North
America (Wellings et al. 2006). In our region, it is not uncommon to find a man
with more than one sexual partner through legal marriage. Men who are married
to more than one woman should be considered as having multiple sexual partner,
and he and his sexual partners are at more risk of HPV infection compared with
men with single wife.
Risk Factors for HPV Persistent and Progression
1. Immune status: Self-immunity plays a major role in clearing up the HPV

infection; immunocompromised women tend to clear the HPV infection less
effectively than women with intact immunity. Immunity can be affected by
internal or external factors. Immunocompromised patients for whatever reason
are requested to take annual cervical smear (when they are eligible for screening)
rather than every 3 or 5 years as per standard recommendation.
2. The presence of other genital microbiomes: Vaginal microbiomes are the micro-
organisms that colonize the vagina. Next-generation sequencing (NGS)-based
studies have facilitated detailed characterization of the “healthy” vaginal micro-
biome and shown that five major community-state types (CSTs) exist; CST I, II,
III, and V are dominated by Lactobacillus crispatus, L. gasseri, L. iners, and
L. jensenii, respectively, whereas CST IV has characteristically low numbers of
Lactobacillus spp. and increased diversity of anaerobic bacteria. There is more
emerging evidence that microbiomes are playing a significant role in HPV
progression. The stability and composition of the vaginal microbiome may play
an important role in determining host innate immune response and susceptibility
to infection. The best studied example was bacterial vaginosis (BV), where
Lactobacillus spp. depletion leads to an overgrowth of anaerobic species and
higher vaginal pH; BV has been associated with increased transmission rates of
sexually transmitted infections (Atashili 2007) and human immunodeficiency
virus (HIV) (Brotman 2010). Likewise, there are more studies in the recent
years suggesting an association between certain bacterial community types of the

vaginal microbiomes and HPV progression (Norenhag et al. 2020). This can
explain to some extent why women with intact immunity respond differently to
HPV infection. It has also been suggested that manipulation of vaginal bacterial
communities using pre- and probiotics can play a role in the domination of
non-healthy microbiomes in the vagina.
3. Smoking: Women who smoke are less likely to clear up HPV infection efficiently
like their counterparts who do not smoke (Marc 2020). Smoking active or passive
has been linked to persistent HPV infection which is a major risk factor for
cervical cancer. In the Arab region, Shisha smoking is quite common in both
men and women, and there is no evidence that Shisha is less harmful than
cigarette smoking. We can conclude that women who smoke Shisha are less
likely to clear HPV infection than those who do not do and therefore at more risk
of cervical cancer.
4. High parity: Repeated trauma to the cervix by vaginal birth and pregnancy make
the cervix not only more susceptible to HPV infection but also less likely to clear up
HPV infection and therefore lead to HPV persistent and possibly progression
especially in the presence of other risk factors like smoking, altered vaginal micro-
biomes, or reduced immunity (Marc 2020). High parity is not uncommon in this
Arab region with a significant number of women having more than five children.
Ethical and Legal Consideration When Counselling Women

with HPV Infection
It is not uncommon to face some difficult situations when counselling women with
positive HPV test. Knowing that HPV infection is a sexually transmitted infection,
many couples in the Arab region ask their physician if a positive test means that one
of the couples is in active sexual relation and therefore not faithful. This is a situation
that physicians should not get trapped in. There are many facts that make the answer
to this question impossible. First HPV infection can be acquired by intimate contact
other than penetrative intercourse and can remain dormant for many years without
showing any sign. It is not common especially in men to be an asymptomatic carrier
for HPV infections for many years. Second there is still some evidence that HPV
infection can be acquired by closer contact other than sexual contact. It is important
for the physician to be clear that we cannot give answers to all patients’ queries and
the primary role of the physician is to provide care for the patients and not make
judgment to other non-medical issues. Immature handling of this difficult situation
by some physicians has led in some cases to divorce and family disruption.
The Epidemiology of HPV and Cervical Cancer
Approximately 570,000 cases of cervical cancer and 311,000 deaths from the disease
occurred in 2018. Cervical cancer is the fourth most common cancer in women,
ranking second after breast cancer (2.1 million cases), colorectal cancer (0.8
million), and lung cancer (0.7 million). The estimated age-standardized incidence of
cervical cancer was 13.1 per 100,000 women globally and varied widely among
countries, with rates ranging from less than 2 per 100,000 women in some countries
to 75 per 100,000 women in other high-incidence countries. There is a marked
variation in the incidence, mortality, and burden of cervical cancer between low- and
high-resource countries. It has been reported that the cumulative rates of cervical
cancer incidence and mortality were two to four times lower in high-resource than
those in lower-resource countries (Marc 2020). In low-resource countries, 1.8% of
women were diagnosed with and 1.3% died from cervical cancer before age
75 years, in the absence of competing causes of death.
The variations in rates are more striking when the focus is on subcontinents.
Overall, the lowest incidence burden was observed in Western Asia, and the lowest
mortality burden was observed in Australia-New Zealand. Rather modest incidences
with age-standardized incidence rates (ASIR) of <10 per 100,000 were also noted in
Australia-New Zealand, Northern America, Western Europe, North Africa, Southern
Europe, and Northern Europe. The highest burden was observed in Southern Africa
and Eastern Africa. A very high burden of the disease (ASIR 15 per 100,000) was
also observed in Western Africa, Melanesia, Middle Africa, Micronesia, Southeast-
ern Asia, Eastern Europe, the Caribbean, and South America (Arbyn 2020).
The HPV prevalence and distribution of HPV subtypes have been reviewed by
Bosch and colleagues who reported that HPV DNA was detected in 93% of the
tumors, with no significant variation in HPV positivity among countries. HPV16 was
present in 50% of the specimens, HPV18 in 14%, HPV45 in 8%, and HPV31 in 5%.
HPV16 was the predominant type in all countries except Indonesia, where HPV18
was more common. There was significant geographic variation in the prevalence of
some less common virus types. A clustering of HPV45 was apparent in Western
Africa, while HPV39 and HPV59 were almost entirely confined to Central and South
America. In squamous cell tumors, HPV16 predominated (51% of such specimens),
but HPV18 predominated in adenocarcinomas (56% of such tumors) and
adenosquamous tumors (39% of such tumors) (Bosch 1995).
Most of the burden of cervical cancer is in sub-Saharan Africa where 70% of all
new cases and deaths take place. Cervical cancer accounts for 25% of all female
cancers in sub-Saharan Africa with an estimated overall age-standardized incidence
rate of 31.0 per 100,000 women which is ten times higher than European countries
(Louie et al. 2009). The incidence rates in Uganda, Mali, and Zimbabwe appear to be
on the rise. The age-specific incidence rate in Uganda was 17.7 per 100,000 in 1960,
and this increased to 44.1 per 100,000 in 1995–1997. An estimated 57,000 cases of
cervical cancer occurred in the year 2000, comprising 22.2% of all cancers in
women, equivalent to an age-standardized incidence rate of 31 per 100,000 (Parkin
et al. 2002). Mortality from cervical cancer in Africa is extremely high. A mortality
rate in Eastern Africa is as high as 35 per 100,000. Reported mortality rates in
developed countries with successful screening programs seldom exceed 5 per
100,000 women. The 5-year relative survival rates in Uganda and Zimbabwe in
1990 were 18% and 30%, respectively, while during the same period, the rate was
72% in the United States. In Zimbabwe, 77% of 284 registered cervical cancer
patients died within 3 years of follow-up. The overall observed and relative survival
at 3 years were 44.2% and 45.2%, respectively (Chokunonga et al. 2003). The
survival rate for cervical cancer in sub-Saharan Africa in 2002 was 21% compared
with 70% and 66% in the United States and Western Europe, respectively (Parkin
and Bray 2002).
Nevertheless, though these numbers represent high incidence of cervical cancer,
the matter of fact is that the actual numbers are even higher as the reported data is
based mainly on hospital registries and not on central and community-based registry.
The lack of access to healthcare in sub-Saharan Africa and the lack of awareness are
the main reasons behind the high incidence and mortality of cervical cancer.
Epidemiology of Cervical Cancer in Arab Countries
The absence of cervical cancer registry in most of the Arab countries has resulted in
the scarcity of data available in individual countries. Most of the data on cervical
cancer in the region are predictable data rather than actual data from cancer registry.
The cancer registry plays a central role in the cancer prevention and control pro-
grams. Kuwait was the first Arab country to establish a cancer registry, a move which
was followed by most of the Gulf Cooperation Council (GCC) countries.
Recent studies from the Arab countries showed significant increase in the prev-
alence of HPV infection. In large Gulf region Arabian study, 21% of women of Arab
origin tested positive for HPV (Ali et al. 2019). We have also recently witnessed an
increase in the percentage of abnormal cervical smears which has increased from
3.6% to 6% among the same cohort of patients over 10 years (Ghazal-Aswad and
Gargash 2006; Al Zaabi et al. 2015).
Recent meta-analysis aimed to evaluate the prevalence of HPV and its high-risk
genotypes in Middle Eastern countries. The pooled prevalence of HPV was 12.3 and
5.2%. The prevalence of HPV in Africa (22%) was higher than that in Europe (8.3%)
and Asia (12.6%). The prevalence of HPV was 14.4, 8.3, 22, and 10.2% in Iran,
Turkey, Egypt, and Arab countries, respectively. The prevalence of high-risk HPV in
the abovementioned countries was 6.5, 6.2, 6.5, and 3.7%. The meta-analysis
concludes that the prevalence of HPV was increased in the Middle East. This
highlights the need for public education, screening, and vaccination programs
(Zare et al. 2020).
All Arab countries are located within the WHO Middle East and North Africa
(MENA) region. According to WHO, cancer ranked as the number 4 cause of death
in the MENA region after cardiovascular diseases, infectious diseases, and inju-
ries. It estimated that 32,859 new gynecological cancer cases were diagnosed each
year in this region. Breast cancer is the leading cancer in women followed by
cervical cancer with 5.1% incidence. Ovarian cancer ranks as the fourth leading
cancer in women. Cervical cancer’s 5-year prevalence rate is 2.7 in this region.
According to the recent data from the Tunisia Center for Public Health, there are
14,280 new cases of cervical cancer in the MENA region in 2018 with 9,354
deaths, accounting for a mortality rate of 65% which reflects late diagnosis of most
of these cases (Table 1).
Table 1 The five leading cancers in women in the MENA region (2018)
Incidence Mortality
Age-standardized Age-standardized
Cancer Number (%) rate for the world Number (%) rate for the world
Breast 99,284 33.9 41.9 42,228 24.0 18.6
Colorectal 14,664 5.0 6.6 9523 5.4 4.3
Cervix uteri 14,861 5.1 6.4 7791 4.4 3.6
Ovary 12,354 4.2 5.3 8708 4.9 4.1
Non- 10,743 3.7 4.6 7279 4.1 3.3
Hodgkin
lymphoma
Source: GOBOCAN 2018: https://gco.iarc.fr/today/fact-sheets-cancers
The burden of cervical cancer incidence and mortality in the Gulf Cooperation
Council (GCC) countries (Bahrain, Kuwait, Qatar, Saudi Arabia, Sultanate of Oman,
and United Arab Emirates [UAE]) and Yemen varies by country, with relatively low
incidence with age-standardized incidence rates by standard world population
(ASIRW) of 2.1 to 7.4/100,000. Available mortality data indicate extremely low
age-standardized mortality rates by standard world population (ASMRW) of 0.2 to
2.7/100,000, but considering the advanced stages at diagnosis, these mortality data
are probably underestimating in the absence of population-based mortality data. Our
own data indicate that the uptake of cervical cancer screening in GCC countries is
exceptionally low not exceeding 20% of all eligible women and hence most of the
cases are diagnosed late.
As for the North Africa region, we have mixed data. Due to the recent war, no
data from Libya were obtained. In Morocco and Algeria, cervical cancer incidence
ranks second after breast cancer and third after breast and colorectal cancer in
Tunisia [3]. In Egypt, cervical cancer does not appear to rank among the first five
female cancers, but cervical cancer incidence/mortality data have been mostly
extrapolated from limited registries [3] and could give a false impression that
cervical cancer is not a major health issue. In Sudan, cervical cancer ranked as the
number 2 cancer among females only second to breast cancer.
Milestones in Cervical Cancer Screening and Prevention
Cervical cancer screening was the first ever cancer to have established screening
program. The story of developing cervical cancer screening is one of the most
successful stories in medical history. In 1886, Sir John Williams first described the
lesion that would eventually be known as carcinoma in situ of the cervix. The
histological details were convincingly illustrated in a text “Cancer of the Uterus,”
published in 1900 (Gullen 1900). It was until 1928 until the “father of cytology”
George N. Papanicolaou who is Greece born and an American pathologist presented
his first data at the Third Race Betterment Conference which indicated cytology had
value as a test in the early detection of uterine cancer by the fact that individual cells
from the cervix have morphological features which may be used to diagnose cancer.
In 1993, Papanicolaou formed a team at Cornell Medical College where he serves to
include gynecologist Andrew Marchetti and pathologist Traut H F to look at the
possibility of creating a test that can detect precancerous cells. The team reported
these findings in a landmark publication in 1941 (Papanicolaou and Traut 1941). It is
this paper which has shaped the way that we screen for cervical cancer to date. Many
well-resourced countries developed their cervical cancer screening programs in the
second half of the twentieth century. All cervical cancer programs started initially as
opportunistic screening, and then by the 1970s, most of these programs became
organized screening programs. It is the turning from opportunistic to organized
screening program which has led to the significant drops in the incidence and
mortality from cervical cancer screening (Fig. 2).
A new chapter in the field of cervical cancer screening and prevention was opened
by Professor Harald zur Hausen, a German scientist who discovered the relation
between cervical cancer and HPV infection. In 1974, zur Hausen published his first
report at attempting to find HPV DNA in cervical cancer and genital wart biopsies by
hybridizing tumor DNA with cRNA obtained from purified plantar wart HPV DNA
(Hausen et al. 1974).
Harald and his team discover in the 1990s that a restricted number of HPV types
as the etiological cause of cervical carcinoma led to a hope for prophylactic vaccines.
Experiments made in dogs and rabbits using purified papilloma virus structural
proteins – which spontaneously assembled into virus-like particles (VLPs) – resulted
in the effective protection against the primary infection. This provided the back-
ground for further development of vaccines against human high-risk HPV types
Fig. 2 Cervical cancer mortality trend in the United Kingdom

based on the synthesis and self-assembly of the major virus capsid protein, L1
(Breitburd et al. 1995).
The Gardasil (HPV4), a Merck vaccine for four types of HPV (16, 18.6, and
11), was approved both in the United States and Europe in 2006; 3 years later,
another vaccine, Cervarix (HPV2) from GlaxoSmithKline, which protects
against two high-risk types of HPV (16 and 18) was approved in 2009. A nine-
valent vaccine (HPV9, Gardasil 9) was approved in 2014; this protects against
HPV subtypes (6, 11, 16, 18, 31, 33, 45, 52, and 58).
As HPV infection is deemed necessary for the development of nearly all cervical
cancers, this led to the change of the way that we screen for cervical cancer as we will
see below.
Current Strategies for Cervical Cancer Prevention and Screening
There are currently several strategies for cervical cancer prevention and screening
(Table 2). No single strategy can be applied globally, as countries differ in their
resources, population, and disease prevalence. In this section, we will discuss briefly
different pros and cons of each strategy, and on the next section, we will apply this to
Arab countries.
Opportunistic Screening with Cervical (Pap) Smear
This strategy is widely applied worldwide; however, it is ineffective in reducing the

incidence or mortality from cervical cancer. Opportunistic screening targeted a
minority of population and mostly the low-risk population. The same screened
minority keeps coming back for follow-up often more frequent than required giving
Table 2 Evaluation of current strategies for cervical cancer screening and prevention
Other
Cervical HP-related
Population Recourses cancer cancer
Strategy Cost coverage needed prevention prevention
Organized High High High High Low
screening
Opportunistic Low Low Low Low Very low
screening
HPV vaccination Medium High Low Very high Very high
to high
Screening + HPV Very high High High Very high Very high
vaccination
Visual inspection Minimum High Low Medium Very low
with acetic acid
(VIA)
false sense of population coverage and safety. Opportunistic screening has not been
shown to reduce cervical cancer incidence or mortality. Opportunistic screening
started a long time ago in developed countries and has not resulted in any significant
drop in the cervical cancer incidence or mortality until these countries move to
organized screening. Most of the women who benefited from opportunistic screening
are those who have good access to healthcare services and therefore are both of good
socioeconomic class and well educated; these women are at low risk of cervical
cancer. The high-risk women in remote areas who have no access to such service but
are at high risk of cervical cancer will never get screened this way.
Organized Cervical Cancer Screening
This has been shown to effectively reduce cervical cancer incidence and mortality
(Fig. 2). Organized screening implies wide population coverage with call and recall
system. The principle of organized cervical cancer screening is that each eligible
woman will get an invitation (call system) to attend for cervical cancer screening
when she reaches the screening age of the country she lives in (usually 21–25 years).
Thereafter, depending on the method of screening and screening program guidelines,
the woman will get invited every 3–5 years (recall system). Women will also be
recalled and referred to colposcopy whenever their cervical smear result showed an
abnormality. The organized screening program also includes effective referral sys-
tem to colposcopy, timely colposcopy assessment, treatment of precancerous lesions,
and follow-up treatment.
Organized screening program can be conducted by (a) cytology alone with
regular cervical (Pap) smears, (b) primary HPV testing alone, and (c) a combination
of cytology and HPV testing. Each one of these three modalities has its own pros
and cons.
The common factor for all components of organized cervical cancer screening is
the high implementation and maintenance costs plus the need for an excellent
well-resourced health system. Though organized screening has been shown for
many years to be remarkably effective, to date, only developed countries have
managed to fully implement organized cervical cancer screening programs due to
high cost so it remains an option only for well-resourced countries.
HPV Vaccination
As mentioned above, the HPV vaccine has been approved since 2006. To date, there
are more than 250 million vaccine doses given without any major side effects, and
there are 3 vaccines in the market which are (a) Gardasil 4 which protects against
HPV 16, 18.6, and 11, (b) Cervix which protects against two high-risk types of HPV
(16 and 18), and (c) Gardasil 9 which protects against HPV subtypes 6, 11, 16, 18,
31, 33, 45, 52, and 58. Cervical cancer protection range from 70% in Gardasil 4 and
Gardasil 4 to 90 with Gardasil 9 (DeSanjosé 2010). Gardasil 4 and 9 give further
protection from genital warts which are caused by HPV 6 and 11. The HPV vaccine
can be given to both females and males from the age of 9 up to the age of 45 years.
Gardasil is also licensed for protections of other HPV-related cancers and lesions
with the following protection rates: 80% of high-grade cervical precancers, 50% of
low-grade cervical lesion, 90–95% of HPV-related anal cancers, 90% of HPV-related
vulvar cancers, 85% of HPV-related vaginal cancers, and 40% of head and neck
cancers (Joura 2014; Alemany 2015; deSanjosé 2013).
HPV vaccination is an effective cervical cancer prevention intervention and can
be integrated easily in the school’s vaccination programs; however, as the protection
is not 100%, it should be ideally combined with cervical cancer screening which is
the case in well-resourced countries.
The main advantage of HPV vaccination is that it does not require extra
healthcare infrastructure as it can be integrated into any national vaccination pro-
gram. The main disadvantage is the cost of the HPV vaccine, which is currently high,
but this might change in the future.
The safety profile of the HPV vaccine is extremely high with no reported major
side effects. The main side effect of the HPV vaccines is pain at the site of injection.
Fainting attack after the vaccine injection is also reported, but this is common with
all injectable medications. The vaccine is meant to give lifelong immunity, and up to
now, the vaccine has maintained its immunogenicity in all women and men who
received it.
Gavi is an international organization created in 2000 to improve the access to new
and underused vaccines for children living in the world’s poorest countries. In 2016,
the Gavi Board approved an acceleration of the HPV vaccine program, allowing
countries in the first year of their program to scale up directly and vaccinate multi-
age cohorts of girls in the age range 9–14 years. Through this new strategy, Gavi
aimed to protect around 40 million girls from cervical cancer by 2020, averting an
estimated 900,000 deaths.
Visual Inspection with Acetic Acid (VIA)
As many countries cannot afford neither organized cervical cancer screening nor
HPV vaccination, some countries started looking at low-cost screening methods that
can be implemented in countries with low resources and less developed healthcare
system; visual inspection with acetic acid (VIA) or visual inspection assessment has
been proposed as an alternative to cytology or HPV testing-based organized screen-
ing program for precancer and cancer detection and the use of cryotherapy as a
precancer treatment method.
The VIA program needs less resources and trained personnel than the ordinary
cytology or HPV testing program. Healthcare providers can be trained in short time
for both diagnosis of and treatment of precancerous lesions. The VIA program relies
mainly on training of village nurses, midwives, and other healthcare providers to
carry out the simple diagnostic procedure which does not require any equipment
other than the speculum, torch, and acetic acid. Women who tested positive will be
treated with cryotherapy using portable nitrous oxide cylinder and re-usable cryo
equipment. VIA has shown good correlation with cytology but a tendency to
overtreat (Naz and Hanif 2014; Ibrahim et al. 2012). It is important to notice that
VIA novel screening method will only give good result if it is part of a wider
organized screening program that covers a vast majority of population and not
selected groups.
Cervical Cancer Screening in Arab Countries
Arab countries are spreading between two continents, Asia and Africa. Despite the
difference in the available resources among Arab countries, there are great cultural
similarities and shared behaviors and values. Nonetheless, there are huge variations
in the Human Development Index among Arab countries (Human Development
Index (HDI) is a statistic composite index of life expectancy, education, and per
capita income indicators, which are used to rank countries into four tiers of human
development. A country scores a higher HDI when the lifespan is higher, the
education level is higher, and the gross national income GNI (PPP) per capita is
higher). Some of the Arab countries are ranked among the lowest Human Develop-
ment Index countries in the world (Table 3). This huge difference in resources makes
the comparison between healthcare systems of these countries so difficult; neverthe-
less, some of the challenges are common in all these countries especially in terms of
acceptability of cervical cancer screening and prevention strategies. There are
14,280 new cases of cervical cancer in the MENA region in 2018 and 9,354 deaths
reported by the Tunisia Center for Public Health (Health 2018), accounting for a
mortality rate of 65% which reflects late diagnosis of most of the cases (Table 1).
At present, the resource for cervical cancer prevention in the region is not
inadequate; it is rather not existing. Most of the limited resources are directed almost
exclusively to treatment of established cancer. With few exceptions, there are no
established cervical cancer screening or prevention programs in the Arab region.
We are not aware of a comprehensive organized cervical cancer screening
program with call and recall system in any Arab country. Kuwait has no national
cervical cancer screening program, although opportunistic screening is carried out in
public and private clinics. A survey of 300 women found that 77% had heard of
cervical smear, mostly from their own gynecologist but not from their primary
healthcare physician (Al Sairafi and Mohamed 2009). In Saudi Arabia, opportunistic
screening is proposed to married women; however, it has been reported that only
16.8% of 500 interviewed have considered it (Sait 2009). In Qatar, a survey
conducted in 2008 reported that 85% of the women knew about cervical cancer
and 76% knew of Pap smears. Almost 40% of the women who previously had a
cervical test and 86% of those who had not indicated their willingness to take the test
(Al-Meer 2011). We reported similar acceptability among women in UAE (Ortashi
et al. 2013b). Oman has a better structural screening service available at tertiary and
regional care hospitals, and screening is performed by gynecologists. Data from the
Ministry of Health indicate that 73% of women aged 20–69 years perform cervical
Table 3 Arab countries ranked by Human Development Index (2019) and cervical cancer cumu-
lative risk and cumulative risk death from cervical cancer
Human Cervical cancer Life
World development Cervical cancer mortality expectancy
rank Country index cumulative risk cumulative risk at birth
35 United 0.866 0.72 0.52 77.8
Arab
Emirates
36 Saudi 0.857 0.28 0.17 75.0
Arabia
42 Qatar 0.848 0.53 0.46 80.1
45 Bahrain 0.838 0.46 0.37 77.2
47 Oman 0.834 0.68 0.46 77.6
57 Kuwait 0.808 0.40 O.29 75.4
82 Algeria 0.759 0.94 0.69 76.7
91 Tunisia 0.739 0.46 0.34 76.5
93 Lebanon 0.730 0.56 0.35 78.9
102 Jordan 0.723 0.31 0.21 74.4
110 Libya 0.708 1.33 0.58 72.7
116 Egypt 0.700 0.24 0.18 71.8
120 Iraq 0.689 0.20 0.15 70.5
121 Morocco 0.676 1.93 1.52 76.5
154 Syrian 0.549 0.36 0.29 71.8
Arab
Republic
168 Sudan 0.507 0.96 0.77 65.1
171 Djibouti 0.495 1.52 1.27 66.6
177 Yemen 0.463 0.20 0.16 66.1
Source: United Nations Development Programme: http://hdr.undp.org/en/content/human-develop
ment-index-hdi
cancer screening; however, as this is not a structural program with call and recall
system, the efficacy of the program is difficult to judge.
In Morocco, the implementation of the opportunistic cervical cancer early detec-
tion program has already shown good response among healthcare providers and
women. There are already different programs using the VIA, and with integrated
treatment of precancer lesion, these programs have shown good success and can be
expanded to national screening program (Khazraji 2012). Algeria has a main prob-
lem of access to healthcare facility, and the lack of access for screening and treating
precancerous lesions and invasive cancer has led to a high percentage of advanced
stages at presentation and, therefore, a high mortality rate. The same applies for
Sudan where most cases presented at stage 4. Egypt has no structural screening
cervical cancer program; however, opportunistic screening is widely practiced in
private practice. Importunely, as stated before, opportunistic screening targeted the
wrong low-risk population and leave the high-risk population exposed. Opportunis-
tic screening always gives a false sense of security.
As discussed above, the best way to minimize the burden of cervical cancer is to
adopt both HPV vaccination program and organized cervical cancer screening. In
some countries like the umbrella of the Gulf Cooperation Council (GCC) countries,
this approach might be affordable; however, for most Arab states, the option of
combined HPV vaccination and organized cervical cancer screening program is not
practical nor realistic because of the limited resources.
Despite the low cervical cancer incidence in EMENA, a recent study found that
HPV vaccination was cost-effective in almost all countries at a cost of 125 US
dollars per vaccinated girl. However, cost-effectiveness diminished with increasing
vaccine cost; at a cost of 200 US dollars per vaccinated girl, HPV vaccination was
cost-effective in only five countries. The study identified opportunities to improve
upon current national screening guidelines, involving less frequent screening every
3–5 years. While pre-adolescent HPV vaccination promises to be a cost-effective
strategy in most EMENA countries at low costs, decision-makers will need to
consider many other factors, such as affordability, acceptability, feasibility, and
competing health priorities, when making decisions about cervical cancer prevention
(Kim 2013).
There has been a longstanding misconception among many policy makers and
even among healthcare providers that HPV vaccination and cervical cancer screen-
ing might not be culturally acceptable in this region, and this conception has been
proved wrong in all population-based studies. Contrarily, we found that the accept-
ability of HPV vaccination and cervical screening among Arab women is compara-
ble to the rest of the world. Not only that, we also reported good acceptability of the
HPV vaccine among males (Ortashi, Raheel, & Khamis, Acceptability of human
papillomavirus vaccination among male university students in the United Arab
Emirates, 2013). There is also a big misconception that HPV-related diseases and
cancers are not common in the Arab region, but this obviously is not supported by
recent studies as was discussed above. The change of style of living with the wide
spread of social media and the ease of travelling has created big changes in the
behaviors and even prevalence of many infections and diseases.
There is no single strategy that will fit all Arab countries because of the variation
in resources and healthcare infrastructure; therefore, the recommendation should be
individualized depending on each country’s resources and the burden of cervical
cancer.
In summary, the big challenges faced by cervical cancer screening in this region
are variation in resources, false feeling of security of low HPV prevalence, and the
misconception among healthcare providers and policy makers that HPV vaccination
and cervical screenings will be not accepted by the public in this region.
Practical Approach to Cervical Cancer Screening and Prevention

in Arab Countries
It is important to understand that there is no single strategy that can be applied across
all Arab countries due to variations in resource, demography, and the burden of
cervical cancer in each country. As we mentioned above, there is an inverse relation
between the Human Development Index and cervical cancer incidence and mortal-
ity; however, this paradox does apply well in Arab countries. Table 3 explains the
rank of each country according to their Human Development Index; it also shows the
burden of cervical cancer in terms of cervical cancer cumulative risk and cervical
cancer mortality cumulative risk. Some countries with low Human Development
Index such as Iraq have low cervical cancer incidence and mortality; the same
applies for Yemen and Egypt. However, it is clear from the data that countries like
Morocco, Djibouti, and Sudan have a high burden of cervical cancer and should seek
an interventional program.
For high-resource countries, an integrated HPV vaccination program and orga-
nized cervical cancer screening programs are the best way forward. Most of these
countries have a low burden of cervical cancer now; however, as the prevalence of
HPV infection is increasing (Ali et al. 2019), it would be wise to consider full
implementation of cervical cancer prevention and screening at earlier stage. HPV
vaccination is much easier to implement compared with organized screening which
needs significant infrastructure. We do recommend for high-resource countries to
start with school-based HPV vaccination program as the first intervention and,
thereafter, to follow this with organized screening program. The main challenge
faced by most of the Arabian Gulf countries is the high percentage of expats
compared with local nationals making it difficult to run a national program without
including this sector of residents.
For medium- and low-resource countries, it will not be practical to allocate their
limited resources to establish an organized screening program as this means shifting
resources from more urgent health problems such as cardiovascular diseases and
diabetes to cervical cancer which will not be politically or strategically acceptable.
For these countries, it will be more practical to adopt HPV vaccination program
combined with either opportunistic screening or visual inspection with acetic acid
(VIA). In fact, looking at the experience of countries with similar resources and
disease burden like India, we do recommend combination of HPV vaccination
program and VIA for Arab countries with middle to low resources.
The VIA program is easy to implement and requires minimum healthcare infra-
structure. One of the major advantages of VIA is that it does target women with the
highest risk of developing cervical cancer in the remote and rural areas who have
limited access to hospitals. Traditionally, these women will never be checked for
cervical cancer and will usually present in late stage if they develop cervical cancer.
Some of the Arab countries have already started this program at a limited scale like
Sudan; however, to see good result, the program must expand to cover a majority of
eligible women.
Some of the medium-resource countries will be able to afford HPV vaccination
program without extra aid. However, for low-resource countries, this might be
challenging. As we mentioned earlier, Gavi allies do provide financial and technical
aids for low-resource countries to support the implementation of HPV vaccination
programs. To date, none of the Arab countries has benefited from the Gavi initiative;
we highly recommend for Arab countries with low resources to engage with this type
of allies to fund their HPV vaccination program. One of the most successful
experiences of HPV vaccination program in low-resource countries using the Gavi
program was in Rwanda. The key factors in Rwanda’s successful implementation

included government ownership and support for the program, school-based delivery,
social mobilization, and strategies for reaching out-of-school girls.
Guidelines for Effective Implementation of HPV Vaccination

in Arab Countries
HPV vaccination has generated significant media attention worldwide as a new

cancer vaccine, and this has led to many anti-vaccine campaigns which in some
cases have caused significant damage to the vaccination program in some countries
like Japan. It is important to make best use of the experience of countries with
successful HPV vaccination programs worldwide and in Arab countries like UAE.
The main challenges faced by the HPV vaccination are safety and misconception
that it can encourage youngsters to start sexual activities at a younger age by giving a
false sense of security.
In Arab countries, there is the subject that HPV vaccination might cause extra
problems if it dealt with in a wrong way. It is particularly important to understand
that no study has shown any different acceptance to HPV vaccination in Arab
countries compared with other countries. In our own studies (Ortashi et al. 2012,
2013b) and (Ortashi, Raheel, & Khamis, Acceptability of human papillomavirus
vaccination among male university students in the United Arab Emirates, 2013), we
found no cultural or religious barriers to HPV vaccination in Arab society.
We do recommend the following steps for the successful implementation of HPV
vaccination in Arab countries:
1. Establish political will: It is so crucial that politicians and leaders are fully aware
and supportive of the HPV vaccination program. We recommend starting the
implementation process with a series of roundtable discussions with politicians
and leaders to make them fully aware of troubleshooting with HPV vaccination
and the inevitable of the initial resistance by some sectors of the community.
Without political will, the program will not have the right momentum and support
to face any anti-vaccine campaign.
2. Define the vaccine as a cancer vaccine rather than an HPV vaccine that protects
against sexually transmitted infection which leads to cancer. The stigma of
sexually transmitted infections is not special to Arab culture; however, it is
more obvious and challenging in Arab countries. Most parent in this region will
not accept discussing sexually transmitted infection with their youngsters at
school prior to administration of the vaccine; however, they do accept the
discussion of the concept of cancer vaccine. We do recommend shifting the
concept of the HPV vaccine from an HPV vaccine to a cancer vaccine which
reflects the ultimate outcome of the vaccine.
3. Educate and train healthcare providers well ahead before implementing the
HPV vaccination program. Most of the public in Arab countries rely on advice
provided to them by their regular healthcare providers like family physician,
nurse, midwife, or school nurses. We have observed a significant drop in the HPV
vaccine uptake in programs which started before training healthcare providers

and resulted in a big confusion among the public. One of the best investments that
any HPV vaccination program can make is to educate and train healthcare pro-
viders to be the advocate for the vaccine.
4. Keep the media well informed: We do recommend involving the media, both
conventional and social, influential in the advancement of the public campaign.
One of the common mistakes is to get media involved after the vaccination
program was launched for the public; this might result in losing the media support
and even might lead to the emergence of anti-vaccine campaign specially in social
media. It is important to pay significant attention to the emerging power of social
media. Most of the population are getting information directly from social media
rather than conventional media, and it is especially useful to engage in social
media by sending short and accurate messages about the HPV vaccine. In the
Arab region, Twitter is extremely popular, and a large percentage of the public get
their information from it, so we do recommend posting messages about the HPV
vaccine regularly well advance before launching the program.
5. Run public campaigns: The public awareness campaign should follow the above
steps. The public should be reached in their workplaces and in shopping malls
and other community gathering places. The public should have the chance to ask
questions and to express their concerns. Public-based surveys are a good tool to
explore the acceptability of the HPV vaccine among the public and at the same
time find out any obstacles and concerns.
6. Run the program as a school-based program: This is very crucial in the success
of each HPV vaccination program. Countries with school-based programs have a
much higher vaccine uptake compared with countries with community-based
programs. The United Kingdom has introduced the HPV vaccination as
community-based programs, and the program suffered low uptake for a few
years before the government decided to change it to a school-based program
after which the vaccine uptake increased dramatically to an acceptable level.
7. Manage anti-vaccine campaigns: The introduction of most of the human vac-
cines has faced resistance which varies from one vaccine to another. Anti-vaccine
campaigns are a well-known phoneme, and it is difficult to imagine any vacci-
nation program without anti-vaccine campaigns. Some of these campaigns if not
managed timely and effectively might result in significant damage. The best well-
known example of an anti-vaccine campaign in recent history was that associated
with the measles vaccine and which resulted in a significant drop in the uptake of
the vaccine in some parts of the world which has led to the re-emergence of the
measles infection in these communities. The HPV vaccine has well faced with a
strong anti-vaccine campaign which can even lead to the ban of the vaccination
program as happened in Japan in 2017. A decision by Japan to stop
recommending adolescent girls to receive an HPV vaccination will likely result
in almost 11,000 deaths from cervical cancer if it is not reversed.
Measurement and monitoring of HPV vaccine confidence over time could help
understand the nature and scale of weaning confidence, define issues, and intervene
appropriately using context-specific evidence-based strategies.
Conclusion
Cervical cancer causes a significant burden on some of Arab countries and will likely
cause more burden in the future without immediate and effective intervention. No
single strategy can be applied across all Arab countries due to variations in resource,
demography, and the burden of cervical cancer in each country. Arab countries with
high resources can adopt both organized screening program and HPV vaccination;
however, in low-resource Arab countries, HPV vaccination in collaboration with
funding agencies such as Gavi allies might be the best cervical cancer intervention
strategy.
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Pediatric Oncology in the Arab World
20
Iyad Sultan
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 436
Epidemiology and Cancer Registration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 438
Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 444
Abandonment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 444
Delayed Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 445
Breaking Bad News . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 446
Political Instability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 446
Policy Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 447
Improving Quality of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 448
Success Stories in the Arab World . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 448
Specific Cancers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 449
Leukemias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 449
Lymphomas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 451
Brain Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 451
Retinoblastoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 451
Special Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 452
Radiation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 452
Multidisciplinary Team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 452
Bone Marrow Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 453
Palliative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 454
Survivorship . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 454
What Can Be Done in the Future? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 454
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 455
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 455
I. Sultan (*)
Department of Pediatrics, King Hussein Cancer Center, Al-Jubeiha, Jordan
e-mail: isultan@khcc.jo

https://doi.org/10.1007/978-3-030-36811-1_17
436 I. Sultan
Abstract
The discipline of pediatric oncology has shortcomings that are similar to other elements
of health care in the Arab world. There are relatively few children with cancer in the
Arab world. It is estimated that there are more than 14,000 children below the age of
15 that are diagnosed with cancer every year in Arab countries. These patients require
relatively more resources to be treated but they have an improved chance of cure in most
of the cases. There are state-of-the-art centers that were launched in different Arab
countries. The best examples are those that mobilized public support in the form of
public awareness, volunteering, and generous financial donations and that established a
clear mission and organized leadership, where donors expect transparency and equality
in care. On the other hand, with the current instability affecting many Arab nations,
there is a deterioration in the care of patients with cancer and the reemergence of
communicable diseases as major causes of death in children. The priority in the Arab
world should be having better cancer registries which provide accurate information,
especially when linked with national survival records, and to secure sustainable funding
for essential drugs and facilities, as well as for training and retaining health workers.
Keywords
Pediatric oncology · Cancer · Arab countries · Children · Leukemia
Introduction
Pediatric cancers are a group of malignancies that differ from adult cancers in their
types, management, and outcomes (Figs. 1 and 2) (Bray et al. 2018; Ferlay et al.
2018). Leukemias, lymphomas, and brain tumors are the three most common groups
of tumors (representing 27%, 17%, and 13%, respectively) while the remaining
types, most being solid tumors, represent 43% of all childhood cancers.
With the dramatic global reduction in child and adolescent mortality over the last two
decades, infectious diseases are no longer the leading cause of death in many countries.
As deaths by infectious diseases fell, mortality rates due to noncommunicable diseases
such as congenital anomalies, hemoglobinopathies, and cancer have risen, on relative
terms, to the point where they are now the leading causes of death. Moreover, there is an
increased interest in the impact of cancer and related therapies in affected patients
(Kassebaum et al. 2017). This highlights the need not only to cure pediatric patients
with cancer but also to minimize the burden of their illness and help provide therapy to
avoid long-term disabilities.
Leukemia and brain tumors reign among the top ten causes of death in children
5–14 years old in the Arab region (Table 1) (Kassebaum et al. 2017). It is clear that
pediatric cancer will negatively impact the survival of the young Arab population.
Realigning resources to alleviate and cure childhood cancer is a challenging preposition
as resources are limited in the majority of Arab countries. One has also to keep in mind
the burden of untreated patients on the health system as well as the unnecessary
morbidity (e.g., enucleation, amputation, or organ damage) due to improper or sub-
optimal treatment.
20 Pediatric Oncology in the Arab World 437
Fig. 1 Types of pediatric cancers in Arab countries according to the GBD registry – accessed in
August 2019 (GBD 2017 Childhood Cancer Collaborators 2019)
Fig. 2 Types of pediatric cancer seen in individual Arab countries presented in (a) frequencies and
(b) percentages; all data present 2017 records per GDB portal (GBD 2017 Childhood Cancer
Collaborators 2019)
438 I. Sultan
Table 1 Incidence and mortality of pediatric cancers in different regions according to Globocan
WHO East. High-middle Low-middle
Mediterranean High income income income Low income
0–14 Mort. 0–14 Mort. 0–14 Mort. 0–14 Mort 0–14 Mort
Incidencea 10 4.3 16 2.4 12.2 2.4 8.5 4.4 8.4 4.4
Leukemia 3.1 1.6 5.3 0.75 4.7 0.66 2.8 1.8 1.5 1.8
Hodgkin 0.66 0.01 0.67 0 0.34 0.01 0.33 0.09 0.45 0.03
NHL 0.98 0.17 1.0 0.09 0.79 0.23 0.76 0.26 1.2 0.14
Brain 1.2 1.0 2.7 0.94 0.46 0.75 0.89 0.70 1.7 0.26
Kidney 0.71 0.16 0.93 0.06 0.55 0.12 0.53 0.15 0.99 0.14
a
Excluding nonmelanoma skin cancer; Mort. mortality, NHL non-Hodgkin lymphoma; data
obtained from Globocan 2018 site, accessed on 16 August 2019 (Bray et al. 2018)
According to estimates from the International Agency for Research on Cancer

(IARC), pediatric cancer claims annually the lives of around 100,000 children world-
wide, with the majority (90%) being in low- and middle-income countries (Bray et al.
2018). It is notable that the 5-year survival rates of children with cancer have improved
dramatically from below 30% to 80% in high-income countries over the past few
decades (Gupta et al. 2014). The same cannot be said about low- and middle-income
countries where survival rates of children with cancer remain substandard.
The world-bank indicators suggest poverty rates of almost 50% of the population
in some Arab nations (Table 2). Anemia is prevalent in many Arab countries, ailing
more than 50% of the pediatric population in Somalia, Sudan and Yemen. Health
expenditure and availability of resources are very heterogeneous among Arab
countries, to the point where even in the same country, some areas, typically near
the larger cities, receive significantly better health-care. Six Arab countries, includ-
ing Egypt which has the largest population in the region, spend less than 200 US$
per capita on healthcare (World Bank 2018). Despite these challenges, state-of-the-
art centers do exist in several Arab countries (Al-Nasser et al. 1996; El-Hayek et al.
2003; Abdel-Rahman et al. 2008).
To put these numbers in perspective in comparison to the rest of the world, the
average rates of anemia in Arab children below the age of 5 years (40%) and
undernourishment (11%) are comparable to middle income countries (42% and
10%, respectively). The average health expenditure per capita in the Arab world
(356 in current US$) is comparable to middle-income countries as well (290 US$).
This contrasts with the expenditure of low-income countries and high-income
countries (37 and 5265 US$, respectively) (World Bank 2018).
Epidemiology and Cancer Registration
Nowadays, different tools are available to evaluate the statistics of cancer globally.
Three resources should be highlighted: Global Cancer Data Registry (Globocan),
Global Burden of Disease (GBD) Data (GBD 2017 Childhood Cancer Collaborators
2019), and the global surveillance of trends in cancer survival (CONCORD) studiers
20
Table 2 Population and other indicators of health status in Arab countries

Pediatric Under-
population % Pediatric to Poverty nourishment Anemia in Health expenditure per Hospital Nurses
Population 0–14 whole population (%) (%) children <5 (%) capita (current $) beds per 1000
Algeria 40,606,052 11,777,882 29 5.5 4.6 30 362 – –
Bahrain 1,425,171 289,189 20 30 1243 2.1 2.4
Djibouti 942,333 297,479 32 23.0 12.8 42 191 1.4 0.6
Egypt 95,688,681 32,008,916 33 27.8 4.5 32 178 0.5 1.4
Iraq 37,202,572 15,080,527 41 18.9 27.8 24 292 1.3 1.8
Jordan 9,455,802 3,383,353 36 14.4 4.2 31 359 1.8 2.9
Lebanon 6,006,668 1,415,645 24 27.4 5.4 25 569 3.5 2.6
Kuwait 4,052,584 850,166 21 2.5 25 1386 2.2 4.7
Pediatric Oncology in the Arab World
Libya 6,293,253 1,788,228 28 29 372 3.7 6.9

Oman 4,424,762 974,968 22 6.2 38 675 1.7 3.3
Morocco 35,276,786 9,726,617 28 3.5 34 190 0.9 0.9
Mauritania 4,301,018 1,724,905 40 31.0 5.3 68 49 0.7
Palestine 4,551,566 1,812,828 40 25.8 26
Qatar 2,569,804 356,736 14 26 2106 1.2 5.7
Saudi 32,275,687 8,241,756 26 4.4 38 1147 2.1 5.2
Arabia
Somalia 14,317,996 6,663,518 47 56 0.1
Sudan 39,578,828 16,292,154 41 25.6 57 130 0.8 1.2
Syria 18,430,453 6,886,362 37 35 66 1.5 2.3
Tunisia 11,403,248 2,726,433 24 15.2 5.0 29 305 2.1 3.2
UAE 9,269,612 1,287,338 14 3.8 27 1611 1.1 3.1
Yemen 27,584,213 11,104,607 40 48.6 28.8 84 80 0.7 0.8
Total 405,657,089 134,689,607 33 11.0 40 356
(average)
439
Data extracted from World Bank website, latest data were included; empty cells indicate no data, accessed in April 2018 (World Bank 2018)
440 I. Sultan
(Allemani et al. 2018). Extensive documentation of these resources are available

online and a comprehensive review of their utility in registering pediatric cancers
was recently published (Bhakta et al. 2019). In general, these tools use national and
subnational cancer registries and mortality records along with different predictive
tools to compensate for quality variations in data capturing, particularly in countries
with low and middle income. Access to data and data visualization is available
online and should be used to understand the scope of cancer in the Arab world.
Cancer statistics are typically presented with incidence rates calculated per
100,000 individuals per year, and often age-stratified (0–4, 5–9, etc.) and then
standardized, i.e., recalculated using a standard population structure to make it
suitable for international comparisons. Due to using different sources and methods,
the two international registries we used to evaluate the incidence of childhood cancer
showed some differences (Fig. 3). However, most Arab countries had annual
incidence rates just above 10 per 100,000 (standardized to world population).
Survival estimates are often presented of 5- and 10-year survival estimates,
typically constructed using the Kaplan-Meier method. While informative, these
survival estimates require meticulous registration of survival time (time from diag-
nosis to last follow up or mortality), information which is often lacking in many
registries. A new way to present these data is the mortality to incidence ratio (MIR),
which is the ratio of cause-specific-mortality to disease incidence. This is an
attractive method that can be used by most registries where data from verbal
Fig. 3 Incidence rates of childhood cancer in Arab countries as depicted by (a) GDB portal and (b)
Globocan; data presented age-adjusted and standardized per 100,000 individuals as per 2017
(GDB) and 2018 (Globocan) (Bray et al. 2018; GBD 2017 Childhood Cancer Collaborators 2019)
autopsies can be extracted, and this metric is the standard way of presenting survival
estimates in the GBD study. Again, the two registries showed noticeable differences
in recording MIRs in different Arab countries. Larger differences were noticed in
countries with active movement of refugees (e.g., Jordan, Lebanon) and in countries
with poor national records, highlighting some of the challenges that are faced when
evaluating cancer statistics in the region (Fig. 4).
Another recently introduced concept is the Disability Adjusted Life Years (DALYs),
which is the sum of life years lost to disease and/or disability. This metric can be used to
compare the impact of different diseases under different situations, and supposedly
works well in understanding the burden of childhood cancer on a global scale (Bhakta
et al. 2019; GBD 2017 Childhood Cancer Collaborators 2019). It is estimated that
childhood cancer ranks sixth among all types of cancers (including adult cancers) in its
global impact, with 11.5 million DALYs in 2017. Childhood cancers ranks ninth among
childhood illnesses, with more profound impact in middle income countries (GBD 2017
Childhood Cancer Collaborators 2019). The DALYs for childhood cancers in Arab
countries is shown in Fig. 5. More DALYs were recorded for children diagnosed before
their fifth birthday and in Arab countries with lower incomes.
The Arab world has a population of more than 400 million, with a pediatric
population (0–14-years-old) of more than 130 million; or in other words, roughly
one-third of the population of the Arab world is under 15 years old. According to
Globocan, 13,720 pediatric cancer cases are diagnosed annually in Arab countries
Fig. 4 Morality-incidence ratio (MIR) of childhood cancer in Arab countries as depicted by (a)
GDB and (b) Globocan. MIR was calculated by dividing the number of children who died due to
cancer in each country by the number of children diagnosed with cancer in 2017 (GDB) and 2018
(Globocan) (Bray et al. 2018; GBD 2017 Childhood Cancer Collaborators 2019)
442 I. Sultan
Fig. 5 Disability adjusted lost years (DALYs) for children with cancer in Arab countries presented
in rates per 100,000 individuals (GBD 2017 Childhood Cancer Collaborators 2019)
(Table 3). The average incidence of cancer is 11.4 per 100,000 children, but with a
wide variation (Fig. 2). While genetic factors can play a role in the development of
pediatric cancers, less than 10% of children with cancer actually harbor germline
mutations, making genetics less likely involved in variations in childhood cancers
incidence. Similarly, environmental factors do not seem to play a major role in the
developmental of childhood cancers. It is assumed that true variations in incidence
reflects differences in data registration (GBD 2017 Childhood Cancer Collaborators
2019). While Globocan previously presented some data on survival estimates, these
estimates did not parallel published reports. As stated above, mortality to incidence
ratio (MIR) is a more robust measure for survival estimates, but with a caveat: poor
registration of cancer can result in a falsely elevated MIR. Nevertheless, MIRs of
childhood cancers in Arab countries as obtained from the GBD portal are in line with
middle-income countries and show some wide heterogeneity (Fig. 6) (Ribeiro et al.
2008).
Reporting childhood cancer has inherent challenges. Just as adult cancer regis-
tration typically follows an anatomical location, childhood cancers should be
recorded according to histology. This is very important due to the rarity of childhood
tumors and the fact that anatomical locations hardly correlate with pathology. For
these reasons, the International Classification of Childhood Cancer (ICCC)
(Steliarova-Foucher et al. 2005) was established; this system should preferably be
used by all registries capturing pediatric malignancies. Additionally, while the TNM
staging method (T refers to size of main tumor, N refers to the number of nearby
lymph nodes with cancer, M refers to whether the cancer is metastasized) is usually
reserved for adult cancers, the same system cannot be applied to pediatric cancers,
Table 3 Number, incidence, and mortality of children with cancer in Arab countries according to
Globocan
Country Number of children with cancer Incidence Mortality MIR (%)
Algeria 1399 11.3 5.3 47
Bahrain 26 8.8 2 23
Djibouti 21 7.2 1.7 24
Egypt 4180 12.6 5.8 46
Iraq 207 10.5 2.8 27
Jordan 1581 10 3.4 34
Kuwait 390 11.3 3.4 30
Lebanon 96 10.9 3 28
Libya 183 13.4 4.4 33
Mauritania 185 10.4 4.8 45
Morocco 97 5.4 0.89 16
Oman 1137 11.7 4.7 39
Qatar 118 11.3 3.7 33
Saudi Arabia 29 7.9 3.5 45
Somalia 989 12 3.9 33
State of Palestine 689 9.8 2.5 25
Sudan 1620 9.7 3.9 40
Syria 710 11.3 4.3 39
Tunisia 309 11.1 4.7 42
UAE 158 12.3 2.8 23
Yemen 1149 10.1 3.3 33
All 21 states 15,273 11.4 7.5 34
Globocan accessed in August 2019; rates are projected to 2018; not all data reflects actual
registration and national mortality was estimated by modeling in many countries; not all data is
age-adjusted; incidence and mortality are presented per 100,000 children 0–14 years old; MIR,
mortality-to-incidence ratio was calculated using this formula (number of children who died of
cancer/number of patients registered to have cancer in the same year). UAE United Arab Emirates
(World Bank 2018)
thus alternative methods should be sought (Gupta et al. 2016). The Toronto Child-
hood Cancer Staging Guidelines are available online and endorsed by many socie-
ties. Cancer registries in the Arab world face many other challenges. Among these
challenges are duplication, poor registration, and lack of trained registry profes-
sionals which make captured data challenging to use and analyze (Jawass et al. 2016;
Missaoui et al. 2011). However, improvement over time is anticipated. When linked
to survival data, available typically through national records, these registries can
become invaluable tools for health policy makers (Khoshnaw et al. 2015). On the
other hand, when the link between cancer registries and survival records is poorly
structured, inaccurate survival rates can unfortunately cloud factual data (Allemani
et al. 2018).
One easy way to check for the reliability of cancer registry data is to look for
diseases with dismal outcomes (e.g., diffuse pontine glioma, expected 2-year sur-
vival of <10%) vs. diseases with a better outcome (e.g., Hodgkin lymphoma,
444 I. Sultan
Fig. 6 Scatter plot of HDI (Human Development Index) vs. MIR (Mortality Incidence Ratio) of all
countries (red) vs. Arab countries (blue); regression lines are shown as well as some names of Arab
countries as space allowed. Data were obtained for year 2017 (a, GDB data) and year 2018
(b, Globocan data) (Bray et al. 2018; GBD 2017 Childhood Cancer Collaborators 2019)
expected 2-year survival of >80%). In addition, survival curves should be contrasted

with published reports from other countries to check the accuracy of the various
survival registrations. Worsened survival rates can be anticipated if there is biased
registration where patients who die from cancer are more likely to be entered into the
cancer registry, whereas better survival in cancer registries is anticipated where there
is poor link between records and death registration. In many cases, the cause of death
is commonly reported to be cardiopulmonary arrest, even for cancer patients. This
makes calculations pertaining to cancer-specific survival rates quite inaccurate.
Training and partaking in repetitive auditing with robust quality control can do
much to improve the situation over time.
Challenges
Abandonment
Among the unique problems that face pediatric oncologists are “treatment refusal,”
where families refuse treatment, or “abandonment,” where treatment is delayed for a
significant period. Abandonment is prevalent in low-income countries (Weaver et al.
2015; Alvarez et al. 2017). One study surveyed 602 respondents from 101 countries and
estimated abandonment rates at 15% of children with cancer, with the vast majority of
them living in low- and middle-income countries (Friedrich et al. 2016). There is a
scarcity of data from Arab countries regarding abandonment. It is possible that the rates
are low, but the strong belief in alternative medicine and the lack of adequate transpor-
tation in some areas may add to this problem. Added to this is the influence of the
extended family and the community surrounding the patients who sometimes encourage
abandonment in favor of traditional and alternative therapies (Mostert et al. 2014).
The most accurate estimates of abandonment were reported in Morocco, where a
rate of 12–37% was reported and was considered among the top challenges that face
pediatric oncology in the country (Hessissen et al. 2010, 2013; Hessissen and
Madani 2012). Addressing this complex problem requires a thorough understanding
of its causes, including family dynamics, perceptions, public awareness, and gov-
ernmental healthcare financing (Friedrich et al. 2016). Financial support can help to
resolve this problem (Srinivasan et al. 2015).
Another related problem is noncompliance. This is particularly important in
patients receiving prolonged courses of oral medications, which occurs in all
cases. A report from Egypt showed that noncompliance occurred in half of the
129 patients surveyed, as confirmed by serum drug levels. This was more common
in patients with large families, poor levels of education, and low socioeconomic
standards (Khalek et al. 2015).
Delayed Diagnosis
Delay in diagnosis of pediatric cancer is common in the Arab countries. Surprisingly,

physicians contribute to more delays than do parents. A recent study from Egypt
analyzed the causes of delays in diagnosis of children with cancer and reported that
physicians-related issues outweighed issues related to parental delays by ten times
(28 vs. 3 days). The same study found that the parent’s level of education or
socioeconomic status had no influence on diagnostic delays (Abdelmabood et al.
2017), highlighting again the role of physicians in postponing diagnosis.
Programs attempting to provide solutions should focus on physicians. Most
pediatricians will encounter only a handful of cases during their careers. This
inexperience is compounded with the fact that pediatric cancer can be asymptomatic
or be present with nonspecific symptoms for a long time, e.g., back pain, nonspecific
abdominal pain that may mimic constipation, intermittent fever, limping or joint
swelling, etc. Among patients who experience the highest number of delays are those
with bone tumors. Our clinic treated cancer patients who were initially treated for
“fractures” or “knee joint problems” for 6–12 months prior to referral to an oncol-
ogist. Some patients had improper interventions or biopsies that rendered the
affected limb unsalvageable. Diagnosis of retinoblastoma can also be delayed if
proper examination under anesthesia is delayed. This diagnosis can be missed when
young children are examined with an ophthalmoscope without proper preparation
and sedation.
446 I. Sultan
Breaking Bad News
“Breaking the bad news” of cancer diagnosis to families is particularly challenging

in all cultures. It is not uncommon for Arab families to exhibit an overwhelming
feeling of guilt; this is further complicated by the rampant mistrust of medical
personnel and facilities in the region (Otmani and Khattab 2016; El Malla 2017).
Added to that is the fear of fully disclosing facts to the patients and families at times
of diagnosis or relapse (El Malla et al. 2017), and the challenges that face parents
who may already be suffering from other socioeconomic challenges (Pelletier and
Bona 2015; El Malla 2017). In many cases, facing the challenge of having a child
with cancer exposes family to additional stress that can lead to marital problems and
other professional or personal hardships (Arabiat et al. 2013).
Loss of workdays or outright abandoning work as well as newfound financial
burdens can further complicate the situation. These issues need to be addressed early
on. Social workers need to work closely with the rest of the hospital team to identify
social problems and openly discuss them. It is essential to encourage parents to
resume a normal life as soon as possible. Leaving work or having both parents in the
hospice alongside the patient at all times should be discouraged. Allowing parents to
leave and having a somewhat normal social life is important, as parents commonly
lose interest in eating and sleep due to their distress. Anger, denial, and bargaining
are all expected phases of bereavement, and are commonly witnessed and should be
anticipated and discussed. Caring for siblings is also an important issue to discuss, as
it is crucial to maintain correct treatment of the affected child while upholding
normal relationships with their siblings.
Informing a child that he/she has cancer is challenging. Two rules apply: First, the
child’s level of understanding should be evaluated before discussing this information
with him/her; and second, one should not provide misleading information. Loss of
trust impacts the pediatrician-patient relationship and can also affect the efficacy of
the treatment the child is receiving. Adolescent girls in particular exhibit a height-
ened concern regarding body image and hair loss. This has to be openly and honestly
discussed and explained. Photos showing children regaining hair after finishing
treatment can help in alleviating distress under these circumstances.
Once the diagnosis is made and information is disclosed, the use of alternative
medicines should be discussed. The treating physician should assume that many
families will explore herbal and other modalities of alternative medicine shortly after
diagnosis (Naja et al. 2011). Honest and open discussion can help parents to be
partners in choosing the best treatment plans and prevent unforeseen drug interac-
tions related to alternative treatment plans.
Political Instability
There has been political uproar in the Arab world, as shown by the recent period of
civil unrest with the eruptions of protests in the region. The historic improvement in
life expectancy in the region ceased, and a reversal leading to an actual decline in life
expectancy has occurred in Egypt, Yemen, Libya, and Syria (Mokdad et al. 2016).
Children suffered significantly during this period, particularly in Syria, where
declining infant mortality rates saw notable increases from 2010 to 2013; this is
now at levels equal or below that in several impoverished sub-Saharan African
countries (Mokdad et al. 2016). An accurate assessment of childhood cancers in
refugees is not currently available. While nongovernmental organizations and gov-
ernmental assistance have made some efforts in this regard, additional efforts are
needed (Kebudi et al. 2016; Silbermann et al. 2016; Saab et al. 2018).
Policy Changes
Pediatric oncology is frequently disregarded in the national cancer control agenda.

Moreover, pediatric oncologists are often not aware of the existence of cancer
control plans (Weaver et al. 2017a). Ideally, children with hematologic disorders,
particularly those needing bone marrow transplantation, should be included in the
national cancer control plans to reduce programmatic redundancies in resource-
limited settings (Weaver et al. 2017b).
Policy makers need to understand that pediatric oncology is a surrogate for
achievements of the health care system. Ribeiro et al. very elegantly showed that
the survival of children with cancer correlates with annual government spending on
health care (Ribeiro et al. 2008). To make the best use of financial resources, policy
makers need to negotiate better pricing with pharmaceutical companies. Chemother-
apy shortages and fluctuating prices can be avoided when governments understand
the dynamics of this industry. An emerging concern is the rapidly increasing prices
of new therapeutics, e.g., immunotherapy for children with neuroblastoma (Capitini
et al. 2014). International collaboration between governments should attempt to end
this unjustified increase of drugs prices. Additionally, policy makers need to under-
stand the flow of work in pediatric oncology. Adding a palliative care service with
home visits might seem like an extra financial burden, while in reality this service
minimizes hospital stays and decreases the cost of caring for terminally ill patients
(Conte et al. 2015).
Oncologists should provide details of childhood cancer and its management to
policy makers. A clear example was the low survival reported in Denmark in many
publications. This led to a national awareness program where cancer was considered
to be an acute illness and received much attention. Hospitals were required to
diagnose and refer patients acutely, and the process was closely monitored. This
led to an observable improvement in the outcomes of patients with cancer (Madsen
and Frolund 2008; Allemani et al. 2018).
In the opinion of the author, hospital administrations need to improve the training
and retention of nurses as a priority in pediatric oncology, and for cancer care in
general. Providing nurses with adequate training and checking their competencies is
essential in establishing pediatric oncology units (Day et al. 2012). A useful example
was pioneered at the King Hussein Cancer Centre, where clinical nurse coordinators
reached new levels of health care competencies that were similar to physician
448 I. Sultan
assistants in other parts of the world. This helped in providing improved care even
though fewer trained oncologists were available (Al-Qudimat et al. 2009).
Improving Quality of Care
A recent computational analysis created simulation models of 200 countries cali-

brated using CONCORD-3 study results (Ward et al. 2019). The estimated net global
5-year survival of childhood cancer is 37.4%, in comparison with 83% in North
America. The model predicts that improving access to services (chemotherapy,
radiation, ophthalmic surgery, neurosurgery, etc.) can only modestly improve cancer
outcomes in children. More impact can be expected only when these services are
provided in a comprehensive way (i.e., multidisciplinary teams) and when levels of
services are improved in related services (e.g., infection control and nutritional
support). For that reason, adopting a holistic approach is preferred when addressing
the poor cure rates of children with cancer, instead of using the current fragmented
approaches (e.g., abandonment, access to chemotherapy).
Success Stories in the Arab World
Obstacles related to chemotherapy availability and pain management have been

largely overcome in Morocco (McCarthy et al. 2004; Hessissen and Madani
2012). A Moroccan NGO (ALSC) was established with a mission to provide
chemotherapy at no cost to all government-run oncology units, where the majority
of children with cancer are treated. This solved a major hurdle for pediatric oncol-
ogists. Identifying simple achievable goals with programs that focus on sustainabil-
ity has dramatically changed pediatric oncology in Morocco (Hessissen and Madani
2012). The program later expanded by partnering with regional authorities on
managing Wilms tumors and brain tumors.
Another success story is the progress at the King Hussein Cancer Center in
Jordan (KHCC), which started as a poorly equipped center that was established
through charity, and that was transformed shortly after the death of Jordan’s King
Hussein bin Talal following a battle with cancer in 1999. The center was renamed
as the KHCC, highlighting its role as a cancer treatment center – and not merely as
a center of hope as it was previously called. Dramatic changes incorporating
inspirational motivation as well as standardization of policies and procedure
contributed to a major transformation in the leadership, structure, mission, and
quality control of the center. This led to it being the first joint commission
internationally accredited hospital in Jordan. KHCC continues to be a source of
pride to Jordanians and serves as an example of a successful nonprofit organization
in the Arab world (Moe et al. 2007).
The inception of the Children’s Cancer Hospital in Egypt (CCHE, also known as
57,357 hospital) in 2007 occurred through an initiative of a group of pediatric
oncologists and policy makers who started an unprecedented campaign in the
Arab world. The dream of having underprivileged children with cancer receive
the highest level of care motivated the public to donate generously to the
project. Maintaining the CCHE, expanding its facilities, and supporting its
growing research activities were all coupled with a sustainable program of
public awareness and motivational TV ads that were aired around the Arab world
(Zaghloul 2009).
In Lebanon, the American University of Beirut Medical Center (AUBMC) and
the Children’s Cancer Center of Lebanon (CCCL) collaborated with St. Jude Chil-
dren’s Research Hospital (SJCRH) in Memphis (USA) and the American Lebanese
Syrian Associated Charities (ALSAC) to establish and maintain a state-of-the-art
new facility. This center is a hub for training and for intense research in pediatric
hematology and oncology. The center also provides healthcare for the Syrian
refugees residing in Lebanon. This humanitarian role highlights the important and
unanticipated roles that pediatric oncology units play in the Arab world (Saab et al.
2018).
It is through the many sacrifices of pediatric oncologists in Iraq that children with
cancer continue to receive care in extremely challenging times. There are many
occasions when two or three patients occupy a single bed in heavily crowded
hospitals. Infection control becomes a less important issue when oncologists needed
to make life-saving decisions (Al-Hadad and Al-Jadiry 2012). Despite these diffi-
culties and a high rate of treatment abandonment, more than half of patients with
high grade B-cell non-Hodgkin lymphoma were cured; this is truly a remarkable
achievement considering the circumstances (Moleti et al. 2011). Similarly, induction
mortality in acute lymphoblastic leukemia dropped from 24% in 2007 to 10% in
2010; another indicator of the great efforts of all the care givers in the country
(Al-Hadad et al. 2011). Furthermore, twinning with a cancer center in Rome
improved the outlook of children with cancer in Baghdad, particularly those with
acute promyelocytic leukemia (Testi et al. 2006).
Specific Cancers
Leukemias
Acute lymphoblastic leukemia (ALL) is the most common cancer type in children.
Due in large part to the historic work of collaborative groups and many studies, most
patients with ALL are cured. Pillars of treatment include intensive courses of
agents such as asparaginase, vincristine, steroids and anthracyclines, high dose
methotrexate, intensive intrathecal chemotherapy to treat or prevent CNS
disease, and prolonged course of up to 2–3 years of maintenance regimen of
oral chemotherapeutic agents. These treatments have resulted in more than 90%
of patients with ALL being cured – defined as being in remission at 4-years
post treatment (Pui et al. 2014).
Delivering adequate therapy to children with ALL requires multiple levels of
supportive care to manage tumor lysis, infections, mediastinal masses, blood
450 I. Sultan
products support, and palliative care (Hunger et al. 2009; Ceppi et al. 2015). A
balance between more toxic regimens that need robust supportive care, such as the
St. Jude total protocol, and a less intensive regimen that can cure many patients with
minimal toxicity, should be carefully selected. The use of intensive regimens has
been successfully implemented in many centers in the Arab world (Rahman Sayed
et al. 2016), while others elected to choose less-intensive and more cost-effective
regimens despite lower cure rates (Tantawy et al. 2013). Impressive survival rates of
patients with ALL was reported by the CONCORD-3 study in Jordan, Qatar, and
Kuwait, bearing in mind the many challenges related to the quality of data on
survival outcomes (Table 4) (Allemani et al. 2018).
A large collaborative study by the Middle East Childhood Cancer Alliance
(MECCA) group reported data on 1171 patients with ALL. The mean age of patients
was 6.1 years and 59% were males. T-cell acute lymphoblastic leukemia and B-cell
precursor ALL represented 15% and 85% of the cohort, respectively. Interestingly,
there was a lower percentage of ETV6-RUNX1 translocation (15%) reported in this
study compared to reports from Western countries, where around 25% of Pre-B ALL
cases are frequently reported (Greaves 2006). The study reported excellent responses
to induction chemotherapy, with 96% of patients achieving complete remission
(Al-Mulla et al. 2014).
Unlike ALL, acute myeloid leukemia is more challenging to treat. A recipe of
intensive chemotherapy, antibiotic prophylaxis, intensive care unit support, nutri-
tional support, and bone marrow transplantation of selected patients is needed for
optimal care of these patients. Reported survival results remain below those in
developed countries (59% vs. 70%), making treatment of acute myeloid leukemia
a unique challenge in the region (Jastaniah et al. 2016).
Acute promyelocytic leukemia represents a unique group of acute myeloid
leukemias. These patients benefit from cytarabine-containing protocol and the use
of all-trans-retinoic acid and/or arsenic trioxide to induce differentiation of malig-
nant blasts. Delays in diagnosis and initiation of therapy can lead to loss of life.
Successful treatment of these patients has been reported in a multicenter study in
Saudi Arabia, despite mildly inferior outcomes compared to developed countries
(Jastaniah et al. 2017).
Table 4 Last reported survival on CONCORD-3 studya

Brain ALL Lymphoma
Algeria 54.1 (39.2–69.0) 30.9 (10.1–51.6) 77.5 (65.4–89.7)
Jordan 57.3 (49.9–64.8) 88.0 (83.1–92.8) 87.0 (81.4–92.6)
Kuwait 59.2 (39.2–79.1) 88.4 (80.6–96.2) 96.3 (91.4–100.0)
Qatar 65.5 (34.5–96.5) 82.6 (61.2–100.0) 95.3 (87.3–100.0)
a
Not all data were age-standardized, and on many occasions, survival estimates were considered
unreliable for different reasons; 100% survival was not listed and a previous reported survival was
chosen to give better representation; latest data available were used in this table (Allemani et al.
2018)
Lymphomas
Many centers in the Arab world report outstanding results in treating children with
Hodgkin lymphomas (Sherief et al. 2015a). The current challenge is to maintain this
high cure rate while minimizing the burden of treatment, e.g., avoiding procarbazine in
males and radiation in females due to the risk of infertility and breast cancer, respectively.
Burkitt lymphoma is the most common type of non-Hodgkin lymphoma in chil-
dren. Successful treatment protocols were established in developed countries (Sherief
et al. 2015b). The high toxicity of these protocols can be balanced by positive
outcomes. Nevertheless, these regimens cannot be undertaken in areas where malnu-
trition and lack of supportive care are common. Alternatively, less toxic regimens exist,
such as the Malawi protocol (28-day treatment with four doses of cyclophosphamide
and intrathecal chemotherapy) which cures half of treated patients at an extremely low
cost of less than 50 US$ (Depani et al. 2015). While this approach might be extreme,
tailoring treatment to available resources is crucial to improving outcomes and mini-
mizing toxicity (sometimes lethal) and abandonment.
Brain Tumors
Children with brain tumors represent a unique concern. While the spectrum of tumors
is similar to developed countries (Ezzat et al. 2016), oncologists in the Arab world face
concerns similar to those in low-income countries. Delay in diagnosis is a serious issue
that often can compromise the survival and neurologic outcomes of children. Reluc-
tance of surgeons to perform complete resection, either because of fear of neurologic
sequelae or lack of experience, jeopardizes the survival outcome of these patients
(Abdalla et al. 2018). Using radiotherapy improves survival but at the cost of reduced
cognitive function due to harm to the developing brain. The outcome of these patients
cannot be measured by “overall survival” data, as tests to determine their IQ, school
performance, and quality of life are equally important.
Retinoblastoma
Retinoblastoma is the most common primary malignant eye tumor in children and
represents 3–5% of all childhood malignancies. The disease represents a classical
example of the two-hit-theory, where a mutation of the Rb-gene on chromosome
13 can lead to an autosomal dominant disease that typically affect both eyes at a
young age; other cases are sporadic and typically presents in one eye after the first year
of life. Successful treatment of retinoblastoma does not imply only saving lives but also
saving eyes and retaining vision. This requires the work of a multidisciplinary team of
dedicated ophthalmologists, aided by functional equipment. As most patients had
enucleation and many died of metastatic diseases in the past (Senft et al. 1988), the
success of the King Hussein Cancer Center in rapidly establishing a successful unit has
been historical. Due to continuous training of staff, results of eye salvage and survival
452 I. Sultan
rates equal those seen in the best medical centers in the world (Al-Nawaiseh et al.
2014). A recent genetic study confirmed a very high rate of germline disease (72%)
that was observed in all patients with bilateral retinoblastoma and in approximately
one-third (30%) of patients with unilateral disease; half of all germline mutations were
inherited from one of the parents (Yousef et al. 2017).
Special Services
Radiation
Radiation therapy is critically needed when treating half of the children diagnosed
with cancer; this is often the most challenging aspect of delivering optimal care, due
to poor availability of this service in many Arab nations. There are several reasons
for this: first, machines are not always available. The number of radiation machines
per million population is an important indicator of cancer care. In upper middle-
income countries, there is an average of 1.4 machines per million population. Half of
the Arab countries have less than 1 machine per million population; moreover,
approximately one fifth of available machines (60 out of 332) are cobalt machines
(Table 5). These machines, while cheaper and needing less maintenance and have a
lower need for stable electrical current and water supplies, still pose an increased risk
of radiation leak. Cobalt machines deliver poorer quality radiation, with higher doses
delivered to the skin and a larger beam, which also can irradiate critical structures
(DDoRChdioAA 2018).
Optimal delivery of radiation requires well-trained radiation oncologists, medical
physicists, the use of masks and other fixation equipment to minimize movement
during radiation, as well as proper sedation of young children. Proper planning starts
with a multidisciplinary team, where the need for radiation and the proper dose and
volume are reviewed. It is essential to use this modality judiciously to avoid
subsequent toxicities. While some poorly equipped centers use 2-D planning, most
children benefit from better planning using CT-planning to deliver 3-D conformal
radiation. For selected tumors (e.g., head and neck cancers), intensity modulated
radiotherapy, or volumetric intensity modulated arc therapy can help by avoiding
applying radiation to nearby critical structures. More recently, proton therapy has
been used to deliver radiation at higher precision than possible with classical photon
radiation (Parkes et al. 2017). Such units will be operational in Riyadh and Cairo in
the coming years.
Multidisciplinary Team
While many centers achieved promising results in treating ALL and lymphomas, the
success in treating solid tumors is still lagging. In particular, bone sarcomas and soft
tissue sarcomas have inferior outcomes compared to treatments in developed coun-
tries. Centers that reported excellent outcomes are those that have regular
Table 5 Number of radiotherapy centers and radiotherapy machines present in Arab countries
according to Directory of Radiotherapy Centers website
Radiotherapy Clinical Co- Total number of Machines per
Countries centers accelerator 60 machines million populationa
Algeria 15 34 4 38 1.0
Bahrain 2 4 0 4 2.9
Djibouti – – – – –
Egypt 70 92 24 116 1.3
Iraq 22 17 1 18 0.5
Jordan 5 12 1 13 1.7
Kuwait 1 3 0 3 0.8
Lebanon 11 16 3 19 3.2
Libya 3 0 2 2 0.3
Morocco 20 35 2 37 1.1
Mauritania 1 1 0 1 0.3
Oman 1 2 0 2 0.4
Qatar 1 3 0 3 1.3
Saudi Arabia 15 35 1 36 1.1
Somalia – – – – –
State of – – – – –
Palestine
Sudan 3 2 5 7 0.2
Syria 3 2 5 7 0.4
Tunisia 11 11 10 21 1.9
United Arab 2 4 0 4 0.4
Emirates
Yemen 1 0 2 2 0.1
a
Machine per million population were calculated using last population reported on the World Health
Organization website accessed in April 2018; data obtained from DIRAC (Directory of Radiother-
apy Centers). https://dirac.iaea.org/. Accessed April 2018
multidisciplinary team meetings (Cantrell and Ruble 2011; Salman et al. 2012;
Al-Jumaily et al. 2013; Hessissen et al. 2013; Abdel-Baki et al. 2015; Elzomor
et al. 2017). Beyond sharing notes and medical reports, oncologists, surgeons,
pathologists, and radiation oncologists discuss cases directly with each other. Plan-
ning surgery and interpreting pathology reports require all these disciplines to meet
regularly and engage in structured discussions.
Bone Marrow Transplantation
Attempts at better regional collaboration led to the establishment of an Eastern

Mediterranean blood and marrow transplantation group, consisting of eight coun-
tries (Egypt, Iran, Jordan, Lebanon, Oman, Pakistan, Saudi Arabia, and Tunisia).
The group recently published its first report of pediatric transplantation. A total of
454 I. Sultan
5187 transplants were performed, with the majority (87%) being allogeneic. More
than one third (39%) were for malignant indications, while the rest (61%) were based
on other nonmalignant indications, mostly hemoglobinopathies and bone marrow
failure. Due to the relatively large family sizes in the Arab world, approximately
95% of the matched donors were related (Hussein et al. 2017).
Palliative Care
Providing palliative care is an integral part of cancer management. Having plans to

deal with symptoms of diagnosis or managing terminally ill children with cancer is
essential. However, there are many obstacles for delivering adequate palliative care
in the Arab world. In many cases, policy makers assign financial resources to
curative care. There is a lack of well-trained professionals able to treat terminally
ill patients, and morphine and other narcotics are often unavailable (Mojen et al.
2017). Moreover, the laws that regulate the end-of-life care are confusing and not
well established in many Arab countries. As in other low- and middle-income
countries, shortcomings in delivering palliative care in the Arab world are related
to lack of national health support systems, specialized education, and adequate
access to opioids (Caruso Brown et al. 2014). Burn-out is a common problem facing
health workers, particularly in those interacting with dying children. Professionals
should provide support to each other, to reduce the stresses associated with these
challenging events.
Survivorship
A growing population of patients with special needs exist as more children with
cancer survive after treatment. Poor vaccination rates, obesity, and hepatitis C virus
infection are common in these patients in the Arab world (El-Rashedy et al. 2017;
Fayea et al. 2017). Survivors of cancer in the Arab world are not well studied. These
patients face challenges in education, employment, and marriage opportunities.
Counseling regarding reproductive life as well as back-to-school programs could
better prepare them for life after treatment. Programs that are familiar with medical
problems of survivors of pediatric cancers can assist in detecting late relapses,
secondary cancers (e.g., thyroid cancer), growth delays, and cardiac dysfunction.
What Can Be Done in the Future?
• Improving data registration, in particular, rates of abandonment and survival

• Partnering with more advanced programs
• Encouraging collaboration between centers in the same country and between
different countries in the Arab world
• Encouraging research activities related to regional needs
• Establishing training programs to train physicians and nurses

• Creating strategies to reduce burnout in health care providers (and increase
resilience)
• Identifying alternative resources for funding
• Improving communications with policy makers and providing them with accurate
information
• Establishing palliative care centers and survivorship programs
• Improving health infrastructure and access to care
Conclusion
Pediatric cancer poses an important problem in Arab countries. Despite many

similarities, huge gaps exist. Closing these gaps requires collaboration, twinning,
and following the many successful examples that exist already. The future of Arab
children with cancer depends on offering trained personnel to offer the optimal level
of care needed, investing in radiation facilities, offering basic chemotherapeutic
drugs, and facilitating the integration of children with cancer in their communities.
The challenge of the ongoing unrest and wars in many Arab countries should not
jeopardize the care of these most-vulnerable patients.
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Radiation Oncology in the Arab World
21
Layth Mula-Hussain, Shada Jamal Wadi-Ramahi,
Mohamed Saad Zaghloul, and Muthana Al-Ghazi
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 463
Methods and Materials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 464
Global and Regional History of Radiation Oncology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 465
Essential Components in Radiation Oncology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 465
Personnel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 465
Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 467
Status of Radiation Oncology in ALC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 469
Creating Knowledge and Building Experience to Bridge the Gap . . . . . . . . . . . . . . . . . . . . . . . . . 469
Licensing, Regulations, and Certification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 470
Intra- and Interregional Networking and Cooperation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 471
Comparison of Need and the Availability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 472
Regional Future Perspectives of Radiation Oncology in ALC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 475
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 477
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 477
L. Mula-Hussain (*)
Department of Radiation Oncology, Cross Cancer Institute – University of Alberta, Edmonton, AB,
Canada
e-mail: LMulaHussain@AOL.com
S. J. Wadi-Ramahi
King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
e-mail: SAlramahi92@kfshrc.edu.sa
M. S. Zaghloul
Radiation Oncology, Children’s Cancer Hospital and National Cancer Institute – Cairo University,
Cairo, Egypt
e-mail: MSZagh@Yahoo.com
M. Al-Ghazi
Chao Family Comprehensive Cancer Center – University of California, Irvine, CA, USA
e-mail: MAlghazi@UCI.edu

https://doi.org/10.1007/978-3-030-36811-1_151
462 L. Mula-Hussain et al.
Abstract
Radiation oncology is a discipline of clinical medicine that uses ionizing radiation
for the treatment of patients with malignant diseases, cancers (mostly), or some
nonmalignant diseases (on occasion). It is an area of medicine where radiation
oncologists are unable to deliver their therapeutic measures without the input
from medical physicists, radiation therapists, and other members of the radio-
therapy team. Tools needed in radiation oncology were first launched in Europe in
1895 and then entered the Arab World in the 1920s. This chapter reviews the
status of radiation oncology in the 22 Arab League Countries where over 400
million of people live and where there were over 400,000 new cases of cancer in
2018. The available data are not always reliable. In spite of some excellent
achievements in some aspects, the facilities available are often suboptimal in
many of these countries, where it is ideally estimated that one treatment machine
supposed to be available for about every 500 new cancer patients. There are
variations in access to care of the population in these countries, with an average of
less than 40% from the ideal required coverage of radiotherapy machines based
on internationally recommended standards. Similarly, there is a shortage of
optimally qualified and trained personnel. The situation requires urgent attention
from all stakeholders in cancer patient care and patient rights.
Keywords
Cancer · Radiation oncology · Arab League Countries
Abbreviations
ABR American Board of Radiology
ARASIA Arab States in Asia
ALC Arab League Countries
ASTRO American SocieTy for Radiation Oncology
CCPM Canadian College of Physicists in Medicine
CQMP Clinically Qualified Medical Physicists
CT Computed Tomography
DIRAC Directory of RAdiotherapy Centres
EBRT External Beam Radiation Therapy
EMRC Energy and Minerals Regulatory Commission
ESTRO European Society for Therapeutic Radiology and Oncology
GTFRCC Global Task Force on Radiotherapy for Cancer Control
GTV Gross Tumor Volume
Gy Gray
h Hour
HDR High Dose Rate
HIC High-Income Countries
IAEA International Atomic Energy Agency
IARC International Agency for Research on Cancer
21 Radiation Oncology in the Arab World 463
IMPCB International Medical Physics Certification Board

IOMP International Organization for Medical Physics
JAMAAC Junior Arab Medical Association Against Cancer
kV KiloVolt
LDR Low Dose Rate
LIC Low-Income Countries
LINAC LINear ACcelerator
LMIC Low-Middle-Income Countries
MDR Medium Dose Rate
MeV Mega-electron Volt
MP Medical Physicist
MRI Magnetic Resonant Imaging
MV Mega-Volta
MVM Mega-Voltage Machines
NCCN National Comprehensive Cancer Network
PDR Pulsed Dose Rate
QUARTS QUAntification of Radiation Therapy infrastructure and Staffing
needs
RO Radiation Oncologist
RT Radio-Therapy
RTT Radiation Therapy Technologist
TPS Treatment Planning System
UMIC Upper-Middle-Income Countries
Introduction
Cancer is the second most cause of death worldwide and was responsible for 9.1
million deaths in 2018. It is estimated that nearly one of six deaths is due to cancer
(Bray et al. 2018). Oncology is the branch of medicine devoted to the study of
tumors. A tumor is an abnormal, benign or malignant, new growth of tissue that
possesses no physiological function and arises from uncontrolled, often rapid,
cellular proliferation. Cancer is a tumor of potentially unlimited growth that expands
locally by invasion and systemically by metastasis. The World Health Organization
(WHO) estimates a rise in the cancer incidence between 2008 and 2030 of 82%,
70%, and 58% in low-, low-middle-, and upper-middle-income countries, respec-
tively, compared with a modest increase of 40% in high-income countries (Alwan
2011). Cancer management involves a multidisciplinary team composed of individ-
uals from different medical and no-medical specialties collaborating to optimize the
care of the cancer patient. Generally, the team consists of surgical oncologists,
radiation oncologists, and medical (adult or pediatric) oncologists, in addition to
many non-physicians who are integral part of the care team.
Radiation oncology is a discipline of clinical medicine that uses ionizing radiation
(such as X-ray, gamma ray, electrons, particles, etc.) from external or internal
sources, either alone or in combination with other modalities for the treatment of
patients with malignant diseases (mostly) or other nonmalignant diseases (on occa-
sion). Radiation oncology is distinctly different from radiology as the former focuses
on using radiation for treatment, while the latter uses radiation for imaging and
diagnosis. This specialty can be practiced as an independent oncology specialty or
may be integrated into the broader medical practice of clinical oncology with the use
of chemotherapy agents and targeted therapy to enhance the effectiveness of radia-
tion in a multimodality setting for providing a comprehensive treatment to cancer
patients. Radiation oncology includes the responsibility for the diagnosis, treatment,
follow-up, and supportive care of cancer patients (IAEA 2009). Radiation oncolo-
gists (RO) collaborate with medical physicists (MP), radiation therapy technologists
(RTT), radiation safety officers, maintenance engineers, and radiation oncology
nurses to provide optimal patient care.
Arab League Countries (ALC) are 22 members in the League of Arab States,
which are in alphabetical sequence: Algeria, Bahrain, Comoros, Djibouti, Egypt,
Iraq, Kuwait, Jordan, Lebanon, Libya, Mauritania, Morocco, Oman, Palestine,
Qatar, Saudi Arabia, Somalia, Sudan, Syria, Tunisia, Yemen, and the United Arab
Emirates. They are distributed in Asia (12) and Africa (10). Only 1 country (Com-
oros) is considered to be a low-income country (LIC) by the World Bank economic
categorization, while 11 countries belong to low-middle-income countries (LMIC),
4 countries to upper-middle-income countries (UMIC), and the remaining 6 are high-
income countries (HIC, all in the Gulf area).
The international guidelines arranged by the European Society for Therapeutic
Radiology and Oncology (ESTRO), termed the QUARTS (QUAntification of Radi-
ation Therapy infrastructure and Staffing needs) guidelines, recommend the avail-
ability of one External Beam Radiation Therapy (EBRT) machine (i.e., megavoltage
machines, MVM, which can be a linear accelerator or radionuclide teletherapy
machine) for every 450 new cancer patients (Slotman et al. 2005). On the other
hand, in order to deliver safe, efficient, and competent radiotherapy service, the
International Atomic Energy Agency (IAEA) recommended one MVM per 180,000
population (International Atomic Energy Agency 2010).
Methods and Materials
A literature search was undertaken on June 11, 2018 for relevant publications. A
search of PubMed using (“Radiation Oncology”[Mesh]) AND “Arabs”[Mesh] was
without success. Using (“Radiation Oncology”[Mesh]) AND “Arab World”[Mesh]
produced only one result, and then using (“Radiation Oncology”[Mesh]) AND
names of all the Arab countries (e.g., AND Morocco, AND Lebanon, etc., in
sequence) produced seven studies. We were unsuccessful when searching Google
Scholar.
More specialized sites produced modest success: the IAEA website/DIrectory of
RAdiotherapy Centres (DIRAC) database that collects information on the radiother-
apy facilities in the ALC and the International Agency for Research on Cancer
(IARC) website/2018 GLOBOCAN database released in September 12, 2018, in

Geneva to collect information on cancer incidence in ALC.
In addition, a survey was also posted on selected social media pages of the Arab
radiation oncology groups, e.g., the Junior Arab Medical Association Against
Cancer (JAMAAC) group on Facebook, and produced a modest response (11 from
4 countries).
Global and Regional History of Radiation Oncology
The discovery of X-rays in 1895 by Wilhelm Conrad Röentgen, a German mechan-

ical engineer and physicist, preceded that of the natural radioactivity (another type of
ionizing radiation) by the French physicist, Henri Becquerel, and his team (Marie
and Pierre Curie) by a few months. Both breakthroughs paved the way for a new era
in science and medicine. Over the next century, discoveries in radiation physics,
chemistry, and biology informed clinical approaches in developing more accurate,
more efficient, and less toxic anticancer therapies. There are essentially four main
schools in the history of radiation oncology in the twentieth century: the German
school (1900 to ~1920), the French school (1920 to ~1940), the British school (1940
to ~1960), and, lately, the North American and European Union schools (1970 to
date) (Bernier et al. 2004).
In comparison, ALC developed this specialty relatively recently. The list of early
examples included the superficial X-ray treatment machine at the Radiology Institute
in Baghdad in the 1920s (Al-Ghazi 2016), the radiation oncology department at the
Hotel-Dieu de France Hospital in Beirut in 1925 (HDF 2013), and the radiation
therapy unit at the Kasr Al Ainy Hospital (Cairo University Hospital) in Cairo in the
1930s that used the ominous sounding “radium bomb” (Zaghloul and Bishr 2018).
Following these initiatives, radiotherapy developed further in other ALC locales.
Essential Components in Radiation Oncology
Personnel
Radiation oncology is a complex science, technology, and practice that requires

highly qualified team members. This team has a wide variety of knowledge and skills
that require extensive training and continuing education for all members. The IAEA
estimated that one radiation oncologist should be available to treat 200–250 cancer
patients (or for every 100,000 persons), one medical physicist for 400–500 cancer
patients (or for every 200,000 persons), and one radiation therapist for 150 cancer
patients (or 2 per MVM up to 25 patients treated daily) (International Atomic Energy
Agency 2010). The Global Task Force on Radiotherapy for Cancer Control
(GTFRCC) estimated the global needs for human resources to be trained in radio-
therapy to provide appropriate service in 2035, based on the countries’ income level,
as follows (Atun et al. 2015):
1,300 MVMs; 3,300 ROs; 2,400 MPs; and 8,100 RTTs in LIC
3,900 MVMs; 9,900 ROs; 7,200 MPs; and 24,900 RTTs in LMIC
7,400 MVMs; 16,800 ROs; 12,500 MPs; and 45,300 RTTs in UMIC
9,200 MVMs; 15,500 ROs; 17,200 MPs; and 51,900 RTTs in HIC
Trained personnel should be able to deliver efficient and safe quality radiotherapy
based on internationally accepted standards of care. The IAEA emphasizes the
importance of education and training of human resources for radiotherapy. The
Division of Human Health developed a series of syllabi for ROs, MPs, RTTs,
radiation oncology nurses, and radiation biologists, which provide the minimal
essential content and can be adapted to the specific needs and character of various
countries and training institutions.
Members of the Oncology Treatment Team
Radiation Oncologist (RO)

A RO is a physician with specialist qualification in the application of radiation in the
treatment of cancer, and who is certified by the appropriate board to practice the
specialty (Zietman et al. 2012).
Medical Physicist (MP)

A MP is a scientist trained in the application of radiation in the treatment of cancer,
and who is qualified by the appropriate board to practice therapeutic medical physics
(Zietman et al. 2012).
Radiation Therapy Technologist (RTT)

A qualified RTT is certified to practice radiation therapy in accordance with the
appropriate qualification for the designation of RTT (Zietman et al. 2012).
Radiation Safety Officer

A radiation safety officer is a person specially trained in mitigating the hazards of
radiation exposure and designing a radiation safety program compliant with appli-
cable radiation regulations. Parameters of such a program ensure the safety of staff,
patients, and the public (Zietman et al. 2012).
Radiotherapy Maintenance Engineers

The role of the radiotherapy maintenance engineer is to ascertain that the treatment
delivery equipment performs according to specifications such that its functionality is
consistent with safe and accurate delivery of treatment to patients (Zietman
et al. 2012).
Radiation Oncology Nurse

A qualified oncology or radiation oncology nurse has oncology certification, in
addition to basic educational preparation to function as a registered professional
nurse, as determined by the individual jurisdiction. Oncology certification can be
obtained through the appropriate training organization in the country or jurisdiction

(Zietman et al. 2012).
Equipment
Clinical Accelerator
Electron accelerators are radiation treatment devices that accelerate electrons using
electromagnetic fields to a required energy (from 4 MeV for a low-energy machine to
a few tens of MeV for a higher-energy machine). Strictly speaking, the “accelerator”
is only the part of the machine in which electrons are accelerated, but the term
“electron accelerator” or “clinical accelerator” is used to describe the whole machine
used to deliver radiotherapy. Electrons are produced by thermionic emission (emis-
sion of electrons from a hot cathode into a vacuum tube) in the electron gun. These
electrons are then injected into the electron accelerator, and the generated electron
beam is guided to the treatment head, where it is subsequently modulated and
prepared for medical use. X-ray photons are produced when these accelerated
electrons collide with a metallic target (a thin layer of a high-Z material such as
tungsten). There are two basic types of electron accelerators according to the
acceleration method: circular accelerators (betatron, microtron) and linear accelera-
tors (often shortened to LINAC). In circular accelerators, electrons generated in the
gun are injected into a torus-shaped vacuum tube placed into the gap between two
magnet poles. The electromagnetic field accelerates the electrons and generates the
beam. In a linear accelerator, electrons are injected into a linear waveguide and
accelerated by the action of radio-frequency electromagnetic waves, producing the
beam (IAEA 2018a).
Radionuclide Teletherapy Unit

Treatment devices incorporating gamma-ray emitting sources for use in external
beam radiotherapy are called teletherapy machines. Two gamma-emitting radionu-
clides have been used in external beam teletherapy: cobalt-60 and cesium-137. The
use of cesium-137 for external beam radiotherapy was discontinued during the
1980s, due to the problems associated with the low activity (large source size and
short treatment distance). Cobalt-60 has been the most widely used isotope for
teletherapy, because it offers a good compromise between the energy of emitted
photons, half-life, specific activity, and means of production. The source movement
from beam-on to beam-off (storage) position is accomplished with mechanical or
pneumatic methods. A very sophisticated cobalt-60 treatment unit dedicated to
stereotactic radiosurgery uses an array of separate cobalt sources housed in the
central body of the unit producing collimated beams directed to a single focal
point and is commonly referred to as a “Gamma Knife” (IAEA 2018a).
X-Ray Generator
Treatment devices incorporating X-ray tubes to produce low-energy (tube potential
40–300 kV) X-rays for use in external beam radiotherapy or brachytherapy are
called X-ray generators. The cathode of the X-ray tube expels the electrons from
the electrical circuit by thermionic emission. Electrons are accelerated electrostati-

cally and strike an anode (composed of a high-Z material such as tungsten), where
the kinetic energy of the electrons is transformed into X-rays (both bremsstrahlung
and characteristic X-rays). There are three types of X-ray generators according to the
energy of the X-rays generated: contact units producing typically X-rays for tube
potentials 40–50 kV, operating at distances <2 cm (electronic brachytherapy falls in
this category); superficial units, producing X-rays for tube potentials 50–150 kV and
operating at distances between 15 and 20 cm; and orthovoltage units generating
X-rays for tube potentials 150–300 kV and operating at distances around 50 cm
(IAEA 2018a).
Particle Accelerator
A particle accelerator is a radiation treatment device that accelerates hadrons (heavy
particles such as protons and carbon ions) using electromagnetic fields to high-
energy beams (60–250 MeV for protons and 350–400 MeV for carbon ions), useful
for medical purposes. The therapeutic advantage is the stronger biological effect (cell
killing per amount of deposited dose) of particles. Particle accelerators use electric
fields to increase the speed and energy of a beam of particles, which are guided and
focused by magnetic fields. Unlike electron accelerators that are compact devices by
design, particle accelerators require a complex setup of different elements and
requiring significantly more space. An ion source provides particles such as protons
or ions, which are to be accelerated. The positively charged particles are formed from
electron bombardment of a gas and extracted from the ions. The injector transports
the particles into a vacuum chamber to a cyclotron (protons) or synchrotron (protons
or ions) for acceleration and beam production. Finally, a high-energy beam transport
system delivers a clinically useful beam (IAEA 2018a).
Brachytherapy Unit
Brachytherapy concerns primarily the use of radioactive sealed sources (or minia-
turized high dose rate X-ray generators in the case of electronic brachytherapy)
placed directly into tissue either inside or very close to the target volume. Brachy-
therapy sources are usually inserted (loaded) into catheters or applicators. Sources
can be hot-loaded (the applicator is preloaded with radioactive sources at the time of
placement into the patient) or afterloaded (the applicator is placed first, and the
radioactive sources are loaded later, either by hand in case of manual afterloading or
by a machine in the case of automatic remote afterloading). Treatment devices
incorporating gamma-ray sources or miniaturized high-dose rate X-ray generators
with a computer-controlled source-drive mechanism for use in brachytherapy are
called afterloaders or afterloading units. Both cobalt-60 and iridium-192 isotopes are
used in modern afterloaders. According to the dose rate (dose delivered per unit of
time), brachytherapy is classified into three categories: low dose rate (LDR) brachy-
therapy ranges between 0.4 and 2 Gy/h, medium dose rate (MDR) brachytherapy
ranges between 2 and 12 Gy/h, and high dose rate (HDR) brachytherapy, where dose
is delivered at 12 Gy/h or more. Pulsed dose rate brachytherapy (PDR) delivers the
dose in a large number of small fractions with short intervals, mimicking the
radiobiology of LDR brachytherapy (IAEA 2018a).
Conventional Simulator
The (conventional) simulator is a machine that emulates the geometry and the
movements of the treatment unit with a diagnostic quality X-ray source instead of
the megavoltage X-ray source of the treatment unit. Planar X-ray reference images of
the patient in the treatment position are generated with an image intensifier, flat panel
detector, or radiographic film (IAEA 2018a).
CT Simulator
The computed tomography (CT) simulator is a dedicated CT scanner for use in
radiotherapy treatment simulation and planning. CT simulators usually have large
bore (opening between 80 – 90 cm) and are equipped with room lasers, including a
movable sagittal laser for patient positioning and marking and flat tabletop and
special software for virtual simulation (IAEA 2018a).
MR Simulator
The MR simulator is a dedicated magnetic resonant (MR) device for radiotherapy
simulation and is used to provide improved quality of soft tissue target definition
(MRI quality). The device possesses the same specification of CT simulator; flat
tabletop overlay with movement that allows any anatomy to be comfortably and
easily positioned at the isocenter, ensuring high image quality at all times, wide bore,
and mobile laser. MR simulator though provides high-quality images for gross tumor
volume (GTV) delineation, but because of its relatively high capital and operational
costs, it still did not come through as a “standard-of-care” system within radiation
oncology departments (Rai et al. 2017).
Treatment Planning System (TPS)

Treatment planning is a process in which the care team defines the characteristics of
the radiotherapy technique for a patient with cancer. Treatment planning consists of
many steps including adequate patient diagnosis and staging, image acquisition for
treatment planning, localization of the volumes of interest, beam arrangement and its
optimization, and treatment simulation. TPS is a combination of software and
hardware used to generate the treatment beam geometry and calculate the expected
dose distribution in the patient’s tissue. Many configurations of software (dose
calculation algorithms) and hardware are possible, making the TPS highly
configurable (IAEA 2018a).
Status of Radiation Oncology in ALC
Creating Knowledge and Building Experience to Bridge the Gap
Early radiation oncology experiences were obtained by bringing external experts to

ALC institutes to work, teach, train, and lead local personnel and facilities in this
new field; locals were also sent to train in European and North American centers and,
upon return, were tasked with transferring knowledge and expertise to local
communities. This was later followed by inter-ALC exchanges of knowledge,

experience, and conceptual activities among member countries of the ALC. Most
of these exchanges were performed by personal or institutional initiatives rather than
through national programs. Such collaborations increased the standard of staff
training in LMIC (Bishr and Zaghloul 2018; Wadi-Ramahi et al. 2017; Khader
et al. 2016; Mula-Hussain et al. 2017; Jaradat et al. 2012).
There is no uniform Arab residency training program in radiation oncology under
the umbrella of the Arab Board of Health Specializations, as exists in other medical
specialties (e.g., internal medicine and general surgery); however, there are national
formal education and training programs for ROs in 10 of 22 (45%) ALC, and many
of these programs are well established and expanding steadily. For example, in
Egypt, ROs can study and train through academic tracks, as MSc and PhD degrees
(either in clinical oncology or radiation oncology), and through clinical tracks, such
as the Egyptian radiation oncology fellowship. The Children’s Cancer Hospital in
Egypt offers a joint fellowship with Dana-Farber Cancer Institute and Massachusetts
General Hospital (USA) in Pediatric Radiation Oncology. The King Hussein Cancer
Center in Jordan has residency and fellowship programs in radiation oncology with
strong agreements with many institutes in North America (Khader et al. 2019). The
Zhianawa Cancer Center in Iraq in 2017 celebrated its first board-certified ROs from
a program started in 2013 (Mula-Hussain et al. 2019).
Education for MPs is provided by science faculties with minimal formal clinical
training programs. Training is usually offered by hospitals or oncology centers.
Some ALC appreciated the importance of these formal academic and practical
training programs and initiated national programs to fulfill these needs. Many
universities in the ALC established certification programs in cancer hospitals to
train MPs, dosimetrist, and RTTs to reduce the gap between available and needed
professionals and reduce the dependence on foreign labor experts (Wadi-Ramahi
et al. 2017).
The situation for RTTs is more challenging due to the limited academic and
training programs offered. Some examples are the Egyptian and Jordanian univer-
sities offering BSc and MSc degrees in radiation therapy technologies (Bishr and
Zaghloul 2018).
Licensing, Regulations, and Certification
All ALC have some form of licensing for ROs, MPs, and RTTs. Radiation oncolo-
gists have to complete a postgraduate level specialty program in order to be awarded
the specialty degree to be eligible to practice independently. In medical physics, the
license is based on a review of academic qualifications and is granted with or without
undergoing a formal examination. In most countries the license to practice is granted
after taking a course in radiation protection principles. Professional certification
similar to the American Board of Radiology (ABR) or Canadian College of Phys-
icists in Medicine (CCPM) where a professional MP undergoes a series of written
and oral examinations does not exist in most of ALC. There is little incentive in the
ALC for MPs to undergo a formal board certification process. The employment of
certified MPs is limited to a few hospitals in countries such as Lebanon, Saudi
Arabia, and Qatar. The situation of RTTs is similar to MPs in this regard.
Recently, and due to the increased awareness of the role of MPs in radiation
oncology, more institutions are encouraging their staff to pass a certification exam
such as the International Medical Physics Certification Board (IMPCB) (www.
impcbdb.org) established through cooperation of the International Organization for
Medical Physics (IOMP) and the IAEA with the support of many medical physics
organizations. This improvement in qualifications of MPs practicing in the regula-
tory bodies led in turn to improved qualifications of MPs working in hospitals. A
case in point is the enactment in 2015 of the Radiation Safety Law in Jordan,
through which Jordan’s Energy and Minerals Regulatory Commission (EMRC)
published various reports including the “Quality Assurance Program for Hos-
pital X-ray Generating Equipment” (visit http://www.emrc.gov.jo). Hospitals
are given a grace period to fulfill the items stipulated in the law and implement
the details outlined in the report.
Intra- and Interregional Networking and Cooperation
The advancements of the medical physics profession in the ALC are not only
dependent on the IAEA projects and support but also on multiple inter- and
intraregional cooperation at country and institutional levels. After more than 25
years of sanctions and wars, Iraq lost many of its professionals; the country has
tapped into the available regional professionals notably from Jordan in the rebuilding
process (Mula-Hussain et al. 2017). Other countries have exchanged expertise and
professional knowledge through hands-on workshops, seminars, and international
conferences conducted in the region (www.radmed.org). Interregional networking
and cooperation occur at institutional levels either through personal interactions
(Mula-Hussain et al. 2017; Wadi-Ramahi et al. 2017) that are limited in scope or
through formal institutional agreements that are more comprehensive and multi-
disciplinary in nature (Khader et al. 2016).
To overcome the shortage of clinically qualified medical physicists (CQMPs), the
IAEA collaborated with member states and initiated several working agreements
through which the IAEA helps member states to establish academic and clinical
training pathways to train CQMPs. ARASIA (http://web.aec.org.sy) (Arab States in
Asia) is one such agreement initiated in 2002 and is defined as a “Co-operative
Agreement for Arab States in Asia for Research, Development and Training Related
to Nuclear Science and Technology.” Under the ARASIA agreements, projects
(Projects: RAS/6/054, RAS6068, RAS/6/084) were carried out since 2009 whose
objective was to upgrade medical physics services through graduate education,
clinical residency programs, and supporting secondary standard and calibration
laboratories. As an outcome of these projects, graduate medical physics programs
at the University of Jordan (Amman, Jordan) and the residency program in radiation
therapy medical physics at the King Faisal Specialist Hospital and Research Center
(Riyadh, Saudi Arabia) were established (Wadi-Ramahi et al. 2015). More nationally
based projects were also established and geared towards specific requirements of the
MS. In addition, dozens of training courses on various aspects of medical physics
have been conducted since the inception of ARASIA.
Comparison of Need and the Availability
This comparison can be viewed in Table 1, which was collected from two main
sources: the 2018 GLOBOCAN to obtain 2018 population numbers (in thousands)
and new cancer cases (in thousands) in ALC (Ferlay et al. 2018) and the DIRAC
database to obtain the current MVMs and brachytherapy equipment in the ALC
(IAEA 2018b). Statistical calculations were made to obtain optimal MVMs in the
ALC (based on the estimated need by IAEA for each 500 new cancer patients), the
ratio of the available MVMs coverage (ratio of the current to the optimal), and the
ratio of the available MVM per million population.
The IAEA estimates that approximately 50–60% of all cancer patients should
receive radiation therapy and that a country needs one MVM for each 450–500 new
cancer patients. The number of these MVMs in industrialized countries ranges from
8.2 machines in the USA to 5.5 machines in Western Europe per million populations
(IAEA 2008). Unfortunately, as shown in Table 1, instead of having the minimum of
859 MVMs for a total of over 422 million people living in ALC, the total reported
number of MVMs is just 339 MVMs; most (>80%) of these are clinical accelerators,
and the remaining are cobalt-60 teletherapy machines. Brachytherapy facilities are
available at only 60 sites (IAEA 2018b).
Comparing the rate of MVMs per population in industrialized countries (6.85
MVMs per million population, on average in the USA and Western Europe) with that
rate in ALC, it is clear that there is low coverage of machines per population in the
ALC, as the availability is 0.85 machine per million population (range, 0.07 in
Yemen to 2.95 in Lebanon). Another indicator is the variation in the ratios of the
MVMs’ coverage (i.e., the current MVMs to the optimal MVMs based on new
cancer cases in that particular country) in ALC, which ranged from 7.6% in Yemen
to 115.4% in Qatar, with an average of 39.5% in all the ALC.
This table shows that the distribution of MVMs across ALC is not uniform. A
case in point is that 20 million (4/22 ALC and 5% of the total ALC population) have
no MVMs (and the question here whether the non-reporting is a true negative due to
unavailability of the service in these countries or is false negative due to non-
reporting issue, for example, when the country is not considered a state by IAEA,
such as Palestine and Somalia). Also, the table shows that 10/22 countries have less
than 1 MVM per million population and 8/22 countries have 1–3 MVMs per one
million population.
The authors were not able to obtain reliable data on person power of radiotherapy
in ALC. QUARTS proposed 1 radiation oncologist per 200–250 patients treated
annually and 1 physicist per 450–500 patients. QUARTS analysis did not find
significant correlations between economic categorization of a country and personnel
21
Table 1 Radiotherapy facilities in Arab League Countries

New cancer
Population cases Ideal EBRT Current EBRT Ratio of EBRT Ratio of EBRT Current
(thousands, (thousands, machine machines machine machine per million brachytherapy
Arab countries 2018)a 2018)b numbersb (2018)c coveraged population equipment (2018)c
Egypt 99,376 128.9 257.8 119 46.2% 1.2 11
Algeria 42,008 53.1 106.2 38 35.8% 0.90 13
Sudan 41,512 25.7 51.4 8 15.6% 0.2 2
Iraq 39,340 25.3 50.6 18 35.6% 0.46 1f
Morocco 36,192 52.8 105.6 38 36.0% 1.05 7
Radiation Oncology in the Arab World
KSA 33,554 24.5 49 35 71.4% 1.04 8

Yemen 28,915 13.2 26.4 2 7.6% 0.07 0
Syria 18,284 23.2 46.4 7 15.1% 0.38 2
Somalia 15,182 9.9 19.8 No information
Tunisia 11,659 15.9 31.8 22 69.2% 1.89 5
Jordan 9,904 10.9 21.8 14 64.2% 1.41 2f
UAE 9,542 4.7 9.4 5 53.2% 0.52 1
Libya 6,471 6.3 12.6 3 23.8% 0.46 1
Palestine 5,053 4.5 9.0 No information
Lebanon 6,094 17.3 34.6 18 52.0% 2.95 3
Oman 4,830 3.3 6.6 2 30.3% 0.41 1
Kuwait 4,197 3.6 7.2 4 55.6% 0.95 1
4,540 2.7 5.4 1 18.5% 0.22 1
(continued)
473
474
Table 1 (continued)
New cancer
Population cases Ideal EBRT Current EBRT Ratio of EBRT Ratio of EBRT Current
(thousands, (thousands, machine machines machine machine per million brachytherapy
Arab countries 2018)a 2018)b numbersb (2018)c coveraged population equipment (2018)c
Mauritania
Qatar 2,695 1.3 2.6 3 115.4% 1.01 1
Bahrain 1,567 1.0 2.0 2 100% 1.28 0
Djibouti 971 0.7 1.4 No information
Comoros 832 0.5 1 No information
Arab 422,718 429.3 858.6 339 39.5% 0.85e 60
countries
Abbreviations: EBRT external beam radiation therapy, UAE United Arab Emirates, KSA Kingdom Saudi Arabia
a
Extracted from 2018 GLOBOCAN – Global Cancer Observatory: Cancer Today (Ferlay et al. 2018). Sep. 2018. http://gco.iarc.fr/today/fact-sheets-populations
Accessed in Nov. 29th 2018
b
Based on the IAEA recommendation of the need for one machine per 500 new cancer cases
c
Extracted from IAEA DIRAC (DIrectory of Radiotherapy Centres) (IAEA 2018b) https://dirac.iaea.org/Query/Countries, including clinical accelerators and
Co-60 megavoltage machines. Accessed in November 29th 2018
d
Ratio between current EBRT machines to ideal required EBRT machines
e
Excluding the population from Somalia, Palestine, Djibouti, and Comoros; otherwise, if there are no machines at all in these four countries, the total rate will be
0.80 machine per million population
f
Updated number based on the corresponding author’s personal knowledge
L. Mula-Hussain et al.
radiation oncology requirements, possibly because wages are typically aligned with
national prosperity. It did not reflect the cancer incidence and population mix.
Regional Future Perspectives of Radiation Oncology in ALC
Based on IAEA recommendations (one treatment machine for each 500 new cancer
patients), we currently need about 858.6 MVMs to address the optimal needs of new
cancer cases. We currently have 39.5% of this requirement. This shortage of
availability of machines (and likely absence of modern radiation treatment tech-
niques in some of the ALC) leads to suboptimal clinical outcomes of cancer patients
in these countries.
Understanding the current situation is critical for future planning. There are no
reliable regional data in this regard. The situation in Eastern Europe is similar to ALC
in many ways. Eastern Europe includes 22 countries of significant variabilities in
population density and economic development. For accelerators, the average was 1 per
183,000 inhabitants in the high, 1 per 284,000 in the medium, and 1 per 500,000 in the
low-resource countries. This is compared to an average of 1 in 1,330,000
(39,000–2,420,000) inhabitants in HIC, 1 in 1,450,000 (34,000–2,190,000) in
UMIC, and 1 in 3,750,000 (84,000–14,460,000) in LMIC in ALC. These rates are
far below the IAEA recommendations, even for high-income ALC. Moreover, ALC
do not have available accurate statistical reports for the radiation oncology personnel
(ROs, MPs, RTTs, etc.). For Eastern Europe the number of ROs varied between 1 per
150–400 patient (average of 250), and there was no clear difference among high-,
medium-, and low-resource countries. For MPs, the average was 1 per 530 patients for
high- and 1 per 610 for medium- or low-resource countries (Esiashvili 2017).
Expecting that the annual need for radiotherapy is estimated as 62.5%–64% of the
number of newly diagnosed cancer patients (Slotman et al. 2005; Delaney et al.
2005; Ringborg et al. 2003) and adopting the QUARTS criteria of maximum 450
radiotherapy courses per machine annually (Slotman et al. 2005) and based on 2018
GLOBOCAN (latest published incidence data) (Ferlay et al. 2018), the number of
radiotherapy patients served by each available MVM in each ALC country is
insufficient in 6 out of the 22 countries (27.3%). The six countries fulfilling the
QUARTS criteria are four HIC (Bahrain, Kuwait, Qatar, and Saudi Arabia), one
UMIC (Lebanon), and one LMIC (Jordon). The HIC have an average of 321.7
patients per available MVM, the UMIC have an average of 927.9 patients per MVM,
and the LMIC have a mean of 1,288.0 patients per MVM.
The need to fill the gap of knowledge and experience in radiation oncology team
members is critical. In countries where radiation therapy is practiced, the breadth and
depth of expertise of CQMPs have large variations. Whereas some countries have
enough CQMPs who provide adequate high-quality service in radiation oncology,
others have none and depend on self-taught physicists. The absence of local guide-
lines from appropriate authorities is not limited to the qualifications of professionals
but also in the minimum quality assurance tests required in radiation oncology. This
latter issue results in variability of MP services rendered in the same country.
Hospitals, mostly large private ones, whose administration is well versed in the
intricacies of radiation oncology, tend to hire CQMPs and enforce the required
standards. In contrast, public/government hospitals or small private hospitals will
overlook quality assurance requirements, resulting in challenges to establish
advanced radiation oncology services in ALC (Wadi-Ramahi et al. 2017).
According to the IAEA Human Health Series Report No 25 (IAEA Human
Health Series 2013): “In order to become a clinically qualified medical physicist,
the academic training at the postgraduate level must be followed by at least two
additional years of structured practical training in a clinical environment.” A large
number of clinical medical physicists (MPs) in ALC do not fulfill this definition. In
many countries, clinical physicists are hired with a BSc degree and then obtain on-
the-job clinical experience. There are examples of some physicists undergoing
graduate education in medical physics followed by a structured residency program,
but those are very few. Fewer still are the number of physicists who hold board
certification, The American Board of Radiology, ABR, www.theABR.org and the
International Medical Physics, Certification Board, IMPCB, www.impcbdb.org, or
equivalent. Report No 25 also mentions that “the competence of medical physicists
should be assessed by an appropriate authority, which results in a formal mecha-
nisms of their registration and/or accreditation of certification.” This condition is
absent from a large majority of the countries in which clinical physicists are hired
fresh out of college. In situations where there is an assessment of competence, it is
usually limited to radiation safety issues.
The need to network and share knowledge among ALC professionals, locals and
worldwide, has led to an annual competition-based learning tool on treatment planning
(Nobah et al. 2017). The idea started as an intraregional (four countries) competition to
compare planning techniques and expanded into an international competition. The
level of knowledge transfer, through webinars and discussion groups, was large that
the initial organizers of the competition incorporated the effort (https://radiation
knowledge.org) on an official website, YouTube channel, and an active social medical
discussion group. This enabled easy and rapid transfer of knowledge, clinical solu-
tions, treatment planning ideas, and solutions to quality assurance problems that can all
occur within minutes of posting the question. The current trend is expected to expand,
connecting not just the medical physicists from one region together but professionals
across the globe. In parallel to the increased proficiency of MPs and the need to obtain
certification, it is expected that national regulations will also improve and set higher
standards for the professional practice of radiation oncology.
We need to define our services based on our circumstances. The National
Comprehensive Cancer Network (NCCN) Framework for Resource Stratification
of Guidelines used a classification system that is intended to guide clinicians to
deliver the highest achievable level of cancer care based on the means available
(Anderson et al. 2008). Within this framework, four levels of resources were defined:
1. BASIC: Core services needed to provide the most fundamental of services,

2. LIMITED: Resources intended to produce major improvements and outcomes
such as increased survival but are still within limited financial means and mod-
erate infrastructure.
3. ENHANCED: Services that are optional but should provide further improve-
ments in outcomes and increase the number and quality of therapeutic options.
4. MAXIMAL: Resources applied in a modern healthcare practice in countries or
settings with high-level resources.
Awareness of the need to improve the current situation in ALC has increased
recently, though still sufficient to satisfy the needs of ALC cancer patients. Attempts
to implement advanced radiation oncology technologies have been made. New
technologies such as CyberKnife, Gamma Knife, tomotherapy, magnetic resonance
simulation, and proton beam therapy have been installed in some of ALC. Collab-
oration with international organizations (IAEA, ESTRO, ASTRO) and European
and North American universities to transfer advanced knowledge and experience to
different ALC oncology centers is an ongoing process with many success stories.
Conclusions
The gap between the needed and actual workforce in radiation oncology services is
quite large. More than 400 million people in the ALC need about 859 MVMs but are
served only by 339 MVMs (39.5%). Four countries (a total of 5%, Comoros,
Djibouti, Somalia, and Palestine) do not have any reported radiation oncology
facilities. Countries with radiation oncology facilities have less than one MVM
(0.85) on average per one million population and just six countries with an average
of 1–3 MVMs per million population. This is to be compared to many industrialized
countries, having 6.85 MVM per million population.
To eliminate or even to decrease this gap, significant effort in terms of time,
financial, and educational resources is needed. Furthermore, the question of quality
and safety in radiotherapy needs to be urgently addressed. Some important needs
include the lack of uniform ALC training programs for ROs, MPs, and RTTs. The
training programs in some ALC countries need to be standardized to decrease the
variability of expertise in these fields in the ALC and ultimately improve cancer care
and outcomes.
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Cancer in War-Torn Countries: Iraq as an
Example 22
Layth Mula-Hussain, Hayder Alabedi, Fawaz Al-Alloosh, and
Anmar Alharganee
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 482
Cancer Trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 484
National Registry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 484
International Estimate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 485
Unique Trends of Blood, Nervous, and Thyroid Malignancies . . . . . . . . . . . . . . . . . . . . . . . . . . . . 487
Crude Incidence Rates over a Quarter of a Century . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 488
Females Versus Males . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 489
Cancer Stage at Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 489
In Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 489
Cancer Care Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 490
Care Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 490
Man Power, Including Oncologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 490
Cancer Treatment Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 491
Clinical and Laboratory Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 491
Legislative Framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 492
In Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 492
Conclusions and Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 493
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 493
L. Mula-Hussain (*)
Department of Radiation Oncology, Cross Cancer Institute – University of Alberta, Edmonton,
AB, Canada
e-mail: LMulaHussain@AOL.com
H. Alabedi · F. Al-Alloosh
Iraqi Cancer Board – Ministry of Health, Baghdad, Iraq
e-mail: hydr_hamza@yahoo.com; fawazaloosh@yahoo.com
A. Alharganee
Oncology Hospital – Baghdad Medical City Complex, Baghdad, Iraq
e-mail: dr_harganee@yahoo.com

https://doi.org/10.1007/978-3-030-36811-1_152
Abstract
Iraq is a multiethnic, developing country in the Middle East. Iraq is home to one
of the oldest civilizations known to mankind and has an estimated population of
over 39 million people living in 18 governorates. This historically prosperous
land, with a rich ancient heritage, has seen all its health systems, including its
cancer care services system, decimated by wars, sanctions, and embargo that has
continued since August 1990. Cancer trends and care in Iraq have transformed as
a result. With reduced services, cancers are discovered in more advanced stages,
reducing curability, and patient suffering has increased. This chapter discusses the
current status of cancer in Iraq, its trends, and the available care services. The
challenging life circumstances that Iraqis continue to face has increased suffering
in the Iraqi people.
Keywords
Cancer · Iraq · War
Introduction
Cancer is characterized by uncontrolled cellular growth, with the ability to spread to

different distant tissues in the body. There were an estimated 18.1 million new cancer
cases and 9.6 million cancer deaths in the world in 2018. Lung cancer is the most
frequent cancer and the leading cause of cancer death in males, followed by prostate
and colorectal cancer (for incidence) and liver and stomach cancer (for mortality).
Breast cancer is the most commonly diagnosed cancer and the leading cause of
cancer death in females, followed by colorectal and lung cancer (for incidence), and
vice versa (for mortality); cervical cancer ranks fourth for both incidence and
mortality (Bray et al. 2018).
In general, many of cancers are treatable to a great extent. Some are highly
curable, but at the same time, others are more difficult to treat due to factors related
to the biology of the disease itself, the stage at diagnosis, patient health history, and
available treatment facilities (Mula-Hussain et al. 2018). The life expectancy at birth
in Iraqi males is 68.3 year, while in females it is 72.3 year (Ministry of Health/
Environment 2018).
Like many other nations that started to modernize in the last century, Iraq became
independent after World War One, when the political leaders in Iraq started to
establish a modern government with the goal of improving the conditions of daily
life, including in the health and education sectors. The first ministry of health (MOH)
and the first medical school were established in 1920s in the capital city of Baghdad.
The development in all life aspects improved continually after that.
Cancer care includes all the diagnostic and treatment measures to manage cancer
as a disease. Baghdad was one of the few cities in the Arab nations that was
considered to be a pioneer in cancer treatment, mostly by surgery and radiotherapy
before the era of chemotherapy. Besides the traditional surgical procedures to
22 Cancer in War-Torn Countries: Iraq as an Example 483
manage solid cancers in the last century, the superficial X-ray treatment machine was
launched at the Radiology Institute in Baghdad in the 1920s to further assist in
cancer treatment (Al-Ghazi 2016). Many of the patients from neighboring countries
used to travel to Baghdad in the 1950s to 1980s seeking better healthcare. The same
was also true for the students, who were spent many years away from their families
to receive medical education in Iraq (Al Hilfi et al. 2013).
Prior to Iraqi invasion of Kuwait in August 1990, there was already a global move
against Iraq in the form of sanctions, embargoes and wars. Not only was man power
and healthcare negatively affected, but so were diseases trends, including cancer.
Cancer incidence was increasing in Iraq, likely due to a combination of war
pollutants such as depleted uranium, deteriorating medical awareness, lowered
socioeconomic status, and by denial of, or cultural misperceptions of, cancer. The
increase in reported cancer cases can be also due to improvements in the cancer
registration system to some extent. Between 50% and 80% of cancers in Iraq are
detected at advanced stages of the disease and are thus incurable even if the best
therapies were to be offered. However, patients with potentially curable cancers can
only receive drugs locally available at the time of their treatment in Iraq (Deli and
Ibrahim 2005; Busby et al. 2010).
Multiple choices of cytotoxic drugs, each composed of one to five drugs, for
example, would be available under ideal circumstances. The oncologist would
normally begin treatment with the first-line therapy before moving to the second
and third lines as necessary. However, in Iraq, due to shortages of many drugs during
the years of embargo, physicians used to give what was available, rather than what
was the ideal choice. This will produce less than optimal therapeutic outcomes.
Karol Sikora, the chief at the World Health Organization’s cancer program, observed
after a visit to Iraq in 1999:
It was immediately clear that there were staggering deficiencies in cancer treatment facilities
because of the United Nations sanctions, which are intended to exclude food and medicines.
A cancer center without a single analgesic; a radiotherapy unit where each patient needs one
hour under the machine because the radiation source is so old; and children dying of curable
cancers because drugs run out are all accepted as normal. . .. Somehow cancer care has
become a Cinderella service. Requested radiotherapy equipment, chemotherapy drugs, and
analgesics are consistently blocked by United States and British advisers. There seems to be
a rather ludicrous notion that such agents could be converted into chemical or other
weapons. . .. Whatever the political legitimacy of the embargo, the needless suffering of
those with cancer is an unacceptable outcome. (Sikora 1999)
Volatile security conditions in most parts of Iraq led to a number of deleterious

consequences for the country’s health sector after the 2003 invasion. These included
the rapid outflow of remaining Iraqi scientists and medical experts, slow progress in
the rehabilitation of the health sector, and reallocation of government financial
resources from civil and developmental sectors (such as the health sector) to the
security sector. In spite of all these challenges, there has been a gradual improvement
in cancer care services and postgraduate oncology training and education in the
country.
This chapter explores cancer trends over recent decades and the current healthcare
cancer facilities available in Iraq.
Cancer Trends
Cancer differs in severity, morbidity, mortality, and incidence; these vary according
to geographical regions and can change with time (Stewart and Wild 2014). In Iraq, a
war-torn, Arab, multiethnic, country, cancer and its trends have unique behaviors as
recent data demonstrates (Mula-Hussain 2015). Cancer is the third leading cause of
mortality in Iraq in 2017 with 9.28% (cerebrovascular diseases, 10.38%, and ische-
mic heart diseases, 9.34%) (Ministry of Health/Environment 2018) and is the
seventh leading cause of morbidity in this country (Al-Mosawi 2012).
National Registry
The Iraqi Cancer Registry Center (ICRC) was established in 1974 in Baghdad
(initially launched by the Iraqi Cancer Society and later under the direction of the
Iraqi Cancer Board at the Ministry of Health). The ICRC provides a nationwide
registry of new cancer cases that has been published in over 20 editions so far, either
combined in consecutive years (1976–1985, 1986–1988, 1989–1991, 1992–1994,
1995–1997, 1998–1999) or separately on an annual basis (2000–onward). The ICRC
is responsible for collecting information relating to every new cancer patient who is
registered with governmental and nongovernmental health institutions [hospitals &
pathological laboratories] in all Iraqi provinces (Mula-Hussain 2012).
The most recent ICRC report is for 2016. In that year, the Iraqi population
was estimated to be of 37,883,543, and the reported new cancer cases were 25,556
(Table 1) with a male-to-female ratio 0.7:1, while the total number of the reported
Table 1 Top ten cancers in Iraq in 2016 (Iraqi Cancer Registry Center 2018)
Cancer No. Percent of total (%)
1. Breast 4,996 19.55
2. Bronchus and lung 2,123 8.31
3. Leukemia 1,657 6.48
4. Colorectal 1,505 5.89
5. Urinary bladder 1,419 5.55
6. Brain and other CNS 1,281 5.01
7. Non-Hodgkin’s lymphomas 1,196 4.68
8. Thyroid gland 1,123 4.39
9. Skin 929 3.64
10. Prostate 791 3.10
Other cancers 8,536 33.40
Total 25,556 100.00
cancer deaths was 7,568 with an almost equal male-to-female ratio. Crude incidence
average was 67.4/100,000 population, although it should be noted that there was a
large variation between the Iraqi governorates, likely because about one third of Iraq
was under ISIS occupation, resulting in large movements of people to different parts
of the country. There is no information on the presenting stage at the time of
diagnosis (Iraqi Cancer Registry Center 2018).
The question here is: Whether these reported cancer incidence and deaths in Iraq
are highly accurate or not? The answer probably is not, as the ICRC is mainly of
hospital-/pathology-based data, some cancer patients are missed from the registry
because they seek care outside the recognized oncology hospitals, or travel abroad.
In addition, some cancer patients died before diagnosis or are financially poor
enough that they were not able to reach the oncology hospital in the city, being a
neglected child by his/her parents in the village. Some of them stay home without
any active treatment altogether. All these postulations will reduce the accuracy of the
ICRC reported incidence of cancer in Iraq. Of note to mention here that Prof. Abdul-
Hadi Al-Khalil “Vice Chairman of the ICB 1999–2005” mentioned in his report that
the percentage of coverage of cancer reporting in Iraq is estimated to be between
70% and 80% (Al-Khalili and Abdul-Hadi 2004; Mula-Hussain 2012).
International Estimate
Based on the latest international estimates by GLOBOCAN 2018 [which was

released in Geneva on September 12, 2018 by the International Agency for Research
on Cancer (IACR)], the Iraqi population is estimated to be 39,339,754. The number
of new cancer cases is estimated to be 25,320, while the number of deaths due to
cancer is estimated to be 14,524, and the number of existing cases (during a 5-year
period) is estimated to be 54,809. The age standardized incidence rate was 105.5 and
the age standardized mortality rate was 64.7. The risk of developing cancer before
the age of 75 years is 11.17%, and risk of dying from cancer before the age of
75 years is 7.07%. The top five cancers in Iraqi males were cancers of the lung
(13.9%), urinary bladder (9.7%), blood (leukemia, 8%), colorectal (6.8%), central
nervous system (CNS, 6.5%), and others (55.1%). The top five cancers in Iraqi
females were cancers of the breast (36.7%), blood (leukemia, 5.5%), colorectal
(4.5%), CNS (4.3%), and others (45.1%) (Ferlay et al. 2018).
Table 2 shows the estimated prevalence of the leading five cancers in males and
females in Iraq and compares this with three neighboring developing countries
(Jordan, Kuwait, and Iran) and three non-neighboring developed countries (Japan,
Germany, and the United States); this data is taken from the 2018 GLOBOCAN
Report (Ferlay et al. 2018). The age-standardized incidence rate, age-standardized
mortality rate, risk of developing cancer before the age of 75 years, and risk of dying
from cancer before the age of 75 years are lower in Iraq. Moreover, Iraq is unique in
having CNS and blood cancers among its top five cancers in males and females, as
the other countries do not exhibit such trend (apart from leukemia in Jordanian and
Kuwaiti males and in Jordanian and Iranian females).
486
Table 2 Basic cancer statistics with the top five cancers in Iraqi males and females, compared to the statistics in six other countries (Ferlay et al. 2018)
Measures Iraq Jordan Kuwait Iran United States Germany Japan
Population 39,339,754 9,903,798 4,197,125 82,01,737 326,766,750 82,293,462 127,185,329
New cases 25,320 10,898 3,582 110,115 2,129,118 608,742 883,395
Deaths 14,524 5,813 1,658 55,785 616,714 247,462 409,399
5Y Prev. 54,809 25,497 10,032 248,392 7,279,710 1,943,860 2,127,559
ASIR 105.5 157.8 121.8 141.6 352.2 313.1 248.0
ASMR 64.7 89.7 68.3 74.5 91.0 104.2 85.2
RDCB75Y 11.17% 16.16% 12.91% 14.14% 33.3% 30.23% 24.61%
RDCB75Y 7.07% 9.41% 7.15% 7.3% 9.64% 10.98% 8.46%
T5 males Lung Lung Prostate Stomach Prostate Prostate CRC
Bladder Bladder CRC Prostate Lung Lung Lung
Leukemia CRC NHL CRC CRC CRC Stomach
CRC Prostate Lung Bladder Bladder Bladder Prostate
CNS Leukemia Leukemia Lung CMM CMM Bladder
T5 females Breast Breast Breast Breast Breast Breast Breast
Leukemia CRC Thyroid CRC Lung Lung CRC
CRC Thyroid CRC Stomach CRC CRC Lung
CNS Corpus Ut Corpus Ut Thyroid Corpus Ut CMM Stomach
Lung Leukemia NHL Leukemia Thyroid Corpus Ut Pancreas
Abbreviation: 5Y Prev., number of prevalent cases for 5 years; ASIR, age-standardized incidence rate (world); ASMR, age-standardized mortality rate (world);
RDCB75Y, risk of developing cancer before the age of 75 years (%); RDCB75Y, risk of dying from cancer before the age of 75 years (%); T5, top five cancers in
males and in females; CNS, central nervous system; CRC, colorectal cancers; CMM, cutaneous malignant melanoma; HL, Hodgkin’s lymphoma; NHL, non-
Hodgkin’s lymphoma; Ut, Uteri
L. Mula-Hussain et al.
Unique Trends of Blood, Nervous, and Thyroid Malignancies
Comparing data from a series of ICRC reports preceding the latest war in 2003 with
the period after the war, blood (leukemia), CNS, and thyroid cancer trends changed.
For example, CNS cancers ranked eighth in 1998, fourth in 2004, then fifth in 2010,
while leukemia ranked fifth in 1998, second in 2004, then third in 2010 (Mula-
Hussain 2015). Of note, both of these cancers are included in the top five leading
cancers in Iraqi males and females in the 2018 GLOBOCAN Report and are likely a
unique feature in Iraq in comparison with many other countries as described in
Table 1. In addition is the increase of thyroid cancers over the last 10 years (Fig. 1),
making thyroid cancer one of the top ten cancers in Iraq in 2014, which continues as
the eighth leading cause of cancer in Iraq in 2016 and the second leading cause of
cancer in females, after breast cancer.
The relative rise in these cancers can be attributed to the environmental hazards
associated with warfare. There is a general agreement that exposure to ionizing
radiation leads to the development of cancer and/or leukemia. Citing a series of
studies on nuclear workers in the United States between 1950 and the 1990s, the
Center for Environmental Health Studies reported a significant association between
exposure to ionizing radiation and the incidence of brain cancer deaths and nervous
system tumors. Another paper by the Center reports a strong association between
exposure to ionizing radiation in US nuclear workers and deaths from leukemia.
According to the World Health Organization, “retention of any radioactive material
in the body will have associated an increase in the probability of cancer,” though the
increase is small and depends on the radiation dose.
In the Gulf Wars, the United States and the United Kingdom made extensive use
of depleted uranium weapons, which are weakly radioactive. Busby C et al.
Incidence of thyroid cancer

3.5
2.5
1.5
0.5
0
2008 2009 2010 2011 2012 2013 2014 2015 2016
Fig. 1 Incidence of thyroid cancer in Iraq, in 2008 through 2016 (Iraqi Cancer Registry Center 2018)
mentioned about Fallujah city (little is known about the types of weapons deployed,
but reports began to emerge after 2005 of a sudden increase in cancer and leukemia
rates), and Hagopian A et al. mentioned about Basra city (it is known that the Basra
region was exposed to environmental insults including chemical weapons agents,
pyrophoric depleted uranium, and the known leukemogen benzene, as well as
ongoing undifferentiated water and air pollution) (Busby et al. 2010; Hagopian
et al. 2010). A recent systematic review strongly supports a widespread and persis-
tent increase in global thyroid cancer incidence (as shown Table 1 in a comparison of
some of countries). Clearly more research is needed on the causal relationship
between use of depleted uranium weapons in the Gulf Wars and increased risk of
cancer in Iraqi civilians (Mula-Hussain 2019; Wiltshire et al. 2016).
Crude Incidence Rates over a Quarter of a Century
If we compare the latest crude incidence mean in 2016 (67.4/100,000 population)

with that in 2006 (52.8/100,000 population) (Fig. 2) and these with the crude
incidence mean in 1992 (44.99/100,000 population), we see a large increase in the
reported incidence of cancers in Iraq. This leads to some key questions: Why is there
such a wide range of incidence rates during a quarter a century (the period from
Fig. 2 The crude incidence rate of cancers in Iraq, between 2006 and 2016 (Iraqi Cancer Registry
Center 2018)
1992 through 2016)? What are the possible explanations for these differences? Is
there a real increase in the incidence of cancer in Iraq or is it a reflection of an
improved cancer registry and from early detection (Mula-Hussain 2012)?
Females Versus Males
Cancer in females was less frequent than males in Iraq in 1976 (38.93% vs. 61.07%),
then the gap narrowed in 1991 (45.37% vs. 54.63%). With this gradual increase,
cancer rates were similar in males and females in 2000. The trends reversed recently
when cancer rates in females surpassing those in males (53.77% vs. 46.23%) (Iraqi
Cancer Registry Center 2012) and a recent 2016 report indicates a rate of 56.2% in
females versus 43.8% in males (Iraqi Cancer Registry Center 2018).
Cancer Stage at Diagnosis
The ICRC has not reported the cancer stage at diagnosis in its published registry. As
reported by Nada Alwan in her study, only about 8% of breast cancer patients in
Baghdad are diagnosed with stage I disease, whereas 92% present with stage II–IV
“including 47% of them with stage III–IV” (Alwan 2010). These numbers are nearly
the same in Kurdistan, Northern Iraq, as reported by Runak Majid (stage I breast
cancer patients constitute about 4.1% whereas stage II–IV about 77.6%, and there
were 18.2% with unknown stage) (Majid et al. 2009). These data are similar to
findings in other developing countries, “or even worse,” as other countries have early
diagnosis, such as in Bahrain and Iran, where the corresponding numbers are about
33% and 25%, respectively. When we compare this group with a similar group in
some of the developed countries such as the United States, the situation appears to be
much better, where early breast cancer is diagnosed in 60% of the patients, regional
stage (with regional nodes’ involvement) in 33%, distant stage (with secondary
metastasis) in 5%, and unknown stage in 2% (Mula-Hussain 2012).
In Summary
Cancer trends in Iraq have a high incidence of central nervous system and blood
cancers as compared with trends in other nations. There is a relative increase in
cancer rates in females. Recent increases in thyroid cancer incidence. To reach sound
conclusions about the extent and determinants of cancer trends in Iraq, a multi-
spectrum, analytic effort is needed. Greater vigilance about cancer patterns in Iraq is
needed at the levels of local and international authorities – this will help to better
understand these trends and assist in providing better management strategies. There
is a great need for population-based and comprehensive cancer registry program to
further improve documentation of the stages of cancer at diagnosis and also to
provide data on disease-free and overall survival.
Cancer Care Services
The cancer care services were effective and functional in the 1970s and 1980s and
were even described by some as “the golden era of oncology in Iraq.” These were
severely impacted by the wars that started in the 1990s and then by the related
embargoes and sanctions through the 2010s. There now appears to be relative
improvements in the care services and in human expertise in oncology.
Care Facilities
There are currently chemotherapy and some radiotherapy services in a few of the
major Iraqi cities –these are in Baghdad, Basra, Sulaimania, Misan, Babil, Najaf, and
Erbil. Bagdad has 16 functioning megavoltage machines with 1 gamma knife
machine, while there is 1 brachytherapy machine in Sulaimania. Most of the
treatment plans are accomplished with basic 2D/3D imaging and some with
advanced techniques like intensity-modulated radiation therapy (IMRT). These
radiotherapy machines constitute just 35.6% of the need for functioning machines
under ideal circumstances. There are bone marrow transplant services for non-
complicated cases in Baghdad and Sulaimania. There is extremely limited access
to nuclear diagnostic medicines and treatment facilities. PET/CT is available in
private sectors in Erbil, Baghdad and Najaf; besides plans are underway to make it
available in public sector in four Iraqi cities as well. Recognized surgical oncology
services are not well established and with just few palliative care initiatives. There is
no comprehensive academic cancer center in Iraq, a type of medical facility known
to improve cancer care outcomes, in addition to advancing knowledge and training
of local health professionals. Most of these cancer services are funded by the MOH,
with some of that are privately (for profit) funded. Iraq does not have any non-
governmental not-for-profit well-organized cancer services (Mula-Hussain 2019).
Man Power, Including Oncologists
The annual statistical report of the MOH in 2017 indicated that the number of all
physicians in Iraq is 31,451 and the specialist physicians is 11,585. Of those, 52 were
medical oncologists and 76 were clinical or radiation oncologists (i.e., total of 128
for a total of 37,139,519 population, with an average of 1 cancer physician per
290,000 population) (Ministry of Health/Environment 2018). This represents a
severe shortage of cancer physicians in the total number of physicians in Iraq.
Comparing this rate (3–4 per million population) in Iraq with the international
recommendations on consultant staffing of 8–12 cancer physicians per million
population (Expert Working Group on Radiation Oncology Services 2003), it
becomes immediately evident that Iraq has significant challenges to face as about
350 (30) more cancer physicians are needed in the country now and this demand
will be increased in the coming years. Obviously, the gap is not limited to the
physicians only but also including other health personnel in relation to cancer care,
like medical physicists, oncology nurses, nutritionists and dietitians, oncology
psychotherapists, etc.
Cancer Treatment Outcomes
With the shortage in many of the services and man power requirements for cancer care
in Iraq, it is not surprising to find poorer treatment outcomes of the cancer patients in
this war-torn nation when compared with other developed nations with advanced
services and stable man power. Using the 2018 GLOBOCAN tools, one can better
appreciate the high mortality to incidence ratio in Iraq as compared to six other Middle
Eastern developing countries and three Western developed countries (Fig. 3).
Clinical and Laboratory Research
Clinical (bedside, interventional/clinical trial based) cancer research is minimal in

Iraq. In general, there are descriptive/retrospective (chart review/case reports) clin-
ical cancer studies from different facilities in Iraq and mostly published in local
medical journals, which are available mainly in print copies (not online), programs
such as the High Diploma, MSc, PhD, Arab Board, and Iraqi Board and Kurdistan
Board theses, in addition to other research non-graduation projects which are usually
Mortality to Incidence ratio ( comparison)
Iraq
Jordan
Kuwait
Turkey
Iran
Lebanon
Saudi Arabia
UK
Canada
USA
0.00 0.10 0.20 0.30 0.40 0.50 0.60 0.70
Fig. 3 Mortality to incidence ratio in Iraq compared to six developing neighboring countries and
three non-neighboring developed countries (Ferlay et al. 2018)
registered with MOH or Higher Education research committees. Laboratory (bench

research) cancer research is limited by host and fund availability, with the main host
being the Iraqi Center for Cancer and Medical Genetic Research in Baghdad, in
addition to some other academic university-based research centers in the country
(Mula-Hussain 2012).
Legislative Framework
Government regulation No. 15 was issued in 2002 by the Ministry of Health in

Baghdad. It was to establish the first comprehensive cancer center in Baghdad. This
center was to provide medical, research, and training services in this field and to keep
abreast of scientific developments that occur inside and outside Iraq. It was to be
composed of departments of surgical oncology, diagnostic oncology, nuclear med-
icine (with a cyclotron for producing radioactive materials), radiation oncology,
medical adult and pediatric oncology, clinical pathology and bone marrow trans-
plant, tumor pathology, tumor biology, rehabilitation medicine, and medical statis-
tics and oncological epidemiology and a focus on early detection, health education,
and cancer prevention and a department for “anesthesia, pain treatment and palliative
care.” Unfortunately, with the invasion and occupation in 2003, this project came to
an abrupt halt (Mula-Hussain 2012).
In Summary
Cancer care services in Iraq have been affected negatively in the last three decades
due to wars, embargoes, sanctions, occupation, mismanagement of budget, and
rampant insecurity. Accordingly, the current condition of the Iraqi healthcare system
is below international standards. Of note is that Iraq has:
• Suboptimal human resources, training programs, and service facilities in cancer

care (including radiotherapy, chemotherapy, cancer surgery, palliative care, bone
marrow transplant, and nuclear medicine, among other forms of cancer care), with
slow achievement of the required improvements for cancer care in Iraq
• Suboptimal cancer research in Iraq, possibly related to inadequate funding, lack
of capacity to host scientists (local and international), lack of time, and difficult
personal circumstances of potentially interested students and faculty
• An absence of unified national cancer care guidelines and comprehensive aca-
demic cancer centers
• Suboptimal governmental financial resources for the health sector in general, in
addition to the absence or inadequacy of the nongovernmental sector (for profit or
not-for-profit) related to cancer care in Iraq
• Suboptimal cancer public prevention education programs (including early detec-
tion and awareness campaigns) and psychosocial and financial support programs
available to cancer patients and families
Conclusions and Recommendations
Cancer trends and care services in Iraq have been affected during the past three decades,
although a close examination of cancer trends in different Iraqi governorates reveals a
more complex picture. To reach sound conclusions on the extent and determinants of
cancer trends in Iraq, immense multi-spectrum, analytic efforts are needed. Both
national and international efforts should pay more attention to these concerns.
Yet, in spite of the difficult challenges the Iraqi people face in recent decades,
there has been partial improvements in the health sector in general and in cancer
services field during the last 10 years (2009 onward). In order to truly reach the
needed standards of medical care, one can suggest the following improvements:
• Policymakers in Iraq should formulate a set of priorities in decision-making for

developing a comprehensive cancer control program at the national level, with a
feasible timeline. An annual conference and an external audit of the plans and
achievements will be helpful in planning and implementation.
• A comprehensive academic cancer center staffed by scientist-clinicians in various
cancer care specialties is urgently needed. The center would lead nationally
coordinated, support collaborative interactions in research and management, be
priority-driven, and have the ability to better understand cancer trends and risk
factors in Iraq.
• More investment by the MOH and the Ministry of Higher Education and Scien-
tific Research is needed to build competent and highly qualified human resources
in all specialties of cancer care through sponsored governmental scholarships
abroad and as important, devising suitable incentives and support systems to
encourage expatriate Iraqi scientists to return to serve in Iraq.
• A sustained commitment at the highest levels of central and local governments is
required for cancer care improvement. Such a commitment could enable the
passage of the first cancer control law in Iraq. The passage of the National Cancer
Act of 1971 in the United States led to many improvements in this regard. That
Act mandated federal budgetary allocations specifically for cancer prevention,
treatment, and research and for the acquisition of all necessary chemical com-
pounds and other materials necessary for cancer research. This Act precipitated
dramatic improvements in cancer outcomes in the decades following its passage.
• Nongovernmental, not-for-profit activities and projects to support cancer preven-
tion and care in this war-torn country that is delivered by public groups and
organizations should be coordinated and supported by the authorities.
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Burden of Cancer in the Arab World
23
Ammar Ahmed Siddiqui, Junaid Amin, Freah Alshammary,
Eman Afroze, Sameer Shaikh, Hassaan Anwer Rathore, and
Rabia Khan
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 497
Global Cancers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 498
Global Patterns for Cancers According to Human Evolution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 498
A. A. Siddiqui (*)
e-mail: ammarqta2002@hotmail.com
J. Amin
Department of Physiotherapy, College of Applied Medical Sciences, University of Ha’il, Ha’il,
Saudi Arabia
e-mail: junaid768@hotmail.com
F. Alshammary
e-mail: dr_freah@yahoo.com
E. Afroze
Private Dental Practice, Islamabad, Pakistan
e-mail: eafroze567@gmail.com
S. Shaikh
Divisions of Oral Diagnosis and Oral Medicine, Department of OMFS and Diagnostic Sciences,
e-mail: smrshaikh@gmail.com
H. A. Rathore
College of Pharmacy, University of Ha’il, Ha’il, Saudi Arabia
e-mail: Ha.Rathore@uoh.edu.sa; hassaan@usm.my
R. Khan
Department of Bio Engineering, Lancaster University, Lancaster, UK
e-mail: r.s.khan@lancaster.ac.uk

https://doi.org/10.1007/978-3-030-36811-1_182
496 A. A. Siddiqui et al.
An Overview of Cancer in the Eastern Mediterranean Region (EMR) and Arab World . . . . . . 499
Regional Age and Sex Variation in Cancer Burden . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 499
Distribution of Cancer According to Income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 499
Key Findings of Cancers in the Eastern Mediterranean Region (EMR) . . . . . . . . . . . . . . . . . . . 500
Leading Cancers in the Eastern Mediterranean Region (EMR) and Arab World . . . . . . . . . . . . . 500
Lung Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 500
Breast Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 504
Prostate Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 505
Colorectal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 506
Incidence and Mortality Rate of Colorectal Cancer in EMR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 506
Colorectal Cancer in the GCC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 507
Cancer Registries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 508
Some Important Steps Undertaken for Registering of Cancers in GCC . . . . . . . . . . . . . . . . . . . 508
Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 511
Benefits and Barriers of Early Cancer Detection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 511
Delayed Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 512
Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 512
Cancer Screening Programs in the EMR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 512
Obesity, Tobacco, and Smoking as Risk Factors of Cancer in the EMR . . . . . . . . . . . . . . . . . . . 514
Recommendations for Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 514
The Need for Action to Implement Effective Cancer Control Programs in the EMR . . . . . . . . . 516
Barriers and Deficiencies for Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 516
Palliative Care and Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 516
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 517
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 517
Abstract
Cancer is a major health burden globally, and the burden of cancer will be
aggrandized mostly by an increasing elderly population as the world population
expands due to greater engagement in cancer-causing habits such as various
forms of smoking and alcoholism. These habits poise cancer to become a leading
cause of morbidity and mortality in almost every region of the globe.
The Arab world is a region of 22 Arabic speaking countries with a popu-
lation of 620 million and straddles the continents of Asia and Africa. This
chapter reviews the incidence, patterns, economic, and health burden of vari-
ous types of cancers in the Arab world. Cancer registries in the Arab region are
excellent resource of various aspects of cancer. In this chapter, a substantial
amount of authentic population-based data on cancer in the Arab world is
narrated.
Progress and achievements in screening, prevention, and management can
reduce cancer incidence and/or mortality rates within the Arab world. This can be
achieved through better coordination of the research and healthcare communities
and such collaborative efforts within the Arab world could bring significant
improvements in cancer control and prevention in the region.
Keywords
Cancer control · Cancer prevention · Epidemiology · Eastern Mediterranean
Region · Arab world
23 Burden of Cancer in the Arab World 497
Introduction
The majority of deaths in the world are from noncommunicable diseases (NCDs),
which include deaths from various types of cancers (Ilbawi and Velazquez-Berumen
2018). The most important threat associated with cancer is that its incidence and
mortality are rapidly rising worldwide. According to the World Health Organization
(WHO), the burden of cancer is estimated to have risen to 18.1 million cases, with
9.6 million deaths in 2018. Approximately every 1 out of 5 men and 1 out of 6
women develop cancer in their lifetimes, and 1 out of 8 men and 1 out of 11 women
die because of it (World Health Organization 2018a, b). Cancer has become the
leading cause of death in those aged less than 70 years in almost 91 countries (Fig. 1)
(Bray et al. 2018).
There can be many probable reasons for the rapid increase of cancer prevalence
around the world. However, these reasons can be attributed to aging and rapid
increase in world population as well as ever increasing range of cancer-causing
risk factors; some of which are dependent on socioeconomic development (Gersten
and Wilmoth 2002). This impact and burden of cancer on socioeconomic growth
cannot be neglected in emerging economies such as those in the Arab world which
are disproportionately affected by cancer where many people are diagnosed with
cancer, leading to a loss of economic development (Maule and Merletti 2012).
According to the WHO, the Eastern Mediterranean Region (EMR) consists of 22
countries located in North Africa and the Middle East, with an approximate popu-
lation of 620 million people in low-, middle-, and high-income countries. This leads
to substantial differences in health outcomes, infrastructure of healthcare and the
level and quality of health expenditure in individual populations of these countries.
In addition, political instability and cultural practices prevalent in these countries
Fig. 1 Global map representing ranking of cancer as a cause of death below the age of 70 years in
2015 (WHO 2016)
pose a tremendous challenge to the development of cancer prevention and control

programs. Hence, a strategic approach is needed to uplift cancer control programs in
the EMR as the burden of cancer is projected to double by 2030 (Lyons et al. 2018).
The focus should largely be on early detection and screening methods, and
healthcare facilities should be within the reach of everyone. Likewise, awareness
should be created in the population so that there is greater utilization of these
healthcare facilities. Only half of the countries in the EMR currently have strategies
for cancer control through easier access for cancer treatment. The hurdles for an
effective cancer control strategy include lack of practitioners from various specialties
such as oncologists, radiologists, chemotherapists, surgeons, medical staff, and
assistants (Lyons et al. 2018). It is also believed that adopting Western lifestyle
has increased the prevalence and incidence of cancer in various countries of the Arab
world, although changing population dynamics and the presence of local risk factors
cannot be neglected (Maule and Merletti 2012). The countries in the Arab world
should adopt a common risk factor approach to combat obesity and smoking, and by
doing so, help in preventing cancer in addition to reducing other common chronic
diseases such as diabetes mellitus, cardiovascular diseases, and even dental caries.
These chronic diseases are an enormous financial burden to the economy of any
country, which also comes with personal experiences in chronic pain, physiological
stress, and a lower health-related quality of life (Agarwal and Lee 2019).
Global Cancers
A study by Bray et al. (2018) reviewed global cancer statistics and estimated the
mortality and incidence of various cancers throughout the globe. They estimated that
there were more than 18 million new cases of cancer [17.0 million cancer cases
excluding nonmelanoma skin cancer (NMSC)] and 9.6 million cancer deaths (9.5
million excluding NMSC) worldwide in 2018. The results further indicated that in
2018, nearly half of the cases and over one-half of the cancer deaths in the world
occurred in Asia, because close to 60% of the global population resides there. Asia
includes countries from the Eastern Mediterranean region (EMR), prominently Arab
speaking countries and the number of new cancer cases in the EMR increased from
495,000 in 2005 to 723,000 cases in 2015 (46.1% increase) (Bray et al. 2018).
Global Patterns for Cancers According to Human Evolution
The overall incidence of most cancers is 2–3 times more in countries with large or
very large human development as compared to those with low or medium human
development. Nevertheless, the variations in death rates between these two groups
are small, likely because some have higher prevalence of certain cancers that are
associated with poor survival and also because timely access to diagnosis and
effective treatments is less common (Bray et al. 2018; IARC and WHO
GLOBOCAN 2018).
An Overview of Cancer in the Eastern Mediterranean Region

(EMR) and Arab World
Cancer is the second leading cause (after cardiovascular related deaths) of mortality
in many countries, contributing to one in eight deaths in the world (Ervik et al. 2016;
Townsend et al. 2015). In the Eastern Mediterranean Region, cancer is the fourth
leading cause of mortality with ~419, 000 deaths due to cancer in 2018 (Kulhánová
et al. 2017; IARC and WHO GLOBOCAN 2018). The incidence of most cancers in
the EMR is predicted to double by 2030 where the most prevalent cancers are breast,
colorectal, lung, liver, and bladder cancers (IARC and WHO GLOBOCAN 2018).
The predominant cancers in males are lung (10.4%), liver (8.4%), and prostate
cancer (8%), whereas major cancers among females are breast (34.7%), colorectal
(5.7%), and cervical cancer (4.6%) (Ferlay et al. 2019). The growing population,
aging, urbanization, industrialization, changing lifestyles, and more frequent expo-
sure to potential causative agents are likely contributors to a higher incidence of
these cancers in the future (Pourghazian et al. 2019).
Regional Age and Sex Variation in Cancer Burden
The age-standardized incidence of cancer in EMR was higher in females than in

males (199.6 in females and 163.3 in males) in 2015. On the other hand, the age-
standardized mortality rate was higher in males (113.8) compared to females (95.8).
Breast cancer, leukemia, and cervical cancer had the highest rates of occurrence in
females with 177,000, 21,000, and 20,000 cases, respectively. Cancers with highest
mortality rates in females were breast cancer (38,000), colon cancer (13,000), rectal
cancer (13,000), and stomach cancer (12,000). Cancers which caused the most
disability in females were breast cancers (1.3 million Disability-Adjusted Life
Years or DALYs), leukemias (498,000 DALYs), and other tumors (459,000 DALYs).
There were 38,000 newly diagnosed tracheal, bronchial, and lung cancers in
males in the Arab world in 2015, which was more than prostate (28,000) and
stomach (27,000) cancers. Cancers which caused the greatest disabilities in males
(in DALYs) were lung cancers (1 million) and leukemias (637,000), while other
tumors were associated with (494,000).
Leukemia, cancers of brain, and nervous system were the most commonly
occurring cancers in children between the ages of 0 and 14. The mortality rates for
these cancers were also high in children. Breast cancers and leukemias were the most
common cancers in adolescents and young adults between the ages of 15 and 39,
which also led to high mortality rates.
Distribution of Cancer According to Income
There is a considerable diversity in the population size, economy, risk factors profile,
healthcare infrastructure, political stability, health expenditures, and access to health
care facilities in the EMR countries (Lyons et al. 2018). Six countries of the EMR
(Qatar, Bahrain, Kuwait, Oman, United, Arab Emirates, and Saudi Arabia) have a
high per capita gross national income, while 12 countries (Lebanon, Iran, Jordan,
Tunisia, Egypt, Libya, Morocco, Sudan, Syria, Pakistan, Iraq, and Palestine) are
considered middle-income countries, whereas the remaining four countries (Afghan-
istan, Yemen, Somalia, Djibouti) are low-income countries (Lyons et al. 2018). The
diversity in economy and the incidence of the top five cancers of various countries in
the EMR is summarized in Table 1.
Key Findings of Cancers in the Eastern Mediterranean Region (EMR)
The statistics shown in Figs. 2, 3, 4, and 5 compare the EMR with other WHO
regions, where it is observed that the incidence of breast cancer is ranked first and
cervical cancer is ranked second in females in the EMR and other WHO regions.
Moreover, the incidence and mortality of cervical cancer is higher in the African and
South East Asian regions (Figs. 2, 3, 4, and 5).
Cancers with high incidence in males are prostate and lung cancers, with the
incidence rate of prostate cancer being higher in the African, American, and Euro-
pean regions as compared to the EMR. On the other hand, the incidence and
mortality of lung cancer is higher in the European and American regions compared
to the other WHO regions, including the EMR (Figs. 2, 3, 4, and 5).
Leading Cancers in the Eastern Mediterranean Region (EMR) and

Arab World
The age-standardized incidence (per 100,000 population) of the five most common
cancers in EMR are breast, prostate, lung, colorectal, and liver. In 2018, the highest
incidence of cancers in males were of lung, prostate, liver, bladder, and colorectal
cancers, whereas breast, colorectal, cervix uteri, ovary, and liver cancers were more
common in females as shown in Table 2. The overall age-standardized mortality rate
was high for lung, liver, stomach, prostate, and colorectal cancers (GLOBOCAN
2018).
Lung Cancer
The most common cancer is the lung cancer in both sexes accounts for 11.6% of all
global burden of cancers (Bray et al. 2018). It is also the most frequent cancer and
leading cause of mortalities among males in EMR (Table 2) and has a higher
frequency in males of Bahrain, Qatar, and UAE. Tobacco smoking is the most
common risk factor in the development of lung cancer but the Arab countries are
experiencing a large shift to water pipe smoking which can also increase lung cancer
23
Table 1 Incidence of top five cancers according to income of countries in the Eastern Mediterranean Region in 2018 (GLOBOCAN 2018)
First Second Third Fourth Fifth
High-income countries (GCC) (Qatar, Bahrain, Kuwait, Oman, Incidence Breast Colorectal Corpus Prostate Thyroid
United, Arab Emirates, Saudi Arabia) (Both sexes) Uteri
Mortality Breast Colorectal Lung Liver Corpus
(Both sexes) Uteri
Incidence Colorectal Prostate Lung Liver Leukemia
(Male)
Incidence Breast Uterus Thyroid Colorectal Leukemia
(Female)
Burden of Cancer in the Arab World
Middle-income countries (Lebanon, Iran, Jordan, Tunisia, Egypt, Incidence Breast Prostate Lung Liver Colorectal
Libya, Morocco, Sudan, Syria, Pakistan, Iraq, Palestine) (Both sexes)
Mortality Breast Lung Liver Prostate Colorectal
(Both sexes)
Incidence Lung Prostate Liver Bladder Colorectal
(Male)
Incidence Breast Colorectal Uterus Ovary Liver
(Female)
Low-income countries (Afghanistan, Yemen, Somalia, Djibouti) Incidence Breast Uterus Esophagus Stomach Prostate
(Both sexes)
Mortality Breast Uterus Esophagus Stomach Prostate
(Both sexes)
Incidence Stomach Esophagus Lung Prostate Lips, oral
(Male) Cavity
Incidence Breast Uterus Esophagus Stomach Uterus
(Female)
501
Fig. 2 Comparison of incidence and mortality rate of East Mediterranean Region with the African
region in 2018 (GLOBOCAN 2018)
Fig. 3 Comparison of incidence and mortality rate of East Mediterranean Region with the
American region in 2018 (GLOBOCAN 2018)
(Lyons et al. 2018). However, in Saudi Arabia, the lower incidence of lung cancer
has been linked to decreased tobacco smoking (Al Hamdan et al. 2009).
High rates of consuming tobacco in the Middle East are of a great concern. The
consumption of tobacco has been reported to be higher in Lebanon, with rates of use
being 50–60% in males. More alarming is that consumption of tobacco products has
Fig. 4 Comparison of incidence and mortality rate of East Mediterranean Region with the
European region in 2018 (GLOBOCAN 2018)
Fig. 5 Comparison of incidence and mortality rate of East Mediterranean region with South-East
Asia region in 2018 (GLOBOCAN 2018)
also increased in Lebanese women with a prevalence of 34.1%. These high rates of
tobacco consumption will increase the incidence of lung cancer in Lebanon within
the next 30–40 years (Middle East Medical Portal 2018).
Survival rate of lung cancer in the EMR region is only 8% despite significant
advancements in their health care system (Jazieh et al. 2019). Other than limited
Table 2 Estimated age-standardized incidence rates of cancers in 2018 in the Eastern Mediterra-
nean Region. Data are for both sexes of all ages (GLOBOCAN 2018)
Country/region First Second Third Fourth Fifth
Afghanistan Breast Uterus Colorectal Prostate Lung
Bahrain Breast Stomach Esophagus Uterus Lips, oral
cavity
Djibouti Breast Prostate Lung Colorectal Uterus
Egypt Breast Liver Bladder Non-Hodgkin Prostate
lymphoma
Iran Breast Prostate Stomach Colorectal Lung
Iraq Breast Lung Bladder Prostate Colorectal
Jordan Breast Lung Colorectal Prostate Bladder
Kuwait Breast Prostate Colorectal Uterus Lung
Lebanon Breast Prostate Bladder Lung Colorectal
Libya Breast Prostate Lung Colorectal Uterus
Morocco Breast Lung Colorectal Prostate Uterus
Oman Breast Prostate Colorectal Stomach Non-Hodgkin
lymphoma
Pakistan Breast Lips, oral Uterus Lung Prostate
Cavity
Palestine (Gaza Strip Breast Colorectal Prostate Lung Non-Hodgkin
and West Bank) lymphoma
Qatar Breast Lung Colorectal Prostate Bladder
Saudi Arabia Breast Colorectal Uterus Thyroid Prostate
Somalia Breast Uterus Prostate Colorectal Ovary
Sudan Breast Prostate Corpus Ovary Leukemia
Uteri
Syria Breast Prostate Lung Colorectal Bladder
Tunisia Breast Lung Prostate Colorectal Bladder
United Arabs Breast Uterus Prostate Colorectal Ovary
Emirates
Yemen Breast Prostate Lung Colorectal Uterus
Overall in EMR Breast Prostate Lung Colorectal Liver
EMR (Male) Lung Prostate Liver Bladder Colorectal
EMR (Female) Breast Colorectal Uterus Ovary Liver
resources, some of the challenges faced by the countries in EMR related to cancer
diagnosis and management are also reflected by a failure in strategic development in
the primary prevention of lung cancer.
Breast Cancer
Breast cancer is the most common cancer in females of the Gulf Cooperation
Council (GCC) countries (Table 1). It constituted 22.7% in Kuwait, 22.4% in
UAE, and 21.7% in Bahrain to the new cases of all cancers of both sexes during
2018, while the lowest incidence in the GCC was reported in Oman (13.7%)
followed by Saudi Arabia (14.8%) and Qatar (15.1%) (IARC and WHO
GLOBOCAN 2018). Breast cancer has been associated with frequency of pregnancy
and breast feeding because of the high levels of oxytocin and estrogen during
lactation and reduced ovulation lowering the possibility of breast cancer.
The incidence and mortality of breast cancer can be significantly reduced if it is
diagnosed and treated before progression to a malignant state. Early detection of
breast cancer varies from self- examination to screening and mammography at least
once a year, and awareness of early detection can reduce the chances of metastasis.
Unfortunately, most women in Arab countries have little self-awareness of breast
cancer and the disease is diagnosed at late stages. A study of Saudi females (200
females aged 20 and over) in Jeddah on knowledge of the warning signs of breast
cancer, its risk factors, screening methods, and self- examination reported that 50.5%
undertook self-examination of breast lumps as a cautionary sign, 57.5% believed that
cancer was related to inheritance, and 20.5% underwent breast screening. About
79% of these females were aware of the concept of breast self-examination; how-
ever, only 47.5% women knew how to perform it (Radi 2013).
Tumors which are diagnosed at an early stage are easier to treat and have better
prognosis. Diagnosis at later stages often means that the tumors may have already
spread to other parts of the body. A study conducted in Riyadh (from 1994–1996)
investigated breast tumors with a favorable prognosis. A broad-brush biopsy
obtained at 1, 3, and 5 years of the study indicated survival rates of 93.9%, 79.2%,
and 59.6%, respectively. The 5-year survival rates of middle- and older-aged women
were between 60% and 69%. Furthermore, localized tumors had better prognosis
(67.5%) as compared to metastasized tumors (57.6%) (Ravichandran et al. 2005).
A poor rate of survival is also associated with late presentation of the cancer and
seeking for help at last stages has been reported in the Middle East. Nearly, 75% of
patients in the UAE seek medical help when they experience a symptom related to
cancer. The key reasons were mostly related with an inability to recognize the
symptoms, social stigma, and abandonment from spouse (Elobaid et al. 2016).
Women in the UAE do not divulge their cancer history in fear of stigmatization,
and as a consequence, such women present at advanced stages of the disease; usually
when it has metastasized. According to the “Cancer Registry Report 2012,” late
presentation of breast cancer is the second most common cause of death in women
(38 per 100,000) (Elobaid et al. 2016).
Another important reason for the late presentation for breast cancer diagnosis or
management in Arab women is their strong belief in religion and spirituality. These
women attain peace through prayers and isolation after they have been diagnosed with
breast cancer. Awareness campaigns should be conducted to encourage these women
to seek medical treatment without the fear of social stigmatization (Assaf et al. 2017).
Prostate Cancer
Prostate cancer is the second most common cancer worldwide after the lung cancer
among men (Bray et al. 2018). It is also the second most frequent cancer leading to
mortalities among males in EMR (Table 2). Prostate cancer occurs most commonly
in world among men between 60 and 70 years old and almost half a million new
cases are diagnosed each year. Prostate cancer has an incidence of only 4% in
developing countries and 15% in developed countries (Quinn and Babb 2002).
According to the latest estimates by IARC and WHO GLOBOCAN (2018), prostate
cancer is the most frequently occurring tumor in men after lung-cancer, with an
incidence of about 1,276,106 and 358,989 deaths worldwide in 2018. The mortality
and incidence rate of prostate cancer increases with an increase in age. The world-
wide average age for diagnosis of prostate cancer in men is 66 years (Rawla 2019).
The incidence and mortality rate of prostate cancer in Saudi Arabia is 2.5% and
1.4%, respectively, ranking 13th in incidence of all cancers and 21st in terms of
mortality (IARC and WHO GLOBOCAN 2018).
There are no early preventive methods that men can take to prevent this disease to
the more advance stage. Some studies reported that consuming alcohol is associated
with prostate cancer while other studies suggested that it is directly related to number
of female sexual partners the subject had (Quinn and Babb 2002). It is a highly
unpredictable tumor and difficult to diagnose at early stage because it remains
dormant until it reaches a size of 1 mm or larger. Thus, the risk for metastasis is
quite higher than other cancers (McNeal et al. 1986).
Colorectal Cancer
Colorectal cancer is the third most common cancer in men (after lung and prostate
cancers) and second most common cancer in females (after breast cancer) in the
world. Colorectal cancer constitutes more than 10% of the global cancer burden
(Bray et al. 2018). The incidence and mortality rate of colorectal cancer in the
EMR is ranked fourth in the six WHO regions (Fig. 1). The GLOBOCAN 2018
survey estimates reported that 1,026,215 new cases of colorectal cancers were
diagnosed in men, and 823,303 in women worldwide in 2018, with 24,031 new
cases in men and 19,762 in women in the EMR. The global age-standardized
incidence rate for colorectal cancer in 2018 was 23.1 per 100,000 in men and 15.7
per 100,000 in women, while in the EMR, these rates were 9.1 per 100,000 in men
and 7.6 per 100,000 in women. The global age-standardized mortality rate was
10.6 per 100,000 in men and 7.0 per 100,000 in women, the rates in the EMR were
5.5 per 100,000 in men and 4.4 per 100,000 in women (IARC and WHO
GLOBOCAN 2018).
Incidence and Mortality Rate of Colorectal Cancer in EMR
The highest incidence of colorectal cancer was reported in Lebanon followed by

Palestine, Jordan, Syria, and UAE, while morality was highest in Palestine followed
by Lebanon, Syria, Jordan, and Qatar. The lowest incidence has been seen in
Afghanistan followed by Pakistan, Sudan, Djibouti, and Iraq, whereas the lowest
mortality rate was reported in Pakistan followed by Afghanistan, Egypt, Iraq, and
Sudan Syria (IARC and WHO GLOBOCAN 2018).
The incidence of colorectal cancer in males was highest in Palestine, followed by
Lebanon, Saudi Arabia, Jordan, and UAE, while the mortality rate due to colorectal
cancer in males was highest in Palestine, followed by Lebanon, Syria, Qatar, and
Bahrain. The incidence of colorectal cancer in females was highest in Jordan followed
by Lebanon, Palestine, Syria, and Kuwait. The mortality rate in females was highest in
Palestine followed by Lebanon, Jordan, Qatar, and Syria (Figs. 6 and 7) (IARC and
WHO GLOBOCAN 2018).
Colorectal cancer incidence rates are related to socioeconomic development and
the highest rates occur in nations with very high ranges of the Human Development
Index (HDI) (Arnold et al. 2017).
Colorectal Cancer in the GCC
Colorectal cancer is the second most common cancer in the Gulf countries (Table 1)
with a spike in incidence and mortality rates noted during the last decade. The role of
improved access to testing or improved testing methods in the Gulf countries in the
greater incidence rates of colorectal cancer is unknown (Al-Sharbatti et al. 2017).
The highest incidence of colorectal cancer was reported in the UAE followed by
Kuwait, Saudi Arabia, and Qatar while morality was highest in Qatar, followed by
Bahrain, Kuwait, and the UAE. The incidence of colorectal cancer in males was
highest in Saudi Arabia followed by the UAE, Bahrain, Qatar, Kuwait, and Oman,
while the mortality was highest in Qatar followed by Bahrain, UAE, Kuwait, Saudi
Arabia, and Oman. The incidence of colorectal cancer in females was highest in
Kuwait followed by Qatar, UAE, Bahrain, Saudi Arabia, and Oman, whereas the
Fig. 6 Worldwide incidence rates of colorectal cancer in 2018 (GLOBOCAN 2018)

Fig. 7 Worldwide mortality rates of colorectal cancer in 2018 (GLOBOCAN 2018)
mortality among females was the highest in Qatar, followed by Kuwait, Bahrain,
UAE, Oman, and Saudi Arabia (IARC and WHO GLOBOCAN 2018).
Cancer Registries
Population-based cancer registries contain the records of each patient diagnosed with
cancer and are used to obtain reliable data on the prevalence, incidence, trends, and
survival of various cancers. Population-based cancer registries are available in 17 of
the 22 countries of the region and half of the countries in the region have adopted
strategies to control and prevent the cancer. In most of the countries (e.g., Oman,
Saudi Arabia, Kuwait, and Pakistan) national level cancer registries are available
while for other countries, specific regional registries are used (e.g., Gulf Cancer
Centre for Cancer Registration). However, Afghanistan, Djibouti, Sudan, Palestine,
and Somalia have not established cancer registries (Table 3).
Some Important Steps Undertaken for Registering of Cancers in GCC
The countries of the GCC started an innovative and unique model for cancer
registration referred as Gulf Cancer Centre for Cancer Registration (GCCR). The
population-based cancer registry, GCCR, was created in the Gulf countries and
started collecting data from 1st January 1998. Lung and prostate cancers in males,
followed by thyroid and breast cancers in females are the most prevalent cancers in
GCC countries. Non-Hodgkin’s lymphoma has also been included in the list of the
top five cancers in the region (Al Hamdan et al. 2009).
Table 3 Cancer registries in the Eastern Mediterranean Region

Country Registry name Population covered Status
Afghanistan Not established yet
Djibouti Not established yet
Bahrain Bahrain cancer National: 742 562 Last data
registry produced in
2006
Uses
CANREG4
Egypt Tanta population- Sub-National: Gharbiah Last data
based registry district published
2007
Uses
CANREG4
Iran, Islamic Republic of National cancer National: Last data
registry of Iran published
2007
66.7 million Uses (PARS)
Iraq Iraqi cancer registry Sub-National (Duhok, Last data
Erbil and Sulaimaniya published
provinces excluded): 2009
23.5 million Uses
CANREG3
Jordan Jordan cancer National: Last data
registry conducted
2010,
published
2012
Uses
CANREG4
Kuwait Kuwait cancer Kuwaitis and non- Last data
registry Kuwaitis: published
2006
2.48 million Uses
CANREG4
Lebanon Lebanese cancer National Last data
registry published
2008
Uses Epidata+
SPSS
Libyan Arab Jamahiriya Lybian cancer Sub-National Last data
registry- African published
Cancer Oncology 2007
Centre Uses
CANREG
(continued)
Table 3 (continued)
Morocco Registre du grand Grand Casablanca Last data
Casablanca district (4 million) published
2004
Uses an Italian
software
Registre du Rabat la population de Last published
Rabatest de 628000 in
habitants English_2005
Uses EPI-
INFO+ SPSS
Oman National Cancer National Last data
Registry published 2011
Uses
CANREG4
Pakistan National Cancer Sub-national Last dated
Registry 2008
Uses
CANREG4
Palestine In plan
Qatar Qatar cancer National Last data
registry published
2008
Uses
CANREG4
Saudi Arabia National cancer National Last data
registry published
2004
Uses
CANREG4
Somalia Not established yet
Sudan In planning stages
South Sudan In planning stages
Syrian Arab Republic Syrian cancer National: 18.2 million Last published
registry data 2006
Uses SPSS
Tunisia Register of North North Tunisia (10 Last data
Tunisia governorates): 4.4 published
million 1995–1998
Uses
CANREG
Register of South South Tunisia Uses locally
Tunisia (7 governorates): 2.2 produced
million software
United Arab Emirates Two central cancer Sub-national Last data
registries published
2003
(continued)
Table 3 (continued)
Uses IMAPC
software
Yemen Aden cancer Sub-national 2004 Not
registry published
Uses
CANREG4
GCCR: Oman, United Gulf Cancer Centre Regional: Last data
Arab Emirates, Saudi for Cancer published
Arabia, Kuwait, Qatar Registration 1998–2005
All GCC countries: Uses
19.5 million CANREG4
Adapted from cancer registration in EMR published by WHO (2012)
Prevention
Cancer prevention involves eradication or reduction in exposure to modifiable risk

factors of cancer. Primary prevention occurs by preventing the occurrence of cancer
while secondary prevention by diagnosing cancer in the early stages to reduce associ-
ated complications and mortality. Screening is a key in secondary prevention. The two
approaches that enable timely diagnosis and treatment of cancer include: (i) early
diagnosis of cancer in symptomatic patients, and (ii) screening for the detection of
cancer in asymptomatic healthy individuals (World Health Organization 2018a).
Benefits and Barriers of Early Cancer Detection
Despite substantial advancement in the healthcare system, cancer control is chal-

lenging for both high-income and middle–low-income countries. In resource-
constrained settings, cancer is frequently identified at late-stages, leading to
decreased survival rates, probably greater morbidity, and higher costs of care.
Almost two-third of cancer related deaths globally occur in developing nations due
to the late-stage presentation and lower access to healthcare facilities (Arnold et al.
2017). In the case of EMR, the mortality rate is higher (especially in less developed
countries) as compared to Europe and the USA, due to late-stage presentation when
cancer is likely to have metastasized (Figs. 3 and 4). Less mortality rate, reduction in
cost of care, and morbidity as well as improved outcomes of the treatment can be
achieved with early-stage detection of the cancer. Therefore, it is highly
recommended to identify the potential barriers to early diagnosis, prevention, and
treatment in the Eastern Mediterranean Region (EMR). An advisory meeting with
national and international experts held in January 2016 proposed policies for the
early detection and screening of five leading cancers (breast, prostate, lung, colo-
rectal, and liver) in the EMR region (Lyons et al. 2018).
It is estimated that ~40% of cancers are preventable, ~40% of cancers are curable,
and ~20% of cancers can be managed with proper cancer care. Early diagnosis and
screening programs can detect cancers at early stages that are curable. The combi-
nation of early detection and optimal management has a high rate of cure or
reduction of some cancers (e.g., of the breast, oral cavity, colon, and cervix). Most
of the countries of the EMR do not integrate primary health care settings to
secondary or tertiary healthcare centers. Focusing on prevention and early diagnosis,
and an integrated health approach of primary, secondary, and tertiary healthcare
settings in the region, can reduce the morbidity and mortality associated with various
cancers (Al-Othman et al. 2015).
Delayed Presentation
A limited awareness of cancer or a lack of access or the availability of screening

resources results in delayed presentation of the cancer (with advanced symptoms) in
many patients, causing patients to seek emergency services instead of primary care
services; this significantly impacts treatment outcomes (Elliss-Brookes et al. 2012).
Public awareness programs related to common cancers in the EMR and the relevant
screening strategies through publicity could improve early diagnosis of many can-
cers. Awareness of breast cancer can reduce the chances of metastasis. The delayed
presentation of the cancer (e.g., oral cancer) is also related to a lack of training
among the professionals (Altamimi et al. 2019; Gómez et al. 2010).
Screening
Cancer is a deadly disease; thus, the main goal of the screening is to reduce
premature mortality (Smith et al. 2017). There are two types of cancer screenings:
organized screening that is offered by the government and opportunistic screening
which is requested by healthcare advisors. Organized screening is more effective as
compared to opportunistic screening for most of the population. Organized screening
programs can ensure improved equity and cost-effectiveness which are the keys to
decreasing the burden of cancer (World Health Organization 2017). The screening
practices of different cancers are described in Table 4.
Cancer Screening Programs in the EMR
In the EMR, both organized and opportunistic cancer screening programs are
available. Opportunistic programs are available for the screening of breast, cervical,
and colorectal cancers in some countries of the region (Pourghazian et al. 2019).
Almost 179,681 patients were diagnosed with one of these three types of cancers
during a single year in EMR (WHO GLOBOCAN 2018). The burden of cancer will
be increased by up to 50% in 2050 due to an aging and growing population.
Table 4 Cancer screening practices

Cancer Screening Main age range Mortality
site Screening test interval (Years) reduction
Image-based screening
Breast Mammography 1–3 50–69 yes
Lung Low-dose computed 1–2 55–74 yes
tomography (CT)
Stomach Upper gastrointestinal X-ray 1–2 >40 Uncertain
Series
Direct or endoscopic visual screening
Cervix Visual inspection with acetic 1–3 30–49 yes
acid
Oral Direct visual inspection 1–3 >35 yes
Colon Colonoscopy 5–10 50–69 yes
Colon Flexible sigmoidoscopy 3–5 55–69 yes
Stomach Upper gastrointestinal 1–2 40–64 Uncertain
endoscopy
Clinical examination screening
Breast Clinical breast Examination 1 40–69 Unknown
Breast Breast self-examination – no
Cell sampling screening
Cervix Cervical cytology 1–3 25–69 yes
Biomarker-based screening
Cervix Human papillomavirus 3–5 30–65 Yes
(HPV) testing
Colon Fecal occult blood test 1–2 50–69 Yes
(FOBT)
Stomach Pepsinogen I/II 40–64 Unknown
Prostate Prostate-specific antigen 1–5 50–74 Uncertain
(PSA)
Liver AFP Every 6 High risk Uncertain
months
Ovary CA125 – – No
Adapted from World Cancer Report (2020)
Opportunistic screening programs are more common and do not reach the entire
population suggesting that greater efforts should be made in this regard (World
Health Organization 2017). The major screening programs in the EMR are aimed
at breast cancer. A survey of NCDs reported that 73% countries in the world have
breast screening programs, subsequently, the mortality associated with breast cancer
has reduced approximately 20% with mammography screening in high-income
countries (World Health Organization 2018a; Pourghazian et al. 2019). It is esti-
mated that 76% countries in the world have cervical screening program and the
mortality related to cervical cancer has decreased by cervical cytology screening in
high-income countries (World Health Organization 2018a). Screening for colorectal
cancer by colonoscopy and sigmoidoscopy reduces the incidence, diminishes
mortality due to the cancer, and improves the health-related quality of life. A case-
control study confirmed that colonoscopy decreases the risk of colorectal cancer
(Azeem et al. 2015; Chen et al. 2017). These screening tests are widely practiced in
many countries of the world.
Obesity, Tobacco, and Smoking as Risk Factors of Cancer in the EMR
Many determinants of cancers are modifiable, especially those related to the envi-
ronment and lifestyles. The prevalence of tobacco smoking is above 30% among
men in EMR (Fouad et al. 2020), and it is a well-established risk factor for cancers of
lung, trachea, bronchi, urinary bladder, oral cavity, pharynx, esophagus, larynx,
cervix, pancreas, and kidney (Lauby-Secretan et al. 2015). The high incidence of
bladder cancer in Egypt has been associated with increased smoking (Bedwani et al.
1997). The increasing use of waterpipe smoking in Arab countries has also led to a
higher incidence of lung cancer (Lyons et al. 2018).
Obesity and lack of physical activity are also well-established risk factors for
most NCDs and its associated mortalities and morbidities. Obesity is also now
recognized as a cause of many types of cancers, based on the direct association of a
higher Body Mass Index (BMI) and the risk of liver, colorectal, esophageal,
kidney, and breast cancer. Likewise, a high BMI can also be a possible cause of
prostate, gall bladder, mouth, stomach, and pharynx and larynx cancer (World
Cancer Research Fund (WCRF) and American Institute for Cancer Research
(AICR) 2018). The mean BMI has increased worldwide since 1980, with the
BMI in men increasing to 0.4 kg/cm2 per decade between 1980 and 2008
(Finucane et al. 2011). The WHO (2016) reported that almost 1.97 billion adults
were overweight or obese and over 338 million children and adolescents were also
reported with higher BMI than the normal. About 50% of men and 35% of women
in the EMR are currently estimated to be overweight or obese (Amin et al. 2020;
World Cancer Research Fund (WCRF) and American Institute for Cancer Research
(AICR) 2018). The prevalence of physical inactivity among young adult was
reported to be 44% in Qatar and 55% in Saudi Arabia (Aljayyousi et al. 2019;
Al-Hazzaa 2018).
Recommendations for Prevention
Maintaining a healthy weight is recommended to prevent NCDs and possibly also

many common cancers. The WCRF and AICR (2018) recommended BMI to be kept
within the healthy range (BMI between 18.5 and 24.9 kg/m2). Overweight individ-
uals can follow the reliable information available at WCRF network or consult the
specialist to achieve the healthy BMI levels, e.g., by engaging in 150 min per week
of moderate intensity of physical activities, e.g., walking, swimming, cycling, and
household chores. A significant reduction of risk was found with moderate to
vigorous leisure-time exercise training for breast, colorectal, esophagus, lung,
liver, kidney, and bladder cancers (Moore et al. 2016).
Likewise, a diet rich in vegetables, fruits, whole grains, and beans is also
desirable to reduce the risk of cancers and protect against obesity as well. Moreover,
limiting the consumption of processed or convenience foods (which are high in fat
and sugar content), alcohol, and smoking can contribute to prevention of a variety of
cancers (World Cancer Research Fund (WCRF) and American Institute for Cancer
Research (AICR) 2018) (Table 5).
Table 5 Evidence supporting the relationship of physical activity, sedentary behavior, and obesity
and the risk of cancer
Cancer site Physical activity Sedentary behavior Obesity
Colorectum Strong evidence for Limited evidence for Strong evidence for
decreased risk (Colon) increased risk (Colon) increased risk
Endometrium Strong evidence for Limited evidence for Strong evidence for
decreased risk increased risk increased risk
Breast Strong evidence for Limited evidence for Strong evidence for
(Premenopausal) decreased risk increased risk increased risk
Breast Strong evidence for Limited evidence for Strong evidence for
(Postmenopausal) decreased risk increased risk increased risk
Esophageal Strong evidence for Strong evidence for
adenocarcinoma decreased risk increased risk
Kidney Strong evidence for Strong evidence for
decreased risk increased risk
Bladder Strong evidence for Strong evidence for
Gastric Cardia Strong evidence for Strong evidence for
Liver Strong evidence for
increased risk
Lung Limited evidence for Limited evidence for Strong evidence for
decreased risk increased risk increased risk
Prostate Limited evidence for Strong evidence for
Ovary Limited evidence for Strong evidence for
Pancreas Limited evidence for Strong evidence for
Gall bladder Strong evidence for
increased risk
Mouth pharynx, Strong evidence for
and larynx increased risk
Cervix Limited evidence
for increased risk
Thyroid Limited evidence
for increased risk
Multiple Limited evidence
myeloma for increased risk
Meningioma Limited evidence
for increased risk
Adapted from World Cancer Report (2020)
The Need for Action to Implement Effective Cancer Control

Programs in the EMR
The burden of most of the cancers in the EMR is predicted to double by 2030 (Lyons
et al. 2018), and after 15 years from now, the EMR will outstrip the incidence of
cancer compared to all six regions of the WHO; this is largely due to population
growth, aging, urbanization, industrialization, changing lifestyles, and increased
exposure to carcinogens in the EMR (Pourghazian et al. 2019). The burden and
types of cancers are quite variable in the EMR, making it difficult to implement
uniform cancer control strategies (Lyons et al. 2018).
Barriers and Deficiencies for Implementation
Diversity in access to cancer treatment facilities is observed in the EMR. Eleven

countries in the EMR do not have guidelines for cancer management and
referral. Other barriers to treatment include lack of multidisciplinary teams,
limited access to cancer surgery, radiotherapy, chemotherapy, and a deficiency
of specialist surgeons, oncologists, and support staff. The primary healthcare
settings are not integrated with secondary or tertiary healthcare in most of the
countries of EMR. Likewise, access to palliative care is difficult due to a lack of
trained staff, low resources, and limited access to pain relieving drugs (Lyons
et al. 2018).
Palliative Care and Rehabilitation
Palliative care and rehabilitation can improve the quality of life and relieve the
symptoms in people with life-threatening or life-limiting diseases (Smith et al.
2012). The delivery of palliative care can be in hospitals (outpatient clinics, inpatient
units or mixed services), nursing homes, and community-based services. Palliative
care is better suited to populations where accessibility or availability of curative
aspects of cancer treatment is limited (Osman et al. 2017).
Patients often seek medical intervention in the late stages of cancer when the
disease is likely to be incurable even with best available facilities. Palliative care
frequently decreases suffering and improves the quality of life of cancer patients;
sadly, palliative care is not offered in most countries of the EMR. Most countries
of the EMR are just starting to establish palliative care services while some
countries such as Saudi Arabia has developed advanced palliative care centers
throughout the country. The main barriers identified for the lack of palliative care
services in the EMR are an absence of national plans and policies, a lack of
funds, limited number of trained personnel, limited access to pain relief medi-
cations, and a lack of awareness among policymakers (Fadhil et al. 2017; Osman
et al. 2017).
Conclusion
Cancer in the Arab world has burgeoned into a significant health problem of
immense proportion in both the middle-to-low income and high-income countries
of the EMR. It is important for low-income countries to address the deficiencies and
shortcomings in the screening and diagnosis of common cancers in the EMR and to
improve treatment and palliative care of the cancer patients in the Arab region. Civil
strife and conflicts in the Arab world compound the ongoing sociopolitical and
economic destabilization which inevitably intensifies the burden of cancer on
healthcare systems in some of the impoverished countries of the EMR region.
Changes in lifestyle, expedited detection and diagnosis, easier access to inexpensive
treatment, and greater availability of palliative care needs to be addressed on an
urgent basis. This requires collaborative efforts from policy makers, healthcare
professionals, and the general public in the EMR.
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Oncology Care in the UAE
24
Ibrahim Abu-Gheida, Neil A. Nijhawan, and Humaid O. Al-Shamsi
Contents
United Arab Emirates Demographics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 522
UAE Healthcare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 524
Oncology Care in UAE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 524
Cancer Statistics in the UAE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 525
Cancer Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 527
Cancer Risk Factors in the UAE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 527
Cancer Prevention Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 529
Cost-Effective Oncology Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 530
Medical Tourism in the UAE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 531
Oncology Physicians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 531
Specialized Oncology Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 532
Advanced Treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 532
Radiation Oncology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 532
I. Abu-Gheida
Emirates Oncology Society, Dubai, United Arab Emirates
Radiation Oncology Department, Burjeel Medical City, Abu Dhabi, United Arab Emirates
College of Medicine and Health Sciences, United Arab Emirates University, Abu Dhabi, United
Arab Emirates
N. A. Nijhawan
Radiation Oncology Department, Burjeel Cancer Institute, Burjeel Medical City, Abu Dhabi,
Department of Palliative Care and Hospice, Burjeel Medical City, Abu Dhabi, United Arab
Emirates
H. O. Al-Shamsi (*)
Emirates Oncology Society, Dubai, United Arab Emirates
College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
Department of Medical Oncology, Burjeel Medical City, Abu-Dhabi, United Arab Emirates
e-mail: humaid.al-shamsi@medportal.ca

https://doi.org/10.1007/978-3-030-36811-1_183
522 I. Abu-Gheida et al.
Pediatric Oncology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 532

Bone Marrow Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 533
Palliative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 533
Cytogenetics and Molecular Genetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 533
Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 534
Education and Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 534
Future of Cancer Care in the UAE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 534
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 535
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 536
Abstract
The United Arab Emirates (UAE) is a cornerstone of the Arab world and the Gulf
Cooperation Council. Despite being a relatively young country, the UAE
healthcare system has proven to be one of the highly ranked healthcare systems
worldwide. Oncology care in the UAE blends a unique mixture and collaboration
between public and private healthcare sectors. This chapter covers the oncology
care in the UAE, and highlights the potential for growth in oncology care in
the UAE, making the UAE an attractive location for medical tourism for oncol-
ogy care.
Keywords
Cancer in the Arab world · Gulf Cooperation Council Oncology · UAE
Oncology · UAE healthcare · Cancer in UAE · Oncology Medical Tourism
United Arab Emirates Demographics
The United Arab Emirates (UAE), located in the southeast of the Arabian Peninsula,
is part of the Gulf Corporation Council (GCC) in the Arab world. The country is
relatively young but with abundant growth potential and has established its presence
clear on the regional and international stages. The UAE was established in 1971, and
is composed of Abu-Dhabi, Dubai, Sharjah, Ajman, Fujairah, Ras Al Khaimah, and
Umm Al-Quwain. The population of the UAE has almost tripled over the past two
decades (www.worldpopulationreview.com), and the current population is estimated
to be ~9.9 million, with an estimated 1.23% growth rate increase in 2020. The
majority of the population is composed of expatriates, with South Asians constitut-
ing the majority (58%) of expatriates (Fig. 1).
The UAE has the third-largest conventional oil, and fifth largest natural gas
reserves in the world. Its 2015 GDP per capita ranked in the 95th percentile globally,
making the UAE a very popular destination for working opportunities and making
the population of the UAE relatively young, with an overall median age of
30.3 years. The UAE also has one the highest gender imbalance in the world, with
a male/female ratio of 2.2 or 2.75 for the 15–65 age groups (https://worldpopula-
tionreview.com/countries/united-arab-emirates-population 2020).
24
Oncology Care in the UAE
Fig. 1 Development of oncology in the United Arab Emirates (Al-Shamsi et al. 2020a)
523
UAE Healthcare
The rapidly growing and developing healthcare system in the UAE is ranked 27th
worldwide by the WHO (Blair and Sharif 2013). This is not surprising since all
citizens are fully covered by a government-funded health insurance. Moreover, all
expatriates and their families are mandated to have at basic health insurance during
their stay in the UAE. Moreover, there are several charities that cover the cost of
therapies such as oncology treatments, and patients also have the option of paying
directly for any healthcare service they receive.
Collaborative efforts across the different authorities in the Emirates govern the
healthcare system. These include the Dubai Health Authority, Department of Health
in Abu-Dhabi, and the Sharjah Health Authority. The primary federal regulatory
health authority of the entire UAE health system is the Ministry of Health and
Prevention (MOHAP) which also governs the northern Emirates health systems
(Health authorities, The official portal of UAE government 2020).
The two most common cause of death in the UAE population are accidents/
injuries followed by cardiovascular disease. Despite having a largely young popu-
lation, cancer remains a major health issue in the UAE and is the third leading cause
of death. The UAE federal government have initiated plans to reduce the number of
cancer-related deaths in its national agenda (The Official Portal of the UAE Gov-
ernment, Cancer 2020).
Oncology Care in UAE
Cancer care within the UAE healthcare has been documented as early as 1981 from a
published report of five hepatocellular carcinoma cases (Tadmouri and Al-Sharhan
n.d.). Al-Ain, one of Abu-Dhabi states main cities (which was created from a desert
oasis), is home to the first and largest cancer care facility in the UAE. The Tawam
hospital (established in 1979) was the first hospital to deliver comprehensive cancer
care in the UAE and was named the official cancer referral hospital in 1983 (https://
gulfnews.com/uae/health/741-bed-hospital-toopen-in-abu-dhabi-1.66698698 2020).
General oncology services were later offered in new public hospitals across the
UAE, which allowed cancer patients to access facilities closer to their residential
areas (Fig. 1). It should be noted the entire cost of oncology treatment of all UAE
citizens and residents living in the UAE was fully covered until 2007. This created
an influx of migrants, as several patients were moving to the UAE to benefit from
free cancer care. This model no longer exists and cancer care is completely covered
for only UAE citizens, and expatriates are expected to pay part of the treatment costs
from the private insurance plans. This coverage is subject to expiration dates, which
sometimes forces expatriates to return to their home countries to continue medical
care. This led to a recent joint publication from the Emirates Oncology Society
(EOS) calling for adjustments of cancer insurance packages across the nation
(Al-Shamsi et al. 2020a).
24 Oncology Care in the UAE 525
Private healthcare systems in oncology care were uncommon, probably due to the
high capital expenditure involved. However, the gradual integration of public and
private sectors for oncology service showed to be a very successful model in the
UAE, with several hospitals and health care-facilities adopted this model (Fig. 1).
Moreover, several privately owned hospitals now provide both basic and compre-
hensive cancer care services.
Cancer Statistics in the UAE
The Tawam Hospital is the first largest cancer tertiary referral hospital within the
UAE and was established in 1983 (Tadmouri and Al-Sharhan n.d.). Other govern-
ment-based hospitals that provided cancer patient treatments also started reporting
their data to the MOHAP (Tadmouri and Al-Sharhan n.d.). The first official cancer
incidence report was published in 2002 (UAE Ministry of Health. Cancer Incidence
Report 2002) and was incorporated into the regional GCC cancer registry
(Al-Hamdan et al. 2009).
The Department of Health in Abu-Dhabi launched its central cancer registry in
2012. They released the first comprehensive cancer incidence data in Abu-Dhabi of
1729 new cancer cases (Fig. 2). Of those, 28% involved UAE citizens and the
remainder (72%) involved expatriates. Breast cancer was the most common cancer
in women, while hematological malignancies were most common in men (Health
Statistics 2012).
The Emirate of Dubai has several hospital-based tumor registries but the com-
bined tumor registry results have yet to be released. All private and public hospitals
in the Northern Emirates share a common tumor registry (established in 2014 by the
government) which mandates registration of all cancer diagnosis (MCCR-01-344
Cancer Notification Policy – United Arab Emirates Ministry of Health Central
Cancer Registry (MCCR) June 2014 2020).
The UAE national cancer registry at the ministry of health and prevention
MOHAP, a population-based cancer registry, was established by the UAE cabinet.
This registry collects, stores, summarizes, and analyzes information on patients who
are diagnosed and/or treated for cancer within the UAE. Data is accumulated from
Abu-Dhabi’s Department of Health Registry, Dubai Health Authority Cancer Reg-
istry, Northern Emirates Registries, all government- and private-based hospitals
records on malignancies that were certified by medical professionals, reports from
pathology laboratories, and mortality data. This data is used to guide the planning of
cancer care services, future expansions, developing screening programs, and cancer
research programs. This registry collects data on malignant neoplasms according to
international standards and a report is released annually.
There are currently approximately 4500 new cancer cases per year diagnosed in
the UAE (The Official Portal of the UAE Government, Cancer 2020). Cancer
mortality data from Abu-Dhabi suggests that cancer constitutes 14% of the causes
of death in the Emirate in 2013, with lung cancer being the most common cause of
cancer-related death in males and breast cancer in females (Health Statistics 2011b).
526
Fig. 2 Cancer incidence in the Emirate of Abu-Dhabi. (Data from the Department of Health, 2012)
I. Abu-Gheida et al.
The latest UAE cancer registry report lists 3968 new cancer cases reported in the
UAE in 2015, of which in situ diseases constituted 224 (5.6%) of the cases.
Approximately, one-third of the new cases occurred in UAE citizens and the remainder
in expatriates. The demographics and most common types of cancer in the UAE
population using data from 2015 is summarized in Table 1 (UAE-NATIONAL ROT,
et al.: CANCER INCIDENCE IN UNITED ARAB EMIRATES ANNUAL REPORT
OF THE UAE-NATIONAL CANCER REGISTRY-2015 2020).
Cancer Screening
The UAE is sparing no efforts to increase cancer screening programs across the
country. Screening programs for breast, colorectal, and cervical cancers were
established in 2014 (The Dubai Health Authority (DHA) 2020). A program started
in 2009 advised all UAE national women older than 40 years to undergo annual
screening mammography. A nationwide colorectal cancer screening program was
launched in July 2010 (UAE takes steps to end the scourge of cancer 2010). Lung
cancer screening with low dose CT scans were implemented after lung cancer
screening data was released in 2017 (Department of Health Abu Dhabi 2020).The
mandatory Dubai health insurance plan covers the costs for screening common
cancers. Finally, several initiatives for cancer awareness and screening, such as the
“Pink-Caravan” event that raises breast cancer awareness and encourages screening,
now occur on a yearly basis and reached more than 45,000 women within the UAE
(The U.A.E. Healthcare Sector: An Update, U.S.-U.A.E. Business Council 2017).
Cancer Risk Factors in the UAE
Obesity rates in the UAE are comparable to those in the USA (Al-Hamdan et al.
2009). In the most recent updated statistics 28% of response reported to be obese
(UAE NHS 2018) The obesity rates was 42% in females, which are known to be
associated with several types of cancers such as breast, colon, and gastric esophageal
(Wolin et al. 2010). Moreover, childhood obesity rates are also high in the UAE (Al
Junaibi et al. 2013), which usually translates into a projected higher rate of obesity in
the future and hence indirectly potential increasing to the risk of cancer.
Smoking is another important modifiable risk factor for cardiovascular diseases
and cancers in the UAE (Al-Houqani et al. 2012). It is estimated that 20.5% males
and 1% females of Emiraties in the UAE are smokers (Al-Houqani et al. 2012).
While different parts of the world offer a variety of ways of inhaling smoking,
cigarette smoking remains the most prevalent form of smoking in the UAE (77.4%),
followed by shisha, midwakh, e-cigarettes and cigars (UAE NHS 2018)
(Al-Houqani et al. 2012). In fact, smoking of shisha is prevalent in premarital
males (7%) and females (3%) in the UAE. It is important to keep in mind that the
content carcinogens in smoking one shisha/hubble bubble, hookah, or narghile is
equivalent to that present in five packs of cigarettes (approximately 100 cigarettes)
Table 1 New Cancer Cases in the UAE (2015) stratified by site, gender, and citizenship status
Non-UAE citizens UAE citizens “Grand
Primary Site ICD-10 Female Male Total Female Male Total total”
(C00-C96) all invasive 1377 1319 2696 605 443 1048 3744
cancers (malignant cases)
C00-C14 lip, oral cavity and 21 66 87 14 16 30 117
pharynx
C15 esophagus 7 13 20 1 4 5 25
C16 stomach 22 56 78 11 19 30 108
C17 small intestine 7 9 16 1 7 8 24
C18-C21 colorectal 84 172 256 57 60 117 373
C22 liver and intrahepatic bile 13 37 50 8 10 18 68
ducts
“C23-C24 gallbladder, other 11 18 29 3 2 5 34
and unspecified part of biliary
tract”
C25 pancreas 14 20 34 8 11 19 53
C30, C31 nasal cavity, 2 2 4 1 1 2 6
middle ear, accessory sinuses
C32 larynx 0 38 38 0 6 6 44
C34 bronchus and lung 33 78 111 15 35 50 161
C40-C41 bone and articular 4 8 12 3 2 5 17
cartilage
C43 skin melanoma 11 16 27 0 4 4 31
C44 skin 32 75 107 4 13 17 124
C45 mesothelioma 3 2 5 0 0 0 5
C46 Kaposi sarcoma 0 1 1 0 4 4 5
C48 retroperitoneum and 2 5 7 5 1 6 13
peritoneum
C49 connective and soft tissue 8 22 30 5 6 11 41
C50 breast 548 8 556 208 1 209 765
C53 cervix uteri 61 0 61 13 0 13 74
C54-055 uterus 64 0 64 35 0 35 99
C56 ovary 45 0 45 17 0 17 62
C61 prostate 0 119 119 0 47 47 166
C62 testis 0 32 32 0 7 7 39
C64-C65 kidney and renal 10 47 57 11 18 29 86
pelvis
C66, C68 ureter and other 0 3 3 1 1 2 5
urinary organs
C67 urinary bladder 11 47 58 11 30 41 99
C69 eye 0 2 2 1 4 5 7
C70-C72 brain and CNS 29 46 75 13 11 24 99
C73 thyroid 173 61 234 83 27 110 344
C74-C75 other endocrine 3 5 8 4 2 6 14
glands
(continued)
Table 1 (continued)
Non-UAE citizens UAE citizens “Grand
Primary Site ICD-10 Female Male Total Female Male Total total”
C76-C80 unknown and 26 24 53 7 9 16 69
unspecified sites
C81 Hodgkin’s lymphoma 14 30 44 6 12 18 62
C82-C85, C96 non-Hodgkin 30 89 119 24 27 51 170
lymphoma
C88, C90 multiple myeloma 13 37 50 2 8 10 60
C91-C95 leukemia 67 119 186 30 37 67 253
Other malignancy 9 9 18 3 1 4 22
(D00-D09) non-invasive 115 44 159 49 16 65 224
cancers (in situ cases)
“D00 carcinoma in situ of oral 0 3 3 1 0 1 4
cavity, oesophagus and
stomach”
“D01 carcinoma in situ of 2 8 10 2 2 4 14
other and unspecified
digestive organs”
D03 melanoma in situ 2 1 3 0 0 0 3
D04 carcinoma in situ of skin 2 2 4 0 0 0 4
D05 carcinoma in situ of 48 2 50 13 0 13 63
breast
D06 carcinoma in situ of 56 0 56 25 0 25 81
cervix uteri
“D07 carcinoma in situ of 3 3 6 2 0 2 8
other and unspecified genital
organs”
D09 carcinoma in situ of other 2 25 27 6 14 20 47
and unspecified sites
Grand total 1492 1363 2855 654 459 1113 3968
(British Heart Foundation 2020). A midwakh is a small smoking pipe of Arabian

origin in which dokha is mixed with aromatic leaf and bark herbs and smoked
(Vupputuri et al. 2016). The bowl of a midwakh pipe is typically smaller than that
of a traditional western tobacco pipe. It is usually loaded by dipping the bowl into a
container of dokha flakes (Jayakumary et al. 2010). Midwakh is primarily produced in
the UAE and Iran. Dokha has similar acute effects on blood pressure and respiratory
rates as other forms of smoking but is suspected to contain significant higher amounts
of carcinogens given the use of the tobacco mixture (Al-Houqani et al. 2012).
Cancer Prevention Program
There are several modifiable risk factors related to cancer incidence in the UAE.
There is an increased awareness of obesity-related malignancies and fighting child-
hood and adult obesity in the UAE (Malik and Bakir 2007). Related to this is that the
government has increased the tax on sweetened beverages in December 2019

(https://gulfnews.com/uae/from-december-1-payextra-for-sweetened-drinks-juices-
1.1575109321210 2020). This is in addition to other measures such as offering
counseling services and programs, and implementing healthy lifestyles to the general
public in the UAE.
Other cancer prevention approach regularly practiced in the UAE is related to
vaccinations. Examples include the hepatitis B vaccine which is mandated in the
UAE in 1991 (Four per cent rise in hepatitis B, C 2012), in large part because
hepatitis B virus infection is related to hepatocellular carcinoma (Xu et al. 2014).
Moreover, the government now screens all new migrants to UAE for hepatitis B and
C infections and checks for hepatitis B immunity and vaccination profiles from 2006
(Screening for Hepatitis for newly employed Health Care Workers 2006).
Another vaccine that is strongly associated with decreasing cancer is the human
papillomavirus (HPV) vaccine. Optional HPV vaccinations have been provided to
all public and private school girls ages 11–12 years since 2008 (Immunization
guidelines - Dubai Health Authority 2020). Further efforts include educating the
public on HPV vaccinations for both cervical and also head and neck cancers in the
UAE, in part because there may be some misconceptions about HPV vaccines
(Elbarazi et al. 2016).
The most important cancer prevention strategy is most likely smoking cessation
programs. Smoking is prohibited in indoor public spaces within the UAE, and the
taxation on tobacco products has been increased in the UAE (Gulf News hgcuf-d–d-
t-b-c-a-e-t-o-i-cs-i-u-A–: Gulf News 2020). The government banned all advertising
of tobacco products in the UAE (as of early 2014) and also mandated warning labels
on all cigarette packages, and restricted selling any tobacco products to anyone less
than 18 years of age. Moreover, the government introduced a law banning smoking
inside personal vehicles in the presence of a child below the age of 12 (UAE Anti-
tobacco 2014). Some Emirates have banned smoking shisha in public areas (Shisha
smoking will invite Dh500 fine in Sharjah 2020).
Cost-Effective Oncology Care
Cost of cancer care is always a burden on both individuals and governments. This
poses a special challenge in the UAE given the expected increase in cancer cases
requiring diagnosis and treatment. Advances in cancer therapy (with new and
expensive drugs such as immunotherapies) means that cancer has become a chronic
disease. Recent efforts led by the EOS (Entrepreneurial Operating System) in the
UAE has attempted to address cost issues by bulk purchasing of drugs from
pharmaceuticals rather than having individual hospitals or institutions buying it
individually (Al-Shamsi et al. 2020a). Finally, seminars and meetings are regularly
held in the UAE to promote awareness of biosimilar agents to benefit UAE cancer
center formularies.
There is a strong drive to ensure reimbursement of costs associated with other
more expensive cancer treatment modalities such as radiotherapy using a per site
model rather than based on per fraction of radiotherapy (Proposed Radiation Oncol-
ogy (RO) Model 2020). This represents more cost-effective treatment of cancer
patients, decreasing the number of treatments, and hence decreasing the potential
days off for patients and their direct family care givers who often drive patients to the
radiotherapy facilities.
Regulation of the use of advanced imaging modalities such as positron emission
tomography (PET/CT) scan has been implemented and this has decreased the costs
of follow-up scans cancer patients often need. Moreover, unnecessary MRI or CT
scans have also been regulated in order to prevent unnecessary and potentially
harming scans for the patient (The Use of Positron Emission Tomography (PET)
for Cancer Care Across Canada, Time for a National Strategy, Susan D. Martinuk
2011).
Another way of cost reduction is early detection and screening for common
cancers. The UAE health authorities have created nationwide cancer screening
programs (United Arab Emirates 2018). However, compliance to these screening
programs is still low. Despite this, there are significant decrease sin patient pre-
senting with advanced stage cancers such as breast cancer, where stage IV breast
cancer diagnosis decreased from 20% to 6% (UAE-NATIONAL ROT, et al.: CAN-
CER INCIDENCE IN UNITED ARAB EMIRATES ANNUAL REPORT OF THE
UAE-NATIONAL CANCER REGISTRY-2015 2020).
Medical Tourism in the UAE
“Medical tourism” defined as the process of intentional travel outside the country of
residence for the purpose of receiving medical care (Connell 2013). There are a
significant number of patients in the UAE who are supported by the government
when seeking cancer care abroad (600 million UAE Dirhams spent on cancer care
medical tourism 2014). Each case is evaluated individually and decisions are made
on whether or not specialized treatment can only be provided abroad. Sponsoring
agencies include the UAE official health authorities, presidential affairs, armies
forces, police, charity organizations as well as direct self-payment from patients.
Oncology and orthopedic surgery constitutes the highest percentage of medical
tourism undertaken by UAE citizens; treatment for cancer constitutes the highest
number of trips and expenditure (Salim et al. 2009). Most of these cancer patients are
treated in the USA, South Korea, Germany, Singapore, and Thailand (Sahoo n.d.).
Oncology Physicians
Oncology societies in the UAE have experts from different nationalities and who
received training in many different parts of the world, such as in North American,
Europe, the Middle East, and India. There are 34 medical and radiation oncologists
registered in the Department of Health of Abu Dhabi Emirate, 26 in the Dubai Health
Authority, and 6 in the Northern Emirates, making a total of 66 registered
oncologists within the UAE (Ministry of Health UAE wide physician census 2016
2016); however, the number of oncologist per 100,000 population remains less
compared to North America and countries in Europe (American Society of Clinical
O 2017). However, the numbers in the UAE are higher than in Turkey and India
which have a larger population.
Specialized Oncology Services
Advanced Treatments
Access to approved medication, even recent immunotherapy drugs, is relatively easy

within the UAE. Patients are usually offered medications as soon as they are
approved by the United States Food and Drug Administration (FDA). Hospitals
offering those drugs usually request it directly from the pharmaceutical companies,
and the drug cost is covered if indicated. One approach to decrease the cost of these
medications is bulk ordering governed by the government rather than directly
by hospitals, as suggested in the recent EOS consensus group recommendations
Radiation Oncology
Highly specialized oncology services such as nuclear medicine and radiation oncol-
ogy are becoming more accessible in the UAE. As radiation oncology usually
includes a significant expenditure and requires complex machinery and maintenance
plans, several public, private, and combination private/public hospitals and facilities
provide this service within the UAE. Radiation oncology is currently offered in one
government and one private facility in Abu-Dhabi, two private facilities in Dubai,
and one public facility in Ras-Al-Khaimah (northern Emirate). However, significant
expansion is expected as several facilities, hospitals, and healthcare systems have
announced plans to provide radiation therapy for the entire spectrum of cancer
treatments (Al-Shamsi et al. 2020a).
Pediatric Oncology
Despite UAE having a mostly young population, pediatric hematology and oncology
cases are within expected percentages, with a total of 165 children (aged 0–14)
diagnosed with cancer in the UAE in 2015 (UAE-NATIONAL ROT, et al.: CAN-
CER INCIDENCE IN UNITED ARAB EMIRATES ANNUAL REPORT OF THE
UAE-NATIONAL CANCER REGISTRY-2015 2020). There are several pediatric
oncology centers within the UAE, located in both public and private hospitals. These
facilities are well staffed with pediatric oncologists, nursing staff, therapists, and
radiation therapy facilities. However, the biggest limitation in pediatric oncology in
the UAE remains in the lack of a hematopoietic stem cell transplant center. However,
several cancer facilities and centers are being established in the country to address
this concern (Al-Shamsi et al. 2020a).
Bone Marrow Transplantation
Malignant hematology care is available in the UAE; however, no hospital is currently

providing bone marrow transplant services, meaning that adult and pediatric patients
in the UAE who require hematopoietic stem cell transplant have to travel abroad to
receive it. This entails significant distress and cost on the patient, their families and to
the healthcare providers. Several models have been initiated and led the UAE gov-
ernment to establish a hematopoietic stem cell transplant within the UAE to cover this
demand (Al-Shamsi et al. 2020a). This situation will also change in the near future as
several leading hospitals and healthcare facilities have also announced plans to include
bone marrow transplant services within the UAE in the near future.
Palliative Care
Early access to palliative care improves patient quality of life and outcomes, leading
to a strong call to promote palliative and support care within the UAE (Ambroggi
et al. 2018). The Tawam hospital (which is the first tertiary cancer care facility in the
UAE) provides palliative care, as does other private oncology providers in the
country. Moreover, the federal government has passed a law (in 2016) that permits
natural death of patients with limited medical intervention or resuscitation in patients
with an incurable disease, or after receiving the advice of the patient’s primary
physician and at least three other consulting doctors. This happens through the
request and approval of the patient, or patient’s guardian (if the patient is unable to
provide consent). Another recent EOS recommendation is to establish a national
palliative and supportive care program across multiple locations in the UAE as part
of the national cancer control plan (Al-Shamsi et al. 2020a).
Cytogenetics and Molecular Genetics
Liquid biopsy, or evaluating circulating tumor DNA (ct-DNA) components, is an

integral part in cancer diagnosis and follow-up response assessment (Sokolenko and
Imyanitov 2018). Access to specialized laboratories equipped for either ct-DNA
detection or molecular testing on cancer specimens is gaining momentum in the
UAE. This will help to individualize cancer treatments and assess the most suitable
target for therapy in the near and distant future, and provide cancer patients with
further treatment options. The recently established Emirates Oncology Society out-
lines the different types of molecular and genetic testing that is currently available, and
is easily accessible for all practicing oncologists in the UAE (https://www.eos.ae).
Research
Research is highlighted more by oncology societies in the UAE. Despite the relatively
limited research capacity, recent publications led by investigators in the UAE are
appearing in premiere medical journals (Abu-Gheida et al. 2020; Al-Shamsi et al.
2020b; Al-Shamsi et al. 2020c). Research specifically targeting the UAE population
should be evaluated in light of the unique biological and epigenetic variables in the
UAE which likely will be different to that in other societies. An example is the earlier
onset of breast cancer in the UAE compared to Western countries (Humaid et al. n.d.).
Therefore, treatment protocols based on a Western-based population may have to be
modified to fit the unique patient population in the UAE.
Education and Training
Dedicated oncology training programs are increasing in the UAE. The first medical
oncology fellowship program was launched in November 2019 at the Tawam
hospital. Other programs in government and private sector hospitals have some
oncology training programs, but as the scope of practice increases, more advanced
training programs are planned for the UAE, allowing medical professional from the
region to train and practice in the UAE (Al-Shamsi et al. 2020a).
Future of Cancer Care in the UAE
Cancer care is improving in the UAE, and the collaboration of public and private
sectors has led to the creation of organizations such as the Emirates Oncology
Society, which aims to standardize oncology care in the UAE (Al-Shamsi et al.
2020a). However, the UAE government continues to support cancer care and cancer
patients within the UAE and those needing and seeking treatment abroad even
though most cancer treatment modalities and therapies are currently available in
the UAE. The Federal Cancer Care Agency advises patients on cancer care. Fur-
thermore, the Federal National Cancer Registry the UAE national cancer regis-
try plays an important role in planning cancer care across the country and in
allocating resources based on populations need.
The cancer system quality index is being established by the UAE Oncology
Society. This will apply variables such as waiting times from diagnosis to treatment,
chemotherapy utilizations, radiation treatment timelines and treatment delivery,
surgical, chemotherapy, and radiotherapy-related complications monitoring. This
model is based on the quality measurement advisory council in Ontario (Canada),
which established an independent advisory cancer care quality council to help unify
and standardize treatment of cancer patients (Anas et al. 2013; Wild and Patera
2013). To make this a reality, it is important that all cancer cares and practices in the
UAE work collaboratively with world leading cancer institutions to regularly mon-
itor outcomes.
Several new cancer care tertiary centers have been announced in the UAE in both
the government and private sectors. These hospitals usually collaborate with world-
leading cancer care facilities, for example, Johns Hopkins Hospital’s collaboration
with Tawam Hospital, the collaboration between the Mayo Clinic and Sheikh
Shakhbout Medical City, and so on. These relationships will increase the number
of highly trained physicians in the UAE and offer complex and comprehensive
cancer treatment. Even though the Tawam Hospital remains the first comprehensive
cancer care facility in the country, its location (far eastern end of the country) makes
transportation to and for the facility more challenging. Therefore, cancer care facility
growth elsewhere will help to establish a comprehensive cancer service that is more
easily accessible to patients within the UAE.
Despite a relatively small population, the UAE’s number of cancer patients is
increasing especially as the economy and population increases in the region. This is
predicted to increase the number of cancer patients that will have better clinical
outcome when treated in high-volume specialized cancer care facilities (Pfister et al.
2015). The recent Emirates Oncology Society recommendations for a new central-
ized cancer care facility equipped with multiple satellites represent the best solution
for a centralized cancer care with accessible clinics throughout the country
Another recommendation that EOS recently released was the establishment of a
nation-wide cancer electronic health record system (Al-Shamsi et al. 2020a). Cur-
rently the EOS has established an online website where all genetic workup platforms
are available for oncologist to request (https://www.eos.ae). A future direction could
be to possibly utilize such platforms to unify treatment protocols by different
institutions, and establish a national chemotherapy/immunotherapy ordering system
to optimize resource allocation across the UAE.
Finally, as cancer care involves a multidisciplinary approach, a centralized virtual
multidisciplinary tumor board could span different health governing facilities across
the UAE. This body should ideally guide the diagnosis and management of all newly
diagnosed cancer cases in the UAE.
Conclusion
The United Arab Emirates healthcare system is one of the leading healthcare systems
worldwide, despite its relatively young age. Comprehensive oncology care is avail-
able in several public and private healthcare facilities. Advancements are planned in
the near future to make the UAE a central part of inflowing medical tourism. Highly
trained healthcare providers, along with government financial and logistic support,
have improved complex cancer care in the UAE. Further steps and development are
needed in collaboration with other national and international cancer centers and
those in the Arab world.
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Cancer Care in Low- and Middle-Income
Countries Affected by Humanitarian Crises 25
Jude Alawa, Adam Coutts, and Kaveh Khoshnood
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 541
Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 541
The Epidemiologic Transition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 542
Challenges of Providing Cancer Care in Humanitarian Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . 544
Chapter Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 546
The Burden of Cancer in the Arab World . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 546
Cancer Prevention and Treatment Strategies in Humanitarian Settings . . . . . . . . . . . . . . . . . . . . . . . . 548
Overview of Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 548
Characteristics of Intervention Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 549
Inpatient Facility-Based Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 549
Outpatient Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 557
Community-Based Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 558
Innovative Financing for Cancer Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 559
Barriers and Facilitators of Cancer Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 561
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 561
Implications for Policy and Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 561
Discussion of Main Findings and Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 568
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 570
J. Alawa
Stanford University School of Medicine, Stanford, California, USA
e-mail: jalawa@stanford.edu
A. Coutts
Department of Sociology, University of Cambridge, Cambridge, UK
e-mail: apc31@cam.ac.uk
K. Khoshnood (*)
Yale School of Public Health, New Haven, CT, USA
e-mail: kaveh.khoshnood@yale.edu

https://doi.org/10.1007/978-3-030-36811-1_215
540 J. Alawa et al.
Abstract
Low- and middle-income countries affected by humanitarian crises now have
older populations with chronic noncommunicable diseases that require long-term
access to specialist care and treatment. Cancer is cited as one of the most common
and deadly noncommunicable diseases in countries experiencing humanitarian
crises, but very little information exists to assess the burden of cancer in such
contexts. Cancer is also a condition that requires access to screening programs,
diagnostic services, surgical treatment, radiotherapy, or chemotherapy. While
resource-stratified clinical guidelines for the prevention and treatment of cancer
in stable settings are available, guidance on addressing cancer during humanitar-
ian emergencies is limited. An analysis of the descriptive epidemiology of cancer
across the Arab World reveals a marked increase in both cancer incidence and
mortality from 2009 to 2019, especially for several low- and middle-income
countries experiencing humanitarian crises. These countries facing humanitarian
situations in the Arab World were found to have some of the highest cancer
incidence and mortality rates among Arab countries. Furthermore, 12 peer-
reviewed publications on cancer prevention and treatment in Jordan, Syria,
Lebanon, Turkey, Nepal, and Pakistan were identified. The interventions and
policies fall into four main categories: (1) inpatient facility-based interventions,
(2) outpatient interventions, (3) community-based interventions, and (4) innova-
tive financing for cancer treatment. A massive influx of additional resources is
required to accurately assess the burden of cancer and to provide comprehensive
cancer prevention and treatment services in low- and middle-income countries
experiencing humanitarian crises. Opportunities exist to improve cancer care in
such contexts, including investing in the development of cancer registries,
improving cancer prevention and screening capacity, increasing the availability
of specialized health services, implementing innovative financing schemes,
empowering refugee and host community perspectives, and developing a policy
framework for cancer care in humanitarian settings.
Keywords
Cancer · Chronic disease · Arab World · Humanitarian crisis · Refugee ·
Displacement · Access to health care · Barriers to treatment
Abbreviations
GBD Global Burden of Disease
GCO Global Cancer Observatory
HDI Human Development Index
IDPs Internally Displaced Persons
IRC International Rescue Committee
LMICs Low- and Middle-Income Countries
NGOs Nongovernmental Organizations
UN United Nations
25 Cancer Care in Low- and Middle-Income Countries Affected by Humanitarian. . . 541
UNHCR United Nations High Commissioner for Refugees

UNRWA United Nations Relief and Works Agency for Palestine Refugees in
the Near East
Introduction
Background
By the end of 2019, the United Nations High Commissioner for Refugees
(UNHCR) recorded 79.5 million people of concern worldwide that were forcibly
displaced as a result of humanitarian emergencies involving, but not limited to,
persecution, conflict, natural disasters, and human rights violations (UNHCR 2020).
This figure accounts for 26 million refugees, 45.7 million internally displaced
persons (IDPs), and 4.2 million asylum seekers (UNHCR 2020). The combined
number of refugees and IDPs – 71.7 million – has more than doubled since 2010 and
has almost tripled since 2000 (Abdul-Khalek et al. 2020). Displaced communities
and underserved host communities represent extremely vulnerable populations in
humanitarian settings and require targeted support, which is typically the task of
national and host governments, international agencies, and other humanitarian
actors to provide.
Despite the growing number of people of concern across the globe, humanitarian
actors, including international agencies and host governments, have struggled to
address their health needs, in part because the norm of humanitarian emergencies has
changed and can now be characterized by protracted crises and fragility that occur in
higher-income countries with comparatively healthier populations (Spiegel et al.
2010; Wal 2015). Middle-income countries affected by conflict now have older
populations with chronic noncommunicable diseases (NCDs) that require long-
term access to specialist care and treatment (Doocy et al. 2015). The four main
types of NCDs are cancer, cardiovascular disease, respiratory disease, and diabetes
(WHO 2018). Managing these conditions effectively requires a robust health system,
as opposed to short-term humanitarian campaigns. Although NCDs represent a
substantial burden in both refugee and host communities requiring humanitarian
support, traditional approaches to providing humanitarian aid have centered primar-
ily on the provision of health-care services to address communicable diseases
(Connolly et al. 2004). That being said, globally, NCDs are the leading cause of
death, and approximately 80% of deaths linked to NCDs occur in low- to middle-
income countries (LMICs), where humanitarian emergencies are concentrated
(Amara and Aljunid 2014). For instance, the pervasiveness of NCDs among urban
refugees in the Middle East is immense and ranges from 9% to 50% depending on
the refugees’ country of origin, with cancer, hypertension, musculoskeletal disease,
diabetes, and chronic respiratory disease among some of the most common NCDs
(Amara and Aljunid 2014). With millions of refugees, IDPs, and host community
members in Arab World countries affected by humanitarian crises suffering from a
542 J. Alawa et al.
substantial burden of NCDs, there is a clear need for stakeholders to transition their
health response in humanitarian settings to NCDs.
Among the different types of NCDs, cancer is considered a particularly difficult
challenge to address in humanitarian settings. Cancer is not only one of the leading
causes of mortality worldwide, but it is also a condition that requires a health system
that can guarantee access to continuous specialist care and treatment, involving
screening programs, diagnostic services, surgical treatment, radiotherapy, or chemo-
therapy (Abdul-Khalek et al. 2020; Levit et al. 2013). In addition to 50% of the
region experiencing protracted humanitarian emergencies, the World Health Orga-
nization (WHO) Eastern Mediterranean Region, which is home to much of the Arab
World, is expected to have the greatest increase in cancer incidence during the next
15 years among all WHO regions (Alawa et al. 2019c). The growing prevalence of
cancer, as well as other NCDs, in LMICs affected by humanitarian crises is typically
attributed a phenomenon called an epidemiological transition (Franceschi and Wild
2013). In spite of this phenomenon, the international humanitarian and global health
communities have been slow to recognize and address the rapid increase in NCDs,
including cancer, that has occurred in countries where humanitarian support is
needed. In fact, conversations surrounding this gap in the provision of chronic
disease care in humanitarian settings have only really begun to be addressed in the
past five years, and much of the focus has been on cardiovascular diseases, hyper-
tension, or diseases with severe and immediate outcomes should care be disrupted
(Slama et al. 2017; Mullins 2012; Van Biesen et al. 2016). In light of this, cancer care
in humanitarian settings remains a substantially neglected gap, in large part because
of the financial costs involved and the health service capacity needed to provide
comprehensive care (Abdul-Khalek et al. 2020).
The following sections describe the rise of NCDs, with an emphasis on cancer,
in LMICs affected by humanitarian emergencies, the unique challenges faced in
providing cancer prevention and treatment services in such contexts, and gaps in the
global evidence base on the burden of cancer and the effectiveness of interventions
targeting cancer during humanitarian crises.
The Epidemiologic Transition
Approximately 84% of the nearly 80 million individuals who have been forced to
flee their homes are hosted by LMICs, which are overwhelmingly the sites of
complex and protracted humanitarian crises (Alawa et al. 2020). A combination of
demographic and epidemiological changes is quickly shifting the disease profiles of
several LMICs, including those affected by humanitarian emergencies (Bollyky
et al. 2017). NCDs have increased dramatically in LMICs as a result of a decrease
in infectious diseases that disproportionately kill infants and children and an increase
in the prevalence of modifiable behavioral risk factors for chronic illnesses, includ-
ing unhealthy diets, substance use, and a sedentary lifestyle (Bollyky et al. 2017).
For cancer specifically, these behaviors include tobacco consumption, alcohol use,
poor nutrition, and a lack of physical activity (Alawa et al. 2019b). While such risk
factors increase in LMICs experiencing humanitarian emergencies, population aging

and growth are accelerating the shift of heath profiles from communicable to
noncommunicable diseases (Bollyky et al. 2017). This phenomenon is commonly
referred to as an epidemiologic transition, a process by which the pattern of mortality
and disease within in a given population becomes less characterized by a health
profile of infectious diseases and high mortality among infants and children, and
instead becomes more characterized by a health profile of degenerative chronic
NCDs that primarily affect older-age groups (Franceschi and Wild 2013). The
epidemiologic transition model is thought to closely coincide with the demographic
transition model, which describes a historical shift from high birth rates and high
infant death rates in less developed societies with low levels of economic develop-
ment to low birth rates and low death rates in societies with more advanced
technology, education, and economic development (McCracken and Phillips 2016).
Understanding the scale and speed of epidemiologic transitions at the country
level is critical for planning the delivery of cancer care services and policy forma-
tion. It is also important in garnering support from the international community to
address NCDs, which receive only 2% of overseas development assistance for health
worldwide (Dieleman et al. 2015). In one study evaluating expected shifts to NCDs
among LMICs, dramatic increases in the burden of premature death and disability
from NCDs were predicted, especially among populations aged 35 and older
(Bollyky et al. 2017). These results suggest that increases in death and disability
due to NCDs will primarily be driven by demographic changes, such as populating
aging and growth that will not be sufficiently countered by less substantial improve-
ments in addressing the morbidity and mortality of NCDs. These disparities are
reinforced by analyses that demonstrate that countries that will experience the
greatest increases in death and disability from NCDs over the next 25 years are
also projected to have the smallest increases in health spending, which is troubling
given that NCDs like cancer often require lengthy and expensive treatments and the
use of advanced health-care technologies (Bollyky et al. 2017).
Because the countries expected to experience the greatest increases in death and
disability from NCDs appear to be the least prepared, health providers and
policymakers in these settings have sought to quantify the burden of chronic
illnesses as a means to identify toward which conditions limited resources should
be allocated. However, literature assessing the burden of NCDs in LMICs affected
by humanitarian crises is extremely limited, and very little primary data on the
incidence, prevalence, cure rate, and death rate of cancer specifically within in
humanitarian settings actually exists (Salim et al. 2009). Of the information available
on NCDs, most efforts have been directed toward studying the burden of NCDs in
the Middle East and North Africa, particularly among Syrian refugees. In 2018,
NCDs accounted for 74% of deaths in the Middle East and North Africa (McNatt
2020). Similarly, NCDs are reported to account for 84% and 76% of deaths in
Lebanon and Jordan, respectively (Mowafi 2011). In pre-conflict Syria, NCDs
accounted for 77% of all deaths, and as of 2019, the majority of the over 7 million
displaced Syrians reside in Jordan, Lebanon, and Turkey, where they are expected to
harbor a similar health profile characterized by chronic illnesses (Mowafi 2011).
544 J. Alawa et al.
Moreover, a recent study examining the prevalence of NCDs among noncamp

Syrian refugees in northern Jordan showed that 21.8% of adults suffered from at
least one NCD (Naja et al. 2019). Another study conducted found that among Syrian
refugees in Lebanon, over half (50.4%) of refugee households reported at least one
member with an NCD (Doocy et al. 2016). With respect to cancer specifically, one
study in Turkey identified found that 38,243 Syrian refugees had cancer and that the
most common types were breast (28.21%), lymphoid leukemia (8.11%), colon
(6.57%), Hodgkin’s lymphoma (4.87%), brain (3.51%), myeloid leukemia
(3.23%), and non-Hodgkin’s lymphoma (2.80%) (Göktaş et al. 2018). A similar
study conducted used age- and sex-specific population-based incidence rates to
estimate that 869 Syrians are diagnosed with cancer in Jordan annually (Mansour
et al. 2018). Despite the significant pressure NCDs are placing on LMICs countries
affected by humanitarian situations and their health systems, there remains a gap in
humanitarian actors’ knowledge of the exact burden of different NCDs in these
settings, such that they can allocate the appropriate resources and create targeted
programs, including those for the provision of cancer care.
Challenges of Providing Cancer Care in Humanitarian Settings
Humanitarian emergencies can cause major disruptions in access to existing health

resources and impair the capacity of these services to meet health needs as a result of
a breakdown in authority, health-care systems, or societal cohesiveness (Perone et al.
2017). LMICs are disproportionately affected by humanitarian crises and often
already have fragile health-care systems that are not able to respond to chronic
health needs. In Syria, for example, only 64% of hospitals and approximately 52% of
primary care centers are still functional; additionally, about 70% of the Syrian health-
care workforce has left the country due to the conflict (OCHA 2020). Beyond the
risk of acute illnesses and injuries that may result directly from a crisis, humanitarian
situations also exacerbate preexisting chronic conditions and risk factors for the
development of chronic conditions like cancer (Perone et al. 2017).
Of all NCDs, cancer prevention and treatment are extremely challenging to
provide in limited-resource humanitarian settings. Poor hygiene, unstable living
conditions, limited health education, poor access to care, and scarce resources in
these settings exacerbate cancer risk factors and contribute to late-stage diagnosis
(Spiegel et al. 2010; Cavalli 2016). In Lebanon, for example, because the majority of
inhabitants are concentrated among the urban poor, they compete for limited services
available to this demographic and grapple with lifestyles characterized by aforemen-
tioned risk factors for cancer (Amara and Aljunid 2014). Early detection of cancer is
critical to improving health outcomes, and a delay of 3 months or more before
diagnosis has been shown to be correlated with increased morbidity and mortality
(Richards et al. 1999). In many LMICs affected by humanitarian crises, the time
from symptom recognition to diagnosis exceeds this time.
Even given timely diagnosis, patients with cancer in crisis settings often suffer
from a lack of access to affordable treatment. Based on the Lebanese Ministry of
Public Health’s utilization and spending data, the annual average cost of cancer drug
treatment, which does not include radiotherapy, is US$6475 per patient, and Syrian
refugee families have been reported to earn an average monthly income of less than
$300 (Elias et al. 2016; World Food Programme et al. 2018). More broadly, national
governments in low-income countries spend approximately 23 US Dollars (USD)/
person annually on health, adjusting for purchasing power parity, while the US
government spends 3860 USD/person on health and the UK government spends
2695 USD (Dieleman et al. 2017; Bommer et al. 2018). The consequence of such
drastic disparities in government spending on health care is that most health services
and medicines are financed out of pocket or by donors in LMICs. When financing is
not available through insurance schemes or donor funding, many important health-
care services, such as those for cancer treatment, are too expensive in such contexts.
As a result, individuals in lower-income humanitarian settings are more likely to
receive late diagnoses for cancers. In the same way, without sustained access to
cancer care because of limited finances, patients with cancer in these contexts are
more likely to die or suffer from disability (Bollyky et al. 2017).
Furthermore, due to the turbulence and unpredictability of humanitarian situa-
tions, individuals seeking diagnostic services or who are already diagnosed with
cancer often see their access to health services disrupted due to a lack of availability
or a lack of access to those services. Access to diagnostic instruments and pathology
services are often limited in humanitarian settings, which results in delays in
processing specimens and interpreting biopsy results (Wilson et al. 2018). In addi-
tion, many countries have limited infrastructure to deliver comprehensive oncology
care, such as chemotherapy or radiation oncology services. For example, approxi-
mately 23% of functional public hospitals in Syria had available cancer treatment
services, and only 46% of patients with cancer in Syria had completed radiotherapy
treatment without interruption (WHO 2017b; WHO Syria Office 2016).
Other factors that may disrupt or prevent access to treatment and diagnostic
services in these settings include fear, distance, time away from work, familial
obligations, cultural stigma, and a variety of similarly interconnected factors (Ban-
ning et al. 2009; Morse et al. 2014; Price et al. 2012). One of the main predictors of
care-seeking behavior for cancer is cancer awareness (Alawa et al. 2019b). Cancer
awareness has been shown to have the potential to contribute to better treatment
outcomes by promoting early diagnosis and treatment (Smith et al. 2005). Patient-
meditated barriers to seeking care for cancer include education level, health literacy,
and employment status, all of which influence knowledge and awareness of cancer
symptoms (Sharma et al. 2012; WHO 2017). That being said, levels of cancer
awareness in humanitarian settings have been found to be especially low. In Jordan,
one study with 3196 participants found that although most participants recognized
the need for regular screening to promote early diagnosis and treatment, only 10% of
participants had received a cancer screening (Ahmad 2015). In Lebanon, two studies
found that both Lebanese citizens and Syrian refugees had low levels of cancer
education and were only able to recognize a low number of cancer symptoms and
risk factors (Alawa et al. 2019b; Telvizian et al. 2020). As a result of low levels of
cancer awareness, as well as a complex interplay of barriers and heightened risk
546 J. Alawa et al.
factors, cancer patients in humanitarian settings often present with an advanced stage
of cancer, which leads to poor health outcomes in many cases.
Chapter Objectives
It is well documented that the global evidence base of research on both the burden of
cancer and interventions to facilitate cancer prevention and treatment in LMICs
affected by humanitarian crises is extremely limited in both quality and quantity
(Ruby et al. 2015; Shah et al. 2020; Alawa et al. 2019c). While resource-stratified
clinical guidelines for the prevention and treatment of cancer in stable settings are
available, little information exists to provide during humanitarian guidance on
addressing cancer emergencies (WHO 2013). Therefore, it is unclear which cancer
care interventions are feasible and effective in such settings and to what extent they
are needed. There have been several calls to action to develop a better understanding
of both the burden of cancer and cancer care interventions in humanitarian settings
(Alawa et al. 2019c; Ilbawi and Slama 2020). However, no recent reviews have
specifically examined the evidence on cancer rates and the effectiveness of inter-
ventions targeting cancer during humanitarian crises. Such a review has the potential
to be powerful in informing future research, policies, and programming by quanti-
fying the burden of cancer and identifying effective interventions and evidence gaps
(Kayabu and Clarke 2013).
The aims of this chapter are to provide empirical estimates of the burden of cancer
in Arab countries experiencing humanitarian crises, and to identify and explore
policies and interventions, implemented by governments, aid agencies, and other
international actors, that aim to support cancer prevention and treatment in human-
itarian settings.
The Burden of Cancer in the Arab World
Twenty-two countries make up the Arab World. In Table 1, information on the

Human Development Index (HDI) rating, HDI world rank, percent change in cancer
incidence and mortality between 2009 and 2019, and 2020 age-standardized cancer
incidence and mortality rates are given for each country in the Arab World. Cancer
incidence and mortality rates between 2009 and 2019 were obtained from Global
Burden of Disease (GBD) Results Tool, while 2020 rates were obtained from the
Global Cancer Observatory (GCO) GLOBOCAN database (Institute of Health
Metrics and Evaluation 2020; Ferlay et al. 2020). The countries that experienced
the greatest percent increases in cancer incidence from 2009 to 2019 in Arab World
include the United Arab Emirates (27.95%), the Syrian Arab Republic (24.23%),
Bahrain (20.08%), and Libya (15.48%). It should be noted, however, that many
LMICs experiencing humanitarian crises within the Arab World also had marked
increases in cancer incidence from 2009 to 2019, including the Syrian Arab Republic
(24.23%), Libya (15.48%), Jordan (9.89%), Palestine (8.90%), and Iraq (8.67%).
25
Table 1 Cancer statistics in Arab countries affected by humanitarian crises (Institute of Health Metrics and Evaluation 2020; Ferlay et al. 2020; UNDP 2019)
Human Rank Percent change in cancer Percent change in age-standardized 2020 age-standardized 2020 age-standardized
Development on incidence/100,000 persons (world) cancer mortality/100,000 (world) cancer (world) cancer
Country Index (2019) HDI between 2009 and 2019 (%) persons between 2009 and 2019 (%) incidence/100,000 persons mortality/100,000 persons
Algeria 0.748 91 8.55 18.26 135.3 76.1
Bahrain 0.852 42 20.08 38.87 112.2 64.3
Comoros 0.554 156 10.63 19.54 111.8 79.0
Djibouti 0.524 166 11.53 20.13 91.0 65.3
Egypt 0.707 116 4.15 6.91 159.4 108.6
Iraq 0.674 123 8.67 28.25 134.9 84.7
Jordan 0.729 102 9.89 16.80 155.3 88.5
Kuwait 0.806 64 11.36 1.79 115.7 63.6
Lebanon 0.744 92 2.26 0.11 156.8 85.6
Libya 0.724 105 15.48 29.17 132.2 88.2
Morocco 0.686 121 4.33 30.57 148.3 87.9
Mauritania 0.546 157 9.95 5.19 108.6 78.3
Oman 0.813 60 9.42 25.63 103.8 64.6
Palestine 0.708 115 8.90 29.93 N/A N/A
Qatar 0.848 45 3.27 1.14 107.2 64.5
Saudi 0.854 40 13.25 14.26 96.4 51.3
Arabia
Somalia N/A N/A 0.06 5.20 118.1 90.9
Sudan 0.51 170 5.82 7.62 95.7 63.2
Syrian Arab 0.567 151 24.23 75.78 149.3 95.6
Republic
Tunisia 0.74 95 10.31 25.44 133.5 78.7
Cancer Care in Low- and Middle-Income Countries Affected by Humanitarian. . .
United Arab 0.89 31 27.95 107.73 106.7 55.9

Emirates
Yemen 0.47 179 6.76 10.53 97.0 76.5
547
548 J. Alawa et al.
A more drastic trend was observed for changes in cancer mortality over the past
decade. From 2009 to 2019, the countries that experienced the greatest increases in
cancer mortality in the Arab World include the United Arab Emirates (107.73%), the
Syrian Arab Republic (75.78%), Bahrain (38.87%), and Morocco (30.57%). Many
of the countries experiencing humanitarian crises in the Arab World also experienced
drastic increases in cancer mortality, including the Syrian Arab Republic (75.78%),
Palestine (29.93%), Libya (29.17%), Iraq (28.25%), and Jordan (16.80%). The
simultaneous rise of cancer incidence and cancer mortality rates in Arab countries,
especially those experiencing humanitarian crises, during this period suggests that
several countries’ health-care systems and the humanitarian campaigns supporting
them may have been ill equipped to both prevent and treat cancer cases. Age-
standardized cancer incidence data from 2020 reveals that the countries with the
highest cancer incidence rates in the Arab World are those that are also in the midst
of humanitarian emergencies due to conflict, displacement, or economic strife. These
countries include Egypt (159.4), Lebanon (156.8), Jordan (155.3) and Syria (149.3).
The same observation holds for age-standardized cancer mortality figures from
2020. The Arab countries with the highest cancer mortality rates are also those
facing humanitarian situations. These countries include Egypt (108.6), Syria (95.6),
Somalia (90.9), Jordan (88.5), and Libya (88.2).
Cancer Prevention and Treatment Strategies in Humanitarian

Settings
Overview of Studies
Twelve peer-reviewed studies that address cancer prevention and treatment strategies
in humanitarian settings from Jordan (n ¼ 3), Lebanon (n ¼ 4), Nepal (n ¼ 1),
Pakistan (n ¼ 1), Syria (n ¼ 1), and Turkey (n ¼ 4) were identified. Table 2 lists the
countries in which the research of each study took place and number of studies
included per country.
The 12 papers that qualified for inclusion in this analysis explored the implemen-
tation or evaluation of policies and interventions aimed at addressing cancer pre-
vention and treatment in LMICs affected by humanitarian settings. All of the studies
included were observational in nature, and one publication involved a pre-post-test
Table 2 Geographic distribution of included publications

Geographic distribution of included publications
Country Number of publications Country Number of publications
Jordan 3 Pakistan 1
Lebanon 4 Syria 1
Nepal 1 Turkey 4
Note: Some publications evaluated policies and interventions in several contexts. Therefore, the
total number of publications listed here exceeds the total number of publications included
intervention design. Nine studies provided a descriptive analysis of intervention

outcomes, while three provided detailed descriptions of interventions with little or no
analysis or measurement of effectiveness and intervention outcomes. Four of the
publications included focused specifically on pediatric cancer cases, while two
studies focused on the provision of cancer care and cancer education among
women. All of the included interventions and policies were aimed at displaced or
underserved populations. In addition, eight of the studies included involved inter-
ventions led or designed by nongovernmental organizations (NGOs) and interna-
tional organizations, such as the UNHCR. A summary of each study, including its
aims, intervention characteristics, intervention outcomes, and implementing organi-
zations, can be found in Table 3.
Characteristics of Intervention Delivery
The interventions and policies identified in this scoping review fall into four main
categories: (1) inpatient facility-based interventions, (2) outpatient interventions, (3)
community-based interventions, and (4) innovative financing for cancer treatment.
Several of the studies included also highlight important barriers and facilitators of
cancer care in LMICs affected by humanitarian crises. All interventions targeted
displaced or underserved populations, including those from Jordan, Syria, Iraq,
Palestine, Somalia, Yemen, Sudan, Pakistan, Afghanistan, Nepal, and Bhutan. A
diversity of actors led cancer care interventions in these contexts, including NGOs
(Multi-Aid Programs, Jordanian Women’s Union, American Lebanese Syrian Asso-
ciated Charities, Institute of Radiotherapy and Nuclear Medicine, and NFCC-Inter-
national), United Nations (UN) agencies (UNRWA and UNHCR), health facilities
(e.g., King Hussein Cancer Centre, American University of Beirut Medical Centre,
Children’s Cancer Center of Lebanon Foundation, and Mustafa Kamal University
Research Hospital), and governmental organizations (Turkish Ministry of Health
and Jordanian Breast Cancer Program).
Inpatient Facility-Based Interventions
The most commonly reported interventions for cancer treatment involved facilitating
treatment services in an inpatient setting. Five studies reported on the delivery of
inpatient cancer treatment. Four of these studies focused on the provision of cancer
treatment to Syrian refugees in government hospitals in Turkey between 2015 and
2018. Another study focused on providing cancer treatment to Afghani refugee
children.
Of the studies conducted in Turkey, one focused on providing cancer care to
refugee children, reporting that 212 refugee children with cancer were treated in 17
centers located in 10 different cities (Kebudi et al. 2016). The median age of patients
was 5 years, and 197 (93%) of patients were from Syria (Wal 2015). Most of these
patients (68%) were treated in regions in the south and southeast of Turkey, close to
550
Table 3 Key characteristics of included studies

Intervention/
Author Target Aim of Intervention/policy policy Outcomes of Implementing
and year Country population intervention/policy characteristics measurement intervention/policy organizations
Alawa Lebanon Syrian Provide breast Multi-Aid Programs, a Descriptive By the end of 2018, the Multi-Aid
et al. refugees cancer services to nongovernmental analysis of program had led a Programs
(2019a) displaced organization, established a services variety of breast cancer
populations in breast cancer program in provided awareness workshops
Lebanon 2015, providing breast cancer and had provided more
education, screening and than 4800
diagnosis, and treatment mammograms, 1500
coordination with in-country ultrasound screenings,
partners and 160 surgical
procedures, ranging
from biopsies to
aspirations, to
displaced women in
Lebanon. They also
diagnosed 76 new
cases of breast cancer
and followed up on 25
previously diagnosed
cases. Of these cases,
58% were diagnosed at
either stage 3 or stage 4
J. Alawa et al.
25
Bhatta Nepal Nepali Provide cervical Participants were Descriptive Of the 647 study NFCC-
et al. women; cancer screening administered a demographic analysis of participants, 8.9% had International
(2017) Bhutanese and referral for and health questionnaire. demographic HR-HPV infections
refugees/ further testing and Cervical-vaginal specimens characteristics and 7.1% had
women treatment, if were collected. Both self- and prevalence abnormal cervical
women had collected and clinician- of HR-HPV cytology. There were
abnormal cervical collected cervical-vaginal infection and no significant
cytology specimens were tested for abnormal differences in HR-
HR-HPV infection. Cytologic cervical HPV positivity or
exam was performed on cytology abnormal cervical
clinician-collected samples, cytology between
and cervical cytology results Nepali and Bhutanese
were categorized according to women
the Bethesda classification.
Women with abnormal
cervical cytology were
recommended for further care
Hakverdi Turkey Syrian Provide surgical Inpatient cancer treatment Descriptive Of 175 cases who Mustafa
et al. refugees treatment for provided to Syrian refugees in analysis of underwent surgery in Kemal
(2017) patients with brain a government hospital in patient the Brain Surgery University
tumors Turkey’s Hatay district demographics, Department at the Research
cancer type, Mustafa Kemal Hospital;
and treatment University Research Turkish
provided Hospital, 136 tumor Ministry of
cases were reported Health
Kebudi Turkey Syrian refugee Provide cancer Inpatient cancer treatment Descriptive Of 212 refugee Pediatric
et al. children treatment to (chemotherapy) provided to analysis of children treated with hospitals in
(2016) children and Syrian refugee children and patient cancer in 17 centers Turkey;
adolescents adolescents at pediatric demographics, located in 10 different Turkish
hospitals in Turkey cancer type, cities, 159 (75%)
551
(continued)
Table 3 (continued)
552
Intervention/
treatment patients were alive, 31 Ministry of
provided, and (15%) had died, and 22 Health
health (10%) were lost to
outcomes follow-up (median
20 months, IQR 1–48).
Khan Pakistan Pakistani Provide screening Hospital in Peshawar was a Descriptive Outcomes not Institute of
et al. children; for pediatrics major referral center for all analysis of the measured Radiotherapy
(1997) Afghan cancers and childhood cancers. cancer types and Nuclear
refugee referral for further Children were screened for diagnosed Medicine
children evaluation, if cancers, typically through
necessary blood tests or biopsies. Then,
they were provided treatment,
which was free of charge for
most patients
Oymak Turkey Syrian refugee Provide cancer Inpatient cancer treatment Descriptive Thirty-six children Turkish
et al. children treatment to (chemotherapy) provided to analysis of with leukemia and Ministry of
(2015) children and Syrian refugee children and patient other cancers were Health;
adolescents adolescents at pediatric demographics, treated with Pediatric
hospitals in Turkey cancer type, chemotherapy at a Hospital in
and treatment pediatric hospital in Turkey
provided Turkey, with 15
patients admitted for
disease relapse.
J. Alawa et al.
25
Saab Lebanon Displaced Provide cancer Humanitarian funding scheme Descriptive Of 575 non-Lebanese American
et al. Syrian care free of charge developed to support analysis of children suspected to University of
(2018) Children; displaced children with cancer participant have cancer, 311 Beirut Medical
Displaced demographics, received direct medical Centre;
Palestinian clinical support, including 107 Children’s
Children; characteristics, patients who received Cancer Center
Families budget trends, full treatment coverage of Lebanon
Traveling and health and 204 patients who Foundation;
from Iraq and outcomes received limited St. Jude
Syria; workup and specialty Children’s
Lebanese services. The Research
Children remaining 264 patients Hospital;
received medical American
consultations Lebanese
Syrian
Associated
Charities
Sethi Lebanon Syrian Provide Community-based primary Descriptive Cancer was identified Primary Health
et al. refugees community-based health care and health analysis of as a major concern Centers
(2017) noncommunicable promotion provided through patient among surveyed operated by
disease care trained refugee outreach demographics, Syrian refugees. No local NGOs;
volunteers health cancer specific Refugee
conditions, outcomes reported outreach
patient volunteers
satisfaction,
and services
provided
Spiegel Jordan, Registered Provide financial Funding scheme developed to Descriptive Outcomes not United Nations
et al. Syria refugees in support to refugees support registered refugees analysis of measured High
(2014) Jordan and with serious with serious medical patient Commissioner
Syria, medical problems; Exceptional Care demographics,
553
(continued)
Table 3 (continued)
554
Intervention/
including conditions, Committees (ECCs) types of for Refugees
Syrian, Iraqi, including cancer comprised of physicians of cancers, (UNHCR)
and Sudanese varying specialties make approvals and
refugees funding decisions based on funding, and
the following factors: reasons for
necessity and adequacy of the denial
suggested treatment, necessity
of assistance (financial
vulnerability), feasibility of
the treatment plan, disease
prognosis, cost of care, and
eligibility as a registered
refugee
Spiegel Jordan, Registered Provide financial Funding scheme developed to Descriptive Outcomes not United Nations
et al. Lebanon refugees in support to refugees support registered refugees analysis of measured High
(2020) Jordan and with serious with serious medical patient Commissioner
Lebanon, medical problems; Exceptional Care demographics, for Refugees
including conditions, Committees (ECCs) cancer type, (UNHCR)
Syrian, Iraqi, including cancer comprised of physicians of treatment
Somali, and varying specialties review coverage status,
Yemeni referrals on a case-by-case cost, and
refugees basis and determine the reasons for
degree of financial support to denial
be provided based primarily
on prognosis, cost, overall
UNHCR budget, and the
availability of funds at the
time of the application
J. Alawa et al.
25
Taha Jordan Palestinian Provide breast Educational intervention Analysis of pre- The mean knowledge Jordan Breast
et al. refugees cancer education to through home visits, which test interview- score increased Cancer
(2014) women living in included offering free administered significantly Program; King
the second largest mammography screening questionnaire (P < 0.001) from 11.4 Hussein
Palestinian refugee vouchers, on changing to assess breast in the pre-test to 15.7 Cancer
camp in Jordan women’s breast health health in the post-test Foundation;
knowledge and screening knowledge and (maximum score: 16). American Near
practices for early detection of practices at Significant East Refugees;
breast cancer; Home visit baseline and improvements were Jordanian
components: (1) a culturally post-test shown at 6 months Women’s
appropriate home-based interview- follow-up. Out of 625 Union; United
breast health educational administered women that received a Nations Relief
session from trained questionnaire voucher for free and Works
community health workers 6 months after a mammography Agency for
and (2) referral of women home visit. screening, 73% Palestine
aged 40 or older, who met the Analysis of attended the Refugees in
inclusion criteria, to a free-of- breast health mammography unit. the Near East
charge mammography knowledge, Women who received (UNRWA)
screening at a nearby changes in their a follow-up visit were
mammography unit reported breast more likely to use the
health mammography
practices, and voucher compared to
usage of the those who were not
free followed up with (83%
mammography versus 67%;
voucher P < 0.001)
(continued)
555
556
Table 3 (continued)
Intervention/
Temi Turkey Syrian Provide cancer Inpatient cancer treatment Descriptive The most common Hospital in
et al. refugees treatment to Syrian provided to Syrian refugees at analysis of cancer types were Sanliurfa;
(2017) refugees a hospital in Sanliurfa, Turkey patient breast and Turkish
demographics, gynaecological Ministry of
cancer type, cancers; 134 patients Health
stage of treated in total. The
diagnosis, majority of patients
treatment type, were diagnosed at a
and health late stage. Median
outcomes follow-up time was
14 months, and 11
patients died (8.2%).
One- and 2-year
survival rate of the
whole group were 93%
and 86%, respectively
J. Alawa et al.
Turkey’s border, and nearly half (45%) were treated in the city of Adana (Kebudi
et al. 2016). The most commonly diagnosed cancers among treated patients were
leukemia, lymphoma, and cancers of the brain and central nervous system (Kebudi
et al. 2016). When compared to Turkish children, the percentage of children with
neuroblastoma and bone tumors was significantly higher in refugees (Kebudi et al.
2016). In terms of outcomes, at the time of the study in October 2015, 159 (75%)
patients were alive, 31 (15%) had died, and 22 (10%) were lost to follow-up (median
20 months, IQR 1–48) (Kebudi et al. 2016). Outcomes did not differ by region of
treatment. Given the Turkish Ministry of Health’s legislation on the “Law of
Foreigners and International Protection,” registered Syrian refugees, including chil-
dren, from this study received free medical treatment – just like Turkish citizens, at
tertiary government and university hospitals (Kebudi et al. 2016). Another study that
focused on pediatric cancer among Syrian refugees in Turkey reported that 36
children with leukemia and other cancers were treated with chemotherapy at a
pediatric hospital in Turkey, with 15 patients admitted for disease relapse (Oymak
et al. 2015). The study found that most patients were admitted at an advanced stage
of cancer because they could not access treatment services in Syria due to the
ongoing war (Oymak et al. 2015).
Another study assessing in-patient cancer treatment in Turkey, specifically for
brain tumors, reported that out of 175 cancer cases that required surgical interven-
tion, 136 brain tumors were discovered (Hakverdi et al. 2017). These services were
provided by the Mustafa Kemal University Research Hospital, a government hos-
pital in the Hatay district that also provides free cancer treatment to registered Syrian
refugees (Hakverdi et al. 2017). Similarly, a hospital-based retrospective study
conducted in Sanliurfa, a city at the Turkish-Syrian border, assessed outcomes
among cancer-diagnosed Syrian refugees, 45% of which were diagnosed at an
advanced stage. In this study, 134 patients were treated for several different types
of cancers, most commonly breast (42.5%) and gynaecological cancers (10.4%),
between 2015 and 2017 (Temi et al. 2017). Ninety-one (67.9%) of patients were
admitted to the hospital from a refugee camp (Temi et al. 2017). Though the median
follow-up was 14 months and the 2-year survival rate of patients was 86%, 11
patients died (Temi et al. 2017). Additionally, a majority of patients completed all
cycles of chemotherapy. Another publication from Pakistan in 1996 reported on
cancer treatment for 1655 Afghan and host community children under 15 years of
age with biopsy-proven cancers (Khan et al. 1997). The authors claim that treatment
is provided free for the majority of patients and that patients are referred to major
teaching hospitals from provincial hospitals for treatment (Khan et al. 1997).
Outpatient Interventions
Two of the publications identified reported on the provision of cancer prevention and
screening services in outpatient settings. One study took place in Nepal and involved
Bhutanese refugees, while the other study took place in Lebanon and involved
refugees and underserved Lebanese residents. Bhatta et al. reports on an intervention
558 J. Alawa et al.
aimed to provide screening and referral, if necessary, for high-risk human papillo-
mavirus infection (HR-HPV) and abnormal cervical cytology among Nepali and
Bhutanese refugee women living in eastern Nepal (Bhatta et al. 2017). Participants
were recruited from a women’s health camp-based organization operated by NFCC-
International, an NGO (Bhatta et al. 2017). Participants were administered a demo-
graphic and health questionnaire, and cervical-vaginal specimens were collected and
tested for HR-HPV infection (Bhatta et al. 2017). Of 647 participants, the prevalence
of HR-HPV was 8.9%, and the prevalence of abnormal cervical cytology was 7.1%
(Bhatta et al. 2017). Diagnosed women were referred to local health-care facilities
for further evaluation, testing, and clinical follow-up, but their health outcomes were
not reported. Furthermore, Alawa et al. describe a breast cancer clinic established in
Lebanon by Multi-Aid Programs, another NGO, in 2015 that provides breast cancer
education, screening and diagnosis, and referral for treatment with in-country part-
ners (Alawa et al. 2019b). In just 3 years, the program had led a variety of breast
cancer awareness campaigns and provided more than 4800 mammograms, 1500
ultrasound screenings, and 160 surgical procedures, ranging from biopsies to aspi-
rations. The breast cancer program diagnosed 76 new cases of breast cancer by 2018
and provided follow-up services for 25 previously diagnosed cases (Alawa et al.
2019a). Of the cases diagnosed, 58% were diagnosed at an advanced stage, and
about half were diagnosed among those under the age of 50 (Alawa et al. 2019a).
The authors note that though the program was able to diagnose and coordinate for
treatment for many displaced women, their findings are alarming and highlight the
need for additional resources to address breast cancer among displaced and under-
served individuals in Lebanon (Alawa et al. 2019a).
Community-Based Interventions
Two of the publications identified reported on the provision of cancer education and
screening services through community-based interventions. One study was
conducted in the second largest Palestinian refugee camp in Jordan, while the
other was conducted in Lebanon.
Taha et al. describes the results of an educational intervention through home
visits, which included offering free mammography screening vouchers, on changing
women’s breast health knowledge and screening practices for early detection of
breast cancer (Taha et al. 2014). This intervention involved the mobilization of local
community outreach workers providing 2400 breast health awareness home visits
(Taha et al. 2014). Of 2400 participants, 2363 women aged 20–79 answered a pre-
test interview-administrated questionnaire to assess their breast health knowledge
and practices at baseline (Taha et al. 2014). Of these women, 625 eligible women
aged 40 years or older were referred for free mammography screening (Taha et al.
2014). Six months later, 594 women participated in a post-test (Taha et al. 2014).
The authors found that mean breast health knowledge score and women’s perceived
breast self-examination both increased significantly (Taha et al. 2014). Out of 625
women that received a voucher for free mammography screening, 73% attended the
mammography unit (Taha et al. 2014). In addition, women who received a follow-up
visit were more likely to use the free mammography voucher compared with those
who were not followed up with (83% versus 67%; P < 0.001) (Taha et al. 2014). The
authors note that home visits by local community outreach workers have the
potential to improve displaced or underserved women’s breast health knowledge
and care-seeking behavior (Taha et al. 2014). The other community-based study
identified reported an intervention involving a mobile clinic in Lebanon providing
services to Syrian refugee and Lebanese host populations in Bekaa Valley between
2014 and 2016 (Sethi et al. 2017). This intervention did not specifically target cancer
care but rather NCDs more generally through mobile medical clinics that provided
clinical consultations, medications, disease monitoring, health education, and refer-
rals to supported primary health-care facilities for diagnostic and screening services.
The authors report that in just 2 years, local clinicians managed the care of over 2000
NCD patients from 120 informal settlements, provided more than 18,000 consulta-
tions, and delivered nearly 54,000 prescription medications (Sethi et al. 2017). Though
no cancer-specific outcomes were reported, the community health program involved
health promotion activities led by trained refugee outreach volunteers and revealed
that cancer was one of the top health concerns among refugees (Sethi et al. 2017).
Innovative Financing for Cancer Treatment
In three of the publications identified, the main purpose of the intervention was to
provide funding to finance cancer care for displaced persons in Jordan, Syria, and
Lebanon. One study described a funding mechanism managed by the UNHCR’s
Exceptional Care Committees (ECCs), which are made up of a UNHCR medical
doctor and local doctors with varying specialties, to finance cancer treatments among
refugees in Jordan and Syria between 2009 and 2012 (Spiegel et al. 2014). The ECCs
require individuals to apply for funds to cover cancer treatments, and then the ECCs
decide whether to approve an application for treatment, depending on the following
criteria: necessity and adequacy of the suggested treatment, necessity of assistance
(financial vulnerability), feasibility of the treatment plan, disease prognosis, cost of
care, and eligibility as a registered refugee (Spiegel et al. 2014). In Jordan, the ECCs
received 1989 applications, of which 511 (25.6%) were specifically for cancer
(Spiegel et al. 2014). During 2011 and 2012, the mean age of cancer applicants
was about 49 years, and about half of the applications were for women (Spiegel et al.
2014). In Syria, between 2009 and 2011, the ECCs accepted 954 applications for
cancer treatment, 580 (60.8%) of which were for women (Spiegel et al. 2014).
In both countries, the most common cancers noted in applications were breast
cancer, colorectal cancer, and leukemia (Spiegel et al. 2014). Furthermore, of 511
applications for cancer treatment reviewed in Jordan, only 246 (48.1%) were
approved and about 70% of approved applications received the full amount
requested (Spiegel et al. 2014). The most common reason for denial was poor
prognosis (Spiegel et al. 2014). Similarly, another study described the same funding
mechanism through the UNHCR among Syrian refugees in Jordan and Lebanon
560 J. Alawa et al.
between 2015 and 2017 (Spiegel et al. 2020). The authors report that in Jordan
between 2016 and 2017 and in Lebanon between 2015 and 2017, slightly greater
than half were from female applications (Spiegel et al. 2020). In Jordan, 116 (95%)
of the 122 patients whose applications were approved were referred to the ECC from
government hospitals, while 39 (14%) of the 282 patients whose applications were
approved were referred by government hospitals, as opposed to private hospitals
(Spiegel et al. 2020). In Jordan, the most commonly applied for cancer was breast
cancer, while central nervous system, genitourinary, and breast cancers were the
most common among applicants from Lebanon (Spiegel et al. 2020). Only 122
(42%) of 289 applications were funded in Jordan between 2016 and 2017, and 282
(79%) of 357 applications were approved in Lebanon between 2015 and 2017
(Spiegel et al. 2020). The most commonly funded treatments were for surgery or
chemotherapy (Spiegel et al. 2020). In Jordan, the mean amount of funding approved
was $1733 (SD 1808) per case for chemotherapy and $1838 (2188) per case for
surgery (Spiegel et al. 2020). In Lebanon, a mean amount of $1827 (SD 1560) of
funding was approved for surgery and $1153 (893) for medical interventions (Spiegel
et al. 2020). Treatment outcomes were not reported in either study.
Saab et al. explored the feasibility of a collaborative approach for the provision of
care to displaced children with cancer in Lebanon, reviewing the experiences of
practitioners between 2011 and 2017 (Saab et al. 2018). In this study, the American
University of Beirut Medical Center and the Children’s Cancer Center of Lebanon
Foundation, in partnership with St Jude Children’s Research Hospital and the
American Lebanese Syrian Associated Charities, utilized an innovative and novel
funding collaborative to provide cancer treatment to 575 non-Lebanese children,
including children from Syria, Iraq, and Palestine (Saab et al. 2018). The authors
noted that while cancer treatment was able to be funded for many patients, the funds
available were often insufficient, given incomplete insurance coverage for most
patients (Saab et al. 2018). Of these 575 children, only 311 received direct medical
support in the form of full-treatment coverage (107) and limited-workup and spe-
cialty (204) services, while 264 received medical consultations (Saab et al. 2018).
The authors found that 29% of patients had a high-risk disease, 49% had interme-
diate-risk disease, and 22% had low-risk tumors (Saab et al. 2018). Of 275 patients
who had received treatment or were continuing on active first-line therapy, 159
(58%) were in remission at the most recent follow-up, 3 patients (1%) had died from
toxicity, 35 (13%) had relapse and disease progression, and 22 (8%) left before
completing treatment (Saab et al. 2018). Some patients relocated to another country
or to their home country, where their status of treatment and health was not available.
Between 2011 and 2013, the Children’s Cancer Center of Lebanon and a few NGOs
provided the funds for the treatment of displaced children (Saab et al. 2018). The
criteria for providing care were the availability of funds and patients having a new
diagnosis and no prior treatment. Between 2013 and 2016, because of increasing
need and a lack of financial support, St Jude Children’s Research Hospital provided
additional funding for a fixed number of patients and partial intervention for surgery,
radiation therapy, or induction chemotherapy (Saab et al. 2018). Between 2014 and
2017, humanitarian-specific grant funds were utilized (Saab et al. 2018). The criteria
were restricted further to documented refugees, and enrolment decisions were made
on a case-by-case basis, depending on the predicted costs of treatment (Saab et al.
2018). Finally, between 2012 and 2017, funds that were not assigned for humani-
tarian purposes were utilized to create disease-specific programs that allowed col-
laboration among community pediatric oncologists and hospitals to enable patients
treated at other hospitals to have access to funding and multidisciplinary treatment
plans (Saab et al. 2018).
Barriers and Facilitators of Cancer Care
Table 4 presents a synthesis of reported barriers and facilitators of cancer care as

reported in the studies identified. The most commonly reported barriers to care
across countries was a lack of funding to finance the cost of cancer treatment, a
lack of awareness about cancer, and a lack of adequate health capacity, all resulting
in either disruptions in care or late-stage diagnosis of cancer. Several included
publications reinforced the notion that when patients are diagnosed at a late stage
or present late for treatment due to an inability to access a health facility which may
be attributed to a variety of compounding circumstances such as legal issues, lack of
awareness, or the unavailability of services in a given area, diseases prognoses are
expected to be worse. Beyond the barriers to cancer care, several studies also reported
on various strategies to effectively deliver cancer care. The most commonly cited
facilitator of cancer prevention and treatment services was an innovative or sustainable
financing scheme, given the expensive nature of treating chronic and complex condi-
tions like cancer. Other commonly reported facilitators include community-based
cancer education programs to facilitate early screening and diagnosis of cancer,
collaboration of care delivery across stakeholders, the utilization of trained outreach
volunteers, and the development of robust national or regional cancer registries.
Conclusions
Implications for Policy and Recommendations
This chapter highlights eight key recommendations that have important implications
for research, policy, and on-the-ground efforts to support cancer prevention and
treatment services in LMICs affected by humanitarian emergencies, especially those
experiencing or harboring large numbers of IDPs or refugees.
Invest in the Development of Cancer Registries and Data Management

Systems
In several of the included studies, and in many studies on cancer in the lower-income
countries, cancer registries and data management systems that provide information
about the burden of cancer are of poor quality or are virtually nonexistent, especially
in LMICs experiencing humanitarian emergencies (Fitzmaurice et al. 2018). Given
Table 4 Synthesis of reported cancer care barriers and facilitators
562
Turkey Jordan Syria Lebanon Nepal Pakistan

Reported barriers
Compliance with therapy Lack of cancer Lack of health Diagnosis at an Lack of screening, Lack of information
awareness systems capacity advanced state diagnosis, and on most common
treatment diagnoses
Delayed access to drugs for Lack of funding/ Lack of funding/ Legal barriers Low levels of
outpatients medical costs for medical costs for cancer awareness
refugees refugees
Food insecurity in refugee Fear of having cancer Lack of secondary/ Low levels of
camps tertiary care services cancer awareness
Language differences Lack of health Lack of funding/
systems capacity medical costs for
refugees
Limited blood transfusions Lack of secondary/ Lack of time
tertiary care services
Poor hygiene for refugees Treatment disruption/ Lack of transport
low compliance
Poor shelters for refugees
Reported facilitators
Balance of primary, Development of Development of Coordination of Access to diagnosis Early diagnosis and
emergency, and referral care better cancer registry better cancer registry care delivery and treatment screening
services
Development of online cancer Early diagnosis and Educational Early diagnosis and Early diagnosis and
registry screening programs screening screening
Extension of free primary and Educational Improved Educational Educational
secondary health care to Syrian programs and home documentation of programs programs
refugees visits NCD interventions
J. Alawa et al.
25
Innovative/sustainable Free screening Innovative/ Establishment of

financing schemes vouchers Sustainable financing guidelines for
schemes prioritization
Promotion of early diagnosis Innovative/ Improved access to
and screening Sustainable financing health services
schemes
Widespread translators Improved Innovative/
documentation of Sustainable
NCD interventions financing schemes
Innovative/ Mobile medical
Sustainable financing clinics
schemes
Trained community Refugee outreach
outreach volunteers volunteers
563
564 J. Alawa et al.
that cancer registries, particularly those that are web based, have the potential to
improve cancer surveillance and to inform the types of interventions necessary in
such contexts, this chapter provides strong support for the need for humanitarian
actors and national governments to invest in the development of robust cancer
registries and data management systems (Spiegel et al. 2020). In particular, a linkage
of cancer registry data during times of peace, conflict, or reconstruction across
countries in the same region would be extremely valuable in accounting for the
burden of cancer among migrants and forcibly displaced individuals and in poten-
tially allowing those displaced to continue treatment when feasible.
Improve Cancer Education, Cancer Prevention, and Cancer Screening

Only five of the included studies in this chapter focused on providing cancer
education, prevention, and screening services in humanitarian settings, and only
three included a specific cancer education component in their intervention design. It
is well established that more than a third of cancers are preventable and that another
third of cancers are potentially curable given that they are detected early (Taha et al.
2014). Given that the norm of humanitarian situations has shifted to protracted crises
including long-standing displacement, primary prevention is necessarily a key pillar
of efforts to improve long-term health. In addition, cancer prevention services tend to
be less expensive than cancer treatment and can shift the focus of cancer services
from expensive hospital services to less expensive health centers and community-
based programs (Bray et al. 2018). Many opportunities exist to engage in cancer
prevention in humanitarian settings among individuals who have not yet been
affected by a cancer diagnosis, and more attention and resources must be provided
for the primary prevention of cancer in such contexts. Chronic diseases, like cancer,
can typically be prevented through lifestyle changes and improved access to screen-
ing services (Shah et al. 2020). Among displaced and underserved populations in
particular, smoking, alcohol consumption, a lack of exercise, and poor nutrition,
which are all risk factors for cancer development, are common (Alawa et al. 2019b).
As such, efforts should be targeted in providing education and screening for com-
mon cancers, such as breast, cervical, and colorectal cancers, and coupling these
services with risk factor reduction campaigns that aim to increase awareness about
smoking, alcohol, and sedentary lifestyles. Though implementing these programs
will likely require additional funding, these efforts are expected to be more cost-
effective in the long term. Several components of existing interventions identified in
this study, such as the training of refugee outreach volunteers, can be adapted to
promote cancer education and screening services. Though not incorporated into any
of the interventions identified in this study, emerging and mobile technologies for
education and coaching have been noted to be effective in promoting early diagnosis
and treatment of NCDs (McNatt 2020). In addition, because primary health-care
services are more accessible than secondary or tertiary services in humanitarian
contexts, integrating cancer prevention and screening services into primary care
settings offers more opportunities to deliver these services to a more diverse and
widespread set of patients (Fitzmaurice and Global Burden of Disease Study Cancer
Collaborators 2018).
Increase Availability and Access to Specialized Health Services

Cancer treatments, including radiation therapy, chemotherapy, and surgery, necessi-
tate long-term access to specialist care. Five of the studies included in this chapter
reported successes in delivery of cancer treatment in inpatient settings involving
access to specialized health-care services. However, the remaining seven studies
focused solely on the provision of primary care services, which makes sense given
that most of the identified implementing organizations were NGOs and UN actors.
Given funding limitations and a lack of experience in addressing cancer care in
humanitarian settings, many NGOs and UN actors focus on providing primary care,
which is often ineffective in providing necessary services for cancer treatment
(Amara and Aljunid 2014). Only providing primary care services without the
inclusion of specialist care from oncologists and other related health personnel
negatively impacts health outcomes for cancer patients, especially in humanitarian
settings where late-stage diagnosis is common. Because of the importance of
providing specialist health services to treat cancer, implementing organizations and
humanitarian actors should emphasize and increase access to advanced secondary
and tertiary cancer care services in humanitarian settings.
Integrate Displaced Populations into Host Country Health Systems and

Provide Coverage to Underserved Host Communities
As previously stated, the provision of cancer prevention and treatment resources are
often neglected in humanitarian settings given the cost of such services. A potential
solution to address the disparities in access to the secondary and tertiary health
services required for cancer care in humanitarian settings is to integrate displaced
populations into host country health systems and provide coverage to underserved
host communities. As noted, four studies included in this chapter were conducted in
Turkey, which has emerged as a leader in the provision of health services – including
for cancer – among Syrian refugees. Turkey has integrated displaced Syrian into its
national health system (Alawa et al. 2019d). In other words, Turkey has extended the
same social services that it provides to its own nationals to registered Syrian
refugees, which has significantly improved the early diagnosis and treatment of
cancer among this vulnerable population (Kebudi et al. 2016). UN actors, such as the
UNHCR, have also promoted policies that focus on integrating refugees into host
health systems and extending insurance schemes to underserved host communities
given the protracted nature of humanitarian crises (Abdul-Khalek et al. 2020). That
being said, efforts to implement such policies have been limited. Instead of
extending services to these vulnerable populations in humanitarian settings, many
actors have opted to provided health services through parallel programs and struc-
tures, which often result in a poor quality of care, limited sustainability, and a
wastage of precious resources (McNatt 2020). In order to improve access to cancer
services and to provide more sustainable access to health insurance, further docu-
mentation and evaluation of strategies that explore integration opportunities and the
effectiveness of such approaches are needed. Ideally, when integrating displaced
populations into the host health system and extending services to underserved host
communities, NGOs and humanitarian relief organizations could target gaps in the
566 J. Alawa et al.
services that host governments provide (Alawa and Bollyky 2020). Doing so would
allow those organizations to conserve limited resources while still providing quality
health services.
Design Innovative Financing Schemes for Cancer Treatment

This chapter identified two studies that detail financing schemes for cancer care
through the UNHCR. In situations where it is infeasible to extend access to special-
ized cancer services through national governments, innovative financing schemes
for the provision of cancer care must be explored. Most humanitarian organizations
rely on annual voluntary contributions, and most have annual budgets. Financial
restrictions, as well as the protracted nature of humanitarian crises today, make
health programs difficult to plan. In addition, many donors choose to direct their
funding to certain health conditions, and cancer is seldom considered a priority given
how expensive it is (Spiegel et al. 2020). One study found that total cancer care costs
for all 4.74 million Syrian refugees in Jordan, Lebanon, and Turkey in 2017 were
estimated to be €140.23 million using a cost per capita approach, €79.02 million
using an age-standardized incidence approach, and €33.68 million using a crude
incidence approach (Abdul-Khalek et al. 2020). Given the cost of cancer care in such
contexts, services provided might not be continuous and may not be long term,
which can devastate patients, their families, and their health providers. Case-by-case
decision-making also does not guarantee cancer patients’ continuous access to
necessary health services. As such, innovative financing schemes, such as social
security and health insurance schemes that are inclusive, must be considered.
Program objectives should facilitate inclusive access to cancer care, ensure that
beneficiaries are offered quality services using the most cost-effective and conser-
vative treatment options available, and coordinate care plans across providers
(Spiegel et al. 2020). Furthermore, humanitarian responses and their financing
could be coordinated with international donor organizations. An integrated
approach, involving a coordination of care across international, national, and local
institutions, to develop innovative financing schemes that take into account existing
development plans and funds for the country and the added burden of the human-
itarian situation could improve long-term provision of cancer care, care-seeking
behaviors among displaced and host communities, and the promotion of cancer
prevention resources (Spiegel et al. 2020).
Empower the Perspectives of Displaced and Host Communities

Only two of the publications included in this chapter’s review incorporate assess-
ments of displaced or host community perspectives of their own health and their
health priorities. One study found that cancer care was a main concern among
refugees in Lebanon, while another study collected self-reported measures of health
among Nepali women and Bhutanese refugee women (Sethi et al. 2017). The limited
availability of research that incorporates the perspectives of displaced and host
communities has been noted by several studies in the literature (McNatt 2020).
This gap in the literature suggests that the researchers and practitioners may have a
limited understanding of health needs among patients and their communities in
humanitarian settings. Assessing the experiences of individuals affected by human-

itarian situations and identifying whether their health needs are being met are
essential to designing interventions to improve access to care and improve compli-
cated health outcomes condition like cancer (Robert et al. 2015; Ocloo and Mat-
thews 2016). It has been well established that health practitioners and policymakers
benefit immensely from engaging and empowering patients and communities
(Batalden et al. 2016). Empowering the perspectives of displaced and host commu-
nities in humanitarian situations allows designed interventions and systems to adapt
to the needs of those that it is intended to serve. In addition, it allows for community
input into the design and evaluation of programs, encouraging patients to take
ownership of their health.
Develop a Policy Framework for Cancer Care in Humanitarian Settings

In all settings, regardless of humanitarian risk, policy frameworks can serve as key
guiding documents for how to address health needs, to identify financial resources,
to cultivate partnerships, and to evaluate the implementation of policy (McNatt
2020). The conception for addressing humanitarian situations is currently outdated
because many crises today are protracted and occur in countries with health profiles
characterized by an immense burden of chronic conditions, like cancer, that require
long-term access to specialist care and treatment (Alawa and Bollyky 2020). Without
the development of a policy framework that accounts for the shifting norms of
humanitarian settings and the greater burden of chronic illnesses, cancer care is
likely to remain inadequately addressed in these contexts. As such, developing such
a framework is absolutely necessary and will require the involvement of a diverse set
of stakeholders, including host governments, health providers, NGOs, international
agencies, and affected populations themselves (Alawa et al. 2019c). An effective
policy framework should identify the relevant resources to finance and provide
cancer services, hold stakeholders accountable for the implementation and evalua-
tion of their efforts, cultivate multisectoral partnerships, and include displaced and
underserved populations in humanitarian settings. Only one of the included studies
in this analysis discussed policy frameworks, assessing Turkey’s extension of social
services, including health care, to Syrian refugees (Kebudi et al. 2016).
Document More Responses to Cancer in Humanitarian Settings

Of the studies identified, the reported cancer care interventions only spanned six
countries and focused primarily on the health of Syrian refugees. Other studies in the
literature corroborate that most of the scare data that exists for cancer in humanitar-
ian settings, especially among refugees, is from the Middle East (Amara and Aljunid
2014). The lack of documentation of responses to cancer in humanitarian settings in
other regions is an important gap to address because nationals and refugees living in
the Middle East tend to have demographic and epidemiological disease profiles
characteristic of middle-income countries, which differ considerably from that of
low-income countries and middle-income countries in other regions (Taha et al.
2014). For example, the health characteristics of low-income countries in other
regions, such as central Africa, are typically characterized by a greater burden of
568 J. Alawa et al.
communicable diseases (Miranda et al. 2008). That being said, it is still unclear what
the current state of cancer care is in low-income countries experiencing humanitarian
emergencies, and it will only become more important to understand the availability
and effectiveness of cancer care in these settings as low-income countries undergo an
epidemiological transition. As such, documentation and responses to cancer must be
improved, providing a stronger evidence base for the provision of cancer care in a
diversity of humanitarian settings.
Discussion of Main Findings and Recommendations
The primary objectives of this chapter were to quantify the burden of cancer in Arab
countries experiencing humanitarian emergencies and to identify peer-reviewed
studies that present interventions and policies aimed at addressing cancer prevention
and treatment in humanitarian settings. Analyzing the descriptive epidemiology of
cancer showed that both cancer incidence and mortality rates from 2009 to 2019
increased across the Arab World, especially for several LMICs experiencing human-
itarian crises. In addition, countries facing humanitarian situations were also found
to have the highest cancer incidence and mortality rates among Arab countries.
The more marked increases in cancer mortality rates, as compared to cancer inci-
dence rates, suggests that health interventions and humanitarian efforts may not
have effectively adapted to address chronic conditions, such as cancer. These
findings also suggest that addressing the burden of cancer should be a priority in
the Arab World and LMICs affected by humanitarian crises and that country-level
analysis, as opposed to generalized analyses of humanitarian settings more broadly,
is integral to evaluating the extent to which cancer care services are required in such
settings.
Furthermore, the chapter identified 12 peer-reviewed publications aimed at
addressing cancer prevention and treatment among individuals living in LMICs
affected by humanitarian emergencies. Despite a multitude of humanitarian crises
affecting countries and regions across the globe, the publications identified by this
scoping review came from six countries, all of which were either in the Middle East
(Jordan, Lebanon, Syria, and Turkey) or South Asia (Nepal and Pakistan). In
addition, all of the publications identified involved enabling the provision of cancer
prevention and treatment among refugees or underserved host community residents,
most of which reside in urban areas. It should also be noted that majority of papers
focused on Syrian refugees as the population of interest. Moreover, four of the
publications included focused specifically on pediatric cancer cases, while two
studies focused on the provision of cancer care and cancer education among
women. The focus on pediatric cancer may be due to the fact that LMICs tend to
have younger populations and therefore, a larger proportion of children with cancer
than high-income countries (Alawa et al. 2019b). The focus on cancer in women in
such contexts is likely due to the unique barriers women face in accessing cancer
care, as well as the reality that breast cancer is the leading cause of cancer death and
the most common female cancer worldwide (Taha et al. 2014).
Interventions and policies identified related to inpatient facility-based care, out-

patient care, community-based programs, and innovative financing schemes to
facilitate cancer care also provided insight into several barriers and facilitators to
providing cancer care in such contexts. The most commonly reported barriers to
providing cancer care were a lack of funding to finance the cost of cancer treatment, a
lack of awareness about cancer, and a lack of adequate health capacity. The most
common facilitators of cancer care during humanitarian emergencies were innova-
tive or sustainable financing schemes, community-based cancer education programs
to facilitate early screening and diagnosis of cancer, coordination of care delivery
across stakeholders, the utilization of trained outreach volunteers, and the develop-
ment of robust national or regional cancer registries.
This chapter’s review of cancer prevention and treatment strategies also revealed
interventions that involved a diverse range of stakeholders that played key roles in
supporting cancer prevention and treatment in humanitarian settings, including
NGOs, hospitals, and international agencies. These stakeholders include Multi-Aid
Programs, Jordanian Women’s Union, American Lebanese Syrian Associated Char-
ities, Institute of Radiotherapy and Nuclear Medicine, NFCC-International,
UNRWA, UNHCR, King Hussein Cancer Center, American University of Beirut
Medical Center, Children’s Cancer Center of Lebanon Foundation, and the Mustafa
Kamal University Research Hospital. Only a few studies, which were conducted in
Turkey and Jordan, drew upon the policies of a national government or host country
to facilitate cancer care. In Turkey, the Ministry of Health played an important role as
a stakeholder because Syrian refugees are eligible for free health care, including
cancer treatment, in Turkey (Alawa et al. 2019d). In Jordan, the Jordanian Breast
Cancer Program, led by the King Hussein Cancer Center and Jordanian Ministry of
Health, played an important role in the provision of comprehensive breast cancer
screening and early detection services for women in Jordan (Taha et al. 2014). Of the
12 publications included, five involved inpatient facility-based interventions; two
involved outpatient interventions; two involved community-based interventions; and
three involved the development of innovative financing for cancer treatment.
The findings of this chapter highlight the paucity of published works that
thoroughly describe cancer prevention and treatment interventions and policies in
humanitarian contexts, and adequately evaluate the efficiency and effectiveness of
such approaches. Previous reviews that focus on NCDs more broadly in LMICs
reinforce the limited literature on cancer care in humanitarian settings, as well as the
reality that most peer-reviewed publications on this subject are dedicated to describ-
ing the challenges of and barriers to providing cancer care in humanitarian settings as
opposed to offering and evaluating concrete solutions. A previous review completed
in 2015 identified no studies that describe interventions to address cancer care, while
a recent scoping review of NCDs interventions for refugees solely yielded two
studies that relate to cancer care interventions (McNatt 2020; Ruby et al. 2015). In
light of the growing burden of cancer in many LMICs, as shown by this study’s
analysis of cancer incidence, as well as the increasing frequency of humanitarian
crises in LMICs, the field of addressing cancer care in humanitarian settings requires
greater investment in research, which has been recommended by other studies in the
570 J. Alawa et al.
literature as well (McNatt 2020; El Saghir et al. 2018; Magrath et al. 2013; Gheorghe
et al. 2020; Sahloul et al. 2017; Mansour et al. 2018).
In light of these findings, an immense amount of work and a massive influx of
additional resources are required to accurately assess the burden of cancer and provide
comprehensive cancer prevention and treatment services to LMICs affected by human-
itarian crises. As such, this study has identified a number of opportunities that exist to
scale up and improve cancer care in these contexts. These include: (1) investments in
the development of cancer registries and data management systems; (2) improvements
in cancer education, cancer prevention, and cancer screening; (3) increased availability
and access to specialized health services; (4) the integration of displaced populations
into host country health systems and extension of coverage to underserved host
communities; (5) implementation of innovative financing schemes for cancer treat-
ment; (6) empowerment of the perspectives of displaced and host communities; (7)
development of a policy framework for cancer care in humanitarian settings; and (8)
increased documentation of responses to cancer in humanitarian settings.
Though several of the interventions and policies analyzed and recommended in
this chapter appear promising, further and more rigorous research is necessary to
determine the scope and effectiveness of cancer care interventions in a diversity of
humanitarian settings. With that said, this chapter is a first step in analyzing the
burden of cancer in Arab countries experiencing humanitarian crises, documenting
current interventions and policies, and recognizing the strengths and weaknesses
of identified approaches. Health practitioners, national policymakers, and interna-
tional donors can utilize the information put forth to develop strategies to more
accurately assess the burden of cancer in humanitarian settings and to effectively
respond to that burden through robust cancer prevention and treatment programs.
Acknowledgments The funding support provided to Dr. Adam Coutts by the UK Research and
Innovation Global Challenges Research Fund: Research for Health in Conflict-Middle East and
North Africa region (R4HC-MENA) is gratefully acknowledged.
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Part IV
Social Determinants of Health
Poverty Reduction Strategies and Health
Outcomes: Jordan as a Case Study 26
Thamer Sartawi
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 579
Social Determinants of Health (SDH), Poverty, and Health Inequalities . . . . . . . . . . . . . . . . . . . . . . 580
Poverty, Ill Health, and Health Inequalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 580
Health Components of Poverty Reduction Strategy Papers (PRSPs) . . . . . . . . . . . . . . . . . . . . . . . . . . 586
PRSPs and Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 586
PRSPs and Health in the EM Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 587
PRSPs and Health Equity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 588
Population Health and Health Inequalities in Jordan and the Wider Eastern Mediterranean
(EM) Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 589
Population Health Inequalities Between Countries in the EM Region . . . . . . . . . . . . . . . . . . . . . 591
The Jordanian Poverty Reduction Strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 593
Overview of the JPRS Health Component . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 594
Poverty and Health Links in the JPRS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 596
Social Determinants of Health and Health Inequalities in the JPRS . . . . . . . . . . . . . . . . . . . . . . . 597
Health Inequality Reduction and the JPRS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 599
Opportunities for Addressing Health Inequalities via the JPRS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 602
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 602
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 603
Abstract
The relationship between poverty and ill health is very well established. One way
to examine the link between poverty, or low socioeconomic status, and health is
utilizing the social determinants of health framework. This chapter uses Jordan as
a case study to assess this link and subsequently examine the health impact of
Jordan’s current poverty reduction strategy. Despite the existing health inequal-
ities between socioeconomic groups in Jordan, the social gradient of health
T. Sartawi (*)
Saint Louis University, St Louis, MO, USA
e-mail: thamer.sartawi@gmail.com

https://doi.org/10.1007/978-3-030-36811-1_21
578 T. Sartawi
inequalities is not addressed in public health policies in the country. As a result,

this chapter assesses the potential contribution of the 2013–2020 Jordanian
Poverty Reduction Strategy (JPRS) to health of the poor in Jordan. First, this
chapter presents a conceptual framework examining linkages between poverty,
ill health, and health inequalities. The framework is used to assess the potential
health equity effects of the JPRS. In doing so, the analysis showed that for a
poverty reduction strategy to contribute to improving health outcomes, it must
include health system, socioeconomic, and structural-level interventions to
break the link between poverty and ill health and subsequently reduce health
inequalities. Second, this chapter presents the case for integration of targeted
health interventions within a universal strategy. The strategy adopts explicitly
targeted health intervention approaches such as healthy villages project (HVP)
and conditional cash transfers (CCTs). Therefore, the JPRS may lead to
individual-level health improvement on outcomes; however, at a population
level, this impact is unclear. This chapter also presents the case for intersectoral
collaboration and overemphasizes health sectoral policies go hand in hand with
socioeconomic and structural interventions. Nevertheless, the JPRS can poten-
tially act as a catalyst toward designing a comprehensive poverty reduction
strategy that would benefit the health of the poor and result in the reduction of
health inequalities in Jordan.
Keywords
Poverty · Health inequalities · Social determinants of health · Poverty reduction
strategies · Jordan
Acronyms
CCT Conditional Cash Transfers
CSDH Commission on Social Determinants of Health
DOS Department of Statistics
EM Eastern Mediterranean
GOJ Government of Jordan
HD Human Development
HDR Human Development Report
HVP Healthy Villages Project
IMF International Monetary Fund
IMR Infant Mortality Rate
JPRS Jordanian Poverty Reduction Strategy
LE Life Expectancy
MM Maternal Mortality
MMR Maternal Mortality Rate
MOH Ministry of Health
PFHS Population and Family Health Survey
PRS Poverty Reduction Strategy
26 Poverty Reduction Strategies and Health Outcomes: Jordan as a Case Study 579
PRSP Poverty Reduction Strategy Paper

SDH Social Determinants of Health
SEKN Social Exclusion Knowledge Network
U5M Under-5 Mortality
UNDP United Nations Development Programme
WB World Bank
Introduction
Human poverty is defined by the United Nations Development Programme (2000,

p. 17) as “impoverishment in multiple dimensions – deprivations in a long and
healthy life, in knowledge, in a decent standard of living, in participation.” Multi-
dimensional poverty – beyond the one dimension of income – portrays poverty as
deprivation that leads to a deficiency in “social capital, human capital, power, and
voice” (Mowafi and Khawaja 2005, p. 3). Thus, with the aim of tackling multi-
dimensional poverty and deprivation, many countries have developed PRSs which
are “documents that set out frameworks for domestic policies and programmes to
reduce poverty” (UNFPA 2013). The United Nations Population Fund (UNFPA)
suggests that a common feature of all PRSs is the inclusion of “civil society
organizations, representatives of the poor and women, the private sector, trade
unions, donors and UN system partner in addition to government” in the process
of designing and implementing a PRS (UNFPA 2013).
In 1996, the IMF and WB launched the heavily indebted poor countries (HIPC)
initiative that aimed at providing debt relief and concessional loans to poor countries.
In 1999, the IMF and the WB required HIPCs to develop Poverty Reduction Strategy
Papers (PRSPs) as a condition to be included in the HIPC initiative (IMF 1999). In
non-HIPC countries such as Jordan, PRSs are also intended to tackle poverty.
Common features of both the JPRS and PRSPs include the utilization of a
multidimensional definition of poverty, the adoption of a multisectoral approach to
poverty reduction, WB involvement in the PRS preparation process, and the inclu-
sion of health components in both PRSs. Unlike HIPCs, the JPRS is not intended to
help Jordan qualify for debt relief but rather as a comprehensive national document
to address poverty. This chapter uses the concepts regarding social determinants of
health inequalities to assess relationship between poverty, poverty reduction strate-
gies, and within-country health inequalities in the Eastern Mediterranean
(EM) region using Jordan as a case study.
Jordan is an excellent case study for the assessment of the interaction between
health inequalities and poverty. Within Jordan, income inequalities and poverty
rates are high. This chapter assesses the stagnation and unequal distribution
of Jordan’s population health gains over the past decade and explores the poten-
tial opportunities that lay in poverty reduction strategies to impact health of
the poor.
580 T. Sartawi
Social Determinants of Health (SDH), Poverty, and Health

Inequalities
In 1978, conveners at the Alma-Ata Conference stated that health inequalities –

defined as health differences that are “systematic, socially produced (and therefore
modifiable) and unfair” (Dahlgren and Whitehead 2006, p. 2) – are “politically,
socially and economically unacceptable” (WHO 1978). Decades later, in 2003, the
World Health Organization’s (WHO) Commission on Social Determinants of Health
(CSDH) was created to promote evidence-informed policies and action to achieve
equity in health and to support a global movement to achieve health equity (CSDH
2008, p. 1). Dahlgren and Whitehead’s much cited “rainbow model” illustrates the
different SDH as multiple layers of influence – the outermost layer represents distal
determinants of health, such as the structural and contextual determinants, whereas
the innermost layer represents the most proximal determinants such as age and
genetics (Dahlgren and Whitehead 1993). The CSDH (2008) proposes that living
and working conditions such as health services, education, unemployment, housing
conditions, and income level represent the social conditions that affect individual
health (CSDH 2008).
The CSDH also uses the SDH framework to explain health inequalities. The
CSDH proposes that the unequal distribution of social determinants such as educa-
tional opportunities, income, and adequate healthcare services between more and
less advantaged population groups and countries leads to the production of health
inequalities between and within countries (CSDH 2008, p. 9). In addressing health
inequalities, Graham also notes that it is essential to identify and tackle the social
determinants of health inequalities – the social processes that lead to the uneven
distribution of SDH (Graham 2007). The CSDH defines social determinants of
health inequities as the “structural social stratification mechanisms, joined to and
influenced by institutions and processes embedded in the socioeconomic and polit-
ical context (e.g. redistributive welfare state policies)” (WHO 2010, p. 26). Accord-
ingly, as major determinants of health lay beyond the reach of the health sector,
improving the health of individuals mandates improving the social conditions in
which people live in and the social processes that lead to their unequal distribution
(Graham 2007).
Poverty, Ill Health, and Health Inequalities
Poverty and ill health are closely linked to each other, and many studies have
attempted to unpack these linkages and associations (e.g., Wagstaff 2002; Krishna
2007; Braveman and Gruskin 2003; Leskošek 2012). Wagstaff proposed that health
and poverty influence each other in a bidirectional manner, creating a vicious cycle
in which ill health and poverty perpetuate and cause each other (Wagstaff 2002).
Poverty is often perceived as a risk factor for health and ill health as a predictive
factor of impoverishment (ibid.). Mowafi and Khawaja described poverty as being
“. . .multidimensional in its symptoms, multivariate in its causes, dynamic in its

trajectory, and quite complex in its interaction to health” (Mowafi and Khawaja
2005, p. 1). This section discusses some of the links between poverty, ill health, and
health inequalities from a SDH angle. In doing so, it unpacks the ill health and
poverty cycle from a health system, socioeconomic, and structural determinant
perspective. The relevance of these different conceptualizations to assessing the
JPRS is also presented.
Health Systems and Poverty Generation

It is widely proposed that ill health reduces earning capacity of the poor and leads to
increased vulnerability to impoverishment (Wagstaff 2002). Generally, compared to
more advantaged groups, the poor adapt poor health-related behaviors to avoid the
risk of losing income. Loss of income due to ill health is brought upon through
missing working days and a reduction in worker productivity. When ill health leads
to disability or is in the form of a chronic debilitating disease, poor health leads to job
losses (McIntyre et al. 2007). Therefore, the poor are less likely to report illness,
utilize health services when sick, or acknowledge illness at early stages (ibid.).
Additionally, the financial costs associated with accessing health services can
cause significant financial hardship and impoverishment affecting poor and vulner-
able households (Dahlgren et al. 2001), especially in countries where health systems
are funded via regressive modes of healthcare payments such as user fees and
copayments. As a result, poor households and individuals contribute a greater
proportion of their income to access healthcare services compared to advantaged
groups (ibid.). Thus, as out-of-pocket payments and catastrophic health expenditures
cause financial hardship, the poor and vulnerable are pushed further into poverty and
impoverishment and fall into a “medical poverty trap” (ibid.). Falling into such a
medical poverty trap often leads to an increase in untreated illnesses, reduced
healthcare access to health services, long-term indebtedness, and increased social
vulnerability to disease (McIntyre et al. 2007).
Additionally, Krishna proposes that poverty reduction efforts are incomplete
unless pathways and processes leading to the creation of poverty are addressed.
In this regard, he points to the momentous role that healthcare expenses play in
poverty creation. Healthcare expenses were found to lead to poverty creation
in both low-income countries, such as Uganda and Kenya, and high-income
countries such as the USA (Krishna 2007). This suggests that social institutions
such as health systems are becoming poverty-generating institutions instead of
promoting the welfare of the population (Krishna 2007; Dahlgren and Whitehead
2006).
The Jordanian health system is one of the well-established systems in the MENA
region (WHO 2006). Nonetheless, it is a highly fragmented system that provides its
services through three major arms of delivery: the public sector, the private sector,
and the non-governmental organizations (WHO 2009). The public sector provides
health services through the Royal Medical Services (RMS) and the Ministry of
Health’s insurance through the Civil Insurance Program (CIP) (WHO 2006). Most
582 T. Sartawi
recent estimates indicate that 22% of Jordanians are not insured (GOJ 2011). The
Royal Medical Services (RMS) and the Ministry of Health (MOH) are the two major
public health insurers in Jordan, each insuring 34% and 27% of the population,
respectively, while the private sector and the non-governmental sector cover 8% and
9% of Jordanians, respectively (GOJ 2011). Uninsured Jordanians can access MOH
healthcare facilities paying 15–20% copayments with the rest of the cost subsidized
by the GOJ (ibid.) or are forced to access healthcare through the private sector. As a
result of lack of health insurance, copayments, and user fees, 40% of healthcare
financing in Jordan originates from out-of-pocket expenditure, and the rate of
catastrophic health expenditure leading to impoverishment is estimated to be 7%
(ibid.).
To remedy this ailment, Labonte proposes that pro-equity health system reform is
essential. Labonte suggests that primary healthcare-oriented reform (opposed to
tertiary hospital-oriented reform) should be undertaken for it favors the poor over
the rich (Labonte 2010). In doing so, he calls for the creation of “progressively
financed health insurance,” financed by cross subsidization from the advantaged
healthy and rich to the disadvantaged sick and poor (ibid.). This involves removal of
user fees and copayments. In effect, these measures would lead to increase fairness in
health systems and prevent financial hardship incurred by the poor to access health
services (ibid.). Consequently, pro-equity primary healthcare reform would contrib-
ute to promoting health equity.
Policy directions for pro-equity health reform in Jordan include the introduction
of an essential services package (ESP) provided via primary healthcare centers
(UNDP 2013b, p. 178). The ESP is proposed to include a variety of basic health
services and medicines aiming to be “available and affordable or free of charge for
all people at public health facilities” (UNDP 2013b, p. 178). Nonetheless, proposed
healthcare reform measures in Jordan do not include the elimination of copayments
or user fees from accessing public health service. This calls into question whether the
reform would make the Jordanian health system more equitable if regressive modes
of healthcare financing are kept in place.
Socioeconomic Deprivation and SDH of Ill Health and Health

Inequalities
The close association between socioeconomic deprivation and its impact on health
was examined by Leskošek (2012) in Slovenia. The study assessed multiple socio-
economic deprivation indicators such as the “multiple deprivation index” developed
by Townsend and deprivation indices in countries such as the UK to establish the
links between socioeconomic indicators and population health. The study proposed
that living in multidimensional poverty entails deprivation in ten major areas (see
Box 1). Leskošek suggests that since “deprivation begins before birth and amplifies
until death,” improved socioeconomic indicators through governmental policies
would contribute to improved health and well-being. Poor public policies leading
to deprivation in these socioeconomic indicators contribute significantly to ill health
of the poor (Leskošek 2012).
Box 1 Major Areas of Socioeconomic Indicators That Matter for Population

Health (Leskošek 2012)
• Material deprivation
• Social capital
• Unemployment
• Housing conditions
• Level of education
• Profession
• Living environment
• Health
• Human safety
• Accessibility to services and ethnicity
Lantz and Pritchard examined the links between socioeconomic deprivation and
health at the community level. They reflect on evidence from the USA as they
identify the three main community indicators contributing to population health at a
community level: community socioeconomic composition, social structure, and
social cohesion and social capital (Lantz and Pritchard 2010). It is proposed that
socioeconomic composition of a community, that is, the “levels of education,
employment, income, and income security in a community,” has significant effects
in “creating and shaping risks and benefits for health, many of which accumulate
over the life course. . .” (ibid.). Social structural factors, such as “income inequality,
racial segregation and discrimination,” were also conveyed as an influential factor
leading to ill health as these factors influence the socioeconomic environment at
a community level. Finally, Lantz and Pritchard suggest that degree of social
cohesion – “extent of connectedness and solidarity among groups in society within
communities” (Kawachi and Berkman 2000) – within communities has very positive
influences on health outcomes (ibid.). The CSDH’s Knowledge Network on Urban
Settings (KNUS) proposed that the effects of socioeconomic deprivation on health
are most elaborately seen in deprived urban areas (Kjellstrom and Mercado 2008).
Globally, it is estimated that more than half of the world’s population are living in
urban settings. Although urbanization is proposed to lead to better living conditions
and health, the aggregate levels of health indicators in urban settings mask the
uneven distribution of health gains within the urban population (Kjellstrom and
Mercado 2008). The poor urban setting is characterized by overcrowding, poor
housing, slum area production, poor basic infrastructure, and poor water, sanitation,
health, and educational services (Kjellstrom and Mercado 2008; de Snyder et al.
2011; Sverdlik 2011). Deprivation in urban settings led to the rise of the “urban
penalty” phenomenon, where health status in urban settings is worse than health in
rural settings and the rise of urban health inequalities (Sverdlik 2011). However,
poor health in poor urban areas is not only a direct consequence of deprivation in
socioeconomic environment but also a consequence of urban social inequalities
584 T. Sartawi
(Kjellstrom and Mercado 2008). The urban penalty phenomenon is closely related to
social inequalities that lead to socioeconomic deprivation of the poor and the
unequal distribution of SDH (Kjellstrom and Mercado 2008; Sverdlik 2011).
In Jordan, approximately 80% of the population live in urban areas. Health
indicators in Jordan point to the existence of the urban penalty phenomenon,
manifested by the higher levels of IMR, MMR, and U5M in urban compared to
rural regions (UNDP 2013b, p. 174). A proxy for social inequalities in urban regions
in Jordan is the income inequality index (Gini index). Jordan’s largest city, Amman,
is the most unequal city in the country; its Gini index is 0.387 compared to national
average of 0.376 (ibid.). The Gini index in urban areas in Jordan is 0.385, compared
to 0.300 in rural regions (UNDP 2013a, p. 39). As proposed above, this urban
penalty in Jordan can be attributed to social inequalities and socioeconomic depri-
vation in urban compared to rural areas in Jordan.
In sum, living in poverty signifies deprivation in SDH to the extreme, and
accordingly poverty and deprivation lead to disproportionately poor health outcomes
among the poor (de Snyder et al. 2011). Nonetheless, although deprivation and
disadvantage in these socioeconomic indicators contribute greatly to poor population
health status, they can be modified via sound national policies. Leskošek proposes
that national antipoverty, social inclusion, and redistributive strategies have a sig-
nificant role to play in this regard (Leskošek 2012). Accordingly, based on
Leskošek’s proposal, the JPRS would include a socioeconomic deprivation and
social inequalities analysis of poor health outcomes in Jordan, if it is to address the
link between socioeconomic deprivation and health.
Structural Links Between Poverty, Ill Health, and Health Inequalities

As the previous two sections assessed the income-related and social dimensions of
the links between poverty on ill health, this section suggests addressing the root
causes of ill health of the poor and also constitutes addressing the structural drivers
of ill health and poverty. In this section, a social exclusion perspective is used to
examine the structural links between poverty, ill health, and health inequalities. The
WHO Social Exclusion Knowledge Network (SEKN) defines social exclusion as “a
dynamic, multi-dimensional process driven by unequal power relationships which
operate along and interact across four main dimensions – economic, political, social
and cultural – and at different levels including individual, household, group, com-
munity, country and global regional levels” (Popay et al. 2008). Living socioeco-
nomically deprived is a byproduct of the uneven distribution of societal resources
that result in the creation of the state of poverty initially. At the root of it, it will be
suggested that neoliberalism is the main structural link leading to poverty, ill health
of the poor, and health inequalities.
The SEKN proposes that social exclusionary processes and power imbalances
ultimately lead to the unequal distribution of societal resources and increase social
vulnerability of the poor to ill health (Popay et al. 2008). Power imbalances within
societies often lead to the exclusion of people in poverty and force them to live in
poor housing conditions, receive poor healthcare, less educational opportunities, and
less chances of employment. Neoliberal policies are proposed to have caused these
power imbalances, the unequal distribution of resources, and resultant social exclusion
(Popay et al. 2008; Mooney 2012). The SEKN proposed that neoliberal policies
of international financial institutions – such as the World Bank – have led to the
entrenchment of social exclusion of the poor, as they have failed to address the drivers
of poverty and social inequality. The SEKN position is also supported by Mooney. He
proposes that neoliberal policies – being the main drivers of poverty and inequality –
have consequently led to a compromised health status of the poor and have exacer-
bated health inequalities at local, national, and global levels (Mooney 2012).
Furthermore, Coburn presented data that reveals an association between increas-
ing poverty and income inequalities and within-country health inequalities in coun-
tries that adopt neoliberal policies compared to others governed by different political
economies (Coburn 2004). Consequently, the production of health inequalities and
poor health of the poor is not only attributed solely to economic poverty but also to a
“poverty of opportunity, of capability and of security. . .” (Kjellstrom and Mercado
2008). Since Jordan is considered as one of the most open economies in the region, is
governed by a neoliberal political economy, and is imposing IMF-led austerity
measures, an assessment of the relationship between neoliberal polices and health
is much needed.
These different conceptualizations of links between ill health, health inequalities,
and poverty from a SDH angle are highly relevant in the assessment of poverty and
health links in the JPRS. This dissertation proposes that for a comprehensive PRS to
contribute to improving health equity, it should take into account all the possible
links between poverty, ill health, and health inequalities. Where a health component
is included in the overall strategy, it is suggested that it should contain health system,
socioeconomic, and structural-level interventions to break the viscous cycle of ill
health and poverty (Box 2). In sum, a thorough understanding of these linkages in
the JPRS and their health equity effects is essential if the JPRS is to contribute to
improving the health of the poor and promoting health equity in Jordan. However, in
addition to the significance of addressing the links between poverty and health at all
levels, health inequality reduction necessitates action on all SDH at all levels. The
next section presents a conceptualization of JPRS’s potential to address health of the
poor and health inequalities in Jordan (Box 2).
Box 2 Multiple-Level Interventions to Break the Poverty and Ill Health Cycle
in PRS
Health system 1. Alleviate the financial burden of healthcare expenses off the poor
2. Pro-equity health system reform
Socioeconomic 3. Socioeconomic interventions and policies to tackle socioeconomic
deprivation and improve the SDH in both urban and rural setting
4. Proportionately universal social inclusion and health policies
Structural 5. Include interventions pointing toward addressing the structural
determinants of income inequality and poverty
586 T. Sartawi
Health Components of Poverty Reduction Strategy Papers

(PRSPs)
Since their emergence in 2001, PRSPs’ contribution to health has received consid-
erable attention (Verheul and Rowson 2001; WHO 2004; Bartlett 2011; Laterveer
et al. 2003). The WHO launched a PRSPs’ monitoring project in 2003 that assesses
whether health components of PRSPs are pro-poor and whether they are leading to
the adoption of pro-poor health strategies in countries in which they are
implemented. In 2003, the WHO created an online database that holds detailed
desk reviews of health components of 50 PRSPs (WHO database on health in
PRSPs http://apps.who.int/hdp/database/ (Last accessed 15 July 2013)). Moreover
a 2004 WHO report examined 21 PRSPs in a collective manner and presented
overarching findings across all PRSPs examined (WHO 2004). The WHO’s assess-
ment of PRSPs and health examined whether (1) the complexity of the links between
poverty and health were presented, (2) health needs of the poor were identified, and
(3) the health component of PRSP included pro-poor strategies (WHO 2004). More
recently in 2011, Bartlett assessed whether the health components of Afghanistan’s,
Haiti’s, and Liberia’s PRSPs reflected the main recommendations of the health
nutrition and population (HNP) chapter in the WB sourcebook (Bartlett 2011).
This is of utmost significance to the JPRS as the WB was extensively involved in
the preparation of the strategy. PRSPs differ from the JPRS in that they are designed
by HIPC governments for the purpose of debt relief and qualification for conces-
sional loans from the IMF and WB. Nonetheless, the common features of PRSPs and
the JPRS allow for similar approaches to be adopted in the assessment of the effects
of these strategies on health equity. Accordingly, this section gives an account of the
main findings of previous assessments of health components of PRSPs, focusing on
PRSPs from EM countries such as Pakistan, Afghanistan, and Yemen.
PRSPs and Health
The WHO assessment of the health components of most PRSPs found them to be
lacking in many aspects. The report reveals that most PRSPs did not extensively
investigate poverty and health links. It points that PRSPs included national health
data on the major diseases in their countries; communicable diseases, life expec-
tancy, and maternal and child health indicators were mentioned in all PRSPs.
However, only few PRSPs, such as Vietnam’s, Gambia’s, and Guinea’s PRSPs,
provided detailed data on the health needs of the poor or the disaggregated health
data (WHO 2004). Nonetheless, most PRSPs fail to account whether these were the
diseases that disproportionately affect the poor. In PRSPs which included an over-
view of diseases specifically affecting the poor, this was not supported by statistical
data or empirical evidence (WHO 2004). Thus, as the health component of PRSPs
largely included an account of the overall disease burden instead of diseases that
affect the poor most, the ability of the PRSPs to address the health needs of the poor
is weakened.
In relation to the health system elements in PRSPs, the report indicates that
financial barriers and geographical barriers in health systems were mentioned in
most PRSPs, but other concerns with health services such as quality of services,
informal payments, and corruption of health systems are not addressed (WHO
2004). With regard to the degree of intersectoral collaboration to improve health
outcomes of the poor, non-health sector contribution in health components of
assessed PRSPs was found to be limited (ibid.). For example, water and sanitation
strategies were addressed separately from health components of PRSPs. Plus, the
links between the health sector and other sectors such as agriculture, housing, or
labor strategies were not drawn in most strategies. However, all of the assessed
PRSPs included nutrition within their health component (ibid.). Few PRSPs such as
Albania’s included a link between educational levels and health outcomes (ibid.).
Plus, PRSPs’ main pro-poor health interventions were directed toward improving
delivery of affordable public health services and strengthening primary healthcare
(WHO 2004). Although it is necessary to improve access to health services, the
WHO assessment suggests that most PRSPs have “no consistent method of pro-poor
targeting – whether rural/urban, regional or quintile – is used within the health
strategies of PRSPs.” (ibid.)
Bartlett (2011) assessed PRSPs of Afghanistan, Haiti, and Liberia with regard to
their contribution to health. Bartlett specifically assessed whether health components
of the PRSPs reflect the recommendations of the WB’s health in PRSP sourcebook.
Bartlett’s assessment examines whether these three PRSPs present data on main
population health outcomes, whether the data presented is disaggregated for income
groups and geographic locations, and whether the proposed health strategies are
designed to meet the needs of the poor (Bartlett 2011). The findings in his analysis
are similar to those of the WHO assessment: that there is a lack of pro-poor targeting
of health strategies, a dearth of disaggregated data, and “insufficient analysis to
portray the health situation in each country” assessed (Bartlett 2011).
Finally, Laterveer and colleagues (2003) assessed whether 23 interim PRSPs
improved vertical equity in public health budget allocation, that is, whether PRSPs
resulted in more resources being directed to meet the needs of the poor. The study
concludes that most PRSPs have not resulted in increased health budget allocation to
meet the needs of the poor (Laterveer et al. 2003). Therefore, collectively, the
weakness in pro-poor targeting of proposed health strategies in PRSPs, lack of
increased budget allocations for health, and lack of disaggregated health data and
intersectoral coordination largely undermine PRSPs’ ability to reach and improve
health of the poor or contribute to improving health equity.
PRSPs and Health in the EM Region
The WHO assessment of health components of the Yemeni, Pakistani, and Djibouti
PRSPs (i.e., PRSPs within the EM region) showed similar results; and of these three,
the Pakistani PRSP seems to have more detailed assessment concerning health. The
Pakistani PRSP acknowledged the significance of ill health in the causation of poverty
588 T. Sartawi
and identified the central role that health plays in human development (WHO 2013c).
Also, health data in the Pakistani PRSP highlighted the main diseases that dispropor-
tionately affect the poor and commented on the differential uptake of vaccination
between the rich and the poor. The Yemeni and Djibouti PRSP did not include
disaggregated health data for income but did include disaggregate data for gender
and geographical locations. Nonetheless, in these three countries, PRSPs’ main health
strategy was strengthening health system factors such as the accessibility and afford-
ability of healthcare services. In Djibouti, one of the main challenges identified is the
shortage in qualified personnel and their unequal distribution across the country (WHO
2013d). In Yemen, illness was identified as the major cause of poverty, and the main
challenge faced by the poor was their inability to finance their treatment. Also,
intersectoral collaboration and coordination to improve health was found to be lacking.
PRSPs and Health Equity
The assessment of the PRSP health strategy documents reveals that they have not
explicitly tackled health inequalities in health outcomes, nor have they promoted
policies to address the matter. This is evident by the shortcomings pointed out by
both Bartlett’s and the WHO’s assessment of the health components of more than
24 PRSPs and in the assessment of PRSPs in the EM region. Most relevant
shortcomings of PRSPs to health equity are the scarcity of disaggregated health
data presented and the weakness of intersectoral collaboration to improve health of
the poor. It is also manifested in the overemphasis of addressing the health needs of
the poor through the health sector, rather than adopting a SDH approach to improve
the health of the poor. Nonetheless, the weak level of SDH and health equity analysis
in PRSPs could be attributed to the weakness of health systems in HIPCs, which are
unable to reach the poor. Thus, PRSPs in HIPCs prioritize health system strength-
ening interventions as the main policy direction. However, this cannot be general-
ized in the case in Jordan. The Jordanian health system is well established and
ensures good accessibility to services. Therefore, it should be pointed out that the
results of these assessments cannot be generalized to a middle-income country such
as Jordan. However, these assessments provide a frame of reference to point to the
significant elements that need to be assessed in the health component of the JPRS.
In light of this assessment of PRSPs, it should be emphasized that health
components of PRSPs should not to be considered comprehensive health strategies
directed toward addressing the health needs of the poor or aimed at reducing health
inequalities. Consequently, Dodd and Hinshelwood point to the significance of rec-
ognizing the difference between “a health strategy for poverty reduction” and a “health
strategy to meet the needs of the poor(est)” when discussing the health components of
PRSPs (Dodd and Hinshelwood 2002). Although both conceptualizations might
overlap, they are distinct. The former stance proposes that health in PRSPs is a tool
for poverty reduction rather than what the latter suggests that health strategies in
PRSPs should be designed to improve the health of the poor. Dodd and Hinshelwood
indicate that the former conceptualization is mostly adopted in PRSPs (ibid.).
In sum, assessments of PRSPs point to the low priority that was given to health,
but via increased intersectoral collaboration, it is acknowledged that PRSPs provide
a significant opportunity to increase the priority of health within national and global
development agendas (WHO 2004). The overemphasis of PRSPs on public health
service delivery compared to action on SDH represents a narrow assessment of
strategies needed to significantly improve the health of the poor. The main backdrop
is the lack of emphasis on improving living and working conditions of the poor as a
means of improving their health, demonstrated by the lack of intersectoral coordi-
nation to orchestrate a comprehensive health intervention. On the other hand, the
studies did not assess the health effects of PRSPs from a SDH perspective, nor have
they included a health equity perspective to their analysis. The comprehensiveness
of PRSPs and their poverty focus make the analysis of its health and health equity
impact relevant and necessary. Simply stated, “If the PRSP is to add value from a
health perspective it should lead to a more detailed analysis of the how health can
better contribute to poverty reduction and begin the process of making the health
strategy more focused on the needs of the poorest” (Dodd and Hinshelwood 2002).
Population Health and Health Inequalities in Jordan

and the Wider Eastern Mediterranean (EM) Region
The EM region is a highly diversified region consisting of 23 countries, 21 of which

are “Arab-speaking countries.” EM countries vary among each other with regard to
income levels (low-, middle-, and high-income countries), human development
(HD) levels, and population health status (Mandil et al. 2013; Boutayeb and Serghini
2006). The 2011 Human Development Report define human development as “the
expansion of people’s freedoms to live long, healthy and creative lives; to advance
other goals they have reason to value; and to engage actively in shaping development
equitably and sustainably. . .” (Klugman 2011, p. 14). Table 1 shows the classifica-
tion of EM countries according to human development and income levels. In the
Table 1 EM countries’ classification according to income and human development (HD) levels
Low income Middle income High income
Low HD Afghanistana, Djibouti, Sudan,
Yemen, Pakistana, Somalia
Medium Palestine, Egypt,
HD Morocco, Syria, Jordan
High HD Iran, Libya, Algeria, Kuwait, Saudi
Tunisia, Lebanon Arabia
Bahrain, Oman
Very Qatar, United
High HD Arab Emirates
Source: Author (Mandil et al. 2013; UNDP 2013a, Boutayeb and Serghini 2006)
a
Afghanistan and Pakistan are the only non-Arab-speaking countries in the EM region
590 T. Sartawi
most recent Human Development Report (HDR), Jordan was ranked 100th out of
186 countries, placing it into the “medium HD” group (UNDP 2013a).
Jordan, a small upper middle-income country located at the heart of the Eastern
Mediterranean (EM) region, has a population of 6,249,000 individuals (DOS 2011),
nearly 80% of whom reside in urban areas distributed across 12 governorates
(UNDP 2013b). Amman, the capital –the largest city in Jordan – is considered to
be one of the most crowded cities in the world with a population of two million and a
population density in some of the city’s neighborhoods of 20,000 per km2 (Ababsa
2011). Jordan’s political economy is largely neoliberal. Generally, a neoliberal
ideology encourages trade liberalization and a diminished role of the state
(Williamson 2009). Welfare service provision in neoliberal states is also minimal
and is subject to strict eligibility criteria to receive social assistance by the state
(Bambra 2011). Jordan initiated its economic liberalization program in 1989 and is
since portrayed by the WB and International Monetary Fund (IMF) as a model
neoliberal reformer (Harrigan et al. 2006).
Over the past decade, Jordan has enjoyed a period of sustained economic growth,
averaging 6.5% of GDP per year during the period ranging from 2000 to 2009 (IMF
2012). Jordan’s GDP per capita doubled between 2003 and 2012, increasing from
$1974 USD to $4945 USD (ibid.). However, in 2010, Jordan’s economy slowed
down as a result of a series of exogenous economic shocks caused by the global
economic crisis. Growth rates dropped from the 2000–2009 average of 6.5% to
2.33% of GDP in 2010, which leads to an increasing fiscal deficit to reach 6% of
GDP (IMF 2012). In response to the growing fiscal deficit, the IMF and the
Government of Jordan (GOJ) agreed upon a $2 billion “standby” arrangement to
address fiscal and external challenges and foster high and inclusive growth (IMF
2012). IMF recommendations included a reduction in social spending which
included reducing universal subsidies that were in place for liquid petroleum gas
(LPG) and food products (ibid.).
Moreover, the economic gains of the previous decade have not been distributed
equally among the Jordanian population. Indeed, the past decade witnessed little
improvements with regard to income inequality and poverty. Income inequality rose
during the period from 2002 to 2008 (Jordan’s Gini index increased from 0.376 to
0.399 in 2006 and 0.393 in 2008) (UNDP 2013b). The trend of increasing income
inequality reversed in 2010, declining back to 2002 levels of 0.376 (ibid.). In 2008, the
wealthiest 10% in Jordan owned up to nine times more assets and wealth than the
bottom 10% (UNDP and MoPIC 2011). In this situation, the poor in Jordan were more
vulnerable to income loss than the rich, and during 2006–2008, the real income of the
poorest quartile decreased by 8.5% compared to a 0.8% decrease within the richest
quartile (ibid.). Poverty rates in Jordan remained relatively constant over the past
decade. The GOJ estimates that in 2010, 14.4% of the population were living below
the national poverty line, compared to 14.2% living in poverty in 2002 (UNDP
2013b). Consequently, as the past period of economic growth caused the poor to get
poorer and the rich to get richer, income inequality and poverty are considered among
the significant human development challenges that face Jordan (UNDP and MoPIC
2011). This has direct consequences for population health in Jordan.
Population Health Inequalities Between Countries in the EM Region
Large gaps in population health levels exist between low-, middle-, and high-income
EM countries. Population health levels in EM countries are shown to improve as
countries are closer to the upper end of the HD and income-level spectrum (Mandil
et al. 2013; Boutayeb and Sirghini 2006). This differential population health status
between EM countries is illustrated in Table 2 which demonstrates that infant mortality
rate (IMR), maternal mortality rate (MMR), and life expectancy (LE) all vary according
to the level of economic development in the region (WHO 2008, p. 13). This table,
which was developed by the WHO, shows that a 33-year gap in life expectancy exists
between low-income and high-income EM countries; LE reaches a low of 44 years in
Afghanistan and reaches up to 77 years in Qatar. IMR in high-income countries reaches
as low as 8 per 1000 while reaching up to 147 per 1000 in other low-income EM
countries. Plus, MMR is close to zero in high-income EM countries, whereas in
low-income EM countries, 350–1600 maternal deaths occur per 100,000 live births.
Population health status in Jordan is good compared to countries at different
income levels in the region. Average LE in Jordan is 73.5 years (UNDP 2013a), IMR
average is at 23.1 per 1000, U5M is at 28 per 1000 (DOS 2013), and MMR in Jordan
is 30 per 1000 (DOS 2008). However, over the past decade, Jordan’s success in
improving health of its population slowed as population health gains stagnated. The
2009 Jordanian Population and Family Health Survey (JPFHS) acknowledged that
“if the 2007 levels of mortality were underestimated, then under-five mortality has
remained unchanged since the 2002 (27 per 1,000 in 2002 versus 28 per 1,000 in
2009)” (DOS 2010). This is demonstrated in Fig. 1 which shows IMR and U5M
levels over the past decade (DOS 2013).
Table 2 Health status indicators in the EM region in 2006

Children with Infant Maternal Life
Newborns with acceptable mortality mortality expectancy
Income birth weight at weight for age rate/1000 ratio/100,000 at birth
status least 2.5 kg (%) (%) live births live births (years)
Low- 63–89 54–74 62–147 350–1600 44–64
income
countriesa
Middle- 88–95 87–99 17–108 11–294 58–73
income
countriesb
High- 92–95 86–93 8–19 0–22 73–77
income
countriesc
Source: Building the knowledge base on SDH, review of seven countries in the EMR (WHO 2008,
p. 13)
a
Afghanistan, Djibouti, Pakistan, Somalia, Sudan, Yemen
b
Egypt, Islamic Republic of Iran, Iraq, Jordan, Lebanon, Libyan Arab Jamahiriya, Morocco,
occupied Palestinian territory, Syrian Arab Republic, Tunisia
c
Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, United Arab Emirates
592 T. Sartawi
In addition to health inequalities between countries in the EM region, within-

country health inequalities exist in the EM region, but are not accounted for in
Table 2. The World Bank (WB) brought attention to this matter in a 2012 publication
called “Health Equity and Financial Protection Datasheet: Middle East and North
Africa” (Bredenkamp et al. 2012). The publication presents a number of tables that
contain disaggregated health data according to wealth quintiles in Jordan, Egypt,
Morocco, Syria, Tunisia, and Yemen. The publication shows that poor groups in
each of these EM countries are disproportionately affected by ill health compared to
their more advantaged counterparts. IMR and under-5 mortality (U5M) rates were
worse among the poor in Egypt, Jordan, and Morocco (ibid.). In most countries, poor
children were found to be disproportionately affected more by malnutrition, diar-
rheal diseases, and acute respiratory infections. With regard to Jordan, as depicted in
Figs. 2 and 3, the past decade also witnessed an unequal distribution of health gains
across all socioeconomic groups in Jordan, favoring those in more advantaged
39
34 34
29 28
27
22 23
21 21
19
17
Infant mortality rate (<1 year) Under-5 mortality rate (0-4 years)
Key 1990 1997 2002 2007 2009 2012
Fig. 1 IMR and U5M in Jordan. (Adapted from (DOS 2013, p. 22))
IMR according to wealth quintiles in Jordan 1997-2009

40
35
30
Key
25
IMR 1997
20
IMR 2007
15
IMR 2009
10
5
0
Quintile 1 Quintile 2 Quintile 3 Quintile 4 Quintile 5
Fig. 2 Distribution of IMR according to wealth quintiles in Jordan (1997, 2007, and 2009).
(Source: Author (using data from DOS 1998, 2008, 2010))
U5M according to wealth quintiles in Jordan 1997-2009

45
40
35
30 Key
25 IMR 1997
20 IMR 2007
15 IMR 2009
10
5
0
Quintile 1 Quintile 2 Quintile 3 Quintile 4 Quintile 5
Fig. 3 Distribution of U5M according to wealth quintiles in Jordan (1997, 2007, and 2009).
(Source: Author (using data from DOS 1998, 2008, 2010))
wealth quintiles compared to the less advantaged (The disaggregated health data
were extracted from the JPFHS of 1997, 2007, and 2009).
During the period from 1997 to 2007, health gains in the wealthiest quintiles
exceeded those in the poorest quintiles; U5M in poorest first quintile decreased by
23% compared to the wealthier third and fourth quintile where U5M decreased by
66% and 48%, respectively. The same pattern is also observed for IMR, malnutri-
tion, and stunted growth in children (DOS 1998, 2008, 2010). It should be noted that
health improvements over the past decade are unequally distributed among all
socioeconomic groups in Jordan. Therefore, rather than being a gap between the
rich and the poor, health inequalities in Jordan occur along a social gradient, favoring
the more advantaged over the less advantaged at all socioeconomic levels.
However, since Jordan so far lacks any public health policy that explicitly seeks
to address health inequalities or its social determinants, the 2013–2020 Jordanian
Poverty Reduction Strategy (JPRS) forms the focus of this chapter. The JPRS is
Jordan’s most comprehensive national strategy to date to include multisectoral
collaboration to address poverty in Jordan. The wide range of proposed interventions
in the JPRS has significant impact on a wide range of SDH of the poor such as
education, health, and social welfare. This choice reflects the widely acknowledged
association between poverty and poor health (Wagstaff 2002) which suggest that a
comprehensive multisectoral policy to tackle poverty could, at least potentially, play
a role in addressing SDH of the poor and subsequently impact their health and lead to
reduction of health inequalities (Leskošek 2012).
The Jordanian Poverty Reduction Strategy
The JPRS was prepared via a wide participatory process that included multiple
stakeholders. Multiple governmental sectors, non-governmental organizations, inter-
national multilateral UN agencies (such as the United Nations Development Pro-
gramme (UNDP), WB), the Columbia University Middle East Research Centre, and
594 T. Sartawi
representatives of civil society in Jordan all participated in the preparation of the

JPRS (UNDP 2013b). Its overall objective is to “contain and reduce poverty,
vulnerability and inequality in the current socio-economic environment of Jordan,
from 2013 to 2020” (UNDP 2013b, p. 8). To achieve these overarching goals, the
JPRS has five main policy pillars: (1) social welfare and gender, (2) pro-poor
employment and entrepreneurship, (3) inclusive health and education services,
(4) pro-poor agriculture, and (5) environment and rural development and transport
and housing for the poor (UNDP 2013b, p. 8). The inclusion of the health component
in the overall strategy is proposed to contribute to poverty reduction through
investment in human capital of the poor. However, the strategy’s overarching aim
of reducing inequality implies that reducing health inequality could also be
addressed in the strategy.
The JPRS aims to address poverty and socioeconomic inequality in Jordan, and
its fourth strategic pillar – “inclusive health and education services” – is designed to
achieve this goal. The main objective of this strategic pillar is to help poor and below
middle-class households overcome “spatial and socio-economic constraints” in
accessing health and education services (UNDP 2013b p. 170). This chapter seeks
to assess whether the health elements proposed in the health component and
elsewhere in the strategy are likely to contribute to reducing health inequalities in
Jordan. The previous two sections helped contextualize the JPRS and are referred
back to for the assessment of the JPRS’s health equity contribution. Overall, this
chapter will demonstrate that health elements of the JPRS would not significantly
contribute to improving the health of the poor or contribute to reducing health
inequalities in Jordan. Nonetheless, it concludes by stating that whether or not the
JPRS is successful in achieving its overall objective of reducing socioeconomic
inequalities is the main factor that will determine the impact of the policy document
on Jordan’s health equity.
In doing so, the next section presents an overview of the health component of the
JPRS and the health policy recommendations. The second section examines the
degree to which health system, socioeconomics, and structural links of poverty and
health were incorporated in the JPRS. The third section assesses the degree to which
health inequalities and SDH analysis appear to have been taken into consideration in
the design of the JPRS health component. Finally, the concluding section explores
possible opportunities that the JPRS present for the reduction of health inequalities
in Jordan.
Overview of the JPRS Health Component
The JPRS health component is divided into two main areas: “health” and “repro-
ductive health.” The first section – the health section – of the assessment addresses
issues such as health system challenges, SDH, health indicators in Jordan, health
sector expenditure analysis, linkage between health and poverty in Jordan, and four
policy recommendations. The reproductive health section also included an assess-
ment of the status of reproductive health of the poor, highlighting maternal mortality,
infant mortality, and fertility reduction as the main policy areas for interventions.
The reproductive health section recommended six policies to address these chal-
lenges. Box 3 below presents the main policies in both sections.
Overall, the health component of the JPRS suffers from the similar shortcomings
of health components of PRSPs assessed above. The JPRS similar to PRSPs
predominately includes health sector-related strategies and lacks an intersectoral
collaborative approach to improve the health of the poor; 6 out of 10 proposed
strategies are directed toward the health sector. The other strategies were two health
promotion strategies: “raise awareness of reproductive health issues” and “improve
women’s nutrition”; and finally, two social interventions, “reforming patterns of
parenthood” and “marriage and cohabitation practices,” were included under repro-
ductive health interventions (UNDP 2013b). The proposed interventions address
health sector issues rather than socioeconomic conditions of the poor. The JPRS
analysis does include an account of the unfairness of healthcare finance in Jordan
and recommends that health sector reform would aim at making health services
“available and affordable or free of charge for all people at public health facilities”
(UNDP 2013b, p. 178). However, the JPRS does not recommend the abolition of
user fees and copayments from public health facilities, thus impeding its pro-equity
healthcare reform recommendations.
The health component includes urban/rural and gendered disaggregate health data
for neonatal mortality rates, IMR, and U5M (UNDP 2013b, p. 174). However,
similar to PRSPs, it lacked a presentation of disaggregated health data for wealth
quintiles. Plus, the JPRS does not include an account of diseases that disproportion-
ately affect the poor. It does not mention IMR, although its rates are higher in poorer
households. Nonetheless, maternal mortality (MM) and obesity are the two health
conditions identified in the JPRS. With regard to MM, the JPRS does not present a
data indicating that this health condition occurs more in poor households. Plus, the
proposed health intervention to reduce MM is a pure medical intervention mainly
directed toward improving post-miscarriage care (UNDP 2013b, p. 188). With
regard to obesity and overweight, the JPRS proposes that overweight affects 49%
of poor women (UNDP 2013b, p. 181). However, there is no evidence that over-
weight and obesity disproportionately affects poor women compared to more afflu-
ent women; on the contrary, obesity and overweight seem to be distributed
proportionately across wealth quintiles in Jordan (Bredenkamp et al. 2012).
Box 3 Health Policies of the JPRS (UNDP 2013b)

Health Policies in the JPRS
• Reform primary healthcare adopting a family practice approach, which
ensures access for the poor to a comprehensive essential services package
(ESP) and essential medicines
• Review and update codes of ethics and conduct in health sector civil service
contracts so as to enhance the ethics of the profession
(continued)
596 T. Sartawi
Box 3 Health Policies of the JPRS (UNDP 2013b) (continued)

• Reform in the health sector functions to improve efficiency, accountability,
and effectiveness of the programs
• Improve women’s nutrition
Reproductive Health Policies in JPRS

• Raise awareness of reproductive health issues
• Reform marriage and cohabitation practices
• Reform patterns of parenthood
• Reduce maternal mortality and morbidity
• Improve access to RH services
• Improve health services for specific RH-related issues
Poverty and Health Links in the JPRS
The JPRS assessment of poverty and health links in Jordan was short. It starts the
analysis by stating that “poor health is also an important correlate of poverty;
therefore, equitable access to health services is another important component of
PRS” (UNDP 2013b, p. 170). A later subsection titled “Linkages between Health
and Poverty in Jordan” (UNDP 2013b, p. 176) referred to “regressive health
financing arrangements” as the main links between poverty and health in Jordan.
The subsection goes further by acknowledging the unfairness of the fragmented
Jordanian health system. The subsection then concludes by identifying the charac-
teristics of households that are at risk of catastrophic health expenditures in Jordan;
urban rather than rural households, households headed by women, and overcrowded
households were among the households proposed to be at higher risk of catastrophic
health expenditure (UNDP 2013b, p. 176). However, the reason why these house-
holds are at increased risk of catastrophic health expenditures is not developed. This
captures a significant element of the link between ill health and poverty, i.e.,
regressive healthcare finance. Nonetheless, the JPRS conceptualization of the com-
plex interaction between poverty and health is weak and incomplete for many
reasons.
Firstly, the analysis does not point to the contribution of poverty to ill health and
the production of health inequalities. Secondly, the conceptualization of a vicious
cycle linking poverty and ill health and the bidirectional relationship between them
are not identified. Thirdly, the JPRS fails to link poor living and working conditions
to poor health in urban and non-urban settings. The analysis does not acknowledge
the effects of socioeconomic deprivation on health of the poor, which could explain
the urban penalty phenomenon in Jordan. Finally, it does not touch upon the
structural determinants that link poverty to poor health. This incomplete interpreta-
tion of the poverty and ill health relationship has problematic policy implications. It
misguides policy interventions toward health sector interventions, rather than to
more collaborative intersectoral interventions to improve the health of the poor. The
JPRS incorporates only two of the five proposed interventions in Box 2 (alleviate the
financial burden of healthcare expenses off the poor and pro-equity health system
reform).
Thus, the financial, health system-related interpretation of JPRS’s account of the
poverty and health links in Jordan implies that the health component of the JPRS is
“a health strategy for poverty reduction” (Dodd and Hinshelwood 2002) rather than
being a strategy to improve the health of the poorest. Nonetheless, since health
systems are an important SDH, pro-equity primary healthcare-oriented health system
reforms proposed in the JPRS do seem likely to contribute to reducing health
inequalities in Jordan. However, the lack of attention to the social and structural
determinants of health in producing poor health outcomes of the poor compromises
this equity contribution of the JPRS.
Social Determinants of Health and Health Inequalities in the JPRS
As opposed to the health components of PRSPs discussed previously, JPRS’s health

component includes a brief account of SDH in Jordan. The JPRS included a SDH
subsection that discussed SDH and the community-based initiative healthy villages
project (HVP). The SDH subsection includes a definition of SDH as being “the
conditions in which people are born, grow, live, work and age, including the health
system” (UNDP 2013b, p. 172). It mentions structural determinants such as “distri-
bution of money, power and resources at global, national and local levels” as main
influences on these social conditions (UNDP 2013b, p. 172). The section also
acknowledges the significance of SDH to health equity by explicitly stating that
“SDH are mostly responsible for health inequities – the unfair and avoidable
differences in health status seen within and between countries” (UNDP 2013b,
p. 173). Finally, the JPRS identifies unemployment and poverty, unplanned urban-
ization, high rates of immigration, a youthful population, a growing elderly popula-
tion, and water scarcity as the main “SDH challenges in Jordan which are likely to
contribute to adverse health outcomes.” (UNDP 2013b, p. 174) However, the
analysis fails to build on the possible links between these different SDH to the health
of the poor or to the Jordanian population in general. Despite referring to the 2006
WHO report on SDH in Jordan, the JPRS does not include an extensive analysis to
explain the possible pathways in which SDH contribute to health inequalities in
Jordan. However, the JPRS does point to the need for “a thorough analysis . . . to
tackle the SDH and inequities” in Jordan (UNDP 2013b, p. 174).
Additionally, the analysis points to the existence of regional health disparities and
presents disaggregated data based on urban/rural divide and gender. It demonstrates
that compared to neonatal mortality (IMR), U5M is higher in males as opposed to
females and in urban rather than in rural areas (UNDP 2013b, p. 174). The report
also points to the slowing down of health gains in Jordan indicated by the stagnation
of improvements in IMR and U5M rates from 2007 to 2012 (ibid.). Furthermore, the
JPRS puts emphasis on adopting an SDH perspective to explain regional disparities
598 T. Sartawi
and the stagnation of the IMR and U5M rates. Plus, where SDH-related policies were
suggested, the intervention was related to reproductive health where the JPRS states
that previous reproductive health programs “failed to address social and economic
determinants of access and utilization of Reproductive Health services” (UNDP
2013b, p. 182).
Otherwise, the JPRS analysis of SDH and health inequalities is both superficial
and incomplete. The analysis suffers from a lack of explanation for higher mortality
in urban compared to rural regions. It also lacks a detailed assessment of the
pathways that abovementioned SDH lead to poorer health outcomes. Plus, despite
explicitly pointing to the existence of regional disparities, it does not include
disaggregate health data on income or geographical location (UNDP 2013b,
p. 174). The JPRS does not acknowledge the existence of socioeconomic health
inequalities in Jordan. Finally, despite the MOH’s SDH mission statement which
calls for health in all policies and intersectoral action to tackle SDH in Jordan (MOH
2013), the JPRS lacks any calls for such action or implementation of health in all
policies to improve the health of the poor. In contrast, the climate change section of
the JPRS points to a joint project implemented in 2010 that aimed to enhance
adaptation to climate change in Jordan. The project involved five ministries along-
side UNDP, WHO, FAO, and UNESCO to address climate change in Jordan and
recommended policy interventions through four sectors: water, health, agriculture,
and education (UNDP 2013b, p. 217). This intersectoral collaboration seems to be
lacking with regard to health.
The second section is the HVP. It is a primary healthcare-oriented SDH program
that aims at improving both health and living conditions in disadvantaged villages
(UNDP 2013b, p. 173). The HVP is a collaborative project between the MOH and
WHO launched in two villages in 1992. Having been expanded since then, the HVP
currently includes 46 villages covering approximately 71,674 individuals, i.e., 1.1%
of the Jordanian population (ibid.). Alongside promotion of primary healthcare in
these villages, the HVP program adopts a comprehensive approach to improving
“health, economic, social and environmental status of these villages” (UNDP 2013b,
p. 173). The program offers a wide range of interventions aimed to enable villagers
to achieve their social, economic, and heath potential. Provision of health and
education services, development of “healthy living places,” aid in income generation
guidance, ensuring food safety, and improvement of water and sanitation services in
the village are but a few of a wide range of interventions and services provided by the
HVP program (ibid.).
However, the main drawback of the HVP program lies in its adoption of an
exclusively targeted approach in the selection of villages; only villages that suffer
from severe social and economic disadvantage and their population does not exceed
2000 villagers are eligible for the HVP to be implemented (UNDP 2013b, p. 173).
Also, since HVP program targets rural villages, impoverished urban areas are
excluded due to ineligibility. Whether the HVP program is successful in improving
the health of the population it serves is not assessed; as such assessments are not
available on either the MOH website or on the Jordan WHO office website.
However, the HVP program proves to be a good example of community-based
action on SDH that has the potential to be scaled up, thus contributing to health
equity more efficiently. Adopting a less strict eligibility criteria and inclusion of
impoverished urban centers could provide a significant tool to addressing health
inequalities in Jordan.
The other health intervention significant to health of the poor and health equity in
Jordan is the conditional cash transfers (CCT) proposed in the JPRS. The CCT
program is administered by the largest social welfare institution in Jordan, the
National Aid Fund (NAF). The NAF provides cash assistance and services to
7.5% of the population (UNDP 2013b, p. 53). It adopts both means, i.e., testing
and categorical targeting, to identify its beneficiaries for CCTs. Its beneficiaries
receive cash assistance on the condition that their children are to attend regular
clinic appointments and participate in national vaccination campaigns (UNDP
2013b, p. 58). However, despite including 7.5% of the population, the NAF’s
coverage of poor households is poor. It only covers 31% of the poorest decile and
10% of the second poorest decile (UNDP 2013b, p. 55), and these two groups
combined receive 67% of NAF, while the rest is distributed to richer households
(ibid.). NAF’s CCT programs operate within a limited universal health protection;
public healthcare services can be used free of charge for children up to the age of
6 (UNDP 2013b). Thus, the incomplete coverage of poor households and limited
health service protection after the age of 6 undermines NAF’s CCT programs’ ability
to contribute to the health of the poor or health equity.
Thus, it can be argued that the JPRS might provide a useful tool in reducing health
inequalities in Jordan if the explicitly targeted approach adopted in the JPRS via the
HVP and CCTs occurs within a universal strategy framework. However, in the
absence of a comprehensive national policy to address health inequalities through
action on SDH, JPRS’s proposed targeted health intervention approaches are likely
to contribute to increasing rather than reducing health inequalities. As a result of the
lack of proportionately universal health policies, the differential health outcomes
along the social gradient are not addressed in Jordan, therefore leading to the
persistence of health inequalities. In sum, the health component in the JPRS is not
comprehensive and inclusive of all social factors that might lead to differential health
outcomes in different population groups. However, despite this lack of elaborate
SDH assessment and health equity assessment in the JPRS, the JPRS analysis is
significant as it opens the door for further analysis of SDH in Jordan and implemen-
tation of action on SDH.
Health Inequality Reduction and the JPRS
Reviewing national health strategies in developed countries, Graham notes that

health inequalities can be either conceptualized as occurring along a social gradient,
as a health gap between the better off and worst off, or being concerned with the
health of the poorest groups in the society (Graham 2009). Graham provided a
matrix through which these different conceptualizations and their implications on
public policy can be viewed (see Table 3) (ibid.). Narrowing health gaps and
600 T. Sartawi
Table 3 Determinant-oriented approaches to tackling health inequalities (as appearing in

Graham 2009)
In broader determinants In individual risk factors
Tackling Reducing (1) Increase in level of (2) Reduction in prevalence
health health determinants in all groups to in all groups to match that
inequalities gradients match that in most advantaged in most advantaged group
group
Narrowing (3) Faster rate of improvement in (4) Faster rate of reduction
health gaps determinants in poorest group in risk factors in poorest
than comparator group group than comparator
group
Improving (5) Improvement in determinants (6) Reduction in risk factors
health of in poorest group in poorest group
poorest
groups
improving the health of the disadvantaged rely on the idea that health inequality is
explicitly linked to and concerned with the health conditions of the disadvantaged;
thus, most policies proposed in this regard are usually targeted to these groups
(ibid.). A social gradient interpretation considers that health inequalities are caused
by the unequal distribution of SDH and are thus occurring across all socioeconomic
groups. As opposed to health gap and health deprivation interpretations of health
inequalities, universal health interventions are required to address the social gradient
in health (ibid.).
It should be noted that although Graham’s matrix reflects on public health
documents in high-income settings, she proposes that it can be used for different
contexts and can also be used “to position strategies. . .or to classify specific inter-
ventions . . . to capture their potential contribution to reducing inequalities in access
to the determinants of good health” (Graham 2009). Therefore, these conceptuali-
zations are of huge significance with regard to the assessment of the health equity
effects of the JPRS. Since the JPRS aims to reduce poverty in Jordan through
addressing its multiple dimensions, the strategy contains health, education, social
welfare, employment, housing, water, and sanitation policies that explicitly target the
poor (UNDP 2013b). In practice, from a health equity policy perspective, the JPRS
can be thought of as a policy that explicitly targets the poor and influences the wider
determinants of the health of the poorest. Accordingly, the debate on whether to
adopt universal and targeted health strategies is closely linked to the possible impact
and role that the JPRS would have on health equity in Jordan.
With regard to targeted measures, conditional cash transfers (CCT) with health
components (e.g., conditions to uptake preventive health services) are very relevant
targeted measures that are proposed to lead to both health improvements and poverty
reduction among the poor (WHO 2013a, p. 45). Gaarder and colleagues reviewed the
evidence concerning the health and nutrition effects of CCT programs in low- and
middle-income countries (LMIC). Their study proposes that when compared to more
universal approaches, the success of CCT in improving health of the poor is
contingent upon the percentage of poor households that CCT programs cover and the
degree of leakage – that is, cash transfers being directed to richer households in these
programs (Gaarder et al. 2010).
Evidence from LMICs suggests that CCTs have resulted in health improvements
in recipients of cash transfers, improved child nutrition reduction of stunting rates,
and slight reductions in morbidity and mortality among program enrollees (ibid.).
Nonetheless, they also point to the shortcomings of CCT programs. As eligibility for
CCTs is established through a rigorous process of means testing, Gaarder and
colleagues found that poor households that include children were more likely to be
selected to receive assistance than households that have no children, thus excluding
those households from receiving assistance (ibid.). Other shortcomings of CCTs
include strict eligibility criteria, stigmatization, poor quality of public services, and
incomplete coverage of poor households, which were shown to have resulted in
reducing uptake to both cash transfers and healthcare services (Gaarder et al. 2010;
WHO 2013b). This largely weakens CCTs’ ability to improve the health of the poor.
These shortcomings are pointed out in a recent report by the WHO called
“Closing the health equity gap: Policy options and opportunities” (WHO 2013b)
which proposes that CCT programs were more successful in reaching their goals if
they were implemented within a universal social protection system. The report refers
to CCT programs in Brazil being linked to universal provision of health and
educational services (WHO 2013b). Opposed to CCTs and targeted policies, the
abovementioned WHO report suggests that universal systems are “the most success-
ful in reaching disadvantaged and marginalized groups as such policies avoid the
problems of social stigma that are inherent in targeting” (WHO 2013b, p. 44). The
report also proposes simplifying eligibility criteria of CCT, and moving toward
more universal approaches in service provision is more likely to improve the health
of the poor and promote social cohesion (WHO 2013b). Consequently, a more
universal approach in health policies and interventions is more likely to contribute
to the reduction of health inequalities than a targeted approach via CCT or
any other modality. This is also consistent with Marmot’s proposal of the adoption
of a proportionately universal policy and health intervention approach introduced
above.
Marmot proposes that a combined approach of targeted and universal health
intervention policies is needed in order to effectively reduce health inequalities, in
what he terms as “proportionate universalism,” where universal health interventions
take aim at improving health along the continuum of the social gradient, and targeted
approaches are designed to meet to the health needs of the most disadvantaged at the
bottom of the gradient (Marmot and Bell 2012). In all cases, these health interven-
tions should include both SDH and individual risk factors if they were to be effective
in reducing health inequalities (Graham 2009). Thus, the main point being, that if
targeted health interventions in the JPRS are part of a universal health strategy aimed
at improving population health in Jordan, then according to the principle of propor-
tionate universalism, the JPRS in theory would contribute toward reducing health
inequalities in Jordan.
602 T. Sartawi
Opportunities for Addressing Health Inequalities via the JPRS
The assessment performed above proposes that the strategy in itself and its health
component are unlikely to contribute to the reduction of health inequalities or even to
notably improve the health of the poor in Jordan. Yet, despite these weaknesses, the
JPRS also seems to provide some opportunities for advancing an agenda to reduce
health inequalities within the Jordanian policy agenda. First, unlike other PRSPs, the
JPRS recognizes the need for addressing SDH and health inequalities in Jordan
(UNDP 2013b, p. 174). Second, the involvement of the MOH in the JPRS process
indicates that the MOH is increasingly being recognized as a partner with regard to
social, economic, and human development in Jordan. Third, intersectoral collabora-
tion potential brought upon through the preparation of the JPRS and climate change
strategies provide an opportunity for the MOH to initiate an intersectoral dialogue on
SDH and health inequality reduction in Jordan. As these opportunities are recog-
nized, this dissertation reflects on these opportunities, JPRS shortcomings with
regard to its contribution to improving health equity in Jordan, and on international
evidence put forward in this dissertation, to present policy recommendations that
would potentially contribute to reducing health inequalities in Jordan (see Box 4).
Box 4 Policy Recommendations to Address Health Inequalities in Jordan

1. Promote public health research on the social determinants of child and
maternal health and noncommunicable diseases in Jordan to better under-
stand the nature and extent of Jordan’s health problems
2. Build on the multisectoral coordination that took place in designing the
JPRS and include multiple stakeholders to design a comprehensive health
inequity reduction strategy through action on SDH in Jordan
3. Pro-equity healthcare reform proposed in the JPRS to include the abolition
of regressive forms of healthcare finance such as user fees and copayments
4. Design proportionate universal health strategies to complement the health
interventions proposed in the JPRS to address the social gradient in health
in Jordan
5. Consider scaling up the HVP to include more villages and poor urban areas
and widening eligibility criteria of CCTs
6. Design policies to address root causes of health inequalities (structural
determinants) within the current political economic context
Conclusion
Over the past decade in Jordan population, health gains stagnated and health
inequalities increased. However, despite the existing health inequalities, Jordan
lacks an explicit public health strategy that addresses SDH or health inequalities.
This chapter sought to contribute to addressing health inequalities and health of the
poor in Jordan by assessing the likely health equity impact of Jordan’s most
comprehensive national strategy to date, the JPRS. The financial health system-
related, socioeconomic, and structural links between ill health and poverty are
numerous. At a policy level, interventions at distinct levels may aid to break the
cycle of poverty and ill health in Jordan. The JPRS could be viewed as a public
health strategy that addresses health inequality from a health deprivation perspec-
tive; and in doing so, the JPRS’s health proposed interventions explicitly target the
poor. For the JPRS to contribute to health equity, it needs to be part of more universal
public health strategy.
The JPRS’s shortcomings are mainly related to the weak conceptualization of the
relationship between poverty and ill health and a failure to link social conditions and
structural determinants to ill health and poverty. In the JPRS, the analysis of poverty
and health links in the JPRS excludes social and structural links. Consequently, the
JPRS only included two of the five interventions proposed above: alleviate the
financial burden of healthcare expenses off the poor and pro-equity health system
reform. Secondly, the JPRS included a weak analysis of SDH and health equity.
Thirdly, the JPRS includes health interventions aiming to reduce MMR and obesity.
However, it did not identify health conditions that mostly affect the poor – obesity is
found to be equally distributed equally across socioeconomic groups in Jordan. This
dissertation argues that although the proposed pro-equity health system reform in the
JPRS is a significant step toward improving health equity in Jordan, its overemphasis
on health sector interventions to achieve its health aims (as opposed to intersectoral
collaboration to improve health of the poor) undermines the strategy’s ability to
(1) contribute to overall health equity in Jordan, (2) break the ill health and poverty
cycle in Jordan, or (3) reduce the prevalence of obesity and MMR.
Finally, based on Graham’s critique of adopting a health deprivation approach in
addressing health inequalities, and Marmot’s proposals for proportionately universal
health interventions, this dissertation argued that the targeted health interventions in
the JPRS (the HVP and CCTs) are unlikely to contribute to health equity as they are
not components of a more universal public health strategy that aimed at addressing
health inequalities in Jordan. The JPRS is unlikely to contribute to the reduction of
health inequalities in Jordan. However, despite identifying these challenges posed by
the JPRS for health equity, there are opportunities that the JPRS presents with regard
to the advancement of health inequality reduction into the policy agenda in Jordan.
Subsequently, six policy recommendations were suggested to promote the reduction
of health inequalities in Jordan. Although the JPRS itself is unlikely to contribute to
the reduction of health inequalities in Jordan, it presents an opportunity to advance
health inequality reduction strategies into the policy agenda in Jordan.
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Environmental and Social Determinants of
Health in Palestine 27
Yaser Y. Issa, Akram Amro, and Raghad K. Rajabi
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 609
Aim and Scope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 610
A Brief History of the Occupied Palestinian Territory (OPT) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 610
1516: Ottoman Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 610
British Mandate: 1917–1947 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 610
1947–1977: Partition Plan; 1948, 1967, 1973 Wars; and Inalienable Rights . . . . . . . . . . . . . . 611
1990–1997: Lebanon, ICQP, and Intifada . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 611
The Peace Process of the 1990s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 612
2000–Present: Second Intifada, Separation Wall, Road Map, etc. . . . . . . . . . . . . . . . . . . . . . . . . . 612
Palestine Today . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 613
Health and Environmental Health Definitions and Their Concepts . . . . . . . . . . . . . . . . . . . . . . . . . . . . 613
Definition of Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 613
Definition of Environmental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 614
Determinants of Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 616
General Determinants of Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 616
Social Determinants of Health (SDH) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 617
Health Status in Palestine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 620
Health System in Palestine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 620
Health Figures of Palestinians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 622
Burden of Some Diseases in Palestine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 625
Environmental Determinants of Health in Palestinians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 632
Y. Y. Issa (*)
Environmental Health Department, Ministry of Health (MoH), Hebron Public Health Directorate,
Hebron, Palestine
e-mail: yaserissa@gmail.com
A. Amro
Department of Physiotherapy, Faculty of Health Professions/Pharmacy, Al-Quds University,
Abu Deis-Main Campus, Jerusalem, Palestine
e-mail: amro@staff.alquds.edu
R. K. Rajabi
Furat Food Industry, Hebron, Palestine
e-mail: Raghad.rajabi@gmail.com

https://doi.org/10.1007/978-3-030-36811-1_22
608 Y. Y. Issa et al.
Tourism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 640
Israeli Occupation and Its Consequences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 640
Population Growth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 643
Public Awareness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 644
Promoting Health Across the Life Course . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 645
Concluding Remarks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 645
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 647
Abstract
Looking after the health of a society and its members is a substantial aspect of the
common good. The factors that determine health lie beyond heredity and indi-
vidual behavior. According to the World Health Organization (WHO), the social
determinants of health are “The social determinants of health (SDH) are the
conditions in which people are born, grow, work, live, and age, and the wider
set of forces and systems shaping the conditions of daily life. These forces and
systems include economic policies and systems, development agendas, social
norms, social policies and political systems” (WHO SDH Brochure, https://www.
who.int/social_determinants/SDH-Brochure). The social conditions in which we
live not only influence our sense of well-being but also determine our chances of
experiencing illness or death throughout the course of our lives. The Government
of Palestine and the WHO are working cooperatively to effectively improve
public health.
The determinants of health among Palestinians are much like that in other
nations but are characterized by the presence of the long-term Israeli occupation
which affects the health of Palestinians directly (by leaving thousands of dead
and wounded/disabled citizens) and indirectly (by its effects on other social
determinants such as denial of education, poverty, loss of work opportunities,
no freedom of movement, inability to build homes, cultivating farm lands, lack
of power and clean water, poor access to healthcare services, insecure food
resources, etc.).
Despite the ongoing effects of the Israeli occupation, the health status of
Palestinians is better than that of many people living in some developing coun-
tries, and this situation is largely due to ongoing support from various countries
and agencies such as the WHO (World Health Organization), FAO (Food and
Agriculture Organization), WFP (World Food Programme), and others.
The environment in all its components, including people and surroundings, in
Palestine has not received much consideration recently, particularly during the
initial years of the Israeli occupation. The land, the water, and the natural
resources were exploited, and resource uses were not planned to preserve the
environment. The ultimate safeguard of Palestine’s environment will be public
knowledge, awareness, support, and activism policies. These must be instilled or
expanded within the minds of all Palestinians regardless of age, sex, education,
income level, place of residence, or professional qualifications. This requires
27 Environmental and Social Determinants of Health in Palestine 609
greater cooperation between health and environmental agencies within the West
Bank and Gaza in Occupied Palestinian Territory.
Keywords
Occupied Palestinian Territory (OPT) · Social determinants · Environmental
determinants · Communicable and noncommunicable diseases · Water crisis ·
Israeli occupation
Introduction
To be born, grow, and live is not merely a matter of having sufficient money or a
suitable place, or a good physical appearance, but is a matter of including different
factors that can interact with each other; this is to enable people to thrive and live
with little or no disease. This status is known as the social determinants of health.
Historically it was known that a person can be diseased due to a single cause
including religion. Microorganisms including viruses or bacteria (agents) were
seen as punishments from God. The diseased person (host) and the agents have
their own environment in which reactions can occur, leading to an environment for
disease to take hold. These factors are now known as the potential causes of
different and unexplained diseases. In the following sections, we will present the
health status and all its determinants (including social and environmental) that can
influence the health status of Palestinians under occupation.
Palestine or what is known as the Occupied Palestinian Territory is the area
which for decades has been subject to ongoing conflict due to the Israeli occupa-
tion. This catastrophe started in 1947 and continues to affect the lives of millions of
Palestinians. From a geographical point of view, this chapter focuses on a small
area, Palestine. This semiarid and arid region enjoys Mediterranean flora and
fauna, as well as the specific Mediterranean climate with long and hot summers
with hardly any rain where most of the precipitation falls in autumn and winter. It is
part of the desert region extending from the Sahara in North Africa, via the Sinai,
Negev, the Jordanian, and Syrian deserts, to the deserts in Central Asia, and thus
water scarcity and stress are common challenges for the whole area. The region has
been a cradle of civilization and of three monotheistic religions (Brauch 2007). The
health of the 2.954 million Palestinians in the West Bank including West Jerusalem
and 1.961 million in the Gaza Strip are shaped by these environmental and social
factors.
The conditions of the environment and health status have been sacrificed time and
time again at the altar of national, ethnic, or political desire. In any case, environ-
mental and health issues cannot be separated from the encompassing financial,
social, political, and military issues. In the case occupied Palestine, this illustrates
the downward spiraling relationship between conflict and environment and health
degradation (Barakat and Heacock 2013).
Aim and Scope
In this chapter I will describe the health determinants of the Palestinian people. I
present the information in an analogous manner similar to presentations from other
countries and will cover all health determinants as adopted by the WHO and other
international agencies. Its main focus is the Israeli occupation which can be consid-
ered as central to all other determinants, as it affects all other social determinants of
health of the Palestinians. This chapter also represents a brief history of Palestine and
gives a picture of the Palestinian health system and the health status of Palestinians
under the Palestinian National Authority. In addition to that definition of health, the
social determinants of health are presented in this chapter. The relation of the
environment and its components with the health status of an individual and the
community are discussed as well. This chapter aims to describe the factors that play a
role in determining the health of Palestinians.
A Brief History of the Occupied Palestinian Territory (OPT)
1516: Ottoman Period
The Ottoman Turks occupied Palestine, which became a part of the Ottoman Empire.
Ottoman rule over the eastern Mediterranean lasted until World War I. During WWI
the Ottomans sided with the German Empire and the Central Powers. This resulted in
the Ottomans being driven out of the region by the British Empire, leading to the
dissolution of the Ottoman Empire. Under the secret Sykes–Picot Agreement of
1916, it was envisioned that most of Palestine, when freed from Ottoman control,
would become an international zone not under direct French or British colonial
control (https://en.wikipedia.org/wiki/History_of_Palestine).
Shortly thereafter, the British foreign minister at the time (Arthur Balfour) issued
the Balfour Declaration of 1917, which promised to establish an arbitrarily designed
“Jewish national home” in Palestine lands (https://en.wikipedia.org/wiki/History_
of_Palestine). The Balfour Declaration stated that the British Government favors the
establishment of a home for the Jewish people in Palestine, emphasizing that nothing
should be done to undermine the civil and religious rights of non-Jewish communi-
ties in Palestine (Batniji et al. 2009).
British Mandate: 1917–1947
Palestine was among the former Ottoman territories placed under UK administration
by the League of Nations in 1922. All of these territories eventually became fully
independent states, except for Palestine. Here, in addition to “the rendering of admin-
istrative assistance and advice,” the British Mandate incorporated the “Balfour Dec-
laration” of 1917, expressing support for “the establishment in Palestine of a national
home for the Jewish people.” During the Mandate (from 1922 to 1947), large-scale
Jewish immigration, mainly from Eastern Europe, took place, with the numbers
swelling even further in the 1930s as a result of the Nazi persecution. Arab demands
for independence and resistance to immigration led to a rebellion in 1937, followed by
continuing terrorism and violence from both sides. The UK considered various
formulas to bring independence to a land ravaged by violence. In 1947, the UK turned
the “Palestine problem” over to the UN (https://www.un.org/unispal/history/).
1947–1977: Partition Plan; 1948, 1967, 1973 Wars; and Inalienable

Rights
After looking at alternatives, the UN proposed terminating the Mandate and

partitioning Palestine into two independent states, one Palestinian Arab and the other
Jewish, with Jerusalem internationalized (Resolution 181 (II) of 1947). One of the two
envisaged states proclaimed its independence as Israel. In the 1948 war involving
neighboring Arab States, Israel expanded to 77% of the territory of Palestine, including
the larger part of Jerusalem. More than half of the Palestinian Arab population fled or
were expelled. Jordan and Egypt controlled the rest of the territory assigned by
Resolution 181 to the Arab State. In the 1967 war, Israel occupied these territories
(Gaza Strip and the West Bank) including East Jerusalem, which was subsequently
annexed by Israel. The war brought about a second exodus of Palestinians, estimated at
half a million. The Security Council (Resolution 242) formulated the principles of a
just and lasting peace, including an Israeli withdrawal from territories occupied in the
conflict, a just settlement of the refugee problem, and the termination of all claims or
states of belligerency. The 1973 hostilities were followed by Security Council Reso-
lution 338, which inter alia called for peace negotiations between the parties
concerned. In 1974, the General Assembly reaffirmed the inalienable rights of the
Palestinian people to self-determination, to national independence, to sovereignty, and
to return. The following year, the General Assembly established the Committee on the
Exercise of the Inalienable Rights of the Palestinian People and conferred on the PLO
(Palestine Liberation Organization) the status of observer in the Assembly and in UN
conferences (https://www.un.org/unispal/history/).
1990–1997: Lebanon, ICQP, and Intifada
In June 1982, Israel invaded Lebanon with the declared intention to eliminate the PLO.
A cease-fire was arranged. PLO troops withdrew from Beirut and were transferred to
neighboring countries. Despite the guarantees of safety for the Palestinian refugees left
behind, a large-scale massacre took place in the Sabra and Shatila camps.
In September 1983, the International Conference on the Question of Palestine
(ICQP) adopted the following principles: the need to oppose Israeli settlements and to
oppose Israeli actions to change the status of Jerusalem. It advocated for the right of all
states in the region to existence within secure and internationally recognized boundaries
and the attainment of the legitimate, inalienable rights of the Palestinian people.
In 1987, a mass uprising against the Israeli occupation began in the Occupied
Palestinian Territory (the Intifada). Methods used by the Israeli forces resulted in
mass injuries and heavy loss of life among the civilian Palestinian population. In
1988, the Palestine National Council meeting in Algiers proclaimed the establish-
ment of the State of Palestine (https://www.un.org/unispal/history/).
The Peace Process of the 1990s
A Peace Conference convened in Madrid in 1991, with the aim of achieving a

peaceful settlement through direct negotiations along two tracks: between Israel and
the Arab States and between Israel and the Palestinians. These were based on
Security Council Resolutions 242 (1967) and 338 (1973). The multilateral track
negotiations were to focus on region-wide issues such as the environment, arms
control, refugees, water, and the economy. A series of subsequent negotiations
culminated in following: the mutual recognition between the Government of Israel
and the PLO, the representative of the Palestinian people, and the signing in 1993 of
the Declaration of Principles on Interim Self-Government Arrangements (DOP or
“Oslo Accord”), as well as the subsequent implementation agreements, which led to
the partial withdrawal of Israeli forces, the elections to the Palestinian Council and
the Presidency of the Palestinian National Authority, the partial release of prisoners,
and the establishment of a functioning administration in the areas under Palestinian
self-rule. The involvement of the UN has been essential both as the guardian of
international legitimacy and in the mobilization and provision of international
assistance. The 1993 DOP deferred certain issues to subsequent permanent status
negotiations, which were held in 2000 at Camp David and in 2001 in Taba, but these
negotiations proved to be inconclusive (https://www.un.org/unispal/history/). The
signing of the Declaration of Principles on Interim Self-Government Arrangements
(the Oslo Accords), and handing over of selected spheres of administration, includ-
ing health care, to an interim Palestinian National Authority. This authority was
intended to govern parts of the West Bank and Gaza Strip during a transitional period
when negotiations of a final peace treaty would be completed (Batniji et al. 2009).
Interim political solution exploded with the second Palestinian uprising, fueled by
widespread discontent with the failure of the Oslo Accords to address accelerating Israeli
confiscation and colonization of Palestinian lands in defiance of international law and by
the shortcomings of the Palestinian National Authority (PNA) (Batniji et al. 2009).
2000–Present: Second Intifada, Separation Wall, Road Map, etc.
The visit by Ariel Sharon of the Likud to Al-Haram Al-Sharif (Temple Mount) in
Jerusalem in 2000 was followed by the second intifada. Israel began the construction
of a West Bank separation wall, located mostly within the Occupied Palestinian
Territory; this was ruled illegal by the International Court of Justice. In 2002, the
Security Council affirmed a vision of two states, Israel and Palestine. In 2002, the
Arab League adopted the Arab Peace Initiative. In 2003, the Quartet (the USA, EU,
Russia, and UN) released a Road Map to a two-state solution. An unofficial Geneva
peace accord was promulgated by prominent Israelis and Palestinians in 2003.
In 2005, Israel withdrew its settlers and troops from Gaza while retaining control
over its borders, seashore, and airspace. Following Palestinian legislative elections
of 2006, the Quartet conditioned assistance to the PNA on its commitment to
nonviolence, recognition of Israel, and acceptance of previous agreements. After
an armed takeover of Gaza by Hamas in 2007, Israel imposed a blockade.
The Annapolis process of 2007–2008 failed to yield a permanent status agree-
ment. Escalating rocket fire and air strikes in late 2008 culminated in the Israeli
ground operation “Cast Lead” in Gaza. The UN Security Council adopted Resolu-
tion 1860. Violations of international law during the Gaza conflict were investigated
by the UN (“Goldstone report”). In 2009, the PA program to build state institutions
received wide international support. A new round of negotiations in 2010 broke
down following the expiration of the Israeli settlement moratorium. In 2011, Pres-
ident Mahmoud Abbas submitted the application of Palestine for membership in the
UN. UNESCO admitted Palestine as a member. Exploratory Israeli-Palestinian talks
were held in early 2012 in Amman. In November, another cycle of violence between
Israel and Gaza concluded with an Egyptian-brokered cease-fire. On 29 November
2012, Palestine was granted non-member observer state status in the UN. The
General Assembly proclaimed 2014 an International Year of Solidarity with the
Palestinian People. A new round of negotiations which began in 2013 was
suspended by Israel in April 2014 following the announcement of a Palestinian
national consensus government. Another round of fighting between Israel and Gaza
took place in July–August 2014. In 2016, the Security Council adopted Resolution
2334 on settlements (https://www.un.org/unispal/history/).
Palestine Today
Palestine is a small nation but with a long and well-known history. Serving as a
haven to the world’s three monotheistic religions, it remains a devout and political
central point drawing worldwide intrigue. In recognition of the broad range of ethnic
and devout differences, historical Palestine is host to a surprisingly large range of
environmental differences. The world’s interest has centered more on the clashing
verifiable and political claims then on the local environment (Isaac 1989).
Health and Environmental Health Definitions and Their Concepts
Definition of Health
Anybody can define health as a concept according to the status in which he lives and
grows. When you ask a person what his perspective about his health status is, the
answer will depend on different factors such as personal perspectives ranging from
acceptable, good, very good, excellent, not so bad, still surviving, etc. These answers
indicate that health status includes the absence of disease or disability which meets
with the World Health Organization definition since 1948: “A state of complete
physical, mental and social well-being and not merely the absence of disease or
infirmity” (WHO Constitution 1946). This definition promoted for the first time that,
in addition to physical and mental health, social welfare is an integral component of
overall health, because health is closely linked to the social environment and living
and working conditions (Svalastog et al. 2017).
From the above definition, we can notice that healthy people are those charac-
terized by having different optimistic components of life including individual,
economic, mental, social, behavioral, environmental, and safe and security factors.
Modern concepts of health consider health as more than the absence of disease or
infirmity, implying a maximum capacity of the individual for self-realization and
self-fulfillment. This means that the human inner forces and possibilities should be in
parallel with the feeling of pleasure or dissatisfaction in their relations with the
environment (Rutter 1987).
It seems that there are different definitions of health reflecting a variety of contexts.
The definitions of health obviously reflect socially and culturally constructed and
tentative categories, particularly health-related factors between an individual and the
society. In particular, in relation to the digital environment, critical analysis of health
concepts helps us to understand better health policies and politics and their conse-
quences. Because health includes societal powers rather than just phenomenological
differences, they accordingly can be accepted, criticized, or even rejected.
In this theme it seems that health is not a rigid concept but it is a relative status and
not completed (i.e., it can be said that my health is good, very good, excellent, not so
bad, but you will never find it is ideal (perfect status)). This range of health status
appears in the response of Arab people when they were asked about their status such
as: “How are you?” (“Keif halak”), “How is your health?” (“Keif Sehatak?”); even-
tually they reply “yes, it is ok,” “fine,” mabsoot (happy). The above are indications
about how Arab people perceive their health status depending on seen and unseen
(hidden) factors including personal and environmental factors. Therefore, health
ranges from poor, acceptable, good, very good, excellent, ideal – depending on visible
factors and other non-visible personal and environmental factors as shown in Fig. 1.
Definition of Environmental Health
Environmental health considers the environment and health, which means making
the surrounding environment with all its components (internal and external) safe and
harmless to the organism (i.e., the human being). From Fig. 1, it can be seen that each
level of health can be determined by different factors related to the human itself and
the surrounding environment.
Environmental health addresses all the physical, chemical, and biological factors
external to a person, and all the other related factors for each level is presented in
Fig. 1 Perception of health. (Source: By Author Yaser Issa)
Fig. 1. A range of factors influence a person’s health, from biomedical factors, such
as blood pressure, cholesterol levels, and body weight, to behavioral factors such as
smoking, alcohol consumption, and exercise. Health can also be affected by social
determinants: the social, economic, political, cultural, and environmental “condi-
tions into which people are born, grow, live, work and age” (WHO 2015) impacting
behaviors. It encompasses the assessment and control of those environmental factors
that can potentially affect health. It is targeted toward preventing disease and
creating health-supportive environments. This definition excludes behavior not
related to environment, as well as behavior related to the social and cultural
environment and genetics (http://www.searo.who.int/).
“What, who, and where” summarize the relation between health and the environ-
ment, represented in what is called the “epidemic triangle” (Fig. 2). What refers to
the agent(s), who refers to the host, and where refers to the environment. Agents can
be microbes, organisms too small to be seen with the naked eye. Disease-causing
microbes are bacteria, virus, fungi, and protozoa (a type of parasite). They are what
most people call “germs.” Hosts are organisms, usually humans or animals, which
are exposed to a disease. The host can be the organism that gets sick, as well as any
animal carrier (including insects and worms) that may or may not get sick. Although
the host may or may not know it has the disease or have any outward signs of illness,
the disease does take lodging from the host. The “host” heading also includes
symptoms of the disease. The environment is the favorable surroundings and
conditions external to the host that cause or allow the disease to be transmitted.
From Fig. 2 we can see that most epidemiological and health workers focus to
break one of the corners of the triangle. The most important factor on which efforts can
Fig. 2 The epidemic triangle.

(Source: River University
online (https://online.rivier.
edu/epidemiologic-triangle/))
be exerted is the environment and its components, because the environment surrounds
both agents and hosts. Sometimes agents can be killed, isolated, removed, or eradi-
cated, but hosts cannot be killed especially if they are a human. So, most efforts are
exerted on the environment and its components, which include both physical and
intangible components. Intangible components are known as indirect causes of poor
health or diseases (i.e., social determinants of health). This figure refuted the ancient
theory of causing diseases which dealt with only one cause for the disease.
Determinants of Health
General Determinants of Health
Health is not the responsibility of medical doctors or health workers. Every person is
responsible for her/his own individual health, which leads to community or popula-
tion health. Health starts in our homes, schools, workplaces, neighborhoods, and
communities. We know that taking care of ourselves by eating well and staying
active, not smoking, getting the recommended immunizations and screening tests,
and seeing a doctor when we are sick all positively influence our health. Our health is
also determined in part by access to social and economic opportunities; the resources
and supports available in our homes, neighborhoods, and communities; the quality
of our schooling; the safety of our workplaces; the cleanliness of our water, food, and
air; and the nature of our social interactions and relationships.
Determinants of health encompass a broad range of personal, social, economic,
and environmental factors that determine individual and population health. The main
determinants of health include:
• Income and social status

• Employment and working conditions
• Education and literacy
• Childhood experiences
• Physical environments
• Social supports and coping skills
• Healthy behaviors
• Access to health services
• Biology and genetic endowment
• Gender
• Culture
• Race/racism
Social Determinants of Health (SDH)
The social determinants of health are the conditions in which people are born, grow,
live, work, and age. These circumstances are shaped by the distribution of money,
power, and resources at global, national, and local levels. The social determinants of
health are mostly responsible for health inequities – the unfair and avoidable
differences in health status seen within and between countries. The conditions in
which people live and die are, in turn, shaped by political, social, and economic
forces (CSDH 2008). According to the WHO, the social condition in which people
are born, live, and work is the single most important determinant of good health or ill
health. As factors that affect health, social determinants can be seen as “causes of the
causes” – that is, as the foundational determinants which influence other health
determinants (www.who.int/social_determinants/sdh_definition/en/).
From Fig. 3 we can see how the social determinants can not only affect the external
factors surrounding the human but extend to include the internal factors including the
individual characteristics such as biomedical factors including genetic and lifestyle
factors. In other words, the social determinants of health working between each other
and with other factors (e.g., education) can determine the nature of work and the
environment of work, good housing can determine the water and sanitation leading to
the good health of residents, etc. The evidence gathered from the ways in which social,
economic, political, and cultural conditions create health inequalities has led to the
identification of key social determinants of health and well-being (CSDH 2008;
Wilkinson and Marmot 2003), including socioeconomic position, early life circum-
stances, social exclusion, social capital, employment and work, housing, and the
residential environment (Australian Institute of Health and Welfare 2016).
Figure 4 shows that the Health Impact Pyramid of the Center for Disease Control
(CDC) makes clear that if policy makers want to have the greatest impact on health,
approaches and investments must move outside of the clinic – and target the places
where people live, work, and age. According to the pyramid, efforts to address
socioeconomic determinants are at the base, followed by public health interventions
that change the context for health, protective interventions with long-term benefits
(i.e., immunizations), and direct clinical care, and counseling and health education
are at the top. While interventions at the top of the pyramid can improve individual-
level health on a case by case basis, interventions that address structural factors at the
bottom of the pyramid are necessary to improve population health (Frieden 2010).
Fig. 3 A framework for determinants of health. (Source: Dahlgren and Whitehead 1991)
Fig. 4 CDC health impact pyramid. (From Frieden 2010)

It is vital that people and policy makers understand the broad range of factors that
affect health and health outcomes and the impact of “place” on health as fundamental
to the social determinants of health – including both social and physical determinants.
Examples of social determinants include:

• Availability of resources to meet daily needs (e.g., safe housing and local food
market)
• Access to educational, economic, and job opportunities
• Access to healthcare services
• Quality of education and job training
• Availability of community-based resources in support of community living and
opportunities for recreational and leisure-time activities
• Transportation options
• Public safety
• Social support
• Social norms and attitudes (e.g., discrimination, racism, and distrust of the
government)
• Exposure to crime, violence, and social disorder (e.g., presence of gangs and lack
of cooperation in a community)
• Socioeconomic conditions (e.g., concentrated poverty and the stressful conditions
that accompany it)
• Residential segregation
• Language/literacy
• Access to mass media and emerging technologies (e.g., cell phones, the Internet,
and social media)
• Culture
Examples of physical determinants include:

• Natural environment, such as green space (e.g., trees and grass) or weather
conditions (e.g., climate change)
• Built suitable and appropriate infrastructure
• Worksites, schools, and recreational settings
• Housing and community design
• Exposure to toxic substances and other physical hazards
• Physical barriers, especially for people with disabilities
• Aesthetic elements (e.g., good lighting, trees, and benches)
By working to establish policies that positively influence social and economic

conditions and those that support changes in individual behavior, we can improve
health for large numbers of people in a sustainable manner. Improving the conditions
in which we live, learn, work, and play and the quality of our relationships will lead
to a healthier population, society, and workforce.
Health Status in Palestine
Health System in Palestine
The Palestinian Health System is composed of governmental (Ministry of Health,

MoH) and Palestinian Military Medical Services (PMMS), nongovernmental
(NGOs), United Nations Relief and Work Agency (UNRWA), and private (profit
and nonprofit) (Jabr et al. 2013; WHO 2006) services delivery (Fig. 5). These health
providers provide overlapping services, although none of these sectors deliver
comprehensive health services. Sometimes duplicated health programs are available
in the same areas depending on the donors and funding. The Palestinian Ministry of
Health (PMoH) is considered the umbrella for all healthcare providers and tries to
integrate services. The MoH endures the heaviest load of the health services respon-
sibility, including approval for programs to be conducted within all MoH protocols
and instructions. The MoH provides primary health care (PHC) and secondary and
tertiary health care for the entire population. The UNRWA, which is the other
healthcare provider in Palestine, provides services at the primary level of health
care. There are 669 primary health clinics and 51 hospitals in the West Bank,
including those of the UNRWA and nongovernmental organizations (see Map 1).
There are 223 primary healthcare facilities and 28 hospitals in the Gaza Strip
(WHO EMRO 2010). However, specialized care is not available in the public health
system, and patients in need of these services are referred to private non-
governmental-managed hospitals in the West Bank, Gaza, or abroad; a significant
Palestinian Health
System
Governmental
Non-governmental
Ministery of Health
(MoH)and Palestinian
Military Medical
Services (PMMS)
Foreign and Local Private

UNRWA
Agencies and societies (Hospitals and Clinics)
Fig. 5 Components of Palestinian Health System

Map 1 Healthcare facilities distribution in the West Bank – Palestine 2017. (Source: WHO EMRO
(2010), http://www.emro.who.int/images/stories/palestine/documents/West_Bank_Health_Facili
ties_Feb_2010.pdf?ua=1
portion are referred to Israeli hospitals. The cost of this referral is entirely covered
by the national governmental insurance. This referral imposes a great burden
on the Palestinian Health System, which recently adapted a multifaceted perfor-
mance improvement approach to reduce the cost of referrals (Bitar 2016; Palestinian
Ministry of Health 2016). In East Jerusalem, the six Palestinian-operated hospitals –
Al Maqassed Islamic Hospital, the Red Crescent Society (PRCS) Maternity
Hospital, Augusta Victoria Hospital, St. John’s Ophthalmic Hospital, St. Joseph’s
Hospital, and Princess Basma Rehabilitation Center – have served for decades as the
main referral centers for the Palestinian population in the West Bank and Gaza Strip
and the central medical training facilities for Palestinian health professionals. Egypt,
Israel, and Jordan also provide important referral centers for treatment for
Palestinians with either government insurance or private patients. In its latest annual
report, “Right to Health: Crossing barriers to access health in the Occupied Pales-
tinian Territory,” the World Health Organization (WHO 2016) draws attention to a
concerning and continuing decline in the approval rates for patient permits to access
health care outside of the West Bank and Gaza Strip.
Health Figures of Palestinians
According to the Palestinian Central Bureau of Statistics (PCBS) (2017), the esti-
mated population living in Palestine is 4,780,978; around 2,881,687 of them live in
West Bank (5,655 sq. km), and 1,899,291 live in Gaza Strip (365 sq. km). The
majority of the population is younger than 17 years old (43.9%). The average family
size is 5.1 (4.8 in West Bank and 5.6 in Gaza). Around 78.3% of the population
(excluding residents of East Jerusalem) are health insured, 98.1% are educated,
27.2% are unemployed, and 5.8% are disabled. A World Bank report (2018)
shows that around 29% of Palestinians live in poverty, while 2.5 million are in
need of humanitarian assistance. Moreover, 22.5 million experience food insecurity
according to the World Food Programme (2018).
Access to health services in West Bank is restricted by the Israeli walls and
checkpoints. Palestinian patients, health workforce, and ambulances are mostly
refused access to referral hospitals in East Jerusalem, as entrance to the city is
possible only for holders of Israeli-issued permits. The process of obtaining a permit
is complicated and often results in delays or denial of care. Gaza patients in need of
specialized health care can also be denied care as a result of the closure of the Rafah
border crossing with Egypt or the complicated process of passing through the border.
Based on the Palestinian Central Bureau of Statistics (2016), the total current
expenditure on health reached 1.419 million US dollars (10.7% of GDP). Expendi-
ture is covered by the government (approximately 37%), private insurance compa-
nies (around 3%), households/out-of-pocket (around 41%), non-profit organizations
(around 18%), and others (around 1%).
The Palestinian Ministry of Health (MoH), UNRWA, Military Health Services,
NGOs, and the private sector cover primary, secondary, and tertiary healthcare services.
The total number of primary healthcare centers in Palestine (up to 2017) as disclosed by
the Palestinian Ministry of Health is 743 (583 in West Bank and 160 in Gaza), and the
number of hospitals is 81 (51 in West Bank including East Jerusalem and 30 in Gaza).
According to the Palestinian Ministry of Health (2017), the burden of non-
communicable diseases in Palestine is high. The leading causes of death are con-
secutively cardiovascular diseases, cancer, cerebrovascular diseases, conditions in
the perinatal period, and diabetes. Related risk factors such as smoking, unhealthy
diet, and sedentary lifestyle are widespread. Life expectancy in Palestine (MoH
2017) has increased to 73.8; 74.1 in West Bank and 73.3 in Gaza; 75.4 for females
and 72.3 for males. Disabilities are 2.7% in West Bank and 2.4% in Gaza.
Due to political instability and worsening living conditions in the Gaza, disabil-
ities, traumatic injuries, and amputations are on the increase. Moreover, the burden
of mental and psychological disorders is expected to increase due to the occupation’s
continuous use of violence, lack of personal security, violation of human rights, and
restrictions on movement.
Water scarcity in Palestine has a serious impact on the Palestinian public health
scene. According to the WHO/UNICEF Joint Monitoring Programme for Water
Supply and Sanitation, the percentage of the population served by piped water
services dropped from 88% in 1995 to 56% in 2015. In the Gaza, high proportions
of fecal indicator bacteria have been detected in drinking-water supplies. Further-
more, the coastal aquifer is low, contaminated, and overused. Wastewater treatment
is inadequate, which results in untreated sewage causing further contamination of
coastal seawater in Gaza (UNICEF 2012).
The PCBS states that infant mortality in 2017 reached 10.7 deaths per 1000 live
births, and the under-5 mortality rate reached 12.1 deaths per 1,000 live births, which
reflects a significant improvement when compared to death rates in prior years. On
the other hand, maternal mortality rate in Palestine was estimated by MoH to be 5.9
per 100,000 live births.
The WHO continues to support the MoH in sustaining a high vaccination
coverage for communicable diseases and effective monitoring of health indicators.
According to the MoH (2017), the incidence rates of reported communicable
diseases are 3.71 for H1N1 (common viral cause of human influenzas), 6.5 for
bacterial meningitis, 3.0 for food poisoning, 9.4 for hepatitis A, and 2.4 for acute
flaccid paralysis (AFP) per a population of 100,000. On the other hand, reported
sexually transmitted infections in 2017 were more than 50,000. In addition to
communicable diseases, mental disorder incidence rates per 100,000 population
was 117.2. Based on PNIPH 2017 research on extent of illicit drug use in Palestine,
only 1.8% of the male population above 15 (26,500 high-risk drug users) were
identified as high-risk drug users.
The Government of Palestine and the WHO are working cooperatively to effec-
tively improve the public health state within the country by concentrating on five key
regional priorities:
• Health security and eradication and management of communicable diseases

• Noncommunicable diseases, such as mental illness, injuries due to violence, and
malnutrition
• Promoting health through the life course

• Strengthening health systems
• Readiness, observation, and response
Reliable and timely health-related data is crucial for policy development, correct
health management, evidence-based decision-making, rational resource allocation,
and the observance and analysis of the general public health situation. While the
demand for health data is increasing in terms of quantity, quality, and levels of
disaggregation, the response to those needs is hampered because of fragmentation
and major gaps and weaknesses in the national health data systems. The strength-
ening of health data systems may be a priority for the WHO agency within the
region.
Palestine faces several challenges associated with the occupation and its conse-
quences that have negatively impacted access to health care and have worsened the
health burden. The conflicts within Gaza Strip in recent years have resulted in large
numbers of permanently disabled individuals (many of whom are children), loss and
injury of medical personnel, and harm to the health system infrastructure. The
Ministry of Health, notwithstanding, strives to supply the simplest potential health
services and has achieved progress in health.
The population of the country has increased by 54.2% within the past 25 years,
reaching 4.5 million in 2015. It is estimated that 25.4% of the population sleep in
rural settings (2012), 36.1% of the population is between the ages of 15 and 24 years
(2015), and the life expectancy index is 74.4 years (2012). The literacy rate for
adolescents (15–24 years) is 99.3%, 95.9% for all adults, and 93.6% for adult
females (2012). The burden of sickness within the West Bank due to communicable
diseases is 15.1% (2012), noncommunicable diseases 74.9%, and injuries 5.5%.
Primary health care is based on practical, scientifically sound and socially
acceptable ways, and technology allows universally access to individuals and
families in the community and at a cost that the community and country can afford
to maintain at each and every stage of their development within the spirit of self-
reliance and self-determination (Abdul Rahim et al. 2014). It forms an integral part
both of the country’s health system and all aspects of development including
environment and social issues. This definition is the basis of what is known as the
primary healthcare approach, the underlying philosophy of which is that health is not
an independent state, rather it is an integral part of overall development. Therefore,
factors which influence health are social, cultural, and economic as well as biological
and environmental. Health is seen as fundamentally related to the availability and
distribution of resources: not only health resources (doctors, nurses, medicines,
clinics) but also socioeconomic resources such as education, water and food supply,
and sanitation facilities. The achievement of better health requires involvement by
the people themselves in adopting healthy behavior and by insuring a healthy
environment.
The Human Development Report (2014) ranked the country at 107 out of 187
countries across the planet on the human development index (Malik 2014). The
personal income level was 25.8% in 2011.The urban population increased from
67.7% to 74.6% between 1990 and 2012, whereas the access of rural population to
improved water sources is at 81% (2015), down from 87% in 1995 (https://www.
pniph.org/public//uploads/water%20report%20final(2).pdf). In 2010, those aged
0–24 years accounted for 63.5% of the whole population (World population pros-
pects 2013). The adult accomplishment rate is 95.3%, and for the youth
(15–24 years) it is 34.6% (World development indicators 2014).
In 2013, the government established a national multi-sectorial social determinants
of health committee. The committee has been commissioned to spot and act on key
social determinants of health, to draft a process to handle priority problems, and to
integrate social determinants of health into all relevant policies and programs. Among
the most important challenges are the occupation by Israel, the political situation and
strained financial resources. This is a significant opportunity for the Ministry of health
to express commitment to mainstreaming social determinants of health and to reduce
health inequities. This commitment has to be escalated and translated into sensible
action, within the type of more allocation of human and money resources to support
the work of the national committee (PCBS 2015, 2016).
The general public health problems facing the country are discussed in the
following sections: “Communicable Diseases,” “Noncommunicable Diseases,”
“Promoting Health Across the Life Course,” strengthening the health systems,
preparedness, monitoring, and response. Each section focuses on the present state
of affairs, opportunities and challenges, and the way forward. Additionally, trends in
population dynamics and the elect health indicators are analyzed to produce proof
for the policy makers and assist with forecasts for designing (Palestine STEPS
Survey 2011).
Burden of Some Diseases in Palestine
Communicable Diseases
HIV
There is a small prevalence (overall cumulative incidence of 0.006%) of HIV
infection among the Palestinian population. Voluntary HIV counseling and testing
is offered free of charge and is integrated with different health services in all districts
and through the outreach programs of nongovernmental organizations targeting
those who inject illicit drugs. Robust political commitment and a public health law
provide for free diagnosis and treatment for the entire population. The country
incorporates a well-established vaccination program, with no notable pockets of
susceptible children and complete coverage of measles and DPT3 vaccines. Routine
testing for HIV is carried out on 89.0% of blood samples that are collected.
A national strategic plan for HIV/AIDS for 2014–2018 has been created. The
worldwide Fund to Fight AIDS, Tuberculosis and Malaria supports the national
AIDS response; the country is within the shift funding mechanism section. Current
interventions embrace opioid agonist therapy, medical aid, and needle exchange.
The Ministry of Health monitoring system requires immediate action when an
HIV-positive identification occurs. Antiretroviral medical aid is provided through

two central specialized clinics (one in Gaza Strip and one in Ramallah). Services are
provided by trained employees (physicians, nurses, laboratory technicians, scien-
tists, psychiatrists). Population size estimates for the most-at-risk populations have
not been determined, and national antiretroviral medical aid pointers need change,
with more work required in preventive intervention strategies for hepatitis C. There
is a great need for regional discussions (Middle East and North Africa Report on
AIDS|2011 2011).
Tuberculosis
The tuberculosis-related morbidity is calculated to be 0.2 per a 100,000 population
(2013). The drug-resistant infectious disease tuberculosis is estimated at 3.7%
among new cases and 20.0% among antecedently treated cases. The reported
incidence of active tuberculosis is beneath 1 per 100,000 population, substantially
below than that in neighboring countries.
Malaria
Malaria is an occasional burden and of low risk in Palestine. The total confirmed
malaria infection cases were reduced from one in 2003 to zero in 2012. The country
is free from local malaria infection transmission. Most primary healthcare clinical
laboratories are able to run some biological tests, and a minimum of one per district
will perform cultures.
Neglected Tropical Diseases

The Ministry of Health faces many challenges in fighting leishmaniosis. One
challenge is the political division of the West Bank into three areas (A, B, and C)
that delays access. This hinders the Ministry’s ability to manage the disease, with
most cases occurring within the Jordan valley (Area C). Another challenge is
coordination with neighboring countries (Israel and Jordan) in preventing the disease
through spraying. As only a few kilometers separate these countries, any action
taken that doesn’t involve all three countries will likely be limited in its
effectiveness.
Additionally, there are funding problems, made even more difficult by the donor-
driven nature of funding. Temperature changes also facilitate the spread of
leishmaniosis within the West Bank into the Jericho and Jordan valley areas.
Opportunities to embrace sturdy political commitment and a public health law that
creates diagnosis and free treatment for the total population, a decent closed-circuit
monitoring system for communicable diseases, and also the work on genotyping and
drug resistance are required (World Health Organization 2015).
Diseases Which Are Prevented by Vaccines

Immunization coverage among 1-year-olds improved between 1990 and 2013 for
BCG from 89.0% to 100.0%, DTP3 from 96.4% to 100.0%, measles from 96.0% to
98.9%, and poliomyelitis from 95.9% to 100.0%. The country has a well-established
vaccination program, with no noted pockets of susceptible children and extremely
high coverage of measles and DPT3 vaccines in 2013. Viral hepatitis B vaccine was
introduced in 1992, Haemophilus influenza group B vaccine in 2007, and diplococ-
cus conjugate vaccine in 2011. Interruption of polio and elimination of infant tetanus
are maintained for several years, and there are no reportable endemic cases of
morbidly for >3 years. No cases of diphtheria have been reported for many years.
Cases of Haemophilus influenza group B infectious disease and viral hepatitis were
reported in 2013; however no cases were detected in 2014 (World Health Organi-
zation 2015).
Noncommunicable Diseases
According to the results of the World Burden of Illness Study (2010), the burden of
noncommunicable illness (cardiovascular disease, cancer, chronic respiratory organ
diseases, and diabetes) in the Arab world as well as in the Palestinian population has
increased, with variations occurring between countries. Behavioral risk factors, as
well as tobacco use, unhealthy diets, and physical inactivity, are prevalent, and
weight gain with obesity in adults and children has reached alarming levels. Despite
an epidemiological directory, the policy response to noncommunicable diseases has
been weak at best (Abdul Rahim et al. 2014).
A dedicated noncommunicable diseases unit exists inside the Ministry of Health.
The “mental state” strategy involves devolving care at the community level, giving
extra responsibilities to primary healthcare groups. They manage common mental
disorders, whereas specialists primarily based in community mental state centers and
hospitals are available for serious or severe mental illness referral. The National
Centre for Non-communicable Diseases exists, and therefore public health policies
regarding diet and physical activity ought to be developed, and cancer registries and
screening program, significantly for breast cancer, need strengthening.
Noncommunicable diseases within the West Bank result in 74.9% of all deaths,
heart diseases account for 44.2%, cancer 18.3%, and diabetes 1.2% (Palestinian
Ministry of Health 2016). As a result, 21% of adults aged 30–70 have a likelihood of
dying from these four main noncommunicable diseases. In Gaza, 21.4% of children
aged 13–15 years (30.2% boys, 11.6% girls) have smoked-cured cigarettes, while
47.4% suffer from passive smoking (World Health Organization 2010).
The prevalence of age-standardized deficient physical activity is 75.3% (63.9%
males, 86.7% females). High blood pressure affects 35.8% of the population older
than 18 years of age (36.0% males, 35.6% females), whereas obesity affects 26.8%
of the population (23.3% males, 30.8% females). All 11 essential medicines needed
for treatment of noncommunicable diseases are accessible within the public health
sector (Palestine STEPS Survey 2011).
Mental Health and Substance Abuse

The human rights-based strategy emphasizes three priorities: trauma and psycho-
therapy, integration of mental health state services into the general health facilities,
and community-based mental health state services. The strategy involves devolving
care to the community level, giving extra responsibilities to primary healthcare
teams. The World Health Organization manages common mental disorders, whereas
specialists based mostly in community mental health state centers and hospitals can
offer referrals to take care of severe mental illness. Mental health staff use evidence-
based approaches together with psychological therapy recovery follow-up, group
psychotherapy, and child and adolescent psychiatry.
The history of Palestine is marked by conflict. This challenging political context
affects the mental well-being and lifestyles of all Palestinians. The 1948 War
between Arab countries and Israel was considered, by the Palestinians, as the
beginning of the “Catastrophe,” known in the Arabic language as “Nakba.” Around
three quarters of Palestinians were displaced or fled due to the conflict and were then
considered refugees by the United Nations (UNISPAL 2012). Many people lost their
lives; villages, homes, and lands were lost in addition to people experiencing trauma
and feeling defeated (El Sarraj and Qouta 2005). The 1967 War had an additional
negative effect on Palestinian well-being and on people’s daily lives. More
Palestinians ended up living in unstable environments or faced dramatic changes.
Many experienced persecution, deprivation, discrimination, and injustice (El Sarraj
and Qouta 2005). There are also specific cultural and contextual influences of health
care in Palestine. For example, family cohesion and support are important aspects in
the lives of patients and the family needs to be included in significant decisions
(Saca-Hazboun and Glennon 2011). The care plans created by Palestinian nurses are
affected by their cultural context and the environment (Abushaikha and Saca-
Hazboun 2009).
Mental health services in the West Bank and East Jerusalem are based on the
community provision of care. The main services are provided by the Ministry of
Health, but there are only 13 community mental health clinics or centers (CMHCs)
in the West Bank, in addition to 1 psychiatric hospital in Bethlehem. In 2013, those
outpatient facilities treated 87.7 new service users per 100,000 population. The
service users treated in CMHCs were diagnosed with neurotic disorders (24.2%),
learning disability (mental retardation) (14.6%), schizophrenia (12.2%), epilepsy
(10.7%), affective disorders (9%), other mental disorders (7.8%), organic disorders
(4.4%), personality disorders (3.3%), and substance abuse disorders (1.7%) (MOH
2013). The quality and quantity of care needs improvement in these community
mental health services (WHO 2015).
Mental disorders in Palestine remain underreported, under-resourced, and
undertreated, while mental health services are underfunded. These services are unable
to meet the burden of need. There is a severe lack of human and infrastructure
resources, for example, there are a total of 20 psychiatrists in the West Bank
(Jabr et al. 2013). Each community mental health center or clinic contains mostly
one psychiatrist, psychologist, or social worker in addition to one not well-trained or
specialized mental health nurse (McAuley et al. 2005). The total number of nurses
who work in community mental health workplaces in the West Bank is only 17,
working with a total population of nearly three million (Marie 2015). A comparison
can be made with Wales (UK), a country with a similarly sized population to the West
Bank but with a total number of community mental health nurses of at least 600
(Burnard et al. 2000). In addition, the Palestinian nurses who work in these clinics or
centers are unable to provide mental health care properly, and some also work as
receptionists or clerks due to the severe shortage of other employees or lack of training.
There remains a need to develop the quality and quantity of mental health care in these
community services (Marie 2015). Mental health services are mostly underdeveloped,
under-resourced, under-researched, and under-supported (Okasha et al. 2012). The
mental health system is negatively affected by the political conflict, and this will likely
increase the challenges facing health workers in their daily routines.
Common mental disorders are being integrated into primary care. Friends and
family associations support service users and advocate for their rights. Mental health
units are established in the Ministry of Health within the West Bank and Gaza. These
units measure mental health and human resources and create strategic plans associ-
ated with an operational policy for community mental health centers. The mental
health units need support to keep up with technology and to advocate for mental
health care by the medical profession. Capacity-building is needed in interpretation
and use of mental health service knowledge. The mental health treatment gap
remains large and support is required to combat misconceptions and stigma
(World Health Organization 2015). The availability and quality of mental health
care should be increased. Mental health policy and services in Palestine need
development in order to better meet the needs of service users and professionals. It
is essential to raise awareness of mental health and increase the integration of mental
health services with other areas of health care. Civilians need to have their basic
human needs met, including having freedom of movement and seeing an end to the
occupation. There is a need to enhance the resilience and capacity of community
mental health teams. There is also a need to increase resources and offer more
support, up-to-date training, and supervision to mental health teams.
Violence and Injury

The percentage of deaths caused by injuries in 2012 within the geographic area was
5.5%. Of this, unintentional injuries accounted for 84.0% (35.2% to road traffic
injuries and 5.0% due to of drowning), whereas intentional injuries accounted for
16.0% (9.8% as a result of self-harm and 9.2% as a result of social violence)
(Palestinian Ministry of Health 2016). The road traffic death rate was 3.2 per
100,000 population in 2010. For post-injury trauma care, there is a universal
emergency access phone number, but less than 10.0% of those injured at work are
transported by ambulance (World Health Organization 2013).
Violence, injuries, and incapacity programs have commenced with the institution of
a road traffic casualties data system and a national injury data system, supported by the
Palestinian National Institute of Public Health. A challenge is the multi-sectorial nature
of the data needed. Laws covering all key road safety risk factors exist but many still
need to be created. Medical aid for injured persons is provided by nongovernmental
organization-managed emergency medical services and by Ministry of Health hospi-
tals. Additionally, referrals can be made to private-sector suppliers. Specialized
national emergency care coaching is on the market for doctors and nurses. There is
a need for modern trauma care system to address existing gaps to boost different
aspects of the services. Approaches to information assortment and analysis should be
harmonized among stakeholders (World Health Organization 2015).
Disabilities and Rehabilitation

Disability prevalence is 6.9% using the wide definition “faces some difficulty in
functioning,” but this becomes 2.7% when using the strict definition of “faces extreme
vital difficulties,” with 2.9% within the West Bank and 2.4% in Gaza (2.9% for males
and 2.5% for females). The prevalence of disability in children aged 0–17 years is
1.5% (1.6% West Bank, 1.4% Gaza; 1.8% males, 1.3% for females).
Mobility-related disabilities have the highest prevalence at 49.0% (49.5% West
Bank, 47.2% Gaza), with learning disabilities second at 24.7% (23.6% West Bank,
26.7% Gaza), noting that an individual might have more than one incapacity
(Palestinian Central Bureau of Statistics Ministry of Social Affaires Disability
Survey 2011 Press conference report, 2011).
The international organization Convention on the Rights of Persons with Dis-
abilities was sanctioned in 2014, and therefore the Constitution includes articles on
incapacity. The overarching legislation is Law No. 4 on the Rights of the Disabled
(1999). The Supreme Council for the Affairs of Persons with Disabilities has been
the national coordination mechanism since 2004 and is chaired by the Minister of
Social Affairs, with some persons with disabilities. A national strategic arrangement
for the incapacity sector has existed since 2012, and a few ministries have developed
their own strategic frameworks on incapacity and have supported it. Challenges
include inadequate resources and funds, the chronic crisis being experienced, diffi-
cult body structures, and inadequate knowledge systems. However, efforts to deal
with totally different incapacity problems are being pursued. Legislation, policies,
and programs are being reviewed against the Convention on the Rights of Persons
with Disabilities and human rights principles, and a multi-sectorial incapacity
strategy is being developed. Screening programs for the first detection and interfer-
ence of incapacity, as well as vision and hearing screening, are offered in by the
college health program. The International Classification of Functioning, Disability
and Health has been introduced to Ministry of Health. After the International
Classification of Functioning, Disability and Health has been introduced to the
Palestinian Ministry of Health. As a result of discussion conducted by the primary
health care managers and technical representatives from the ministries of Social
Affairs, Education and Labour, the Ministry of Health has adopted the implementa-
tion of this classification, but a major challenge is the lack of funding. The updating
and upgrading of the existing screening programme, including learning disabilities
and genetics within this classification, has also been included in the Ministry of
Health’s strategic plan (World Health Organization 2015).
Nutrition
The prevalence of several conditions due to malnutrition in children under 5 years
old is 4.4% for wasting, 10.3% for stunting, and 20.0% for overweight (Fondo de las
Naciones Unidas para la Infancia – UNICEF, Organization, & The World Bank
2015). The prevalence of anemia in women of reproductive age (15–49 years) is
20.0%, and iodine deficiency affects 26.8% of the population. Initiation of
breastfeeding during 1 h after birth is 40.8%, while 38.6% of children under 6 months
are completely breastfed. The prevalence of low birth weight is 8.3% (PCBS 2015).
A national nutrition policy has been set up and is available for the period
2011–2013. Anemia among children under-5 and pregnant women is a problem of
current concern; but the majority of cases are either mild or moderate. Weight gain
and obesity are high in all age groups, with associated low levels of physical activity.
Nutritional monitoring surveillance is in place through routine growth checkups of
under-5s and periodic screening of schoolchildren. The International Code of Pro-
moting of Breast-milk Substitutes has been adopted and applied through national
regulation. The International course of regulation and Marketing of Breast-milk
Substitutes has been adopted and applied through national regulation, accompanied
by regulation of infant formula and follow-on formula, infant and toddler, and
medical foods. National policies and interventions targeting unhealthy nutrition
practices and physical inactivity still need to be developed.
Reproductive, Maternal, Newborn, Child, and Adolescent Health

Maternal mortality declined by 61.9% between 1990 and 2015 (from 118 to 45 per
100,000 live births) (Ross et al. 1990). The under-5 mortality rates diminished from
43 to 21 deaths per 1000 live births (UNICEF 2012). The proportion of women
receiving antepartum care coverage ranges from 99.4% (at least 1 visit) to 95.5% (at
least 4 visits) (PCBS 2015), and contraceptive use is 57.2% (PCBS 2015).
Reproductive, maternal, newborn, and child health services are available at no
cost at Ministry of Health medical aid facilities. The first care package of services for
procreative health is comprehensive, comprising services covering the whole pro-
creative cycle and including youth and adolescent care; ceremonial care; care
throughout menopause; and screening for breast and cervical cancers. Healthcare
facilities administer all deliveries, mainly in hospitals and a number of complete
maternity units. Postnatal coverage remains low. Newborn and children health
services embrace growth observation, nursing support and substance supplementa-
tion, and testing for catalyst and internal secretion deficiencies. The Integrated
Management of Childhood Illness, a technique enforced on all Ministry of Health
facilities and most health suppliers, is commonly used. However, maternal and
under-5 mortality indicators have not achieved Millennium Development Goal
targets. There remains a requirement to update and standardize the rules for prenatal,
postnatal, and infant care and to implement a harmonized procreative health written
record within the Ministry of Health.
Aging and Health Life Expectancy

Life expectancy for males is 71.5 and females is 74.4 (Palestinian Ministry of Health
2016). In 2010, the aging population (adults older than 60 years of age) accounted for
4.4% of the overall population (Malik 2014). While there are national interventions
aimed toward supporting the growing aging population, there is no national multi-
sectorial and knowledge domain program on aging. The Ministry of Social Affairs
includes a department on aging and provides a small regular payment to the aged living
in poor financial conditions. The Ministry of Health provides primary healthcare and
hospital services to any or all insured voters no matter their age; but the particular needs
of the aging population have not been integrated into the health service delivery system.
The National Higher Council on Aging has developed a law for the aged.
However, because of the political status, it has yet to be to be sanctioned. With the
shortage of public aged services, nongovernmental organizations have programs
providing day care, institutional care, and residential care to the aged; however
services in these areas are fragmented and unregulated. The Ministry of Health has
initiated an Associate in Nursing for the initial assessments of the health status of the
aged population within the country. This is supported by the resultant findings and
suggestions from an associate with nursing knowledge to make sure that the aged
receive the required support.
Gender, Equity, and Human Rights Mainstreaming

In female adults (above 15 years of age), literacy is relatively high at 93.6%, but
participation in the labor force is relatively low at 15.2%. The Human Development
Report (2014) graded the country at 107 out of 187 countries across the globe on the
human development index (Malik 2014). The national health strategy aims to
confirm and insure rights based on comprehensive and integrated health services
to all voters (regardless of gender, age, disability, geographical distribution, and
therefore the political and socioeconomic situation). The Ministry of Health pro-
motes gender issues in policies and multi-sectorial efforts against social violence.
However, there is a requirement to enhance observation and analysis to confirm
that gender equity and human rights principles are applied. Equitable access to
services, as well as referral care, remains troublesome to monitor and is not improved
by knowledge quality and analysis. Challenges embrace the chronic crisis and
unstable political situation, and inadequate human and financial resources, with
intermittent international funding. This is made more difficult by the continued
occupation, frequent military escalations, and therefore the deteriorating economic
status. The general public health system lacks the required specialists, diagnostic
instruments, and medical capability to produce comprehensive services and depends
heavily on referring patients to nongovernmental facilities for specialized diagnoses
and treatments. This leads to unmet medical needs, notably for complicated medical
cases. Patients usually are compelled to travel to neighboring countries for treatment
and rely completely on totally on governmental funding. The financial crisis of the
government has resulted in shortages of necessities such as medicines and medical
supplies within the Ministry of Health. This is notably acute in the Gaza Strip, and
there are huge debts to suppliers. The progressively unpredictable nature of interna-
tional funding has from time to time harmed the health system, initiating a sting of
hospital closures in 2013 (WHO video: how social factors determine health in
Gaza 2016).
Environmental Determinants of Health in Palestinians
There are no estimates for the burden of environmental factors on health, although
access to improved sanitation facilities is 99.0% and access to improved drinking
water is 92.0% (Palestinian Ministry of Health 2016).
There is reason to believe that the burden of illness has increased as a result of
various environmental health emergencies within the country. Although air pollution
is not properly monitored, evidence suggests high levels of particulate matter in the
air in the West Bank and Gaza. Environmental risk factors contribute heavily to both
communicable and noncommunicable diseases. Poor water quality and sanitation
services are major environmental hazards contributing to the burden of communi-
cable diseases in some sections of the country.
Sadly, the continuing emergency state of affairs means that the number of
environmental health services is deteriorating. The government has been working
on strengthening national capability for environmental health readiness and
responses to emergencies associated with waste management, water supply, and
sanitation. The government supported the World Health Organization regional
environmental health strategy and framework for action 2014–2019 and initiated a
national multi-stakeholder method to develop a national strategic environmental
health framework for action in 2015–2016. There is a desire to strengthen cooper-
ation between the health and environment within the West Bank and Gaza
(Isaac 1989).
The occasion of World Environment Day (WED) is celebrated every year on the
5th of June since 1972. While the world celebrated the WED 2010 and applauded its
environmental achievements and the level of quality of life of its citizens, this date is
a reminder to the Palestinians of the Israel’s occupation of the West Bank, including
East Jerusalem, the Gaza Strip, and other Arab Territories in 1967. The Palestinians
still live under occupation, and this is depleting the environmental resources in the
Palestinian Territory. The depletion and destruction of environmental resources
caused largely by Israeli actions (most notably the illegal settlements) have a harmful
impact on the Palestinian environment; the occupation resulted in land being con-
fiscated from the Palestinians, and they are prevented from re-entry to their land to
work. It has also depleted Palestinian water resources and promoted wastewater,
solid waste, air pollution, noise, and the destruction of cultural heritage and the
agricultural sector (Barakat and Heacock 2013).
The following represent an overview of the natural resource components of the
Palestinian sustainable development. The current status is outlined, and blueprints
for environmentally sound development are presented.
Land
Land is the basis of the Palestinian-Israeli struggle, and at the same time it is the basis
of agricultural production. The total area of the West Bank, including Jerusalem, is
about six million dunums (1 dunum = 1000 m2), of which 31.7% are cultivated.
The Gaza Strip is an area of 365,000 dunums, of which 47.8% are cultivated
(Box et al. 1994).
Land, as a major physical resource for agriculture, has proportionately different
economic significance to Israel and Palestine. While the farming sector in Israel
accounts for 3% of the gross domestic product (GDP), in Palestine it accounts for
22–30% (Box et al. 1994). For political and ideological reasons, Israel continues to
deprive Palestinians of their natural agricultural potential and now control 70% of
the West Bank. Up until the accomplishment of the Cairo convention, Israel con-
trolled 60% of the Gazan land. Taking the occupied Palestine territories as a whole,
2.61 million dunums have been claimed by Israeli settlements and 1.16 million
dunums by military installations (Rete and Larghe 1993). Even after the Cairo
convention, Israel controls 22% of the Gaza.
Research needs to be done on the effects of agricultural, pastoral, and infrastruc-
ture usages of the different types of land in Palestine. Guided by the results of this
research, the Palestinian authorities will need to move quickly to provide regulations
and incentives for sustainable land usage. Finding a means of limiting agriculture,
grazing and building construction are going to be of the utmost importance, as are
coming to terms with the problem of land tenure and ownership rights.
The extent of Israeli control has fostered overgrazing and continuous cropping on
Palestinian-controlled land and hence to the desertification of vast tracks of the
occupied Palestine territories. This is particularly the case in the eastern slopes
region of the West Bank, where attempts to reverse overgrazing and desertification
must be prioritized. Serious consideration must be given to how best to utilize the
“closed military zones” in this region – which currently account for 85% of all
pastoral land – once it is returned from the Israeli military control. Programs of
native plant reestablishment and reforestation would cost around $200 per dunum.
Urban land use must also be considered. Land devoted to urban development is
growing despite Israeli restrictions on construction and efforts to impede growth in
other sectors of the economy, such as industry. Urban planning is the responsibility
of the Israeli Civil Administration, local municipalities, and/or village councils, and
consequently an integrated approach is currently difficult to implement. Despite this,
the Palestinian authorities should begin to look seriously into ways to limit the
expansion and growth of cities, towns, and villages on the valuable arable land. They
must embark on a participatory process to develop and implement town plans and
zoning requirements at the earliest date possible (Isaac 1989). Considering the issue
of Palestinian territories and the problem of areas affecting the environmental and
health determinants, the Gaza Strip is the most populated place in the world.
The exploitation and misuse of natural resources by the Israeli occupation affect
the environment and add pressure on natural resources. The Palestinian Territories
suffer from a high population density and a scarcity of natural resources. The
population density in the Palestinian Territories reached 663 persons/km2 in 2009
(439 persons/km2 in the West Bank and 4,140 persons/km2 in Gaza Strip), compared
to 350 persons/km2 in Israel. Despite the high population density, there are no
renewable natural resources, which causes a deterioration of life and environment,
a deterioration of water quality and deficiency, and a deterioration of agricultural
land and forests (Barakat and Heacock 2013).
Water in the Palestinian Territory
Current Status and Challenges

There are a number of factors that form risks to the water sector in Palestine,
including the excessive consumption of water by the Israeli occupation and settlers,
which led to the depletion of available groundwater stocks. But extremely important
are the Israeli procedures and actions taken against the Palestinians to reduce their
consumption of water. One of the Israeli actions is the limiting of the amount of
water extracted from Palestinian wells where it should not exceed 100 cubic meters
per hour and preventing Palestinians from drilling new wells or reducing the depth of
approved wells to no more than 140 m. Israel prevents the Palestinians from using
the waters of Jordan river and impedes the provision of water to local municipalities.
The Israeli’s unregulated use of water, population growth rate of 2.9% per year,
fluctuating amounts of rainfall from year to year, and large consumption of water
have led to decreased availability of water in Palestine. Information from 2009 show
that the amount of water purchased for local use from the Israeli Water Company
(Mekorot) amounted to 47.4 million cubic meters in the West Bank. In 2008, the
yearly available quantity of water in the Palestinian Territories was 308.7 million
cubic meters. Data also shows that the quantity of water supplied for local use in the
Palestinian Territories in 2008 was 185.5 million cubic meters and the daily distri-
bution per capita of the supplied water for domestic use in the Palestinian Territories
was 132.9 (liter/capita/day) (Barakat and Heacock 2013).
Water, perhaps the most scarce and valuable resource in the region, has been
another focal point of the Palestinian-Israeli conflict. Israeli power has limited water
usage and exploited Palestinian water wealth. It almost goes without saying that
addressing the issue of water rights, and coordinating water usage (with an emphasis
on wise use and maximum efficiency), will be key to achieving sustainable devel-
opment in the region.
The region’s groundwater resources, namely, the coastal and mountain aquifers,
underlie, to varying degrees, both Palestine and Israel. Surface water resources
include the Jordan and Yarmouk Rivers, to which both Israel and Palestine are in
the riparian zones. The West Bank farmers exploit the waters of the Jordan River to
irrigate their fields, but this source has become quite polluted as it serves as a
receptacle for waste disposal upstream. Moreover, Israeli diversions from Lake
Tiberias into the National Water Carrier have reduced the flow of the Jordan River
considerably. Other Gazan water resources, such as runoff from the Hebron hills,
have been diverted for Israeli purposes. Partly because of this, and partly because of
undue pumping, Gaza’s coastal aquifer is now suffering from seriously severe
saltwater intrusion. In the West Bank, Israeli restrictions on drilling have diminished
the water resources available to Palestinian consumers. In Israel, by contrast, farmers
are permitted to drill bore hole wells, accessing water resources before they reach the
higher ground of the Palestinian wells. With regard to total water consumption, an
Israeli uses 375 cubic meters per year (cmy), a Palestinian uses 107–156 cmy, while
a Jewish settler uses 640–1,480 cmy. Israelis use around 500 million cubic meters
per year (mcmy) from the West Bank water resources, while Palestinians are using
only 115 mcmy of their own water (Isaac and Selby 1996).
Palestinian consumption of local water resources takes place mainly in the
agricultural sector. The West Bank irrigated farming utilized 88 mcmy, while
irrigation in Gaza use is 65–70 mcmy (Isaac 1989). Israeli restrictions have drasti-
cally limited the irrigation of Palestinian land so that today only 5.5% of the West
Bank land cultivated by Palestinians is under irrigation, the same proportion as that
in 1967. By contrast, about 70% of the area cultivated by Jewish settlers is irrigated
(Isaac and Selby 1996). Unfair water allocations similarly account for the enormous
discrepancy in water consumption between Palestinians and Israelis. However,
average domestic water consumption among Palestinians in the West Bank is
estimated to be just 70 l per capita per day (lpcd), falling short of both the “absolute
minimum” standard of 100 lpcd recommended by the World Health Organization, as
well as its “preferred minimum” standard of 150 lpcd; average domestic water
consumption in Israel stands at 300 lpcd (Amnesty International 2009).
Not only is there an imbalance in the distribution and consumption of water
between Palestinians and Israelis – the pricing of water is also discriminatory. The
high prices serve as a deterrent to moderate use and partially explain the low per
capita consumption in Palestine. While the actual cost of supplying one cubic meter
of water in Israel is estimated at $0.36, Jewish settlers, who receive large subsidies,
pay $0.16 and $0.40 per cubic meter for agricultural and domestic purposes,
respectively. Palestinian consumers can pay as much $1.20 per cubic meter of
water, with no subsidized rate for agriculture (Isaac and Selby 1996).
To date, neither the multi-lateral negotiations on water nor the bilateral talks have
broached the sensitive issue of equitable sharing of water resources. Water rights, it
can only be presumed, will be one of the issues to be discussed as part of final status
negotiations which began in 1996. Only serious insight into this problem will lead to
potential peace and avoid environmental disaster. In addition to resolving the
problem of water allocations, emphasis must be placed, throughout the region, on
increasing the level of supply relative to the demand. Supplies could be enhanced
through water importation, although it seems that such options could be economi-
cally, environmentally, and politically dangerous. A more feasible option would be
to concentrate on increasing rainwater harvesting and enhancing agricultural water
supplies through using brackish water and wastewater for irrigation. In addition,
emphasis should be placed on the suitable use of water resources. Consumption
should be governed by recognition that the Middle East is an arid region where water
supplies are never going to be plentiful.
Water Pollution in the Palestinian Territory

Water is delineated as contaminated if pollutants are found to a degree which hinders
the use of the water for various functions such as drinking and irrigation. Only 1
cubic meter of contaminated water could pollute 40–60 cubic meters of clean and
unpolluted water. Reasons of water pollution include infectious agents, agricultural
and animal residues, detergents, oil and petroleum products, chemicals, radioactive
substances, and heavy metals. The most important aspects of pollution in the
Palestinian water are the increase of salts and nitrates. The concentration of salts in
the Jordan River is 5,000 ppm, which represents a large increase from less than
600 ppm in 1925. The concentration of chloride has increased from 24 mg/l to
1,365 mg/l in the Jericho governorate during the past 20 years. The excessive Israeli
pumping of groundwater led to extensive salinity within the groundwater; the
salinity of water has reached 27.2% within the West Bank, and this is over acceptable
international levels (50 mg/l). The nitrates pollute many of water resources; in
Tulkarm the amount of water free from pollution by nitrates does not exceed
27.0%, while the percentage reached 23.0% in Qalqilya. High rates of nitrates
(50 mg/l) exist in 14.0% of the water wells in the West Bank. In the Gaza Strip,
concern about water pollution is larger than in the West Bank because the quantity of
chloride in some areas reaches 1500 mg/l, and therefore the areas where extracted
water with low levels of chloride (250 mg/l) do not exceed 45 km2 within the
northern regions and 35 km2 in the southern regions. The water in the Gaza Strip
is classified as alkaline water, with high levels of chloride. About 85% of water wells
in Gaza Strip is not suitable for drinking due to components of alkalinity, and this has
increased the concentration of salts (1,000 mg/l) and nitrates (Barakat and Heacock
2013; Isaac and Selby 1996).
Air and Environment

Air quality is mostly acceptable throughout Palestine but is of increasing concern for
Palestinian environmentalists. While the industrial sector is underdeveloped, the
number of cars is on the rise and may present the biggest problem to air quality
control. The absence of accurate information on the numbers, types, and ages of
vehicles used (cars, tractors, trucks, etc.) and systems for monitoring pollution by
road traffic prohibit adequate description of current conditions.
In time, a major concern for both Palestine and Israel will be the coordination of
programs for air quality monitoring and control. Statistics for ambient air quality in
Israel are at best spotty. One can speculate that continued development of industry
along the coast will have a major impact on the air quality of residents in adjacent
parts of the occupied Palestine territories, and, likewise, industrial development in
Palestine will have repercussions on Israeli air quality (World Health Organization
2013).
Agriculture and Environment

The soil in Palestine is exposed to several human, agricultural, and industrial
activities; these have negative effects on the fertility of the land. The most prominent
issues facing the soil in Palestine are the excessive use of fertilizers and pesticides.
Because of the rapid increase in population and the diminishing agricultural area,
people feel forced to use fertilizers and pesticides to increase the productivity of
agricultural land. In the West Bank, the annual rate of use of agricultural fertilizers
reached 30,000 tons of chemical fertilizers and manure, and the annual rate of use of
pesticides reached to 502.7 tons, consisting of about 123 types, 14 of which are
internationally banned for health reasons. In the Gaza Strip, the annual rate of
agricultural fertilizer use reached 12,000 tons of chemical fertilizers, and the annual
rate of use of pesticides reached 893.3 tons, containing around 160 different types,
19 of which are internationally banned for health reasons. Accumulation of agricul-
tural fertilizers and pesticides and their residues reduces soil fertility and increases
water pollution.
Agriculture is the largest sector of the Palestinian economy, generating 22–30%
of the GDP of the West Bank and Gaza and providing employment to over 15% of
the population (Isaac 1989; Box et al. 1994). However, the Palestinian agriculture is
far from flourishing. The reasons for this are the high costs of production, particu-
larly the cost of labor, and the rapidly rising cost of living is forcing marginal farmers
to abandon their lands and seek employment elsewhere in Israel. Other important
considerations include capital insufficiency that imposes economic constraints on
farmers; the high competition with Israeli farmers who receive large government
subsidies; unfair trade laws permitting subsidized Israeli produce into the territories
whereas restricting access of Palestinian farmers to markets in Israel; and lack of
adequate analysis and outreach services to support farmers to improve their produc-
tion and efficiency. With the arrival of peace, the agricultural sector is expected to
develop rapidly, acting as the engine of growth for the Palestinian economy. How-
ever, to ensure that agriculture develops in a sustainable and productive manner,
Palestinians will need to address a number of issues.
Firstly, Palestinians will need to consider the relationship between economics and
agriculture. This must include sound analysis of the economic opportunities avail-
able for farmers and an outreach program that will help farmers to determine the
economic feasibilities of different crops and to have access to all appropriate
technology necessary for maximum economic adequacy.
A second focus of research should be to increase efficient water use in agriculture.
This should include attempts to increase supplies through, for example, water
harvesting and wastewater reuse. Attention should also be paid to improving crop
varieties, so as to enable cultivation using brackish waters and to allow for reduction
in water requirements. Additionally, research needs to be conducted on the potential
for increasing the productivity of rain-fed agriculture, and cultivating traditionally
irrigated crops, such as vegetables that can be grown without irrigation.
Thirdly, consideration of pest management and pesticide use will be vital.
Farmers in the West Bank and Gaza are currently use environmentally and humanly
unsafe practices during application of pesticides, as well as unsafe pesticide types,
including seven of the internationally banned “dirty dozen.” This is in large part
because of inadequate labeling and safety regulations and the lack of extension
services. The Palestinian authorities will have to enforce new labeling, distribution,
and disposal requirements. A regional program to develop integrated pest manage-
ment strategies (aimed at minimization of crop damage through the use of crop
rotations and biological control) is much needed.
Waste Management
Although waste is described as a resource of no net income value, its management is
vital to sustainable development. The disposal of sewage and solid waste creates
demands on resources and can be potentially harmful to water resources. Approx-
imately 275,000 tons of solid waste are generated annually in urban areas in the
Occupied Palestinian Territories, most of which are placed in landfills or dumped
randomly (Isaac 1989). Nearly 65% of this waste is estimated to be organic,
implying real opportunities for waste disposal schemes that emphasize recycling.
However, as of yet, no clear answers exist as to how to best handle waste disposal
either in Israel or in the Occupied Palestinian Territories. Another important issue in
waste management is related to waste that comes in from the Israeli side without
control by the Palestinian National Authority; most of this waste is dangerous and
includes electronic waste and medical waste (Environmental assurance quality
authority, personal communication 2018). These waste products are treated by
untrained people as a source of income, and the waste resulting from recycling
these products go into the surrounding water, air, and soil and so also negatively
affects human health (MoH, Hebron, personal communication, 2018).
Among the major issues to be considered is how to monitor and prevent the
contamination of precious groundwater resources when landfill sites are selected.
This issue is of particular importance in Gaza, where environmental pressure on
water resources is most intense. For this reason, and also because such a high
proportion of the waste is organic, it may be environmentally preferable to incinerate
Gaza’s solid waste. Another option to be considered is recycling. The establishment
of any comprehensive scheme should involve regional cooperation; however, this
may be difficult given the small population of Palestine (much smaller than the
populations of Israel, Jordan, and Lebanon) and the shortage of financial resources.
Climate Change and Environment

Massive quantities of harmful poisonous gases made from Israeli factories are
transferred to the Palestinian airspace by the wind. In addition, smoke and gases
from coal-fired power plants in Ashdod and Ashkelon are transferred to the Gaza
Strip. The Israeli industries in the West Bank and Gaza Strip, as well as other
industries in Israel, constitute the greatest threat to atmospheric pollution in the
Palestinian Territories. Climate experts expect that gases emitted from the 1948
territory will be increased by 40% by the year 2020.
Climate change in Palestine includes reductions in rainfall and increases in
temperatures. The amount of rainfall ranges between 593.1 mm in Jenin Station
and 115.7 mm in Jericho during 2009. The annual mean rainfall was 942.7 mm in
Nablus Station in 2003. The lowest monthly mean maximum air temperature is
12.2 C in Hebron Station in January, while the highest monthly mean maximum air
temperature was 39.8 C in Jericho Station in July. Time series data indicates that the
annual mean of minimum air temperature over the period 1975–1995 was between
11.2 C in Hebron Station and 15.7 in Jericho Station. The annual mean minimum air
temperature ranges between 12.8 C in Hebron Station and 18.3 in Kardala (Tubas
Governorate) Station in 2009 (Bircher and Kuruvilla 2014; Isaac 1989).
Mineral Resources
Mineral resources, both metallic and nonmetallic, are limited. Quarrying (mainly of
lime, limestone, and marble) is common, but it is exploited below its potential due to
restrictive policies on permits, exploitation, extraction, and exports, as well as the
absence of research institutions and reliable data on mineral resources. Prior to
expansion of the mineral exploitation sector, a comprehensive resource policy
should be formulated and implemented. This would greatly assist efforts to employ
clean technology within the extraction processes, to encourage correct waste dis-
posal, and to conserve resources for future generations (Isaac 1989).
Tourism
Tourism presents tremendous opportunities for the newly emerging Palestine. Esti-
mates are that two million people would be expected to visit Palestine annually in the
near future. In addition, several hundred thousands of the Palestinian diasporas will
be expected to spend their summer vacations with their relatives in Palestine. Serious
consideration must be given as to how this regular population influx can be produc-
tively exploited without damaging the environment.
Israeli Occupation and Its Consequences
The effect of Israeli occupation can be considered as the main determinant of the
health of Palestinians. Its effect started from the first day after Nakba of 1948 when
millions of people were displaced and were left without adequate homes, food, and
drinking water and led an insecure life. Various unknown causes of death became
common then and this continues as the occupation expands. Hundreds of thousands
remain without work due to the lack of permission to enter Israel. This led to
financial constraints in obtaining education, food, and health care, leading to poor
population health overall. It became clear that the Israeli occupation has influenced
all segments of the Palestinian life including their food, education, work, health,
freedom, free movement, construction of homes, prisoners, wounded and injured
people, disabilities, etc. Israeli forces regularly invade hospitals, attack ambulances,
leave the wounded to die, prevent vaccines from getting into the Palestinian areas,
prevent the Palestinian National Authority to work freely in Area C; these are some
examples of the negative impact of Israeli occupation. In fact, analysis of social
factors outside of a consideration of the political systems and power relations in
which they arise can be misleading or patronizing at best (Ben Bouquet 2014).
The separation wall has affected the healthcare system in the Occupied Palestin-
ian Territories, and the healthcare system has been seriously disrupted by the Israeli’s
restricting movement on the population. Israel’s recent construction of the separation
wall isolates parts of the West Bank from each other and cuts off the West Bank from
East Jerusalem, which Israel annexed illegally shortly after the 1967 war and
occupation.
Patients and hospital staff are required to apply for Israeli-issued permits to access
specialized hospitals in East Jerusalem since 2016. These permits are difficult to
obtain for many and may carry “conditions,” such as providing information about
colleagues to security authorities. Even with a permit, barriers to health access for
Palestinian patients can include delays at checkpoints, limitations on family mem-
bers seeking to accompany children and the elderly to hospital, longer distances to
service centers, and physical demands of access for people with physical disabilities
and the chronically ill (Batniji et al. 2009).
The United Nations Common Country Analysis (UNCCA) for 2016 emphasizes
that the primary driver of vulnerability in Palestine continues to be the military
occupation. Access to health care is one important social determinant of health, and
barriers to accessing healthcare can be financial, political, geographical, and social.

The WHO report Right to Health: Crossing barriers to access health in the occupied
Palestinian territory, 2014–2015 points out that the prevailing restrictions on move-
ment through the system of checkpoints and permits impact upon Palestinians’
access to healthcare and life-saving treatments. In addition, restrictions on the
entry of medications and medical equipment to Gaza affect the availability of
essential therapeutics (WHO 2016a) (Fig. 6). Beyond health care, restricted access
to resources including land, water, gas and oil reserves, quarries, and Dead Sea
minerals has impeded Palestinian economic development (where these resources in
the occupied territory have directly profited Israel) (Al-Haq 2016). Trade restrictions
imposed by Israel since its occupying Palestinian territories in 1967 have cut off
Palestinian producers from their traditional trading partners (UNCCA 2016). Such
economic conditions impact upon access to secure employment, which has impor-
tant implications for social and psychological well-being and long-term physical
health. The unemployment rate for Palestine was the highest in the world in 2015 (at
25.9% of the working-age population), and the figure was most dire for the Gaza
Strip (with 44% of the working-age population unemployed).
Poverty is a major factor affecting health in Palestine. Even where individuals are
covered by Government Health Insurance, access to health care can be prevented by
costs of travel, loss of revenue, and lack of information. Poverty influences access to
decent housing, heating, food, clean water, and adequate sewerage, all of which have
consequences on health. According to UNRWA, a third of households in Palestine
experienced food insecurity in 2014 (UNRWA 2014). The situation is worst in Gaza,
where 57% of households experienced food insecurity and, according to the
Israeli soldiers attacking a Palestinian Ambulance Palestinians climb the Separation Barrier
on their way to Jerusalem
Lost childhood A Palestinian wedding at a checkpoint
Fig. 6 Some examples of how Israeli occupation affects Palestinian daily life
Palestinian Micronutrient Survey in 2014, 29% of children were stunted due to

chronic malnutrition (Rau 2015). Living in a particular area of the West Bank or
Gaza influences a person’s chances of experiencing poverty or deprivation and of
suffering from the associated detrimental effects on long-term health. A map show-
ing the percentage of poverty in various localities, published by the Palestinian
Central Bureau of Statistics (PCBS) in 2009, demonstrates wide disparities in the
level of poverty in different areas in Palestine (see Map 2). The poorest areas
Map 2 Distribution of poverty among Palestinians. (Source: Central Bureau of Statistics, PCBS
2009)
correspond to those most affected by what the UNCCA highlights as locational

drivers of vulnerability. These include residing, working, or accessing services in
Area C of the West Bank (WB) (around 65% of the area of the West Bank, under
direct Israeli military control); Area H2 in Hebron (20% of the WB’s largest city,
under direct Israeli control); East Jerusalem; the Seam Zone (the area between the
1949 Armistice or Green Line and the separation barrier); and the Gaza Strip (Ben
Bouquet 2014) (Fig. 7).
Population Growth
A critical issue in the discussion of sustainable development is that of population.

Environmental degradation and population growth can form a cyclical process of
reinforcement. A growing population obviously signifies an increasing demand for
food, water, and energy, among other things, and requires equally rapid growth
merely to maintain a constant standard of living. Likewise, poor environmental
quality can increase poverty and reduce opportunities for better living standards
which in turn increase the fertility rate.
This issue is politically charged in the context of the Palestinian-Israeli conflict.
While the Palestinian natural population growth rate is high, between 3 and 3.5%,
education
movement
employment
inside and
(workforce)
outside
injuries ,
social
disabilities,
relationships
and death
health care
violence services inside
and outside
food and
Stress
water scarcity
Fig. 7 Israeli occupation as the determinant of health and environmental health of Palestinians
the immigration into Israel means that the Israeli rate of population increase is even
higher, at 4.2% (Isaac 1989). All are higher than the projected rate for the Middle
East and North Africa (2.9%) (Middle East and North Africa Report on AIDS|2011
2011).
These rates of growth will certainly lead to additional strain on the natural
resources, including water and land. Serious consideration must be given as to
how to cope with these rates of growth. Traditional factors instrumental in reducing
fertility rates (i.e., family planning, elevating the status of women, and eliminating
poverty) must be targeted. Above all, the socioeconomic characteristics of the
population must be considered.
Public Awareness
Palestinians are more concerned with their struggle for self-determination and the
attainment of the right to pursue the development they choose than to contemplate
“better” or “more appropriate” patterns of resource use when they have little or no
choices to begin with. While it should be noted that segments of the Palestinian
society were involved in environmentally sound practices such as recycling long
before it became vogue, the general lack of environmental awareness is obvious to
anyone passing through the Gaza or driving the back roads of the West Bank.
Mounds of rubbish, scattered tins, discarded plastics, and dismembered car bodies
discarded on roadsides and in ravines demonstrate the lack of shared responsibility
and respect for a shared public space. Such litter is a blight to the naturally pristine
beauty of Palestine. Roadside debris, when compared to the dangers of industrial
waste or overgrazing, may not be all that menacing. This is symptomatic of a lack of
awareness of environmental concerns.
Despite this general lack of awareness with environmental concerns, there is a
perceptible increase of environmental consciousness among Palestinians. The envi-
ronmental education initiative has been taken up by grassroots organizations and
NGOs, but this must expand to be shared at all levels, from the policy makers to all
grassroots organizations. Palestinian leaders have a responsibility to make the
protection and care of their environment a priority of the highest national impor-
tance. Publications, media programming, regular columns, school educational cur-
ricula, and the formation of formal institutions such as a Palestinian Nature
Protection Society may be forums for expanding awareness. An “environmental
ethic” must be cultivated and adopted, in which resources – clean air, land, and
water – are viewed as precious assets to be carefully protected, managed, and
allocated. Environmental education must receive priority status in the quest for
sustainable development, and sufficient financial resources must be allocated to
transform this into reality (Isaac 1989).
Sustainable development is a process of change in which the exploitation of
resources, the direction of investments, the orientation of technological develop-
ment, and institutional change are all in harmony and promote both current and
future potential to meet human needs and ambition. Thus, sustainable development
should address the past, the present, and the future. To understand potential devel-
opment in Palestine, one ought to look at the carrying capacity and natural compo-
sition of the land through history. From there it will be necessary to assess the most
important environmental and socioeconomic issues of the day and project these into
the future. This information will then form the basis for conclusions about what
actions should be taken to insure that society develops in an environmentally sound
manner (Isaac 1989).
Promoting Health Across the Life Course
• The first care package of reproductive health services is providing comprehensive

coverage for the complete reproductive lifetime including youth and adolescent
care; premarital care; care throughout the menopause; and screening for breast
and cervical cancers.
• The Ministry of Health provides primary healthcare and hospital services to all
citizens regardless of age; specific requirements of the aging population have not
yet been integrated into the health service delivery system.
• In 2013, a national multi-sectorial social determinants of health committee was
established to spot and act on key social determinants of health, to draft a thought
process to handle priority problems, and to integrate social determinants of health
into all relevant policies and programs.
• The government has supported the WHO agency regional environmental health
strategy and framework for action 2014–2019 and can initiate a national multi-
stakeholder method to develop a strategic environmental health framework
for action in 2015–2016. This can concentrate on many environmental health
priorities, together with environmental health preparation and response to
emergencies.
Concluding Remarks
We characterize the survival, development, and well-being in the Occupied Pales-

tinian Territory using human security as a framework. Palestinian security has
deteriorated rapidly since 1948 and even more rapidly after 2000. More than 6000
Palestinians were killed by the Israeli military, with more than 1300 killed in the
Gaza Strip during 22 days of aerial and ground attacks ending in January 2009.
Israeli destruction and management of infrastructure has severely restricted fuel
provisions and access to water and sanitation. Palestinians are tortured in prisons
and humiliated at Israeli checkpoints. The separation wall and the checkpoints
prevent access to jobs and businesses, visiting family, sites of worship, and
healthcare facilities. Poverty rates have increased sharply, and almost half of
Palestinians are dependent on food aid. Social cohesion, which has kept the
Palestinian society intact, including the healthcare system, is now strained. More
than US$9 billion in international aid have not promoted development because
Palestinians do not have basic security. International efforts concentrated on preven-
tion of modifiable causes of insecurity and reinvigoration of international norms.
Greater support of Palestinian social resilience and establishments that protect them
from threats is needed, and a political solution is needed to improve human security
in the Occupied Palestinian Territory which is a responsibility of all stakeholders
(Batniji et al. 2009).
The Palestinian perspective on environmental protection and sustainable devel-
opment is one that takes account of the need for institution, infrastructure, and
capacity-building as tools for the implementation of a national strategy. Outlined
above are the areas that will need to be the major foci in achieving this goal. Overall,
a theme of this work must be public participation – the ability for Palestinians from
all parts of society to become involved in carrying out sustainable development. A
plethora of economic and other mechanisms exist for encouraging environmentally
sound development, and Palestinians have the advantage of being able to implement
these from the beginning of the development process.
However, the important precursor for any of this to take place is Palestinian
control over the natural resources within the borders – which the international
community recognizes as Palestine. Without this empowerment, attempts at sustain-
able development will be for naught. While the Palestinian authorities must design
environmentally sound development plans in the areas agreed upon in the first phase
of the Declaration of Principles, they must also gain control of the other areas under
occupation at the earliest possible date. Only through sovereignty over, and devel-
opment of, all areas of Operations will Palestinians be able to utilize and protect their
natural resources in an integrated and sustainable manner.
Finally, based on our experiences as environmental health workers and teachers,
other environmental determinants can be added to those mentioned previously
including the lack of community participation and concern for the surrounding
environment, lack of community understanding of the concept of environmental
health, intentional and unintentional aggression against the environment for the sake
of personal interest without taking into account the public interest, misconception of
society that the environment does not concern or affect it, and the overlap of laws
and powers of regulatory authorities in the protection of the environment, which
weakens this protection by relying on each other. Moreover, the health of
Palestinians has been affected by the Israeli occupation through different means
including the military authority and the resulting permanent victims and disabilities,
displaced persons, demolition of homes, restriction of movements, etc. Lastly,
Palestinian culture related to marriage (early and consanguineous marriages) and
rapid, consecutive childbirth after marriage can threaten the Palestinian health. Thus,
the environmental and social determinants of health in Palestinians can be internal
(community built-in) and external (Israeli occupation) in origin. Changing these
determinants will not be easy and need action from all sectors and at all levels (local,
national, and international).
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Health-Risk Behaviors of Adolescents from
Arab Nations 28
Caroline Barakat and Susan Yousufzai
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 652
Adolescence in Arab Nations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 654
Health-Risk Behaviors Among Adolescents from Arab Nations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 657
Dietary Behaviors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 657
Physical Activity and Sedentary Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 659
Tobacco Smoking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 664
Consumption of Prohibited Substances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 666
Over-the-Counter Medication Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 667
Other Health-Risk Behaviors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 669
Health Care and Accessibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 670
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 671
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 671
Abstract
This chapter highlights patterns of health-risk behaviors among adolescents from
Arabic-speaking regions. It provides a synthesis of the literature on diverse
health-risk behaviors, including dietary behaviors, physical activity, sedentary
behaviors, tobacco smoking, consumption of prohibited substances, over-the-
counter medication use, and other less common health-risk behaviors. Lastly,
the topic of health care and accessibility for adolescents from Arab nations is
examined. Arab nations are composed of the 22 states of the Arab League.
Despite their commonalities revolving around language and some cultural or
religious practices, there are recognizable sociodemographic and economic dif-
ferences. These differences, among other factors, affect the health and behaviors
of adolescents living in Arab nations. A large population of youth reside in Arab
C. Barakat (*) · S. Yousufzai

Faculty of Health Sciences, Ontario Tech University, Oshawa, ON, Canada
e-mail: Caroline.barakat@ontariotechu.ca

https://doi.org/10.1007/978-3-030-36811-1_24
652 C. Barakat and S. Yousufzai
nations, with approximately 20% aged between 10 and 19 years. This chapter
provides evidence in support of the need for research and action in relation to
health-risk behaviors among adolescents who reside in Arab nations. While
research on dietary behaviors, physical activity, and tobacco smoking are
documented, more action research that addresses these health-risk behaviors is
needed. Additional research areas that are under-studied include sexuality, sub-
stance abuse, sleep issues, hygiene practices, and sun exposure of adolescents
from Arab nations.
Keywords
Adolescence · Arab nations · Health-risk behaviors · Development · Adolescent
health · Eastern Mediterranean Region (EMR)
Introduction
Adolescence is a period that describes the transition from childhood to young

adulthood, representing a critical developmental period that usually occurs between
the ages of 10 and 18 (WHO 2017). How this transition is defined and recognized
differs between cultures (WHO 2018). Although the initiation of adolescence is
generally acknowledged through the biological event of puberty, the end of this
period is often culturally defined (Arnett and Taber 1994). For example, in some
societies of the Eastern Mediterranean Region (EMR), this transition is assumed to
occur abruptly through puberty (Albuhairan et al. 2015). Comparatively, Western
cultures regard the passage through adolescence to young adulthood as a process that
is gradual that can take many years, based on various factors such as the achievement
of independence and individualism (Arnett and Taber 1994). Overall, the nature of
adolescence is changing, with the length of the transitional adolescent period
increasing in most societies. Correspondingly, the age of onset of puberty is decreas-
ing, and the age at which young adults attain mature social roles is rising (Sawyer
et al. 2012). In fact, the concept of adolescence is undergoing reconstruction through
accelerated changes such as population growth, globalization, new technologies, and
societal changes (Larson et al. 2009).
Adolescence can be challenging with young people having to deal with a range of
different ordeals related to the demands of this sensitive transition. The extensive and
general malaise of adolescent development involves many substantial changes
associated with the young individual. This involves interpersonal, biological, and
cognitive changes that occur at an accelerated rate (Sawyer et al. 2012). These
challenges are composed of multiple factors that range from hormonal changes
that affect the individual emotionally and physically to cognitive changes associated
with learning to adopt mature and adult characteristics. This entails the inescapable
task of preparing for adulthood and planning for the future, which may serve as
important motivators of behaviors that affect choices and health. In fact, many
factors shape health in adolescence, including the interactions between the prenatal
28 Health-Risk Behaviors of Adolescents from Arab Nations 653
and initial childhood periods of development, biology, social roles, and lifestyle
(Sawyer et al. 2012). Adolescents who tend to hold hopeful expectations and
aspirations about the future are relatively more likely to uptake healthy behaviors
and are less likely to abuse substances (Mahler et al. 2017). In addition, the relation-
ships between adolescents and their diverse environments influence risk and protec-
tive factors, which affect the adoption of certain health-related behaviors. For
example, a positive relationship between the adolescent and his or her family is
more likely to lead to open channels of communication and family support, which in
turn reduce the adolescent’s exposure to health risks.
Research increasingly suggests that adolescents are highly impacted and suscep-
tible to changes to their social and physical environments (Barakat-Haddad 2013). In
this way, adolescence is an opportune time for the emergence and prevention of new
behaviors and is critical in shaping future health conditions (Albuhairan et al. 2015).
Adolescents are particularly vulnerable to their social settings and learn from their
social networks through imitation of behaviors of parents, peers, role models, and
other societal influences (Sawyer et al. 2012). This has implications for the emer-
gence of exploration and experimentation that takes place during adolescence (WHO
2018). Furthermore, as early adopters of knowledge in rapidly changing social and
technological environments, they are predisposed to the impacts of social media,
including product marketing that may promote the use or overconsumption of
relatively unhealthy choices, such as tobacco or high-fat foods and alcohol (Sawyer
et al. 2012). Therefore, it is important for adolescents to have access to effective and
positive guidance, support, and knowledge that assist them in establishing the
foundation for patterns of health-promoting behaviors and disease prevention
(Sawyer et al. 2012; Achhab et al. 2016).
Studies highlight the importance of social determinants of adolescent health, such
as safe and supportive families, schools, peer groups, and communities (Viner et al.
2012). Other factors that can affect adolescent development and contribute to the
prevalence of health-risk behaviors include having to deal with academic and career
challenges and financial hardship (Al-Bahrani et al. 2013; Sawyer et al. 2012).
Indeed, adolescents growing up in low-income families may have an increased
likelihood of engaging in delinquent behavior and experiencing poor academic
outcomes compared to their more affluent counterparts (Gershoff et al. 2007).
Other studies have attributed the impact of mass media and marketing of unhealthy
products as emerging drivers of adolescent health behaviors (Sawyer et al. 2012).
Research findings highlight concerns for various health-risk behaviors that become
prominent in adolescence that contribute to the leading causes of mortality and
morbidity. Health-related concerns that affect adolescents include mental health
issues, obesity, and many of the preventable risky behaviors, such as substance
misuse, injuries, and the various risks associated with unprotected sexual behavior
(Moradi-Lakeh et al. 2016; Achhab et al. 2016; Al-Bahrani et al. 2013).
Adolescents from around the world are exposed to different environments,
societal norms, and expectations, so that the opportunity to engage in health-risk
behaviors for adolescents varies relative to time and place (Steinberg 2014). Indeed,
risk-taking is correlated with the level of freedom or constraints and cultural
expectations placed on adolescent behavior that limits or provides opportunities for

them to engage in risk behaviors (Duell et al. 2017). For example, in the Western
world, the age of adolescence is often regarded as a time of carefree recklessness,
experimentation, and sensation-seeking behaviors, whereas in many non-Western
cultures, self-indulging and risk-taking behaviors, such as experimentation with
drinking, drug use, and premarital sex, are not viewed as normative and vigorously
discouraged (Harden and Tucker-Drob 2011). While the latter may seem as a
concept of adolescent self-regulating behavior, some constraints and cultural expec-
tations are at times ineffective in prohibiting adolescents from partaking in risky
behaviors, largely due to curiosity, peer pressure, and the quest for adventure. In fact,
constraints can be barriers in relation to receiving the much-needed knowledge on
health-related behaviors. For example, premarital sex and the risks associated with
unprotected sex in some countries in the EMR often occurs in the context of secrecy,
as a consequence of adolescents challenging the culture (Massad et al. 2014;
Salameh et al. 2016). Although relatively socially conservative societies may differ
in terms of cultural norms, the same societal changes that compose and shape
adolescent behavior in the West influence adolescents from non-Western societies
as well (Larson et al. 2009).
Adolescence in Arab Nations
Adolescence is universally considered a challenging intermediate life stage. In some

regions, humanitarian crises, unrest, and economic changes magnify these chal-
lenges (Mokdad et al. 2016). Arab nations are composed of the 22 states of the
Arab League. Although these nations share many commonalities such as language
and some cultural or religious practices, there are major sociodemographic and
economic differences. Characteristics in key areas – such as economic structure,
level of development, geographic location, and type of governance and institutions –
vary immensely across Arab nations (Elbadawi 2005). For example, while the Gulf
states (Bahrain, Iraq, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab
Emirates) are some of the richest countries globally, poverty rates remain high in
many other countries of the EMR. The proportion of the population living below the
national poverty line exceeds 20% in Egypt (22%), Iraq (23%), Palestine (22%),
Sudan (47%), and Yemen (35%) (World Bank data 2017). Thus, adolescents who
reside in relatively low socioeconomic regions may experience a greater prevalence
of ill health due to barriers faced by economic differences, quality and accessibility
of health services, inequities across socioeconomic groups, and armed conflict. In
addition, lack of productive time usage and positive experiences may increase the
likelihood that young people engage in risky behaviors (Massad et al. 2014).
Productive time usage and positive experiences are hard to achieve given data
from the Human Development Report (2015) that the youth unemployment rate in
Arab states is 29%, the highest in the world (UNDP 2016). In addition, in countries
like Saudi Arabia, Qatar, Jordan, and Egypt, a substantial gap exists between young
male and female employment, with female unemployment rates reported to be 10%
higher than that of males (Chaaban 2009). These socioeconomic circumstances can
take a toll on the adolescent population. For example, a Jordanian-based study found
that poverty was associated with depressive symptoms among male youth and that
depressive symptoms led to risk behaviors such as violence, consuming alcohol, and
smoking (Ismayilova et al. 2013).
Although there has been a decrease in communicable diseases and the health
consequences of natural disasters between 1990 and 2015 in the EMR (GBD 2015),
these improvements in health outcomes have been substantially offset by the impacts
of war and the emergence of non-communicable diseases, including mental health
disorders, unintentional injury, and self-harm. In Arab nations, the top 10 leading
causes of years of life lost (YLLs) in 2017 and resulting in premature mortality were
road injuries, ischemic heart disease, cerebrovascular disease, chronic kidney dis-
ease, congenital defects, chronic obstructive pulmonary disease, diabetes, self-harm,
falls, and adverse medical treatment (GBD 2017). Many of these health outcomes
are linked to preventable health-risk behaviors, especially if interventions occur
early on in adolescence. For example, research suggests that the number of young
heart patients in the United Arab Emirates is associated with high prevalence of
diabetes and unhealthy lifestyles, including smoking, sedentary lifestyle, stress, and
unhealthy eating habits, all of which are preventable behaviors (Ismail 2011).
The emergence of mental health issues among adolescents from Arab nations is
not surprising given that many Arab nations have experienced years of violence,
armed conflict, and war (Dardas et al. 2017; Hassan et al. 2016). Conflict and civil
unrest have a large impact on adolescent health, both acutely (due to higher rates of
mortality and morbidity from violent acts) and in the long term (through mental
health disorders and poor sexual and reproductive health) (Viner et al. 2012).
Recently, Arab nations such as Iraq, Palestine, Sudan, and Syria have suffered
humanitarian crises, with many people suffering the consequences. Research sug-
gests that in comparison to other regions, mental health problems – specifically
depression – account for a greater proportion of DALYs lost among Arab adoles-
cents (Charara et al. 2017). Several other factors that influence access to mental
health and psychosocial support magnify the high prevalence of mental health
problems in the region; these include language barriers and stigma associated with
seeking mental health care (Hassan et al. 2016).
Some research on adolescents from Arab nations has focused on coping styles or
the prevalence or determinants of mental health conditions. For example, while
assessing adolescents’ coping styles of 1843 Omani adolescents, Al-Bahrani et al.
(2013) found that the style of coping strategy is very limited in Arab nations.
Maladaptive coping style included self-blame, crying, ignoring the problem, wishful
thinking, hiding feelings, and anxious anticipation. The study found that the levels of
perceived problems were positively associated with maladaptive coping styles, with
female adolescents using maladaptive coping styles more than males (Al-Bahrani
et al. 2013). Among adolescent girls in Riyadh, Kingdom of Saudi Arabia, 30% of
participants were classified as depressed (Raheel 2015). Depression was associated
with not having good relationships with peers and family, and not being happy with
their body image. Adolescents from Jordan endorsed multiple etiological factors for
depression; factors were stressful events in one’s life (72%), social factors (65%),
and weak will (56%) (Dardas et al. 2017). Suffering from depression during adoles-
cence can lead to increased suicidal tendency, anxiety, conduct disorders, and
substance abuse and can lead to depression later in life as well. Therefore, it is
essential for adolescents to maintain good mental health in order to deal with the
challenges of adolescence and prepare for adulthood (Raheel 2015).
Adolescents in the Arab nations may face a higher burden of health concerns due to
specific cultural and gender expectations. Cultural and religious beliefs generally
encourage traditional gender roles in attitudes and behaviors (Schvaneveldt et al.
2005). For example, studies of adolescents from Arab nations identified that cultural
barriers to physical activity were higher among females than males (Musaiger et al.
2013). Girls in Arab nations report engaging less in physical activity and more in
sedentary behavior, due to the prohibition of wearing sports clothing or exercising
outdoors for religious reasons. Other restrictions include increased safety concerns
and less access to space for physical activity (Musaiger et al. 2013). Indeed, the literature
suggests that there has been a significant decrease in motivation toward physical activity,
which has contributed to the prevalence of overweight and obesity, cardiovascular and
metabolic conditions, and mental health disorders among female adolescents living in
Arab nations (Khansaheb et al. 2016; Al-Bahrani et al. 2013; Sharara et al. 2018).
Despite the deeply rooted cultural and religious beliefs, youth identities in the
region are evolving and are impacted by both local and foreign values. In general,
adolescents are adopting values toward a more liberal orientation (Albuhairan et al.
2015; Schvaneveldt et al. 2005). Social media and technology allow for greater
access to other cultures and expose adolescents to new behavior-promoting practices
such as normalized images of substance use (Mauseth et al. 2016). Indeed, in many
Arab nations, the increase in use of technology and the access to a “global culture”
and economy are having an impact on substance use (Al-Oqily et al. 2013).
However, despite the dramatic upheaval of substance use and its relative acceptance
among adolescents from Arab nations, disapproval of substance use driven by
cultural or religious beliefs creates a social stigma in addressing this trend and
providing treatment options (Mauseth et al. 2016).
Overall, a large proportion of the population in Arab nations consists of youth,
with about 20% of the population aged 10 to 19 years and approximately 60% under
25 years old. This large population of adolescents represents more than a quarter of
the population in the East Mediterranean Region (EMR) (GBD 2015). The large
population of young people in the Arab nation, the “youth bulge,” represents a
demographic opportunity to promote health and reduce disease burdens (Albuhairan
et al. 2015). Arab youth are increasingly regarded as vital components of the region
and important to the development of societies. Thus, investing in their health and
well-being will positively affect economic development. Adolescents must be pre-
sented with opportunities to succeed and live healthy lives (Chaaban 2009). Impor-
tant recommendations are needed on when, how, and why to utilize appropriate
interventions to improve adolescent health (Dardas et al. 2017). This chapter con-
tributes to this goal by highlighting the most prevalent health-risk behaviors among
adolescents from Arab nations.
Health-Risk Behaviors Among Adolescents from Arab Nations
Health-risk behaviors become prominent during adolescence and may carry risk for
poor health in and beyond adolescence (Achhab et al. 2016). The majority of
adolescent deaths and illnesses caused by specific risk behaviors often fall into the
following categories: tobacco, alcohol, drug use, dietary behaviors, physical activity,
and sexual behaviors (Achhab et al. 2016). Specifically, in both high- and middle-
income countries, approximately 80% of lifetime smoking and alcohol use com-
mence in adolescence (Degenhardt et al. 2008). However, despite the emergence of
various health-risk behaviors during adolescence, young people have received little
attention and too few resources in addressing their health concerns, considering that
adolescence is usually a healthier stage of life. Specifically, in the EMR, the health
needs of adolescents across these countries have often been overlooked by maternal
and child services and by services for adults (UNFPA 2014). This puts limitations on
young adult-focused health-care services that can address their specific needs.
Accordingly, this chapter focuses on adolescent health in Arab nations by synthe-
sizing evidence from the literature on health-risk behaviors, mainly dietary behav-
iors, physical activity and sedentary behaviors, tobacco smoking, consumption of
prohibited substances, over-the-counter (OTC) self-medication, other health-risk
behaviors, and accessibility to health care.
Dietary Behaviors
The spread of eating disorders in adolescents is associated with the growing prev-
alence of obesity. Studies suggest that childhood obesity is associated with an
increased risk of disordered eating, eating attitudes, weight concern, binge eating,
anorexia, and bulimia (Goldschmidt et al. 2008). According to Schulte (2016),
maladaptive coping strategies, such as emotional eating and body-related guilt,
were the most consistent and powerful predictors of binge eating, which happens
to be a common concern among youths in the United Arab Emirates. Stress levels
and body-related shame were also statistically significant predictors. The prevalence
of binge eating among adolescents has been examined in Saudi Arabia (69.9%),
Jordan (16.9%), the United Arab Emirates (32%), and Lebanon (4.2%). In Oman,
15.0% of sampled students showed a propensity for binge eating or bulimia, while in
Egypt 82% of females and 76% of males reported at least one binge eating episode
(Schulte 2016).
Research conducted in the United Arab Emirates suggests that childhood obesity
is a major health concern (Khansaheb et al. 2016). In particular, a study by Bin Zaal
et al. (2009) shows that the highest percentage of obesity was observed among 14-
year-old boys (30.5%) and 13-year-old girls (35.4%). A study that examined the
prevalence of overweight and obesity among a sample of adolescents from Irbid
Governorate, Jordan, reports a lower prevalence for adolescents who live in rural
areas (22.8%) compared to those who live in urban areas (28.3%) (Baker and
Daradkeh 2010). In relation to obesity, the opposite trend is seen with a higher
prevalence in urban areas (12.4%) compared to rural areas (7.2%). These prevalence
rates suggest that the prevalence of overweight and obesity for Jordanian adolescents
is higher than reported data from the United States (16.3%), Canada (19.6%), and
France (22.7%).While many factors interplay to influence body mass index, much
research points to predictors related to physical inactivity and skipping breakfast
(Abolfotouh et al. 2011).
In relation to eating disorders, when assessing the prevalence of disordered eating
attitudes (EAs) among adolescent males and females from seven Arab countries
[Algeria, Jordan, Kuwait, Libya, Palestine, Syria, and the United Arab Emirates],
Kuwaiti adolescents (aged 15–18) showed higher prevalence of disordered eating
attitudes than their counterparts in other countries (Musaiger et al. 2013). The
prevalence of disordered eating attitudes ranged from 13.8% to 47.3% among
males and from 16.2% to 42.7% among females. The risk of disordered eating
attitudes among females was twice as high as that among males in Jordan, Libya,
Palestine, and Syria. However, male adolescents in Kuwait showed a higher prev-
alence of disorder EA (47.3%) than females (42.8%). Similarly, eating attitudes in
the United Arab Emirates were relatively high in male adolescents, in comparison to
many developing and developed countries, and ranged from 33.1% to 49.1%, with
an average of 41.2% (Musaiger et al. 2014). Moreover, students living in the
Emirates of Dubai and Al-Fujairah have double the risk of disordered eating attitudes
compared to students living in the other Emirates (Musaiger 2015). The prevalence
of disordered eating attitudes between Emirati male adolescents is close to female
adolescents in most of these Arab countries (ranging from 32.6% in Libya to 42.7%
in Jordan). This suggests that disordered eating attitudes are a problem of consider-
able concern among adolescents in Arab nations, and, thus, require further assess-
ment (Musaiger et al. 2014).
Due to the extensive developmental changes during puberty, the concern over
body image may take a mental toll on adolescents (Tayyem et al. 2016). For
example, a study revealed that 21.2% of Jordanian girl adolescents, aged between
10 and 16 years, experience body image dissatisfaction due to physical changes of
puberty, which corresponded to practicing negative eating behaviors (Mousa et al.
2010). Similarly, the risks of disordered eating among women (15–19 years of age)
were very high in the state of Khartoum, Sudan, with all 17 interviewed participants
identified as at high risk of eating disorders (Lau and Ambrosino 2016). Eating
attitudes and behaviors included extreme dieting and exercising, regularly eating less
than one meal per day or restriction from food until feeling dizzy or fainting, and
binge eating. Over 41% described crying about body weight or shape. Studies found
that adolescents who reported being dissatisfied with their weight were more likely
to feel fat or not attractive than adolescents who were satisfied with their weight
(Sabbah et al. 2009). In addition, dissatisfaction with weight among adolescents
links to somatic and/or psychological health complaints. Girls who were dissatisfied
with their weight also felt lonely very often or often (Sabbah et al. 2009).
Besides dietary habits, the high prevalence of obesity among adolescents from
Arab nations is also due to several other factors, including the lack of importance
given to sport participation or physical activity, using cars for even short-distance
travel, taking afternoon naps, exposure to mass media, globalization, westernization,

family environments, social changes, and cultural transitions (Musaiger et al. 2014).
Indeed, some countries with high economic status such as Kuwait and the United
Arab Emirates have experienced a nutrition transition earlier than other Arab nations
(Musaiger et al. 2013). For example, adolescent diets and food habits in the United
Arab Emirates are characterized by high consumption of fat, energy, and salt and
low consumption of dietary fiber and fruits and vegetables (Musaiger et al. 2014).
Tables 1 and 2 prevent key findings from the literature on the topics related to dietary
behavior and eating attitudes among adolescents from Arab-speaking nations.
Linked to dietary habits and lifestyle is the topic of vitamin D deficiency. Despite
the prevailing sunny climate in the Middle East, levels of vitamin D registered across
these nations are the lowest worldwide. Individuals across various stages of life,
including pregnant women, neonates, infants, children, adolescents, adults, and the
elderly, are affected by this major public health concern. This trend is attributed to
limited sun exposure due to cultural practices, dark skin color, and very hot climate
in several countries in the Gulf area that hinders outdoor activities (El-Hajj Fuleihan
2009). Intake of vitamin D supplements or in food fortification thus becomes a major
preventative factor in vitamin D deficiency. There are significant gender differences
in vitamin D deficiency, with a prevalence of 47.0% among females compared to
19.4% among males (Al-Daghri et al. 2015). Vitamin D deficiency was significantly
associated with type 2 diabetes mellitus [OR 3.47 (CI 1.26–5.55); p < 0.05] and pre-
diabetes [OR 2.47 (CI 1.48–4.12); p < 0.01] in boys. Furthermore, vitamin D
insufficiency was significantly associated with abdominal obesity in boys [OR
2.75 (CI 1.1–7.1); p < 0.05]. Along with dietary habits, many adolescents have a
heavy reliance on car transport and lead relatively sedentary lifestyles. These health-
risk behaviors are discussed in the next section.
Physical Activity and Sedentary Behavior
Physical inactivity is one of the main contributors of health risks in the region of oil-
producing countries of the Arabian Peninsula (Mabry et al. 2016). This is partly due
to the increase in home entertainment facilities provided by televisions, videos, and
computers (Albarwani et al. 2009). For example, a UAE-based study reports that the
prevalence of sedentary behavior among adolescents is as high as 40%, the highest
compared to Oman, Libya, Jordan, Djibouti, Egypt, Tunisia, Morocco, and Yemen
(Subhi et al. 2015). The prevalence of physical activity for all countries was very low
(19%), while the level of sedentary behavior was much higher (29%) among
adolescents (Table 3). In Morocco, one in five adolescents surveyed were inactive,
and approximately 45% of the sample reported television viewing for more than 2 h/
day and 38% for computer use (Hamrani et al. 2014). Comparatively, in a sample of
12,575 Saudi adolescents, almost half of all adolescents did not engage in any
physical exercise, and 42% spent at least 2 h/day watching television (Albuhairan
et al. 2015). Responses regarding physical activity among male adolescents indi-
cated that physical activity was not practiced by 20.1% of students, while 48.6%
Table 1 Summary of associations between health risks and dietary behaviors among adolescents
from Arab-speaking regions
Author (year) Results
Tayyem et al. 2016 Adolescents from Jordan (n = 795) exhibited a high influence of reading
magazines on the subject of dieting to lose weight, which was directly
proportional to the risk for obesity specifically for females (OR 2.55; CI
1.25–5.21, P-Trend = 0.017). The prevalence of overweight and obesity
was 7.8 and 14.0% for male students and 3.0 and 20.0% for females,
respectively. The internet has a significant influence on dieting to lose
weight in obese males (71.3%) compared to non-obese males (56.7%)
( p = 0.023)
Albuhairan et al. In a sample of 12,575 adolescents across Saudi Arabia, 54.8% were found
2015 to consume breakfast daily/most of the time. 38% and 54.3% of
adolescents had at least one serving of fruit or vegetable per day,
respectively. 38% and 21.8% reported drinking at least two carbonated
beverages or one energy drink daily, respectively, while 30.0% were
overweight/obese, and 95.6% were vitamin D deficient
Al-Daghri et al. Among 2225 adolescents and 830 adults from Saudi Arabia, there were
2015 significant gender differences in vitamin D deficiency (47.0% for females
vs. 19.4% for males). In boys there were more significant inverse
associations between serum 25(OH)vitamin D levels and cardiometabolic
indices than females, while in contrast women had more significant
associations than men. Vitamin D deficiency was significantly associated
with type 2 diabetes mellitus and pre-diabetes, and vitamin D insufficiency
was significantly associated with abdominal obesity in boys [OR 2.75 (CI
1.1–7.1); p < 0.05]
Musaiger 2015 Approximately 32–39% of female university students (n = 1134) from
Bahrain, Egypt, Jordan, Oman, and Syria were dissatisfied with their
weight; 17–31% wanted their body shape to be similar to Western fashion
models; 5–16% believed that men preferred plump women; 22–37% of
females dieted to lose weight; 8–15% performed exercises to improve
body shape most of the time
Hamrani et al. 2014 Adolescents (n = 669) reported that they do not have breakfast or
consume milk and dairy products, fruits, and vegetables on a daily basis.
Those who did not consume breakfast at home on a daily basis were at
increased risk to be overweight compared to their counterparts. Most
adolescents reported consumption of doughnuts, cakes, candy, and
chocolate more than three times per week; approximately 50% consumed
sugary drinks more than three times per week. For females, consumption
of sugary drinks increased the risk of being overweight (OR = 2.48; 95%
CI 1.24, 4.96)
Abolfotouh et al. Prevalence rates of pre-hypertension and hypertension for adolescents
2011 from Egypt (n = 1500) were 5.7% and 4.0%, respectively. Obesity was
seen in 34.6%, 16.1%, 4.5%, and 16.7% according to BMI, waist-to-hip
ratio, waist circumference, and waist-to-height ratio. High blood pressure
was significantly associated with overall obesity (OR = 2.18, 95%
CI = 1.38–3.44) and central obesity (OR = 3.14, 95% CI = 1.67–5.94)
Baker and In a random sample of 1355 adolescent school students from Irbid
Daradkeh 2010 governorate, Jordan, the prevalence of overweight and obesity was 15.7%
and 8.7%, respectively, and was significantly higher in females, those
from urban areas, and those with working parents
(continued)
Table 1 (continued)
Bin Zaal et al. 2009 Among 661 adolescents from the United Arab Emirates, the highest
percentage of obesity was observed at 14 years of age in boys (30.5%) and
at 13 years of age in females (35.4%). There was a significant association
between the frequency of eating breakfast, snacking between breakfast
and lunch, and obesity in females. A high risk of obesity was associated
with eating breakfast at school in both males (OR = 3.0; CI 1.1–8.3) and
females (OR = 3.4; CI 1.6–7.4). Fast foods showed a significant
association with obesity in females, but the risk of obesity was higher in
males who ate fast foods at home (OR = 1.3; CI 0.5–3.2)
Table 2 Summary of associations between health risks and eating attitudes among adolescents
from Arab-speaking regions
Lau and Around a third (32.6%) of participants (women) scored as having high risk
Ambrosino 2016 of eating disorders. Interviews showed recurring themes determining
eating attitudes including intention, knowledge, environment, and habit.
Stakeholders’ opinions depended on whether they work directly with those
affected by ED or in policy-making. The former advocated increased
attention on ED, the latter did not
Schulte 2016 Moderate to severe binge eating was reported by one-third of 254
adolescents in the United Arab Emirates. Emotional eating and body-
related guilt were the most consistent and powerful positive binge eating
predictors. Binge eating is a common concern among adolescents in the
United Arab Emirates with prevalence rates similar to Western samples
Musaiger et al. Disordered eating attitudes among 731 male students in the United Arab
2014 Emirates were relatively high compared with many developing and
developed countries and ranged from 33.1% to 49.1%. Students living in
the emirates of Dubai and Al Fujairah had double the risk of having
disordered eating attitudes compared with students living in the other
emirates
Musaiger et al. Risk of disordered eating attitudes was twice as high among females than
2013 in males in Jordan, Libya, Palestine, and Syria. Kuwaiti adolescents
showed higher prevalence of disordered eating attitudes than their
counterparts in other countries. Association of obesity with disordered
eating attitudes was statistically significant (n = 4698)
Mousa et al. 2010 Among a sample of 326 adolescent females from Amman, Jordan, 21.2%
displayed body image dissatisfaction and were associated with physical
changes linked with puberty and exhibiting negative eating attitudes.
Additionally, mass media messages, as well as peers and family pressures
toward thinness, were associated with participants’ preoccupation with
their body image
practiced low levels of activity for 1 to 2 days per week, 15.9% practiced 3 to 4 days per
week, and only 15.5% practiced 5 or more days per week (Alsubaie and Omer 2015).
Overall, the study reports that over 48% were adopting a less active lifestyle (48.6%).
In most Arab nations, cultural restrictions on female activities in both urban and
rural communities are a contributing factor in the development of negative health
Table 3 Summary of studies on the prevalence of physical activity and sedentary behavior and
associated health risks among adolescents from Arab-speaking nations
Sharara et al. 2018 General norms and gender norms converge to discourage physical activity.
Hot climate limits outdoor physical activity to relatively short seasons and
requires special indoor facilities. The built environment, inadequate public
transportation systems, and lack of spaces for walkers or joggers
discourage exercise. Parents appear to favor educational and spiritual
activities over physical activities for their children, and lack of support for
physical activity is also noted among friends, peers, and even teachers.
Less physical activity among women is attributed to gender norms
including conservative dress, the need to be chaperoned in public spaces,
and the paucity of gender-segregated fitness facilities
Subhi et al. 2015 Significant differences were found regarding the overall prevalence of
physical activity (19%) and sedentary behavior (29%) among adolescents
from ten EMR countries (n = 23,652). Prevalence of sedentary behavior
was the highest in the United Arab Emirates (40%) and lowest in Pakistan
(8%). Physical activity was lower and sedentary behavior was higher
among female adolescents
Albuhairan et al. Sedentary behaviors were highly prevalent across adolescents from Saudi
2015 Arabia (n = 12,575). Almost half of all adolescents did not engage in any
physical exercise. Females reported complete absence of exercise much
more than males (59.3% vs. 31.7%, p < 0.0001). 42% of adolescents spent
at least 2 h/day watching television, and considerable amounts of time were
spent performing other sedentary activities
Alsubaie and This study revealed low prevalence of physical activity among male high
Omer 2015 school students in Riyadh, Saudi Arabia (n = 453). 20.1% were found to
be inactive and not practicing physical activity at any day. Barriers
inhibiting physical activity were lack of sports facilities in the community
(74%), lack of friends and peer support (59.4%), and lack of suitable public
sport clubs in the community (54.6%)
Hamrani et al. Among Moroccan adolescents (n = 669), males were more active than
2014 females across a typical week and engaged in more vigorous-intensity
physical activity than female adolescents, who spent more time than male
adolescents in moderate-intensity physical activity. Close to half (45%) of
the sample reported television viewing for more than 2 h/day, and 38%
engaged in computer use for a similar period
Koura et al. 2013 Among 370 adult females in Dammam, Saudi Arabia, 13.5% were pre-
hypertensive. Risk factors for cardiovascular diseases were physical
inactivity (53.2%), followed by overweight/obesity (29.1%). 16.3% of pre-
hypertensive students had three or more risk factors
Albarwani et al. Body mass index of Omani urban boys and girls (n = 529) was
2009 significantly higher than that of their rural counterparts. Urban boys and
girls spent significantly fewer weekly hours on sports activities and
significantly more weekly hours on TV/computer games, achieving a
significantly less V[O.sub.2]max than rural boys and girls. Overweight and
inactivity had significant negative effects on cardiorespiratory fitness in
urban boys and girls as compared to their rural counterparts
Sabbah et al. 2009 Among 17,817 adolescents from Palestinian schools, 16.5% were found to
be overweight, and 32.1% were dissatisfied with their weight (i.e., dieting
or perceiving a need to diet). Males reporting overweight or weight
(continued)
Table 3 (continued)
dissatisfaction were more likely to have mothers with higher education or
to be from more affluent families. Among both genders, but especially
females, weight dissatisfaction was positively associated with body image,
health complaints, risk behaviors, and television viewing, regardless of
weight status
outcomes (Albarwani et al. 2009). For example, the most prevalent risk factor for
high blood pressure among young adult female university students from Dammam
(Saudi Arabia) was physical inactivity (53.2%), followed by overweight and obesity
(20.6% and 8.5%, respectively) (Koura et al. 2013) (Table 3). Multiple studies have
reported a significant difference between levels of physical activity among female
and male adolescents, with females reporting lower physical activity and higher
sedentary behaviors than males (Subhi et al. 2015). Specifically, in Saudi Arabia,
females reported complete absence of exercise much more than males (59.3% vs.
31.7%, p < 0.001) (Albuhairan et al. 2015). This trend was also apparent in
adolescents in Morocco, with male adolescents more active than females across a
typical week and engaging in more vigorous-intensity physical activity; females
tended to spend more time in moderate-intensity physical activity (Hamrani et al.
2014). Moreover, Sharara et al. (2018) report a high level of consistency with 31
studies documenting a higher prevalence of inactivity among females from Arab
nations compared to their counterparts.
In most Arab nations, the socioeconomic differences between urban and rural
populations are wide. Although this gap is narrowing with population growth,
differences in sedentary behaviors remain in adolescents. Specifically, adolescents
from urban areas spent significantly less time per week on sports activities and spend
significantly more weekly hours on TV and computer games than those who reside in
rural areas (Albarwani et al. 2009). This translates to significantly higher body mass
indices for males and females from urban areas (25.8 and 27.7 kg/m2, respectively)
compared to males and females from rural areas (21.9 and 22.4 kg/m2). Moreover,
the study also reports significantly less maximal aerobic capacity (VO2 max) for
males and females from urban areas compared to their rural counterparts (44.2 and
33.0 vs. 48.3 and 38.6 mL/kg/min, respectively) (Table 3).
Several studies have linked dissatisfaction with body weight to sedentary behav-
ior, which in turn appears to be linked to violent activities (Sabbah et al. 2009;
Celedonia et al. 2013). Specifically, a Palestinian-based study found that adolescent
males who were classified as overweight were significantly less physically active
than their counterparts (Sabbah et al. 2009). Dissatisfaction with body weight was
also correlated with involvement in risky behaviors such as bullying others at school,
being bullied, and smoking shisha and more likely to report a high frequency of
somatic and/or psychological health issues (Sabbah et al. 2009).
Although children and adolescent sedentary behaviors are a worldwide problem
(Sharara et al. 2018), adolescents living in Arab nations may face multiple perceived
barriers to physical activity that are related to the social and cultural landscapes
(Musaiger et al. 2013). For example, perceived barriers for not practicing physical
activity among high school adolescents in Riyadh (Saudi Arabia) were lack of
friends (59.4%) and lack of sports facilities in the community (74%) (Alsubaie and
Omer 2015) (Table 3). Similarly, lack of support from peers, friends, and even
teachers to participate in physical activity was reported in studies conducted in
Egypt and Jordan (Sharara et al. 2018). The latter study along with a study conducted
by Bauman et al. (2011) points to additional weather-related and cultural barriers to
physical activity, such as hot weather, the built environment, the promotion of a car
culture, discouragement of physical exertion, and parental preferences favoring
spiritual and educational activities (Table 3).
Tobacco Smoking
The global decrease of traditional cultural prohibitions against the practice of

smoking has diminished sex differences in adolescent smoking rates (Sawyer et al.
2012). The recurrence of this habit in the modern age among young adults in the
Middle East is spreading more among females due to social acceptability (Amin
et al. 2012). Indeed, where older studies have shown that men were four times more
likely to smoke than women (WHO 1997), more current studies report that boys
(aged 13–15 years) are only 2 to 3 times more likely to smoke than girls their age
(Warren et al. 2006; Sawyer et al. 2012). Reports from the Global Youth Tobacco
Survey (WHO 2001–2012) of adolescents aged 13–15 years indicate that 11 to 42%
of boys reported using tobacco in the past 30 days in many Arab countries (Bahrain,
Djibouti, Egypt, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Qatar,
Saudi Arabia, Sudan, Syria, Tunisia, the United Arab Emirates, Yemen). Whereas
the prevalence among girls just exceeded 10% in countries such as Bahrain, Dji-
bouti, Iraq, Jordan, Kuwait, Lebanon, Qatar, Syria, and the United Arab Emirates.
The lower prevalence in girls may be related to norms about appropriate female
behavior in the Arab culture. However, these norms are slowly changing with the
rising trends in hookah use by young women, specifically in restaurants and cafes
(Mauseth et al. 2016).
Multiple factors influence the different forms of smoking and tobacco use that are
popular among the adolescent population. A Saudi-based study by Amin et al.
(2012) found that the most frequently stated reasons for smoking among adolescents
were boredom, outings, meeting friends, and family gatherings among adolescents.
Significant predictors for water pipe smoking were male gender, increasing age,
water pipe smoking among close family and friends, and socializing. Moreover,
53.9% of current smokers were using water pipe, with significant differences among
males (61.6%) and females (12.5%). Evidence suggests that a large proportion of
adolescent water pipe smokers believe that water pipe smoking was less harmful
than cigarettes (47.8%) and had no addictive properties (65.9%); furthermore, 59.2%
believed that harmful substances were purified through water filtration, while 54.1%
regarded water pipe smoking as socially more acceptable than cigarettes (Amin et al.
2012). These beliefs are concerning given research findings on adolescents that the
integrated impact of cigarette and water pipe tobacco may contribute to a median of
36.4% of the total toxicant exposure from tobacco and may reach up to 73.5% and
71.9% of total carbon monoxide and benzene exposure respectively (Jawad and
Roderick 2016).
A study conducted by Fida and Abdelmoneim (2013) found that 37% of male
secondary students in Jeddah, Saudi Arabia, currently smoked, with 83.7% starting
at the age of 14 years or less. The most common reason for smoking was the
influence of family and peers, especially the presence of someone at home who
smoked (65.9%) and friends who smoked (42.5%). Many participants reported
searching for information on the risks of smoking (66.3%), and 63.2% of those
who smoked reported wanting to quit smoking, especially if suitable help was
offered; meanwhile, 60.9% had tried to quit (Fida and Abdelmoneim 2013). Other
factors that influenced adolescents to smoke were associated with recreational and
entertainment purposes (50%); 33.6% students reported that they had difficulty
avoiding smoking in non-smoking areas. Comparatively, another study reported
that the overall prevalence of ever smoking among male adolescents was 35.6%,
and most of the participants who had ever smoked had begun smoking by 12 years of
age (74.4%), with more than 25% having begun smoking by 10 years of age (Al-
Sheyab et al. 2014). Water pipe use was also very common, with 48.6% (n = 396)
reporting use and 25.6% (n = 209) using both water pipe and cigarettes (Al-Sheyab
et al. 2014).
A UAE-based study found that the prevalence of smoking among a sample of
6363 adolescents was 14.7% and was significantly higher among expatriate males
(25%) compared to expatriate females (6%). These rates were notably high among
adolescent expatriates from Arab or Middle Eastern countries (27.7%, 37% among
males only) and Western origins (27.5%) (Fig. 1). The same applied for exposure to
secondhand smoking with a larger proportion of males exposed to passive smoke
(50%) compared to females (31%) (Barakat-Haddad 2013). The majority of adoles-
cents smoked cigarettes (8.9%) followed by shisha (7.4%), other forms of tobacco
6.4%, and midwakh (a small pipe for smoking tobacco products mixed with herbs
and leaves) (6.3%) (Siddiqua et al. 2018). In addition, results consistently indicated
that the prevalence of tobacco use was higher among men than women and 24% of
men vs. 5.5% of women were current smokers (Siddiqua et al. 2018) (Fig. 1). In
addition, the authors also found that being male and ever having used illegal drugs
consistently emerged as significant predictors of all forms of tobacco use. Significant
predictors of smoking more than one form of tobacco also included daily or
occasional exposure to tobacco at home or with friends and nationality (Arab or
Middle Eastern, Arab African or Western) (Siddiqua et al. 2018).
Consistently, reported predictors of tobacco use include being male and non-
religious and having higher behavioral intentions, positive attitudes regarding the
use of psychoactive substances, and lower hardiness (Azaiza et al. 2009). Among
females, the slow rise in water pipe smoking relates to perceptions of social
acceptability and low health risks. Overall, adolescents from Arab nations display
smoking behaviors that suggest an eagerness for experimenting with various
methods and types of smoking, including cigarettes, shisha (hookah or water
Tobacco Forms Current Smoking

Passive Smoke Smoking Prevalence
>1 form
Other Forms
Midwakh
Shisha
Cigarettes
No Nationality/Other
Western
South East Asia
Arab/Africa
Arab/Middle East
GCC
UAE
Female
Male
0% 10% 20% 30% 40% 50% 60%
Fig. 1 Prevalence of smoking exposure and different forms of tobacco use among adolescents who
reside in the United Arab Emirates (n = 6363) (Barakat-Haddad 2013; Siddiqua et al. 2018)
pipe), and nargila (water pipe for smoking flavored tobacco) (Fida and
Abdelmoneim 2013). This also suggests that this health-risk behavior is embedded
in a culture of acceptance, where family members and peers highly influence
adolescent behaviors.
Consumption of Prohibited Substances
Research on illicit drug use, substance abuse, and alcohol use among adolescents
from Arab nations is generally scarce, largely because alcohol and drug consumption
are prohibited in many Arab nations such as Jordan, Saudi Arabia, Egypt, and the
United Arab Emirates. Few studies have reported increases in substantial alcohol use
or a new openness to alcohol or hashish (cannabis) use among adolescents from
Arab nations (Mauseth et al. 2016). A study led by Azaiza et al. (2009) examined
the rates of legal and illegal psychoactive substance use among Arab high school
dropout adolescents (12 to 18 years old). The authors reported that 36% of
participants consumed alcohol in the previous year and that predictors of alcohol use
include gender and religiousness. Females were less likely to use alcohol, possibly
due to greater supervision and cultural restrictions of girls and women in Arab
societies. Low religiousness was associated with increased likelihood of substance
use (Azaiza et al. 2009).
A UAE-based study involving 6363 adolescents aged between 13 and 20 years
suggested that significant predictors of respiratory health among UAE adolescents
was linked to behavioral factors such as purposely smelling gasoline fumes, glue,
correctors, car exhaust, or burning black ants (Barakat-Haddad et al. 2015). The
results of the study indicated that overall, 29% of participants reported to have
purposely smelled gasoline fumes, glue, correctors, car exhaust, or burning black
ants. Burning black ants in particular is a health-risk behavior adopted by adoles-
cents in Arab Nations as an alternative in seeking a similar sensation or “high” as
smoking marijuana. This sensation is received from the heating of formic acid found
in the ants, which also produces a poisonous gas that is highly detrimental to
respiratory health when inhaled (Barakat-Haddad et al. 2015; The National 2014).
Participating in these behaviors were significant predictors of wheeze and dry cough,
which were prevalent in 12.2% and 34.8% of adolescents in the past year respec-
tively (Barakat-Haddad et al. 2015). Therefore, given the high prevalence of respi-
ratory conditions among adolescents in the United Arab Emirates, and the likelihood
of experimenting with different substances during adolescence, it is essential to
address the health threats related to using unconventional drugs.
A study on 1837 students from Beirut, Lebanon, found that 67.1% of students
aged 16 to 18 years consumed alcohol in their lifetime, 5.8% percent reported
lifetime alcohol abuse, and 4.3% reported lifetime alcohol dependence. Lifetime
alcohol use, abuse, and dependence were all significantly less prevalent among
believers than non-believers of God, in both Christian and Muslim students
(Ghandour et al. 2009). While substance abuse in Arab nations is becoming more
acknowledged, adolescents are often not being educated on the subject. A study by
Harden and Tucker-Drob (2011) on substance abuse among adolescents in Jordan
contends that while most Jordanian adolescents have a basic understanding of
substance use, the information may primarily be coming from the mass media and
peer groups. While it is important to regulate the use of prohibited substances, there
remains a clear need to educate adolescents from Arab nations on the health risks of
prohibited substances and to tailor education campaigns to adolescents that are more
likely to abuse these substances.
Over-the-Counter Medication Use
Over-the-counter (OTC) self-medication is defined as the practice of consuming and

getting drugs without the guidance of a physician. Although it is recognized as a
worldwide public health problem, it is practiced more heavily in developing coun-
tries (Azodo et al. 2013). The advice of relatives or others often influences self-
medication practices, such as consuming leftover medicines already available at
home, including buying drugs by reutilizing or resubmitting a previous prescription

(Helal and Abou-Elwafa 2017). A major barrier in terms of receiving adequate
health care is the costs associated with obtaining general medical help, such as
consulting a general practitioner, completing routine and specialist health checkups,
and buying prescriptions. In particular, the costs are more preventative for adoles-
cents without medical insurance and thus increase the odds of self-medication
(Barakat-Haddad and Siddiqua 2017).
Data collected on the prevalence of over-the-counter medication use for a sample
of 6363 adolescents found that 51% reported the most common form being acet-
aminophen (Fig. 2). Significant predictors of over-the-counter medication use were
nationality (UAE, GCC, Arab/Middle East, Arab/Africa, Western, others), needing
Needed health care but did not receive it Medical Diagnosis

Use of prescription Medicine Age
Nationality Sex
Type of OTC
Yes
Yes
Yes
>19
18
17
16
15
<14
Western
South East Asia
Arab/Africa
Arab/Middle East
GCC
UAE
Female
Male
NSAIDs & peripheral analgesics
Peripheral analgesics
NSAIDs
0% 10% 20% 30% 40% 50% 60% 70% 80%
Fig. 2 Predictors of over-the-counter (OTC) medication use among adolescents residing in the
United Arab Emirates (n = 2935) (Barakat-Haddad and Siddiqua 2017). NSAIDs = nonsteroidal
anti-inflammatory drugs
health care but did not receive it, sex (female), age (15–18 years), any medical
diagnosis, unconventional drug use, sedentary behavior, and using prescription
medicines (Barakat-Haddad and Siddiqua 2017). The study reported earlier on
Arab adolescent high school dropouts found that 11% report non-medical use of
medications (Azaiza et al. 2009). An Egypt-based study found that the prevalence of
self-medication practices among university students (mean age 20 0.7 years) was
62.9% (Helal and Abou-Elwafa 2017). A high percentage of the students were
females (78.1%), and the majority (91%) were ever married. Younger age, female,
and ever-married students tended to self-medicate more than their peers did. In
addition, the likelihood of self-medicating was independently associated with
being a medical student, being from an urban area, having good current health
condition, being careless about health, and having a home pharmacy (Helal and
Abou-Elwafa 2017).
Other Health-Risk Behaviors
Other health-risk behaviors among adolescents from Arab nations that have gained
little attention include those associated with gaming, violence, sexual, and hygiene
practices. It is unfortunate that some behaviors among adolescents are propagated
through peer pressure and are motivated by popularity. Self-strangulation or what is
known as the “choking game” has recently been examined among adolescents from
Arab nations (Albuhairan et al. 2015). The study reported that two out of five cases
of young male adolescents aged 10 to 13 years resulted in death due to this non-
suicidal self-strangulation game.
Violence is another area that has been reported recently in the literature.
Celedonia et al. (2013) reported on violent behavior among a sample of 5138
adolescents from Egypt; the authors found that 31% of adolescents aged 11 to
17 years old reported being involved in a physical fight. Predictors of violent
behavior include depressive symptoms and bullying victimization (OR = 2.44;
CI = 2.12–2.83), while protective factors include having helpful peers
(OR = 0.75; CI = 0.62–0.90), understanding parents (OR = 0.67;
CI = 0.56–0.81), and having fewer friends (OR = 0.75; CI = 0.60–0.92).
In relation to sexual behavior practices, Massad et al. (2014) found that many
youth in Palestine engaged in various types of sexual activity outside of marriage.
Associations with sexual activity coincided with reasons such as challenging the
culture, financial constraints, basic human needs, suppression, boredom, inability to
marry, and proving manhood. Alarmingly, most participants reported not usually
using protection. Another study on university students from Lebanon found that
15% had engaged in sexual activity, while 20% were regularly sexually active, and
only 36% regularly used condoms during their relationships (Salameh et al. 2016).
More females than males had never had sexual activity (85.1% and 34.8%, respec-
tively). Factors associated with sexual activity were having a liberal attitude towards
sex, identifying as male, motives for risky behavior, current cigarette smoking, and
problematic alcohol consumption.
Hygiene practices is another topic that has been examined in research that focuses
on health-risk behavior among adolescents from Arab nations. For example, a
Kuwait-based study on students aged 11 to13 years found that participants who
felt happy were more likely to brush their teeth at least twice per day than those who
did not feel happy (Honkala et al. 2007). According to Ranasinghe et al. (2016), the
Global School-Based Student Health Survey (GSHS) statistics indicate significant
associations for both male and female students between symptoms of depression and
the likelihood of handwashing in Arab participating countries for both females
(OR = 1.63, 95% CI = 1.29–2.16) and males (OR = 1.73, 95% CI = 1.40–2.12).
Health Care and Accessibility
A number of studies have reported on health-care accessibility of adolescents from

Arab nations. Khansaheb et al. (2016) found that adolescents who were between 15
and 19 years of age received little or no health education from their health-care
provider between 2008 and 2010 in the United Arab Emirates. Specifically, 94.2%
reported that they did not receive any information about using a helmet for bicycle
and motorbike safety, 88.2% reported receiving no information about drug use, and
81.9% reported that they received no information about smoking. However, in
relation to health education material, 65% of participants reported seeing or hearing
safety tips; 84.9% reported hearing or seeing health information about healthy diet,
physical activity, and exercise; and 79.2% reported seeing or hearing information
about the risks of smoking and substance abuse (Khansaheb et al. 2016). The authors
concluded that preventative health services are rarely provided to adolescents.
Utilization of primary health-care services is an important determinant of health.
Individuals who receive health care from primary health-care physicians are gener-
ally healthier than those who do not. A UAE-based study found that common
reasons for adolescents for not obtaining care were busy schedules, dislike or fear
of doctors, and long waiting times (Barakat-Haddad and Siddiqua 2015). In addition,
predictors of not obtaining needed care included nationality and income, while those
for having a routine checkup were mother’s education and car ownership.
A study by Albuhairan et al. (2015) reported that 24% of adolescents reported
difficulty in accessing health-care services when in need and only 52.0% reported
spending sufficient time with the physician during their health-care visit. When
comparing health-care use, such as routine checkup, using a physician office, or
getting an oral examination, Moradi-Lakeh et al. (2016) found that a routine checkup
in the last 12 months was reported by only 7.3% of 15- to 19-year-old Saudi youth,
while 87.5% reported never or not having a routine checkup in the past 5 years, and
44.5% reported never or not visiting a physician in the past 5 years. In addition, 90.9%
of youths reported never or not having a general checkup examination in the past year.
In Dubai, 35.2% of adolescents between the ages of 15 and 19 years reported that they
had not seen a health-care provider in the last 2 years (Khansaheb et al. 2016).
In examining research on health-care provision, researchers have noted that
health care in Arab nations remains either child- or adult-focused, with the age
cutoff being somewhere between 12 and 14 years (Albuhairan et al. 2015). This
fragmented model is problematic since it does not address issues commonly faced by
adolescents. Unfortunately, related influencing factors that health-care providers
have reported include the time needed to consult adolescents on health issues
(Khansaheb et al. 2016). This is seen as a barrier by many clinicians, as service
times can range depending on the level and number of risk factors associated with
adolescents, with longer times waited by adolescents with higher risk or multiple
factors. Other issues related to the health-care system include lack of resources such
as referral sources, scarce education materials, and skilled staff (Park et al. 2001).
The relatively high rates of not obtaining regular routine checkups among Arab
youth may also be due to the lack of established guidelines enforcing scheduled
adolescent visits (Khansaheb et al. 2016). Lack of enforcement in obtaining regular
routine checkups and the relative absence of information from a trusted source such
as a health provider about ways to improve adolescent health will most likely
influence the quality of life for adolescents, at a time where many health conditions
and outcomes that are predictors of long-term health are preventable.
Conclusion
This chapter highlights patterns of health-risk behaviors among adolescents from

Arab nations. It is evident that there are many areas related to health-risk behaviors
that are in dire need of research and action. These include dietary habits, physical
activity, sedentary habits, tobacco reduction initiatives, substance abuse, sexual
practices, over-the-counter self-medication, and health-care accessibility. It is nec-
essary to extend and differentiate between health services and health information
provision to target specific age groups, including adolescents and youth. Improve-
ments in addressing other relatively culturally sensitive health-related behaviors,
such as sexuality and substance abuse, are highly recommended. Other health-risk
behaviors and problems that have been given little to no attention among adolescents
from Arab nations include sleep issues, hygiene practices, and sun exposure prac-
tices. Future research should address these topics. Adolescent health has significant
implications for the next generations and is a driving force for socioeconomic
development. Young people are indispensable partners in the development of their
families, communities, states, regions, and the world at large and thus require the
adequate resources for health promotion and disease prevention.
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Health Impact of Demographic Changes in
the Gulf States 29
Asharaf Abdul Salam
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 678
Transitions in Public Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 681
Vital Statistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 681
Changing Demographics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 684
Manifestations of Demographic Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 690
The 5-Year Age Groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 690
Sex Ratio . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 692
Reflections of Age Composition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 693
Conclusions and Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 697
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 697
Abstract
The Arabian Gulf consists of six states in the Middle East with public health
statistics and facilities that are somewhat comparable to those in developed
nations. However, family-level indicators, traditional values and customs, religi-
osity, and religious practices are valued as societal strongholds. Thus, there
is a tension between modern and traditional lifestyles, so complicating the
theoretical explanations and models of transitions in health, epidemiology, and
demography. This chapter reviews (i) population trends – size, distribution,
growth, and structure – and (ii) transition in public health statistics, fertility, and
mortality, using the US Census International Database accessed in 2012 and
2015.
The rapidly falling fertility has reached replacement levels, with low overall
mortality levels as well as age-specific mortality rates. Efforts to achieve such
A. A. Salam (*)
Center for Population Studies, King Saud University, Riyadh, Saudi Arabia
e-mail: asharaf_a@hotmail.com

https://doi.org/10.1007/978-3-030-36811-1_28
678 A. A. Salam
a demographic and public health scenario have led to transformations in socio-

economic and infrastructural resources, such as improved living conditions,
which in turn hastened the transition of demographics, with respect to the size,
structure, and distribution of the population. Both these processes – public health
transition and demographic changes – complement each other. Nevertheless,
these changes need to be assessed with caution, by policy makers and program
planners, in impacting national scenarios, and with impacts on the indigenous
population.
Keywords
Population structure · Vital statistics · Arabian Gulf · Demographic transition ·
Epidemiology
Introduction
The Arabian Gulf is a distinctive region in terms of both geographic dimensions and
population characteristics, which is spread over six independent states, Bahrain,
Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates, and sharing
a common language and lifestyles. All these states share common geography and
religious beliefs and practices, and also oil wealth that has created economic
equalities. These states are part of the League of Arab Nations, which serves to
create internal peace and harmony within and between the 22 Arab countries (Fig. 1).
This Arabian Gulf region has rich petroleum reserves that facilitate fast growth
of the population due to natural increases and immigration. This created a youth
bulge – a rapidly growing youth population – but a complicated social change due to
economic strains and wrenching political transformations (Khraif et al. 2016; Salam
and Mouselhy 2013; Canning 2011; Yount and Sibai 2009; Saxena 2008; Roudi-
Fahimi and Kent 2007; Tabutin and Schoumaker 2005; U.S. Department of Com-
merce 2003; Jacobson 1994). The region has resisted rapid demographic changes
and promotes excellence in educational, health, and public utility infrastructure that
is at par with developed countries. The region accommodates a large migrant worker
population needed to services in all areas of need such as domestic services,
commercial enterprises, etc. In some cases, the expatriate population exceeds the
native population (Courbage 1995; ESCWA 2008; Salam et al. 2015).
The population of the Arabian Gulf, with a rapidly declining death rate and
slowly declining birth rate, grew rapidly during the second half of the twentieth
century, especially since the 1950s, and is projected to continue to grow in the future.
However, a youth bulge resulting from immigration of adults due to increased
pressure from the labor market – in education, housing, health, and other public
services – influences family formation. On the other hand, the adult population
continues to decline resulting in corresponding increases in the proportion of
elderly/aged persons, mostly due to gains in life expectancy (Khraif et al. 2014;
Asharaf and Alshekteria 2008; ESCWA 2002).
29 Health Impact of Demographic Changes in the Gulf States 679
Fig. 1 Map of Arabian Gulf states. (Source of data: https://apps.cndls.georgetown.edu/projects/

borders/items/show/1100)
The demographic transition experiences of the Arabian Gulf states are compara-
ble to that of other developed and developing countries. Although the transition has
a late onset as compared to other regions, it is faster than elsewhere (Pew Research
Center 2009; Tabutin and Schoumaker 2005; Rashad 2000), due mainly to cultural
factors combined with greater opportunities and improved economic conditions
associated with family formation variables (Courbage 1995; Khraif et al. 2016).
This analysis of the Arabian Gulf (Gulf Coordination Council (GCC) states)
examines the demographic changes leading to public health under resourceful
economies starting in 1992. This chapter reviews (i) the population trends – size,
distribution, growth, and structure – and (ii) the transition in public health statistics,
fertility, and mortality.
This review analyzes data extracted from the International Data Base (IDB) of US
Census Bureau for various periods – 1992, 2002, 2012, and 2015 (accessed on June–July
2012 and April 2015). These databases offer a variety of demographic indicators,
estimates, and projections with periodic revisions – birth, death, growth, migration, infant
mortality, and life expectancy and population by age and sex. For the purpose of this
chapter, demographic indicators are calculated using the following formulae:
• Sex ratio, the ratio of males to females in a given population, expressed as the
number of males for every 100 females
680 A. A. Salam

number of males
Sex Ratio ¼ 100
number of females
• Density of population, the number of persons per square kilometer

total population
Density ¼
total area
• Age-specific sex ratio, number of males in a given age per 100 females of the
same age

number of males at age i
Age Specific Sex Ratio ¼ 100
number of females at age i
• Sex ratio of broad age groups, number of males in the broad age group per 100
females of the same age
• Population growth, the difference between population of two points
• Population growth rate, the exponential growth rate calculated by using the
formula:

1 P2
Growth Rate ¼ LN
T P1
where
P2 population of last census
P1 population of previous census
LN natural logarithms
T intercensal period
• Net migrants, the difference between immigrants and emigrants
• Natural increase, difference between births and deaths
• Population change, sum of net migrants and natural increase
• Proportion of population by broad physiological age group, number of per-
sons in the physiological age group to 100 persons in the total population
• Proportion of population by 5 year age groups, number of persons in the 5 year
age group to 100 persons in the total population
• Child-woman ratio, number of children of age 0–4 years per 1000 women aged
15–49 years
• Aged-child ratio, number of persons aged 60 years and above per 100 children
aged 0–14 years
• Median age, calculated by using the formula
0n 1
Cf i
Median Age ¼ lmd þ @2 Ax
fm
where:
l lower limit of the median class

N total population
Cfi cumulative frequency of class preceding median class
fm frequency of median class
X class interval
• Age dependency ratio, number of persons aged 60 years and above per 100
persons aged 15–59 years
Transitions in Public Health
Population growth impacts upon various aspects of daily life and which leads to
improvements in education, housing, and healthcare. On the other hand, it influences
demands and greater expectations. Such improvements depend largely on demo-
graphics – size, structure, and vital statistics (Jacobson 1994; Canning 2011; Khraif
et al. 2016; Salam et al. 2015). In other words, population serves as the denominator
of all public health programs and infrastructure. That is, all structures and systems,
both in the public and private domains, depend largely on the population require-
ments, demands, and expectations (Khraif 2009a; Khraif et al. 2016).
Vital Statistics
Vital statistics relating to both fertility and mortality were considered for reviewing
the impact of population growth: fertility indicators included crude birth rates, total
fertility rates, and general reproduction rates, while mortality indicators included
crude death rates, infant mortality rates, under 5 mortality rates, and expectation of
life at birth (Table 1).
Fertility
Fertility rates in Arab countries are high. There was a declining trend commensurate
with the pace of development and quality of life (Salam et al. 2015; Roudi-Fahimi
and Kent 2007; Courbage 1999). For example, as the Arabian Gulf countries
improved their social and economic conditions to reach a lifestyle similar to other
modernized countries, fertility rates in these countries fell rapidly as understood
from indicators such as crude birth rates (CBR), total fertility rates (TFR), and
general reproduction rates. While a decline in CBR occurred from ~25 in 1992 to
~15 in 2012, the TFR decline was from ~4.0 in 1992 to ~2.5 in 2012. Both these
declines have implications for public health in terms of maternal, neonatal, infant,
and child healthcare. Moreover, fertility rates determine population age groups,
which in turn influence the demand for public health services. That is, societies
having high fertility rates emphasize maternal and child health, whereas those with
declining fertility focus on adolescent and youth health, adult (reproductive) health,
and geriatrics (Yount and Sibai 2009; Khraif 2001, 2009b). In short, emphasis on
public health specialties depends largely on the demographic transition stages (Salam
and Mouselhy 2013; Mathew et al. 2011; Saxena 2008; United Nations 2008).
682 A. A. Salam
Table 1 Changes in public health statistics with time (Source: U.S. Department of Commerce,
International Database of US Census Bureau accessed in 2012 and 2015)
Indicators/year Bahrain Kuwait Oman Qatar Saudi Arabia UAE
CBR
1992* 25.8 24.8 32.7 22.6 33.9 24.6
2002 19.5 20.9 24.5 17.3 24.6 16.3
2012 14.0 21.0 24.0 10.0 19.0 16.0
2015 13.7 19.9 24.4 9.8 18.5 15.4
TFR
1992* 3.4 3.4 6.0 4.0 5.5 4.0
2002 2.4 2.6 3.5 2.8 3.5 2.5
2012 1.9 2.6 2.9 1.9 2.3 2.4
2015 1.8 2.5 2.9 1.9 2.1 2.4
GRR
1992* 1.7 1.7 2.9 1.9 2.7 1.9
2002 1.2 1.3 1.7 1.4 1.7 1.2
2012 0.9 1.3 1.4 1.0 1.1 1.2
2015 0.9 1.2 1.4 0.9 1.0 1.2
CDR
1992* 3.6 2.4 4.4 2.3 4.4 2.9
2002 3.0 2.1 3.7 2.0 3.6 2.3
2012 3.0 2.0 3.0 2.0 3.0 2.0
2015 2.7 2.2 3.4 1.5 3.3 2.0
IMR
1992*
Male 26.6 12.8 25.1 13.5 29.7 26.2
Female 19.4 10.5 23.3 13.2 22.8 18.6
Total 23.1 11.7 24.2 13.4 26.3 22.5
2002
Male 17.2 10.6 20.5 8.9 24.7 18.6
Female 13.0 10.3 20.8 8.5 18.4 13.1
Total 15.1 10.5 20.1 8.7 21.6 15.9
2012
Male 11.4 7.6 15.3 7.1 17.9 13.5
Female 8.9 8.2 14.6 6.5 13.2 9.6
Total 10.0 8.0 15.0 7.0 16.0 12.0
2015
Male 10.4 7.1 13.9 6.6 16.2 12.4
Female 8.3 7.5 13.2 6.0 11.9 8.8
Total 9.4 7.3 13.6 6.3 14.1 10.6
U5MR
1992*
Male 32.1 15.9 33.7 21.0 35.3 31.4
Female 23.3 13.4 33.4 17.0 27.5 22.3
(continued)
Table 1 (continued)
Indicators/year Bahrain Kuwait Oman Qatar Saudi Arabia UAE
Total 27.8 14.7 33.5 19.1 31.5 26.9
2002
Male 20.3 13.1 27.3 13.3 28.9 22.0
Female 15.5 12.6 27.9 10.8 21.6 15.5
Total 17.9 12.8 27.6 12.1 25.3 18.8
2012
Male 13.4 9.5 19.5 9.7 20.8 15.8
Female 10.5 9.9 19.6 8.1 15.3 11.1
Total 12.0 9.0 20.0 9.0 18.0 14.0
2015
Male 12.3 8.4 17.5 8.9 18.7 14.4
Female 9.8 9.0 17.5 7.4 13.8 10.2
Total 11.1 8.7 17.5 8.1 16.3 12.3
Life expectancy at birth
1992*
Male 70.0 72.2 68.3 72.2 68.9 69.7
Female 74.2 75.0 71.7 75.2 72.5 74.4
Total 72.1 73.5 70.0 73.7 70.7 72.0
2002
Male 73.5 73.8 70.3 74.5 70.3 72.1
Female 77.4 76.5 73.7 77.9 73.9 77.1
Total 75.4 75.2 72.0 76.2 72.1 74.6
2012
Male 76.2 76.1 72.6 76.1 72.4 74.1
Female 80.5 78.5 76.4 80.1 76.4 79.4
Total 78.3 77.3 74.5 78.1 74.4 76.7
2015
Male 76.5 76.5 73.3 76.6 73.0 74.7
Female 81.0 79.2 77.2 80.7 77.2 80.0
Total 78.7 77.8 75.2 78.6 75.1 77.3
*Data of Oman for 1993
CBR crude birth rate, TFR total fertility rate, GRR gross reproductive rate, CDR crude death rate,
UMR under 5 mortality rate, IMR infant mortality rate
Mortality
Indicators of mortality reviewed here include crude death rate, infant mortality rate,
under 5 mortality rate, and expectation of life at birth. All these indicators suggest
low levels, indicating improved public health conditions and health status at a macro
level. These rates match the desired levels set by the Millennium Development Goals
(MDGs) of the UNDP (United Nations 2013a, b; WHO 2010) and indicate the rapid
pace of achievement in reducing mortality rates in the region.
A low crude death rate (CDR) has been reported in all these countries since 1992
and shows an impressive decreasing trend, as shown by Shawky (2001). Among the
684 A. A. Salam
six countries, the two larger ones (Oman and Saudi Arabia) have higher but fast
declining death rates (from 4.4 to 3.3 and 4.4 to 3.4 from 1992 to 2015) since 1992.
The other states, which are smaller in terms of area and population, have lower levels
of CDR since 1992 and also declining.
Infant mortality rates (IMR) remained low in all the GCC countries since 1992.
They remain below 30 for both males and females. While Kuwait and Qatar recorded
remarkably low rates, Saudi Arabia showed the highest rate, with Bahrain, Oman,
and UAE having intermediate levels. The IMR declined to ~10 in Kuwait and Qatar,
to ~15 in Bahrain and UAE, and to ~20 in Oman and Saudi Arabia. Such a declining
trend continued to 2015 when it was less than 10 in Bahrain, Kuwait, and Qatar and
below 15 in Oman, Saudi Arabia, and UAE.
Child mortality below the age of 5 years (U5MR) is higher than that in developed
countries. Perhaps, the maternal and child healthcare components influence under 5
mortality, especially with higher-order births and poor infant care practices.
But there has been a rapid decline above 35 in 1992 (except Kuwait and Qatar
reporting lower levels) to below 30 in Oman and Saudi Arabia and to below 20 in
other countries in 2002, to below 20 in Oman and Saudi Arabia and below 15 in
other countries in 2012, and then to below 15 in Oman and Saudi Arabia and below
10 in other countries by 2015. These declines mark excellent achievements of
ambitious targets set by public health units to establish an internationally competi-
tive health scenario in consonance with the changing population characteristics and
living conditions (Khraif et al. 2016; Salam et al. 2015).
Expectation of life at birth is another indicator of health improvement and is high
in the Gulf countries, which might have roots from cleanliness, dietary habits,
activity profile, and lifestyles facilitated by infrastructure and quality of utilities
(Khraif et al. 2014; Salam et al. 2015). All countries in GCC had a life expectancy
above 70 years, for both males and females. There were gains in life expectancy of 2
years in each decade for both males and females. Throughout the period, Oman and
Saudi Arabia registered lower levels of life expectancy, possibly due to their
comparatively larger populations.
Changing Demographics
The Arabian Gulf population increased from 23,535,857 in 1992 to 43,148,976 in

2015. The population in the countries on this region experienced a higher increase
in male population. Such a demographic phenomenon occurred due to immigration
from Southeast Asian and African countries. Such employment-oriented immigra-
tions on specific labor VISA neither with provisions for dependents or families nor
with privileges of citizens influence the population age structures and thereby vital
rates (Salam et al. 2014).
Still, with such clear demarcations of native and expatriate population, no specific
data bifurcations for demographic analyses are hardly available. This creates mis-
leading interpretations of natural growth, birth and death rates, migration rates, and
vital rates due mainly to the absence of at-risk population of expatriate labor force, in
the respective population. This leads to incorrect inferences due mainly to the
denominator (total population) to indicators of fertility, mortality, and related vital
statistics (Fig. 2).
Population growth of the Arabian Gulf seems different from other regions due
to labor-oriented immigration. These oil-rich countries drew manpower from
Asian and African countries to meet their increasing demands – professional,
service, commercial, and support levels. This phenomenon exaggerates population
growth in these countries. However, population of this region grew from
23,535,857 (1992) to 31,874,738 (2002) to 40,785,224 (2012) and to 43,148,976
(2015) (Table 2). This registers a 35% increase in 1992–2002; 28% in 2002–2012;
and 5.8% in 2012–2015: partially due to the labor importations. The overall
increase during 1992–2012 was 73.3%. The Kingdom of Saudi Arabia had the
highest number of people and which increased from 17,060,750 in 1992 to
22,274,039 in 2002 to 26,534,504 in 2012 and to 27,752,316 in 2015 reflecting
percentage of increase of 30.6, 55.5, and 62.7, respectively. Moreover, variations
in the rate of increase in these countries depend largely upon the labor policies and
restrictions imposed upon expatriate employment, to boost employment of native
population.
The population of the Arabian Gulf countries nearly doubled in the last 23 years
(1992–2015), due to both natural increase and migrations, recording an increase of
19,613,119 persons. Of these 10,691,566 were added in Saudi Arabia whereas the
rest 8,821,553 elsewhere. All those countries, except Bahrain, added more than one
million persons. However, these additions to the population during 2002–2012 were
higher than that of 1992–2002, except in Kuwait and in Saudi Arabia. Moreover,
there were wide male-female differences in the increase, except in Oman. While the
Fig. 2 Population change in the Arabian Gulf (1992–2015). (Source of data: International Data-
base of US Census Bureau accessed in 2012 and 2015)
686 A. A. Salam
Table 2 Population and its manifestations in the GCC countries

Saudi
Bahrain Kuwait Oman Qatar Arabia UAE Total
Population
1992
Male 308,668 788,581 1,177,938 305,635 9,543,505 1,367,343 13,491,670
Female 229,352 614,140 836,628 157,876 7,517,245 688,946 10,044,187
Total 538,020 1,402,721 2,014,566 463,511 17,060,750 2,056,289 23,535,857
2002
Male 410,991 1,231,230 1,433,251 465,535 12,469,458 2,428,671 18,439,136
Female 303,840 852,075 1,107,827 237,852 9,804,581 1,129,427 13,435,602
Total 714,831 2,083,305 2,541,078 703,387 22,274,039 3,558,098 31,874,738
2012
Male 756,746 1,555,502 1,695,541 1,496,609 14,516,106 3,650,063 23,670,567
Female 491,602 1,090,812 1,394,609 454,982 12,018,398 1,664,254 17,114,657
Total 1,248,348 2,646,314 3,090,150 1,951,591 26,534,504 5,314,317 40,785,224
2015
Male 816,237 1,631,973 1,791,594 1,695,234 15,105,575 3,962,699 25,003,312
Female 530,376 1,156,561 499,583 499,583 12,646,741 1,817,061 18,145,664
Total 1,346,613 2,788,534 2,194,817 2,194,817 27,752,316 5,779,760 43,148,976
Population growth
1992–2002
Male 102,323 442,649 255,313 159,900 2,925,953 1,061,328 4,947,466
Female 74,488 237,935 271,199 79,976 2,287,336 440,481 3,391,415
Total 176,811 680,584 526,512 239,876 5,213,289 1,501,809 8,338,881
2003–2012
Male 345,755 324,272 262,290 1,031,074 2,046,648 1,221,392 5,231,431
Female 187,762 238,737 286,782 217,130 2,213,817 534,827 3,679,055
Total 533,517 563,009 549,072 1,248,204 4,260,465 1,756,219 8,910,486
2013–2015
Male 59,491 76,471 96,053 198,625 589,469 312,636 1,332,745
Female 38,774 65,749 100,733 44,601 628,343 152,807 1,031,007
Total 98,265 142,220 196,786 243,226 1,217,812 465,443 2,363,752
1992–2015
Male 507,569 843,392 613,656 1,389,599 5,562,070 2,595,356 11,511,642
Female 301,024 542,421 658,714 341,707 5,129,496 1,128,115 8,101,477
Total 808,593 1,385,813 1,272,370 1,731,306 10,691,566 3,723,471 19,613,119
Growth rate
1992–2002
Male 2.86 4.46 1.96 4.21 2.67 5.74 3.12
Female 2.81 3.27 2.81 4.10 2.66 4.94 2.91
Total 2.84 3.96 2.32 4.17 2.67 5.48 3.03
(continued)
Table 2 (continued)
Saudi
Bahrain Kuwait Oman Qatar Arabia UAE Total
2003–2012
Male 6.10 2.34 1.68 11.68 1.52 4.07 2.50
Female 4.81 2.47 2.30 6.49 2.04 3.88 2.42
Total 5.58 2.39 1.96 10.20 1.75 4.01 2.47
2013–2015
Male 2.52 1.60 1.84 4.15 1.33 2.74 1.83
Female 2.53 1.95 2.32 3.12 1.70 2.93 1.95
Total 2.53 1.74 2.06 3.92 1.50 2.80 1.88
1992–2015
Male 4.23 3.16 1.82 7.45 2.00 4.63 2.68
Female 3.64 2.75 2.52 5.01 2.26 4.22 2.57
Total 3.99 2.99 2.13 6.76 2.12 4.49 2.64
Area (sq. 760 17,818 309,500 11,586 2,149,690 83,600 25,729,542
km)
Density
1992 708 79 6 40 8 25 9
2002 941 117 8 61 10 43 12
2012 1,643 149 10 168 12 64 16
2015 1,772 157 11 189 13 69 17
Source of data: U.S. Department of Commerce, International Database of US Census Bureau
accessed in 2012 and 2015
male population increased rapidly than that of females, Oman has retained a gender
balance in immigrations.
There were declines in growth rate in 2003–2012 as compared to 1992–2002,
especially sensitive to females. This probably shows not only the declining natural
increase but also the restrictions in labor importations. Except Oman, all other
countries’ male population grew faster. This might be due to the male selective
labor immigrations. As far as the natives are concerned, there was no gender
imbalance (Salam et al. 2014).
The Arabian Gulf extends to 2,572,954 square kilometers with Saudi Arabia
having the largest geographical area: other states are located on its eastern and
southeastern sides. All these countries have large uninhabited deserts. Thus, density
of population remained low in these countries. For example, Saudi Arabia had
a density of 13 persons per square kilometer. At the same time, there were small
urbanized countries like Bahrain with higher densities (1772 persons per square
kilometer). The population of all these countries are concentrated in the urban
locations leaving the uninhabited deserts and rural areas. This reflects in overall
density, but in reality, all the metropolitan cities (like Dubai, Abu Dhabi, Sharjah,
Ras Al Khaimah, Muscat, Salalah, Kuwait City, Doha, Manama, Riyadh, Jeddah,
688 A. A. Salam
etc.) and other urban agglomerations (Al Ain, Ajman, Dammam, Al-Khobar, etc.)
have high population density.
Annual growth rates were higher in 1992–2002 but it reduced noticeably in
2002–2012. Higher growth rates prevailed in Qatar, UAE, and Bahrain. Countries
like Saudi Arabia and Oman had low growth rates in 2002–2012 and 2012–2015.
Such a population growth has, apparently, occurred in two ways: (i) natural
increase – number of births and deaths, and (ii) net migration – number of immi-
grants and emigrants. The overall contribution of natural increase and net migration
adds up to the existing population, thus resulting in growth. As the Arabian Gulf
have labor requirements for extraction of petroleum and in building human
resources, they depended upon expert manpower from other countries, especially
from America and Europe. Further, at secondary and support levels, these nations
brought skilled labor from the South Asian and African countries. The resultant
increase in population expanded the commercial and service activities, for which
another set of foreigners were brought into the country. At the same time, the wide
gap in fertility and mortality resulted in an expansion of native population. All these
lead to a rapid increase in the population (Table 3).
During 1993–2002, the population of the Arabian Gulf increased by a total of
8,387,262 persons which were added more through natural increase (6,445,602 –
76.8%) than net migration (1,941,658 – 23.2%). These proportions vary between the
countries, e.g., Qatar and UAE had more net migrants than natural increase, whereas
Oman and Saudi Arabia had lesser migrants. On the other hand, the change in
population was higher during 2003–2012, which is proportional to population size
at that point in time. Of the increase of 8,888,372 persons in the decade, share of
natural increase was 6,243,289 (70.2%), and migration was 2,645,083 (29.8%). Two
of the countries – Oman and Saudi Arabia – have shown a negative net migration,
perhaps due to no movement of the expatriate population outside of these countries.
For example, there are many African and Asian expatriates living permanently in
these countries, without traveling outside. Yearwise, an increase in the share of
migration in population change has been observed, which reflects a rise in develop-
ment and commercial activities demanding more migrants to uplift the socioeco-
nomic life.
The three years (2013–2015) have not added many persons (2,343,286):
1,945,717 due to natural increase and 397,569 due to migration. During this period,
three countries – Kuwait, Oman, and Saudi Arabia – showed a decline in net
migration, which could be attributed to the massive localization of labor force,
focusing employment of native population, through labor importation regulations.
Both Kuwait and Saudi Arabia implemented various strategies to limit the expatriate
labor force in many employment sectors such as private organizations, Internet and
mobile phone shops and establishments, cosmetics and ladies’ textiles, hypermarkets
and supermarkets, etc. Such regulations implemented, actively, since 2010 shall
have far-reaching effect on the population size and structure and thereby public
health measures, in the coming decades.
Table 3 Components of population change, the vital events (1993–2015)

Natural Net Population
States Births Deaths increase migrants change
1993–2002
Bahrain 142,575 19,932 122,643 79,887 202,530
Kuwait 414,300 39,825 374,475 292,147 666,622
Oman 650,613 92,610 558,003 26,344 584,347
Qatar 109,715 11,871 97,844 150,369 248,212
Saudi 5,633,399 780,518 4,852,881 307,251 5,160,135
Arabia
UAE 510,309 70,553 439,756 1,085,660 1,525,418
Total 7,460,911 1,015,309 6,445,602 1,941,658 8,387,260
2003–2012
Bahrain 165,520 27,741 137,779 379,427 517,206
Kuwait 525,086 51,966 473,120 86,763 559,883
Oman 664,471 100,171 564,300 10,244 554,056
Qatar 161,929 22,116 139,813 1,140,528 1,280,341
Saudi 5,143,434 844,930 4,298,504 73,028 4,225,476
Arabia
UAE 726,693 96,920 629,773 1,121,637 1,751,410
Total 7,387,133 1,143,844 6,243,289 2,645,083 8,888,372
2013–2015
Bahrain 54,831 10,527 4,4304 53,604 97,908
Kuwait 166,637 17,771 148,866 9,040 139,826
Oman 236,176 32,651 203,525 4,344 199,181
Qatar 63,310 9,751 53,559 175,244 228,803
Saudi 1,539,374 272,643 1,266,731 48,101 1,218,630
Arabia
UAE 262,322 33,590 228,732 230,206 458,938
Total 2,322,650 3769,33 1,945,717 397,569 2,343,286
1992–2015
Bahrain 362,926 58,200 304,726 512,918 817,644
Kuwait 1,106,023 109,562 996,461 369,870 1,366,331
Oman 1,551,260 225,432 1,325,828 11,756 1,337,584
Qatar 334,954 43,738 291,216 1,466,141 1,757,357
Saudi 12,316,207 1,898,091 10,418,116 186,122 10,604,238
Arabia
UAE 1,499,324 201,063 1,298,261 2,437,503 3,735,764
Total 17,170,694 2,536,086 14,634,608 4,984,310 19,618,918
690 A. A. Salam
Manifestations of Demographic Change
Population growth manifests into the structure, characteristics, and distribution,

thereby impacting upon public health policies and programs through creation of
agendas and targets. The Arabian Gulf region has a young population but with an
adult boom. Their economically active population increased from its 55.9% in 1992
to 62.8 in 2002 to 69.2 in 2012, perhaps due partly to fertility decline and to
immigrant labor force. This increase was accompanied by a corresponding decrease
in childhood population (from 40.5% in 1992 to 25.4% in 2015); a drastic decline
attributed to the fertility transition coupled with age-specific labor immigration.
Nevertheless, this fertility decline has not started inflicting upon the aging popula-
tion, which might be due to the wide adult population, including immigrants.
There is a marked change in broad age groups of population – children (less than
15 years), adults (aged 15–59 years), and old aged (60 years and above). Their
percentages were 40.5, 55.9, and 3.6, respectively, in 1992 with marked differences
between males and females. While the percentage of females were higher in child-
hood ages and lower during adult ages as compared to males, this imbalance might
explain the paradox, demographic dilemma, created through immigrant labor
force. Sex wise, the percentage distributions vary (Table 4). A higher percent of
males are adult working ages making their percentage of children lower than usual.
Surprisingly, more than 60% of the male population in the region are aged 15–59
years (the working age), especially higher in Qatar (75.9%) and UAE (76.1%).
The percentages of broad age groups changed to 33.6, 62.8, and 3.5, respectively,
in 2002: a slight increase in adults with a corresponding decrease in children.
Not only the fertility but also the immigration has, perhaps, played significant
roles in this age structural change, which in turn influenced the age-sex structure.
In this period, the percent of female children also shrank because of a widened adult
age population. This could probably show the changing labor laws and expanding
avenues for female expatriates. That is, countries have started attracting females to
fulfill their requirements, in the service sectors especially education and health and
also in certain commercial enterprises’ administration, cash, sales, and marketing.
Furthermore, the percent of children shrink in 2012 to 26.6% with more adults
(69.2%) and old aged (4.1%). These changes are equally observed in males and
females. Noticeably higher percentage of adult males, nearly to 90%, have been
reported in some countries: such statistics are worrisome to the social scientists and
policy makers for social vigilance on safety and security. The trend continues till
2015 but has started influencing the percent of old aged. It might be due to
population concerns and pressures toward native employment, labor regulations,
and changing labor contracts of expatriates.
The 5-Year Age Groups
Usually, demographic analyses concentrate on 5-year age groups for explaining

population with definite, equal intervals. A picturesque description of 5-year age
structure is the population pyramid, the shape of which describes the developmental
Table 4 Age-sex structure changes (1992–2015)

Children (below 15
years) Adults (15–59 years) Old aged (60+ years)
States Male Female Total Male Female Total Male Female Total
1992
Bahrain 28.1 36.8 31.9 68.4 59.1 64.3 3.6 4.1 3.8
Kuwait 33.0 40.4 36.2 64.2 56.9 61.0 2.9 2.7 2.6
Oman 36.4 49.1 41.7 60.3 46.9 54.9 3.1 3.8 3.4
Qatar 22.4 40.9 28.6 75.9 57.1 69.5 1.9 2.0 2.0
Saudi 38.8 47.5 42.6 57.1 48.7 53.4 4.1 3.7 3.9
Arabia
UAE 22.4 42.3 29.0 76.1 56.4 69.5 1.5 1.4 1.5
Total 36.0 46.5 40.5 60.4 49.9 55.9 3.6 3.6 3.6
2002
Bahrain 24.1 31.4 27.3 72.2 63.6 68.6 3.6 4.9 4.2
Kuwait 24.0 32.2 27.4 73.4 64.9 69.9 2.5 3.0 2.7
Oman 33.2 41.0 36.6 63.2 55.1 59.6 3.7 4.1 3.8
Qatar 18.4 34.4 23.8 79.3 63.3 73.7 2.4 2.2 2.4
Saudi 33.2 40.2 36.2 63.1 55.9 59.8 3.7 3.9 3.9
Arabia
UAE 16.6 34.2 22.2 81.7 64.4 76.3 1.7 1.5 1.6
Total 29.8 38.9 33.6 66.8 57.4 62.8 3.4 3.7 3.5
2012
Bahrain 17.0 25.3 20.2 79.1 69.4 75.5 3.8 5.0 4.3
Kuwait 22.7 29.9 25.8 74.0 65.8 70.7 3.2 4.3 3.7
Oman 28.9 33.3 30.8 66.6 61.5 64.4 4.5 5.3 4.8
Qatar 8.3 26.5 12.6 90.0 71.2 85.6 1.6 2.5 1.7
Saudi 27.0 31.0 28.8 68.4 64.0 66.5 4.6 4.8 4.7
Arabia
UAE 15.3 31.9 20.5 82.9 66.0 77.6 2.0 1.9 1.9
Total 23.5 30.9 26.6 72.6 64.5 69.2 3.8 4.5 4.1
2015
Bahrain 16.3 24.3 19.5 79.1 70.1 75.5 4.6 5.6 5.0
Kuwait 22.5 29.3 25.3 74.0 65.7 70.5 3.5 5.0 4.1
Oman 28.4 32.4 30.2 66.9 62.1 64.7 4.7 5.5 5.1
Qatar 8.2 27.1 12.5 89.9 70.2 85.4 1.9 2.7 2.1
Saudi 25.5 28.9 27.1 69.5 65.6 67.8 5.0 5.4 5.2
Arabia
UAE 15.6 32.4 20.9 82.4 65.5 77.0 2.1 2.1 2.1
Total 22.5 29.4 25.4 73.4 65.6 70.1 4.2 5.0 4.5
stage and the demographic transition, thereby facilitating formation of public health
and medical intervention strategies. For example, the Arabian Gulf age pyramid was
of an expansive shape in 1992 with a little variation in the percent of males of age
between 20 and 45 years. That is, an effect of labor immigrations has started prior to
692 A. A. Salam
this period. Changes in the pyramid along the periods (1992, 2002, 2012, 2015) are
not vivid in this geographic region, which might be due to the immigrations that
replace the working age population. There is an absolute size of working age
population retained through labor importations. This keeps the age structure intact
throughout the period. Therefore, only an examination of the native population shall
reveal the dynamics of demographic transition and age structure (Fig. 3).
Age pyramid showed some change, though little, in 2002 that there was some
decline in percentage of children and subsequent years but a slight increase in the
older ages. Age pyramid lost its expansive shape in 2012, shrinking at its base and
expanding at subsequent ages. There was an expansion at the top of the age pyramid
as well (ageing of population). Age pyramids show an unexplained trend. It was due
to the foreign labor force, majority of whom were of adult males. This complicates
their pyramids for interpretations and understanding.
Sex Ratio
Sex ratio, defined as males per 100 females, appeared favoring males (138). Sex ratio
kept on increasing but at a slower pace (Table 5). A faster increase was noted in
Qatar from 194 in 1992 to 196 in 2002 to 329 in 2012 and in UAE from 199 to 215 to
219. But that of Oman declined during this period from 141 in 1992 to 129 in 2002 to
122 in 2012. The major reason behind this male excess in the population is
employment-oriented immigration from South Asia and Africa.
Fig. 3 Age structure of the Arabian Gulf. (Source of data: U.S. Department of Commerce,
International Database of US Census Bureau accessed in 2012 and 2015)
Table 5 Sex ratio of population

States 0–14 15–59 60+ Total
1992
Bahrain 103 156 114 135
Kuwait 105 145 137 128
Oman 104 181 111 141
Qatar 106 257 183 194
Saudi Arabia 104 149 136 127
UAE 105 269 200 199
Total 104 163 136 134
2002
Bahrain 103 154 101 135
Kuwait 108 163 129 145
Oman 105 149 115 129
Qatar 104 245 202 196
Saudi Arabia 105 144 123 127
UAE 105 273 243 215
Total 105 160 127 137
2012
Bahrain 103 175 117 154
Kuwait 108 160 108 143
Oman 105 132 105 122
Qatar 103 417 220 329
Saudi Arabia 105 129 112 121
UAE 105 275 225 219
Total 105 156 117 138
2015
Bahrain 103 181 127 154
Kuwait 108 165 101 141
Oman 105 133 101 120
Qatar 103 463 232 339
Saudi Arabia 105 130 110 119
UAE 105 294 211 218
Total 105 161 115 138
Reflections of Age Composition
Age composition serves as guide to social policies and programs, influencing public
health as most of them depend largely upon statistically derived indices of popula-
tion characteristics (Table 6). These indices are calculated by taking population of
specific age as the denominator.
694
Table 6 Age-based indices for GCC population

Child-woman ratio Aged-child ratio Median age Age dependency ratio
GCC Male Female Total Male Female Total Male Female Total Male Female Total
1992
Bahrain 262.3 251.9 514.2 12.6 11.4 12.0 27.3 21.8 25.1 5.2 7.1 5.9
Kuwait 282.3 271.3 553.6 8.7 6.6 7.7 26.1 19.7 23.0 4.5 4.7 4.6
Oman 435.9 416.9 852.8 8.5 8.0 8.3 24.1 15.4 19.7 5.1 8.4 6.3
Qatar 315.1 297.7 612.8 8.7 5.0 6.9 31.1 20.6 28.6 2.6 3.6 2.8
Saudi Arabia 414.1 397.7 811.9 10.6 8.1 9.3 22.1 16.2 19.2 7.2 7.9 7.5
UAE 348.2 334.6 682.9 6.8 3.5 5.2 31.7 19.9 28.0 2.0 2.7 2.2
Total 395.5 379.6 775.1 10.1 7.7 8.9 24.2 16.8 20.7 6.0 7.2 6.4
2002
Bahrain 197.2 191.9 389.1 15.3 15.7 15.5 29.6 25.2 27.8 5.1 7.8 6.1
Kuwait 213.6 199.6 413.3 10.6 8.9 9.8 28.4 24.7 27.4 3.5 4.4 3.8
Oman 288.0 274.4 562.5 11.1 10.1 10.6 23.4 18.8 21.3 5.9 7.5 6.5
Qatar 210.9 203.0 414.0 12.8 6.6 9.8 32.6 24.1 30.3 3.0 3.6 3.2
Saudi Arabia 275.8 264.9 540.7 11.6 9.9 10.8 23.7 19.4 21.8 6.1 7.1 6.5
UAE 210.4 201.8 412.3 10.4 4.5 7.5 31.7 23.6 29.6 2.1 2.4 2.2
Total 262.8 251.8 514.6 11.5 9.5 10.5 26.0 20.1 23.6 5.1 6.5 5.6
A. A. Salam
29
2012
Bahrain 144.4 141.1 285.5 22.9 20.2 21.6 32.5 28.3 31.1 4.9 7.3 5.8
Kuwait 215.5 200.9 416.4 14.3 14.4 14.4 29.9 26.4 28.6 4.4 6.5 5.2
Oman 222.1 211.6 433.8 15.6 15.6 15.6 25.7 22.8 24.4 6.7 8.5 7.5
Qatar 161.5 157.2 318.7 19.9 9.3 14.7 33.2 27.8 32.2 1.8 3.5 2.2
Saudi Arabia 182.7 175.2 357.8 16.8 15.8 16.3 26.7 24.4 25.7 6.6 7.6 7.1
UAE 210.7 201.8 412.4 12.9 6.0 9.5 32.1 25.0 30.2 2.4 2.9 2.5
Total 188.9 180.8 369.8 16.4 14.7 15.5 28.7 24.6 27.1 5.3 7.0 6.0
2015
Bahrain 139.5 136.1 275.6 28.1 22.9 25.5 33.2 29.0 31.8 5.8 8.0 6.6
Kuwait 206.4 192.4 398.9 15.8 17.0 16.3 30.2 27.0 29.0 4.8 7.6 5.9
Oman 224.4 213.9 438.3 16.4 17.1 16.7 26.3 23.7 25.1 7.0 8.9 7.8
Qatar 162.5 158.6 321.1 22.6 10.0 16.4 33.9 27.9 32.8 2.1 3.9 2.4
Saudi Arabia 172.0 164.9 336.9 19.5 18.7 19.1 27.6 25.8 26.8 7.2 8.3 7.6
UAE 211.2 202.2 413.4 13.3 6.6 10.1 32.2 25.0 30.3 2.5 3.3 2.7
Total 181.1 173.3 354.4 18.6 17.0 17.8 29.4 25.8 28.0 5.7 7.6 6.5
Source of data: International Database of US Census Bureau accessed in 2012 and 2015
Health Impact of Demographic Changes in the Gulf States
695
696 A. A. Salam
(a) Child-woman ratio, the number of children below 5 years of age per 1000
women of age 15–49 years was calculated separately for male and female
children. This being an indirect indication of fertility shows a marked decline
in the 1992–2002 period from 775.1 to 514.6. The decline during 2002–2012
was comparatively lower – from 514.6 to 369.8. This indicates not only of
reductions in the number of children in the population leads to shrinking of
age structures. A higher decline in the number of male than that of female
children was observed between the period of 1992–2002 and 2002–2012.
There were unnoticed countrywide differentials. Within the countries, the
child-woman ratio declined further from a high of 775.1 in 1992 to 514.6 in
2002 to a low of 369.8 in 2012, with an equal decline for both males and
females. The child-woman ratio was found to be the lowest in Bahrain during
all the periods followed by Kuwait, Qatar, and UAE in 1992; the order was
UAE, Kuwait, and Qatar in 2002 and Qatar, Saudi Arabia, and UAE in 2012.
Declines of both males and females were found to be equal during these
periods.
(b) Aged-child ratio, the number of persons aged 60 years and above to 100
children of age below 15 years indicates the two sides of the age structure –
bottom and top. A visible increasing trend indicates that the number of people
aged 60 years and above has increased over time. The 8.9% during 1992
increased to 10.5 in 2002 and 15.5 in 2012. There was a steady increase of
this ratio between 1992–2002 and 2002–2012. It has increased to 17.8 in 2015.
The change was higher among the females than males indicating that older
males increased slower than older females, although with countrywide varia-
tions: Bahrain standing on one side while UAE on the other. The aged-child
ratio was found to be lower but with a faster increase from a low of 8.9 in 1992
to 10.5 in 2002 to 15.5 in 2012. The highest ratio was noted in Bahrain over
all the periods, which was followed by Saudi Arabia and Oman. Except UAE,
all the countries had a higher ratio during 2012 with negligible male-female
difference.
(c) Median age, the average age of the population shows not only the fertility
and mortality situation but also the population and development. Arabian
Gulf countries’ median age has raised from 20.7 years in 1992 to 23.6 years
in 2002 to 27.1 in 2012 and to 28.0 in 2015. Males have higher median age
than females, throughout the period in all the six countries. Qatar had the
highest median age among the countries, during all the periods, followed
by UAE.
(d) Age dependency ratio, the percent of old aged (60 years and above) to the
working age people (15–59 years) reflects the burden of social welfare and
public benefit programs in a particular population. There was a higher ratio in
the Arabian Gulf, which varied during the period: a decline in 1992–2002 but an
increase in 2002–2012. Age dependency ratio was lower: it remained almost
equal in all the three periods around 6.0. Saudi Arabia had the highest age
dependency ratio, followed by Oman, for all the periods.
Conclusions and Implications
The Arabian Gulf countries (namely, Bahrain, Kuwait, Qatar, Oman, Saudi Arabia,
and UAE) form the Gulf Cooperation Council and have a strong oil-based economy.
They are the key decision-makers of the Arab nations and are widely accepted as
employment providers for low-income Asian and African countries. Their strong
rooted traditions, customs, and religious practices restrict acceptance of modern values
and lifestyles. But with the increasing number of Western-educated and multi-cultured,
technology-savvy people in the region (both natives and immigrants), the values are
changing toward an openness to modernization and modern lifestyle.
Such changes in values and lifestyles influenced the demographics and the values
of children leading to declining fertility preferences and better control of infectious
diseases. This effort to create to build a healthier generation results from utilizing
technologies in education, health, and employment. In turn, it influences the size,
structure, characteristics, and distribution of the population. As such, the fertility
indicators suggest a rapidly declining trend, in these countries. Such, rapid declines
in the demographic rates influenced not only the future of population dynamics but
also have implications on health services planning and policies. That is, a rapid
decline in demographic rates demanded changes in health priorities and also health
services administration. For example, national health systems in the Arabian Gulf
countries have started to address these demographic changes, especially of the public
health sector that caters to the native population.
The region has historically attracted large numbers of foreign workers. But their huge
numbers have exaggerated socioeconomic and demographic issues show inequities and
imbalances in the distribution of resources and infrastructure. This is a dilemma faced not
only by these countries but also by social scientists and demographers and their needs to
be addressed in the coming censuses and national-level surveys.
The collection, compilation, derivation, and dissemination of statistical data in the
Arabian Gulf need concerted efforts by national and international agencies,
concerned research professionals, policy makers, and activists. In addition, there is
a need to build reliable statistical data reflecting public health and demographics; this
is needed for better management of social and healthcare programs. Such efforts will
help to bridge the gap between the population groups such as male-female, native-
expatriate, Arab-non-Arab, salaried-business, and urban-rural.
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Communicable and Noncommunicable
Diseases in Conflict Zones 30
M. Daniel Flecknoe, Mohammed Jawad, Samia Latif, and
Bayad Nozad
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 700
Recommendation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 702
Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 703
Communicable Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 704
Noncommunicable Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 706
Protection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 708
Communicable Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 708
Noncommunicable Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 711
Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 713
Post-Conflict Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 717
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 719
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 721
M. D. Flecknoe (*)
Derby Teaching Hospitals NHS Foundation Trust, Derby, UK
University of Sheffield, Sheffield, UK
Médecins Sans Frontières, London, UK
e-mail: daniel.flecknoe@nhs.net
M. Jawad
e-mail: mohammed.jawad06@imperial.ac.uk

https://doi.org/10.1007/978-3-030-36811-1_33
700 M. D. Flecknoe et al.
Abstract
Modern armed conflict represents a significant risk to global health. This risk is
partly inherent in the use of mass violence to advance political goals but also
arises in large part from the contemporary trend of warring parties failing in their
duty to abide by International Humanitarian Law. The deliberate targeting (or
negligent destruction) of civilian and health infrastructure, the endangerment of
health workers, and the subjection of a civilian population to starvation, unnec-
essary forced displacement, and other cruelties are war crimes which should not
be normalized. As well as the direct toll of morbidity and mortality that they bring
in the form of short-term injuries and deaths, these actions dramatically increase
the risk of communicable and noncommunicable disease incidence and simulta-
neously reduce the ability of a society to prevent and control such risks. Armed
conflict degrades the capacity of health systems to gather vital data and plan
effectively for future emergencies, and all of these impacts can persist long after
the guns have fallen silent. A fuller understanding of the many and various ways
in which warfare affects public health (in the separate but linked senses of the
professional discipline and the collective health and well-being of the public)
would be highly beneficial to international policy-makers, humanitarian workers,
and health professionals of whatever background who work (or are planning to
work) in or near conflict zones.
Keywords
Armed conflict · War/warfare · Public health · Communicable disease ·
Prevention · Protection · Planning · Post-conflict · Vaccination · Humanitarian
Introduction
Warfare is an integral component of human history. With relatively few exceptions, it

is responsible for the formation of our national borders and is also the means by
which nation-states defend those borders. It is the greatest existential threat to
S. Latif
e-mail: Samia.Latif@phe.gov.uk
B. Nozad
e-mail: bayad.nozad@nhs.net
30 Communicable and Noncommunicable Diseases in Conflict Zones 701
humanity (especially since the development of nuclear weapons) and yet also the
catalyst for much of our most inspiring art, most admired historical figures, and most
advanced lifesaving technology. It is an effective tool of hegemonic oppression,
massively impoverishing the countries in which it is fought while simultaneously
enriching those who facilitate it by manufacturing and supplying the necessary
armaments. It perpetuates itself through intergenerational cycles, as the prior aggres-
sions of our neighbors are generally felt to justify those which are perpetrated against
their descendants. It transforms sons, brothers, and husbands into heroic martyrs,
trading their lives for a transient immortality which only serves to further sanctify the
conflict in the eyes of many and generally forgetting the names of all the women and
children who died along the way. It shatters, bankrupts, displaces, poisons, trauma-
tizes, and embitters whole societies, and yet many leaders still continue to see it as a
legitimate tool of politics and statecraft.
The boundaries of the modern “Middle East” were created in the ruins of World
War I, as the soon-to-be victorious allies privately divided up the spoils of the
disintegrating Ottoman Empire. The repercussions of those century-old decisions
still materially affect the lives of millions. In recent years this influence has been felt
most strongly through the reactionary violence of the Islamic State (or “Daesh”),
whose ambition has been to create a region-spanning caliphate which forever
dismantles the boundaries created by the Sykes-Picot Agreement. However,
although attention is inevitably drawn to those deaths which are the direct result of
violence, it should not be forgotten that armed conflict has also killed many millions
of people who never came anywhere near the front lines. For example, the same
global war which birthed today’s Middle East also gave rise to a global outbreak of
communicable disease, the “Spanish flu” pandemic, which killed more people
worldwide (50–100 million by most recent estimates) than died in all the battles of
1914–1918 (Flecknoe et al. 2018). The mechanisms by which conflict can lead to
outbreaks of communicable disease, as well as exceedances of noncommunicable
diseases, and how these can be prevented and/or controlled, will be the primary
focus of this chapter. Recommendations, both individual and societal, for improving
the health status of civilian populations in conflict zones will also be discussed.
“Armed conflict” and “warfare,” terms that from here onward will be used
interchangeably, exist on a spectrum of human violence from the interpersonal
(i.e., assault) to the group level (i.e., gang violence) all the way up to sustained
multination hostilities (i.e., a world war). Every level on this continuum of dishar-
mony carries the potential for both direct and indirect health consequences. For
example, a violent mugging will often cause physical cuts and bruises, which may be
the most obvious effects of the encounter from an outside perspective. However, the
mental health impacts of a traumatic and disempowering experience can be far
slower to heal and are likely to exert a significant negative effect on the victim’s
professional and personal life. Similarly, a war (usually defined as an outbreak of
organized mass violence leading to 1,000 or more battle-related deaths within one
calendar year) invariably has long-lasting indirect impacts as well as its more
immediately obvious ones. This is true for international conflicts involving two or
more opposing nation-states and, for civil wars, fought either between the
government military and nongovernmental armed groups or sometimes entirely

between such non-state actors (ICRC 2008; Pettersson and Wallensteen 2015).
Although the direct health impacts of a legally conducted war can be severe
enough, it is important to notice that many of the most serious public health impacts
of armed conflict are actually caused by war crimes. International Humanitarian Law
(IHL) places an obligation upon armed groups to not target civilian noncombatants
nor to either target or impede health professionals in their duties (ICRC 1949). If the
rules of war were adhered to by all sides in modern conflicts, then a significant
proportion of the public health impacts described within this chapter would not exist.
In this sense, IHL functions as a classic “harm reduction” tool – limiting the excess
damage that would otherwise be caused by an inherently health-risking behavior.
The authors have no wish to normalize the distressing trend of warring parties
disregarding these established rules. While denying vital imports of food and
supplies, bombing public health infrastructure (such as water treatment plants,
hospitals, and nonmilitary industries) and targeting medical first responders within
an “enemy” population may be considered to be a good strategic way of weakening
that population; it is also an unequivocal violation of both law and decency. The
authors will continue to refer to “war” as it is currently fought but encourage
the reader to bear in mind how much of a departure from established norms is the
prevailing state of affairs. We strongly advocate for universal compliance with
International Humanitarian Law as the most rapid and effective way of improving
public health within conflict zones.
Recommendation
• Universal compliance with International Humanitarian Law could be the single

most effective public health intervention for populations in conflict-affected
areas, if it could be achieved. Citizens of nonauthoritarian countries should
therefore use their democratic influence to advocate for the re-establishment of
international deterrence against war crimes and the prosecution of individuals or
governments (regardless of nationality) who deliberately target civilian
populations, health workers, or public health infrastructure.
Another point of terminology that is worth clarifying at the outset relates to the
dichotomous connotations of the term “security” within this subject area. When that
word is used in this chapter, it will be intended in the original sense of the Latin “se”
and “cura,” meaning “free from care or anxiety.” Reference may be made to “food
security” and “water security,” meaning a desirable state, from a public health and
human rights perspective, in which these essentials of daily living can be easily
obtained by the population. And yet in another meaning of the term, “security” has
often been used as the justification for military investment and interventions which
directly threaten the health and security (in the sense we mean) of millions.
Acknowledging the paradox of these divergent connotations, the authors feel obli-
gated, as public health professionals, to champion the former meaning of the term
and to insist that as far as humanly possible military objectives should never come at
the expense of population health. The ancient Roman historian Tacitus scathingly
described the brutal battle tactics of a particular enemy chieftain as being akin to
“creating a wasteland” and then “calling it peace” (Tacitus 1872, p. 372). Although
this example no doubt would have been counted by some as a great military victory,
it represents the polar opposite meaning of human “security” from the one that the
authors would advocate.
There is a great deal of overlap between the various impacts of conflict upon
public health. Forced displacement, for example, adversely affects the food and
water security of a population, makes them more vulnerable to communicable
diseases in overcrowded camps, exerts a detrimental effect on their mental health,
distances them from familiar health service providers for any chronic conditions they
may have, and weakens their resilience against future disasters. Displacement
therefore spans quite a wide range of public health topics and is difficult to discuss
within any one single category. However, at the risk of some slight repetition, it was
felt best to provide a categorical structure for this chapter, and an adapted version of
the “3 Ps” framework was eventually chosen. We will begin by examining issues
relating to the “prevention” of disease and then move on to discuss the “protection”
of populations against existing ones. These categories can encompass both commu-
nicable and noncommunicable diseases in different but often complimentary ways.
Next we will review the way that armed conflict affects health service “planning”
and finish with a crosscutting discussion of public health considerations in “post-
conflict” settings. It is hoped that this will provide a helpful framework for readers to
locate their particular topics of interest, if you happen to prefer not to read the chapter
from beginning to end.
Prevention
Preventative medicine is the most cost-effective and arguably the most essential
form of healthcare. Not only is the prevention of a communicable disease outbreak
or exceedance of noncommunicable disease a huge benefit in terms of the financial
cost of treatment, it also represents a net reduction in human suffering, due to all of
the associated intangible costs (mental health, family stability, etc.) that are thereby
averted. Like public health infrastructure, preventative medicine is easy to take for
granted, since it tends to only come to the attention of policy-makers when it fails.
The successful prevention of negative health outcomes is also very difficult to ever
conclusively demonstrate, which makes this type of intervention relatively unap-
pealing to leaders who prefer having a list of tangible results to cite for any particular
service or policy. And yet for all of its seemingly insubstantial and elusive aspects,
high-quality preventative medicine for a large population is technically challenging
to deliver, requiring good data collection, well-trained staff, and functional health
infrastructure. These vital building blocks of prevention can all be disrupted or
destroyed by warfare.
Although, as already mentioned, direct attacks on healthcare professionals and

services are radically discordant with the International Humanitarian Law, they are
also sadly not uncommon and exert the (presumably) intended effect. Whether
through injury, death or simply the intolerable risk of either outcome causing health
professionals to leave the conflict zone, civilian populations in such areas are
frequently left without significant protection against disease outbreaks. Health
surveillance largely ceases, and the preventative efforts which would usually help
to shield the populace from disease become far less effective. This dynamics cuts
across all of the four Ps (prevention, protection, planning, and post-conflict) which
make up the framework of this chapter and amounts to the indirect use of disease
as a weapon of war. Although the general insufficiency of health workers in conflict
zones will be touched upon again below, it should be borne in mind by the reader as a
relative constant within this subject area. Modern conflict zones, largely as a result of
the conduct of local armed groups, are frequently unsafe places for health pro-
fessionals, and civilian populations suffer from a disastrous lack of medical assis-
tance as a result (Fouad et al. 2017).
Communicable Disease
The prevention of communicable disease is a multifaceted endeavor, which depends

upon significant local infrastructure, human resources, and training in order to be
effective. It is also made considerably more difficult when the population is
displaced from their familiar environment, confined in overcrowded camps, mal-
nourished, and denied access to safe drinking water or sanitary facilities. Displaced
persons’ camps, as mentioned above, are ideal breeding grounds for outbreaks of
water- and foodborne diseases such as cholera, dysentery, hepatitis A and E, and
leptospirosis, not to mention measles, malaria, tuberculosis, meningococcal disease,
and influenza. As armed conflicts (and the global population in general) have
become more and more urban over recent decades, many cities in and adjacent to
conflict zones have also become breeding grounds for the sort of disease outbreaks
previously characteristic of refugee camps (Spiegel et al. 2010). Many of these
diseases are easily preventable, either by vaccination or other basic public health
measures, so their disproportionate prevalence in populations displaced by armed
conflict is indicative of their root cause. Full prevention and control of communica-
ble disease is effectively deliverable only by well-resourced local and national
partnerships of the sort that modern warfare frequently makes virtually impossible
(WHO 2014).
Communicable diseases can spread through a variety of pathways – airborne,
food- or waterborne, blood-borne, or transmitted by zoonotic vectors (such as
mosquitos or fleas). Preventing the spread of such diseases entails containing or
eliminating their source, interrupting the pathway of transmission, and protecting the
vulnerable potential receptor. This inevitably requires reliable data on local sources
of disease, a clear understanding of the relevant transmission pathways, and up-to-
date intelligence on the population at risk, including vaccination status and other
indicators of receptivity. This explains why the gathering of health surveillance data
is such a vital tool for the prevention of and early response to infectious disease
outbreaks. Whether through a lack of available staff or general insecurity, the
disruption of surveillance systems inevitably leads to delays in recognizing and
responding to spikes in infectious disease incidence, preventing adequate control
measures from being implemented.
In areas with very poor baseline levels of health infrastructure, it is possible that
the influx of medical nongovernmental organizations (NGOs) which can accompany
the outbreak of war could actually increase local health surveillance capacity.
However, this hopeful possibility is modified by the degree to which those NGOs
are able to operate freely in such a high-security context. Ismail et al. describe the
challenges of implementing communicable disease surveillance during the Syrian
conflict. These difficulties have been largely related to population displacement,
insecurity, and attacks on healthcare workers leading to a loss of trained staff and
equipment necessary to maintain effective monitoring systems throughout the coun-
try (Ismail et al. 2016). The sort of data collection that informs good epidemiological
surveys can often be mistaken for malicious intelligence gathering by both military
actors and by the population themselves. However, in the absence of such data,
prompt and effective public health action against emerging communicable disease
threats cannot be taken.
Recommendation
• Effective data collection is essential to public health prevention efforts which can
avert communicable disease outbreaks that have the potential to cause massive
loss of life. Although not an immediately obvious infraction of international law,
the prevention by warring parties of nonmilitary civilian health data collection
should be considered an indirect crime against humanity on this basis.
Vaccination is one of the most powerful and cost-effective prevention strategies

for communicable diseases that have so far been discovered. However, vaccination
rates tend to fall rapidly in conflict zones as levels of access to the population and
safety for health workers decrease. Other factors, including the aforementioned
dearth of trained health professionals, the destruction and looting of healthcare
facilities, cold chain failure due to interruptions in the power supply, and a lack of
trust in medical NGOs, also exert a negative effect. Violations of medical neutrality
by all sides contribute to this atmosphere of mistrust. For example, the Taliban are
known to have frequently targeted vaccination workers (which helps to explain why
polio and other vaccine-preventable diseases are rife in Afghanistan and parts of
Pakistan), but this indefensible behavior is hard to disentangle from the fact that
when US special forces were hunting for Osama bin Laden in Northern Pakistan,
they sometimes disguised themselves as vaccination workers (Scientific American
2013). Any infringements of the inviolability of medical staff in conflict zones,
whether aggressive or covert, can have severe consequences for the credibility and
safety of genuine health professionals in that area. And those consequences fall most
heavily on the civilian population, especially when a reduction in vaccine coverage
leads to a reduction in the herd immunity which would otherwise protect against the
re-emergence of vaccine-preventable diseases.
In Syria, the proportion of children immunized against major vaccine-preventable
diseases (polio, diphtheria, pertussis, and tetanus) declined from 80% in pre-conflict
2010 to only 41% in 2015 (Nnadi et al. 2017). In Yemen, a lack of herd immunity
(among many other factors) caused by low vaccination rates has led to a number of
large outbreaks of vaccine-preventable diseases since the conflict there began. The
huge cholera epidemic is the best-known of these, but in 2017 the WHO in Yemen
also declared an outbreak of diphtheria, with a total of 333 suspected cases including
35 deaths (case fatality ratio = 10.5%) reported from 20 governorates. A lack of
available laboratory testing capacity forced clinicians to rely on clinical diagnosis of
this outbreak, creating a further barrier to effective assessment and control of the
disease (WHO 2017a).
Once again, in an effort to avoid the normalization of war crimes, it is worth
noting that humanitarian ceasefires have often been negotiated in the past in order to
allow vital vaccination campaigns, food distribution, and other public health inter-
ventions to proceed unhindered (WHO 2018a). War is not an inevitable obstacle to
full vaccination coverage and should not be treated as such merely due to a
contemporary trend of military and/or political leaders disregarding the continued
health of local civilian populations at the expense of military objectives.
Recommendation
• Violations of medical neutrality (which include combatants posing as health
workers, as well as deliberately targeting them) should be condemned and,
where possible, punished by the international community. Warring parties who
oppose or obstruct humanitarian ceasefires to allow preventative public health
interventions (such as vaccination campaigns) to be safely delivered in conflict
zones should face sanctions and/or prosecution.
Noncommunicable Disease
The Arab world contains the full spectrum of economic development and includes
many middle-income countries which have undergone the epidemiological transition
from infectious disease to chronic lifestyle-related disease prevalence. When hostil-
ities break out in such countries, the health impacts of war occur in a context of
relatively high risk for hypertension, heart disease, diabetes, and other conditions
associated with longer life expectancy. However, the prevention of such non-
communicable diseases in conflict zones is equally handicapped by the prevailing
conditions of war. Lifestyle-related disease prevention requires good-quality public
health data systems, culturally appropriate behavior change strategies, and locally
tailored community engagement in order to be successful. Healthy eating or smoking
cessation campaigns in peaceful and prosperous nations may be held up as good
examples of how this kind of work can be effective in the absence of armed conflict.
However, although they are less technologically dependent, health promotion
interventions designed to prevent noncommunicable diseases are no less affected by

armed conflict than are vaccination campaigns. The safety and training of local
health professionals remain a primary concern. In the absence of good faith guaran-
tees from warring parties regarding medical neutrality, NGOs and other international
health sector actors are unlikely to risk intervening. And there are numerous other
factors that make noncommunicable diseases a particularly significant risk for
conflict-affected populations.
Regardless of their level of health literacy, populations subjected to high and
chronic stress levels (whether through displacement or exposure to physical danger)
are disproportionately likely to engage in behaviors linked to noncommunicable
diseases. Increased rates of tobacco smoking, alcohol and drug use, and other risk
factors for a wide range of chronic diseases are all reliably found in such populations
(Forouzanfar et al. 2015; Jawad et al. 2019). Armed conflict also reduces access to
routine medical care, whether through displacement or insecurity or the economic
hardships (in countries without free-at-the-point-of-access healthcare systems)
caused by either of the previously mentioned factors, so that the prevention or
early detection capacity for noncommunicable diseases is invariably reduced.
Although such links are difficult to prove, some types of battlefield tactics may
also exert a negative long-term impact on noncommunicable disease levels within a
population. For example, the relatively high incidence of some cancers and respira-
tory problems in parts of Iraq may well be linked to the use of chemical weapons
during the Iran-Iraq War and/or the burning of the Kuwaiti oil fields and use of
depleted uranium munitions during the first Gulf War. Full investigation of these
possible health impacts of earlier conflicts is made more difficult by ongoing
violence and insecurity in the country.
Physical injuries, more likely to occur in conflict zones, often impose a financial
burden upon struggling families but also create a psychological one, as can chronic
stress. Mental health problems arguably sit somewhere in between the communicable
and noncommunicable disease categories, since although they are not “infectious” in
the sense that influenza or HIV is, they can definitely be contagious. Unacknowledged
and untreated emotional/psychological consequences of severe trauma may manifest
themselves in behavior which creates a secondary cycle of victimization (and attendant
psychological consequences) for family members and especially for children. In
cultures where there is significant mental health stigma acting as a barrier to anyone
who might want or need to come forward for help, this risk of intergenerational cycles
of traumatization is particularly high (WHO 2008). Prevention of mental health
problems in conflict zones therefore necessarily overlaps with the topic of protection,
which will be discussed in greater detail in the following section.
Recommendation
• The causal pathways between armed conflict and noncommunicable disease risk
are likely to be complex and multifactorial, almost certainly driven by underlying
stress responses, disruptions to healthcare provision, malnutrition, and physical
inactivity. Further research into this pathway would be helpful to guide future
interventions in this area.
Protection
The logistics of health protection (i.e., keeping the population safe from existing
sources of disease, injury, and premature death) are hampered by armed conflict in a
very similar way to those of prevention. A dearth of health professionals may be
caused by a combination of preexisting scarcity (countries impoverished by war tend
not to invest in institutes of higher education, such as nursing and medical schools)
and an exodus of those who were qualified due to the insecurity caused by illegal
actions by the warring parties. Whatever the cause, the human resource conse-
quences are a significant handicap to any health protection activities. Restricted
availability of other physical resources can also be an important contributor to poor
health outcomes. The availability of food and medical supplies may be reduced by
economic sanctions or blockades, such as has been the case in Yemen over recent
years. This enforced poverty has impacts which cut across communicable and
noncommunicable disease control, since malnutrition exacerbates the severity and
fatality rates of many diseases, while a lack of medical supplies prevents effective
treatment from being administered (MSF 1997; Lowcock 2018). The civil war in
Yemen, the airstrikes, and external blockades which have accompanied it are a
necessary root cause of the country’s 2017–2018 cholera epidemic – the largest in
recorded history – which infected more than a million people (Camacho et al. 2018;
Flecknoe et al. 2018).
Recommendation
• Sanctions or blockades which restrict the availability of food or medical supplies
to conflict-affected civilian populations should be considered a war crime and
opposed on humanitarian grounds.
Communicable Disease
Effectively controlling outbreaks of communicable disease requires a number of

processes to be in place and functional: firstly, the gathering of reliable information
about confirmed cases, which insecurity and inadequate staffing make much harder
to obtain; secondly, swift and effective treatment of those cases to prevent transmis-
sion of the disease to others; thirdly, the interruption of transmission pathways,
whether these are person-to-person, via contaminated water supplies, or zoonotic
vectors (all of these interventions require a functional public health infrastructure);
and finally, the protection of vulnerable receptors (in the case of vaccine-preventable
diseases) can be most easily accomplished through widespread targeted vaccination
campaigns, which require significant demographic data, organization, and freedom
of movement to accomplish. It should be apparent that every step of this process can
be hindered or made completely impossible by active conflict in the area. On top of
the increased susceptibility to communicable diseases caused by malnutrition (in
besieged and blockaded locations) and overcrowding (in displaced persons camps),
this makes conflict-affected populations almost uniquely at risk of communicable

disease outbreaks.
Vaccination and antibiotics are both, in their own ways, the paradoxical offspring
of war. Progress toward effective mass vaccination campaigns has been inextricably
linked with armed conflict, as military leaders realized that here was the best way to
keep their troops fighting fit for battle. George Washington famously vaccinated his
soldiers against smallpox, thus contributing to his victory in the American Civil War,
and the first influenza vaccine was developed for use by the US army during World
War II. Similarly, Alexander Fleming first stumbled upon penicillin during the wave
of post-World War I influenza experiments motivated by the “Spanish flu” pandemic
which wartime conditions so successfully spread around the world (Dehner 2012).
It is tragically ironic that the human activity – war – which was so much of an
inadvertent catalyst for both of these lifesaving discoveries is also a major obstacle to
their effective use in the present day. The negative impact of armed conflict upon
vaccination campaigns (which can be potent tools of both prevention and protection)
has already been remarked upon. The negative impact of armed conflict upon
antibiotic use, not only within the conflict zone itself but also globally, requires
further explanation.
Armed conflict frequently contributes, via factors already mentioned, to a lack of
effective drug stewardship. Improper antibiotic prescribing, exacerbated by medica-
tion shortages and a lack of trained staff, has been shown to increase the prevalence
of antimicrobial resistance. On top of this, population movements leading to reduced
treatment compliance, the use of expired pharmacy stock, the destruction or looting
of healthcare facilities, and the free availability of drugs in an unregulated market-
place all help to create a melting pot for the generation of antibiotic-resistant
organisms (Gayer et al. 2007; Abbara et al. 2018). This is one of the several
examples where local armed conflict can have international implications.
Communicable diseases are no respecter of borders, and that very much includes
newly multidrug-resistant organisms which can threaten the efficacy of routine
treatment regimens in far distant countries.
New pandemic diseases are only ever a single genetic mutation away, and armed
conflict often leads to the mingling of previously immunologically isolated
populations, the obscuring of data, and the destruction of protective health and
risk identification systems. Syndromic early warning response systems have the
potential to fill some of the gaps created by conflict, especially in resource-poor
areas where laboratory diagnostic confirmation is a scarce commodity. However,
a lack of reliable data is crippling to effective health protection interventions.
Modern war zones are therefore extremely high-risk areas for the emergence of
novel communicable diseases, and the inevitable delays in identification and control
caused by the chaos of war make it very possible that such an epidemic could
successfully metastasize and spread (Ismail et al. 2016). Ensuring that national and
local surveillance systems remain flexible and responsive during times of crises
should be highlighted as a key priority, as demonstrated during a large outbreak of
dengue fever in the Solomon Islands in 2016–2017 (Craig et al. 2018).
Recommendation
• Modern war zones are high-risk areas for the spread of potential future pandemic
diseases, but local surveillance systems are usually inadequate for the purpose of
catching such outbreaks early. Syndromic early warning systems, and other
potential means of mitigating this global threat, should be high-priority research
areas.
Global health partnerships such as the World Health Organization (WHO) have
an important role to play in implementing a coordinated public health response in
conflict zones. But these responses are often hampered by parochial sovereignty
concerns and the level of cooperation provided by government, rebel, and insurgent
groups. The 2013 Syrian polio outbreak, for example, itself an entirely predictable
outcome of the civil war’s detrimental effect on preventative vaccination campaigns,
demonstrated the regional inequalities that can be caused or exacerbated by
armed conflict. Established early warning surveillance systems functioned only in
government-controlled areas, and a fully effective public health response was only
possible when led (in many areas) by nonpartisan NGOs in cooperation with
neighboring countries, militant groups, and local grassroots organizations (Kennedy
and Michailidou 2017). Similarly, protecting the population of the Democratic
Republic of the Congo against the 2018 Ebola virus epidemic was fraught with
complexity due to the minimal preexisting health infrastructure, entrenched animos-
ities, and ongoing violence and required significant international intervention
(WHO 2018b).
Efforts to control and eradicate polio (theoretically possible, since it has no
animal reservoir and the successful treatment of all existing patients could there-
fore permanently wipe it out) have been significantly hampered by armed conflict
(Verma et al. 2018). At the time of writing, polio is only endemic to conflict-
affected countries, most of which are in the Arab world (currently Afghanistan,
Pakistan, and Nigeria). All of the previously identified logistical obstacles to
comprehensive vaccination campaigns apply in these settings – infrastructure
damage, general insecurity, and cold chain failure. On top of these challenges,
suspicions about the motives of humanitarian NGOs attempting to conduct vac-
cination campaigns can be an additional obstacle. This distrust may well be
exacerbated by instances of combatants posing as aid workers or the occasions
when Western governments attempt to “take credit” for the humanitarian work of
NGOs. Both of these actions can create the (usually false) assumption that
international NGOs are acting in accordance with Western foreign policy (since
many NGOs are based in Western countries). Widespread rumors that polio
vaccines are contaminated, poisoned, or part of a plot to sterilize or otherwise
weaken the local population may stem from this sort of mistrust. In Pakistan and
Afghanistan, over 90% of local imams were at one time reported by the WHO to
have campaigned against distribution of the polio vaccine on the assertion that it is
religiously forbidden (Nishtar 2009). Needless to say, this also significantly
reduced uptake.
Recommendation
• Building public trust, which is often in short supply in conflict-affected areas, is
crucial to implementing effective prevention or health protection campaigns.
Humanitarian NGOs should make transparency, honesty, and engagement with
local stakeholders their priority when working in conflict zones in order to
overcome suspicion and mistrust about their motives.
Vector control programs are crucial for both the prevention of and protection from
diseases that have either an animal reservoir or an animal host as a necessary part of
their lifecycle. However, these programs can also be seriously disrupted by conflict,
leading to avoidable increases in disease such as malaria, yellow fever, and dengue.
The WHO Eastern Mediterranean Regional Office (EMRO) estimated more than five
million cases of malaria in the region in 2015 with five countries accounted for the
overwhelming majority of these cases: Sudan, Pakistan, Afghanistan, Yemen, and
Somalia. It is unlikely to be coincidental that all of these countries are conflict-
affected and face considerable associated challenges including but not limited to
financial constraints, lack of prevention and monitoring programs, and an insuffi-
ciency of trained medical staff (Rowland and Nosten 2001; WHO 2017b).
This concatenation of risk factors tends to result in uncontrolled outbreaks of
communicable disease in conflict zones, and since these impacts also accumulate
over time, the situation is likely to get progressively worse the longer a conflict drags
on. In Syria, teams from Médecins Sans Frontières observed a distinctive dose-
response relationship in which communicable disease prevalence appeared to rise
dramatically with each passing year of conflict. For example, the proportion of
outpatient consultations for under 5 years old that were recorded as being due to
communicable diseases rose from 15% in 2013 to 51% in 2014 and up to 75% by
2015 (Meiqari et al. 2018). Reasonable protection against many of these diseases can
be achieved locally through relatively simple procedures such as handwashing,
mosquito nets, and good basic primary care. Their resurgence in any conflict zone
therefore represents a serious indictment against the state in question for failing in its
duty of care toward the civilian population.
Noncommunicable Disease
One of the lesser-noticed health impacts of armed conflict is the “opportunity cost”
that it imposed upon a society caught up in it. An opportunity cost is the benefit or
gains that are forfeited by choosing one alternative over another. For example, the
opportunity cost of choosing to study medicine might be a successful career in a
different field, as well as all the items that the money spent on medical tuition fees
could have purchased. The most obvious opportunity cost of a decision to go to war
is all of the positive benefit to a society in terms of protection from communicable
and noncommunicable diseases that could have been accrued if the resources, time,
and money that go into warfare were instead invested in public health. Box 1
illustrates one example of a very common opportunity cost of armed conflict

(preventable micronutrient deficiency blindness) encountered by one of the authors.
When political disputes are escalated into violence, it is usually at the expense of the
citizens of which each side in the conflict claims to be the rightful representative. The
impacts of this kind of willful neglect cut across all areas of health and well-being
and are likely to lead to a widening of existing health inequalities.
Box 1 An Example of the Opportunity Costs of Armed Conflict

[Darfur, 2008]
“I was sitting on the shady steps of the medical centre, scribbling notes for
the next Pharmacy order, when a skinny girl of about seven years of age came
out of the building and sat down next to me. I was so used to Sudanese children
reacting to my white skin with a mixture of fascination and horror that I was
positively thrilled by her disinterest – she barely even seemed to notice me, just
sat staring up at the sky. I wished her a good afternoon in my faltering Arabic
and she returned the greeting. We chatted for a little while longer, then she
stood up and turned to go back inside. One thin leg pawed the air in search of
the edge of the step while she supported herself on the doorframe, and her
cloudy eyes, which I now saw properly for the first time, still stared sightlessly
upwards. She was blind, of course.” – D Flecknoe.
The WHO estimates that somewhere between 250,000 and 500,000, chil-
dren around the world are blinded by easily preventable micronutrient defi-
ciencies every year. Half of those children will die 12 months of losing their
sight. (WHO 2018c)
In the absence of either national or local government investment in protecting

population health, whether through a lack of resources or a decision to invest
resources elsewhere, international humanitarian NGOs will often intervene to fill
the gap. However, foreign NGOs attempting to carry out health promotion activities
often encounter significant obstacles to operating effectively. International staff may
struggle to fully understand the local cultural context, beliefs, and taboos, which can
render a public health campaign wholly ineffective or even counterproductive if not
taken into account. Despite their best intentions to serve the local population, many
NGOs are functionally more accountable to their donors than to their beneficiaries,
and foreign donors are likely to have even less insight into the health needs of the
population than international staff in the field. This makes it vital that health
promotion and protection interventions by humanitarian NGOs are informed by
extensive community engagement throughout the project cycle.
Recommendation
• In order to be effective and credible, public health interventions must be driven by
the needs of the local population, not by the perceptions of either foreign donors
or NGO staff. Comprehensive community engagement is therefore necessary to
inform and steer such interventions.
The detrimental impact of conflict on the educational system can also have health
impacts over time, particularly on the control of noncommunicable disease. The public
provision of education is likely to be affected in very similar ways to the provision of
healthcare – infrastructure damage and an exodus of trained professionals leading to a
reduction in the quality of service that can be provided. Long-standing conflicts
therefore result in adult populations with very low levels of health literacy, and
unscientific beliefs about disease causation are likely to predominate (such as the
idea that mental illness is a result of demonic possession), making effective health
promotion and improvement activities all the more challenging. A chronic lack of
secondary education in an area is also likely to contribute to a dearth of locally trained
medical personnel, meaning that NGOs will be forced to import more staff, either from
other parts of the country or by using international volunteers. As discussed above, this
necessity carries with it the inherent problem of cultural differences between health
workers and beneficiaries, which often require significant investment of time and
resources to overcome in order to be able to deliver effective health protection
interventions. Armed conflict thereby both simultaneously creates a problem and
frustrates its solution.
Planning
Public health emergencies, including armed conflicts, have the potential to generate
large and severe health, social, and economic consequences that cannot be contained
by existing national infrastructures. Contingency plans to adequately prepare for,
detect, and respond to public health emergencies are therefore in the best interests of
nation-states. The concept of public health emergency preparedness (PHEP) has
been defined as “the capability of the public health and health care systems,
communities, and individuals, to prevent, protect against, quickly respond to,
and recover from health emergencies, particularly those whose scale, timing, or
unpredictability threatens to overwhelm routine capabilities” (Nelson et al. 2007a).
From a public health perspective, emergencies tend to be characterized by disrup-
tions in essential services, such as utilities, transportation, and food supply, and may
not necessarily connote the sense of a sudden and unexpected disaster. In the Middle
East, which is the most unstable region in the world according to the 2018 Global
Peace Index (Eldis 2018), the need for PHEP has never been greater.
As already discussed, armed conflict increases the likelihood that future public
health emergencies (such as large outbreaks of communicable disease) will occur.
Through many of the same mechanisms, it also degrades a nation’s ability to
undertake the sort of risk assessments, planning, and preparation which are vital
components of effective PHEP, so as to be able to mitigate those emergencies. As is
so often the case, groups that are already deprived and vulnerable are most at risk
from this lack of effective planning. Communicable disease outbreaks frequently
exhibit a steep inequality gradient in terms of morbidity and mortality, meaning that
the poor and socially isolated, displaced, and socially stigmatized populations
generally suffer the greatest consequences. Innovative strategies are required to
address these risks and prevent existing inequalities from being further compounded
by a lack of effective preparation (WHO 2008; Gonzalez et al. 2018).
The impacts of population movements out of conflict zones, including an exodus
of trained healthcare workers, on health system capacity within those conflict zones
have already been mentioned. In terms of wider impacts, it is also worth discussing
capacity issues in the non-conflict areas which receive these (often very large)
population movements. Many of the risk factors for both communicable and non-
communicable disease outbreaks generated within the war zone from which a
population is fleeing will travel with them to their new, otherwise safer location.
However, on arrival those factors can be exacerbated by overcrowding, isolation,
lack of health information, and linguistic, cultural, or religious barriers to adequate,
timely, and appropriate healthcare in the receiving countries or areas. The huge
burden placed upon countries such as Jordan and Lebanon by the Syrian Civil War
and the emergence of disease outbreaks in both the host and displaced populations
are an example of this phenomenon (Nimer 2018). The PHEP requirements imposed
by armed conflict are therefore often not confined within national borders but are
also imposed upon surrounding countries and continue well into the post-conflict
phase, as will be discussed below.
The most readily apparent direct public health consequence of armed conflict is
the increased burden of injuries and deaths which are caused by violent attacks. Not
unlike mental health impacts, for the purposes of our discussion, these fit best into
the “noncommunicable” category, despite having an undeniably contagious and self-
perpetuating quality. It is worth noting that in the Nelson et al. definition of PHEP,
responsibility for planning and mitigation is not solely restricted to government
agencies but also civil society and nongovernment groups. This is significant given
that many first responders to public health emergencies are from the local civilian
population. A recent example can be seen in White Helmets/Syrian Civil Defence
organization, a volunteer group of 2,900 rescue workers that have reportedly saved
over 80,000 lives in the ongoing civil war (Fouad et al. 2017). Integrating PHEP
across national systems is crucial but may be challenging in conflicts where political
differences prohibit collaborative working. For example, the White Helmets cur-
rently restrict their activities to selected nongovernment-controlled areas of Syria
due to the Assad regime’s classification of them as terrorists. The proliferation of
online “fake news” propaganda against groups whose existence and work are
embarrassing to various warring parties (including international governments) only
increases the fog of war with regard to reliable data for health systems planning and
preparedness in this and other conflicts (Starbird et al. 2018).
Assessing the readiness of a health system to prevent, detect, and respond to
emergencies is a challenging component of PHEP. Policy-makers’ investment in
PHEP can be stifled without clear definitions of performance indicators against
which to measure progress. Numerous frameworks and tools exist to assess readi-
ness, but these are generally fast-moving and are not well-represented in the peer-
reviewed literature, given the newness of PHEP in modern public health service
provision. Conceptual frameworks tend to involve a classic “structure-process-
outcome” theme, although the evidence base linking these three components is
relatively thin (e.g., often because it is harder to evaluate outcomes than structures).
A commonly used tool to assess PHEP includes written assessments, which can vary
widely in scope but could involve self-reported questionnaires assessing generic
preparedness (e.g., the Public Health Preparedness and Response Capacity Inven-
tory), specific staff competencies (e.g., Core Public Health Worker Competencies),
or narrative performance reports. Another commonly used tool is group exercises,
which can be either discussion-based (e.g., group tabletop discussions about a
particular scenario) or operations-based (e.g., undertaking active drills following
simulated intelligence) (Nelson et al. 2007b). It is obviously much easier to facilitate
exercises of this kind, which help to assess health system readiness for catastrophic
shocks (such as armed conflict), in times of peace.
Written reports by stakeholder organizations are cost-efficient, low resource
intense options for assessing PHEP capacity, but obvious drawbacks include their
tendency to focus more on public health structures and to be biased given that such
assessments are self-reported. Multiagency exercises could provide a better indica-
tion of preparedness than written assessments but are often financially and human
resource intense, without standard metrics of what constitutes adequate performance
(ibid). International agencies such as the WHO would be well advised to invest more
effort in strengthening and testing the systems designed to protect civilian
populations from both the direct and indirect health impacts of armed conflict.
Recommendation
• Efforts to test the resilience and effectiveness of public health emergency pre-
paredness (PHEP) should be designed to assess both systems and outcomes and
should not only rely on self-reporting.
Resilience is the ability of a health system to sustain or improve access to healthcare

during shocks, such as armed conflict, while ensuring long-term sustainability.
Thomas and colleagues break down the definition of health system resilience into
three domains. “Financial resilience” refers to the protection of funds for healthcare,
particularly that of the most vulnerable sections of a population. “Adaptive resilience”
pertains to the ability of government and providers to manage the system with fewer
resources through efficiencies while not sacrificing key priorities, benefits, access, or
entitlements. Finally, “transformatory resilience” is the ability or capacity of a gov-
ernment to design and implement desirable and realistic reform when the current
organization, structures, and strategies are no longer feasible (Thomas et al. 2013).
This model of health system resilience indicates the complexity of the PHEP challenge
to be faced, even when a government is committed to planning for the health of its
population.
Other researchers on this topic have proposed a health system resiliency index
that encompasses 25 indicators, including the distribution of health system assets,
health system utilization, and a functioning civil registration and vital statistics
system (Kruk et al. 2017). Such indicators can be difficult to measure in low- or
middle-income countries even in times of peace, and during times of armed conflict,
accessing reliable and valid data securely and on a regular basis becomes ever more
challenging. In appreciation of this challenge, the World Health Organization has

implemented a “Health Resources and Services Availability Monitoring System”
(HeRAMS) in several conflict-affected countries: the Central African Republic, Fiji,
Mali, Nigeria, the Philippines, Syrian Arab Republic, and Yemen (WHO 2018d).
This system aims to monitor the availability of health services during an emergency
and goes some way toward understanding health system resilience in conflict-
affected countries.
Adequate PHEP can strongly lend itself to improving health system resilience,
and using data from the Health Resources and Services Availability Monitoring
System (HeRAMS), there are clear examples where public health emergencies in the
form of armed conflict may have overwhelmed health system capabilities. For
example, Fig. 1 presents the HeRAMS results of a broad assessment of damage to
public hospitals in Syria (WHO 2018e). In this assessment, around 50–60% of
hospitals remained undamaged between 2014 and 2016, and 10–15% of hospitals
were fully damaged or destroyed. Given the lack of clear trends, this may suggest
that most damage to public hospitals occurred prior to the commencement of
surveillance, that is, sometimes between 2011 and 2014, with little or no repair or
rebuilding having been possible during the time period surveyed. The extent of
damage to healthcare infrastructure appears to have been worse in conflict-affected
Yemen, and although trends were unavailable for analysis, only 45% of health
facilities were fully functional in 2016. This may reflect a less resilient health system
at the pre-conflict baseline (WHO 2018f).
Further examples of low health system resilience in Syria and Yemen can be
found using HeRAMS data. In Yemen, there were no medical doctors in 49 out of
276 surveyed districts and only 2 doctors or less in 42% of surveyed districts in 2016
(WHO 2018f). In Syria, it was reported that half of the 30,000 doctors thought to be
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Undamaged Partially damaged Fully damaged No report
Fig. 1 Damage to public hospitals in Syria, April 2014–December 2016 (WHO 2018d)
practicing prior to the conflict left the country following the start of the civil war
(Karasapan 2016). A similar proportion were reported to have left neighboring Iraq
since the US-led invasion in 2003 (Mohammed 2010). Adapting health systems to
such a catastrophic shortage of healthcare workers and human capital in these
countries poses huge challenges to maintaining the health of their populations and
the financing of their health system.
As mentioned above, it is not only countries undergoing armed conflict that need
to be mindful of the resilience of their health system, as neighboring countries too
can feel the indirect destructive effects of war. As well as the pressures that have
been placed upon the health systems of Jordan, the Syrian Civil War has also forcibly
displaced over one million Syrians into neighboring Lebanon. An analysis of health
system resilience in Lebanon in 2014–2015, using secondary data sources from the
Lebanese Ministry of Public Health, generally showed a surprisingly resilient system
(Ammar et al. 2016). For example, financial resilience (from the Thomas et al. model
discussed above) was demonstrated by changes in patterns of public spending on
health to meet the needs of arriving Syrian refugees, even though these changes were
considered not in proportion to those needs and had to be supported by money from
international donors. In another example, transformatory resilience was considered
present after the initial “parallel” health system created by humanitarian agencies in
Lebanon was integrated with the National Health Service to provide a more coordi-
nated and less fragmented approach to healthcare in the country (ibid.). By 2015, the
Lebanese government and its stakeholders had established 20 new public health
centers and directly supported 100 private health centers, increasing primary care
capacity by 40% (Kruk et al. 2017). There is a great deal to learn from the innovative
and integrative (but frequently underreported) success stories in those countries that
have received the overwhelming majority of Syrian refugees.
Recommendation
• The global health community as a whole has much to learn from both the
successes and failures that have accompanied efforts to manage the huge popu-
lation movements resulting from the Syrian Civil War. This is a rich area for high-
value research to inform future PHEP.
Post-Conflict Settings
Although the definition of a “post-conflict” state remains in many instances unclear

(Haar and Rubenstein 2012), there are some commonalities. After the cessation of
active violence, by whatever means it is achieved, the negative impacts created by
the violence almost all still pertain. The rebuilding and restaffing of a functional
public health system are not achievable overnight, and many of the humanitarian aid
organizations that have been filling the gap during the conflict are likely to withdraw
once it is over. The deficit between the supply and demand for medical services can
often thereby increase, rather than decrease, in the aftermath of war. The tensions and
hostilities that led to violence are usually still present to a large degree, and all of the
basic development needs generated by it (such as education, transportation, water,

and electricity) will remain, at least in the short term, unfulfilled. This is a dangerous
time, when there is a high probability of a resumption of conflict without significant
diplomatic and development interventions.
Effective approaches to post-conflict reconstruction can be based upon the World
Health Organization’s six health system building blocks: leadership and governance,
health services, health information, human resources, financing, and access to essential
medicines, vaccines, and technologies. Yet achieving stronger health systems in post-
conflict settings remains challenging for a number of reasons. Spiegel (2017) has
described the humanitarian system, which traditionally includes governments, donors,
multilateral and bilateral agencies, international and national nongovernmental orga-
nizations (NGOs), community-based organizations, UN agencies, and international
agencies such as the International Committee of the Red Cross, as no longer fit for
purpose in this regard. The existing humanitarian model centers on relief rather than
development, often aiming for rapid resolutions rather than long-term sustainability.
This approach, known as the humanitarian-development nexus, is regularly
uncoordinated with and runs in parallel to existing national infrastructures, which
can negatively affect state legitimacy and be potentially destabilizing. In recent
conflicts, humanitarian actors have been working more closely with development
organizations in recognition of this problem, but it has not yet been fully solved.
Recommendation
• Humanitarian NGOs are advised to move away from the traditional paradigm of
“aid” and “development” as nonoverlapping endeavors. Integrated working to
alleviate current adverse conditions while also working to build and develop local
capacity will result in more sustainable positive outcomes for the local population
which can then continue into the post-conflict phase.
Reinvestment and rebuilding in post-conflict societies are not only for the purpose
of undoing the damage created by conflict but also have a preventative effect against
future conflicts. In the longer term, stronger health systems lead to a healthier
society, more economic growth, and political stability and therefore reduce the
likelihood of any renewal of violence (Collier et al. 2009). Good governance is
required to oversee the kind of post-conflict investment which appears, since some
commercial enterprises which are extremely detrimental to population health – such
as the tobacco industry – may also be the most reactive to new markets, leading to an
increase in noncommunicable diseases in the post-conflict phase (Roberts et al.
2012). Some increased reporting of all types of disease is to be expected as
surveillance systems are rebuilt and strengthened, however, and this can be hard to
separate from the “double burden” health impacts of the transition to a more affluent
peacetime lifestyle.
Recommendation
• As tobacco use is one of the main risk factors for noncommunicable disease and
tobacco industries are often among the first to establish themselves in the post-
conflict setting, more research attention should be paid to this variable.
Recommendation
• Public health practitioners and policy-makers should be mindful that many
diseases may be under-recorded and underdiagnosed during times of armed
conflict, so a post-conflict rise in recorded prevalence is to be expected, especially
if economic growth results in higher uptake of the unhealthy “Western” behav-
iors, e.g., physical inactivity, consumption of unhealthy foods, tobacco and
alcohol use, etc.
Conclusions
The risk that armed conflict poses to global health is partly inherent in the use of
mass violence to advance political goals but also arises from the contemporary trend
of warring parties failing in their duty to abide by International Humanitarian Law.
The deliberate targeting (or negligent destruction) of civilian and health infrastruc-
ture, the endangerment of health workers, and subjecting a population to starvation,
unnecessary forced displacement, and other cruelties are war crimes which should
not be normalized. As well as the direct toll of morbidity and mortality that they
bring in the form of short-term injuries and deaths, these actions dramatically
increase the risk of communicable and noncommunicable disease incidence and
simultaneously reduce the ability of a society to prevent and control such risks.
Armed conflict degrades the capacity of health systems to gather vital data and plan
effectively for future emergencies, and all of these impacts can persist long after the
guns have fallen silent. A fuller understanding of the many and various ways that
warfare affects public health (in the separate but linked senses of the professional
discipline and the collective health of the public) would be highly beneficial to
international policy-makers, humanitarian workers, and health professionals of
whatever background who work (or are planning to work) in or near conflict zones.
Recommendations
• Universal compliance with International Humanitarian Law could be the single
most effective public health intervention for populations in conflict-affected
areas, if it could be achieved. Citizens of nonauthoritarian countries should
therefore use their democratic influence to advocate for the re-establishment of
international deterrence against war crimes and the prosecution of individuals or
governments (regardless of nationality) who deliberately target civilian
populations, health workers, or public health infrastructure.
• Effective data collection is essential to public health prevention efforts which can
avert communicable disease outbreaks that have the potential to cause massive
loss of life. Although not an immediately obvious infraction of international law,
the prevention by warring parties of nonmilitary civilian health data collection
should be considered an indirect crime against humanity on this basis.
• Violations of medical neutrality (which include combatants posing as health
workers, as well as deliberately targeting them) should be condemned and,
where possible, punished by the international community. Warring parties who
oppose or obstruct humanitarian ceasefires to allow preventative public health
interventions (such as vaccination campaigns) to be safely delivered in conflict

zones should face sanctions and/or prosecution.
• The causal pathways between armed conflict and noncommunicable disease risk
are likely to be complex and multifactorial, almost certainly driven by underlying
stress responses, disruptions to healthcare provision, malnutrition, and physical
inactivity. Further research into this pathway would be helpful to guide future
interventions in this area.
• Sanctions or blockades which restrict the availability of food or medical supplies
to conflict-affected civilian populations should be considered a war crime and
opposed on humanitarian grounds.
• Modern war zones are high-risk areas for the spread of potential future pandemic
diseases, but local surveillance systems are usually inadequate for the purpose of
catching such outbreaks early. Syndromic early warning systems, and other poten-
tial means of mitigating this global threat, should be high-priority research areas.
• Building public trust, which is often in short supply in conflict-affected areas, is
crucial to implementing effective prevention or health protection campaigns.
Humanitarian NGOs should make transparency, honesty, and engagement with
local stakeholders their priority when working in conflict zones in order to
overcome suspicion and mistrust about their motives.
• In order to be effective and credible, public health interventions must be driven by
the needs of the local population not by the perceptions of either foreign donors or
NGO staff. Comprehensive community engagement is therefore necessary to
inform and steer such interventions.
• Efforts to test the resilience and effectiveness of public health emergency pre-
paredness (PHEP) should be designed to assess both systems and outcomes and
should not only rely on self-reporting.
• The global health community as a whole has much to learn from both the
successes and failures that have accompanied efforts to manage the huge popu-
lation movements resulting from the Syrian Civil War. This is a rich area for high-
value research to inform future PHEP.
• Humanitarian NGOs are advised to move away from the traditional paradigm of
“aid” and “development” as nonoverlapping endeavors. Integrated working to
alleviate current adverse conditions while also working to build and develop local
capacity will result in more sustainable positive outcomes for the local population
which can then continue into the post-conflict phase.
• As tobacco use is one of the main risk factors for noncommunicable disease and
tobacco industries are often among the first to establish themselves in the post-
conflict setting, more research attention should be paid to this variable.
• Public health practitioners and policy-makers should be mindful that many
diseases may be under-recorded and underdiagnosed during times of armed
conflict, so a post-conflict rise in recorded prevalence is to be expected, especially
if economic growth results in higher uptake of the unhealthy “Western” behav-
iors, e.g., physical inactivity, consumption of unhealthy foods, tobacco and
alcohol use, etc.
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School Health in Arab Countries
31
Hamid Yahya Hussain and Waleed Al Faisal
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 726
School Health in the Arab World . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 726
School Health and Public Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 727
School Health Policies, Plans, and Guidelines in Arab Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 728
School Health Program and Components . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 729
School Health Research in Arab Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 730
School Health Services in Arab Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 732
School Health Services in Times of Conflict . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 732
School Health Prospects in Arab Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 734
Global Recommendations on School Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 735
Global School Health Initiatives: Achieving Health and Education Outcomes
(Bangkok, 2015) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 735
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 736
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 736
Abstract
A comprehensive school health program requires an organized set of policies,
procedures, and activities designed to protect and promote the health and well-
being of students and staff. This has traditionally included health services, a
school environment promoting healthy habits, and health education. Establishing
healthy behaviors during childhood is easier and more effective than trying to
change unhealthy behaviors later in adulthood. Schools play a critical role in
promoting the health and safety of young people and helping them establish
H. Y. Hussain (*)
Faculty of Medicine, University of Baghdad, Dubai, UAE
e-mail: hussainh569@gmail.com; hussainh569@outlook.com
W. Al Faisal
Dubai, UAE
e-mail: wldalfaisal@gmail.com

https://doi.org/10.1007/978-3-030-36811-1_34
726 H. Y. Hussain and W. Al Faisal
lifelong healthy behaviors. To better serve the unique needs of students, school
leaders and staff should consider incorporating the WSCC (“whole school, whole
community, and whole child”) model components according to the needs of their
schools.
Keywords
School health · Arab world
Introduction
School Health in the Arab World
The Arab world has a combined population of nearly 422 million inhabitants, of
which over half are under 25 years of age. As with all other populations, those below
25 years old are enrolled in schools or other educational institutions, which in the
Arab countries amounts to about 200 million students. It is in the long-term interest
of the economic, political, and social wellbeing of the country that the physical and
mental health of school-aged children is maintained.
Most overweight or obese preprimary schoolchildren in Saudi Arabia hail from
high-income or affluent families (Alshammari et al. 2017) and can be associated with
the poor quality of school meals (resulting in overfeeding at home, usually with
“convenience foods”) and low awareness of mothers (lack of healthy-nutrition
awareness.” This necessitates nutrition training for children, teachers, and parents
to support healthy eating habits and lifestyles in school and at home (Peterson et al.
2017; Halloran et al. 2017). Being overweight, obese or diabetic is related to
frequently consuming sugar, savory and crispy snacks, flavored milk and soda
drinks, and snacking between meals (Eid et al. 2018), as is the case in preprimary
school children according to the Saudi School Meal and Home Meal Study
(SSMHMS) which reported that a low calorie intake at breakfast (23% of total
requirement) and a higher calorie intake at lunch time (40% of total requirement).
The meals consumed for lunch at schools had higher levels of both carbohydrates
and saturated fats (>7%) (Wang and Stewart 2013).
According to the World Health Organization (WHO), “A successful school health
program can be one of the most cost-effective investments a nation can make to
simultaneously improve education and health. WHO promotes school health pro-
grams as a strategic means to prevent important health risks among youth and to
engage the education sector in efforts to change the educational, social, economic
and political conditions that affect risk.” Over 90% of children of primary school
age, and over 80% of children of lower secondary school age, were enrolled in
schools globally in 2013. In high-income countries, school settings represent an
extended arm of primary health care by providing basic health care services. Partner-
ships between schools, families, and community members can enhance student
learning, promote consistent messaging about health behaviors, increase resources,
31 School Health in Arab Countries 727
and engage, guide, and motivate students to eat healthily and be active. Both parents
and children from Health Promoting Schools (HPS) undergo significant changes in
their eating patterns and lifestyles following child nutrition programs; they consume
more fiber, healthy snacks, milk, water, fruit and vegetables, and reducing their
intake of creamy, fatty, and sugary foods (Eid 2019).
A recent (2019) survey (Wainwright et al. 2000) of Saudi kindergarten-aged
children reported the following:
1. Child nutrition programs are a relatively new concept in the region, and only
about 5% of schools had structured health related activities related to health
assessment, emergency management and identifying students’ health status by
health professionals. An absence of such programs could affect educational
achievement (Moon and Jang 2002).
2. School meals are not professionally planned, as most (92%) schools do not
employ dieticians/nutritionists. Schools in other parts of the world almost uni-
formly all employ dieticians/nutritionists to help produce healthy, nutritious
meals (Jang and Kim 2003; Alam 2008).
3. The dietary habits of kindergarten children in KSA are influenced by the type of
food presented, parental knowledge of nutrition, household income, cost of food,
individual preferences, cultural beliefs, and cultural traditions, followed by family
and social influencers, such as maternal employment, and the preference for
sweets. More Saudi women are now joining the workforce, causing young
children to be routinely fed poor quality meals by caretakers (Cooper et al.
2013). This creates an opportunity to provide nutrition education for caregivers
(e.g., delivered via mail or social media such as Facebook, allowing caregivers to
access the information at their own convenience).
The Arab world urgently needs to address the all features of school health in terms of
the status of school health (school health policies, plans, and guidelines), school health
programs and services, school health in times of conflict, and the monitoring of school
health quality in Arab countries. It is well known that many behaviors, habits develop in
early childhood – and that these habits and behaviors remain in adolescence and
adulthood. Therefore, acquiring healthy habits in school provides basic knowledge
and experiences that influence lifestyles in adulthood and influence the lives of other
family members and the community (Al-Beiruti and Al-Faisal 2002).
School Health and Public Health
The school health program is a unique public health program. The school is the only
setting where effective intervention, promotion, rehabilitation, and curative care can
be introduced in a highly organized pathway and process, with a goal of improving
the health status of the nation’s youth.
Many of the health challenges currently facing young people are different from
those of previous generations. Advances in medications and vaccines have largely
reduced the illness, disability, and death caused by infectious diseases in children.
The health of young people, and the adults they will become, is critically linked to
the health-related behaviors they choose to adopt as youth. Behaviors that are often
established during the early years contribute markedly to major causes of death in
modern society, such as heart disease, cancer, and injuries. These unhealthy behav-
iors include tobacco use, eating unhealthy foods, sedentary lifestyles, using alcohol
and other drugs, and engaging in unsafe sexual behaviors that can cause HIV
infection and other sexually transmitted diseases.
School Health Policies, Plans, and Guidelines in Arab Countries
While most Arab Countries enjoy substantial economic progress, there has been
little improvement in ensuring equitable access to health care. The majority of
people in most Arab countries have limited access to basic school health services,
which largely tend to typically be of poor quality and usually not well suited to local
needs. The region is also highly vulnerable to environmental challenges due to water
scarcity, social and political upheavals, poverty, food insecurity, and weak political
institutions. Scientific output is extremely low in spite of adequate resources and
plays little or no role in guiding national and regional development. With social and
political changes sweeping the region, there are opportunities for structured reform,
building partnerships, and enhancing public health education in the Arab world.
Some Arab countries have established a National Committee of School Health
from the different sectors responsible for school health. It was established in Egypt
(1993), Lebanon (1996), and Iraq (2002) and is being established in Morocco.
Policies and guidelines are designed to help school health leaders, teachers,
school-based staff, and other stakeholders to ensure the delivery of quality health
care, disease prevention, and promoting healthy life styles. All policies issued by the
Policy Sector and part of the Policy Manual are mandatory and must be implemented
by all schools.
Most Arab countries have National School Health plans, but the planning is not
based on a solid background with well-formulated objectives. Some of the objectives
have short-term goals while others are based on long-term planning. The general
objectives of the National School Health plans can be summarized as follows:
1. Implementing health education and health promotion programs for children,

teachers, and parents
2. Fulfilling the requirements of complete physical, mental, and social well-being
3. Adequate coverage by school health services
4. Prevention of health hazards and control of common health problems (e.g., anemia,
rheumatic fever, and rheumatic heart disease)
5. Improving school health environment
6. Early detection and providing care for disabled children
7. Supporting community schools and school health curricula
School Health Program and Components
Arab countries such as Syria follow the WHO guidelines and apply the concept of
health promotion in schools, while countries such as the United Arab Emirates apply
the principles of the Centers for Disease Control and Prevention (CDC) in terms of a
coordinated school health program.
The Coordinated School Health Program (CSHP) (Source: http://www.jcschools.
org/jcs/index.php/8-home/185-coordinated-school-health) is a collaboration between
eight sectors: health education, counseling services, health services, health school
environment, nutrition services, family and community involvement, health promo-
tion of staff, and physical education. The CSHP model connects health services and
learning, based on these components. This approach helps students by improving their
overall health and their capacity to learn through personal health-related responsibil-
ities, with the support of families, communities, and their schools.
Physical
education
Health Health
Promotions
for Staff Education
COORDINATED
SCHOOL HEALTH
Counseling, Health
Psychological &
Social Services Services
Family &
Community Nutrition
Involvement Services
Healthy
School
Environment
Modern Approaches in Improving Health in Schools:
1. Collaborative learning is an educational approach to teaching and learning that

involves groups of students working together to solve a problem, complete a task,
or create a product. It is through discussions that learning occurs. There are many
approaches to collaborative learning.
2. The normative concept of education: Educational programs using defined nor-

mative standards. Normative in this sense means a standard for evaluating or
making judgments on behavior or outcomes. Normative is sometimes also used,
somewhat confusingly, to mean relating to a descriptive standard: doing what is
normally done or what most others are expected to do in practice.
3. Peer learning refers to situations where peers support each other in the learning
processes. There are different forms of peer learning such as peer support groups,
supplemental instruction, peer tutoring, peer teaching, and peer-assisted learning.
4. Competency-based learning refers to a system of instruction, assessment, grad-
ing, and academic reporting that is based on students demonstrating that they
have acquired the knowledge and skills they are expected to learn at that stage of
their journey in the educational curriculum.
School Health Research in Arab Countries
Research activities in schools are well organized and easy to access, with many
research projects being conducted. A review of the burden of ill health among
adolescents in Arab countries suggests that it is, largely, related to preventable factors
associated with unhealthy behaviors and outcomes (Obermeyer 2015). Chief among
those are factors related to unhealthy diets and insufficient physical activity, resulting
in poor nutritional status, high body mass index, unsafe transport, reckless driving,
unintentional injuries, tobacco and alcohol use (Al Makadma 2017).
However, the levels of research productivity in the region need to be increased in order
to improve public health practices and encourage evidence-based policymaking. To foster
collaboration and capacity building across disciplines, institutions and geographical
borders, additional school health research themes need to address non-communicable
diseases, monitoring health inequities, and the impact of war and the regional governance
crisis on formulation of public policies, strengthening of public health by the training of
more school health professionals.
The number of years lost to both premature mortality and disability is calculated
by the disability-adjusted life years (DALYs). This calculation shows that mental
and behavioral disorders, which contribute to nearly 25% of DALYs in the MENA
region, are considerably higher than their contribution in other parts of the world.
The contributions of musculoskeletal disorders, nutritional deficiencies, transport
injuries, chronic respiratory diseases, cardiovascular/circulatory disorders, and dia-
betes to DALYs are also higher in MENA than at a global level, while the percent-
ages of diarrhea/infections and unintentional injuries are lower. Among those causes
that make a much lower contribution to DALYs in MENA than globally are maternal
health, HIV, tuberculosis, and intentional injuries.
Another study lists the leading contributors to DALYs for adolescents in 2012 as
unipolar depressive disorders, anxiety disorders, alcohol abuse, road traffic injuries,
back and neck pain, and asthma. Migraine is also a leading contributor to DALYs in
younger adolescent girls (10–14 years), whereas childhood behavioral disorders are
among the top five contributors for younger boys. Among older male and female
adolescents, alcohol use disorders outrank asthma, whereas for boys, self-harm
contributes more to DALYs than does anxiety. Together, mental health and substance
use issues account for more than one-half of the top-ranked DALYs among adoles-
cents in high-income countries such as those in the GCC.
Taken together, these data underscore the fact that for most of the region, the
epidemiological transition has already taken place, and the burden of disease has
largely shifted away from communicable and maternal causes, towards non-
communicable chronic causes. These results also highlight three health problems
for adolescents in the region. First, the contributions of cardiovascular/circula-
tory diseases and diabetes to ill health are considerably higher than the global
average, which is consistent with the high-risk factors in adults of the region. The
unfavorable health statistics of Arab adolescents represents an alarming pattern.
Second, another cause of ill health among adolescents, which is also consider-
ably higher than the global average, is the high percentage of deaths due to
transport injuries, which raises questions about road safety and driving by Arab
adolescents. Injuries, both intentional and unintentional, also figure prominently
in the region and are part of a cluster of eminently preventable causes of ill
health. A third major cause of ill health is the burden of mental and behavioral
problems among adolescents in MENA, which is also higher than the global
average.
Increased emphasis should be placed on the relationship between basic research
and their outcomes and their dissemination in the population. Research is needed on
the effectiveness of specific intervention strategies such as skills training, normative
and peer education. More data are needed on the effectiveness of specific interven-
tion strategies such as abstinence versus harm reduction, and the required intensity
and duration of health education programming. It is likely that common underlying
factors may be responsible for the clustering of health-compromising behaviors, and
interventions are likely to more effective if they address these underlying factors in
addition changing risk behaviors.
Research is also needed to understand the etiology of problem behaviors and to
develop optimal problem behavior interventions. Since the acquisition of health-
related social skills – such as negotiation, decision-making, and refusal skills – is a
desired end of school health programs, research is needed to develop valid measures
of social skills that can then be used as proxy measures of program effectiveness.
Diffusion-related research is critical to ensure that efforts of research and develop-
ment lead to improved practice and a greater utilization of effective methods and
programs. Therefore, greater priority should be given to understanding how pro-
grams are adopted, implemented, and institutionalized. The feasibility and effective-
ness of techniques for integrating concepts of health into science and other school
subjects should also be examined.
More data are needed on the advantages (cost and effectiveness) and disadvan-
tages of providing health and social services in schools compared to other commu-
nity sites – or compared to not providing services anywhere – as a function of
community and student characteristics. This information will require overall con-
sensus about the criteria for determining the quality of school health programs. It is
also important to know how best to influence changes in the climate and organiza-
tional structure of school districts and in individual schools in order to facilitating the
adoption and implementation of school health programs.
School Health Services in Arab Countries
School health programs differ in the Arab Countries in terms of who is responsible
for these. In some countries, it is the Ministry of Health (MOH), and in others, it is
the Ministry of Education (MOE). Therefore, the work systems and references are
accordingly different.
Dedicated school health personnel usually provide school health services in Arab
Countries within the school premises. Services are provided in 16 areas: the top five
interventions include vaccinations, sexual and reproductive health education, vision
screening, nutrition screening, and nutrition health education. Important areas such
as mental health, injury, and violence prevention may not be given sufficient
consideration in routine service provision (Baltag et al. 2015).
School health services in Arab countries vary from high standards to medium or
low standards, based on the national health care system capacity as well as econom-
ical and socio-developmental staging. Areas that need development in school health
services include:
• Evaluation of school health programs status

• Benchmarking with best practices
• Coordination among several sectors and partners responsible for school health
services
• Training program for school health officials
The school health services provided in Arab countries vary in the types and
coverage rates, but data is not available for all areas (as shown in Table 1) (Al-Beiruti
and Al-Faisal 2002).
School Health Services in Times of Conflict
Conflict and war impede the creation of new intrastate equalities and further
compromise the use of aggregate statistics. Chronic and recurrent conflict has
plagued Iraq, Tunisia, Egypt, the occupied Palestinian territory, Lebanon, and
Somalia. The recent Arab uprisings have given way to armed conflict in Libya,
Syria, and Yemen. Furthermore, external stakeholders have imposed economic
sanctions, seeking to weaken these governments. For example, these sanctions
had a crippling effect on the health of the population in Iraq, where the infant
mortality has risen from 47 to 108 per 1000 under sanctions from 1994 to 1999,
Table 1 School health services: coverage rates (2001–2002)

Egypt Iraq Jordan Lebanon Morocco Syria
Service % % % % % %
Periodical examination 98.3 100.0 98.0 82.2a 86.0 15.0–
50.0
Immunization 96.9– 90.0– 99.0 – ? 70.4–
99.3 100.0 87.2
Treatment on demand 19.85 20.0
Communicable diseases 11 15.0–
screening 87.2
Skin diseases screening 11.0 26.0 50.0
Vision examination 98.3 100.0 100.0 89.0 15.0–
50.0
Hearing examination 17.0 50.0
Weight and height 98.3 100.0 50.0
Disability screening 98.3 50.0
Psychological status 100.0
screening
Others
a
This rate is for the academic year 1998–1999
and under-5 mortality has risen from 56 to 131 per 1000 in the same period.
However, in Iraq under sanctions, childhood mortality is determined by region,
rather than wealth, because people living under the UN sanctions saw sharp rises
in child mortality, whereas in the autonomous northern region of Iraq, childhood
mortality actually declined. Similarly, in the occupied Palestinian territory, mal-
nutrition is determined by geography rather than by physical access to food due to
road closures, or by financial limitations. The many uprisings have created new
waves of migration to escape ongoing violence, and new regional disadvantages
are being created, especially for Syrian refugees (Ali and Shah 2000; Batniji et al.
2009; Dewachi et al. 2014; World Health Organization (WHO) 2015; Lankarani
and Joulaei 2012).
Armed conflict in Arab countries have harmed medical workers and patients,
decimated medical infrastructure, and robbed countless civilians of vital medi-
cal care. Armed groups targeted schools, medical workers, and the health care
system for attacks. Conflict groups have systematically attacked schools and
medical workers and facilities as a weapon of war since 2011. Students in
conflict zones face extraordinary risks at times of armed conflicts and other
emergencies. Violence against wounded and sick students, and against school
facilities and personnel, is a mostly overlooked humanitarian issue. This raises
the issue of the requirements needed for improving the experience of health
workers in fragile states. Efforts are needed to establish performance-manage-
ment systems, support promotion, and provide opportunities for professional
development.
School Health Prospects in Arab Countries
A standards-driven approach allows health services to realize aspirational but

achievable goals through assisting the implementation of appropriate practices and
guiding continuous quality improvement. Standards for school health services allow
managers and providers to reduce variability and ensure a minimal required level of
quality in school health services, moreover, and enable them to advocate for
necessary resources. In addition, setting standards enhances accountability. Regional
and global standards could accelerate this process; instead of recommending a
specific way of organizing school health services, mandating a single process for
dividing work among health professionals, or creating a definitive set of quantitative
values for system inputs, regional/global standards should allow individual countries
to tailor them to their own specific needs.
More engagement that is active is needed in global, regional, and national
advocacy. This will support the recognition of school health services as important
contributors to adolescent health and as a good investment of public funds. It is not
an easy task – effective advocacy will depend on the implementation of the above
recommendations, and vice versa, their implementation is only possible with more
investment that comes with effective advocacy. Advocacy will be necessary on a
long-term basis to increase interest from the research community, governments,
donors, and international development organizations, professional and other societal
organizations (Sutton et al. 2004).
The following are some recommendations that could improve school health in
Arab countries:
• Utilize electronic health monitoring within school health systems.

• Conduct and support research related to knowledge, attitudes and skills of
teachers, students, and their parents to enable defining priorities of health and
social problems in schools and creating solutions for confronting these problems.
• Implement health promotion projects in schools in countries where these are
currently not in use.
• Studying the possibility of implementation of the global school-based student
health survey (GSHS) in countries, which have not yet conducted the survey. This
could be done in coordination with EMRO (Eastern Mediterranean Regional
Office).
• Encourage the visits of professionals in school health (Health Education) by
members of the Council States with the objective of exchanging experiences
and learning from successful models.
• Finding mechanisms for integration and investment of the UN FRESH initiatives:
The FRESH (Focus Resources on Effective School Health) framework is an
interpectoral partnership in the health promoting schools project.
• Circulation of successful experiences for utilization.
• Including the concept of information education in the school curricula and
increase nonscholastic activities to counteract the negative impact of commercial
information on the health of children and youngsters.
• Provision of technical and material support to enrich training programs, studies,

and research in school health.
• Finding a mechanism for coordinating and integrating the different initiatives
related to school health.
• Enriching Arab countries with international experiences in school health.
The Seventh Meeting of the Gulf Committee for School Health was held in
Muscat Oman (9-10 Rabi II, 1428 H/26-27 April 2007). The committee discussed
setting a strategy for the next 5 years to be presented at the next meeting. Recom-
mendation of this meeting included the following:
• Request member states to implement recommendations of the first Gulf confer-

ence on school health held in Muscat, Oman (6–8 Rabi II, 1428 H/23-5 April,
2007).
• Calling upon the countries to state their viewpoints on the second edition of the
Unified School Health Training Manual in member states.
• Countries which have not yet implemented the Global School Health Student
survey should utilize the experiences of those who have already implemented the
survey (UAE- Oman).
• Urging member states who have not yet conducted the health promoting schools
project to promptly implement it.
• Emphasis on the previous recommendation of the Executive Body about the
necessity of participation of a member from the Ministry of Education from
each country in meetings of the Gulf Committee for School Health (Lankarani
and Joulaei 2012; Sutton et al. 2004).
Global Recommendations on School Health
Global School Health Initiatives: Achieving Health and Education

Outcomes (Bangkok, 2015)
The following recommendations aim to address some of the barriers and facilitate
the strengthening of school health promotion, and the way forward at the regional
and country level:
• Respond to the UN Sustainable Development Goals through further multisectoral

coordination and roles of school health programs or HPS
• Create a national strategic plan for school health (including prioritizing, costing
and setting a time frame, monitoring and evaluation)
• Strengthen the connections between the health and education sectors across all
regions and with other sectors (agriculture, local government, etc.) and strengthen
collaboration within sectors (e.g., among different units in a ministry) to improve
efforts within educational systems
• Cost of programs and advocate for sustainable financing
• Strengthen human resources (e.g., develop training curricula and modules for
preservice teacher training)
• Share good practices from other countries (within Arab region and beyond)
Conclusions
The following actions are important for follow-up at national and regional levels in
the Arab nations:
1. Increase the understanding of how different cultures and various diversities affect
the development, implementation, and maintenance of school health programs
and approaches
2. Conduct a situation analysis and prepare country profiles (especially if African
Arab countries)
3. Set up a school health technical expert group
4. Advocate for the importance of comprehensive and integrated school health
programs packages (including the development of integrated packages)
5. Ensure that decision-makers pay attention to school health based on evidence-
based practices
6. Prioritize issues that are important by country/regional context, including
research in human resources (e.g., examining the impact of school health
among students at the population level)
7. Improve the collection of baseline health information data (e.g., expanding target
populations from secondary to preschool and primary school children in statisti-
cal surveys, such as the Health Behavior in School-aged Children Survey and the
Global School-based Student Health Survey), and make better use of data and
monitoring/reporting surveys and data sources/reports in decision-making
8. Study the effectiveness of school-based interventions, such as the contribution
harm reduction in schools related to things such as tobacco control interventions,
or school health deworming programs
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The Health of Arab Americans in the
United States 32
An Update
Nadia N. Abuelezam and Abdulrahman M. El-Sayed
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 740
Arab Americans in the United States . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 741
State of the Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 742
Health Behaviors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 742
Tobacco Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 742
Physical Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 743
Alcohol and Drug Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 744
Vaccination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 745
Morbidity Clusters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 745
Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 745
Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 747
Women’s and Children’s Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 748
Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 750
Cardiovascular Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 752
Other Health Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 753
Populations of Interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 754
Elderly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 754
Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 754
Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 755
Future Research Directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 756
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 757
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 757
N. N. Abuelezam (*)
Boston College, William F. Connell School of Nursing, Chestnut Hill, MA, USA
e-mail: nadia.abuelezam@bc.edu
A. M. El-Sayed
Wayne State University, Detroit, MI, USA
e-mail: elsayeda@detroitmi.gov; abdul.m.elsayed@gmail.com

https://doi.org/10.1007/978-3-030-36811-1_35
740 N. N. Abuelezam and A. M. El-Sayed
Abstract
A comprehensive review of the Arab American health literature is presented
alongside recommendations for future research to better understand the health
needs of this minority population in the United States. Health literature is
reviewed by health behavior (vaccination, tobacco use, drug and alcohol use,
and physical activity), health outcome (diabetes, mental health, cardiovascular
disease, cancer, and women’s and children’s health), and population at increased
risk of poor health outcomes (adolescents and the elderly). A description of the
methodological challenges to undertaking research on the health needs of Arab
Americans is also presented.
Keywords
Arab Americans · Minority health · Arab health · Health behaviors · Health
outcomes · Vulnerable populations · Methodology
Introduction
The population of the United States is composed of many immigrant groups from
almost all parts of the world. One group that is historically represented but
invisible in conversations of race and ethnicity are Arab Americans. The classi-
fication of Arab Americans within the United States’ racial schema as “white”
makes them invisible as a minority group, but politics, war, and violence in the
Middle East and stigmatizing representation in the media makes Arabs highly
visible within American society. This discrepancy of being highly visible and
stigmatized alongside a general lack of visibility in official documents or health
records places Arab Americans in an interesting position in the healthcare system
(Jamal and Naber 2008). The work on understanding the health needs of Arab
American in the United States has lagged behind that of other immigrant sub-
groups primarily due to an inability to identify and isolate groups of Arab
Americans from official forms and surveys. This nascent and developing literature
provides an interesting examination of the impact of race and culture on health of
this minority population in the United States.
This review provides an updated comprehensive assessment of the peer-reviewed
literature on the health of Arab Americans living in the United States and summa-
rizes key health indicators in this population. While a systematic review of the Arab
American health literature was provided in 2009 (El-Sayed and Galea 2009b), we
aim to update this review with information on more recently published studies in this
population, to synthesize current knowledge about health risks facing Arab Amer-
icans to better inform interventions for this vulnerable population, and to encourage
additional research.
32 The Health of Arab Americans in the United States 741
Arab Americans in the United States
Arab Americans are those individuals with ancestral, cultural, ethnic, linguistic,
familial ties or heritage to one or more of the 22 Arab League countries. It is
estimated that there are approximately 3.5 million Arab Americans living in the
United States (Arab American Demographics. Arab American Institute Foundation
2014). Arabs are disproportionately represented among recent immigrants to the
United States due to war and instability in the Middle East. Arab Americans have
diverse composition, with many Arab Americans living in ethnic enclaves, like
Dearborn Michigan, and others living all across the United States. Further, the
diversity in country of origin of Arab immigrants makes understanding health
indicators difficult, as the differences in health outcomes among Arabic League
countries can be disparate. Social determinants in these countries vary dramatically
from high poverty and war torn to highly affluent and stable. Arab Americans have
varied nativity in the United States: foreign born (first generation), US-born children
of immigrants (1.5 and second generation), or US born to US-born parents (third and
greater generations) (Brittingham and De la Cruz 2005). The diversity in country of
origin, geographic location, tenure in the United States, and acculturation makes
studying Arab Americans difficult and the task of generally understanding Arab
American health monumental.
While a history of Arab American immigration to the United States has been
published elsewhere (Orfalea 2006), we provide a brief overview to contextualize
our findings. Arabs from the Middle East began immigrating to the United States as
early as the late 1800s and early 1900s. Three major waves of Arab immigration to
the United States are often cited: the early wave of primarily Christian laborers and
merchants from Lebanon and Syria who immigrated to better their economic
situations, the second wave after WWII and the establishment of the state of Israel
of Muslims and other displaced Arabs, and the third wave of immigrants aiming to
escape war and instability in their home countries (Awad 2010; Jamal and Naber
2008). Prior to the 1940s, the position of Arab immigrants in the US racial system
was unclear if not ambiguous (Jamal and Naber 2008). The Census Bureau decided
in the 1940s that Arab Americans were to be treated like other European immigrant
communities (Hassan 2002). The Office of Management and Budget of the US
government has outlined that Arab Americans belong to the “White” racial category,
as having origins from the Middle East (Executive Office of the President, Office of
Management and Budget (OMB), Office of Information and Regulatory Affairs.
Standard for the Classification of Federal Data on Race and Ethnicity 1995). Arab
American organizations and community members began advocating for a dedicated
Middle East and North African (MENA) identifier on the US Census in the 1990s
(Karoub 2015). A test of this category was done on the 2015 Census, but recently the
US Census decided not to include the MENA category on the 2020 Census (Using
Two Separate Questions for Race and Ethnicity in 2018 End-to-End Census 2018).
State of the Literature
Since the publication of the last systematic review, 169 papers have been published
accounting for 68% of all publications reviewed. We organize our findings around
health behaviors, health outcomes, and populations of interest. We examine health
behaviors among Arab Americans including tobacco use, physical activity, alcohol
and drug use, and vaccination. We examine seven morbidity clusters for health
outcomes including diabetes, mental health, women’s and children’s health, cancer,
cardiovascular disease, and other health outcomes. Finally, we examine two distinct
populations of interest for Arab American health: adolescents and the elderly.
Papers describing the health of Somali immigrants and their descendants in the
United States (N = 66, 27%) accounted for the largest immigrant subgroup, while
Iraqi immigrants (N = 39, 16%) accounted for the second largest subgroup in recent
literature. Nearly half of all papers examined the health of a mix of countries of
origin or did not specify the composition of the groups they included (N = 122,
49%). The number of US cities and regions in which Arab American health research
is taking place has expanded since the last systematic review. While the majority of
studies are still being undertaken in Michigan (N = 90, 36%), many other states are
represented in the literature including Minnesota (N = 30, 12%), California (N = 11,
5%), New York (N = 8, 3%), and Virginia (N = 4, 2%). Eight studies have studied
national samples of Arab Americans (3%), while some studies examined Arab
Americans from multiple cities (N = 9, 4%).
The epidemiologic composition of publications examined has shifted dramati-
cally since the last systematic review was written. There has been an increase in the
number of studies testing interventions (N = 15, 6%) and the number of longitudinal
studies (N = 30, 12%) among Arab Americans. Novel methodologies like snowball
sampling (N = 13, 5%) and web-based surveys (N = 3, 1%) were also used in
addition to more traditional qualitative methods like focus groups (N = 77, 31%).
Health Behaviors
Before understanding the burden of disease in the defined morbidity clusters, it is

important to understand the health behaviors commonly found among Arab Amer-
icans. These health behaviors can serve as risk factors and precursors to the mor-
bidity discussed later in this chapter.
Tobacco Use
Research regarding tobacco use and addiction has had a strong foothold and
publishing record in the Arab American health literature. The first study on
Arab American smoking prevalence occurred in 1992 and aimed to estimate
community prevalence among Arab Americans (38.9%) in Michigan (Rice and
Kulwicki 1992). Since that first study was published, a number of other studies
have examined the prevalence of smoking among Arab American populations,

primarily in the Michigan area (Kulwicki et al. 2007; Templin et al. 2005), but
also in Houston, Minnesota, and Virginia (Athamneh et al. 2015; El-Shahawy and
Haddad 2015; Giuliani et al. 2012) with smoking prevalence ranging from 6% to
45%. Generally, it has been found that less assimilated Arab Americans have a
higher dependence on nicotine and tobacco products with the use of tobacco
correlating negatively with time spent in the United States (Al-Omari and
Scheibmeir 2009).
More recent literature aims to understand the predictors of water pipe smoking
and of quitting smoking in Arab American populations. Generally, very little
evidence has been found that Arab Americans desire to quit water pipe smoking
(Athamneh et al. 2015). An intervention study performed in a Midwest school aimed
at discouraging high school students from starting smoking or continuing smoking
showed improvements in non-Arab American and Arab American teens (Rice et al.
2010). Arab American students were generally less likely to have ever, currently, or
regularly smoke than their non-Arab counterparts (Rice et al. 2010). Additionally,
one intervention study aimed to understand the impact of a culturally tailored
smoking cessation program for Arab American males (Haddad and Corcoran
2013). While the study managed to develop materials, they were not able to prove
the efficacy of their intervention.
Future studies should aim to perform smoking cessation interventions and edu-
cational campaigns in this vulnerable population to aim to reduce smoking preva-
lence. International studies may aim to reduce smoking and increase cessation in
Middle Eastern countries in order to better support cessation among immigrants to
the United States. Educating adolescents (and adults) about the risks associated with
water pipe smoking will also be important given the relatively low proportion
interest in quitting.
Physical Activity
Despite strong support for physical activity and self care in both Islamic and
Christian religious texts, physical activity practices among Arab Americans are
under researched and relatively unknown (Devlin et al. 2012). Immigration status,
religion, and other acculturation factors play a role in the amount of physical activity
Arab American participate in. Most of the studies performed to understand physical
activity among Arab Americans are from small convenience samples often
performed at religious sites, or samples are pulled from religious communities.
Further, many of these samples are taken from ethnic enclaves and areas where a
large number of Arab immigrants live. Some studies have examined the impact of
acculturation on physical activity and found that individuals with lower American
acculturation tended to have less physical activity (Kahan 2011) while those found to
be more acculturated tended to participate in more physical activities (Aqtash and
Van Servellen 2013). Further, some barriers to physical activity have been identified
including a lack of knowledge about how to use machines at the gym (Mohamed
et al. 2014), lack of money for gym memberships (Dharod et al. 2013), and mixed
cultural messaging on body image (Kahan 2011).
There are many ways that public health and medical practitioners can improve
physical activity among Arab Americans including culturally competent physical
activity promotion in Arab American enclaves (Mohamed et al. 2014), providing
gym membership subsidies to those who cannot afford gym membership costs
(Mohamed et al. 2014), understanding the coping mechanisms for stress in the
Arab American community (Dharod et al. 2013), and increasing the availability of
women’s only exercise opportunities to increase participation by Muslim and immi-
grant Arab women (Devlin et al. 2012). More research should be conducted to
understand the physical activity practices of non-Muslim Arab women and first-
and second-generation Arabs and understand the attitudes and beliefs shaping
physical activity among Arab American adolescents.
Alcohol and Drug Use
While there is some research aiming to understand alcohol and drug use patterns
among Arab Americans, many research gaps remain. A study aimed at estimating
the prevalence of binge drinking among Arab Americans at both national and state
levels found that nationally Arab Americans had lower prevalence of lifetime
alcohol consumption and consumption in the last month than non-Hispanic Whites
(Arfken et al. 2011). The national data also showed that Arab American men were
1.78 times more likely to have had alcohol in their lifetime than women (Arfken et al.
2011). The investigators examined alcohol use in Michigan from the Behavior Risk
Factor Survey (BRFS) and found that while past month alcohol use was lower
among Arab Americans than non-Hispanic Whites, binge drinking in the past
month and heavy alcohol consumption prevalence among Arab Americans were
similar to that of non-Hispanic Whites (Arfken et al. 2011). An exploratory quali-
tative study performed by the same investigators aimed to understand the potential
reasons for this discrepancy found that alcohol was easily accessible in Arab
American communities and environments in Michigan, that social pressures encour-
aged people to drink at social gatherings, and that populations that were more highly
acculturated tended to have higher drinking prevalence than those who were not
(Arfken et al. 2012). Some research has been done to understand the low represen-
tation of Arab Americans in substance abuse treatment centers in Michigan (Arfken
et al. 2008). Researchers found that this was not an underreporting issue but rather
language and cultural barriers prevented Arab Americans from enrolling in these
programs (Arfken et al. 2009). Given the large amount of attention paid to the
current opioid and injection drug use epidemic in the United States (Hansen and
Netherland 2016), more research is needed to understand the risks for Arab Amer-
icans and the interventions that may reduce harm from alcohol and drug use in this
population.
Vaccination
Research on vaccination behavior among Arab Americans lacks behind our knowl-
edge of vaccination among other immigrant and minority groups (Burger et al. 2017;
Fry et al. 2016; Galbraith et al. 2016). A study with data from a national health
survey found that Arab Americans had lower estimated rates of recommended
vaccinations (flu and pneumonia) when compared to non-Hispanic Whites (Dallo
and Kindratt 2015). Human papilloma virus is known to cause cervical cancer
among adolescents in the United States; a great deal of research is currently being
undertaken to better understand why certain minority populations in the United
States do or do not take up the human papilloma virus vaccine (Galbraith et al.
2016). Only one study among Somali adolescents in Minnesota examines the uptake
of human papilloma virus vaccinations. This study showed that while Somali
adolescents are accepting the vaccine, they are less likely to complete the vaccine
series when compared to non-Arab, non-Hispanic Whites in the same area (Pruitt
et al. 2013). More research is needed to help contextualize choices Arab Americans
make around vaccination for their children and for themselves. Additionally, cultur-
ally competent interventions to improve vaccination rates in ethnic enclaves should
also be undertaken.
Morbidity Clusters
We now examine the burden of disease, knowledge, and barriers to care for the
following morbidity clusters: diabetes, mental health, women’s and children’s
health, cancer, cardiovascular disease, and other health issues.
Diabetes
The literature on diabetes in Arab American populations has matured over time with
older papers estimating burden and more recent papers focusing on the potential for
intervention in Arab American populations.
Burden of Disease: Estimates of diabetes prevalence in Arab American
populations range from 4.8 to 23% (Dallo and Borrell 2006; Jaber et al. 2003,
2004). Diabetes rates in Somalia are the lowest in the Middle East, but immigration,
eating patterns, and physical activity habits of Somalis in the United States have
influenced their diabetes risk and put them at increased odds of diabetes (Njeru et al.
2016a, b). Due to the high prevalence of diabetes and higher odds of diabetes when
compared to non-Arab, non-Hispanic Whites found in many Arab American
populations, including Somali Americans (Njeru et al. 2016b), researchers have
examined biological and genetic pathways for these differences. Specifically, work
has found that vitamin D insufficiency and hypovitaminosis D are common among
Arab Americans and are linked to insulin resistance, metabolic syndrome, and
glucose intolerance in Arab American men (Pinelli et al. 2010b). Metabolic defects
may also exist among Arab Americans suggesting that interventions enhancing
insulin sensitivity and preserving beta-cell function may be efficacious (Salinitri
et al. 2013). Researchers have also hypothesized that differences in disease burden
may also be a result of lack of knowledge and care in this marginalized population.
Knowledge and Barriers to Care: A number of studies have found a lack of
appropriate diabetes education tools for Arab Americans (Bertran et al. 2015; Fritz
et al. 2016). Cultural and linguistic deficiencies in the existing educational literature
may be preventing Arab Americans from fully understanding their risk for diabetes
and their ability to improve their health. Additionally, researchers found conflicting
evidence that the patient provider power dynamic improves diabetes outcomes
among Arab American patients, with some citing an inability to learn from their
providers (Bertran et al. 2015; Fritz et al. 2016). Cost and access to appropriate
healthcare were barriers identified in a number of studies (Bertran et al. 2017).
Acculturation was found to influence diabetes control differently for men than for
women. Negative associations between Arab acculturation and diabetes risk were
found among Arab American men, while American acculturation was found to be
associated with diabetes risk among women (Al-Dahir et al. 2013). There were some
religious barriers to diabetes control. Some woman cited concerns about modesty
that prevented them from exercising properly (Bertran et al. 2015). Ramadan poses a
potential barrier to diabetes control in this population as well (Pinelli and Jaber
2011).
Interventions: One of the first intervention studies implemented among Arab
Americans was the adapted Diabetes Prevention Program (DPP) group lifestyle
intervention (Jaber et al. 2011; Pinelli et al. 2011). The DPP was tailored linguisti-
cally and culturally to Arab American populations in the Dearborn Michigan area to
encourage individuals to lose weight and understand their risk for diabetes. The
program was successful, with individuals losing weight if they had family support
and were appropriately educated on the benefits of the program. This intervention
was one of the first successful implementations of intervention research in the Arab
American community. The authors attribute their success to targeting gaps in
knowledge and reducing misconceptions in recruiting and promoting participation.
Arab Americans who perceived they were at increased risk of diabetes were more
willing to participate in a lifestyle intervention than those who did not perceive they
were at risk (Pinelli et al. 2010a).
While the majority of studies focusing on diabetes among Arab Americans relied
on cross-sectional data or focus groups in the Dearborn Michigan area, one of the
first interventions among Arab Americans to change lifestyle patterns influencing
diabetes risk was conducted. Improving the availability of culturally and linguisti-
cally appropriate care and educational material and having access to Arabic speaking
providers may help improve diabetes outcomes in Arab American populations.
Future work should aim to prevent diabetes from occurring, develop culturally
appropriate interventions to help detect diabetes early, and understand diabetes
health outcomes among older Arab Americans.
Mental Health
Research on mental health outcomes and the needs of Arab Americans with regard to
mental health has increased since September 11. While discrimination against Arab
Americans is not new, discrimination and stigmatization have increased in the
United States over the past two decades (Amer and Hovey 2012). Additionally,
many Arab immigrants come to the United States from war-torn and conflict-ridden
regions increasing their exposure to traumatic and stressful experiences. The current
and divisive political climate makes the study of Arab American experiences with
discrimination and trauma ever more important to improving the health needs of this
population.
Burden of Disease: Studies have documented higher incidence of psychological
distress in the years following September 11 among Arab Americans (Padela and
Heisler 2010). The overall prevalence of depression and other adverse mental health
outcomes in Arab Americans is still relatively unknown. Recent studies among Arab
American adolescents estimate that 14% of Arab Americans living in the Dearborn
ethnic enclave are diagnosed with depression (Jaber et al. 2015), while another
online study found that 50% of Arab American respondents met criteria for depres-
sion (Amer and Hovey 2012). In particular, studies among Iraqi refugees suggest that
this group is at particularly high risk for PTSD and overall health problems (Jamil
et al. 2002) and that a longer tenure in the United States is associated with increased
depression for this population (Taylor et al. 2014). The effort to estimate this
psychological burden is deterred by a number of methodological challenges includ-
ing the inability to easily identify Arab populations (Abuelezam et al. 2017), the
negative cultural attitudes toward counseling and psychotherapy (Abu-Ras and Abu-
Bader 2008; Awad 2010; Ellis et al. 2010a, b; Martin 2014), and the lack of targeted
and culturally competent mental health services (Abu-Ras and Abu-Bader 2008;
Amer and Hovey 2007) for Arab Americans.
Predictors and Barriers to Care: Stigma is a particularly strong predictor of poor
mental health outcomes (Kira et al. 2014), especially when stigma is internalized.
Discrimination is the primary predictor of psychological distress among Arab
Americans (Abdulrahim et al. 2012). Recent research on resilience suggests that it
is inversely related to psychological distress among Iraqi refugees in the United
States (Arnetz et al. 2013). Media consumption is also related to poor mental health
outcomes in first-generation Arab immigrants (Samari 2016).
Anti-Arab sentiment has been associated with poor mental health outcomes
including depression, distress, and unhappiness in Arab American populations
(Abdulrahim et al. 2012; Padela and Heisler 2010). Recent studies examine the
relationship between immigrant generation and other immigration-related variables
including cross-border associations. Samari notes that cross-border ties are associ-
ated with greater odds of distress for all generations of Arab Americans, but the
participation in cross-border organizations increases the odds of being happy in this
group (Samari 2016).
Stress, specifically related to migration and the immigration experience, was
examined among a group of Arab immigrant woman and found that post-
immigration-related stressors were correlated with depression and PTSD (Norris

et al. 2011). In a study of Iraqi immigrants, pre-migration trauma was associated with
higher rates of depression and PTSD (Arnetz et al. 2012). In one of the only
randomized clinical trial reviewed, Iraqi refugees who had experienced post-
traumatic stress were randomized to brief narrative exposure therapy or control
(Hijazi et al. 2014). Investigators found that those who received brief narrative
exposure therapy had greater posttraumatic growth and increased well-being along-
side reduced symptomology for depression (Hijazi et al. 2014). Evidence suggests
that there are challenges to psychotherapy for Arab Americans including hesitancy
in discussing family problems outside of the family and a hesitancy to seek treat-
ment. When individuals do seek therapy, therapists report a large amount of
intergenerational conflicts and a difficulty to adjust to mainstream culture as primary
complaints (Martin 2014).
Collecting data on religion should become a regular part of studies on mental
health among Arab Americans. Evidence shows that assimilated Muslim Arab
Americans experience higher levels of discrimination compared to their less assim-
ilated counterparts and assimilated Christian Arab Americans (Awad 2010). A better
understanding of the role of religion could lead to productive collaborations between
mental health providers and faith-based institutions. Future studies should aim to
understand the potential impact of resilience on Arab American mental health.
Studies on mental health in this population rely heavily on older surveys, including
the 2003 Detroit Arab American Study (Abdulrahim et al. 2012; Samari 2016). Most
studies performed among Arab Americans rely on self-reported measures of depres-
sion and poor mental health suggesting that results can potentially be biased or
inaccurate.
Women’s and Children’s Health
The research in Arab American women’s and children’s health is primarily focused
on intimate partner violence, sexual health, obstetrics, and birth outcomes.
Intimate Partner Violence: The prevalence of intimate partner violence in Arab
American communities is not clear from the literature. Some studies have found high
prevalence of intimate partner violence in Arab American communities (Barkho et
al. 2011). Generally, Arab American women who have been exposed to intimate
partner violence are at higher risk of depression (Kulwicki et al. 2015). Women who
have experienced intimate partner violence have many barriers to receiving care and
support including language barriers, fear associated with discrimination, lack of
culturally sensitive help, and a lack of trust of American providers (Barkho et al.
2011; Kulwicki et al. 2010). There is mixed evidence for police intervention and the
use of shelters for Arab American women (Kulwicki et al. 2010). Some work has
been done to understand the structural causes of intimate partner violence in Arab
American populations including dependence on male relationships for stability and
safety post immigration (Kulwicki et al. 2010), patriarchal Arab culture, the lack of
cultural support for seeking marital help outside of the family (Kulwicki et al. 2015),
and family honor and blaming (Abu-Ras 2007; Kulwicki et al. 2010). There is
generally a critical need for domestic violence awareness and prevention programs
in Arab American populations (Kulwicki and Miller 1999). Additionally, educating
women about their rights and the care available to them may improve health seeking
behavior alongside the increase in culturally competent healthcare providers for
Arab American patients (Abu-Ras 2007; Barkho et al. 2011; Kulwicki et al. 2010).
Empowering women to take control of their health and the care they seek would be
an important way forward.
Female Genital Mutilation and Sexual Health: The majority of the literature
regarding the sexual healthcare needs of Arab American women focuses on Somali
women and those who have experienced female genital mutilation. Female genital
mutilation is the practice of partially or totally removing external genitalia of young
girls and women for nonmedical reasons (World Health Organization 2018). This
practice is common in 30 countries in Africa, the Middle East, and Asia (World
Health Organization 2018). Recent media coverage and attention by the public
health community have shed light on the health ramifications of the practice includ-
ing sexual problems, pain, scar tissue, and psychological problems (World Health
Organization 2018). The prevalence and practice of female genital mutilation in the
United States is low and rare (Connor et al. 2016; McNeely and Christie-de Jong
2016), but the number of those who come to the United States having experienced
this in other countries is high (Connor et al. 2016). More research is needed in more
diverse populations to understand the FGM practices in the United States and their
impact on Arab American women’s sexual health.
Knowledge and care for sexually transmitted diseases and HIV among Arab
Americans is relatively low. While research studies that examine the sexual health
needs of Arab American women are limited, a study performed among Somali
immigrants found low knowledge of STI/HIV risk factors, low condom use, and
low incidence of extramarital sex (Connor et al. 2016). More studies are needed to
understand the risk factors for sexual risk taking in this population; the risk of
sexually transmitted infections among first-, second-, and third-generation immi-
grants; and the changes to perceptions and beliefs on sexual health among Arab
American immigrants.
Obstetrics: Understanding the birth experiences and needs of Arab American
women is a relatively understudied topic, despite evidence that there are differences
in birth outcomes for Arab American women and non-Arab, non-Hispanic White
women. All studies aiming to understand the obstetric needs of Arab Americans
focused on Somali American populations. Some of the results may be generalizable
to other Arab American subpopulations. Among Somali refugees, women prefer
little obstetric intervention (Brown et al. 2010) and clinicians who are more conser-
vative with the use of C-sections (Beine et al. 1995; Johnson-Agbakwu et al. 2014).
Some authors have noted that this is due to the fact that many women feel that in
Somalia death after obstetric intervention is common (Brown et al. 2010) and many
feel there is a risk of not having future children after intervention (Ameresekere et al.
2011). Prenatal education and programs helping mothers understand the options for
obstetric care and reducing language barriers between patients and providers could
reduce adverse obstetric outcomes (DeStephano et al. 2010; Herrel et al. 2004;
Jacoby et al. 2015).
Birth: Arab immigrants have lower odds of preterm birth than US-born mothers
(El-Sayed and Galea 2011). This trend is not unique to Arab Americans but to many
immigrant groups (Singh and Yu 1996). Some theorize that the reasons for this
difference in preterm birth include the fact that immigrants who are able to immi-
grate to the United States are those that are healthy (Wingate and Alexander 2006).
Arab mothers tend to be healthier than non-Arab mothers with less tobacco use (El-
Sayed and Galea 2009a), less pregnancy-related hypertension and diabetes (El Reda
et al. 2007), lower rates of birth defects (Yanni et al. 2010), and more consistent
prenatal care (Ma et al. 2013). Somali women in particular faced poorer obstetric
outcomes due to poorer prenatal care (Johnson-Agbakwu et al. 2014) and feeling
vulnerable and uninformed, but their outcomes improved with doula support
(Wojnar 2015). While there is great interest in whether or not adverse birth outcomes
increased after September 11, El-Sayed (2008) did not find evidence of increased
adverse birth outcomes after September 11 despite showing that stress and discrim-
ination increase this risk among Arab mothers (El-Sayed and Galea 2010).
Cancer
Cancer rates among Arab American populations are relatively unknown, although
the majority of work in this field has focused on breast cancer.
Breast Cancer: Our literature review yielded a large number of papers examining
breast cancer among Arab American women. The majority of these papers discussed
the barriers to screening and treatment in this population, while a few papers
examined disease progression and incidence. It is important to note that many of
the papers examining breast cancer among Arab Americans also included other
minority populations like African Americans and Latina Americans as comparison
groups in the analyses. This type of comparison across populations of color in the
United States may help public health practitioners develop more culturally compe-
tent care plans. This is also the primary way investigators attain funding for Arab
American health studies.
Whether or not Arab Americans have a higher breast cancer-associated mortality
rate than non-Arab, non-Hispanic Whites is unclear. Evidence has been found in
both directions (Hensley Alford et al. 2009; Kawar 2009). Arab American women
tend to be diagnosed at a later stage of breast cancer and yet have higher overall
survival than European and American women (Arshad et al. 2011; Hirko et al. 2013).
Barriers to breast cancer screening for Arab Americans include immigration-related
barriers, fear, lack of knowledge, and access issues (Al-Amoudi et al. 2015; Kawar
2013; Petro-Nustas et al. 2012; Saadi et al. 2012, 2015; Williams et al. 2011). Arab
American women with higher levels of education and who have lived in the United
States for long periods of time are more likely to get screened for breast cancer than
their counterparts (Padela et al. 2015). Fatalism and religious beliefs have been cited
by some authors as barriers to breast cancer screening (Obeidat et al. 2012). A recent
study by Padela et al. found no correlation between fatalism and screening rates
among Arab Americans. This study suggests a more unified approach to understand-
ing the impact of fatalism of health behaviors in Arab Americans including a call for
a unified definition of fatalism (Padela et al. 2015).
Other Cancer: Studies examining the perceptions of cancer among Arab Amer-
icans found that education, employment status, and the length of time one spends in
the United States affect one’s knowledge of cancer and screening (Dallo et al. 2011).
Many Arab Americans generally fear cancer (Elmubarak et al. 2005), and some
believe in keeping cancer diagnoses a secret in order to protect the image of the
family in social settings (Mellon et al. 2013). In one study of Arab American men
and women, women were found to be more knowledgeable about the modifiable risk
factors associated with cancer but that changing food habits was a point of concern
for many in the study (Elmubarak et al. 2005). To improve perceptions and knowl-
edge about cancer in Arab American populations, community educational programs
targeting practices and knowledge within the Arab American community may help
create change and awareness of risks (Dallo et al. 2011; Mellon et al. 2013).
The barriers to screening and treatment of cancer among Arab Americans include
lack of knowledge (Ghebre et al. 2015; Raymond et al. 2014; Sewali et al. 2015b;
Talaat 2015), religious and cultural beliefs about sickness (Ghebre et al. 2015;
Sewali et al. 2015a), fear and embarrassment (Elmubarak et al. 2005; Raymond et
al. 2014), language (Sewali et al. 2015a, b), lack of culturally sensitive healthcare
providers (Ghebre et al. 2015), lack of access to healthcare (Morrison et al. 2013),
and a need to maintain secrecy of sickness or disease (Mellon et al. 2013). Commu-
nity-based participatory research was conducted among Arab Americans to address
cancer education, prevention, and screening (Vicini et al. 2012). This type of
research was successful and found to increase cancer screening rates among an
Arab American community in Detroit and can be used in future studies aiming to
improve education and screening of other diseases.
Studies that aim to estimate the incidence of particular cancers primarily focused
on two comparisons: comparisons within Arab Americans (place of birth, gender,
and country of origin) and comparing Arab American incidence to non-Hispanic,
non-Arab White cancer incidence. Differences were observed in the incidence of
cancer between foreign-born and US-born Arab Americans and also between male
and female Arab Americans (Khan et al. 2013). Differences of cancer incidence by
country of origin were also found (Schwartz et al. 2004). Arab Americans, especially
women, are at increased risk for thyroid cancer (Bergmans et al. 2014; Khan et al.
2013; Peterson et al. 2011; Schwartz et al. 2004). Arab American men were found to
have an increased risk of lung and prostate cancer when compared to Hispanic men,
but lower rates when compared to Black men (Bergmans et al. 2014). Manifestations
of cancer may also differ with Arab American men suffering from higher urinary
incontinence associated with prostate cancer than White men (Moussawi et al.
2013). Arab American men have higher rates of bladder cancer than both Hispanic
and black men (Bergmans et al. 2014).
Risk factors for cancers differ between Arab American and non-Hispanic, non-
Arab White women. White women tend to have a higher incidence of
hormone exposure, tobacco, and alcohol use, while Arab American women have
high vitamin D-related deficiency and radiation exposure (Peterson et al. 2011).
Additionally, some studies found that Arab Americans had lower socioeconomic
status and general health status when compared to White populations (Moussawi
et al. 2013). The geographic separation of Arab American populations and the lack
of a racial identifier make it difficult to find representative samples of Arab Amer-
icans for study (Bergmans et al. 2014; Khan et al. 2013; Moussawi et al. 2013). In
particular, the use of surname algorithms, a method used particularly in Arab
American cancer research, creates room for error (Schwartz et al. 2004). Future
studies should aim to understand the genetic, epigenetic, and environmental risk
factors that contribute to Arab American cancer incidence (Khan et al. 2013;
Moussawi et al. 2013).
There is a surprising lack of reliable and nationally representative data on cardio-

vascular disease among Arab Americans. Despite the fact that Arab Americans are
generally cited to have higher cardiovascular disease risk than the general popula-
tion, there is little evidence for this from the existing literature.
Burden of Disease: Prevalence of self-reported hypertension among Arab Amer-
icans (13.4%) was found to be lower than prevalence among non-Hispanic Whites
(24.5%) in an analysis of the 2000–2003 National Health Interview Survey (Dallo
and Borrell 2006). A cross-sectional descriptive study among Arab Americans in
Southern California found a high prevalence of hypertension (36.5% and 39.7% pre-
hypertensive) (Tailakh et al. 2013). The differences in magnitude between these two
estimates emphasize the importance of not generalizing prevalence values from
convenience samples but aiming to understand nationally representative prevalence
where possible.
A cross-sectional study among Arab Americans in Michigan found an overall
prevalence of self-reported heart disease of 7.1% and that Arab Americans were four
times more likely to have heart disease than Black Americans in this sample (Jamil
et al. 2008). Another study aimed to show that Arab Americans had increased
cardiovascular reactivity and slower recovery from stress that lead to a higher
prevalence of hypertension and cardiovascular risk factors than other minority
groups (Chatkoff and Leonard 2009). While this study was not able to support this
hypothesis, they were able to show that Arab Americans had slower heart rate
recovery and less reactivity suggesting chronic stress was present (Chatkoff and
Leonard 2009).
Studies of hypercholesterolemia found prevalence ranged from 24.6% to 44.8%
among Arab Americans in various national- and community-level convenience
samples (Al-Dahir et al. 2013; Jamil et al. 2009). These numbers are well below
the national average of 50.4% hypercholesterolemia in the United States population
but are not rigorous prevalence estimates using national and representative sampling
methods (Jamil et al. 2009).
Knowledge and Barriers to Care: Tailakh and colleagues attempted to under-

stand the awareness of hypertension among a cross-sectional sample of Arab
Americans in Southern California and determined that only 67.4% were aware of
their hypertension and 52.2% were taking their antihypertensive medication (with
46% of those on medication having controlled blood pressure) (Tailakh et al. 2013).
More information is needed about how access to healthcare impacts Arab Americans
ability to properly care for their cardiovascular disease and attain appropriate
medications. Adherence to medication is also not known and should be studied.
Interventions: To our knowledge, no interventions have been tested to alter
cardiovascular status among Arab Americans or influence the risk of developing
cardiovascular disease in this population. This is in contrast to the numerous studies
developing interventions to improve cardiovascular disease in the United States in
other populations. While there is no mechanistic reason why interventions developed
in other communities would not be transferrable to Arab Americans, it will be
important to develop culturally relevant cardiovascular disease interventions for
this population.
Novel studies in this area aim to understand the relationship between cardiovas-
cular diseases and other chronic diseases like asthma through environmentally
induced pathways (Johnson et al. 2010). Moving away from self-reported cardio-
vascular disease will be important to understanding true prevalence of cardiovascu-
lar disease in this at-risk population. Specifically, identifying Arab Americans in
large national and regional datasets may help us understand their cardiovascular
risks and needs.
Other Health Issues
Other health issues identified in the Arab American health literature include infec-
tious diseases and asthma.
Infectious Disease: The majority of research on infectious disease outcomes
among Arab Americans focuses on Somali immigrant populations in the Minnesota
area (Kempainen et al. 2001; Rock et al. 2006). More recent literature examines
hepatitis C among Somali immigrants in Minnesota and among Arabs in Southeast
Michigan. Somali immigrants in Minnesota had high rates of hepatitis and hepato-
cellular carcinoma suggesting targeted interventions are needed for this population
(Shire et al. 2012). The prevalence of hepatitis C virus antibodies among Arab
Americans in Southeast Michigan was found to be triple the national average
(5.4%) suggesting the need for more studies assessing the burden of hepatitis C in
this community (Jamil et al. 2013).
Asthma: Asthma prevalence has been found to vary by racial and ethnic groups
in the United States (Gold and Wright 2005). Evidence from recent studies shows
that Arab Americans tend to have lower prevalence of asthma (9.4%) than other
racial and ethnic minorities including non-Hispanic Whites and Black Americans
(14.4%) (Jamil et al. 2011). An important initiative, the Arab American Environ-
mental Health Project (AAEHP) aimed to understand the impact of the environment
on health among Arab American populations. One of the first studies published from
this interdisciplinary project suggested that asthma prevalence was higher than
previously reported among Arab Americans (16%) but that asthma was more
strongly correlated with environmental exposure among those with hypertension
(Johnson et al. 2010). Asthma management was also found to vary by English
language fluency and acculturation variables, suggesting targeted interventions
may need to be put in place to help those Arab Americans affected by asthma
(Johnson et al. 2005).
Populations of Interest
While many studies focus attention on the adult Arab American population in the
United States, there are at-risk populations within this community requiring special
examination.
Elderly
Global demographics have shifted such that life expectancies are longer and many
countries and populations are experiencing aging. The attention paid to the needs of
elderly Arab Americans in the public health literature is minimal. Better understand-
ing the healthcare, social, and medical needs of the aging Arab American population
in the United States is an important and urgent area of study. In our literature review,
only three papers examined the needs of older Arab Americans. While Dallo and
colleagues found a reduced likelihood of reporting a disability among Arab Amer-
icans when compared to other groups of color in the United States (Dallo et al.
2015), Ajrouch synthesizes information from a face-to-face survey and finds that
well-being varies with social capital for Arab American elders (Ajrouch 2007). More
work is needed in this area to understand how to best care for aging Arab Americans
and ensure their mental and physical well-being.
Adolescents
A burgeoning area of research among Arab Americans is to better understand

adolescent health needs. Adolescent Arab Americans are mostly composed of
second-generation Arab Americans, born in the United States to immigrant parents.
In a large sample of Arab American adolescents, Ahmed et al. (2011) found that
there was a strong relationship between perceived discrimination and poor mental
health among adolescents. Further, adolescents reporting more religious coping,
strong ethnic identity, and religious support were found less likely to be psycholog-
ically distressed (Ahmed et al. 2011). An analysis by Aroian and colleagues (2009)
found that the quality of the mother-adolescent relationship was the most important
predictor of adolescent behavior and stress (Aroian et al. 2009). Adolescents
experience a great deal of discrimination from teachers, school administrators, and

their classmates suggesting the need for more dedicated research on how discrimi-
nation impacts adolescents (Aroian 2012). A recent analysis by Munro-Kramer et al.
found two distinct subgroups of Arab American adolescents in their sample from the
Midwest: those with multiple high-risk behaviors and those with minimal risk
behaviors and more positive life experiences (Munro-Kramer et al. 2016). This
analysis of high-risk behaviors like sexual activity, tobacco use, and physical activity
provides a perspective on the potential health needs of Arab American adolescents.
The research on Arab American adolescents and their unique health risks requires
further exploration and research.
Discussion
In this updated systematic review of Arab American health, we have found that the
literature describing Arab American health outcomes and needs in the past decade
has increased but still trails behind the trajectory of many other minority groups in
the United States. There are a number of reasons for this including the lack of a
dedicated racial/ethnic identifier, the relative “invisibility” and camouflaged nature
of Arab identity in the United States, and the political and social environment of the
United States.
Advocates, public health professionals, and community members have all empha-
sized the need for a dedicated racial and ethnic identifier to better understand the
health needs of Arab Americans. Investigators have used a variety of methods to
isolate Arab Americans from larger datasets including convenience sampling, Arab
surname algorithms, and using place of birth and Arabic language as indicators.
Little is known about the generalizability of the findings from each of these methods.
The US public health community has a long history of successful longitudinal
studies aimed at understanding the burden of chronic diseases within particular
populations (e.g., Framingham Heart Study, Nurses’ Health Study, etc.), but the
richness of these datasets cannot be used to understand Arab American health
because, despite their likely presence in these datasets, Arab Americans cannot be
isolated.
The nature of the Arab racial experience in the United States is often one of
confusion. For Arabs, race is both highly visible and highly invisible at the same
time (Jamal and Naber 2008). While media portrayals of Arabs are consistently
focused on war and atrocities abroad, Arabs are not distinguished within the racial
schema in the United States. Funding agencies and general clinicians and profes-
sionals do not know about the needs of this population, because they are not a
population that is easily identified through standard surveys. Asking about ethnicity
and culture in an exam room or during an appointment can be awkward, especially
given the racially charged social and political climate. This makes discussions of
race highly politicized but not highly visible in the public health medical literature.
This leads to a general lack of funding dedicated to the study of Arab American
health and culturally tailored interventions in this population. The cyclical nature of
the relationship between media attention and poor health outcomes makes this issue
important to public health.
This review highlighted some methodological shortcomings of the existing
literature on Arab American health that may prevent comparisons of health indica-
tors to other ethnic groups in the United States. One of the main methodological
challenges to understanding Arab American health is the inability to generalize
findings from ethnic enclaves to areas where Arab Americans may be dispersed
among other ethnic populations. The majority of studies aiming to understand health
outcomes and health needs of Arab Americans have taken place within ethnic
enclaves, primarily Dearborn Michigan and Somali enclaves in Minnesota. In fact,
regionally representative datasets using rigorous sampling methodologies (that have
been invaluable for our understanding of Arab American health needs) have been
overused and overpublished in the literature, suggesting that much of the informa-
tion we have on Arab populations stems from a few datasets (e.g., Detroit Arab
American 2003 survey). While the identification and recruitment of Arab individuals
in these areas is made easier by social and cultural community connections, the lived
experiences of these Arabs likely differ from those living in other parts of the
country. Further, the diversity of Arab populations residing in the United States
with regard to country of origin, immigrant generation, and religion necessitates the
study of a nationally representative Arab sample in future studies.
Another challenge is the fact that almost all studies were recruited through
convenience sampling and very few studies used rigorous sampling methodologies
to recruit samples of Arab Americans. This is in large part due to the issues cited
above related to an inability to identify Arab Americans on a wider scale and is a
previously mentioned concern by other authors (Dallo 2015; El-Sayed and Galea
2009b). Additionally, there is a general lack of prospective studies and longitudinal
studies in this population; most studies are cross-sectional in nature. Longitudinal
studies are able to follow individuals for longer periods of time to understand disease
development. The longitudinal studies that have been performed in this population
have aimed to increase education, screening, or knowledge. Very few are aimed to
alter disease status or examine interventions specific to disease reduction. These
methodological challenges should be considered in the context of the future research
directions recommended.
Future Research Directions
Future studies should aim to understand the role of ethnic enclaves as a social
determinant of health for Arab American populations. In areas with high Arab
population density, community health assessments should be conducted. Few com-
munity health assessments have been previously conducted. A study by Sarsour
et al. (2010) performed a health assessment in Brooklyn and found that more than
40% of Arab Americans in Brooklyn reported problems in getting healthcare
(including inability to pay, language barriers, and insurance) (Sarsour et al. 2010).
They also reported that 42% of men in Brooklyn were smokers. Health assessments
provide an opportunity to better understand the needs of communities and should be
undertaken among Arab American communities across the United States to better
understand the heterogeneity in health behaviors and morbidity.
Institutions and organizations with an interest in helping improve health in Arab
American populations should aim to identify these populations in their databases and
their services to provide improved care. Further, information taken on intake forms
should include information on religion and cultural practices that may impede the
care or health decision-making of some of these populations. Interventions should be
developed using community-based participatory research to understand the health
needs and desires of Arab American populations and deliver the best possible care to
these institutions.
Understanding the needs of elderly Arab populations and the impact that
increased life expectancy will have on these populations will be essential. The
cultural processes/traditions associated with elder care and the medical care of elders
may influence the health and stress of these populations over time. Studies aiming to
examine Arab American sexual health should expand beyond the realm of female
genital mutilation and attempt to provide culturally competent care and culturally
relevant solutions to women’s health issues in this population.
Increasing the amount of information collected about acculturation status includ-
ing immigration generation will also be important and necessary. Understanding the
resiliency factors that make Arab American health and Arab immigrant health better
than that of the health of other ethnic minorities in the United States will help
contextualize Arab American health in the minority health landscape in the United
States. More creative studies using natural political or environmental experiments
will also help understand the needs of this population in relation to the changing
social and political environment in the United States.
Conclusion
Arab Americans compose a socially and politically important immigrant group in the
United States that has been increasing in size due to increased immigration over the
past decade. More attention is needed to better understand the health needs of this
population in the context of the changing political climate. Public health and medical
researchers can help improve their understanding of the health needs of this popu-
lation through the active recruitment, identification, and culturally competent
engagement with Arab Americans. Understanding Arab American health needs in
the context of the existing racial and minority health landscape in the United States
will be important to better understand immigrant health in the United States.
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Halal Certification of Food, Nutraceuticals,
and Pharmaceuticals in the Arab World 33
Jawad Alzeer and Khaled Abou Hadeed
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 766
Halal-Tayyib Relationship . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 767
Halal Production . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 768
Halal Certification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 769
Islamic Views on Healthiness and Halalness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 771
Potential Non-Halal Ingredients in Food and Pharmaceutical . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 772
Drugs with Animal-Derived Ingredients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 775
Drugs with Ethanol Content . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 777
Halalopathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 778
Necessities Overrule Prohibitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 784
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 784
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 785
Abstract
Food is an organic need and essential to our survival, whereas nutraceuticals and
pharmaceuticals play an important role in disease prevention and cure. The food
processing and healthcare industries are often linked together for economic
growth and health promotion. However, the complexity of the ingredients and
processes led communities to question their motivation, accuracy, and imposed
standards. Different standards are often applied to ensure high quality, reproduc-
ibility, and traceability. Many processed products contain ingredients derived
from animals, where the consumption of such products is prohibited by several
J. Alzeer (*)
Department of Chemistry, University of Zurich, Zurich, Switzerland
e-mail: jawad.alzeer@chem.uzh.ch
K. A. Hadeed
Department of Chemistry, University of Zurich, Zurich, Switzerland
Halalopathic Research Unit, Dübendorf, Switzerland

https://doi.org/10.1007/978-3-030-36811-1_36
766 J. Alzeer and K. A. Hadeed
religions and lifestyles. Patients who want to avoid certain medications derived
from animal need to know the source of origin and detailed ingredients contained
in their medicines. Recently many Muslim and non-Muslim countries have
realized the value of Halal products and led to an increase in Halal awareness.
This chapter aims to provide more insight into the issue of Halal status of food
and medications in the context of healthcare and describe the process of certifi-
cation and the list of ingredients and drugs with potential non-Halal sources.
Traceability procedure and identification of a long list of ingredients is a chal-
lenge but also key for verifying the Halal status of the end product. Implemen-
tation of Halal-Tayyib concept is essential to determine the Halalness of food and
pharmaceuticals. To increase confidence, eliminate suspicion, and improve trust
with producers, Halal certification is required. However, exerting 100% effort is
possible, whereas achieving products that are 100% clean and pure and comply
with Shari’ah is debatable.
Keywords
Halal pharmaceuticals · Food · Halal standard · Tayyib · Halal certification
Introduction
Human is rational by nature and seeks a rational path that would fill the heart with
tranquility. A human being’s vision of life varies from nation to nation, and Islamic
vision is based on the idea that humanity is created by Allah, life is mortal, hell and
paradise are real, and ticket of entry is solely dependent on human deeds and action
during life: “Whosoever does an evil deed shall be recompensed only with the like of
it, but whosoever does a righteous deed, whether male or female, while he is a
believer, those shall enter Paradise, being given provision therein without account”
(Ghāfir 40:40). The main mission of humans is to civilize the earth and create a
continuous relationship between man and man: “. . .He has raised you from the earth
and settled you in it, enabling your dignity and prosperity. . ..” (Hud 11: 61). The
pillars of civilization have been clearly described by Prophet Muhammad (PBUH):
“Whosoever begins the day feeling secure, having good health; and possessing
enough food for his day is as though he possessed the whole world” (Al-Tirmidhi).
Health, food, and security play essential roles in evaluating and shaping the living
standard of different societies. Health is a state of well-being, and maintaining
strength and good health is a basic human right: “Your body has a right over you”
(Sahih al-Bukhari). Eating food is an organic need and essential to our survival; thus
promoting health and food will have a positive impact on the progress and growth of
societies. Meanwhile, security is responsible for creating peace, jollity, and tranquil-
ity. Prophet Ibrahim made a devout and humble supplication to Allah to bless the city
of Mecca. He prayed: “I beseech You, Allah, my Creator, to make this city a safe
retreat affording security and peace of mind. And provision its people with the
earth’s kind fruits” (Al-Baqara 2: 126).
33 Halal Certification of Food, Nutraceuticals, and Pharmaceuticals in. . . 767
The Halal term is frequently used in the Muslim and non-Muslim worlds;
however, Halal is regarded as a concept for Muslims, an idea for non-Muslim, and
an issue for certifying bodies. Halal concept means permissible and covers all human
actions and deeds, which include eating, wearing, seeing, and talking. For Muslims,
Qur’an is a book of signs; interestingly, whenever the concept of Halal is presented
in the context of food, the concept of Tayyib is explicitly coupled; therefore it is
necessary when Halal food is presented, the combined expression, Halal-Tayyib, is
used. The concept Tayyib refers to being clean, pure, and compliant with Shari’ah
(Arif and Ahmad 2011), whereas Halal concept organizes behavior; hence what we
eat will have an impact on our character (Jiang et al. 2014), duaa (supplication)
acceptance, and personality. The phrase “you are what you eat” has been frequently
used by many and supported by Qur’an: “O you Messengers! Eat of the clean and
pure (Tayyib) and act righteously” (Al-Muminun 23: 51). The contrary of Tayyib is
“Khabith” which connotes to everything impure, harmful, and disgusting: “. . .makes
lawful to them the pure things and makes unlawful to them impure things. . ..” (Al-
Aʿrāf 7: 157). The concept of Halal-Tayyib has been described frequently in many
publications (Arif and Ahmad 2011, Arif and Sidek 2015), and most opinions
suggest that Tayyib is related to food safety (Demirci et al. 2016). In this chapter,
we would like to present a detailed description of Halal in the context of food,
nutraceuticals, and pharmaceuticals, discuss the process of Halal certification, and
give a general view about ingredients and drugs either potentially derived from
animal or suspended in ethanol.
Halal-Tayyib Relationship
The core definition of Halal is based on general Islamic principles where it says
everything is permissible (mubah) by nature: “And He has also made subservient to
you all that is in the heavens and the earth, most surely there are signs in this for a
people who reflect” (Al-Jāthiyah 45: 13), non-Halal has been specified as the
exception, and the main exceptions of Halal are khamr (ethanol) (Alzeer and Abou
Hadeed 2016), blood, pork, carnivores and omnivore animals, food contaminated
with non-Halal ingredients, and food with potentially toxic ingredients that may
expose human health to danger. Islam emphasized strongly on the issue of food
safety and contamination, therefore frequently associate Halal concept with Tayyib
when Halal is related to food: “O ye who believe! Eat of the clean and pure that We
have provided for you, and be grateful to Allah, it is Him ye worship” (Al-Baqarah 2:
172). Tayyib in Arabic means clean and pure; therefore the concept of Tayyib,
concerning food, represents a process through which the food passes through, to
achieve both objectives: maximum hygiene (clean) and minimum contamination
(pure) with any potential toxic, Najis (ritually unclean), and Khabith (impure)
ingredients; thus how Halal, which is a subject, is being processed will determine
if Halal is Tayyib or not. Chicken as a subject is Halal, but how the chicken is
handled, treated, fed, and slaughtered will determine if the chicken is Halal-Tayyib
or not. As both objectives are targets for Muslim and non-Muslim industries, what
makes Tayyib unique for Muslims is its goal, which is to create calmness and
comfortable feelings when food is taken. “We only wish to eat therefrom to reassure
and comfort our hearts” (Al-Māidah 5: 113). The comfortable feeling cannot simply
be achieved through a healthy and safe diet, which is essential; however pleasant and
comfortable feeling is achievable if what we eat is compatible with what we believe.
Comfort food that is selected and influenced by what we believe is known to
improve our mood, make us feel better, and give us a sense of well-being (Wansink
et al. 2003; Bublitz et al. 2013). Therefore, the Tayyib processing of Halal will have a
positive impact on mood, health, and faith practicing: “Verily Allah the Exalted is
pure (Tayyib). He does not accept but that which is pure (Tayyib)” (Sahih Muslim-a).
The contrary of Tayyib is Khabith. According to the Arabic dictionary, Khabith
refers to everything which is disgusting and cannot be used as a source of food such
as snakes, lizards, scorpions, pests, beetles, and mice. Thus, the concept of Khabith
concerning food reflects unpleasant and uncomfortable feelings with disgusting
consequences resulting from the incompatibility of food and lifestyle (faith). This
is a natural reflection, mostly occurring to people following specific lifestyle such as
vegetarian, vegan, kosher, and Halal. Anything disgusting and repulsive by human
nature or has the potential to harm human health, no matter if it is described or not in
Qur’an and Hadeeth, is considered Khabith and non-Halal. Interestingly, cancer in
Arabic is also called Khabith; thus any potentially carcinogenic ingredients are
Khabith as well. Therefore, eating Halal-Tayyib is the path toward achieving com-
plete satisfaction; however disgusting and repulsive feeling is unhealthy and may
lead to stomach discomfort (Alzeer et al. 2018a). Qur’an strongly recommends
eating Tayyib and avoiding Khabith: “Not equal are the khabith and the Tayyib,
although the abundance of Khabith might impress you” (Al-Māidah 5: 100).
An ancient Greek philosopher, Hippocrates, proposed a notion: “let food be thy
medicine and medicine be thy food”; the Qur’an supported the notion by describing
honey as a source of food and cure: “. . .There comes out of their (Bees) bellies a
drink of different colors, wherein is a cure for mankind. Indeed in that is a sign for a
people who give thought” (Al-Nahl 16: 69). Food may also act as a potential vehicle
for disease transmission; thus the implementation of Tayyib concept (clean and
pure), as a public health priority, is essential for the protection of human health
and improvement of life quality. Tayyib takes into consideration, safety, contamina-
tion, pesticides, and hygiene; meanwhile it complies with Shari’ah and enriches
societies with spiritual, moral, and human values.
Halal Production
Nutrients play an important role in human life. It acts as a source of energy, enables
us to perform work, and provides the body with diverse building blocks for DNA,
proteins, fats, minerals, vitamins, and antioxidants. Inundation of body with random
and uncontrolled diet will have an impact on body weight and oxidative stress; long-
term effects may lead to DNA damage, protein cross-linking, and lipid oxidation,
ultimately leading to onset and progression of diseases. Many nutrients are based on
regional, religious, and cultural influences (Alonso 2014), and the relation of the
nutrient contents and benefits of various diets on health and attitude has been studied
by many groups (Alzeer et al. 2018b).
The production and consumption of Halal are obligatory for all Muslims. Lack of
knowledge (Sadeeqa and Sarriff 2014), awareness, and understanding of the Halal-
Tayyib concept may cause loss of interest and appreciation to Halal products,
particularly by the non-Muslim manufacturers. In general, Halal food is healthy
and contains all necessary building blocks such as minerals, fats, carbohydrates,
amino acids, and vitamins which are required for biochemical reactions and involved
in the production of DNA and functional proteins. Previously, many understood that
food and drugs are Halal as long as they do not contain pork or ethanol; this notion is
not enough to declare they are Halal unless the entire process fulfills the following
criteria:
1. Ingredients are safe and free from ethanol, blood, pork, carnivores, omnivore
animals, and human parts.
2. Maximum hygiene and minimum contamination with any potential toxic, Najis
(ritually unclean), and Khabith (impure) ingredients are applied.
3. The process of cultivation, manufacturing, preparation, packaging, storage, and
distribution must be ensured to be clean, pure, and compliant with Shari’ah.
4. The whole Halal production must be physically separated from non-Halal
production.
5. Any potential cross-contamination between Halal and non-Halal ingredients and
products must be completely avoided.
In general, Muslims do not eat animals that are classified as a carnivore (consume
only meat) and omnivore (consume both meat and plant). Dead animals and birds
with claws or birds that feed by snatching and tearing are also prohibited. All forms
of water, fruits, and vegetables are Halal and can be taken except fermented ethanol,
blood, and any poisonous, intoxicating, and harmful drinks. Additionally, there are
animals and insects forbidden to be killed in Islam and thus prohibited to be eaten
such as ants, bees, frogs, and woodpeckers (Rahim 2018). Any source of food
reflects to be repulsive, disgusting, and decayed may classify as Khabith and
forbidden to be eaten. Clearly, reading labels and envisaging the content are not
enough to realize the Halal status, and many consumers demand to know the process
and the source of their food; therefore Halal certification is necessary to ensure
quality with regard to processes, ingredients, and compliance with Shari’ah
(Mursyidi 2013).
Halal Certification
The main goal of food and pharmaceutical manufacturers is to keep their products
profitable and irresistible; therefore industries are innovative and adaptive to help
products stay in compliance. Manufacturers are facing a growing demand for
natural, clean, and safe products that may comply with various lifestyles. Qur’an
addresses all human beings including Muslim and non-Muslim to search for Halal:
“O mankind, eat of the good and lawful things on earth and do not follow the
footsteps of Satan. Indeed, he is to you a clear enemy” (Al-Baqarah 2: 168). The
basic issues in Halal production are cleanliness, purity, and compliance with Sha-
ri’ah (Riaz and Chaudry 2004), as defined in Qur’an: “Eat from the pure and lawful
things that God has given to you. Have fear of God in Whom you believe” (Al-
Māidah 5: 88).
The production of Halal products is a new challenge for food and pharmaceutical
companies (Norazmi and Lim 2015). Muslim countries recently start demanding
Halal certificates for products coming from non-Muslim countries. Halal certifying
bodies are growing in numbers and endeavor to improve Halal guidelines to comply
perfectly with Shari’ah (Jais 2016). In principle, Halal certificates could be issued for
meats, ingredients derived from fruits and vegetables, naturally and chemically
synthesized ingredients, cosmetics, nutraceuticals, and pharmaceutical drugs
(Mohamad 2015). The process of certification is developed to ensure zero suspicion
of a manufactured product that is clean, safe, and compliant with Shari’ah. The main
stage in Halal certification is conducting the site audit which can be classified into
three steps:
1. Documentation review: All documents will be reviewed; in this context, all

ingredients are being classified into three categories:
(a) Highly critical: Contain either ethanol or derived from animal, where only
Halal certificate is required
(b) Critical: Processed ingredients either extracted from the natural products or
synthesized in the lab where Halal certificate or questionnaire is required
(c) Noncritical: Natural and non-processed ingredients where Halal certificate or
questionnaire or declaration is required
During documentation control, all ingredients with regard to safety, toxicity, and
Halal status will be evaluated, the validity of Halal certificates is checked, and
questionnaires are studied. Finally, the compatibility of storage, lubricant,
cleaning agents, and packaging material to Halal-Tayyib is verified.
2. Physical/on-site audit: During the on-site visits, the production line is followed
stepwise, and manufacturing premises, equipment, and other facilities are ensured
to be clean and free from filth, dirt, and harmful and non-Halal elements. All
standard operating procedures (SOP) for maintaining hygiene and safety are
ensured to adhere to Halal guidelines (Halim et al. 2015).
3. Review/closing meeting: At the end of the audit, critical remarks are mentioned,
missing documents are presented, and requests for special procedures are pointed
out. The final report will be submitted to the Halal expert committee and a
decision will be made.
Certifying bodies insist on both physical and spiritual cleanliness: “. . .He loves
those who keep clean” (Al-Baqarah 2: 222) and “And purify your clothes” (Al-
Mudathir 74: 4); thus, utilizing both concepts, Halal-Tayyib (Yunus et al. 2010), is
essential for the Halal certification process and for the determination of the Halal
status of food and pharmaceutical products (Sadeeqa 2015). Halal certification
cannot be solely done by religious scholars, as they are unable to deal with the
complex ingredients and traceability issues (Majid et al. 2015); certification require
highly qualified scientists (Muslims and non-Muslims) in the field of chemistry, food
technology (Khattak et al. 2011), or other related science with biotechnological or
pharmaceutical background and experts in religious jurisprudence to cover all Halal
issues (Norazmi and Lim 2015).
Islamic Views on Healthiness and Halalness
By nature, humans are healthy, and disease is a temporary condition in which the
body becomes unable to function collectively; such a situation potentially deterio-
rates if the immune system could not resist or inappropriate medication was used.
The strength of physical competence is crucial to play a productive role in society.
The strength and capability of Prophet Musa (PBUH) have been described in the
Qur’an and promoted him (besides being trustful) to get married and find a job: “One
of the women said, O my father, hire him. Indeed, the best one you can hire is the
strong and the trustworthy” (Al-Qasas 28: 26). Allah regarded the human body as a
trust to profit from it but must be kept in the best state; therefore mankind is
responsible to keep their body away from any harm, danger, and diseases.
Maintaining good health and avoiding killing ourselves is Allah’s order as stated
in Qur’an: “. . .And do not kill yourselves [or one another]. . .” (Al-Nisa 4: 29).
Medicines play a vital role in human development and influence morbidity and
mortality as well as improve the quality of life. From an Islamic perspective,
preserving human life and reducing suffering and pain is a noble act: “. . .We decreed
upon the Children of Israel that whoever kills a soul unless for a soul or for
corruption in the land, it is as if he had slain mankind entirely. And whoever saves
one, it is as if he had saved mankind entirely. . .” (Al-Māidah 5: 32). Prophet
Muhammad (PBUH) requested us to seek medicine if our body got sick and clearly
manifested that Allah created for every disease a remedy: “take medicine, for Allah
Almighty has not created a disease without having created a remedy for it except one
disease, Old age” (Al-Tirmidhi). The disease ends when the proper cure is applied,
indicating that when the two opponents meet, proper remedy and disease, recovery
from illness occurs: “Every illness has a cure, and when the proper cure is applied to
the disease, it heals by Allah’s Will” (Sahih Muslim-b). Those statements have
inspired Muslim scientists through the centuries to pursue medical knowledge.
Seeking treatment is highly recommended, but when treatment is certain to be
beneficial, and illness could lead to disability, death, or contagious disease, then it is
obligatory: “Indeed Allah has sent down both illness and its cure, and He has
appointed a cure for every illness, so treat yourselves medically, but use nothing
unlawful” (Sunan Abu Dawud 3874). Islam has made it a priority to use medicines
derived from Halal ingredients for effective treatment, whereas non-Halal
ingredients may lead to discontinuation of medications (Sattar et al. 2004) and

relapse of symptoms, thus leading to noneffective treatment: “Indeed Allah has not
placed cure in that which He has made unlawful for you” (Sahih Ibn Hibban).
Medicine is a combination of active ingredients and excipients, obtained from a
variety of sources: animals, plants, or synthetic origin. Medicine is like food, which
could be potentially non-Halal; thus pharmaceutical companies are requested to take
suitable steps in the production of Halal medicine that comply with Halal standards
(Sadeeqa and Sarriff 2014).
Potential Non-Halal Ingredients in Food and Pharmaceutical
Many ingredients are involved in the food processing and used as flavoring, stabi-
lizing, or coloring agents, whereas additives in pharmaceutical drugs are used as part
of the formulation process to stabilize active ingredients and facilitate absorption,
distribution, and elimination of the drug. Many of those ingredients are either
naturally extracted or chemically synthesized, whereas other ingredients are derived
from the animal. Thus, ingredients could be classified (Table 1) into highly critical,
critical, and noncritical. Criticality is determined by the source, nature, and the
process being used during the production. In general, highly critical is potentially
non-Halal until proven otherwise. A critical ingredient that needs further evaluation
is mushbooh, whereas noncritical is Halal. Ingredients, process, and location are
strongly correlated with the Halal-Tayyib systems, which are the basic principles for
understanding and producing Halal products.
Main sources of non-Halal ingredients are:
1. Ingredients derived from pork

2. Ingredients derived from an animal not slaughtered properly
3. Ingredients which are genetically modified
4. Ingredients which are extracted with ethanol or derived from blood
In general, ingredients are listed in descending order of predominance; the

complete ingredient list is difficult to obtain from the label. Ingredients present in
trace amount are not included in the list. FDA (Food and Drug Administration) does
not define “trace amounts”; however, there are some exemptions for declaring
ingredients present in “incidental” amounts in a finished product. If an ingredient
is present at an incidental level and has no functional or technical effect in the
finished product, then it does not need to be declared on the label. Note that major
food allergens, regardless of whether they are present in the food in trace amounts,
must be declared. Sulfites added to any food or to any ingredient in any food and that
have no technical effect in that food are considered to be incidental only if present at
less than 10 ppm. It is not necessary to specify spices and flavor; they are declared in
ingredient lists by using the declarations “spices,” “flavor” or “natural flavor,” or
“artificial flavor.”
Table 1 An alphabetical list of potential non-Halal ingredients

Halal
Ingredients status Remarks
Adrenaline Highly It is used for circulatory support, correction of
critical hypervolemia, metabolic acidosis, and hypoxia or
hypercapnia. It is normally produced by animal or
synthesized from epinephrine
Aprotinin Highly It is a small protein bovine pancreatic trypsin inhibitor
critical (BPTI) obtained from bovine lung
Bacon Highly It is used as a flavor component and prepared from
critical pork belly
Beractant Highly It is a modified bovine pulmonary surfactant
critical containing bovine lung extract
Cholecalciferol Critical It is vitamin D3 used as a supplement and produced by
the irradiation of 7-dehydrocholesterol
Cholesterol Highly It is used to build up cells and certain hormones in the
critical body and derived from animal origin
Co-trimoxazole Highly It is used for the treatment of Pneumocystis jiroveci
critical (carinii) pneumonitis and contains 13.2% vol. ethanol
(alcohol)
Curosurf (poractant alfa) Highly It is used as a natural surfactant and prepared from
critical porcine lungs
Diglyceride Critical It is used with defatted flour as emulsifier. It could be
derived from animal and plant origin
Fluenz Tetra nasal spray Highly It is influenza vaccine and contains a very small
(vaccine) critical amount of gelatin that comes from pork
Fragmin (dalteparin Highly It is used to prevent blood clots and is derived from
sodium) critical sodium heparin which potentially could be obtained
from porcine
Gelatin (Jell-O Gelatin) Highly It is used in capsule production and usually derived
critical from animal origin, mostly from pig
Glycerol Critical Glycerol is generally obtained from plant and animal
sources where it occurs as triglycerides
Glycerine Highly It is used as a laxative and naturally prepared from
critical tallow, a form of beef
Heparin sodium Highly It is used to treat and prevent blood clots and is derived
critical from porcine intestinal tissue
Indigo carmine Critical It is used as coloring agent and is derived from indigo
by sulfonation; indigo is a blue coloring agent derived
from natural products
Lard Highly It is commonly used as a cooking fat or shortening and
critical is derived from pork
Magnesium stearate Critical It has binding and lubricating properties that help
lubricate and aid the ejection of tablets and could be
derived from animal
Monoglycerides Critical It is used as an emulsifier, a dispersing agent, and a
stabilizer; it could be derived from animal and plant
origin
(continued)
Table 1 (continued)
Halal
NovoSeven (eptacog alfa) Highly It is used for the treatment and prevention of bleeding
critical and is derived from hamster kidneys
Nutrizym 22, Pancrease Highly It is used to treat chronic pancreatitis, enzymes
HL, Pancrex (pancreatin) critical (lipases, proteases, and amylases), derived from
porcine pancreas
Oleic acid Critical It is used in manufacturing of surfactants, soaps, and
plasticizers and produced from saturated fatty acid that
occurs naturally in various animal and vegetable fats
and oils
Oxytocin Critical It is used for induction and augmentation. Derived
synthetically
Pancreatin (Creon) Highly It is used as a digestive aid and is derived from beef or
critical pork pancreas
Pepsin Highly It is used to break down proteins into smaller peptides
critical and is derived from animal tissues particularly from
pork stomach
Polyethylene glycol Critical It is used as a humectant, laxative, stabilizer, and
bulking agent and produced by the interaction of
ethylene oxide with water, ethylene glycol, or ethylene
glycol oligomers
Polyoxyl hydrogenated Critical It is used as solubilizer and produced from castor seeds
castor oil
Polysorbate Critical It is used as emulsifier and produced from fatty acids
Priadel liquid (lithium Highly It is used for manic-depressive disorder and contains
citrate) critical 5% ethanol
Propylparaben Critical It is used in many cosmetics and may be found in
lipsticks, foundations, and eye shadows. It is produced
from plants and some insects
Rennin (rennet) Highly It is used to curdle milk and produced mostly from
critical stomach lining of a calf, ewe, or plant sources
Sorbitol Critical It is used as a sweetener and produced synthetically
from glucose or naturally derived from placenta
Sorbitan trioleate Critical It is used as nonionic surface agent, dispersing agent,
co-emulsifier, and stabilizer, for mineral oil used in
food and cosmetics, and used as excipients in
veterinary medical products prepared from sorbitol
and fatty acid
Stearic acid Critical It is used as an emulsifying agent, solubilizing agent,
and tablet and capsule lubricant. It is derived from
either tallow or vegetable sources
Shortening Critical It is used in backing, and it is fat mostly derived from
vegetable oils
Sodium biphosphate Highly It has multiple uses, originates from several sources
critical including animal bones or bone ash, and has bovine
origin
(continued)
Table 1 (continued)
Halal
Sodium glutamate Critical It is used as a flavor enhancer and produced either
synthetically or by bacterial fermentation
Sodium starch glycolate Critical It is used in tablets to disintegrate and dissolve them to
be absorbed by the body. It is made from a number of
different starchy foods, including corn, wheat, rice,
and potatoes
Triacetin Critical It is used mainly as a plasticizer and a gelatinizing
agent in polymers, produced from a multistage
reaction sequence involving glycerine, acetic acid, and
acetic anhydride as raw materials
Vanilla Critical It is used as flavoring and mostly derived from plants
and extracted with ethanol
Vitamins Critical Vitamins are used for stress, allergies, fatigue, and
building the immune system. It is derived mostly from
plants
Vaccines Highly In the preparation of vaccines, animal sera are
critical frequently added to culture media to provide nutrients
for microbial growth
Drugs with Animal-Derived Ingredients
Pharmaceutical drugs are derived from a variety of sources, including natural and
man-made ingredients. Some of the drugs derived from animal ingredients are listed
in Table 2. The animal ingredients could exist as active drug constituents or part of
inactive excipients. Many of those ingredients would have implications for patients
with a different lifestyle. Pharmaceutical companies are becoming increasingly
aware of these limitations; therefore animal ingredients have been replaced by
synthetic alternatives. Inactive ingredients, including those containing ethanol, gel-
atin, or stearic acid, are still a challenge for pharmaceuticals.
Most ingredients are chemically manufactured to keep control of the process
and maintain the purity of the active ingredients. There are exceptions such as
insulin used to treat diabetes, which is derived from the animal sources, usually
from pigs. Gelatin, a common active substance in pharmaceutical products, is
manufactured from bones, skin, and connective tissue of animals, mainly pigs,
cattle, and fish, and used in the manufacture of capsules and tablets. Collagen is
another ingredient, produced from animal bones, and used in arthritis and for
improved skin elasticity, skin moisture, and skin texture (Porfirio and Famaro
2016). Hormones like estrogen and estradiol are produced from female hormones
of pregnant mares and used in a variety of medical uses (Cox 1996). Heparin is
used as a blood anticoagulant drug and derived from mucosal tissues of the
porcine intestine or bovine (cow) lung (Tovar et al. 2013). Stearic acid, made
Table 2 An alphabetical list of selected drugs with potential animal ingredients

Product name (generic
name) Comment
Advate (octocog alfa) It is a human coagulation factor VIII produced by recombinant DNA
technology in Chinese hamster ovary
Aldurazyme (laronidase) It is a recombinant form of human α-L-iduronidase produced by
recombinant DNA technology using mammalian Chinese hamster
ovary
Aranesp (darbepoetin) It is an erythropoiesis-stimulating protein produced in Chinese
hamster ovary cells
Avastin (bevacizumab) It is an angiogenesis inhibitor produced in a Chinese hamster ovary
Avonex (interferon beta-1a) It is an immunomodifier protein produced by recombinant DNA
technology using genetically engineered Chinese hamster ovary
cells
BeneFIX (nonacog alfa) It is a hemostatic agent and contains recombinant coagulation factor
IX derived from a Chinese hamster ovary
Cerezyme (imiglucerase) It is an enzyme replacement therapy and is generated from
transduced Chinese hamster ovary cells
Clexane (enoxaparin) It is an anticoagulant and antithrombotic medication, which is made
from heparin
Creon (pancrelipase) It is a digestive pancreatic enzyme prepared from porcine-derived
lipases, proteases, and amylases
Curosurf (poractant alfa) It is a respiratory agent, used as a surfactant, and extracted from
porcine minced lungs
Elonva (corifollitropin It is a pituitary hormone produced in Chinese hamster ovary (CHO)
alfa)
Enbrel (etanercept) It is a recombinant human soluble tumor necrosis factor receptor
fusion protein derived by introducing human DNA into Chinese
hamster ovary cells
Ethical Nutrients It is a digestive enzyme used to assist protein digestion in the
Digestion Plus stomach and contains betaine, gentian, lutea, and pepsin
Fragmin (dalteparin) It is an anticoagulant made from heparin
Gelofusine (gelatin It is a volume expander, which contains 4% solution of succinylated
succinylated) bovine gelatin
Heparin sodium injection It is an anticoagulant made from heparin
Heparinized saline It is an anticoagulant made from heparin
Heparinized saline It is an anticoagulant made from heparin
injection
Haemaccel (polygeline) It is a plasma volume expander, a derivate of gelatin, from bovine-
derived bone
Insulin It is used to treat people who have type 1 diabetes. It is derived from
genetically modified yeast, cow, or pork
Orgaran (danaparoid) It is hemostatic agent isolated from animal mucosa (porcine)
Panzytrat 25000 It is a digestive supplement (amylase, lipase, pancrelipase, protease)
and contains a porcine pancreatic enzyme
Prothrombinex-VF It is hemostatic agent with active ingredients such as factor IX,
factor II, factor X, human antithrombin III; heparin, factor V, and
factor VII
(continued)
Table 2 (continued)
Product name (generic
name) Comment
Rotarix It is a live oral rotavirus vaccine developed from a single protective
human strain and contains porcine circovirus type 1 (PCV-1)
RotaTeq It is a live, oral pentavalent vaccine and contains a porcine-derived
material
Travelan Travelan is an antidiarrheal natural product and is derived from
bovine colostrum
Varivax (varicella zoster It is a vaccine and contains inactive components including
vaccine) hydrolyzed gelatin and traces of bovine serum
Vivaxim It is a hepatitis A vaccine and contains bovine serum albumin
Zostavax (zoster virus It is a live attenuated virus vaccine and contains hydrolyzed porcine
vaccine live) gelatin
Zyderm collagen It is a sterile device composed of highly purified bovine dermal
implants (collagen) collagen
from the fat of cows and pigs (tallow), is often used in a salt form such as
magnesium stearate which has binding and lubricating properties that help lubri-
cate and aid in the ejection of tablets from the tablet press (Li and Wu 2014).
Lactose, the most common animal-derived ingredient, is widely used as a filler or
diluent in tablets and capsules. Cysteine, an amino acid, is derived from hair that
could come from animal source and used in hair-care products, creams, in some
bakery products, and in wound-healing formulations.
Drugs with Ethanol Content
Ethanol is an important organic solvent and substrate that is widely used in food,
pharmaceutical, cosmetic, and many other industrial applications. Many active
ingredients are suspended in ethanol solutions such as cough remedies, mouth-
washes, or children’s medicines. Halal status of ethanol is highly controversial,
and many Muslim scholars consider ethanol as non-Halal, no matter how it has
been prepared. More rational studies revealed the Halalness of ethanol is dependent
on the source and concentration (Alzeer and Abou Hadeed 2016). According to
Alzeer studies, any ethanol produced by anaerobic fermentation and ranging
between 1% and 15% is considered to be non-Halal, whereas ethanol produced by
natural fermentation and less than 1% is considered a preserving agent and its Halal
status is allowed. Any ethanolic solution higher than 15% is treated as a toxic
solution; therefore it is strictly forbidden to drink, and attempts to drink toxic
solution is considered suicide attempts and strongly forbidden in Islam. On the
other hand, toxic ethanol solution is allowed to be prepared, held, transferred, and
used for disinfection and other industrial use. An ethanolic solution prepared by
dilution from absolute or denatured ethanol is allowed for industrial use but toxic for
human consumption. However, any concentration varying from 0.1% to 100%
prepared with the intention to be used as a beverage drink is considered non-Halal.

Drugs with a significant amount of ethanol have been summarized in Table 3.
A study was conducted to evaluate the Halal status of selected cardiovascular,
endocrine, and respiratory drugs stored at the pharmacy of a Malaysian state hospital
(Sarriff and Razzaq 2013). The study showed the proportions of Halal (noncritical),
mushbooh (critical), and haram (highly critical) products were at 19.1%, 57.1%, and
23.8%, respectively. The concept mushbooh is used when the Halal status is doubtful
or unclear whether it is Halal or haram (consumption is prohibited). The highly
critical ingredients are present substantially in many drugs, and their compatibility
with Halal status is questionable. Therefore, it would be pertinent to look into
various items of human consumption, and the production of Halal drugs needs to
be re-evaluated and optimized to produce drugs that comply with Shari’ah.
Halalopathy
Halalopathy is a holistic form of medicine that aims to make the prevention and/or
healing of diseases more effective by integrating the principles of naturopathy and
allopathy and by incorporating the principles and practices of the halal guidelines
(Alzeer 2019). Naturopathy employs natural means and natural therapies to correct
the structural, physiological, and psychological balance. As naturopathy is a holistic
treatment, the patients are given recommendations for their diet, exercise, and
lifestyle. The allopathic approach focuses on the physical signs and symptoms, the
pathological changes, and infection caused by microorganisms. The core of allo-
pathy is a chemical drug designed rationally to adjust the speed of biological
functions in the body. Drugs can either speed up or slow down biochemical reactions
in the body, mostly by binding to receptor sites to either activate (agonists) or
inhibit (antagonists) receptor function and regain a dynamic equilibrium state
(Alzeer 2018).
Halalopathy or permissible therapy offers a new option to prevent diseases by
controlling the entropic state (“a state of disorder”) and/or to treat diseases by
applying the concept of permissible drugs. A high entropic state leads to internal
disorders, while the permissible drug provides a compatible relation between ther-
apeutic medicine and the human lifestyle. The compatibility between drugs and an
individual’s beliefs enhances trust and lowers entropy, which are essentials for
activating the placebo effect and increasing potential energy, respectively. The
placebo effect initiates the healing process, whereby the potential energy provides
an important energy source to activate the immune system. These are the favorable
circumstances that work cooperatively with the prescribed therapeutic drugs to
promote the healing process toward recovery. The healing power of halalopathy is
not limited to a strong placebo effect but is based on a synergistic effect in which
each component contributes to the overall healing process and enhances the total
drug effect (Fig. 1).
Production of permissible drugs is achieved by evaluating ingredients and mon-
itoring the production process to ensure specific and well-defined standards,
Table 3 An alphabetical list of selected drugs with ethanol content (Sober Link)
Drug Ethanol%
Actol Expectorant Syrup 12.5
Alamine 5.0
Alertronic 0.5
Alomine C 5.0
Alomine Expectorant 7.5
Alurate Elixir 20.0
Ambenyl-D 9.5
Ambenyl Expectorant 5.0
Anahist 0.5
Aromatic Elixir 22.0
Anaspaz-Pb Liquid 15.0
Asbron Elixir 15.0
Atarax Syrup 0.5
Bactrim Suspension 0.3
Benedryl 14.0
Belladonna 67.0
Benadryl Elixir 14.0
Benedryl Decongestant 5.0
Bentyl-Pb Syrup 19.0
Benylin Expectorant 5.0
Black Draught 5.0
Breacol 10.0
Brondecon Elixir 20.0
Bronkelixir 19.0
Butibel Elixir 7.0
Calcidrine Syrup 6.0
Cas Evac 18.0
Aromatic Cascara Sagrada 18.0
Carbrital Elixir 18.0
Dr. Caldwell’s Senna Laxative 4.5
Cerose & Cerose DM Expectorant 2.5
Citra Forte Syrup 2.0
Cetro-Cerose 1.5
Cheracol & Cheracol D 3.0
Choledyl Elixir 20.0
Chlor-Trimeton Syrup 7.0
Codimal DM 4.0
Coldene Cough Syrup 15.0
Cologel Liquid 5.0
Coltrex 4.5
Coltrex Expectorant 4.7
Conar Expectorant 5.0
Contact Severe Cold 25.0
(continued)
Table 3 (continued)
Drug Ethanol%
Contrex 20.0
Copavin Cmpd Elixir 7.0
Coryban D 7.5
Cosanyl DM & Cosanyl Syrup 6.0
Cotussia 20.0
Darvon-N Suspension 1.0
Daycare 10.0
Decadron Elixir 5.0
Demazin Syrup 7.5
Dexedrine Elixir 10.0
DIA Guel 10.0
Dilaudid Cough Syrup 5.0
Dimetane Expectorant 3.5
Donnagel-PG 5.0
Doxinate Liquid 5.0
Dimetapp Elixir 2.3
Dimacol Liquid 4.8
Donnatal Elixir 23.0
Dramamine Liquid 5.0
Endotussin NN 4.0
Ephedrine Sulfate Syrup USP 3.0
Feosol Elixir 5.0
Fer-ln-Sol Drops 0.3
Fer-ln-Sol Syrup 5.0
Fletcher’s Castoria 3.5
Formula 44 Cough 10.0
Formula 44 D 20.0
Geriplex-FS 18.0
Gevabon Liquid 18.0
GG Tussin 3.5
G Tussin DM 1.4
Halls 22.0
Head & Chest 5.0
Hycotuss Expectorant & Syrup 10.0
Hydryllin Comp. 5.0
Iberet Liquid 1.0
Ipecac Syrup 2.0
Isuprel Comp. Elixir 19.0
Kaon Elixir 5.0
Kaochlor 3.8
Kay-Ciel Elixir 4.0
Lanoxin Elixir Pediatric 10.0
Liquid Lomotil 15.0
(continued)
Table 3 (continued)
Drug Ethanol%
Luffyllin-GG Elixir 17.0
Marax Syrup 5.0
Mediatric Liquid 15.0
Mellaril Concentrate 3.0
Mercodol w/Decaprin 5.0
Mesopin Elixir 12.5
Minocin Syrup 5.0
Modane Liquid 5.0
Naldecon Dx 5.0
Nembutal Elixir 18.0
Night Relief 25.0
Nortussin 3.5
Nicol Elixir 10.0
Nico-Metrazol Elixir 15.0
Novahistine DH 5.0
Novahistine Expectorant 5.0
Novahistine Elixir 5.0
Novahistine DMX 10.0
Novafed 7.5
Novafed A 5.0
Nyquil Cough Syrup 25.0
Mol Iron Liquid 4.8
Organidin Elixir 23.8
Ornacol Liquid 8.0
Tincture Paregoric 45.0
Pabizol with Paregoric 9.6
Parapectolin 0.7
Parelexir 18.0
Parepectolin 0.6
P.B.Z. Expectorant with Ephedrine 6.0
Pediquil 5.0
Percy Medicine 5.0
Periactin Syrup 5.0
Pertussin 8 Hour Syrup 9.5
Pinex 3.0
Phenergan Expectorant Plain 7.0
Phenobarbital Elixir 14.0
Phenergan Expect. w/Codeine 7.0
Phenergan Expectorant VC Plain 7.0
Phenergan Expectorant VC w/Codeine 7.0
Phenergan Expectorant Pediatric 7.0
Phenergan Syrup Fortis (25 mg) 1.5
Polaramine Expectorant 7.2
(continued)
Table 3 (continued)
Drug Ethanol%
Propadrine Elixir HCI 16.0
Quibron Elixir 15.0
Quelidrine 2.0
Quiet Nite 5.0
Quintess 0.9
Robitussin Syrup 3.5
Robitussin AC Syrup 3.5
Robitussin DM and Robitussin CF 1.4
Robitussin PE 1.4
Romilar CF 0.0
Rondec DM Syrup and Drops 0.6
Roniacol Elixir 8.6
Senecot Syrup 7.0
Serpasil Elixir 2.0
SK APAP Elixir 8.0
Sudafed Cough Syrup 2.4
Tedral Elixir 15.0
Temaril Syrup 5.7
Tempra Syrup & Drops 10.0
Terpin Hydrate Elixir 42.0
Theo Organidin Elixir 5.0
Tolu-Sed 10.0
Tolu-Sed DM 10.0
Tonecol 7.0
Triaminic Expectorant 5.0
Triaminic Expectorant DH 5.0
Trind DM 5.0
Tussend Liquid 5.0
Tussar-2 Syrup 5.0
Tussar SF Syrup 2.0
Tussi-Organidin Expectorant 5.0
Tussar SF Syrup 2.0
Tylenol Liquid & Drops 7.0
Tuss-Ornade Syrup 7.5
Tylenol Elixir 7.0
Tylenol with Codeine Elixir 7.0
Tylenol Drops 7.0
Ulo-Syrup 6.7
Valadol Liquid 9.0
Valpin-PB Elixir & Valprin 5.3
Vicks Cough 5.0
Viromed Liquid 6.6
Vita Metrazol Elixir 5.0
(continued)
Table 3 (continued)
Drug Ethanol%
Vitamin – Ce-Vi Drops 5.0
Vitamin – Fumeral 5.0
Vitamin – Ganatrix 15.0
Vitamin – Geralix Liquid 15.0
Vitamin – Geriplex FS Liquid 18.0
Vitamin – Geritol 12.0
Vitamin – Geritonic 20.0
Vitamin – Gevrabon 18.0
Vitamin – Gerizyme 18.0
Vitamin – Mol from liquid 4.8
Vitamin – Niferix Elixir 10.0
Vitamin – SSS Tonic 12.0
Vitamin – Zymalixer 1.5
Vitamin – Zymasyrup 2.0
Vicks Formula 44 10.0
Wal-Act 5.0
Halalopathic Values
Moral Spiritual Human Material
Create a connection between Create a state of Create a trust with Rational drug
drug and patient’s belief no fear and no grief patient design
Compatibility Tranquillity Trust Qualified drug
State of low entropy State of high potential Placebo effect Therapeutic effect
Synergistic effect
leads to
Complete recovery
Fig. 1 Halalopathic path toward complete recovery
depending on the requirement of the lifestyle or belief of the patient. Halalopathic

principles are mostly adapted from Islamic references, but many of these are shared
with other religions (Alzeer 2019). The guidelines for the production of permissible
therapy “halal pharma” have been implemented in many Muslim countries. The
production of drugs complying with halalopathic concepts is a straightforward
process, as many of the existing drugs have the potential to be Halal. It is
recommended that the processing and formulation of newly approved drugs occurs
according to the standards of Halal-Tayyib. Drugs labeled with “Halalan-Tayyiban”
are preferred by Muslim patients. The “Halalan-Tayyiban” label is intended to
convey to the patient that the medication has been manufactured under maximum
hygiene and minimum contamination, and that the entire process is clean, pure, and
follows Islamic principles. This knowledge will create trust, establish a compatible
system between drugs and belief, and eventually, tranquility.
The core principle of halalopathy is to build a compatible system between drug,
patient, and mind. Often, higher efficacy can be achieved either by increasing the
dose or by extending the duration of action; however, increasing the dose tends to
result in a higher incidence of side effects. The tolerant system resulting from the
compatibility between therapy and mind often creates a state of existing together,
and may lead to treating the drug as a compatible entity; consequently, the rejection
mechanisms are reduced and the duration of action is prolonged.
Necessities Overrule Prohibitions
Allah has honored and preferred mankind over other creation: “And We have
certainly honored the children of Adam and carried them on the land and sea and
provided for them of the good things and preferred them over much of what We have
created, with [definite] preference” (Al-Isra 17: 70). The preservation of human life
is indispensable and has the highest priority in Islam. Under severe circumstances,
Islam is flexible and tolerable. Though eating Halal is mandatory for Muslims, if
there is nothing to eat and the Muslim’s life is in danger, then Islam allows Muslims
to eat non-Halal food: “if one is forced by necessity, without willful disobedience,
nor transgressing due limits, then he is guiltless. For Allah is Most Forgiving and
Most Merciful” (Al-Baqarah 2: 173). Based on the Islamic principle “Necessities
overrule prohibitions,” many Muslim scholars allowed patients to use medicines
from non-Halal sources provided that the medicine is prescribed by a reliable
physician, that human life is at risk, and that no alternative medicine is available
(Halim et al. 2014, 2015; Halib et al. 2016).
Conclusion
The Halal production of food, nutraceuticals, and pharmaceuticals in Muslim coun-

tries is a growing concept with high demand. Many ingredients involved in the
production of food and medications are either non-Halal or produced by the non-
Halal process. Drug formulations and food processing are complex and difficult to
ascertain with accuracy the origin of some of the ingredients used in medication and
food preparations. A potential solution is to establish reassurance on traceability and
production processes that may help to promote confidence in the integrity and origin
of the ingredients. The implementation of the Halal-Tayyib concept is essential for
the determination of Halal status. The process will have to comply with maximum
hygiene and minimum contamination, whereas Halal ingredients are used through-
out the process. The production process needs to be monitored by qualified scientists
with Halal quality assurance experience. Further research is needed to identify
alternative ingredients in compliance with Halal standards. The rational design
could be used to replace non-Halal ingredients with reasonable alternatives, to
eliminate any potential suspicion and remove mushbooh substances. Halal certifica-
tion remains a necessary step to ensure quality in terms of processes, ingredients, and
Shari’ah compliance. However, if there are necessities and the non-Halal product is
lifesaving, then all treatment options are approved regardless of the origin.
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Tackling Noncommunicable Diseases
in the Arab Region 34
Sameh El-Saharty, Toshiko Kaneda, and Aviva Chengcheng Liu
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 792
Burden of NCDs in Arab Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 794
Cardiovascular Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 798
Cancers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 799
Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 800
Chronic Respiratory Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 803
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 804
Main Risk Factors of NCDs Among Arab Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 805
Tobacco Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 806
Alcohol Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 808
Unhealthy Diet and Physical Inactivity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 810
Overweight and Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 811
Main Risk Factors of NCDs Among Arab Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 812
Tobacco Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 814
Alcohol Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 816
Unhealthy Diet and Physical Inactivity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 818
Overweight and Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 818
Policies and Strategies for NCDs in Arab Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 820
Health-in-All Policies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 821
S. El-Saharty (*)
The Middle East and North Africa Department, The World Bank, Washington, DC, USA
e-mail: selsaharty@worldbank.org
T. Kaneda
The Population Reference Bureau, Washington, DC, USA
e-mail: tkaneda@prb.org
A. C. Liu
Public Health Policy Consultant, The World Bank, Washington, DC, USA
e-mail: aviva.chengcheng.liu@gmail.com

https://doi.org/10.1007/978-3-030-36811-1_85
790 S. El-Saharty et al.
A Policy Framework for Reducing Risk Factors for NCDs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 823

Policy and Strategy Implementation: The Regional Experience . . . . . . . . . . . . . . . . . . . . . . . . . . . 826
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 832
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 832
Abstract
In the Arab region, the burden of noncommunicable diseases (NCDs) is huge and
has continued to grow in recent decades. In 2017, NCDs were responsible for
about 1.5 million deaths, accounting for 65% of all deaths. Moreover, one in five
persons is at risk of premature death (between ages 30 and 70) from NCDs.
Young people between ages 10 and 24 in the region are suffering from NCDs, but
have less lost years of life due to NCDs than the elderly populations.
The leading NCDs in the Arab region are cardiovascular diseases (CVDs),
cancers, diabetes, and chronic respiratory diseases, which accounted for 1.3 million
deaths or 57% of all deaths in the region in 2015. It is estimated that 54% of deaths
from noncommunicable diseases are due to cardiovascular diseases. Deaths attrib-
uted to CVDs (of total deaths) ranged from 49% in Oman to 13% in Somalia. The
region was home to about 5.3% of the world’s population but accounted for about
6.3% of the world’s prevalence of diabetes in 2017.
Substantial reduction of NCD mortality requires a whole-of-government
approach that considerably reduces the main risk factors of NCDs. NCDs are
associated with metabolic, behavioral, and environmental risk factors. Metabolic
risk factors include high blood pressure, high blood glucose, high blood choles-
terol/lipids, and overweight/obesity. NCDs are also associated with behavior risk
factors that usually precede the metabolic conditions, namely, tobacco use,
physical inactivity, poor diet, and harmful use of alcohol.
Tobacco use is by far the number one preventable cause of death globally and is
only one of the four risk factors that contributes to all four main NCDs. Arab
countries today have some of the highest tobacco use rates in the world where half
of these countries observe more than one-third of adult men (aged 15 years and
older) who smoke tobacco products. Arab countries, especially GCC countries, are
facing some of the world’s highest prevalence of physical inactivity. In addition,
many Arab countries have witnessed unhealthy dietary changes prevalent in
children, adolescents, and adults, heavily influenced by the global fast food indus-
tries. It is common to find refined and processed food, carbonated beverages,
increased food portion sizes, and diets high in calories, fat, and salt consumed in
most Arab countries. Arab people also have low intake of fruits and vegetables that
is below the recommended daily allowance in all age groups.
The WHO Eastern Mediterranean Region, including most Arab countries,
reported the world’s third highest prevalence of adult obesity rate (21%) in
2016. Kuwait, Saudi Arabia, and Qatar observed the highest obesity rates of
more than one-third of all adults and more than 40% of females in 2016. Women
have higher obesity rates than men in the region.
The four main risk factors of NCDs are influenced by modifiable behaviors,
typically initiated or established during adolescence or young adulthood. These
34 Tackling Noncommunicable Diseases in the Arab Region 791
set the stage for NCDs later in life. In fact, 70% of premature deaths in adults are
due to behaviors established in adolescence that share common risk factors.
Preventing and reducing risk behaviors among Arab youth today can minimize
the future burden of the growing NCD epidemic.
The prevalence of the four main risk factors is rising among young people
worldwide and in Arab countries. In about half the region’s countries, more than
one in two boys who are current tobacco users smoke cigarettes. One major
concern in Arab countries is the growing use of water pipes (such as shisha and
nargile), especially among youth. On the other hand, assessing the actual level of
alcohol use in the region is particularly challenging among youth. However,
market research shows a sharp increase in overall alcohol consumption in the
region between 2001 and 2011, including in countries that ban alcohol. Youth in
Arab countries have experienced substantial changes in their diet and physical
activity levels over the last four decades, due to the changing environment
resulting from a combination of economic development, urbanization, and glob-
alization. The diets of young people in Arab countries today consist increasingly
of calorie-dense, highly processed food with large amounts of sugar, salt, and
saturated fat. Young people also have greater access to soft drinks and other
sugar-sweetened beverages that add substantially to their calorie intake. In addi-
tion to having a less healthy diet, young people spend less time being physically
active and more time in sedentary activities, such as watching television and
using a computer. Physical activity levels are low in Arab countries for both
sexes, but particularly for girls. The above behavioral risk factors led to high rates
of overweight and obesity among youth in many parts of Arab countries, espe-
cially in the Gulf States. Surveys conducted between 2007 and 2015 show that
more than 25% of male and female secondary school students, ages 13–15, in
about half of the region’s countries were either overweight or obese.
The growing burden of NCDs and the alarming prevalence of risk factors urge the
Arab countries to act together to address the epidemic crisis swiftly and comprehen-
sively. Policies of many sectors can have a profound effect on people’s health
behaviors and the population health outcomes. Effective prevention of NCDs and
risk factors requires joint actions beyond the health sector. In fact, more than half of
the NCDs burden could be prevented through targeted actions beyond the health
sector that focus on a few key risk factors. To tackle this issue requires political will to
engage in a “whole-of-government” approach across multiple players.
Policy programs to prevent NCDs can range from heavy to light government
interventions, which include: command and control, price-based regulation,
behavioral insights or nudging, voluntary agreements and partnerships, and
education and information. Establishing rules through legislations, regulations,
and administrative orders is a pervasive instrument of government policy in the
health fields. A suite of legal measures – taxes, minimum purchase age, smoking
bans in public places, and marketing bans – transformed culture and behaviors
relating to tobacco. Price-based regulations including taxes and subsidies use
financial incentives and disincentives. Policy makers may use these mechanisms
to coax changes for health, political, or social reasons. It is not feasible to ban
smoking in people’s homes, but sufficiently high and comprehensive taxes are the
single most cost-effective measure to discourage new smokers and reduce use.
Also, increasing fuel taxes and subsidizing public transport will encourage people
to walk more. In this example, synergy results from involving more than one
sector. Behavioral insights or nudging may or may not involve regulation. This
policy instrument uses nonfinancial incentives and disincentives to induce behav-
iors. Rising evidence suggests that placing healthy foods at the entrance or at eye
level will result in people choosing healthier options. Placing staircase rather than
elevator in the center of buildings encourages people’s physical movement and
reduces elevator use. Voluntary controls, agreements, and partnerships are useful
to ensure that there is buy-in from key stakeholders. A good example is voluntary
self-regulation within an industry. So far, the efficacy of this approach is doubtful
due to the possibility of default by one party. Such initiatives more frequently
arise where an industry is either homogeneous (e.g., bread makers in Buenos
Aires) or dominated by one or two big companies (e.g., soda manufacturers).
Education and the provision of information are often supported by the public
sector to promote public health. Increased awareness and information has been
shown to modify attitudes about the health consequences of behavior. However,
there remains serious limitations on the effectiveness of these education measures
to modify actual behavior in all but children of school going age.
Generic policy frameworks require local adaptation and reinvention to pro-
duce lasting health benefits. As Joseph Stiglitz points out, we should “scan
globally for best practices” but “test them locally” in each country context.
Some Arab countries have already begun to implement successful policy and
structural interventions to curb harmful NCD risk behaviors. Although the extent
to which they have improved the targeted health outcomes varies, development of
these policies and regulations is an important step toward curbing NCDs.
Adopting the right mix of policies and effective interventions to curb the NCD
epidemic is critical for building human capital and will allow people to better
contribute to economic growth and sustainable development.
Keywords
Noncommunicable diseases · Risk factors · Cardiovascular diseases · Diabetes ·
Cancers · Chronic pulmonary diseases · Smoking · Unhealthy diet · Physical
inactivity · Alcohol · Overweight · Obesity · Arab region · Youth · Burden of
disease
Introduction
Noncommunicable diseases (NCDs) have become the world’s leading cause of

death. Globally, NCDs are responsible for 41 million of the world’s 57 million
deaths (71%) in 2016, 15 million of which were premature deaths between 30 and
70 years. The major global burden of NCDs include cardiovascular diseases (CVDs)
(accounting for 44% of all NCD deaths), cancers (22% of all NCD deaths), chronic
respiratory diseases (9% of all NCD deaths), and diabetes (4% of all NCD deaths)
(WHO 2018a).
The burden of NCDs is rising disproportionately among lower income countries
and populations. In 2015, over three quarters of NCD deaths – 30.7 million –
occurred in low- and middle-income countries, with about 48% of deaths occurring
before the age of 70. Meanwhile, the likelihood of dying prematurely (between ages
30 and 70) in 2015 from any of the four main NCDs was 12% in high-income
countries. Compared to high-income countries, NCDs in lower income countries
generally claim lives at younger ages, often at the peak of individuals’ economic
productivity. The Arab region is home to about 420 million people with Arabic as the
common language and to countries with Muslim-majority populations (World Bank
2019a). (The Arab region includes Algeria, Bahrain, Comoros, Djibouti, Egypt, Iraq,
Jordan, Kuwait, Lebanon, Libya, Mauritania, Morocco, Oman, Qatar, Saudi Arabia,
Somalia, Sudan, Syria, Tunisia, the United Arab Emirates (UAE), West Bank and
Gaza, and Yemen.) In the past 40 years, the Region experienced a large boom in its
young population aged between 10 and 24 years, increasing from a total of 59 million
in 1980 to 136 million in 2017. In 2017, young population represented one-third of
the total population.
In the Arab region, the burden of NCDs is huge and has continued to grow in
recent decades. The region’s high prevalence of NCD risk factors – especially
tobacco use, physical inactivity, unhealthy diet, and overweight and obesity – will
lead to an increasing burden of NCDs in the foreseeable future. These risk factors are
all modifiable behaviors that are typically initiated or established during adolescence
or young adulthood. These set the stage for NCDs later in life. The World Health
Organization (WHO) estimates that behaviors begun in adolescence account for 70%
of premature deaths in adults worldwide.
Addressing NCDs is not only a one-country issue but also a regional agenda.
Even though NCDs are not infectious and non-transmissible, people often learn and
develop risk behaviors – the precursors of NCDs – such as tobacco smoking among
peers. The frequent travel, migration, and trade across Arab countries help spread
over risk behaviors, e.g., one can find shisha (artificially flavored water pipes) in any
Lebanese, Egyptian, Syrian, and Kuwaiti restaurants. Moreover, the regional ties in
culture and trade have fostered policy learning and adaptation across governments in
different Arab countries. Governments in the region often look at each other for
common lessons and best practices of health interventions.
Since the “Arab Spring” uprising in 2011, the Arab region is “experiencing an
unprecedented escalation of conflicts that undermine gains of development, and in
some instances reverse progress” (United Nations Development Programme 2016,
p. 8). The human capital development in the region is lagging behind the world,
according to recent global surveys. Most of the middle- and lower-income groups
are suffering from poor education, ill health, and insecure job opportunities.
Measured in terms of Human Capital Index (HCI), all Arab countries score
lower than 0.7, indicating that the productivity of the Arab people has not reached
70% of its full potential (World Bank 2018, 2019b). Even the resource-rich GCC
countries are ranked among the lower HCI in the world, only slightly higher than
the average of the resource-scarce sub-Saharan African countries. A key indicator
of the HCI is adult survival rate, which is mostly affected by the deaths from NCDs
and injuries.
This chapter focuses on four main NCDs including: CVDs, cancers, chronic
respiratory diseases, and diabetes, and the four shared risk factors including: tobacco
use, harmful use of alcohol, physical inactivity and unhealthy diet, and overweight
and obesity in the Arab region. We analyze the most recent data from the Global
Burden of Disease study and the World Health Organization’s global health surveys.
This chapter aims at providing an evidence-based roadmap for policy makers,
program managers, and researchers in the region to formulate effective prevention
policies and strategies.
This chapter posits that NCDs pose a broad threat not only to the health and well-
being of the Arab population but also to the economic growth and sustainable
development of Arab countries. This underscores the importance of prioritizing the
prevention of NCDs. The scale and scope of the NCD challenges in the Arab region
require a comprehensive policy intervention be conducted in an inclusive process,
especially among the youth. Preventing and reducing NCD risk factors are the most
cost-effective policy measures and should be placed at the center of all health-related
policies.
NCD prevention in Arab countries aligns with the targets of the WHO Global
Action Plan for the Prevention and Control of NCDS 2013–2020 and the United
Nations (UN) Sustainable Development Goals (SDGs). Both initiatives aim to
reduce premature deaths from NCDs by one-third by 2030. Because countries across
the Arab region vary in their experiences and progress in addressing the risk
behaviors among youth, valuable opportunities exist for countries to learn from
the experiences of others, including their neighbors in the region.
Burden of NCDs in Arab Countries
This section will analyze the regional burden of NCDs for the total population and
for the young people between age 10 and 24, using the most widely used measures
including death rates, years of life lost (YLLs), and years lived with disability
(YLDs).
In 2017, NCDs were responsible for about 1.5 million (exactly 1,481,000) deaths,
accounting for 65% of all deaths (WHO 2017a). In 13 high- and upper middle-
income countries, NCDs have caused more than two-thirds of all deaths (Fig. 1).
Lebanon has the highest percentage of deaths due to NCDs (89%), followed by
Bahrain (85%), Tunisia (85%), and Egypt (83%). Lower-income countries including
Somalia, Mauritania, Comoros, and Djibouti report the lowest percentages of
NCD-caused deaths.
Moreover, one in five persons will experience premature death (between ages
30 and 70) from NCDs (WHO 2017a). The risk of premature death from NCDs is
higher than 20% in 9 Arab countries, most of which are lower-middle-income and
Fig. 1 Deaths caused by NCDs as a percentage of all causes in 2017. (Data source: World Health
Organization 2017a)
Fig. 2 Risk of premature deaths caused by NCDs as a percentage of all causes in 2017. (Data
source: World Health Organization 2017a)
low-income countries (Fig. 2). Yemen has the highest risk of premature death from
NCDs at 31% of all causes, followed by Sudan (26%), Syria (24%), and Egypt
(24%). Higher income countries, especially three GCC countries Bahrain, Qatar, and
Saudi Arabia, have the lowest risk of premature death caused by NCDs.
NCDs account for more than 50% of YLLs for the total population in two thirds
of the countries in the region (Fig. 3). Bahrain, Lebanon, and Tunisia had the highest
percentages of NCDs-caused YLLs out of total YLLs in 2017. In every 100 years of
life lost, people in these three countries lost over 70 years due to NCDs-caused
premature deaths. In comparison, young people are suffering from NCDs but have
less NCDs-caused YLLs than the elderly. Young people in Bahrain and Lebanon
reported over 40% of YLLs due to NCDs in 2017, yielding the highest shares of
NCDs-caused YLLs among the young in the region.
Bahrain
Lebanon
Tunisia
Morocco
Kuwait
Egypt
Algeria
Libya
Palestine
Jordan
Qatar
Saudi Arabia
Oman
Comoros
Sudan
Iraq
Syria
Djibouti
Yemen
Mauritania
Somalia
0 20% 40% 60% 80%
YLLs due to NCDs for all ages (%) YLLs due to NCDs for youth (%)
Fig. 3 Years of life lost due to NCDs as a percentage of all causes in 2017. (Data source: Global
Burden of Disease Collaborative Network 2018)
NCDs are the dominant cause of people living with disability or disease in the
region, for the young as well as elderly. In 2017, NCDs caused more than 60% of
YLDs in every country of the region (Fig. 4). In half of the countries in the region,
including all GCC countries, NCDs accounted for over 80% of YLDs, with the
highest of 87.7% in Tunisia and 87.6% in Saudi Arabia. In other words, in every
100 years of living with disability or disease, almost 88 years are due to NCDs in
Tunisia and Saudi Arabia. The young in the region experienced around 65–85% of
YLDs due to NCDs, while Saudi Arabia led with 86.1%.
While the above data have demonstrated the relative burden of NCDs in terms
of YLLs (reflecting premature mortality) and YLDs (reflecting morbidity), most of
the literature use disability-adjusted life years (DALYs), which combine YLLs and
YLDs. It is important to unpack DALYs into YLLs and YLDs because they depict
different aspects of the burden of disease and require different strategies and
interventions. For example, while the rate of DALYs for young people in the
region is relatively low, the relative burden of YLDs is much higher among than
YLLs (see Fig. 5). That means many young people will not die prematurely;
however, they will live long with chronic conditions. Such distinction will be
masked if DALYs are used in the analysis. Therefore, the rest of the chapter will
use YLLs and YLDs for the burden of disease analysis with focus on the four main
NCDs in the region.
The leading NCDs in the Arab region are CVDs, cancers, diabetes, and chronic
respiratory diseases. These four main NCDs accounted for 1.3 million deaths, or
57% of all deaths in the region in 2015 – an increase from 0.9 million deaths in 2000
Tunisia
Saudi Arabia
Qatar
Bahrain
Kuwait
Morocco
Algeria
Oman
Lebanon
Egypt
Libya
Jordan
Palestine
Syria
Sudan
Iraq
Djibouti
Comoros
Mauritania
Yemen
Somalia
0 20% 40% 60% 80%
YLDs due to NCDs for all ages (%) YLDs due to NCDs for youth (%)
Fig. 4 Years lived with disability due to NCDs as a percentage of all causes in 2017. (Data source:
Global Burden of Disease Collaborative Network 2018)
Fig. 5 Rate per 100,000 of years of life lost, years lived with disabilities and disability-adjusted life
years due to NCDs for young people in 2017. (Data source: Global Burden of Disease Collaborative
Network 2018)
(Althoff et al. 2017). In the coming decades, these NCDs are projected to account for
an even greater proportion of the region’s deaths. Arab countries have some of the
world’s highest diabetes rates, and CVDs are already the single largest killer in the
region (Jensen et al. 2013). Chronic respiratory disease prevalence is also high and
rising, reflecting the region’s high use of smoked tobacco. Moreover, the region’s
new cancer cases are projected to nearly double by 2030 (The Global BMI Mortality
Collaboration 2016).
Cardiovascular Diseases
In the region, it is estimated that 54% of deaths from NCDs are due to CVDs.
Deaths attributed to CVDs (of total deaths) ranged from 49% in Oman to 13% in
Somalia. The burden of CVDs largely varies across Arab countries. In 2017, CVDs
in Tunisia and Morocco caused nearly 40% of YLLs among the total population,
whereas in Somalia, they only caused 5.9% of YLLs. Kuwait is the only high-
income GCC country that has more than 30% of YLLs due to CVDs (Fig. 6).
Furthermore, the youth in Kuwait suffer from the highest YLLs due to CVDs
(10.5%) as a percentage of all causes in the whole region, followed by the youth in
Morocco and Libya.
Tunisia
Morocco
Egypt
Kuwait
Lebanon
Algeria
Libya
Oman
Saudi Arabia
Bahrain
Palestine
Syria
Jordan
Qatar
Yemen
Sudan
Iraq
Comoros
Djibouti
Mauritania
Somalia
0 10% 20% 30% 40%
YLLs due to CVDs for all ages (%) YLLs due to CVDs for youth (%)
Fig. 6 Years of life lost due to cardiovascular diseases as a percentage of all causes in 2017. (Data
source: Global Burden of Disease Collaborative Network 2018)
Tunisia
Morocco
Algeria
Egypt
Syria
Iraq
Libya
Jordan
Lebanon
Palestine
Kuwait
Saudi Arabia
Oman
Comoros
Bahrain
Sudan
Djibouti
Mauritania
Yemen
Qatar
Somalia
0 1% 2% 3% 4%
YLDs due to CVDs for all ages (%) YLDs due to CVDs for youth (%)
Fig. 7 Years lived with disability due to cardiovascular diseases as a percentage of all causes in
2017. (Data source: Global Burden of Disease Collaborative Network 2018)
Comparing to YLLs, YLDs due to CVDs account for a much smaller percentage
of all diseases in the region (Fig. 7). In 2017, Tunisia and Morocco had the highest
percentage of YLDs caused by CVDs (4.04% and 3.9%, respectively), while
Somalia had the lowest percentage (1.96%). The youth in Qatar and Bahrain have
the lowest percentage of YLDs due to CVDs (0.6% and 0.7%, respectively), while
Djibouti’s young people report the highest percentage (1.4%).
Combining Figs. 6 and 7, we can see that the burden of CVDs is substantially
different for different age groups, especially in terms of YLLs. Tunisia and Morocco
have the highest burden of CVDs for the total population in the region, both in terms
of YLLs and YLDs as a percentage of all causes. Kuwait has the highest burden of
CVDs for the total population among the GCC countries, both in terms of YLLs and
YLDs. Kuwait also has the highest YLLs due to CVDs among Arab youth, while its
GCC neighbors Qatar and Bahrain have the lowest YLDs due to CVDs as a
percentage of all causes.
Cancers
Cancers cause a relatively low burden on the youth’s health in the region in terms
of YLLs. Although CVDs caused more YLLs than cancers among the total Arab
population, cancers had a higher share of YLLs among the Arab youth than CVDs
Lebanon
Bahrain
Tunisia
Libya
Qatar
Kuwait
Palestine
Jordan
Algeria
Morocco
Saudi Arabia
Comoros
Oman
Egypt
Djibouti
Mauritania
Iraq
Syria
Yemen
Sudan
Somalia
0 5% 10% 15% 20% 25%
YLLs due to cancers for all ages (%) YLLs due to cancers for youth (%)
Fig. 8 Years of life lost due to cancers as a percentage of all causes in 2017. (Data source: Global
in 2017. Lebanon has the highest percentage of YLLs due to cancers for the total
population (24%) and the youth (20%) in the region. The second highest percent-
age of YLLs caused by cancers are 17.7% among the total population in the UAE
and 17.6% among the youth in Qatar (Fig. 8). In five countries, namely, Qatar,
Jordan, Egypt, Sudan, and Somalia, the burden of cancers on the youth is even
higher than that on the total population, measured by YLLs due to cancers as a
percentage of all causes.
The overall YLDs due to cancers are low in the region. Lebanon had a substan-
tially higher percentage of YLDs due to cancers than the rest of Arab countries
(Fig. 9) in 2017, i.e., 1.3% among the total population and 0.6% among the youth.
Most Arab countries report YLDs due to cancers lower than 0.5% of all causes.
Figures 8 and 9 jointly suggest that Lebanon suffers from a substantially higher
burden of cancers relative to other causes than other Arab countries. Qatar has
proportionately the highest burden of cancers compared to other causes among the
youth in the GCC countries, both in terms of YLLs and YLDs.
Diabetes
The region was home to about 5.3% of the world’s population but accounted for
about 6.3% of the world’s prevalence of diabetes with about 26.4 million adults
Lebanon
Libya
Tunisia
Saudi Arabia
Comoros
Djibouti
Morocco
Jordan
Algeria
Egypt
Kuwait
Syria
Mauritania
Palestine
Bahrain
Somalia
Qatar
Oman
Sudan
Iraq
Yemen
0 0.5% 1% 1.5%
YLDs due to cancers for all ages (%) YLDs due to cancers for youth (%)
Fig. 9 Years lived with disability due to cancers as a percentage of all causes in 2017. (Data source:
Global Burden of Disease Collaborative Network 2018)
living with diabetes in the region in 2017 (International Diabetes Federation 2017).
Only 52.3% are diagnosed. Meanwhile, there are 12.6 million persons who are not
diagnosed, thus revealing a gap in reaching out to high-risk populations and missed
opportunities for screening at encounters with health professionals.
Saudi Arabia has the highest prevalence of 18.2% (Fig. 10). Overall, all the
GCC countries, Egypt, Lebanon, and Libya, have a prevalence of more than 10%,
which is mostly due to unhealthy behaviors, such as unhealthy diet and lack of
physical activity.
Egypt has the largest number of adults living with diabetes about 8.5 million and
is among the top 10 countries globally. Not only are the current figures of diabetes
alarming but the future is also startling, as the number of people with diabetes is
projected to nearly double by 2035 (Abuyassin and Laher 2016).
Diabetes-related deaths are estimated at 228,123 deaths, representing about
15.4% of total NCD-related deaths in the region (International Diabetes Federation
2017). Diabetes-related deaths account for more than 25% of all NCDs-caused
deaths in Bahrain and Qatar – the highest percentage in the region (Fig. 10). More
than two-thirds of Arab countries have diabetes-related death rates higher than 15%
of the total NCDs-caused deaths.
YLLs due to diabetes in Bahrain are significantly higher than the rest of Arab
countries (Fig. 11). In Bahrain, diabetes causes 12.3% of YLLs among the total
population and 1.5% among the youth. The second highest percentage of YLLs due
Fig. 10 Prevalence of diabetes and deaths caused by diabetes as a percentage of all deaths caused
by NCDs in 2017. (Data source: International Diabetes Federation 2017)
Bahrain
Qatar
Lebanon
Oman
Jordan
Palestine
Libya
Morocco
Tunisia
Egypt
Algeria
Comoros
Kuwait
Djibouti
Saudi Arabia
Iraq
Mauritania
Somalia
Sudan
Yemen
Syria
0 5% 10% 15%
YLLs from diabetes for all ages (%) YLLs from diabetes for youth (%)
Fig. 11 Years of life lost due to diabetes as a percentage of all causes in 2017. (Data source: Global
to diabetes is 4.7% among the total population in Qatar and 1.2% among the young
people in Egypt. To the contrary, conflict and fragile states, including Syria, Yemen,
Sudan, and Somalia, observe very low percentage of diabetes-caused YLLs.
Bahrain experiences the highest percentage of YLDs due to diabetes among the
total population (6.7%) in the region. Most Arab countries report that diabetes causes
around 4–6% of YLDs (Fig. 12). Saudi Arabia and Qatar have the highest percentage
Bahrain
Libya
Lebanon
Qatar
Egypt
Oman
Morocco
Kuwait
Algeria
Tunisia
Jordan
Saudi Arabia
Iraq
Comoros
Palestine
Djibouti
Syria
Mauritania
Somalia
Sudan
Yemen
0 2% 4% 6% 8%
YLDs from diabetes for all ages (%) YLDs from diabetes for youth (%)
Fig. 12 Years lived with disability due to diabetes as a percentage of all causes in 2017. (Data
source: Global Burden of Disease Collaborative Network 2018)
of diabetes-caused YLDs among young people. Yet, all countries report less than 2%
of YLDs due to diabetes among the youth.
Figures 10, 11, and 12 all suggest that diabetes has become a heavy burden on the
health of the entire population in the region, especially in the GCC countries, Egypt
and Lebanon.
Chronic Respiratory Diseases
Chronic respiratory diseases cause more current threats to the youth’s health than
diabetes in terms of YLLs and YLDs, even though diabetes is a bigger challenge to
the total population health. The UAE reports the highest percentage of YLLs due to
chronic respiratory diseases out of all causes, which is 2.6% for the youth and 5.6%
for all ages. Egypt observes the second highest percentage of YLLs caused by
chronic respiratory diseases, 2.2% for the youth, and 3.1% for the total population.
In countries other than the UAE and Egypt, YLLs due to chronic respiratory diseases
account for less than 2% of all causes for young people (Fig. 13). Oman and Qatar,
along with Iraq and Somalia, have the lowest percentages of YLLs due to chronic
respiratory diseases.
Lebanon, Egypt, and the UAE have the highest percentages of YLDs due to
chronic respiratory diseases, approximately 4.3–4.6% among the youth and

Egypt
Tunisia
Morocco
Bahrain
Lebanon
Libya
Algeria
Comoros
Saudi Arabia
Palestine
Mauritania
Syria
Jordan
Kuwait
Yemen
Djibouti
Sudan
Qatar
Somalia
Oman
Iraq
0 2% 4% 6%
YLLs from chronic respiratory YLLs from chronic respiratory

diseases for all ages (%) diseases for youth (%)
Fig. 13 Years of life lost due to chronic respiratory diseases as a percentage of all causes in 2017.
(Data source: Global Burden of Disease Collaborative Network 2018)
5.4–5.8% among the total population (Fig. 14). Saudi Arabia, Yemen, and Oman
have the lowest percentage of YLDs due to chronic respiratory disease, about
2.4–2.8% among the youth and 3.2–3.3% among the total population.
Summary
NCDs are already taking a heavy toll on adult population’s health in all Arab
countries, both in terms of fatal and nonfatal health outcomes. According to recent
international health data, NCDs have caused more than 20% of all YLLs in most
Arab countries, and more than 40% in Bahrain and Lebanon. Moreover, NCDs
have caused more than 60% of all YLDs of Arab youth and more than 80% in half
of the Arab countries. If Arab youth continue their current lifestyles, they are likely
to face the rising burden of NCDs seen as for the total population in the coming
years.
Among the four main NCDs in the region, cancers are the leading cause
of YLLs for Arab youth, the highest of which accounts for approximately 20%
of all YLLs in Lebanon. Chronic respiratory diseases are the leading cause of
YLDs for young people, the highest of which accounts for 4.6% of all YLDs in
Lebanon.
Lebanon
Egypt
Algeria
Jordan
Syria
Morocco
Tunisia
Bahrain
Kuwait
Libya
Iraq
Sudan
Mauritania
Comoros
Palestine
Qatar
Djibouti
Somalia
Oman
Yemen
Saudi Arabia
0 2% 4% 6%
YLDs from chronic respiratory YLDs from chronic respiratory

diseases for all ages (%) diseases for youth (%)
Fig. 14 Years lived with disability due to chronic respiratory disease as a percentage of all causes
in 2017. (Data source: Global Burden of Disease Collaborative Network 2018)
Young people in the GCC countries, Lebanon and Egypt are suffering from the
highest percentage of burden from NCDs in the region. The conflict and fragile states
in the region tend to have lower burden of NCDs as a percentage of all causes. But
the link between per capita income level and the burden of NCDs is not linear. For
example, Oman, Qatar, and Saudi Arabia have the lowest percentages of YLLs and
YLDs due to chronic respiratory diseases, while the UAE with similar per capita
income levels report the highest percentage. The data analysis in the section “Main
Risk Factors of NCDs Among Arab Adults” of this chapter sheds light on the
importance of analyzing risk factors of NCDs across Arab countries to design
effective youth policies and health interventions.
Main Risk Factors of NCDs Among Arab Adults
Substantial reduction of NCD mortality requires a whole-of-government approach

that considerably reduces the main risk factors of NCDs. NCDs are associated with
metabolic, behavioral, and environmental risk factors. Metabolic risk factors
include: high blood pressure, high blood glucose, high blood cholesterol/lipids,
and overweight/obesity. NCDs are also associated with behavior risk factors that
Fig. 15 Behavioral and metabolic risk factors of NCDs. (Source: Authors)
usually precede the metabolic conditions, namely, tobacco use, physical inactivity,
poor diet, and harmful use of alcohol. This can be illustrated in Fig. 15. Behavioral
risk factors can directly contribute to NCDs and/or show effects in individuals, such
as raised blood pressure, raised blood glucose, raised blood lipids, and overweight
and obesity (WHO 2017b).
For example, the most important behavioral risk factors for heart disease and
stroke include unhealthy diet, physical inactivity, and tobacco use as illustrated in
Fig. 16. These behavioral risk factors affect the individual’s blood pressure, serum
cholesterol level, level of lipids, and body weight. The amount and content of dietary
fat is the major determinant of serum cholesterol level, which in turn is the most
important cardiovascular risk factor in industrialized countries, explaining nearly
half of the incidences of coronary heart disease (CHD) at population level
(Laatikainen et al. 2005). Furthermore, high salt (sodium) and excessive alcohol
intake, physical inactivity, and obesity raise blood pressure. High blood pressure is
an important risk factor for CHD, and it is the major risk factor for stroke (Jousilaht
2006, p. 45). These metabolic risk factors are often measured in health care facilities
as an indication for increased risk of developing a heart attack, stroke, heart failure,
and other complications (WHO 2017b).
Recent data suggest that behavioral risk factors – particularly tobacco use,
unhealthy diets, and physical inactivity – are prevalent in the Arab world. Obesity
has reached an alarming level in many Arab countries. The remaining section will
discuss the five leading risk factors, i.e., tobacco use, alcohol use, physical inactivity
and unhealthy diet, and overweight/obesity. Due to data limitations, this chapter will
not discuss environmental risk factors.
Tobacco Use
Tobacco use is by far the number one preventable cause of death globally and is the
only one of the four risk factors that contributes to all four main NCDs (WHO
THE WHOLE CHD RISK

TO BE EXPLAINED
SEDENTARY
LIFESTYLE
37%
HIGH
OBESITY CHOLESTEROL
6% (>5.2 mmol/l)
46%
HIGH BLOOD
PRESSURE
(>140/90
mmHg)
13%
SMOKING
19%
Fig. 16 The role of risk factors on the development of coronary heart disease. (Reprinted from
Health in all policies prospects and potentials, Ståhl PT et al (eds), The promotion of heart health: a
vital investment for Europe, Jousilaht P, Page 46, Copyright (2006). Access on July 21, 2019, http://
www.euro.who.int/en/health-topics/health-determinants/social-determinants/publications/pre-2007/
health-in-all-policies-prospects-and-potentials-2006)
2018a). Each year, tobacco use claims the lives of six million globally, and this figure
is projected to increase to eight million by 2030 (WHO 2014a). Tobacco use is the
leading cause of the world’s most damaging NCDs, and cigarettes are among the
deadliest artifacts in the history of human civilization (Proctor 2012).
When individuals inhale cigarette smoke – the most common form of tobacco
used in most of the world – either directly or indirectly as secondary inhaling, they
are inhaling more than 7000 chemical compounds: hundreds of these are hazardous,
and at least 69 are known to cause cancer (U.S. Department of Health and Human
Services 2010). Tobacco use is also a primary cause of chronic respiratory diseases,
including chronic obstructive pulmonary diseases; a major risk factor for CVDs,
including coronary heart disease and stroke; and it increases common diabetes-
related complications (WHO 2017b, d, 2018b).
Tobacco use is a pressing public health issue in many Arab countries. Arab countries
today have some of the highest tobacco use rates in the world. Recent data from WHO
(2018a) report tobacco use in 14 Arab countries (see Fig. 17). Half of these countries –
including Lebanon, Tunisia, Egypt, the UAE, Bahrain, Kuwait, and Morocco – observe
more than one-third of adult men (aged 15 years and older) who smoke tobacco
Tunisia
Egypt
Morocco
Lebanon
Kuwait
Bahrain
Algeria
Qatar
Yemen
Saudi Arabia
Djibouti
Comoros
Oman
0 20% 40% 60% 80%
Males Females
Fig. 17 Tobacco smoking among adults aged 15+ in 2016. (Data source: World Health Organi-
zation 2018a)
products. The prevalence among Arab women is low. Lebanon has the highest rate at
26% in 2016.
The highest prevalence of tobacco use in Arab countries include 66% of men in
Tunisia, 26% of women in Lebanon, and 33% of total population in Tunisia and
Lebanon. The prevalence of tobacco smoking in eight countries – including Leba-
non, Tunisia, the UAE, Bahrain, Egypt, Kuwait, Morocco, and Qatar – is higher than
the global average of 20% in 2016 (WHO 2018a). In contrast to the global decline of
tobacco use, cigarette consumption in Arab countries has increased by about
one-third since 2000 (WHO 2017b).
Despite the adoption of the Framework Convention on Tobacco Control (FCTC)
by most Arab countries, the region has failed to implement serious government
regulations and public health interventions in response to the tobacco epidemic
(Maziak et al. 2014). Five out of the 14 countries in Fig. 17 have not set up national
target on reducing tobacco use, including Tunisia and Egypt – the two countries with
the highest prevalence of tobacco use in total population (WHO 2018a).
Alcohol Use
The harmful use of alcohol is one of the leading risk factors for population health
worldwide and is known to cause heart diseases, cancers, liver diseases, a range of
mental and behavioral disorders, other noncommunicable conditions, and commu-

nicable diseases (WHO 2018a). Worldwide, the harmful use of alcohol caused an
estimated 3 million deaths and 132.6 million disability-adjusted life years (DALYs)
in 2016, including 1.7 million NCD deaths (4.3% of all NCD deaths) and 65.6
million NCD DALYs (4.2% of all NCD DALYs) (WHO 2018c). About 49% of
alcohol attributable DALYs are due to noncommunicable and mental health condi-
tions and about 40% are due to injuries (WHO 2018c).
The Arab countries have low levels of alcohol use as it is officially prohibited in
Libya, Saudi Arabia, Kuwait, and Yemen and is socially taboo in many other Arab
countries. As a result of these policy interventions, Arab countries have the lowest
alcohol consumption and lowest alcohol-attributable deaths and DALYs in the
world.
Recent data from WHO (2018a, c) report zero alcohol consumption per person
over the past 12 months in Kuwait, Yemen, Saudi Arabia, Mauritania, Somalia, and
Libya. The UAE tops the Arab countries with 5 liters of pure alcohol consumption
per man and 1 liter per woman in 2016, which is still below the global average of 6.4
liters (see Fig. 18). Only 0.9% of males and 0.1% of females aged 15 years or older
are heavy episodic drinkers in the WHO Eastern Mediterranean region (EMR),
which includes most Arab countries plus Iran, Afghanistan, and Pakistan (WHO
2018c). Furthermore, alcohol consumption attributes to 6.1% of the
age-standardized burden of NCDs in EMR, a sharp contrast to the 22.4% worldwide
(WHO 2018c).

Tunisia
Lebanon
Bahrain
Qatar
Comoros
Algeria
Syria
Sudan
Oman
Morocco
Jordan
Iraq
Egypt
Djibouti
0 1 2 3 4 5
Pure alcohol consumption among male adults (litre)
Fig. 18 Harmful use of alcohol among male adults aged 15+ in 2016. (Data source: World Health
Organization 2018a)
Unhealthy Diet and Physical Inactivity
Unhealthy diet and physical inactivity are well-known leading risk factors for NCDs.
Healthy eating habits and well-balanced nutrition intakes are essential to our health
status and quality of life. For example, consuming a diet high in salt contributes to
raised blood pressure and increases the risk of heart disease and stroke (WHO
2018a). Energy-dense foods that are high in sugar and saturated fat may increase
the risk for obesity and other metabolic disorders (WHO 2018b). Low intake of fruits
and vegetables may increase the risk for obesity, CVDs, and some types of cancers
(WHO 2017c, 2018b, d).
Many Arab countries have witnessed unhealthy dietary changes prevalent in
children, adolescents and adults, heavily influenced by the global fast food
industries and the increasing availability of highly-processed food. Currently,
data on mean population intake of sodium, fat, and sugar are not widely
available. But it is common to find refined and processed food, carbonated
beverages, increased food portion sizes, and diets high in calories, fat, and salt
consumed in most Arab countries (Rahim et al. 2014). Arab people also have
low intake of fruits and vegetables that is below the recommended daily allow-
ance (>400 g) in all age groups and both genders (Musaiger and Al-Hazzaa
2012, p. 207).
People who are physically inactive have an increased risk of all-cause mortality,
compared with those who regularly exercise at least 30 min a day (WHO 2018a).
Physical activity improves musculoskeletal health and function, helps maintain a
healthy weight, lowers risk of NCDs including CVDs, hypertension, diabetes, and
breast and colon cancers, prevents cognitive decline, and reduces symptoms of
depression and anxiety (Althoff et al. 2017; Guthold et al. 2018).
Despite the known health benefits of physical activity, the prevalence of physical
inactivity has remained high in nations at various income levels, partly due to the
sedentary nature of modern work and transportation. Arab countries, especially GCC
countries, are facing some of the world’s highest prevalence of physical inactivity
(WHO 2018a; Guthold et al. 2018; Althoff et al. 2017).
According to recent data from WHO (2018a), more than half of adults are
physically inactive in Kuwait, Saudi Arabia, and Iraq (see Fig. 19). Kuwait has
73% of females, and 60% of males aged 18 years and over not meeting the WHO
recommendations for physical activity – the highest prevalence in the world.
Most Arab countries have more than one-quarter of adults who are physically
inactive, compared to the global average of 28% prevalence. (WHO (2018b)
recommends 150 min of moderate-intensity physical activity per week or 75 min
of vigorous-intensity physical activity per week or an equivalent combination of
moderate- and vigorous-intensity physical activity.) Jordan and Comoros have
the lowest prevalence of physical inactivity in Arab countries with observed data,
i.e., 8% of male adults in Comoros and 13% of female adults in Jordan. Women
are less active than men in all Arab countries – the same as most countries in the
world.
Kuwait
Saudi Arabia
Iraq
Qatar
Mauritania
Libya
Algeria
Oman
Egypt
Tunisia
Lebanon
Morocco
Comoros
Jordan
0 20% 40% 60% 80%
Males Females
Fig. 19 Physical inactivity among adults aged 18+ in 2016. (Data source: World Health Organization
2018a)
From 1975 to 2016, the global prevalence of obesity nearly tripled (NCD Risk
Factor Collaboration 2017). In 2016, more than 1.9 billion adults were overweight
and more than 650 million were considered obese (WHO 2018a). Being overweight
and obese is associated with increased risk of many NCDs, including type 2 diabetes,
coronary heart disease, atrial fibrillation, stroke, and cancers (Garcia-Moll 2018;
WHO 2018a). Obesity is also linked to hypertension and other risk factors for NCDs.
Once considered a problem of the rich, obesity has become a major epidemic of this
century across all income and age groups.
The WHO Eastern Mediterranean Region, including most Arab countries,
reported the world’s third highest prevalence of adult obesity rate (21%) after the
Region of the Americas (29%) and European Region (23%) in 2016 (WHO 2018a).
Three Gulf countries – Kuwait, Saudi Arabia, Qatar – observed the highest obesity
rates of more than one-third of all adults and more than 40% of females in 2016 (see
Fig. 20). (The World Health Organization (2018a) measures adult obesity as the
percentage of the population aged 18 years and older having a body mass index
(BMI) 30 kg/m2.) Women have higher obesity rates than men in the region. In
12 Arab countries, more than one-third of female adults is obese, including all Gulf
countries except Oman.
If the current trend continues, by 2030, as high as 90% of all adult men and
women in Kuwait will be classified as being overweight and obese (BMI 25.0 kg/m2),
which continues to top the record of overweight and obesity in the region
Kuwait
Qatar
Saudi Arabia
Jordan
Egypt
Libya
Bahrain
Tunisia
Lebanon
Iraq
Algeria
Syria
Morocco
Oman
Yemen
Mauritania
Djibouti
Comoros
Somalia
0 10% 20% 30% 40%
Males Females
Fig. 20 Obesity among adults aged 18+ in 2016. (Data source: World Health Organization 2018a)
(Kilpi et al. 2013). If Kuwait can lower its adult obesity rates by 5%, the country
will prevent 63,217 incidence cases of type 2 diabetes, 39,905 cases of CHD and
stroke, and 1032 cases of cancer by 2030 (Kilpi et al. 2013). In Saudi Arabia, a 5%
reduction in obesity can prevent 550,000 cases of type 2 diabetes and 350,000
cases of CHD and stroke by 2030 (Kilpi et al. 2013). Other Arab countries, such as
Bahrain, Lebanon, and Oman, can also expect considerable prevention of NCD
cases if the population-level BMI is lowered even to a small percentage (Kilpi
et al. 2013).
Main Risk Factors of NCDs Among Arab Adolescents
The four main risk factors of NCDs are influenced by modifiable behaviors, typically
initiated or established during adolescence or young adulthood. These set the stage
for NCDs later in life. In fact, 70% of premature deaths in adults are due to behaviors
established in adolescence that share common risk factors (Sawyer et al. 2012,
p. 1637). Preventing and reducing risk behaviors among Arab youth today can
minimize the future burden of the growing NCD epidemic.
The early development of risk factors is interlinked with the social transfor-
mations and biological changes that adolescents are going through at this distinct
100 % of
Cohort
Schooling Working
Forming families
Taking health risks
Exercising Citizenship
Age
12 24
Fig. 21 The five transitions of youth. (World Bank. 2006. World Development Report 2007:
Development and the Next Generation. World Bank. © World Bank. https://openknowledge.
worldbank.org/handle/10986/5989 License: CC BY 3.0 IGO.)
time of life. Young people undergo a sensitive period of building identities,

transforming social roles, and increasing autonomy and control over their own
lives. Young people share critical social transformations of schooling, working,
forming families, exercising citizenship, and taking risks, which are all key for
social mobility and economic growth (Fig. 21) (World Bank 2006).
Biologically, young people are more likely to make risk-seeking decisions and are
more affected than adults by exciting or stressful situations – the so-called hot
cognitions – especially in front of peers (Steinberg 2008; Sawyer et al. 2012).
Young people between ages 10 and 15 are willing to take risks to experiment with
new, stimulating experiences, affected by puberty (Martin et al. 2002; Sawyer et al.
2012). This sensation-seeking mentality makes young people most vulnerable to
tobacco, alcohol, drugs, energy-rich fast foods, and carbonated beverages high in
sugar. These life course changes may affect the likelihood of young people devel-
oping behavioral risk factors associated with NCDs.
Over the past 30 years, controlled trials and health programs in high-income
countries have shown that preventive interventions can effectively and efficiently
reduce adolescent problem behaviors and improve their health (Catalano et al.
2012; Aos et al. 2011). In Lancet’s recent special issue on NCDs, collaborators
emphasize that “NCD-caused deaths in people less than 30 years of age can be
largely avoided through prevention and treatment, as evidenced by very low
mortality in this age group in high-income countries” (Beaglehole et al. 2018,
p. 1078). The earlier we intervene with young people to avert these risks and to
promote healthy behaviors, the more health benefits we can achieve at personal,
family, community, national, and regional levels. In other words, a lifetime
opportunity for prevention of NCDs arises from addressing risk factors that
begin in or even before adolescence.
Alcohol and tobacco use are often initiated during adolescence and young
adulthood, when peer pressure and the desire to fit in among peers are high, and
developmental changes increase vulnerability to substance use and addiction (Ham-
mond et al. 2014; WHO 2017b, 2018c). Although dietary and physical activity
patterns may start to form during childhood, adolescence and young adulthood are
typically the time when they are more firmly established as youth gain more control
over their diet and activities. When started or supported during this phase of life,
healthy behaviors such as eating well and exercising regularly are likely to carry
through to adulthood. Meanwhile, unhealthy habits started young can persist and be
difficult to change.
The prevalence of the four main risk factors is rising among young people
worldwide and in Arab countries. Over the last few decades, Arab countries have
experienced dramatic social, economic, and political changes at expedited speeds.
These social changes have been driving a rise in NCD risk behaviors among the large
cohort of Arab youth, setting them up for poorer health in adulthood than is found in
adults today.
Tobacco Use
Tobacco use is widely prevalent among young people in the region. Among 13- to
15-year-old boys in secondary school, the most recent surveys show that more than
half in the West Bank were current tobacco users (defined as using any tobacco
products in the past 30 days including cigarettes, water pipes, and smokeless
tobacco), followed by approximately a third in Jordan, Lebanon, and Syria, and
more than a quarter in Bahrain and Kuwait, according to the WHO and CDC Global
Youth Tobacco Survey (see Fig. 22).
In about half the region’s countries, more than one in two boys who are current
tobacco users smoke cigarettes. While cigarette smoking is still relatively low in the
other half of the region, signs point to cigarette use increasing as the tobacco industry
targets the region’s youth (and women) with advertising. Actually, one-third of tobacco
experimentation among youth globally is due to tobacco advertising, promotion, and
sponsorship (TAPS) (WHO 2013a). The large and growing population of young
people in Arab countries is a prime target for the tobacco industry because the region’s
cultures have a long history of tobacco use and smoking is becoming increasingly
more socially acceptable. Among secondary school students in Djibouti, one in six
reported ever being offered a free tobacco product from a tobacco company in 2013. In
Yemen, almost 3 in 10 reported owning items bearing a tobacco brand logo in 2014.
Girls’ rates of tobacco use are typically half or less than boys’ rates, especially for
cigarette smoking. However, tobacco use among girls – particularly the use of
products other than cigarettes such as water pipes and smokeless cigarettes – is
increasing in some countries because of changing norms and greater access to
different products.
One major concern in Arab countries is the growing use of water pipes (such as
shisha and nargile), especially among youth. In Lebanon, about 40% of boys and
F
West Bank (2016) M
F
Kuwait (2015) M
F
Bahrain (2016) M
F
Lebanon (2011) M
F
Jordan (2009) M
F
Qatar (2013) M
F
Saudi Arabia (2010) M
F
Tunisia (2010) M
F
Syria (2010) M
F
Gaza Strip (2013) M
F
UAE (2013) M
F
Algeria (2013) M
F
Yemen (2014) M
F
Iraq (2014) M
F
Djibouti (2013) M
F
Oman (2015) M
F
Morocco (2016) M
F
Egypt (2014) M
F
Libya (2010) M
0 10% 20% 30% 40%

cigarettes other tobacco products
Fig. 22 Secondary school students aged 13–15 who smoked any tobacco product in the past
30 days. (Data source: Centers for Disease Control and Prevention 2017a)
30% of girls aged 13–15 in secondary schools were using water pipes in 2011. Water
pipe use is typically initiated earlier than cigarettes and acts as a gateway for cigarette
smoking (Kheirallah et al. 2015, 2016).
Many people falsely believe that water pipe smoking is less harmful than
cigarettes. However, the nicotine dose in a typical shisha smoking session is more
than 1.7 times higher than that contained in one cigarette (Eissenberg and Shihadeh
2009). Moreover, smoking shisha necessarily involves deep inhaling of smoke,
which does not characterize cigarette or cigar smoking. Furthermore, while second-
hand smoke from any smoked tobacco poses health risks, 1 h of exposure to shisha
smoke compared to similar exposure to cigarette smoke may result in 2–10 times the
amount of harmful chemicals in the air, including some that cause cancer (Daher
et al. 2010).
Although still much lower compared to water pipe use, e-cigarettes are also
starting to become popular in the region, including in some countries where their
sale is banned. While the ingredients can vary, the nicotine in most e-cigarettes is still
addictive. This creates concerns among public health experts that e-cigarettes also
may act as a gateway to cigarette smoking among youth. However, most available
policy and program interventions for tobacco use both globally and regionally focus
on cigarette smoking but do not address water pipe or e-cigarette smoking. Greater
attention to the use of these other tobacco products is urgently needed to protect the
health of young people in the region.
Despite the high and increasing prevalence of tobacco use among youth in the region,
the availability of cessation support for any type of tobacco products is substantially
limited, especially those targeting young people. Although more than 60% of the
secondary school students ages 13–15 in both Qatar and the UAE in 2013 reported
trying to stop smoking during the previous 12 months, only 26% and 21% of students in
these countries, respectively, reported ever receiving help or advice from a program or
professional to stop smoking. Given that a large percentage of secondary school students
who currently use tobacco reported wanting to stop smoking throughout the region, a
critical need exists to step up efforts to ensure that youth can access cessation support.
Alcohol Use
In 2012, an estimated 3.3 million deaths worldwide were attributable to alcohol,

more than half of which were related to NCDs – primarily CVDs, diabetes, cancers,
and gastrointestinal diseases (WHO 2014a). Alcohol use among youth is also linked
to many other health risks, including road traffic accidents, risky sexual behaviors,
violence, and poor mental health. Because alcohol is particularly harmful to a young
and developing body – and because early initiation substantially increases the
likelihood of developing alcohol dependency later – any amount of alcohol use
among children and youth should ideally be avoided (Grant and Dawson 1997).
Assessing the actual level of alcohol use in the region is particularly challenging
among youth. Representative data on alcohol use among youth in the region is
scarce. The Global School-Based Student Health Survey conducted by the WHO
and the US Centers for Disease Control and Prevention was administered in 22 Arab
countries, but only three countries – Lebanon, Morocco, and Syria – have ever
included questionnaires on alcohol use.
Among 13- to 15-year-olds in secondary schools, the share who reported cur-
rently using alcohol (defined as any use in the past 30 days) were substantially higher
in Lebanon at 37% and 22% among boys and girls in 2011, respectively, compared
with 12% and 3% in Syria in 2011 and 6% and 2% in Morocco in 2006. The trend
data available for Lebanon between 2005 and 2011 show increases by 28% among
boys and 75% among girls over the 6-year period, which narrowed gender differ-
ences in alcohol use. In both Lebanon and Syria, a large majority (88%) of students
who reported ever having alcohol had their first drink before age 14.
Binge drinking, which is exceedingly harmful to the body, is more common
among youth. More than one in five students (21%) in Lebanon reported ever
drinking so much alcohol that they were extremely intoxicated, compared with
one in 25 (4%) in Morocco. Despite the relatively low prevalence of current alcohol
use and heavy episodic drinking in Morocco, as many as 15% of all boys and 12% of
all girls in secondary schools reported ever having a problem that resulted from
drinking alcohol, such as having a hangover, feeling sick, getting into trouble with
family or friends, missing school, or getting into fights.
Understanding alcohol use among young people in the countries across MENA,
regardless of their official stance on alcohol use, is important since market research
shows a sharp increase in overall alcohol consumption in the region between 2001
and 2011, including in countries that ban alcohol (Ghandour et al. 2016). The sale of
liquor grew by 72% in the region during the period, compared with the global
average of 30%. While alcohol sales in some of the region’s countries declined in
recent years (due to economic slowdowns and increased health awareness in the
public), market research documents continued growth in other countries. Egypt, for
example, saw a steady increase in the sale of alcoholic beverages in 2016, despite the
large price increases due to the introduction of a value-added tax and the devaluation
of its currency (Euromonitor International 2017a). While it is not clear whether any
of the trends in alcohol sales reflected changes in consumption among young people
themselves, it is possible that the trends may have influenced their behavior.
Studying alcohol use among youth is also important because the alcohol industry
considers the region’s large and growing population of young people a great
opportunity to increase their sales. For example, it has started using innovative
marketing strategies, such as introducing non-alcohol alternatives to enhance
“brand recall” among its consumers, particularly young people (Ghandour et al.
2016). Saudi Arabia has a total ban on alcohol, but low- or nonalcoholic beer is in
demand among the large and growing youth and young adult population, who are the
primary target for beer consumption. While sales of low or nonalcoholic beer
products in Saudi Arabia stalled in 2016 due to economic slowdowns after showing
steady growth earlier, young people ages 18–35 remained the primary customers
(Euromonitor International 2017b). Alcohol companies have continued targeting
young people by creating new flavors and running extensive advertising using
satellite television channels and promotional campaigns in stores, such as offering
discounts for purchasing multiple packs.
Egypt is one of only four countries in the region with an adopted national alcohol
policy, including measures to keep alcohol away from young people, such as
regulating alcohol advertising and marketing, mandating a minimum legal drinking
age, and reducing the density of venues selling alcoholic beverages. Nevertheless,
online retail of alcohol is becoming popular among young Egyptians (Euromonitor
International 2017a). Online retailing by two of the largest Egyptian alcoholic
beverage companies provide wide access to alcoholic beverages, especially for
young people, by making it possible to order from anywhere and to have products
delivered to most locations.
While neither Saudi Arabia nor Egypt have alcohol consumption data for a
nationally representative sample of youth, the alcohol marketing trends described
above – particularly the alcohol industry’s targeting of young people – underscore
the importance of collecting data. Assessing the levels of alcohol use among youth in
all the region’s countries, regardless of the existing alcohol bans or policies, will help
those working to support healthy youth behaviors to stay abreast of the evolving
situation and better plan for youth needs in the future.
Unhealthy Diet and Physical Inactivity
Youth in Arab countries have experienced substantial changes in their diet and
physical activity levels over the last four decades, due to the changing environment
resulting from a combination of economic development, urbanization, and globali-
zation. Though diet in the region varies across geography, there has been a shift away
from healthier, traditional diets, generally consisting of vegetables, fruits, whole
grains, and moderate or small amounts of fat and meat.
The diets of young people in Arab countries today consist increasingly of calorie-
dense, highly processed food with large amounts of sugar, salt, and saturated fat. Young
people also have greater access to soft drinks and other sugar-sweetened beverages that
add substantially to their calorie intake. A nutrition study in the UAE showed that
beverage calories were one of the major contributors to total calories consumed among
youth, making up as much as 14% of total calories among boys (Ng et al. 2011). In
8 Arab countries among 14 for which data were available, half or more secondary
school students (ages 13–15) reported usually drinking sugary carbonated soft drinks at
least once per day during the past 30 days, with the rate as high as 77% in Algeria,
according to the WHO and CDC Global School-Based Student Health Survey.
In addition to having a less healthy diet, young people spend less time being
physically active and more time in sedentary activities, such as watching television
and using a computer. With urbanization and socioeconomic development, physical
activity levels that used to be required for work and transportation have been
significantly reduced. At the same time, being physically active and exercising in
the open air has become more challenging due to heavy traffic, limited recreation
spaces, air pollution, and crime-related safety concerns.
Many young people fail to meet the physical activity level recommended by the
WHO (2017e), which is 60 min of moderate- to vigorous-intensity physical activity
daily for young people ages 5–17. While physical activity levels are low for both
sexes, they are particularly low for girls. According to the Global School-based
Student Health Surveys, around 70–80% of boys and 80–90% of girls in the region
did not meet the recommended level of physical activity (Fig. 23). Physical activity
not only helps young people maintain healthy weight and develop healthy bodies, it
also helps with their mental health, reducing the anxiety and depression that are
common among young people. Young people who are physically active are also
generally less likely to have an unhealthy diet and to use tobacco and alcohol.
While rates of overweight and obesity are rising among youth around the world, the
rates are particularly high in parts of Arab countries, especially in the Gulf States.
Surveys conducted between 2007 and 2015 show that more than 25% of male and
female secondary school students, ages 13 to 15, in about half of the region’s
countries were either overweight or obese (see Fig. 24). As many as three countries
Yemen (2014)
Morocco (2016)
Djibouti (2007)
Qatar (2011)
Oman (2015)
Egypt (2011)
Tunisia (2009-10)
Syria (2010)
Libya (2007)
Jordan (2007)
Algeria (2011)
West Bank (2010)
Iraq (2012)
Bahrain (2016)
Kuwait (2015)
Gaza (2010)
UAE (2010)
Lebanon (2011)
0 20% 40% 60% 80% 100%
Males Females
Fig. 23 Physical inactivity among secondary school students aged 13–15 in 7 out of the past
7 days. (Data source: Centers for Disease Control and Prevention 2017b)
had overweight and obesity rates that were 40% or higher among boys – Bahrain,
Kuwait, and the UAE – and one among girls – Kuwait.
The high and increasing rates of overweight and obesity among youth in MENA
are particularly troubling because of the high diabetes rates in some of the countries.
According to the International Diabetes Federation, Bahrain, Egypt, Kuwait, Leba-
non, Saudi Arabia, and the UAE all have estimated prevalence rates of 15% or higher
among the adult population ages 20 to 69 in 2017 (International Diabetes Federation
2017). Between 2017 and 2045, the number of adults with diabetes in MENA is
projected to double from 39 million to 82 million.
Diabetes not only lowers the quality of life, but it creates a significant financial
burden – diabetics require two to three times the health care resources as people
without diabetes (exact expenditure amounts vary across countries depending on the
available resources) (American Diabetes Association 1998). In Saudi Arabia, health
expenditures per person with diabetes in 2015 were an estimated US$1145, which is
projected to increase to as high as US$1430 by 2040 (Zang et al. 2010).
While many countries in the region are fighting high rates of obesity, others are
facing the double burden of both increasing overweight and obesity on the one hand
and persistent undernutrition on the other. Among 13- to 15-year-old boys in
secondary school, 12% in Yemen in 2014 and 13% in Morocco in 2010 were
overweight or obese, while 18% and 11% were underweight, respectively.
60%
50%
40%
30%
20%
10%
0
M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F
Kuwait UAE Bahrain Lebanon Egypt Oman Jordan Syria Iraq (2012) Libya West Bank Gaza Strip Djibouti Morocco Yemen Algeria
(2015) (2010) (2016) (2011) (2011) (2015) (2007) (2010) (2007) (2010) (2010) (2007) (2010) (2014) (2011)
Overweight Obese
Fig. 24 Overweight and obesity among secondary school students aged 13–15. (Data source:
Centers for Disease Control and Prevention 2017b)
Policies and Strategies for NCDs in Arab Countries
The growing burden of NCDs and the alarming prevalence of risk factors urge the
Arab countries to act together to address the epidemic crisis swiftly and comprehen-
sively. Contrary to our common perceptions, “professional medical and nursing
services make only a relatively small contribution to population health. More
important are population-based interventions that modify core risks to health, such
as diet, smoking, alcohol, and physical activity.” (Gostin 2019, p.1). These inter-
ventions are not simply products of medical advice but are driven by law, strategies,
sound policies, and custom-tailored implementation programs.
Effective government strategies and policies should be coordinated across multiple
sectors with a mix of interventions, while also taking advantage of opportunities for
intervention at all stages of the life course (Fuster and Kelly 2010). The challenge does
not fall to any single entity. Rather, by collaborating across sectors on various risk-
reduction strategies, multiple groups can create a powerful approach to support popu-
lation health and lower medical costs in the future. Successful implementation requires
strong public and political commitment, multisectoral collaboration, strengthening of
regulatory capacity, and coordination among responsible entities. By implementing a
smart combination of effective, sustainable interventions that focus on creating long-
lasting healthy behaviors, it is possible to make changes and see progress within a
generation.
Health-in-All Policies
Tackling NCDs and its risk factors is not solely a health sector responsibility. It
embraces broad policy and social issues, such as a shifting focus of food industry
regulation and a change of people’s lifestyle choices. Policies made in many
sectors can have a profound effect on people’s health behaviors and the population
health outcomes. Effective prevention of NCDs and risk factors requires joint
actions beyond the health sector, including sectors of labor, education, agriculture,
energy, urban design, etc. (illustrated in Fig. 25). In fact, more than half of the
NCDs burden could be prevented through targeted actions beyond the health sector
that focus on a few key risk factors (Meiro-Lorenzo et al. 2011; Pierre-Louise et al.
2012). To tackle this issue requires political will to engage “the whole of govern-
ment in health” with institutional capacity to coordinate among multiple players
(WHO 2014b).
Growing evidence suggests that “the production of health” is mostly the result
of interventions from outside the health sector. In recognition of this fact, the
World Health Organization has identified the determinants of health as the
conditions in which people are born, grow, work, live, and age, and the wider
Fig. 25 Impacts of multisectoral interventions on health outcomes. (Source: Adapted from Pierre-
Louise et al. (2012))
set of forces and systems shaping the conditions of daily life. These forces and
systems include economic policies and systems, development agendas, social
norms, social policies, and political systems (Commission on the Social Deter-
minants of Health 2008). In Canada, for example, these social determinants of
health include: income and income distribution, education, unemployment and
job security, employment and working conditions, early childhood development,
food insecurity, housing, social exclusion, and social safety network (Bryant
et al. 2011). Findings from the USA suggest that health care is responsible for
only 20% of the population’s health, while the remaining 80% is due to other
conditions and sectors (Institute for Clinical Service Improvement 2014):
• 40% is related to socioeconomic factors, such as education, employment, income,

family/social support, and community safety.
• 30% is due to health behavior such as tobacco use, diet, exercise, alcohol use, and
unsafe sex.
• 10% is linked to the physical environment, such as environmental quality and
built environment.
The above evidence has led to the mobilization and engagement of many sectors
at improving health outcomes through Health-in-All-Policies (HiAP). HiAP is “an
approach to public policies across sectors that systematically takes into account the
health implications of decisions, seeks synergies, and avoids harmful health impacts
in order to improve population health and health equity” (WHO 2014b, p. 7). The
key in engaging other sectors is “synergy.” The focus of HiAP is to identify policy
measures that provide “win-win” or “co-benefits” that contribute not only to
improved health outcomes but also to outcomes desired by other sectors, such as
education, social protection, environment, welfare, agriculture, and transportation.
As such, HiAP has been suggested as an approach to addressing policy problems that
are complex or intractable and may require solutions of an interdependent effort
(Kickbusch and Buckett 2010).
HiAP intervention may target at the population and individual levels. However, the
population-level programs often result in broader policy impacts than the individual-
level intervention due to the positive externality of public health. As discussed in the
previous sections, much of the rise in NCDs is attributable to the shared and
modifiable risk factors including tobacco, alcohol, unhealthy diet, and physical
inactivity. These behavioral risk factors have negative externalities, i.e., a negative
valued impact resulting from a risk behavior on other people (Weimer and Vining
2017). For example, a person who is smoking tobacco in a restaurant releases toxic
chemicals into the air and harms the health of other people in the same place. A
mother-to-be who is always eating junk foods during her pregnancy puts her unborn
child at high risk of obesity and diabetes. However, people due to their different
education and socioeconomic backgrounds often place different values on these
externalities. While some people are making all their efforts to avoid these risk factors,
others simply do not care. As a result, self-initiating action by a single player is
necessary but insufficient to tackle NCD challenges at the country and regional levels.
A good example of the population-level HiAP intervention is the Healthy Cities

programs. Starting in 1986, the first Healthy Cities programs were launched in
developed countries, including Canada, the USA, Australia, and many European
nations. Around 1994, developing countries used the resources and implementation
strategies of initial successes to begin their own programs. A Healthy City aims to:
(a) create a health-supportive environment, (b) achieve a good quality of life,
(c) provide basic sanitation and hygiene needs, and (d) supply access to health
care. Being a Healthy City depends not only on current health infrastructure but
also on a commitment to improve a city’s environs and a willingness to forge the
necessary connections in political, economic, and social arenas. Implementation
strategies are quite individual by city, though they follow the basic idea of involving
many community members, various stakeholders, and commitments of municipal
officials to achieve widespread mobilization and efficiency. Today, thousands of
cities worldwide are part of the Healthy Cities network.
Evaluations of Healthy Cities programs have proven them successful in increas-
ing understanding of health and environment linkages and in the creation of
intersectoral partnerships to ensure a sustainable, widespread program. The most
successful Healthy Cities programs maintain momentum from the commitment of
local community members, a clear vision, the ownership of policies, a wide array of
stakeholders, and a process for institutionalizing the program. Healthy settings and
networks, created through intersectoral collaboration and public-private partnership,
have developed a culture of healthy living for all people.
In the Arab region, there are several registered “healthy cities” but only one,
Sharjah, was actually awarded the “Healthy City” status (WHO 2010). The global
experiences provide several lessons for the Arab region to support its implementa-
tion of HiAP, ranging from identifying the success factors, the preconditions, the
governance models, implementation challenges, and practical implementation tools.
A Policy Framework for Reducing Risk Factors for NCDs
Adopting the right mix of policies and effective interventions to curb the NCD
epidemic is critical for building human capital and will allow people to better
contribute to economic growth and sustainable development. WHO has identified
several “best buy” policy interventions for NCDs that are cost-effective and high-
impact, and feasible to implement, even in resource-constrained settings. These
approaches include: taxation and bans on advertising and promotion for tobacco
and alcohol products, regulations for alcohol availability, enforcement of smoke-free
environments in public places, and regulations for the food industry on salt and
saturated fat content.
Successful interventions to reduce risk factors for NCDs should be comprehen-
sive and include multiple components. For example, effective, school-based inter-
ventions on diet and physical activity should include lessons on healthy eating and
physical activity led by trained teachers, exercise programs, healthy foods available
on site, parental or family engagement, and supportive policies. Policy programs to
Heavy Government Intervention Light
Command- Price- Behavioral Voluntary Education

Control based Insight/ Agreement and
Regulation Regulation Nudge and Information
Partnership
Fig. 26 Levels of government interventions in reducing risk factors for NCDs. (Source: Adapted
from: Meiro-Lorenzo et al. (2011))
prevent NCDs can range from heavy to light government interventions, which
include: command and control, price-based regulation, behavioral insights or nudg-
ing, voluntary agreements and partnerships, and education and information (illus-
trated in Fig. 26).
To underpin action to prevent NCDs, policy makers may make use of one or
more of these policy instruments to enforce or encourage behavior shifts by
individuals or organizations. Different instruments are more or less effective in
different situations and contexts. It is important to note that combinations of policy
levers can tackle a particular risk factor more comprehensively. For example, bans
on smoking in public areas together with taxes on cigarettes can lead to effective
control of tobacco use.
Command and Control

Establishing rules through legislations, regulations, and administrative orders is a
pervasive instrument of government policy in the health fields. “Government uses
rules to coerce, rather than induce (through incentive), certain behaviors” (Weimer
and Vining 2017, p. 231). Command and control, if exercising in good governance
and the rule of law, can shape individual behaviors, social norms, policy processes,
and institutions to attain the highest attainable standard of physical and mental health
for the world’s population.
Governments across countries have practiced some command-and-control for
NCDs that successfully reduces risk factors of NCDs. The WHO’s Framework
Convention on Tobacco Control (FCTC) – adopted in 2003 – set up a model of
legislation and regulation in NCD prevention. “A suite of legal measures – taxes,
minimum purchase age, smoking bans in public places, and marketing bans trans-
formed culture and behaviors relating to tobacco” (Gostin 2019, p. 2). Similar
measures can be adapted and reinvented for the NCD risk factors including:
• Bans or restrictions on the advertisement, promotion, sponsorship, and sale of

harmful substances to children or adolescents, including tobacco, alcohol, and
unhealthy food
• Enforcement of minimum age requirements for the purchase of tobacco products
and alcohol, and restrictions on their sale near schools
• Mandates for schools and other public places where young people congregate to
be 100% tobacco and alcohol free
• Regulation on the types of meals, snacks, and beverages that are offered in
schools
• Regulations governing the food industry, such as directives on maximum salt,
sugar, or saturated fat content in food products, and front-of-package food
labeling
Price-Based Regulations
Price-based regulations including taxes and subsidies do not prohibit or mandate a
behavior but use financial incentives and disincentives. Where there is insufficient
consensus and it is not feasible to eliminate or enforce behavior, policy makers may
use these mechanisms to coax changes for health, political, or social reasons. It is not
feasible to ban smoking in people’s homes, but sufficiently high and comprehensive
taxes are the single most cost-effective measure to discourage new smokers and
reduce use. Also, increasing fuel taxes and subsidizing public transport will encour-
age people to walk more. In this example, synergy results from involving more than
one sector. Similar policy measures include:
• Taxes on harmful substances such as tobacco, alcohol, and soda to make them less
affordable and accessible. The revenue generated from taxes can be used for
interventions targeting substance use or for other health initiatives.
Behavioral Insights or Nudging

Behavioral insights or nudging may or may not involve regulation. This policy
instrument uses nonfinancial incentives and disincentives to induce behaviors. As
described by Oliver (2011), the essence of the approach is to apply behavioral
economic insights (for example, loss aversion – losses tend to “hurt” more than
gains of the same size) to policy considerations to change the environment. The role
of the government is seen as one of an enabler – it can create environments where
nudges to encourage more healthful behaviors are present, but it does not enforce the
practice of these behaviors.
Rising evidence suggests that placing healthy foods at the entrance or at eye level
will result in people choosing healthier options. Placing staircase rather than elevator
in the center of buildings encourages people’s physical movement and reduces
elevator use. Coordinating the actions of industry, retail, revenue, and consumer
groups gives best results. Employing similar measures across a variety of outlets,
sectors, and industries will create maximum impact, including:
• Health warnings on tobacco and alcohol products, especially large graphic

warnings on packaging
• Creation of safe public spaces and infrastructure for sports, leisure, active trans-
port, and other forms of physical activity
• Regulation of product placement in school cafeterias and fast food outlets outside
the perimeter of schools
• Reducing portion sizes of alcohol, sugar-sweetened beverages, and junk foods
Voluntary Controls, Agreements, and Partnerships

Voluntary controls, agreements, and partnerships are useful to ensure that there is
buy-in from key stakeholders. A good example is voluntary self-regulation within an
industry. So far, the efficacy of this approach is doubtful due to the possibility of
default by one party, even where there is a genuine interest in healthier practices.
Such initiatives more frequently arise where an industry is either homogeneous
(e.g., bread makers in Buenos Aires), or dominated by one or two big companies
(e.g., soda manufacturers). Even in such cases, the industry may eventually request
government regulation to ensure cooperation. Lawmakers can support and encour-
age similar initiatives including:
• Risk-factor screening, counseling, and tobacco and alcohol cessation programs,

provided within a range of settings
• Workplace programs to encourage regular physical activity and other healthy
habits
• Local business initiatives to encourage responsible purchasing among youth
Education and Information

Education and the provision of information are often supported by the public sector
to promote public health. Increased awareness and information has been shown to
modify attitudes about the health consequences of behavior. However, there
remains serious limitations on the effectiveness of these education measures to
modify actual behavior in all but children of school going age. For this reason,
these instruments are more useful when applied in tandem with other policy
measures, both as a way to foster acceptance of them and to facilitate coordinated
vision and implementation among different players and sectors. Other education
measures may include:
• School-based nutrition, exercise, or harmful substance education and intervention

programs.
• Media-based education and messaging via television, movies, and radio, as well
as social media platforms such as Facebook, Twitter, and YouTube. Mass media
campaigns to warn the public about the tobacco and tobacco harms are an
example of a WHO best buy intervention.
• Community-based education and behavior change programs.
Policy and Strategy Implementation: The Regional Experience
Generic policy frameworks require local adaptation and reinvention to produce

lasting health benefits. As Joseph Stiglitz (1999) points out, we should “scan
globally for best practices” but “test them locally” in each country context. Some
Arab countries have already begun to implement successful policy and structural
interventions to curb harmful NCD risk behaviors. Although the extent to which they
have improved the targeted health outcomes varies, development of these policies
and regulations is an important step toward curbing NCDs.
Tobacco Control
The WHO Framework Convention on Tobacco Control (FCTC) is a legally binding
treaty that requires countries to implement several evidence-based measures to
reduce the demand for and supply of tobacco products, and to reduce tobacco
harm. Almost all Arab countries have ratified the FCTC (WHO 2017b). However,
only some countries have implemented the treaty, and levels of enforcement vary
widely. Examples of Arab countries’ progress on implementing FCTC measures
include:
• Most Arab countries impose some taxes on cigarettes that accounts for more than
75% of the total product price, which is, as suggested by research, the effective
rate at reducing the demand for tobacco products. For water pipe tobacco, only
nine countries impose any taxes, and only West Bank and Gaza sets the rate as
high as 75% or higher, with a 79% imposed tax. Evidence shows that taxes work
particularly well for young people who are more sensitive to price increases than
adults.
• Libya and West Bank and Gaza have complete bans on smoking in all public
places, but they also have low compliance rates. All other countries have partial or
no bans. Research has shown that only a complete ban provides full protection
from the harm of second-hand tobacco smoke for youth and the population in
general.
• Bahrain, Djibouti, Libya, Qatar, Kuwait, and the UAE ban all forms of tobacco
advertising, promotion, and sponsorship (TAPS), including advertising on tele-
vision and the internet, billboards, and at points of sale; featuring tobacco on
television and in films; free distribution of products; and contributions to any
events or activities. Because TAPS is a set of tactics that the tobacco industry uses
to attract youth, completely banning these marketing activities is essential to
prevent youth from initiating tobacco use.
• Djibouti and Egypt require large health warnings on all cigarette packages that
cover at least 50% of both the front and back, and include graphic warnings
known to be particularly effective for youth.
Tobacco Control Programs and Implementation

• In Egypt, during World No-Tobacco Day 2016, the Egypt Health Foundation
launched Ermeha (Throw It), an initiative designed to discourage smoking during
Ramadan (NCD Alliance and EMRO NCD Alliance and WHO Regional Office
for the Eastern Mediterranean (EMRO) 2017). To date, it has used a variety of
tools including print and audiovisual materials, public events, and mass and
digital media campaigns to raise awareness about the impact of tobacco use and
secondhand smoke on health, particularly among youth. The social media cam-
paign has reached two million Internet users, as well as garnered 40,000 likes,
40,000 subscribers, and 300,000 reactions through its Facebook page. The
initiative uses various role models for youth, including celebrities, who also
serve as champions for the cause. Key factors contributing to the program’s
success in reaching young people include partnerships with a variety of local
organizations, and the use of innovative communication strategies developed by
young people themselves.
• In Egypt, the nongovernmental organization Hayah Bela Tadkheen launched an
anti-tobacco campaign in 2004 that included a cell phone application offering
comprehensive guidance on how to stop smoking (NCD Alliance and EMRO
2017). The widespread use of mobile phone technologies among young people
makes the application easily accessible. Specifically, the application enables the
user to identify the best strategy to stop smoking based on individual character-
istics such as age, health, and the amount of tobacco consumed; offers advice on
how to resist smoking triggers; provides a question-and-answer service for
medical advice; and offers recommendations for where to get free testing and
treatment. It also sends out cessation incentive messages, invitations to events,
and various polls that, in turn, allow the organization to build a database on
smokers, their behaviors, and attitudes for further improving the application.
Involving young people who work on mobile application technologies was key
to the program’s success.
• In Lebanon, an intervention study to prevent or delay initiation of water pipe
tobacco smoking was conducted among about 1600 6th and 7th grade students
over 5 months in 2012 (Bteddini et al. 2017). The students in intervention schools
received 8–10 of a 50-min session to increase knowledge about the health impact
of water pipes and other tobacco products use; to increase media literacy; to
develop decision-making and refusal skills; and to make a “social promise” by
signing a group pledge to avoid smoking for a period of time. The sessions used a
participatory approach and included games, videos, and role-play. The evaluation
showed that students from the intervention schools were less likely to report
having used water pipe tobacco in the month prior to the end of the study (48%
vs. 55%). Knowledge and attitudes toward water pipe tobacco smoking after the
study also differed between the two groups, with 81% of the students in the
intervention schools demonstrating knowledge of water pipes compared with
54% in the control group schools.
Tobacco Control and Healthy Diet

• Saudi Arabia and the UAE imposed excise taxes of 100% on tobacco products
and caffeinated energy drinks, and 50% on sugar-sweetened soft drinks in 2017
(Saadi 2017). Other GCC countries are also expected to implement such taxes.
The tax on sugar-sweetened beverages that Mexico introduced in 2014 has been
successful in reducing overall consumption of these beverages in the population,
particularly among young people. Because the Arab region has some of the
world’s cheapest tobacco products and soft drinks, the price increases are
expected to induce some current users to stop and to prevent new users from
starting.
Tobacco Control, Healthy Diet, and Physical Activity

• The Nizwa Healthy Lifestyle Project (NHLP) is the oldest, community-based
health promotion project in Oman. The NHLP begun in 2004 to prevent NCDs by
addressing tobacco use, unhealthy diet, physical inactivity, and road and house-
hold accidents in Nizwa Wilayat – a district with a population of more than
80,000 (Oman Ministry of Health 2012). The project includes a wide range of
population-based interventions, including school programs and those that target
high-risk groups. Examples of school-based programs include integration of the
“Move for Health” exercise program in Nizwa’s primary school curriculum.
Initially developed to promote physical activity among children in the Gulf
States, the program offered teaching modules and guidance for providing inter-
active training on physical activities, as well as a parents’ guide. The program also
introduced whole grain bread and low-fat dairy products to the markets as well as
schools. The NHLP also established gymnasiums in two female secondary
schools to promote physical activity among female students. The program eval-
uation conducted in 2009–2010 does not report results specific to young people
but demonstrates improvements in various health behaviors in the general pop-
ulation. For example, the percent of the population aware that physical inactivity
is a risk factor for NCDs increased from 7% to 93%, while the percent partici-
pating in physical activity during leisure time increased from 39% to 71%
between 2001 and 2010.
Healthy Diet
• In Oman, the Ministry of Health collaborated with other government agencies and
the private sector to reduce salt content. They succeeded in achieving a 10%
reduction in the salt content in bread products produced by the bakeries supplying
about 80% of the country’s bread in 2015 (WHO 2019). In 2016, the bakeries
agreed to reduce the salt content further to 20%. Salt content is monitored
regularly through sample testing conducted by the municipalities. Like many
other countries in the region, average salt intake is high in Oman and is estimated
to be twice the WHO recommendation, as close to 10 g per person a day.
Reducing the typically high salt content in bread products, which are staples in
the diet in Oman and other countries in the region, is an important way to cut back
on the population’s overall salt intake.
• In the UAE, as part of its public school policy manual, the Abu Dhabi Education
Council governing public schools published clear mandatory requirements on
promoting healthy eating within their school communities in 2015 (Abu Dhabi
Education Council 2014). Schools are mandated to make healthy food options
available in their cafeterias daily, including low-fat dairy products, at least one
type each of cooked vegetables and vegetable salad, and at least three kinds of
fruit. They are also required to provide salad and fruit both during breakfast and
lunch.
• In Qatar, the Supreme Council of Health released dietary guidelines in 2015 to
complement the national nutrition and physical activity plan launched in 2011
(Qatar Supreme Council of Health 2015). One of the main aims of the guidelines
is to lower the risk of NCDs in the Qatari population. The nutrition guide defines
six food groups, as well as the number of daily-recommended servings and
portion sizes for each group. Besides basic nutrition and fitness guidelines, it
also describes the specific needs of children and youth. More specifically, it
discusses the importance of parents helping children establish a healthy routine
by modeling healthy eating and physical activity. Qatar plans to apply the
guidelines on a public policy level to guide food industry marketing and nutrition
labeling, and to develop guidelines for school meals and snacks.
Healthy Diet and Physical Activity

• In Sousse, Tunisia, a 3-year, school-based overweight and obesity intervention
study was conducted in three regions between 2009 and 2012 (Maatoug et al.
2015). The program encouraged physical activity and healthy eating among
students in the intervention schools using various measures: educational sessions
provided by teachers who received training from the program; organized soccer
games after school; and healthy options in school snack stores with a monthly
reward for students choosing healthy snacks. The program also trained some
students to serve as leaders and help implement the program. An evaluation
showed a significant increase in fruit and vegetable consumption and a significant
decline in the number of overweight students in the intervention schools. Mean-
while, changes in the opposite direction or no change were observed among the
students in the control group.
• In Dubai, UAE, a school-based obesity intervention program was conducted in
private schools covering grades 1 through 12 (aged 5–18), over three consecutive
academic years between 2014 and 2017 (Hussain and Fiasal 2018). Interventions
to address overweight and obesity among students included physical activity
programs, nutrition education, and school cafeteria policies and guidelines on
serving healthy food options. The program also implemented “happy school”
initiatives to promote students’ holistic development; promoted obesity aware-
ness among parents; and gave awards to schools making unique achievements in
supporting the health and well-being of students. The body mass index (BMI)
measurements taken at the end of each academic year in June show reduction
from 10% to 8% in the share of obese students over the 3-year period.
• In Oman, the WHO’s Health-Promoting Schools (HPS) Initiative was
implemented in 2004 and provided interventions to promote healthy eating,
physical activity, and mental health (WHO 2013b). It targeted students in grades
K-12 in 19 schools, with the initial phase lasting for four academic years. The
wide range of interventions included an anti-tobacco campaign, expanded green
space within the school environment for physical activity, substance abuse
education, revised school food policies, and increased physical education time.
The program also incorporated components that involved parents and community,
including evening physical activity classes for mothers. An external evaluation of
the program showed that students in HPS were significantly more likely to eat
breakfast and to have fruits and vegetables three or more times per day (the
recommended amount) than those in non-HPS. The students in HPS
demonstrated greater knowledge of nutrition, physical activity, hygiene, and

tobacco use compared with those in non-HPS.
Physical Activity
• In the UAE, the Ministry of Education implemented a new physical and health
education curriculum in public schools, from kindergarten through grade 12 in
2017 (UAE Ministry of Education 2017). The new curriculum covers a wide
range of topic areas, including health and well-being, fitness training and testing,
diet and nutrition, and anatomy and physiology – focusing on practical and
interactive activities. It also includes an English component to teach students
how to read nutrition information on products that are typically available only in
English. The curriculum also involves parents encouraging their children to
develop healthier behaviors.
Alcohol Control
According to the 2018 WHO Global Status Report on Alcohol and Health, Saudi
Arabia, Mauritania, Somalia, Sudan, and Yemen completely ban alcohol consump-
tion. Algeria, Egypt, Lebanon, Djibouti, and the UAE adopt national alcohol policies
(WHO 2018c). The data on alcohol policies are missing in Qatar and Tunisia. Other
exemplary alcohol-related policies and interventions include:
• Algeria, Egypt, Jordan, Lebanon, Morocco, Oman, the UAE, Syria, Comoros,
and Djibouti impose taxes on alcoholic beverages. Algeria, Egypt, Jordan, Leb-
anon, Morocco, Oman, Iraq, and Syria set up a minimum legal drinking age
(either age 16, 18, or 21, depending on the countries and types of beverages).
Research suggests that excise taxes and minimum legal drinking ages are most
effective in reducing traffic fatalities among youth.
• Algeria, Jordan, Oman, the UAE, Morocco, Egypt, Comoros, Djibouti, Iraq, and
Syria have legally binding regulations on alcohol advertising. Algeria, Jordan,
Oman, the UAE, Lebanon, Egypt, Morocco, Comoros, Djibouti, and Iraq restrict
the number of establishments selling alcohol for consumption – either on or off
premises in particular areas. Research links alcohol advertisements, especially
those that target youth, and many alcohol sellers per area to increased consump-
tion of alcohol among young people.
• Algeria, Egypt, and Morocco require health-warning labels on alcohol advertise-
ments. Djibouti and Lebanon also require such labels on alcohol containers.
• Djibouti and the UAE have zero tolerance for drink driving for all drivers, while
Iraq, Jordan, Lebanon, Morocco, Oman, and Tunisia have set up legal blood
alcohol content levels for drinking and driving.
• In Bahrain, the Interior Ministry launched a national anti-drug campaign called
“Together Against Violence and Addiction” in 2011. The campaign encouraged
young people to lead safe and healthy lives by resisting negative influences, such
as alcohol, drugs, and violence. The program is part of the US-based international
initiative Drug Abuse Resistance Education (D.A.R.E.) and is the first to be
delivered in Arabic. D.A.R.E. programs are conducted by local police officers
globally. The program in Bahrain provided extensive training of community

police officers, resulting in 124 officers trained by 2015, and reaching 66,000
students in 110 public schools.
Conclusion
In conclusion, NCDs increasingly threaten the health and economic security of Arab
countries. These diseases will continue to place a growing burden on health care
systems – and limit economic growth and development – by significantly increasing
health care costs and reducing the productivity of working-age people. This negative
trajectory can be averted. The decisions made today can change the course of the
future if preventing NCD risk behaviors becomes a priority. With a large and growing
population of young people, Arab countries now have a window of opportunity to
lower NCD risk factors levels to curb the growing health and economic burden of
NCDs on individuals, families, and societies, and ensure that they lead healthy,
productive lives.
A successful effort to adapt and scale up strategies to address the four key NCD
risk behaviors at the population level will require collaboration and coordination
across multiple sectors, as well as involvement of social societies and individuals.
Filling the critical information gaps with frequent and comprehensive surveillance of
risk factors, as well as rigorous monitoring and evaluation of policies and programs,
is also essential for identifying the most effective and sustainable interventions for
the countries in the region. Investing in the health of the young is essential for
building the foundation of the countries’ future. Helping people avert the premature
onset of NCDs and enabling them to reach their full potential will decrease health
care costs and enable them to more fully contribute to national growth and vitality.
Today’s actions for population health will set Arab countries on a path toward
continued economic growth and prosperity.
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Sports Medicine in the Arab World
35
Mohamad Y. Fares, Hamza A. Salhab, Hussein H. Khachfe,
Youssef Fares, and Jawad Fares
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 838
Health and Physical Activity in the Arab World . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 839
History of Sports in the Arab World . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 841
Sports Medicine in the Arab World . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 842
Research in Sports Medicine in the Arab World . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 844
Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 845
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 846
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 846
Abstract
The rise in popularity of sports worldwide has shed light on the importance of
sports medicine on both individual and community-based levels. The increasing
participation of Arab countries in global sporting events, the rise of talented Arab
athletes worldwide, and the greater allocation of funds towards Arab sporting
organizations have attracted many investors and promoters to the region. This
M. Y. Fares
Neuroscience Research Center, Faculty of Medicine, Lebanese University, Beirut, Lebanon
College of Medical, Veterinary, and Life Sciences, University of Glasgow, Glasgow, UK
H. A. Salhab · H. H. Khachfe
Y. Fares
J. Fares (*)
Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University,
Chicago, IL, USA
e-mail: jawad.fares@northwestern.edu

https://doi.org/10.1007/978-3-030-36811-1_165
838 M. Y. Fares et al.
helped establish better sporting facilities and enhance and promote athletic youth
development. Nevertheless, sports medicine remains a young medical field in the
Arab world. This is unfortunate, given the health problems facing Arab countries,
evident by the prevalence of obesity and physical inactivity among its population.
The Arab world is noticeably lagging when it comes to sports medicine research.
The lack of research culture, deficiency of adequate funds, and the political
turmoil embroiling the region are some of the reasons as to why this medical
field is not developing properly. It is essential to solve these problems if we ought
to remain up-to-date with the academic advancements achieved worldwide. Forg-
ing scientific collaborations, expanding research activities, and harboring politi-
cal and regional stability are essential for the research culture to thrive and
prosper in the Arab world.
Keywords
Sports medicine · Exercise medicine · Physical activity · Arab world ·
Research activity · Sports research · Orthopedics
Introduction
Sports medicine is a branch of medicine that deals with physical fitness and the
treatment and prevention of sports-related injuries. Sports medicine combines gen-
eral medical knowledge with the principles of orthopedics, nutrition, body biome-
chanics, exercise physiology, and sports psychology, with an aim to help people
engage in sports safely and efficiently to attain their training goals (Snook 1984).
This field is comprised of two main areas: exercise and physical activity and sports-
related injuries (Bahr 2001). The first area has increasingly garnered attention, now
that obesity and inactivity are prevalent. The second area has also been gaining
attention due to the increased participation and professionalism in sports (Bahr
2001). The foundation of sports medicine dates back to Herodicus, a Greek physi-
cian of the fifth century BC, who was among the first to prescribe an exercise
regimen as a therapeutic modality for disease and health maintenance. Since then,
sports medicine has played an important role in many cultures and has been
mentioned in many historical teachings and writings (Snook 1984; Fares et al.
2017c).
Physical inactivity is considered one of the leading risk factors for global mor-
tality, responsible for around 3.2 million deaths worldwide (World Health Organi-
zation 2017). It is also highly associated with multiple comorbidities, including
cardiovascular disease, diabetes, obesity, and depression (Khachfe et al. 2019a;
Fares et al. 2017a; Fares et al. 2017c). In 2010, it was reported that around 87% of
children and adolescents and 33.2% of adults in the Arab world were inadequately
active. The rise in the incidence of ailments related to physical inactivity has caused
an elevated interest in sports and exercise in the region, and as a result, the field of
35 Sports Medicine in the Arab World 839
sports and exercise science and medicine has been growing steadily (Snook 1984;
Fares et al. 2017c).
The Arab world is constituted of 22 countries that form the Arab League, with an
estimated combined population of around 400 million people (CNN Library 2017).
These countries are often considered a single unit, since they share similar historical
and religious backgrounds and speak a common language. In 2016, the Arab world
made up 5.5% of the world’s population and contributed up to 3.31% of the world
gross domestic product (GDP) (Population Reference Bureau 2016). Nevertheless,
significant socioeconomic variations exist between the different countries of the
Arab world, and this leads to a disparity in medical advances and research output.
The domain of sports medicine is still relatively new in the Arab world, and as a
result, many aspects of the field are yet to be explored. With the recent surge
in popularity of some sports amongst the Arab population, along with the rise in
investments allocated toward sporting events, the field of sports medicine is
expected to grow and elevate significantly. The aim of this chapter is to assess the
health and physical activity of the Arab population, explore the history of sports in
the Arab world, evaluate the status of sports medicine research and practice, and
provide recommendations for the future of the field.
Health and Physical Activity in the Arab World
There exist substantial economic and demographic differences between the 22 Arab
countries that translate into variations in GDP and population (Khachfe and Hussein
2019; CNN Library 2017; Population Reference Bureau 2016) (Table 1). Neverthe-
less, common burdens to most Arab countries have been poor dietary habits and
physical inactivity. The poor dietary habits and the unhealthy lifestyle of most of the
Arab population have been a great concern for the local health authorities in Arab
countries (Musaiger 2011; Musaiger et al. 2013). This is mainly due to the high
association of these factors with the increased prevalence of obesity and chronic
noncommunicable disease, like cardiovascular disease and diabetes, over the last
decade (Musaiger and Hazza 2012). Obesity has reached an epidemic rate in the
Arab world among both children and adults. A study on seven Arab countries
reported that the proportions of overweight and obese adolescents (15–18 years)
ranged from 25% to 60%, indicating a major public health issue that needs to be
addressed (Musaiger et al. 2012). This is mainly due to the environmental factors in
the Arab world that promote excessive food consumption, sedentary behaviors, and
physical inactivity.
Several studies have reported that the dietary habits of the Arab people have
become more westernized, evident by a low intake of milk, fruits, and vegetables,
and a high intake of sugar-sweetened beverages, sweets, and fast foods (Musaiger
2002; Ng et al. 2011; Sibai et al. 2010; Al-Haifi et al. 2013). This diet is highly
associated with an increase in incidence of obesity and chronic diseases. A study
Table 1 The countries that constitute the Arab world along with their respective average gross
domestic product (GDP) and average population
Country Average GDP (in billion US$) Average population (106)
Algeria 133.40 35.60
Bahrain 23.50 1.00
Comoros 0.50 0.70
Djibouti 1.10 0.80
Egypt 194.30 79.60
Iraq 125.00 30.90
Jordan 23.60 6.40
Kuwait 113.60 3.00
Lebanon 33.20 4.50
Libya 50.40 6.10
Mauritania 3.70 3.40
Morocco 84.10 32.00
Oman 52.40 3.20
Palestine 8.30 4.10
Qatar 11.60 1.40
Saudi Arabia 496.90 27.80
Somalia 5.80 9.40
Sudan 54.50 39.30
Syria 37.50 19.90
Tunisia 39.30 10.50
UAE 271.90 6.30
Yemen 26.20 23.10
Total 1891.00 137.70
assessing the daily intake of fruits and vegetables by Arabs aged 15–29 years
reported consumption of 296 and 323 grams for Arab males and females, respec-
tively; significantly lower than the favorable baseline choice of 600 grams (Musaiger
et al. 2013). Increasing this intake is necessary for improving cardiometabolic health
and decreasing the risk of morbid diseases.
In addition, the lifestyle of Arab adolescents has become more sedentary and
inactive, due to several factors that include long durations spent on playing video
games, watching television, and using the internet (Musaiger 2002; Ng et al. 2011;
Sibai et al. 2010). It has been reported that most of the Arab youth do not engage in
the recommended amount of daily physical activity: 60 min of physical activity per
day (Guthold et al. 2010). This physical inactivity is one of the fastest growing risk
factors associated with chronic diseases in the Arab world, and several hurdles stand
in the way of solving this problem (Musaiger et al. 2013). In Western countries, the
most important factors related to physical activity in both male and female genders
were age, BMI, parental attitudes towards physical activity, psychosocial factors,
social attitudes towards body shape, and environmental barriers (Kahn et al. 2008).
However, not all these factors may apply to the Arab world, due to the sociocultural
differences between Western and Arab countries. In several Arab countries, gender
plays a major factor with respect to physical activity, as women face more barriers
towards exercising than men. Less places available for exercise, social and religious
norms, and abiding by specific types of clothing are some of the factors that
discourage Arab females from exercising and remaining active. These challenges
have to be faced in order to attain a healthy active population. Creating more public
spaces available for women to engage in physical activity, and possibly designing
sportswear that take into consideration the sociocultural norms may encourage Arab
women to exercise and remain active.
Changing the poor sedentary condition of the Arab population is imperative for
attaining a better health status. In order to do so, it is necessary to emphasize and
promote the importance of physical activity and sports in the Arab countries.
Reducing sedentary behavior and increasing moderate activity will enable individ-
uals to stay active and adhere to their activity plan (Nelson et al. 2007). Taking a
gradual approach is important as well to ensure continuous improvement and
advancement in activity levels (Nelson et al. 2007).
In order to achieve these arrangements, governmental initiatives need to be
implemented to boost the sports sectors in the Arab world. This is essential to help
promote nationwide sports participation and encourage individuals to engage in
exercise and physical activity. In addition, the field of sports medicine must be
promoted to evaluate proper sports participation guidelines, and help reduce sports-
related injuries and activity-related adverse effects.
History of Sports in the Arab World
The interest of Arabs in sports dates back to the beginning of their history. Arab
tradition is rich with stories about horse and camel racing, archery, falconry, sailing,
and many others (Amara 2014). In Islamic tradition, the Hadith states that the
Prophet Muhammad (p.b.u.h.) advises his believers to teach their children swim-
ming, archery, and horse riding (Amara 2014). Abu Hamid Al-Ghazali (1058–1111),
one of the most prominent Islamic polymaths, was a huge promoter of the health
benefits of physical exercise and sports activities (Youcef 1994). Some of these
activities included traditional sailing, horse riding, and wrestling, and were linked to
religious festivals and seasonal celebrations (Youcef 1994).
Sports and physical activities intended for entertainment and enjoyment took
place in the Arab world prior to colonialism. In contemporary history and in relation
to modern sports, Egypt was the first Arab country to have joined international sports
organizations and to participate in international sports competitions (Lopez 2012).
Other Arab countries, like Algeria, Morocco, and Tunisia, started their involvement
with international sports institutions after their independence from the colonial rule
(Amara 2012; Abbassi 2007). As years passed, Arab involvement with international
sporting bodies grew, and sooner than later, Arab countries started hosting and
organizing major sports events, like the Mediterranean Games in 1975, and the
African Games in 1978 (Amara and Henry 2004).
Sports constitute a prominent institution in the modern Arab world and a con-
nective tissue that binds people together, both across and within societies. Through-
out the troubled times the region has lived through, sports remained a popular
foundation of Arabian culture and a hallmark of modern entertainment, accessible
to all social classes and all age groups. Aside from the commercial aspect of
competition, sports provide an enjoyable way of exercising and maintaining a
healthy fit body (Hallal et al. 2006). Passion towards a certain type of sports varies
across the different regions of the Arab world, with popular sports including
basketball, volleyball, tennis, and mixed martial arts. Nevertheless, soccer remains
the most popular sport in the Arab world and is often the main attraction with respect
to investments and commercialization (Malkawi 2006).
This increased interest in sports development saw several Arab countries hosting
international tournaments and organizing global sporting events in different sports,
which include basketball, football, mixed martial arts, and others (Zeigler and
McGregor 1958; UFC 242 Abu Dhabi 2019). However, the most evident culmina-
tion of these efforts was the appointment of Qatar by the FIFA council to host the
2022 World Cup (Brannagan and Giulianotti 2014). This groundbreaking accom-
plishment marks the first time an Arab country serves as a host for the distinguished
tournament and is bound to increase the impact of sports marketing and research in
the region (Brannagan and Giulianotti 2014). In addition, the rise of exceptional
Arab athletes in international competitions has helped promote their nations’ sport-
ing bodies and raise the attentions of potential investors. One example would be
Mohamad Salah, the Egyptian footballer who rose to fame after excelling with
Liverpool FC, a team competing in the English Premier League (Alrababah et al.
2019). Due to his outstanding performance, the footballer was able to shed light on
Egyptian football and raise the hopes of many Arab youths towards competing on a
professional level.
Nevertheless, the Arab world is still modest with respect to athletic achievements
in international sporting events. Arab nations have often competed in global tour-
naments across different sports but rarely has an Arab country attained high acco-
lades. On a more recent note, 2018 marked the first World Cup in which four Arab
nations qualified for the tournament. Even though many Arab nations have qualified
to reach the World Cup over the years, none were ever able to win the tournament
and hold high the coveted cup (Table 2). Such modesty with respect to sporting
achievements is reflected by a lack of proper funding and research into fields like
sports science and sports medicine in the region. This would affect the performance
and outcome of the Arab athletes when competing with more sport-investing nations
on a global scale.
Sports Medicine in the Arab World
Sports medicine evolved with the evolution of sports, thousands of years ago. Sports
originally began as practice for combat skills and hunting, required for the survival
of the primitive man’s family and tribe (Snook 1984). It then developed into athletic
Table 2 Qualification of Arab countries to the World Cup and their respective best result
Country Appearances Best result
Saudi Arabia 5 Round 2
Tunisia 5 Round 1
Morocco 5 Round 2
Algeria 4 Round 2
Egypt 3 Round 1
Kuwait 1 Round 1
Iraq 1 Round 1
United Arab Emirates 1 Round 1
contests for leisure and entertainment, and as a result, the subfield of sports-related
injury was born (Snook 1984). While early athletic injuries were medically treated,
the first use of exercise as a treatment dates back to the Hindus and the Chinese
around 1000 years BC. As the times passed, the Islamic and Western civilizations
adopted the use of exercise as a therapeutic modality, and physical therapy became a
major field of medicine (Snook 1984).
On a contemporary note, sports medicine was introduced to the United States
of America and the United Kingdom during the mid-nineteenth century, when
athletic training and physical education started to become integrated into academic
curricula and scientific publications (Darling 1899; Snook 1984). However, it was
not until the early twentieth century that sports medicine started growing as a
scientific field and started diverging into multiple subcategories which include sports
science, injury prevention, sports psychology, and sports nutrition (Snook 1984;
Nichols and Smith 1906; Nichols and Richardson 1909; Ryan 1971).
In the Arab world, sports medicine started gaining attention during the late
twentieth century and started flourishing during the early twenty-first century
(Fares et al. 2017c). The globalization and commercialization of sports worldwide
led to an increased interest and a surge in investments with regards to sports
academies and institutions dedicated for injury research and rehabilitation (Ginesta
and San Eugenio 2014). An example to this would be the establishment of Aspetar,
the first specialized orthopedic and sports medicine hospital in the Gulf region
(About Aspetar 2019). This hospital specializes in the medical treatment of sports-
related injuries and rehabilitation, and is associated with Aspire academy, an insti-
tution dedicated for the development and training of talented future athletes. Other
institutions like the FIFA Medical Center of Excellence Dubai and the Sports
Performance Institute are two of many examples of novel establishments that signify
an increase in the attention of sports medicine in the Arab world (Malliaropoulos
et al. 2017; SPI 2019).
Nevertheless, research output in the Arab world remains inferior when compared
to Western counterparts (Khachfe and Refaat 2019; Salhab et al. 2018; Fares et al.
2017c). Several political, economic, and social factors play a role in shortage of
research in the field of sports medicine in the Arab world, and these will be discussed
in the next section.
Research in Sports Medicine in the Arab World
Sports medicine is a novel field in the Arab world with a modest research output. A
study conducted in 2017 reported that the 22 Arab countries together contributed
only to 0.49% of the world’s literature on sports and exercise medicine in the last
15 years (Fares et al. 2017c). The study standardized research output to the
Arab countries’ GDP and population, and it turned out that Tunisia ranked first
with respect to publications per average GDP, while Qatar ranked first with respect to
publications per average population (Fares et al. 2017c) (Table 3).
Several factors play a role in the shortage of sports medicine research output in
the Arab world. Research culture seems to be lacking in the Arab countries, and
consequently, academic medical centers are scarce (Fares and Fares 2017; Giles
2006). This deficiency in research funding and infrastructure can only serve to
further increase the gap between the Arab world and the Western countries
(Almansour 2016; Rosselli 1999). Moreover, poverty is widespread in many Arab
Table 3 The number of sports and exercise medicine publications in the Arab countries averaged
by gross domestic product (GDP) and population
Number of sport and
exercise medicine Publications per Publications per million
Country publications billion US$ of GDP individual of population
Algeria 6 0.04 0.17
Bahrain 5 0.21 5.00
Comoros – – –
Djibouti 1 0.91 1.25
Egypt 114 0.59 1.43
Iraq 7 0.06 0.23
Jordan 92 3.90 14.38
Kuwait 35 0.31 11.67
Lebanon 37 1.11 8.22
Libya 3 0.06 0.49
Mauritania – – –
Morocco 28 0.33 0.88
Oman 26 0.50 8.13
Palestine 2 0.24 0.29
Qatar 352 3.15 251.43
Saudi 175 0.35 6.29
Arabia
Somalia – – –
Sudan – – –
Syria 1 0.03 0.05
Tunisia 236 6.01 22.48
UAE 28 0.10 4.44
Yemen – – –
Total 1148 0.61 8.34
countries, and this takes a toll on the countries’ education, health, security, and
proper nutrition. As a result, academic research is often ignored and sidelined to
focus on fulfilling the countries’ basic needs; it is often evident that countries with a
higher GDP produce a greater research output than those with a low GDP (Fares
et al. 2017c).
In addition, military conflicts and political instability constitute major hurdles for
many Arab countries with regards to advancement of the scientific research sector
(Fares et al. 2019; Khachfe et al. 2019b; Fares and Fares 2018; Bizri et al. 2018;
Fares et al. 2013a, b, 2014; Fares and Fares 2013; Fares et al. 2017b; Salhab et al.
2019a; Hoteit and Fares 2014; Hoteit 2015, 2016; Puddington 2012). War-torn
countries like Yemen, Palestine, Libya, Syria, and Somalia often suffer from brain
drain, poor research funding, and fewer research opportunities (▶ Chaps. 102,
“Conflict Medicine in the Arab World,” and ▶ 136, “Academic Medicine and the
Development of Future Leaders in Healthcare”; Mowafi 2011; Sweileh et al. 2014).
It has also been noted that poor governance, technological dependency, and exploi-
tation, themes linked to many Arab nations, are associated with a higher percentage
of youth and sports sector marginalization, poor scientific performance, and illiter-
acy (Hoteit and Fares 2014; Hoteit 2015; Zahlan 2012).
Nevertheless, and despite all the challenges, sports and exercise research output
has been on the rise for the past few years. In 2017, it was reported that 53.6% of all
Arab publications on sports medicine were published during the previous 3 years,
further confirming the novelty of this medical field in this region (Fares et al. 2017c).
This can be attributed to the allocation of larger funds for academic research and an
increased regional and global interest in the sports sector (Fares et al. 2017c). Gulf
countries like Saudi Arabia and Qatar have been establishing proper research
institutions, increasing research fund allocation, and attracting international research
personnel to help advance their academic stature (Giles 2006). In addition, more oil-
rich countries are getting involved in international sports events and federations, and
this further boosts the significance of the field of sports medicine in the region
(Amara 2011). Besides the economic benefit and the entertainment component
associated with sports investment, sports medicine research aids in the advancement
of athletic performance, enhancement of athletic youth development, and prevention
of serious athletic injuries (Fares et al. 2018; ▶ Chaps. 102, “Conflict Medicine in
the Arab World,” and ▶ 136, “Academic Medicine and the Development of Future
Leaders in Healthcare”; Salhab et al. 2019b). This reconfirms the need for enhanced
scientific collaborations with the Western world and expansion of sports medicine
research activities in the Arab community. The growth of sports medicine research is
imperative for the advancement of the sports sector in the Arab world.
Recommendations
Amidst the global rise in the popularity and participation in sports, the field of sports
medicine is witnessing substantial growth and developing the approach towards
sports injuries and physical activity worldwide. As a result, it is imperative for the
Arab countries to ride the wave, in order to advance their health and sports sectors
congruently with the Western countries.
Building well-designed allotted spaces for exercise that adhere with the region’s
sociocultural norms, and campaigning for physical activity and exercise is essential
for promoting health and prosperity among Arab youth. Increasing governmental
funding towards local sports organizations and endorsing the national leagues will
attract the interest of investors and funders. In addition, the continuous involvement
of the Arab world with international sporting events will help shed light on the
region and its athletes. Nonetheless, fostering young Arab athletes, and working on
youth development is essential for nurturing future stars that can hold their country’s
flag high on national and international levels.
On the other hand, and with respect to sports medicine research, forming scien-
tific collaborations with foreign leaders in the field is required for the advancement
of the academic sector in the Arab world and expanding research activities.
Establishing Arab medical journals that adhere to international standards can help
grow the lacking research culture. Finally, Arab countries need to advocate for
democracy and fight corruption in order to ensure peace and security. This is
necessary for harboring a scientific research environment that allows researchers to
thrive and prosper, both on a national and international level.
Conclusion
Sports have witnessed a surge in popularity in the recent years, evident by a rise in
promotion and commercialization worldwide. Arab countries have increased partic-
ipation in major international sporting events and organizations, and this led to the
greater allocation of funds towards the sports sector, the attraction of many foreign
investors towards the region and the development of talented Arab athletes. This
growth has led to the founding of several renowned athletic facilities, and helped
renovate national leagues and federations. Nevertheless, the field of sports medicine
remains novel in the Arab world, and sports medicine research is lacking. The lack of
proper funding, the absence of a proper research culture, and the political instability
haunting the region are several reasons behind the stagnation of this field. That is
unfortunate, given the prevalence of obesity and physical inactivity among the Arab
population. Enhancing the field of sports medicine in the region is essential to
improve the health status of the Arab population, set proper sporting guidelines for
injury prevention, and remain up-to-date with worldwide scientific breakthroughs.
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Social Determinants of Health in Fragile
and Conflict Zones Before and During the 36
Coronavirus Pandemic, with a Focus on the
Gaza Strip
Mohammed AlKhaldi, Samer Abuzerr, Hassan Abu Obaid,

Ghada Alnajjar, Ahmed Alkhaldi, and Abdulsalam Alkaiyat
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 852
The Social Determinants of Health in the Gaza Strip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 853
Socioeconomic Determinants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 853
Environmental Determinants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 863
Agricultural and Food Determinants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 865
Political Determinants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 867
Health System, Services Delivery, and Key Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 867
M. AlKhaldi (*)
Council on Health Research for Development, COHRED, Genève, Switzerland
Department of Public Health, Unit of Health Systems and Policies, Swiss Tropical and Public
Health Institute (Swiss TPH), Basel, Switzerland
Faculty of Medicine and Health Sciences, An-Najah National University (NNU), Nablus, Palestine
S. Abuzerr
Department of Social and Preventive Medicine, School of Public Health, University of Montreal,
Montréal, QC, Canada
Quality Improvement and Infection Control Unit, Ministry of Health, Gaza, Palestine
H. A. Obaid
Ministry of Health, Indonesian Hospital, Gaza, Palestine
G. Alnajjar
Ahli Arab Hospital, Gaza, Palestine
A. Alkhaldi
Faculty of Sciences, Al-Azhar University, Gaza, Palestine
Al-Awa’ael Investments and Trading, Gaza, Palestine
A. Alkaiyat

https://doi.org/10.1007/978-3-030-36811-1_203
852 M. AlKhaldi et al.
Health System in the Gaza Strip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 867

Essential Health Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 868
Health Services Coverage and Accessibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 869
Permit and Referral System and Its Impacts on Health Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . 870
Perceptions of Policymakers and Patients from the Gaza Strip on Health System and
Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 871
Effect of COVID-19 and SDH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 873
Conclusion and Policy Pathways and Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 873
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 875
Abstract
Addressing the health of people in the context of the Social Determinants of
Health (SDH) is a priority in the Gaza Strip, a setting experiencing protracted
emergencies and facing pressing situations. This chapter explores the SDH in the
Gaza Strip in order to suggest possible entry points for the decision-makers to
address the avoidable and unfair inequities, harms, and deprivation faced by the
people in the Gaza Strip at the levels of socioeconomic context, exposure,
vulnerability, healthcare outcomes, and social consequences. Four methods
were used: literature review, desk review, in-depth interviews, and focus group
discussions. The SDH in the Gaza Strip greatly affects the health of people as
shown by various indicators, rates, and levels. This situation remains and con-
tinues to impact two aspects of health in the Gaza Strip: (1) the health of
individuals and families and (2) the capacity and performance of the health
system to respond to the citizens’ urgent needs and priorities. Difficulty accessing
care; shortages in resources, medicines, and supplies; inadequate health facilities
and workforce capacity; extremely challenging living conditions; a fragmented
healthcare system; and increasing chronic diseases impact the health of people in
the Gaza Strip. The Israeli occupation and intra-Palestinian dispute are key
influences of health in the Gaza Strip. Improvements can only come from
committed political will, transparency from all regulators, strategic dialogue,
comprehensive planning, and active international support.
Keywords
Social determinants of health · Socioeconomic determinants · Environmental
determinants · Agricultural and food determinants · Political determinants ·
Conflict settings · Gaza Strip · Palestine
Introduction
The World Health Organization (WHO) remains firmly committed to the principles
set out in the preamble to the Constitution by defining health as a state of complete
physical, mental, and social well-being and which is not defined merely by the
absence of disease or infirmity (WHO 2006). This definition sheds light on the
importance of the Social Determinants of Health (SDH), a notion that ensures people
36 Social Determinants of Health in Fragile and Conflict Zones Before and. . . 853
enjoy the highest attainable standard of health, as one of the fundamental rights of
every human without distinction of race, religion, political belief, and economic or
social condition. The WHO defines SDH as “the conditions in which people are
born, grow, work, live, and age, and the wider set of forces and systems shaping the
conditions of daily life” (Bouquet 2017). This implies that the social conditions in
which we live not only influences our sense of well-being but also determines our
chances of experiencing illness or death throughout the course of our existence
(Göran and Whitehead 2007).
The SDH concept has emerged due to two key influences: first, increasing
international concern, which urges the WHO member states to tackle health ineq-
uities within and across countries and regions through a political commitment to the
key principle of “closing the gap in a generation,” and second, the SDH which
addresses the vast differences and disparities in health across different populations
and societies, with the aim of understanding the causes and effects through a
comprehensive picture (WHO 2011).
The “Health in All Policies” was adopted globally to address the wide-ranging and
interconnected aspects of healthcare and its determinants and challenges (WHO
2017a). Regions experiencing conflicts and instability, such as Palestine and the
Gaza Strip, in particular, are required to address the SDH systemically as a national
priority in light of rapid changes and deterioration in all aspects of daily life. The
approaches and strategies introduced earlier can improve the SDH, reduce the dispar-
ities among people everywhere and in the Gaza Strip specifically, and bridge the gaps
across sectors and geographical areas. The map of the Gaza Strip is shown in Fig. 1,
which indicates crossing points, and also illustrates its location from historic Palestine
(Gisha 2020). This chapter investigates the SDH in the Gaza Strip by considering the
main determinants so as to provide a comprehensive understanding that could estab-
lish better practices and policy interventions. This has been achieved by using a
mixed-method approach using four tools: literature review, desk review, interviews,
and focus group discussions. The purpose of this diverse methodology is to reach a
high level of reflection of the wide-ranging facing the SDH in the Gaza Strip.
The Social Determinants of Health in the Gaza Strip
Socioeconomic Determinants
Poverty and Unemployment

Poverty, one of the main components of SDH, is particularly acute and widespread in
the Gaza Strip, as reflected in data from the Palestinian Central Bureau of Statistics
(PCBS). Poverty in Gaza is largely driven by the extreme volatility of its economy,
which is characterized by short periods of growth, followed by prolonged and deep
recessions. This has resulted in some of the highest unemployment rates in the world as
shown in Fig. 2 (Gisha 2019). Multiple factors affect these dynamics, including the
longstanding Israeli blockade, the internal Palestinian divide, recurrent outbreaks of
Fig. 1 Map of the Gaza showing its borders and crossing points. (Source: Posted in RelifeWeb
network, Gisha 2020)
Fig. 2 Unemployment rates (2007–2018) in the Gaza Strip. (Source: Gisha 2019)
hostilities, the chronic energy crisis that has devastated the infrastructure, and the
government’s inability to assume its responsibilities toward the people of the Gaza Strip.
The economy of the Gaza is fully dependent on humanitarian aid, which has
helped to reduce poverty and unemployment levels, but this stimulus package is
unsustainable considering the magnitude of the issues faced in the Gaza. According
to the PCBS, public aid has reduced poverty rates by 11.5%, with extreme poverty
reduced by 20%. The PCBS indicates a significant increase in poverty rates in the
Gaza Strip from 38.8% (in 2011) to 53% (by the end of 2017), which is equivalent to
about 1.01 million people, including over 400,000 children. This means that poverty
increased by more than 14% over 6 years and reached 49.1% during the first quarter
of 2018. In addition, the Ministry of Social Development in the Gaza Strip and the
General Federation of Palestinian Trade Unions warned that poverty rates have
reached unprecedented levels in the Gaza Strip, with poverty exceeding 80% in
2019. Unemployment is also at record levels: the Gaza Strip had the third-highest
unemployment rate in the world (at 44%) in 2017. The number of unemployed
persons in 2018 was 295,000. Unemployment in the besieged enclave was at 54.9%
in 2019; the horrendous unemployment rates and poor social conditions are impor-
tant indicators of the deteriorating economic situation in the Gaza (WHO 2019a).
Poor people are defined as those living on less than US$4.60 per day (including
social assistance and transfers), which is estimated by the PCBS as the minimum to
pay for basic household needs (shelter, clothing, food), healthcare, education, and
transportation. Moreover, nearly two-thirds of the poor, or about 656,000 people, are
living in “deep poverty,” which means they survive on less than $3.60 per day, the
minimum required to pay for only shelter, clothing, and food.
Gaza’s unemployment rate rose by 0.4% from the first to the second quarter of 2019
and now stands at 46.7%. The PCBS reported an apparent drop in the unemployment
rate in the first quarter of 2019. During the second quarter of 2019, this rate was
43.1%, meaning that unemployment effectively increased by about 3.5% between the
second quarter of 2018 and the second quarter of 2019 (OCHA 2020a).
Gender, Vulnerability, Social Inclusion, and Disability

The potential impact of some aspects of SDH are not always clear. This chapter
focuses on three main vulnerable groups, women, children, and the elderly, and
addresses issues of gender inequality and violence, the well-being of children, and
social inclusion. There is a belief that these issues are part of determinants and
directly affect health in the Gaza Strip. The reality is that the condition of these three
groups, combined with disability and social inclusion, is at great risk, mainly
because of political reasons and the inefficiencies of the social systems. The majority
of women in the Gaza Strip are educated, and their participation in specific aspects of
public life is increasing as early marriages are declining. However, women’s rights
and choices are still restricted as violence against women is widespread (PCBS
2019a; OCHA 2019). There are many reasons for this, but in large part is driven by
the restrictions imposed by the Israeli occupation and the consequences of the intra-
Palestinian divide. Both reduce freedom of movement, remove a supportive legal
system, increase political deterioration, and exacerbate socioeconomic tensions.
Children aged under 18 years form 48% of the total population in the Gaza Strip.
While school enrollment rates are high, the dropout rate is low not only in the Gaza
Strip but also in Palestine in general. In contrast, child labor is at about 1.3%, and
10,477 children live with at least one type of disability; children are increased risk of
being killed during military operations, and the percentage of children who suffer
from extreme poverty rose from 22% in 2011 to 34% in 2017 (PCBS 2019a). More
than two-thirds of post-graduate students (beyond the Bachelor’s degree) can either
not pay any part or pay only a portion of their university tuition fees, resulting in a
dropout rate of 70% in 2019 according to the Al Mezan Center for Human Rights.
Estimates from UNICEF suggest that nearly 15% of boys and 7% of girls aged
15 years old drop out of schooling. It is important to note that Palestinian women are
among the most educated (94% literacy rate) in the Arab world, and in 2006, 14,064
more women are enrolled in university than their male counterparts (United Nations
Relief and Works Agency for Palestinians Refugees in the Near East. https://www.
unrwa.org/activity/education-gaza-strip).
Despite increases in life expectancy over the last two decades, the percentage of
elderly persons is relatively low (4.3%) and is expected to remain below 5.0%.
Geriatric services in the Gaza Strip are not well-established even though chronic
illnesses in the elderly have significantly increased over the last 10 years (PCBS
2018). Thus, the primary drivers of vulnerability and social exclusion continue to be
contextual, intersectional, environmental, attitudinal, and institutional. The major
challenges in public services delivery provided to women and girls with disabilities
is illustrated in Fig. 3 and indicates the urgent need to address these determinants and
gaps in public health (UNFPA 2019).
Economy
The economic situation in Gaza is beyond dire: the economy has collapsed, and
many industrial and manufacturing facilities were destroyed. The people of the Gaza
Strip depend almost entirely on foreign aid and the payment of public employee
salaries, which account for about 85% of family income (PCBS 2019b). About 70%
of the citizens of the Gaza Strip receive aid from the United Nations Relief and
Works Agency, which employs 13,000 people and provides assistance and protec-
tion for about 5.6 million Palestinians (UNRWA 2017). In total, there are 118,620
employees in the public sector and related services, including municipal services and
UNRWA (UNRWA 2018). In most cases, these employees support their extended
families as well as their immediate family members.
This unsustainable situation could spiral into a serious humanitarian crisis in the
short term. This chapter highlights the role of the Palestinian Authority (PA) to
reconsider reducing public employee salaries or force early retirement, as this could
inevitably lead to an imminent humanitarian crisis. Such scenarios would likely
escalate border violence with Israel and drive the region toward further economic
burden and tension. The situation is not beyond repair, however. The implementation
of immediate, targeted easing measures could stop the freefall of Gaza’s economy
and put it on a course to recovery. Since Israel’s disengagement from the Gaza Strip
in August 2005 and Hamas’s takeover from the Palestinian Authority in 2007,
Fig. 3 Challenges facing healthcare to females with disabilities in the Gaza Strip. (Source: United
Nations Population Fund 2019)
Gaza’s real gross domestic product (GDP) has averaged only 1% a year, compared
with 6% in the West Bank. The combined effect of an almost-stagnant GDP and a
high population increase (3.5%) has seen a sharp drop in GDP per capita: GDP per
capita in Gaza in 2017 was 25% lower than in 2005, and it continues to decline
(IGC 2018).
A one-off clearance revenue transfer of fuel taxes (US$560 million) was made by
Israel in August 2019. This enabled the Palestinian Authority to muddle through 2019
with reduced spending. The Palestinian Authority made a series of cuts in its transfers
to the Gaza, including gradually reducing public employees’ salaries by up to 50%,
forcing more than 20,000 to retire, and reducing the supply of electricity, fuel, and
medical supplies to the population. These measures, in addition to a further sharp
decline in foreign aid to the Gaza, have crippled the economy. They ended a short
period of modest economic recovery that followed Israel’s Protective Edge Operation in
July–August 2014 and the start of the Gaza reconstruction effort in 2015–2016. The
IMF estimates that real GDP growth in Gaza declined from 6% to 8% a year in 2015–
2016 to 0% in 2017 and forecasts that it will decline by 4% in 2019 (IMF 2018).
Various economic indicators show that the decrease in public spending has not
resulted in a significant downward adjustment in consumption and investment
patterns in 2019, as the crisis has been perceived as liquidity rather than a solvency
problem. As a result, real GDP growth reached 1.4% in 2019 along with other main
economic outlines (clarified in Table 1) on Palestine and Gaza Strip in particular
(International Monetary Fund 2018). Implementing immediate targeted easing mea-
sures in six areas can significantly improve the economic situation in Gaza in the
short term; these measures include (i) making regular salary and humanitarian
payments, (ii) increasing the electricity supply, (iii) facilitating movement and access
through Israel and Egypt, (iv) expanding agriculture and fisheries, (v) advancing
reconstruction and housing, and (vi) allowing Gazans to work in Israel. These
measures should be part of a comprehensive plan to improve the key economic
indicators to restore the health and well-being of the people of the Gaza Strip.
Education
Recurrent escalations, ongoing blockades, frequent damage, and destruction of
educational facilities have disrupted services and impacted the psychosocial well-
being of children and teachers. The educational system in Gaza is also affected
negatively by 11 years of blockade and the continuing failure to effect real intra-
Palestinian reconciliation. Over 450,000 students in primary, secondary, and
kindergarten schools (and the teachers in these schools) are identified as “people
in need” in the 2018 Humanitarian Response Plan (HRP). About 50% of students
(aged 5–17 years) do not achieve their full educational potential, meaning that the
psychological impact of hostilities worsened learning outcomes and caused diffi-
culties in reading and writing (OCHA 2018a). Schools are chronically over-
crowded: 70% of UNRWA schools and 63% of schools run by the Ministry of
Education operate on a double shift system. This reduces instructional hours in
core subjects and foundational learning; it also makes it difficult for students to
focus on their studies and increases levels of violence in schools. In addition to
overcrowded classrooms, there is limited time to reinforce learning, support slow
learners, and provide remedial education programs or extracurricular activities
(OCHA 2018b).
Almost 86 new school buildings need to be built to provide a safe and adequate
learning environment, and another 1081 classrooms need to be added to existing
buildings by 2021. In 2018, the Ministry of Education announced that it would build
100 new Palestinian Authority schools in the Gaza and improve the kindergarten
school system, which currently serves 66,150 children in 683 kindergartens. Cur-
rently, only 30% of children aged 3–6 attend licensed preschools, leaving many
neglected in this critical phase of learning and development. Importantly, student
performance and motivation are also undermined in the context of the ongoing
difficulties in the Gaza: continuous power outages and electricity rationing, poor
shelter and living conditions, frequent military escalations, and economic depriva-
tion (OCHA 2018c).
Table 1 The economic outlook in the Gaza. (Source: International Monetary Fund 2018)
GDP per capita: $2926; 2017
Poverty rate: 14% in the West Bank and 53% in Gaza Strip; 2017 est.)
Projection
2016 2017 2018 2019 2020 2021 2022 2023
Output and prices (Annual percentage change)
Real GDP (2004 4.1 3.1 1.4 1.4 1.7 1.7 1.7 1.7
market prices)
West Bank 3.0 4.3 3.0 2.2 2.2 2.2 2.2 2.2
Gaza 7.7 0.3 4.0 1.5 0.0 0.0 0.0 0.0
CPI inflation rate 1.0 0.0 1.0 1.7 2.2 2.2 2.2 2.2
(end-of-period)
CPI inflation rate 0.2 0.2 0.8 1.5 2.0 2.2 2.2 2.2
(period average)
Public financesa (% of GDP)
Revenues 25.8 24.6 23.7 21.6 21.6 21.6 21.7 21.8
Recurrent 31.4 30.1 29.4 29.4 29.3 29.3 29.2 29.3
expenditures and net
lending
Wage expenditures 15.2 14.6 13.0 13.1 13.2 13.2 13.3 13.5
Nonwage 14.1 13.7 14.4 14.4 14.4 14.4 14.4 14.4
expenditures
Net lending 2.0 1.8 2.0 1.9 1.8 1.6 1.5 1.4
Recurrent balance 5.6 5.5 5.8 7.8 7.7 7.6 7.6 7.5
(commitment, before
external support)
Recurrent balance 1.1 1.2 6.4 8.5 8.3 8.2 8.1 8.0
(cash, before
external support)
Development 2.5 2.5 2.5 2.5 2.5 2.5 2.5 2.5
expenditures
In millions of US 335 367 381 391 408 426 445 464
dollars
Overall balance 8.1 8.1 8.3 10.4 10.3 10.2 10.1 10.0
(commitment, before
external support)
Total external 5.7 5.0 4.5 4.1 4.0 3.9 3.8 3.7
support, including
for development
expenditures
In millions of US 760 722 674 636 646 656 667 678
dollars
External support for 603 546 490 440 440 440 440 440
recurrent
expenditure (in
millions of US
dollars)
(continued)
Table 1 (continued)
GDP per capita: $2926; 2017
Poverty rate: 14% in the West Bank and 53% in Gaza Strip; 2017 est.)
Projection
2016 2017 2018 2019 2020 2021 2022 2023
Financing gap (in – – 620 1008 1053 1102 1153 1200
millions of US
dollars)
In percent of GDP – – 4.1 6.5 6.5 6.5 6.6 6.6
Monetary sectorb (Annual percentage change)
Credit to the private 20.0 15.0 12.0 8.0 6.0 6.0 6.0 6.0
sector
Private sector 7.8 9.5 5.1 4.0 4.4 4.1 4.1 4.1
deposits
a
Commitment basis
b
End-of-period; in US dollars
The chronic daily electricity cuts restricts student study times and their ability to
learn; it negatively impacts their ability to access educational resources and increases
dropout rates. The deteriorating socioeconomic situation in Gaza means that the cost
of higher education is a significant burden for most families: some 20,000 graduates
there have not been awarded their certificates due to their inability to pay their tuition
and other fees (OCHA 2018c).
When Hamas took over the Gaza in 2007, thousands of civil servants paid by the
Palestinian Authority, including teachers, were either forced by the Palestinian
Authority to stop working or were replaced by civil servants recruited by the Gaza
authorities and not salaried by the Palestinian Authority. Hundreds of government
projects were halted, and the Palestinian Authority budget for Gaza branches of
ministries, including the Ministry of Education, was cut. This creates an ongoing
need to recruit new teachers to bridge staffing shortages. Currently, there is no
operational budget for replacement teachers for those on maternity leave or other
temporary leaves of absence; this affects an estimated 54,000 children. There is also
is a critical need to ensure that returning and newly recruited teachers are suitably
trained in the new school curriculum (OCHA 2018c).
The UNRWA provides primary education to 271,161 Palestinian refugee
students in 275 schools across the Gaza Strip that is staffed of 8800 teachers.
This is an increase of about 10,000 students over the 2016–2017 school year. This
severe shortage in funding also forced the UNRWA to make further cuts to critical
routine operations and programs in general, and in education in particular, such as
maintenance for schools, generators, and sanitation facilities, and to reduce the
number of guards and attendants in schools (OCHA 2018c). Some pictures
depicting the reality of Palestinian educational institutions in the Gaza Strip
impacted by military attacks, overcrowding and dilapidation, and poor environ-
ment are shown in Fig. 4.
862
Fig. 4 Schooling in the Gaza Strip. (Source: AlJazeera 2016)

M. AlKhaldi et al.
Environmental Determinants
Water, Sanitation, Hygiene, and Climate Change

The relationship between the environment and health is well studied in the Gaza
Strip, where a high population density combined with severe poverty creates a
high-risk environment for the spread of diseases. The Gaza has been classified by
the Organization for Economic Cooperation and Development (OECD) as a
“highly fragile” region where conditions are worsened by a crippling Israeli
blockade that affects all aspects of SDH, including water, sanitation, hygiene
(WASH diseases), and healthcare and economic development (AlFar et al. 2017;
OECD 2016) (Fig. 5). Fuel shortages required to power wastewater pumps have
further increased the discharge of raw sewage to flood into residential neighbor-
hoods (Abuzerr et al. 2018; Efron et al. 2018). Desalination of brackish waters has
been introduced as a promising option to improve groundwater quality, the only
source of water in the Gaza Strip. Notwithstanding, microbiological contamina-
tion of desalinated water, mainly due to non-hygienic transportation and storage
practices, has been detected (Abuzerr et al. 2019a, c, 2020; Zaqoot et al. 2016;
Aish 2013).
A household-based study investigated WASH facilities in the Gaza Strip and
their associations with acute diarrhea in children under 5 years reported that
69.7% of heads of households reported diarrheal episodes in their children. In
addition, sewage water near households was associated with an increased risk for
acute diarrhea (Abuzerr et al. 2019b). A survey of 1857 households reported an
overall prevalence rate of diarrhea of 3.8/100 individuals; socio-demographic,
economic, water, sanitation, and hygiene factors were predictors of the diarrheal
illness (Abuzerr et al. 2019a). The Israeli occupation of many years continues to
cripple the Gaza sewage infrastructure. With the increases in the population,
Gaza’s damaged sewage system is unable to cope with the sewage from the
neighborhoods, leading to overflow into residential areas (Thöni and Matar
2019; Gisha 2017) (Fig. 5).
As climate change continues to become more severe and also the pressure to
conform to Israeli law, Palestinians are unable to take positive action against
climate change. Israel has left Gaza with only one aquifer that is replenished
through rainfall. However, with the severity of climate change increasing rapidly,
the sustainability of the groundwater system is put in doubt. Over the last two
decades, the average temperature has increased, while the amount of rainfall has
decreased, causing many people of Gaza surely to save every drop of freshwater
(Agha 2019; Bodetti 2019).
The widespread mobile station antennas and the increasing number of mobile
phones users throughout the Gaza Strip has caused a debate on the effects of
overexposure to electromagnetic radiation from the antennas of mobile base
stations (Yassin et al. 2019a). In addition, a better understanding of the potential
health risks from natural radioactive sources such as indoor radon emissions is
required in order to mapping radon-borne areas throughout the country (Yassin
et al. 2019b).
864
Fig. 5 Recent photos of the deterioration in water, sanitation, and hygiene status in the Gaza Strip. (Source: Reports by UN agencies)
M. AlKhaldi et al.
Fig. 6 Housing conditions in the Gaza Strip. (Source: UNOCHA)
Housing
The population in the Gaza is steadily growing with unprecedented increase in
poverty rates; 75% of the housing units were destroyed (either partially or totally)
during the 2014 war. This mass destruction of civilian buildings and properties is
shown in Fig. 6. Even before the war, 20% of existing units were below acceptable
standards and in need of rehabilitation to meet minimum criteria for safe housing.
About 30% of families in the Gaza Strip live in crowded housing units with three
persons or more living in one room. More than 60% of families will need at least one
extra housing unit by the year 2023, 70% of whom cannot afford the related costs
and thus need additional financial assistance. The Gaza Strip will need 125,000 more
housing units by 2023, and more than 50,000 housing units must be rehabilitated to
comply with minimum housing criteria (Hasayna 2014).
Agricultural and Food Determinants
Agriculture
The importance of agriculture in the Gaza Strip stems from its production to food
security and the creation of jobs. To be a farmer in the Gaza Strip that borders Israel
increases the dangers and challenges unrelated to farming practices. An energy crisis
resulting from internal political disputes affected the Gaza Strip for many years.
Thus, electricity used for irrigation systems is available only 4–6 h a day and often
only during the night, causing farmers to often work in the dark (MEE 2019).
There is a decrease in agricultural land to about 100,000 dunum (24,700 acres).

The most important reasons for this include an accelerated annual population growth
(3.5%), resulting in the conversion of agricultural land for housing. This coupled to
restricted access due to the establishment of a buffer zone of about 17,000 dunum
along the Gaza Strip’s fence with Israel caused the loss of 15% of very fertile
agricultural land. This buffer zone, which is classified as “Access Restricted Area
(ARA)” and runs from the north to the south, is famous for the cultivation of
tomatoes, potatoes, watermelons, and onions (GUPAP 2019; UN 2019). Moreover,
the fragmentation of agricultural property (1–3 dunum/farmer, where 1 dunum is
1000 m2 or about ¼ acre) means that farming is done in small land areas (FAO
2019). Fishing is confined to an area of not more than 3 nautical miles; the annual
output of the fishing sector ranges from 2000 to 2500 tons, compared to an annual
consumption of more than 8000 tons/year. Some encouraging alternatives to marine
fishing are being developed in the form of private aquaculture farming projects.
Export restrictions in the Gaza hamper the development of export chains; a focus
on cash crops resulted in a shift from local to foreign markets, causing increased use
of scarce quality water resources, fertilizers, and pesticides (further increasing soil
and water pollution). The shift from food crops (vegetables, fruits, field crops) to
cash crops (strawberries, ornamental flowers) also led Gaza to now import some field
crops, vegetables, and fruits, causing price hikes and deteriorating local food security
(GUPAP 2019; UN 2019). There is a need to re-focus on food crops (field crops,
vegetables, fruits, animal products, honey, fish) and strengthen the local food system
to ensure less dependence on international markets, lower the ecological foot/
footprint, lower vulnerability to climate change, and reduce the impact of military
and other occupational measures that affect urban agriculture production in the Gaza.
Food Security and Nutrition

About 1.3 million people in the Gaza experience severe or moderate food insecurity,
according to the preliminary findings of the latest Socio-Economic and Food Secu-
rity Survey carried out in 2018 (WHO 2008). Concerning nutritional status, a
protracted crisis continues in the Gaza Strip that impacts nutritional status. After
years of a relative absence of armed conflict since the 2014 hostilities, there was a
sharp deterioration in the humanitarian situation in 2018 (OCHA 2020b). The United
Nations Children’s Fund (UNICEF) and World Food Program (WFP) report that
23% of households in the Gaza had a sub-optimal Food Consumption Score (FCS);
80% of these households receive some form of humanitarian aid. These households
do not consume enough iron-rich food groups, leading to a high risk of iron
deficiency anemia. The coping strategies of the population are to reduce the number
of meals and the variety of foods consumed. About 18% of pregnant women and
14% of lactating mothers are malnourished. Malnutrition occurs in 4% of children
aged 6–59 months – which is still below the emergency thresholds of the WHO.
More than 6% of infants have never been breastfed, and more than 55% of infants are
not exclusively breastfeeding. Breastfeeding continuation occurs at very low rates,
being at 45% after 1 year and 12.5% after 2 years. The majority of households
receive infant formula through relief agencies. The minimum acceptable diet, a
combined indicator that measures how much of the nutritional needs of the children
are met, is at a dangerously low level of only 14% (WFP 2017, 2018). More than
40% of children aged 2–5 years old experienced acute respiratory infections (ARI),
while almost 40% experienced diarrhea (Abuzerr et al. 2019b; UNICEF 2010).
Political Determinants
Stages of Political Situation and Events

The political instability has direct and indirect impacts on the healthcare setting in Gaza,
and analyzing SHDs outside of a consideration of the political systems and power
relations can be misleading or patronizing at best. Therefore, healthcare in the Gaza
Strip is affected by both the ongoing occupation (resulting in blockades, bombings,
etc.) and ongoing internal disputes between the various Palestinian political factions.
Political transitions that occurred in the Strip during the last 15 years has framed the
current reality that has resulted in a severe weakening of the social and health system. A
year after the 2006 election of the Palestinian Legitimate Council, the Hamas faction
unlawfully took control over the Gaza Strip. This resulted in an administrative and
political division between the West Bank and Gaza and led to the formation of parallel
government institutions. For example, the health, social judicial, and financial systems
were split into two, and public servants based in Gaza were ordered to stay home and
continue to receive their salaries. Added to this internal division, the Israeli occupation
imposed a strict blockade on the Strip that continues to impact the daily life of Gazans
and all social systems, basic public services, and needs. The Gaza Strip suffered from
three major military escalations over the following years (2008, 2012, and 2014),
causing numerous injuries to the inhabitants and damage to the infrastructure that
weakened an already crippled health system. The health system continues to be very
inadequate and wholly unable to cope with the humanitarian and health crises in the
Strip. This is exacerbated by a health system operating with low capacity and a scarcity
of resources, capabilities, and an inability to compensate health professionals. The most
recent uprising is the Great March of Return (GMR), which has left hundreds wounded,
including women, children, persons with a disability, and, importantly, health workers
performing first aid. The Israeli occupation also targeted ambulances, hindering the
transfer of the injured to receive proper treatment outside the Gaza Strip despite
movement restrictions. The key updates of attacks on healthcare providers, vehicles,
and facilities during the Gaza Great March of Return in 2019 are shown in Fig. 7.
Health System, Services Delivery, and Key Indicators
Health System in the Gaza Strip
The challenges faced by the healthcare system in Palestine have similarities to those
faced by other countries in the region. The healthcare system in Palestine has four
healthcare providers: the Palestinian MOH, UNRWA, nongovernmental
Fig. 7 Health impacts of the Gaza Great March of Return. (Source: WHO 2019d)
organizations (NGOs), and the private sector with MOH being the main provider and
the responsible governor. A defining feature of the health system in Gaza is its
fragmentation, and being an emergency-oriented, and highly politicized system with
severe shortages in its resources, capacity, and supplies that is dependent on uncer-
tain foreign aid. The health expenditures are not publicized, and health outcomes are
below expectations considering current spending levels. Overall health expenditures
(public and private) have fluctuated during the last decade at the expense of lower-
priority sectors that receive an adequate budget. Long-term depletion of essential
medicines and supplies and limited access to healthcare and violence against health
professional and system facilities are key obstacles and determinants of health in the
Gaza Strip (WHO 2019b).
Essential Health Indicators
The health indicators in Palestine are better than in other neighboring countries, but
improve and decline according to the volatility in the Gaza Strip, limiting any
chances of recovery of the healthcare system. Life expectancy rates continued to
increase in the Gaza Strip over two decades, from 68.5 years in 1990 to 73.8 years in
2017 (ICBS 2019). Additional key health indicators include a sharp decline in the
infant mortality rate (IMR) from 127/1000 live births (1960), 20.2 in 2006, 22.4 in
2011, and currently 20/1000 live births according to the UNRWA (WHO 2019d; Van
den Berg et al. 2018).
The under-five mortality rates have significantly improved from 45/1000 live
births in 1990 to less than 20 in 2018 and are currently at 12.1/1000 (UNICEF 2019;
Van den Berg et al. 2018). The reason for this improvement is the implementation of
national health programs such as the Mother-Child Health (MCH) services
supported by international agencies. There are also modest improvements in the
health of women in the Gaza, with the maternal mortality rate (MMR) in the Gaza
Strip changing from 31/100,000 live births in 2013, to 30 in 2014, 25 in 2015, and
27.0 in 2017 according to the Palestinian MOH (Van den Berg et al. 2018;
Knoema 2018).
There is a significant improvement in most health indicators over the last two
decades, but the main concern is to preserve this improvement in light of political
and economic uncertainties. Healthcare inequalities still exist, being worse for some
indicators in the Gaza Strip, for instance, noncommunicable diseases (NCDs) are the
leading cause of death and a major economic and social burden. The NCDs in the
Gaza include hypertension, cardiovascular diseases, cancers, diabetes, and mental
illnesses, which in combination contributed to more than two-thirds of all Palestinian
deaths in 2017 (MOH 2018). The top ten causes of death in Palestine were caused by
NCDs (MOH 2016). Mental illnesses represent one of the most significant public
health challenges in Palestine. In the Gaza Strip, the WHO has declared that the
chronic state of mental health is mainly the result of the Israeli occupation. Over half
of conflict-affected children are affected by posttraumatic stress disorder, while “an
estimated 210,000, or over 1 in 10, people suffer from severe or moderate mental
health disorders in the Gaza Strip” (HRW 2019).
Palestine in general, and Gaza Strip in particular, is experiencing a rapid epide-
miological transition that is challenged by the increasing prevalence of NCDs (WHO
2020; Ghosh et al. 2007). Palestinians are frequently exposed to different forms of
violence from armed conflicts: 299 Palestinians were killed and 29,878 injured by
the occupation and armed conflicts in 2018, particularly since the beginning of the
GMR on 30 March 2018. The GMR further increases the burden on an already
fragile health system and its services.
Health Services Coverage and Accessibility
Approximately 78% of Palestinians in the Gaza Strip are covered by some form of
prepayment for healthcare, according to data from the PCBS. The major providers of
health coverage, the Government Health Insurance and UNRWA, account for over
90% of the coverage provided. The government health insurance covers primary
services including maternal and child health services, secondary care, prescription
medicines on the essential medicines list, and tertiary care services not available in
MOH facilities and purchased from non-MOH facilities within and outside Pales-
tine. Some 45.5% of health financing comes from out-of-pocket payments. The
UNRWA operates 65 health centers in the Gaza Strip; the UNRWA faced an
unprecedented financial crisis in 2018, jeopardizing the continuation of UNRWA’s
essential primary healthcare services. The MOH operates approximately a third of
the 160 primary health clinics, with a larger role played by UNRWA and non-State
actors. Bed capacity is approximately 1.7 beds/1000 population, with the MOH
providing 73% of bed capacity and non-State actors accounting for 22% and the
Military Medical Services providing for 6% of bed capacity (UNRWA 2019). Forty-
nine percent of the total MOH expenditure was for human resources, with workforce
scarcity and wage reductions of the public servants an ongoing issue. The vaccina-
tion program is one of the most successful programs in Gaza’s health system, with a
coverage of over 95% over 20 years due to international pledges to ensure that
children in the Gaza get vaccinated (MOH 2018).
Permit and Referral System and Its Impacts on Health Access
The Gaza Strip is a locked area surrounded by two border authorities, Israel and Egypt
(Fig. 1). Freedom of movement is challenging for patients seeking healthcare outside the
Strip. Movement restrictions also apply to goods, materials, and supplies. The Palestin-
ian territories are divided geographically and politically, posing major challenges for the
mobility of Palestinians arriving at Israeli checkpoints to seek healthcare (Fig. 8). The
access to specialized care in the West Bank that is unavailable in the Gaza Strip is a
challenge faced continuously by those in need of healthcare due to the Israeli permit
system for Palestinians, which extends to patients, their companions, and health
workers. All patients and patient companions from the Gaza Strip must apply for Israeli
permits to exit the Gaza Strip to access hospitals in the West Bank, including East
Jerusalem and Israel (WHO 2010, 2019a, c; HRW 2019; Abdalla et al. 2019). Unfor-
tunately, the treatment of patients with cancer in the Gaza Strip remains problematic
(WHO 2020; Abuzerr et al. 2019d).
Fig. 8 Applications for permits at Israel-Gaza border. (Source: OCHA 2020c)

Perceptions of Policymakers and Patients from the Gaza Strip on

Health System and Services
We conducted in-depth interviews with key health policymakers and experts on their
perceptions on the health system in the Gaza Strip. In addition, transcripts of real-life
stories from focus group discussions (with various healthcare seekers, including
cancer patients) who explained their journeys to seek healthcare are also provided
below.
Perspectives from Policymakers and Experts in the Health Sector

The overall perception of access to healthcare in Palestine, especially in Gaza, was
described by policymakers who described the deteriorating access to services due to
several factors, the most important of which are intra-Palestinian political fractures, and
the Israeli occupation and the ongoing blockades that impedes freedom of movement of
people and goods movement. In addition, logistical factors related to the availability of
services, equipment, medicine, and the lack of manpower affect the quality of services.
Finally, other factors such as the bureaucratic referral system frequently caused delays
in receiving adequate services promptly and in the right place.
A government official from the department of purchasing health services sum-
marizes many of the key factors affecting access to healthcare in Palestine and the
Gaza Strip by noting: “Access to health care since the beginning of the Palestinian
political split has deteriorated because there are no new jobs generated and talented
and skilled Palestinians are leaving the Strip. In addition to that, there has been no
increase in the number of beds and there is a lack of medicines and supplies. Most of
the injured who return are rejected for healthcare abroad and a very limited number
of them are allowed to travel. Furthermore, accessing health care in Egypt is also
difficult because sometimes there are no specialized healthcare institutions, and
travel difficulties due to the high cost of this journey, especially for low-income
families. Why is this happening? It may be because the MOH in the West Bank
recently decided to stop and restrict medical referrals for the sake of ‘localizing of the
service.’ This decision is unfortunately inappropriate, and we are not ready for such
major interventions in the health institutions. Things that adversely affected the
approvals system led by Israeli occupation and referrals system are fake medical
reports in order to have a chance to move to the West Bank. This resulting in about
2700 persons who left Gaza to Israel or the West Bank and did not return. In addition,
the process of applying for medical referral and getting it issued is relatively long,
and this process delays access to health care. There must be supervision and
monitoring systems to centrally manage referrals so that not all doctors are allowed
to issue and approve referrals.”
Translating International Laws and Conventions on Healthcare

Accessibility
The experts and policymakers described the application and compliance state of the
international laws and conventions of health rights as a serious challenge, and they
pointed out that a systematic violation of those laws and treaties prevails, by which the
Israeli occupation does not respect the laws and denies to access health services. Some
experts place responsibility on the three parties: Israel, the PA, and the local ruling party
in Gaza, who are in charge of all Gazans’ needs. One of the key perceptions, delivered
by a human rights activist, highlighted most of these issues as follows: “Everything that
happens to patients and citizens in the Gaza Strip is contrary to international agree-
ments and conventions related to human rights, specifically the right to health. In
accordance with Article 12 of the special Covenant on Economic, Social and Cultural
Rights, Palestinians in the Gaza Strip have the right to health services and to enjoy the
highest level of access that can be reached, but what we find is the opposite because
accesses to health service is unaffordable and unavailable for everyone. This is because
of the Palestinian division and the Israeli blockade which hinders the provision of
healthcare, and this reality contributes greatly to these violations and stops people from
enjoying their right to health in the Gaza Strip. The Palestinian Authority has joined
this covenant on economic, social and cultural rights, and we hope that it will make a
greater commitment to the right to health and provide all health services in the Gaza
Strip and to all citizens in general. Likewise, the Israeli occupation does not abide by
international agreements and violates them, and the international community overlooks
Israeli practices against the residents of the Gaza Strip and collective punitive measures
that directly affect their health and patient rights.”
Stories of Patient Journeys to Seek Healthcare in the Gaza Strip

A story from patient number 2: “I am a breast cancer patient who became ill and
diagnosed in 2015. I went for ultrasound mammography at a government health center,
but the machine was not working. So I went to a private facility and paid my own
expenses. At another time, I visited Al-Shifa Hospital, the main public hospital, for
breast surgery. I was given a very long wait for an appointment time and then I went to a
UNRWA health center, and they gave me a referral to Jerusalem Hospital for surgery. Of
course, they took the sample for analysis and I paid for analyzing the sample, which cost
me 600 shekels (equals USD150). After that, I received chemotherapy, where I received
four doses at the European Hospital in Gaza, where I remained from 7 am to 4 pm until I
got home. I finished chemotherapy and booked for a radiogram in Jerusalem. They gave
me a late date, which prompted me to change the referral report to do this analysis in
Jordan and meet my family there. After that, I went back to Jerusalem to take treatment
there. From that time until now, I am continuing my treatment plan.”
A story from patient number 5: “I got shot in my feet with an explosive bullet in
East Gaza City by the Israeli troops. My foot was almost amputated, as I was
transferred directly to Al-Shifa Hospital, and I was admitted to the emergency
department. After the doctor examined my case, he decided that my foot should be
amputated by 18 cm. I got into the operating room for surgery. The local surgeon
came to get my father’s consent for the surgery; my father refused and requested
repairs to the foot, not for the foot to be amputated. At that time, an international
surgical delegation was visiting Gaza, so my case was introduced directly to this
delegation and an external device was put on my feet. The arteries were connected by
a vascular specialist. After 6 months, I followed up with the orthopedic doctor, who
agreed that they cannot perform this surgical operation inside Gaza and issued a
referral report to Egypt for the surgery to be performed there. I did not have the
financial means to travel to Egypt. My dad started looking for financial help so we
could cover the expenses for traveling and staying there. My father did not succeed
in providing enough expenses, as the referral report was renewed four times due to a
lack of financial availability. As a result, I was unable to travel to Egypt. I went back
to Al-Shifa Hospital again, to meet with the international medical delegation regard-
ing the surgical operation. They recommended a visit to the Doctors Without
Borders, a medical international organization working in Gaza City, and their
response was that there is no possibility to perform the operation and sent me
home again. I then returned to Al-Shifa Hospital and got a referral report to the
West Bank for treatment there. I still have not received a referral report issuance, for
which I have been waiting 8 months now, and I continue to suffer from many health
complications including pain in my feet.”
Effect of COVID-19 and SDH
As the COVID-19 pandemic spreads, concerns are particularly serious in conflict

and humanitarian settings. Tackling the pandemic in those countries is challenging
due to the fragility of socioeconomic and health systems. Palestine is one of those
countries that is facing compounding challenges, instability, fragility, living condi-
tions, poverty, and mobility, all of which are caused by multifactorial etiology. The
pandemic shows triple tragedies; virus (COVID-19 pandemic), ongoing Israeli
occupation (politics), and intra-Palestinian divide (policies). Yet, Palestine’s
response to the pandemic is outperforming many countries in the region. The early
preventative lockdown measures in the West Bank found effective and not over-
whelming the already over-stretched health system. While in the Gaza Strip, the
response was slow and this area is much more affected by COVID-19 where this
pandemic has significantly doubled all current conditions and preexisting chronic
problems that relate to SDH. Prisoners, labors, besieged people, socioeconomic-
disadvantaged classes, and refugees were put at additional high risk. Nonetheless,
measures taken were unconsolidated in both regions largely due to the political
factors. A little collaboration and inter-agency task forces in preparedness and
response was observed, and the mechanisms and governance remain ambiguous.
A consolidated and evidence-based nation-wide plan is required, whereby state and
non-state actors have a clear and transparent exit strategy. A new thinking approach
to promote the public health system and evidence-informed policies to improve SDH
in Palestine is an urgent national priority (AlKhaldi et al. 2020).
Conclusion and Policy Pathways and Recommendations
Determinants of health include a broad range of personal, social, economic and

environmental, and political factors that shape the health status of the individuals and
populations living in stable or unstable and in fragile or cohesive settings. These
determinants influence health in many positive and negative ways by direct or indirect
processes. The Gaza Strip is an exceptional case that requires immediate attention. Four
methods (literature review, desk review, interviews, and focus group discussions) were
used to consider healthcare in the Gaza Strip. This chapter depicts a microcosm of the
interactions of all the determinants of healthcare in this narrow geographical area. This
chapter considers the SDH affecting the Gaza Strip based on international resolutions
and conventions. Some factors that were discussed include geography and demogra-
phy, socioeconomic, environmental, food and agriculture, political, and health system,
services, and governance. The main conclusions are as follows:
• The numerous conditions harming the health of the population in the Gaza Strip
are interconnected.
• The socioeconomic determinants, including poverty, unemployment, education,
and gender violence, disability, and social exclusion, affect the health of Gazans
in an unprecedented manner over the last 20 years.
• Environmental determinants (e.g., availability of clean water, sanitation, housing,
climate change) negatively impact the health in the Gaza, in addition to the
hardships caused by corruption, resource scarcity, and territorial restrictions.
• Agriculture and food determinants adversely impact socioeconomic, environmen-
tal, and political determinants. The agricultural sector still faces many obstacles,
especially funding, access to farms, clean water, floods or sun waves, inadequate
technologies, and lack of resources. This has social and economic consequences
and creates food insecurity in most families. The ongoing Israeli occupation and
the intra-Palestinian dispute between its two main political factions ensure the
instability of food security.
• The health system in the Gaza Strip is extremely weak, highly fragmented, and
resourceless. This means that it is not responsive and emergency-oriented rather
than functioning in a regular manner; this is related to frequent military opera-
tions, blockades, severe scarcity of medical supplies, and salary cuts in the
healthcare sector. This has resulted in the healthcare quality, access, and special-
ized care in the Gaza Strip being at their lowest points.
In summary, the social determinants in the Gaza Strip must be now on the
politicians’ agenda before the opportunity of recovery and solution closed.
Healthcare is systematically violated in the Gaza Strip where people do not enjoy
minimum levels of well-being and health promoted by the WHO. As healthcare is
largely determined by the decisions of political powers, the SDH in the Gaza Strip
should be addressed by all different stakeholders using geopolitical and inter-sec-
toral approaches to overcome the growing challenges of health, social, and human
rights in the Gaza Strip. Policy changes should focus on three aspects: (a) internal
and external political will and commitment, (b) developing a comprehensive devel-
opment plan based on cooperation and collaboration, and (c) ensuring that interna-
tional stakeholders play more active and sustained roles.
Acknowledgments The Islamic Development Bank provided partial funding for the stipend for
Dr. Mohammed AlKhaldi who has led this work.
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Social Determinants of the Wellbeing
of the Poor, the Homeless, 37
and the Imprisoned in Arab Countries
Nacer Amraoui
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 880
Social Obligation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 880
Sadaqah and Zakat (Charity and Alms) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 882
Social and Community Welfare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 884
Homeless . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 885
Imprisonment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 886
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 887
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 889
Abstract
This chapter provides a comprehensive analysis of the emergence of the zakat
system and its contributions to the socioeconomic needs of the community within
an Islamic framework. This system is designed to build a healthy and balanced
society where the poor and the disadvantaged members are well looked after and
valued. Explicit references from both the Qur’an and sources of Hadeeth that
urge the faithful to coexist in unity and in harmony are used to stress the social
responsibilities towards each other. Improving community wellbeing through acts
of zakat are as important as the spiritual rituals.
Keywords
Islam · Zakat · Sadaqah · Qur’an · Hadeeth · Social obligation · Homeless ·
Imprisonment · Community Welfare
N. Amraoui (*)
Bedford, UK
e-mail: nacer.amraoui@justice.gov.uk

https://doi.org/10.1007/978-3-030-36811-1_221
880 N. Amraoui
Introduction
From the social view point in Islam, a society can only flourish when its members
work together to fulfill the needs of others by inclining towards a common good and
a common vision. This prepares the ground of belonging and togetherness by all
members of the community, where people from different circumstances are appre-
ciated and positively valued.
In dealing with the above title of this chapter, and when examining and evaluating
such breadth of diverse views and opinions on this topic, one must go back to the
sources of the Qur’an and the tradition of the Prophet Mohammad in order to
establish a clear analysis and understanding of Islamic rulings and jurisprudence.
Imam Suyuti (1445–1505 AD) also known as Ibn al-Kutub (son of books) states that
“Everything is based on the Qur’an.” The Qur’an is the word of God, the supreme
authority in Islam and the fundamental source of the creeds, rituals, and ethics of the
Islamic religion. It is also the basis of all Islamic laws and theology. The entire life of
Muslims is built and shaped around the Qur’an. As a consequence of the Qur’an, the
Arabic language moved far beyond the Arabian Peninsula, deeply penetrating many
other cultures and languages within the Muslim world such as Farsi, Urdu, Turkish,
Spanish, and others.
The Qur’anic discourse with its moral language is universal and accessible to any
human being regardless of their faith, race, or and gender, calling upon humanity to
respond to its original nature of moral guidance empowered with an instinct to
distinguish right from wrong naturally, “and adhere to the true nature on which Allah
has created human beings” (Qur’an 30:30). This human instinct is known as fitrah.
No human endowed with this natural faculty of intellect, consciousness, and wisdom
can fail to understand the moral universal language of the Qur’an. Hence, the Qur’an
urges all of humanity to respond to their natural predisposition so as not only to be
aware of the meaning of fairness, justice on earth, and moral sense of right and
wrong, but also to be accountable for their actions and deeds. Allah created mankind
in the best and most beautiful form, physically and intellectually, “Surely we created
man in the finest structure” (Qur’an 95.4). Then, due to his or her evil deeds and
mischief on earth, that finest creation reverted to the lowest of the low, “Then We
reverted him (mankind) to the lowest of the low” (Qur’an 95.5).
Social Obligation
The Qur’an stresses that in order to have a healthy and balanced community, it is
necessary that its members maintain justice and adhere to social responsibility such
as enjoining what is good and forbidding what is evil. This concept is laid down in
the Qur’an and in the tradition of the Prophet Mohammed as a set of statutory rules
not only to establish justice and social solidarity but also a degree of shared
responsibility and accountability.
Human dignity has been one of the main themes highlighted in the Qur’an. Verses
have been repeated over and over again, illustrating the highest moral purity in
37 Social Determinants of the Wellbeing of the Poor, the Homeless, and the. . . 881
several chapters. Explicit verses viewed the spiritual nobility of man, the sanctity of
life, human dignity and property, feeding the hungry and the necessity for freedom,
including religious freedom, as a divine command. Mankind, or the son of Adam,
has always been regarded as the noblest and most honoured of all creatures, not for
his social status, but for the fact that they are human-beings. Therefore, human
dignity is the absolute right of everyone. “Indeed, we have honoured the children of
Adam; provided them with transport on land and sea; given them for sustenance
things good and wholesome, and favoured them especially above many of those We
have created” (Qur’an 17.70). In this verse human dignity is affirmed very explicitly
under the umbrella of the human family (Children of Adam), as Adam was the first
man and father of humanity, God’s vicegerent on earth, and every terrestrial good-
ness has been created for his benefit.
Furthermore, if honor and dignity are a common heritage of human beings as
God’s creatures, then it is only necessary and logical that they all must treat each
other with justice and equity through cooperation and social solidarity. One of God’s
attributes that is repeated again and again in the Qur’an is al-Adil, the Just. The
Qur’an says, “. . .and when you judge between people, judge with justice” (Qur’an
4.58). Justice is also associated with piety, moral purity, and a high standard of
conduct, which are all prerequisite ingredients to build an equitable system that
leaves no room for any section of the community to feel deprived and isolated. The
Qur’an commands Muslims to do justice, deal with others in fairness, and to give
charity. It urges believers to strive in spending for His sake and not to delay.
This basic Islamic teaching of cooperation has been articulated repeatedly in the
Qur’an. “And let there be arising from you a nation inviting to all that is good,
enjoining what is right and forbidding what is wrong, and those will be the
successful” (Qur’an 3:104).
“And cooperate in righteousness and piety, but do not cooperate in sin and
aggression. And fear Allah” (Qur’an 5.2).
“They believe in Allah and the Last Day, and they enjoin what is right and forbid
what is wrong and hasten to good deeds. And those are among the righteous”
(Qur’an 3:114).
“The believing men and believing women are helpers of one another. They enjoin
what is right and forbid what is wrong and establish prayer and give zakah (alms)
and obey Allah and His Messenger” (Qur’an 9:71).
The above verses undoubtedly affirm the comprehensive nature of solidarity and
social responsibility where human dignity is valued and cannot be taken away. Thus,
caring for the poor and the needy is one of the divine purposes and commands upon
the Muslims. Each Muslim is under the obligation to incline towards the
community’s common good; to alleviate suffering and hardship by feeding the
hungry, the orphan, and the prisoner; and to maintain a healthy, balanced society
where disadvantaged members are well looked after and valued, as the Qur’an states;
“And they give food, in spite of love for it, to the needy, the orphan, and the captive”
(Qur’an 76;8,9).
Moreover, the Prophet Mohammad encouraged his companions to adopt the
concept of takaful, which is a sort of strategical sponsorship to fight poverty and
882 N. Amraoui
protect the less fortunate members of the community. He said; “I and the sponsor of
the orphan will enter Paradise together like this, raising his forefinger and middle
finger jointly, leaving no space in between” (Bukhari). It has been narrated that the
Prophet Mohammad said: “The believers, in their affection, mercy, and compassion
for each other, are like a single body; if one limb feels pain, the whole body becomes
feverish and restless” (Bukhari). The prophet Mohammad also said: “A believer to
another believer is like a building whose different parts enforce each other”
(Bukhari). He also said “None of you truly believes until he loves for his brother
what he loves for himself” (Bukhari and Muslim).
The above hadeeths encourage believers to coexist in unity and in harmony in
which social responsibilities towards each other are as important as the spiritual
rituals towards oneself. Thus, serving the community, doing good and alleviating
suffering and hardship are not only important virtues that Muslims should observe,
but a profound act of worship that leads to piety and moral consciousness.
Poverty (al faqr) in the Islamic traditions is considered as a common social issue
and a threat to the community. It is mentioned in the Qur’an several times, whereas
the word fuqara’a, which is the plural form of faqir (poor) which, in some cases, has
the meaning of spiritual poverty, is also mentioned in the Qur’an about 12 times. The
Prophet Mohammad sought refuge in Allah from the danger of poverty, indicating
that poverty is a danger and a threat to both individuals and societies. The Prophet
clearly points out that poverty is an unwanted circumstance from which every person
should protect himself/herself. He himself prayed, “O Allah, I seek refuge in you
from the evils of poverty”. He advised his companions to repeat the following
prayer: “O Allah, we seek refuge in you from the evils of poverty, famine, degrada-
tion, oppressing and being oppressed” (Ibn-Hanbal).
As a result of this social problem, which has various negative impacts on different
communities, families, and individuals, Islam puts forward a set of foundational
concepts and strategic measures as divine commands, both communal and individ-
ual, for supporting the needy, the poor, and the destitute. The Islamic solution is
feasible and achievable not only to minimize the social risk of this problem but to
uplift human dignity while providing the basic needs of survival.
Sadaqah and Zakat (Charity and Alms)
In discussing poverty in the Islamic theology, I will mainly focus on the concepts of
sadaqah and zakat.
There are many verses in the Qur’an, some of which relate to sadaqah and some
to zakat.
Sadaqah is a charity or the act of voluntary giving out of kindness and generosity
to support the needy and the less fortunate. The word derives from the Arabic verb
sadaqa: to be truthful and sincere. Sadaqah in Islam is more than merely acknowl-
edging the others by giving money, clothing, and food to the poor and needy. It is a
great act of worship that leads to moral consciousness. Whereas the word zakat
signifies that which purifies and increases. It is a form of compulsory alms-giving,
which, by Qur’anic ranking, immediately follows prayer in importance. It is also one

of the Five Pillars of Islam. It is based on income and the value of all of one’s
possessions and wealth provided that the person is adult and of sound mind.
Zakat should be given as soon as possible after it becomes due. It is a certain
percentage of one’s wealth, which is regarded as a spiritual investment that purifies
the person who fulfills it from the destructive impurities of niggardliness. It is a way
to demonstrate gratitude for God’s blessing and to keep the giver away from sin,
ostentation, and hypocrisy. The giver should give sadaqah or zakat, if possible, in
secret to the extent that the recipient does not know the giver. By doing so, the giver
will save himself from moral corruption resulting from the love of wealth, selfish-
ness, and greed.
The recipient of zakat according to the Qur’an is indicated in Surat Attawbah
(chapter 9) where it states; “Zakat is for the poor (fuqara) and the needy (masakeen);
and those who collect it (al-amileen); for those whose hearts are to be reconciled
(mualafati qulobohom); and to free the prisoners (arriqab) and the debtors (al
gharimeen) and for the cause of Allah (fi sabili Allah); and for the wayfarer (ibnu
sabeel); a duty ordained by Allah. And verily Allah is all knowing, all Wise”
(Qur’an 9;60). And; “Take, O Muhammad, take from their wealth a charity by
which you purify them and cause them increase, and invoke Allah’s blessings upon
them. Indeed, your invocations are reassurance for them. And Allah is Hearing and
Knowing” (Qur’an 9.103).
The above verse mentioned the recipients who are entitled to receive zakat,
including the poor (fuqara), the needy (masakeen), referring to those who are
extremely in need to the extent that they are forced to beg for their food, and to
free the captives.
Qur’an states, “O Prophet!, Tell those of My servants who believe that they
should establish Prayer and spend out of what We have provided them with, both
secretly and openly, before there arrives the Day when there will be no bargaining,
nor any mutual befriending” (Qur’an 14:31).
Furthermore, the Prophet Mohammed instructed the Zakat collectors (adminis-
trators) to take some of the wealth of the rich and return it to the poor as if it belonged
to the poor (Bukhari). This indicates that the giver should not feel that he or she is
doing a favor to the poor and the needy. In fact, the giver should deem himself a
beneficiary. It is therefore his duty to acknowledge the poor and the needy who has
made their hands a substitution for that of God. The Prophet Mohammad said,
“Verily, sadaqah and zakat fall into the hand of God before they fall into the
hands of the poor who receive them” (Bukhari).
The Qur’an states: “Righteousness is not that you turn your faces toward the east
or the west, but true righteousness is in one who believes in Allah , the Last Day, the
angels, the Book, and the prophets and gives wealth, in spite of love for it, to
relatives, orphans, the needy, the traveller, those who ask for help, and for freeing
captives; and who establishes prayer and gives zakat; those who fulfill their promise
when they promise; and those who are patient in poverty and hardship and during
battle. Those are the ones who have been true, and it is those who are the righteous”
(Qur’an 2.177).
884 N. Amraoui
This verse is a confirmation that piety is not a matter of turning one’s face towards
the east or the west in which one will prostrate during the five-times-per-day ritual
prayer. The verse puts great emphasis on social action and active engagement in the
service of humanity; through meeting one’s social obligations, especially through
generous spending of one’s substance on those who are near and less fortunate; and
recognizing an external accountability for our actions. Thus, faith, rituals, and
spirituality must manifest themselves in humanity and service to it; it is about
returning us to our natural disposition of a pure heart (fitrah), about doing the
work that supports human dignity and the well-being of others (Mustansir p 38).
As we can clearly see from the above verse, spending on those in need, reaching
out to our fellow human beings who find themselves outside the margins of society is
highly commended, and in some cases is an obligation upon Muslims to intervene, to
give and spend for Allah’s sake in order to alleviate hardship.
The Qur’an also discusses the concept of charity in depth so that all Muslims are
engaged with this act of nobility. “You shall not attain righteousness until you spend
out of what is dear to you. Allah knows whatever you spend” (Qur’an 3:92).
The Prophet Mohammad said, “Allah said, ‘O son of Adam! Spend, and I shall
spend on you” (Bukhari).
Social and Community Welfare
Soon after the death of the Prophet Mohammed, during the time of the second Caliph
Omar, the Islamic state extended beyond the Arabian Peninsula and Zakat money
started to come in large amounts. After consulting the companions, Omar established
the first financial institution known as Bayt al-mal, an Arabic term that is translated
as House of Money or House of Wealth. The institution’s main responsibility is to
administer Zakat revenues for the social welfare of the Islamic society.
In today’s world, the concept of Bayt al-mal is no longer in existence as most
Muslim states are following the global Western financial system. Therefore, Zakat is
no longer paid to the state. The majority of Muslims pay their Zakat independently.
As a result, charitable organizations and welfare associations became an integral
part of Islamic societies across the Muslim world. There are several charitable
organizations and projects that depends on Zakat funds to manage their activities
in serving the poor and the disadvantaged according to Islamic traditions. From
building hospitals and schools to digging wells and farming projects.
In Egypt, despite the state restrictions, several Islamic medical clinics and social/
educational institutions are becoming widespread and well embedded across the
country. Islamic medical clinics are one of the most successful independent Islamic
welfare activities in the region. These activities are mainly supported and sustained
by Zakat funds, managed locally and often operating from the basement of mosques
and in the neighboring area. They address the socioeconomic needs of the commu-
nity within an Islamic framework. They are accessible to everyone regardless of their
faith, social class, or political orientation. They also provide an alternative service to
the inadequate government services and the expensive private institutions.
Children’s Cancer Hospital in Cairo, also known as 57,357 hospital which was
opened in 2007, is one of the largest pediatric oncology hospitals in the world.
57,357 is the bank account number for donations. The project was funded entirely by
Egyptian citizens through donations. One reason that the project was successful is
that The Grand Mufti in Egypt urged all Egyptians and Muslims around the world to
pay their Zakat towards the 57,357 Hospital project.
Some writers such as Alain Roussillon argued that these social welfare Islamic
institutions are used as “missionarism” to spread Islamic ideology (Clark 2004).
Whereas Janine A. Clark, the author of “Islam Charity and Activism” argued that as
a Western Christian who lived in Cairo for few years and visited the Islamic medical
clinics on several occasions that was not her experience. She states; “I had visited
when I was ill. As a Christian, I had not observed ‘adherence to Islam’ to be a
criterion for entry, nor had I witnessed the provision of health care to the poor only.
While there were certainly patients of what appear to be of all socioeconomic classes
at the clinic. I had not witnessed a predominance of poor patients” (Clark 2004).
The other initiative that is sustained by donations mainly from Zakat fund is the
Egyptian Food Bank (EFB). The EFB was granted government authorization from
Dar al iftaa to collect Zakat and donations. The monthly feeding program provides
essential basic food to families in need including single mothers, elderly people,
building kitchens in schools, School meals, and Iftar Sa’em (feeding the fasting).
According to EFB, number of families benefited from the monthly feeding program
are as follows:
Year Number of families supported by feeding program

2014 240,000
2015 250,000
2016 240,000
2017 240,000
Taken from: https://www.egyptianfoodbank.com/en/feeding-programs
Homeless
However, Allah describes a certain category of people who demonstrated the

concept of selfless act in relation to social obligations and fulfilling the needs of
others.
“And also those who were settled in al-Madinah and adopted the faith before
them. They love those who emigrated to them and find not any grudging in their
hearts of what the emigrants were given but give them preference over themselves,
even though they are in privation” (Qur’an 59:9). The above verse refers to the
concept of altruism at the time when the homeless muhajiroon (term referring to the
emigrants were the first to embrace Islam in Mecca and emigrated to Medinah as a
result of persecution) arrived to Medinah with nothing except what they were
wearing. The Ansar (term referring to the residents of Medinah who embraced
886 N. Amraoui
Islam and gave refuge to the prophet and his followers the Muhajirun into their home
when they escaped persecution in Mecca) shared their wealth and property with the
Muhajirun and hosted them indefinitely. Moreover, they did this noble act for the
sake of Allah and the love of brotherhood while seeking nothing else other than
Allah’s pleasure. One migrant testified to the Prophet Mohammad of the remarkable
hospitality of the Ansar in the following statement; Imam Ahmad recorded that Anas
said; The Muhajirun said, “O Allah’s messenger! We have never met people like
those who we emigrated to, comforting us in times of scarcity and giving us with a
good heart in times of abundance. They have sufficed for us and shared their wealth
with us so much so that we feared that they might earn the whole reward instead of
us. The prophet said, No they won’t, as long as you thank them for what they did and
invoke Allah for them” (Ibn Hisham p 267).
The virtuous quality of the believers is to give to others even when they
themselves are in desperate need. This quality was beautifully demonstrated in the
actions of the companions of the Prophet, as can be seen from the account of the
emigrant. The Ansar preferred giving to the needy and the homeless rather than
attending to their own needs, and began by giving to the people before their own
selves, even though they too were in desperate need. This is of a higher virtue than
those who give wealth, in spite of their love for it, but are not necessarily in dire need
themselves, because the Prophet Mohammad said in an authentic hadith: “The best
charity is that given when one is in need and struggling” (Bukhari).
It is worthwhile to ponder; how can the believers give to others even though they
are themselves needy? And the answer to that is, by complete reliance on Allah and
extreme love for other human beings. This act of disinterested selflessness for the
well-being of others is regarded as one of the highest acts of piety and righteousness,
known as ihsan excellence.
Imprisonment
“And they give food, in spite of love for it, to the needy, the orphan, and the captive”
(Qur’an 76;8,9).
This verse provides us with a clear instruction on the way Muslims should deal
with prisoners. Very clear instructions urging the believers to feed the captive while
seeking nothing else other than God’s pleasure. According to the above verse, there
is no distinction between prisoners, orphans, and the poor as they are all in the state
of a desperate need of assistance. The Prophet Mohammad is said to have ordered his
companions to subsist on dry dates, while reserving their bread for his prisoners. It
was also a frequent practice of his to provide prisoners in need with clothing.
Soon after the battle of Badr, the Qur’an started to develop a humane policy
dealing with prisoners of war. It decreed that they must be treated humanely with
dignity and must be either released or returned for ransom. If there were no ransom,
they would then be allowed to work in order to buy their own freedom. Should their
captors wish to grant them their freedom, the captors are praised for their virtuous
and charitable acts. The Prophet Mohammad insisted on his companions to treat their
captives humanely. He said; “You must feed them as you feed yourselves, and clothe
them as you clothe yourselves, and if you should set them on a hard task, you must
help them in it yourselves” (Armstrong, p. 180).
When the Prophet Mohammad returned from the battle of Badr, he had with him
his own two captives from Quraysh. He could not sleep during that night as he was
thinking about his captives lying miserably and uncomfortably in captivity and gave
the order for their freedom. This act of fairness and kindness paid off. Some of the
prisoners were impressed by his conduct, which led them to embrace Islam.
Conclusion
“Those who spend their wealth in the cause of Allah, and do not follow up their
charity with reminders of their generosity or with injury, their reward is with their
Lord. On them shall be no fear, nor shall they grieve. Kind words and forgiving of
faults are better than Sadaqah (charity) followed by injury. And Allah is Rich and He
is Most Forbearing” (Qur’an 2;262). We should not, of course, expect any return or
favors from those who receive our sadaqah. Neither should we expect that they will
be grateful and kind to us and give us something in return nor should we be
motivated by a worldly reward. Concerning our attitude to charity for His sake,
Allah reminds us: “O you who believe, make not your charity worthless by
reminders of your generosity, and by causing vexation” (Qur’an 2: 264). Our
sadaqah should be qard hasan, a loan given for the sake of Allah without any
expectation of any kind of profit or return.
Sadaqah or charity is very highly recommended as an act of worship. Extreme
love for worldly possessions and miserliness are considered as a disease of the heart,
while the purpose of sadaqah is to act as its antidote or cure for this spiritual disease.
Sadaqah and zakat strengthens the ties of love and mercy between the rich and poor
and serves as a form of prayer to remind us that all forms of wealth and belongings
come from Allah, and what we possess is simply a short-term loan for which we will
be held responsible and accountable. This loan, if we use it to help other fellow
human beings will undoubtedly give us in return happiness and tranquility of the
heart.
A generous person is close to Allah, close to Paradise, close to people, and far
from Hell. However, a miserly person is far from Allah, far from people, far from
Paradise, but close to Hell. The Prophet Mohammad said; “Allah loves more an
ignorant man who is generous than a worshipper who is miserly” (Tirmidhi).
Instead of hoping for some worldly reward from our sadaqah, we should be
thankful and grateful to those who accept it from us, for they have given us an
opportunity to invest our wealth in a business venture with Allah, who has promised
in return a reward seven hundred times greater. The Qur’an states; “The parable of
those who spend their wealth in the service of Allah is that of a grain, out of which
grow seven ears, in every ear hundred grains”. Qur’an 2: 261.
888 N. Amraoui
The Prophet Mohammad was the most generous person in his community, owing
to his unique sense of kindness, affection, and generosity, which attracted the hearts
of the people around him and brought them into Islam. His role model example was
the most important form of inviting people to Islam. Imam Bukhari has recorded that
the close Companion of the Prophet, Jabir, testified that he never witnessed the
Prophet refusing anyone who requested something from him. The Prophet
Mohammad has himself testified: “If I had a mountain of gold, I would not like to
save any of it for more than three days, except something I put aside to pay debts”
(Bukhari). The magnanimity of the blessed Prophet is the model exemplar – we must
strive to follow in his footsteps, especially in dealing and interacting with others.
The Prophet Mohammad illustrates in a long, beautiful profound hadeeth the
importance of giving charity to the needy in secret, when he states that one of the
seven types of people who will be under the shade on the Day of Judgement,
protected and honored on that day, is a man who gives charity in secret, such that
his left hand does not know what his right hand is spending (Bukhari).
Moreover, as I have mentioned earlier, one of the most distinguishing features of
any flourishing society is the mutual support, cooperation, and solidarity. It is, in a
way, a two-way achievement; in fulfilling our social duty towards the less privileged
members of the community through social solidarity and support, and achieving our
spiritual contentment in pleasing God through our actions of love and compassion.
Whereas Bukhl or Miserliness, which is the contrary of generosity and kindness
leads to an unbalanced society, sleepless nights and depression. The miserly appear
rich but in reality, are actually poor. They possess wealth but cannot spend it on
themselves as they love hoarding. Miserliness is a disease resulting from fear of
poverty leading man to abandon his fitra, his obligations towards others, his good
morals, and spiritual commitments.
Finally, this wonderful, beautiful, and compassionate Hadeeth, which Muslims
share with the Christian teaching, strongly emphasizes the bond and spirit of
brotherhood, that service to others is a way forward in life that leads to happiness,
and how Allah is with those whose hearts are troubled, as is the case with the person
who is sick.
Allah the Exalted will say on the Day of Resurrection: O son of Adam, I was sick
but you did not visit me. He will say: O my Lord, how can I visit you when you are
the Lord of the worlds? Allah will say: Did you not know that my servant was sick
and you did not visit him, and had you visited him you would have found me with
him? O son of Adam, I asked you for food but you did not feed me. He will say: My
Lord, how can I feed you when you are the Lord of the worlds? Allah will say: Did
you not know that my servant asked you for food but you did not feed him, and had
you fed him, you would have found me with him? O son of Adam, I asked you for
drink but you did not provide for me. He will say: My Lord, how can I give you drink
when you are the Lord of the worlds? Allah will say: My servant asked you for a
drink but you did not provide for him, and had you given it to him, you would have
found me with him. (Imam Muslim).
References
Armstrong K (2001) Muhammad. A biography of the Prophet. Phoenix Press Phoenix
Clark JA (2004) Islam, charity, and activism. Middle-class networks and social welfare in Egypt,
Jordan, and Yemen. Indiana University Press, Bloomington
https://www.egyptianfoodbank.com/en/feeding-programs. http://www.egyptianfoodbank.com/en/
school-feeding-kitchen
Ibn Hisham (2003) Sirat Ibn Hisham. Almaktabah Al-asriyah. Sayda, Beirut
Imam Al-Bukhari translated by Dr. Muhammad Matraji 1995. Sahih Al-Bukhari, New Delhi
Imam Muslim. Translated by Abd-al-Hamid Siddiqui 2009. https://d1.islamhouse.com/data/en/ih_
books/single/en_Sahih_Muslim.pdf
Mir M (2016) Understanding the Islamic scripture. Routledge, London and New York
Part V
Obesity and Systems Biology
Health Promotion for Preventing Obesity
in the Arab Gulf States 38
Anastasia Samara, Pernille T. Andersen, and Arja R. Aro
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 896
Common Vision/Actions in the Eastern Mediterranean Countries and the Gulf States . . . . . . . 897
Political Declaration of the High-Level Meeting of the General Assembly on the
Prevention and Control of Noncommunicable Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 897
Eastern Mediterranean Region and Prevention and Control of Noncommunicable
Diseases/Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 898
Health Ministers’ Council for the Gulf States . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 899
Arab Taskforce for Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 899
Food-Based Nutritional Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 900
Food Labeling for the Gulf States and Trans Fat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 900
Kingdom of Saudi Arabia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 901
General Organization of the Healthcare System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 901
Agencies/Departments Involved in Health Promotion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 903
Overview of National Plans and Health Promotion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 906
Healthcare Strategic Plan 2011–2020 and Health Promotion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 907
National Strategy for Diet and Physical Activity 2014–2025 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 907
Health Education and Health Promotion Professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 908
Examples of Specific Interventions and Initiatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 909
Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 910
Main Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 910
Current Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 912
Kuwait . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 912
A. Samara (*) · P. T. Andersen · A. R. Aro

Unit for Health Promotion Research, University of Southern Denmark, Esbjerg, Jutland, Denmark
e-mail: anastasia.samara@outlook.com; asamara@health.sdu.dk; ptandersen@health.sdu.dk;
araro@health.sdu.dk

https://doi.org/10.1007/978-3-030-36811-1_37
894 A. Samara et al.
National Health Development Plan 2010–2014 and Health Promotion . . . . . . . . . . . . . . . . . . . . 914

National Framework for Youth Empowerment and Mainstreaming . . . . . . . . . . . . . . . . . . . . . . . . 915
Strategies and Visions for Nutrition and Physical Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 916
Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 919
Main Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 919
Bahrain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 921
National Health Strategies and Health Promotion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 925
National Plan of Action for Nutrition in Bahrain (1995) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 926
Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 928
Main Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 930
Qatar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 931
National Nutrition and PA Action Plan 2011–2016 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 938
Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 942
Main Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 944
United Arab Emirates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 945
Overview of Abu Dhabi and Dubai Plans and Health Promotion . . . . . . . . . . . . . . . . . . . . . . . . . . 958
Overview of Strategies on Nutrition and Physical Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 959
Example of Specific Interventions and Initiatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 960
Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 960
Main Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 961
Oman . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 962
National Nutrition Strategy 2014–2050 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 970
Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 973
Main Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 974
Summary and Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 975
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 986
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 986
38 Health Promotion for Preventing Obesity in the Arab Gulf States 895
Abstract
This chapter focuses on the Health Promotion (HP) initiatives to combat obesity
in the Gulf States, a part of the Arab world that is particularly affected by a rapid
shift to Westernization with junk food and physical inactivity being prevalent in
the society. Here we explore the overall health and Health Promotion strategies
and the policies and regulations in relation to nutrition and physical activity. The
chapter discusses actions beyond prevention strategies and awareness/informa-
tion campaigns as well as the role of primary healthcare in Health Promotion. We
also describe the available departments/units of Public Health and Health Pro-
motion within the various Ministries of Health, as well as their roles and respon-
sibilities. Other governmental organizations that contribute significantly to
promoting physical activity are also considered. Finally, the availability of the
workforce needed to achieve Health Promotion in the Gulf States is discussed,
particularly since health promoters/educators is a new field in these countries. It is
apparent that there are variations in Health Promotion in different Gulf States,
with some states being more advanced than others. The many challenges associ-
ated with prevention strategies in the Gulf region make it crucial for continuous
sustainable development, capacity building, and increasing implementation of
Health Promotion policies, systems, and efforts.
Keywords
Arabs · Obesity · Health policy · Health Promotion · Nutrition policy · Primary
care
Abbreviations
ADEC Abu Dhabi Education Council
ADFCA Abu Dhabi Food Control Authority
ADM Abu Dhabi Municipality
CBIs Community-based initiatives
CCS Country Cooperation Strategy
DHA Dubai Health Authority
DM Dubai Municipality
EMRO Eastern Mediterranean Region Office
GAYSW General Authority for Youth and Sports Welfare
GCC Gulf Cooperation Council
HAAD Health Authority-Abu Dhabi
HC Healthy Cities
HE Health education
HiAP Health in All Policies
HIS Health Improvement Strategy
HMC Hamad Medical Corporation
HP Health promotion
HPS Health-promoting schools

HS Health Strategy
MOE Ministry of Education
MOH Ministry of Health
MOHP Ministry of Health and Prevention
MOPH Ministry of Public Health
NCDs Noncommunicable diseases
ND Nutrition Department
NDS National Development Strategy
NGOs Nongovernmental organizations
NHA National Health Authority
NHS National Health Strategy
NNS National Nutrition Strategy
NU Nutrition Unit
PA Physical Activity
PAYS Public Authority for Youth and Sport
PE Physical Education
PH Public Health
PHC Primary Healthcare
PHCC Primary Healthcare Corporation
PHD Public Health Directorate
QOC Qatar Olympic Committee
SCH Supreme Council for Health
SEC Supreme Education Council
Introduction
Obesity and diabetes are tremendous health challenges particularly in the Gulf
States, which are the Kingdom of Saudi Arabia (KSA), Bahrain, Kuwait, Qatar,
United Arab Emirates (UAE), and Oman, and their prevalence continues to increase.
According to a meta-analysis in 2014 for the Gulf States, diabetes ranged from 5.9%
in UAE to 32.1% in KSA. The prevalence of diabetes in KSA had increased
threefold within 20 years (10.6% in 1989 to 32.1% in 2009) (Alharbi et al. 2014).
Prevention strategies often target the individual, who then assumes full respon-
sibility for their health status (Petersen and Lupton 1996). However, there are
broader factors and determinants that influence an individual’s habits, behaviors,
and lifestyle. In the case of the Gulf States, one of the main reasons for the rise of
obesity is the rapid Westernization of the society especially in terms of food
consumption and lack of physical activity (PA) (Musaiger et al. 2012). Therefore,
the spread of the obesity epidemic worldwide and in particular the Gulf region
requires a structured health promotion (HP) framework rather than the current
approaches of individually assessing and addressing one’s risk.
HP goes beyond prevention and relies on creating environments and conditions

that support and promote health for the whole population. HP includes but also goes
beyond health education (HE) (mostly in the form of awareness) which is the main
tool used for disease prevention. Moreover, HP is defined as the combined work of
HE (that promotes empowerment through knowledge) and healthy public policy. In
addition, it prioritizes equality heavily when it comes to health (Green et al. 2015).
Healthy public policy is “characterized by an explicit concern for health and equity
in all areas of policy and an accountability for health impact” (WHO 1988).
According to the Ottawa Charter (WHO 1986) developed at the first International
Conference of HP in 1986, there are five key action areas that are central to HP:
1. Build healthy public policy.

2. Create supportive environments.
3. Strengthen community actions.
4. Develop personal skills.
5. Reorient health services.
As an overall statement, HP underlines the importance of (1) empowerment of the

individual through developing various cognitive and behavioral skills (Marmot
2006), (2) active participating communities (WHO 1997), (3) policies supporting
healthy life and easy choices, and (4) Health in All Policies (HiAP) for cross-
governmental action (WHO 2013b). As defined by WHO: “Health in All Policies
is an approach to public policies across sectors that systematically takes into account
the health implications of decisions, seeks synergies, and avoids harmful health
impacts in order to improve population health and health equity. It improves
accountability of policymakers for health impacts at all levels of policy-making”
(WHO 2013b).
This chapter discusses current initiatives, strategies, and policies underway in the
Gulf States for promoting a healthier life through nutrition and PA. For the following
work, we relied on publically available resources and did not contact policy-makers,
stakeholders, or government agents. The work was updated for the summer of 2017.
Common Vision/Actions in the Eastern Mediterranean Countries

and the Gulf States
Political Declaration of the High-Level Meeting of the General

Assembly on the Prevention and Control of Noncommunicable
Diseases
In 2011, the General Assembly of the United Nations adopted the Political Decla-
ration of the High-level Meeting on the Prevention and Control of Non-
communicable Diseases (NCDs) (UN 2011). The declaration reaffirmed the
importance of implementing the strategies suggested by the World Health
Organization (WHO) in the 2008–2013 Action Plan for the Global Strategy for the
Prevention and Control of NCDs (WHO 2008) as well as in the Global Strategy on
Diet, PA, and Health (WHO 2004). The declaration also welcomed the first Minis-
terial Conference on healthy lifestyles and NCD control that occurred a few months
prior to the declaration (WHO 2011a).
This declaration underlined the importance of engaging the totality of govern-
mental and societal efforts, intersectoral strategies as well as the significance of
health-promoting strategies. Obesity was acknowledged as a high priority as it is
closely associated to NCDs. There was also recognition of significant inequalities in
disease and in access to prevention and control. Moreover, HP-related approaches
and principles were encouraged: (1) HiAP including sectors such as education,
energy, agriculture, transportation, etc.; (2) a supportive environment for healthier
choices; (3) participation of different segments of the society such as academia,
media, private sector, and industry and inclusion of families and communities;
(4) empowerment of the individual through public policies; (5) HE and health
literacy; (6) workplace HP; (7) access to primary healthcare (PHC) for achieving
health services for all; and (8) community capacity building (strengthening the skills,
competencies, and abilities of people and communities). Health literacy is “the
degree to which an individual has the capacity to obtain, process and understand
basic health information and services needed to make appropriate health decisions”
(Ratzan and Parker 2000).
Eastern Mediterranean Region and Prevention and Control

of Noncommunicable Diseases/Nutrition
A plan of action was developed for the Eastern Mediterranean Region Office
(EMRO) in 2011 and was based on the principles of the 2008–2013 Action Plan
for the Global Strategy for the Prevention and Control of NCDs (WHO EMRO
2011). Some important actions related to HP presented in this action plan were
(1) policies to promote health beyond health policies (intersectoral approaches);
(2) equity in terms of exposure to risk and access to care; (3) reorientation of the
healthcare system by emphasizing PHC; (4) development of interventions involving
different sectors, community mobilization, urban planning, etc.; (5) development of
guidelines such as food-based dietary and PA guidelines; and (6) ensuring proper
food labeling, etc. Similarly, in 2010, a framework with a HP direction was devel-
oped for the region in order to implement the WHO Global Strategy on Diet, PA, and
Health (WHO EMRO 2010a).
A regional strategy on nutrition for the period 2010–2019 was also developed and
was the first nutrition strategy developed in the region (WHO EMRO 2010b). The
strategy discussed challenges related to NCDs but also to malnutrition, an issue
facing many Eastern Mediterranean countries. Main targets of this strategy were for
all countries to develop a National Nutrition Strategy (NNS) and plan of action, as
well as a nutrition surveillance system. The approaches regarding NCDs included
(1) nutrition awareness through education, improved food labeling, and food-based
dietary guidelines, (2) shift education of the PHC professionals toward nutrition and
healthy lifestyle, and (3) enhanced nutrition and PA policies through school policies
and transportation policies. However, the strategy did not suggest specific actions
and programs.
Health Ministers’ Council for the Gulf States
Specifically for the Gulf States, the Health Ministers’ Council and its Executive
Board is the official governmental body that supports and encourages improved
coordination of health sectors in the Gulf States. Moreover, during a conference
in 2003, the council established a dedicated and specialized department on
NCDs and in 2004 approved the creation of a Gulf committee for NCDs. It is
noteworthy that all Gulf programs on NCDs are under the umbrella of HP and
lifestyle, and in 2007, a workshop discussing HP was held. Thus, recommenda-
tions involved community initiatives and development of regulations that pro-
mote healthy diet and PA, as well as enabling a global strategy for diet, PA, and
health through health programs. At the same time, the focus remained on
prevention and fighting NCDs and their risk factors more than promoting health
(Gulf Health Council n.d.-a).
As for the PHC, in the Qatar Declaration in 2008, the Gulf States agreed to
commit to HP through making PHC an integrative part not only of preventing and
educating but also of promoting health, through participating actively in community
and supporting health for all citizens (Gulf Health Council n.d.-b).
Finally, the council has been concerned about the health of schoolchildren since
1982. A Gulf School Health Committee exists, and Gulf States were encouraged to
create links between the Ministry of Health (MOH) and the Ministry of Education
(MOE). In a meeting of the committee in 2002 in Dubai, the importance of
collaboration among the Gulf States and the importance of healthy diet and PA in
schools were highlighted. The health-promoting school (HPS) initiative developed
by WHO was also suggested for the Gulf States, and efforts were made to implement
the initiative in all states during a meeting of the committee in 2004 in Abu Dhabi
and also during the first Gulf Conference on School Health in Oman in 2007 (Gulf
Health Council n.d.-c).
Arab Taskforce for Obesity
A strategy to combat obesity and promote PA was developed by the Arab Taskforce
for Obesity and PA and was presented during the third Arab Conference on Obesity
and PA in 2010 (Musaiger et al. 2011). The creation of the taskforce was suggested
during the first Arab Conference on Obesity and PA in 2002 (Musaiger 2007). The
strategy of the taskforce covered 5 years and was approved by all 14 participating
Arab countries. The strategy suggested the establishment of national committees
(e.g., Abu Dhabi established such a committee in 2016, as discussed below) for
undertaking the task of improving nutritional habits and increasing PA in the

population.
The strategy involved a comprehensive set of objectives and actions needed to
achieve the above. Moreover, it tackled important areas such as school and work-
place, food manufacturing and food preparation and service institutions, media,
public benefit organizations, PHC, and secondary healthcare. It discussed the impor-
tance of creating appropriate policies, collaborations between the government and
private sector, and shifting PHC toward a service with greater health-promoting
elements.
The strategy went beyond creating guidelines and increasing awareness (which is
lacking in Arab countries) to capacity building, creating supporting environments
through policies and local participation, etc. In addition, the taskforce strategy was
distributed to different governmental and private agencies; future developments
involved the support from the taskforce on different countries.
It should be noted that the follow-up of the strategy lacked a schedule to be
followed by the participating countries. This, together with the lack of a report
stating the specific actions to be taken by each country, makes it challenging to
evaluate the impact of the strategy, even if there are actions that were inspired by it.
Food-Based Nutritional Guidelines
The Arab Center of Nutrition is an NGO and has been a partner and initiator of the
Arab Taskforce for Obesity and the food-based nutritional guidelines. The Arab
Center provides support on nutritional education and has developed several pro-
grams and initiatives on nutrition awareness, for example, in primary schools in the
Arab region (“Food for Life”) and in KSA (“Al Haraka Baraka”) (Arab Center for
Nutrition n.d.-a).
Food-based nutritional guidelines were developed for the Gulf States as a result
from the efforts of the University of Bahrain, Qatar University, and King Saud
University of KSA (Musaiger et al. 2012). Food-based guidelines have the advan-
tage of being more informative for the public compared to nutritional guidelines
because they translate nutrient needs (e.g., amount of calcium/day) into food items
(e.g., number of servings to cover the daily needs for calcium). They are easier to
adopt, require less nutritional knowledge, and can give direct guidance on local
products, thus adjusting to the local food culture.
Moreover, these guidelines were the continuation of an initial effort (a booklet)
created for and distributed to the public known as the Food Dome (Arab Center for
Nutrition n.d.-b).
Food Labeling for the Gulf States and Trans Fat
In 2014, the European Food Information Council published an update on nutrition

labeling for prepackaged goods from other countries. The Gulf States have a
mandatory requirement for the nutrient contents of food to be stated, but there is no
obligation for labeling of the nutritional value (e.g., calories, amounts of fat, sugar,
salt, etc.) or health claims (e.g., low in cholesterol) on the label, even though it is a
significant part of information for the consumers (European Food Information
Council 2016).
In addition, the Gulf Cooperation Council (GCC) has approved food labeling
standards for the amount of trans and saturated fats in all food that are either
imported or locally produced (WHO EMRO 2015). However, as discussed later, it
is left to each country to individually adopt and implement this policy.
Companies in the Gulf States that are under the International Food and Beverage
Alliance would ban trans fat in their products in 2018 (Trade Arabia 2016). How-
ever, further actions are needed to ban trans fats from all food produced/imported in
the Gulf States.
Kingdom of Saudi Arabia
General Organization of the Healthcare System
The total population, surface area, and percentage of expatriates for KSA are shown
in Table 1 (General Authority for Statistics KSA 2016, 2017). The country is
composed of 13 regions (emirates), and each emirate has a number of governorates
(118 in total). The Riyadh and Makkah regions have the largest populations (~7
million inhabitants each) followed by the Eastern Region (~4 million inhabitants).
The Eastern Region is the biggest in size, followed by the Riyadh region. Other
regions have as little as 0.5 million inhabitants (such as the Northern Border, Hail
and Al Jouf regions in the north, and Najran and Al-Baha regions in the south)
(census year 2010) (General Authority for Statistics KSA 2010).
According to the WHO, the Saudi healthcare system ranks 26th in a list of
100 countries and is higher than some developed countries such as the USA,
Denmark, Finland, and New Zealand (WHO 2010b). This is considered a success
based on the large geographic expanse of KSA. At the same time, the country faces
challenges due to the rapid epidemiological transition to chronic diseases. The
prevalence of overweight and obesity for males/females is presented in Table 1
(WHO 2014b).
In KSA, the healthcare system is centralized, but decentralization is a part of the
country’s vision for the future. This requires substantial management training at the
subnational and local levels according to the Country Cooperation Strategy (CCS)
for KSA (WHO 2013d). It also requires financial independence at the regional level,
which is not yet in place. The MOH supervises 20 regional health directorates. Each
directorate is responsible for a number of hospitals and health sectors and each health
sector for a number of PHC centers. The directorates are responsible for
implementing the plans and policies of the MOH, managing and supporting MOH
health services, etc. (Almalki et al. 2011).
Table 1 General characteristics of the Gulf States

United
Arab
KSA Kuwait Bahrain Qatar Emirates Oman
Population 32,612,641 4,132,415 1,423,726 2,700,539 9,121,167 4,634,812
(2017) (2016) (2016) (2017) (2016) (2017)
Surface area 2,149,690 17,188 774 11,628 77,700 309,500
(square km)
Percentage of 37% (2017) 70% (2016) 52% (2014) Not available 89% (2010) 46% (2017)
expatriates
Obesity 28% 32% 25% 34% 28% 23%
prevalence
(males) 2014
Obesity 41% 44% 37% 45% 41% 34%
prevalence
(females)
2014
Overweight 66% 73% 65% 72% 68% 61%
and obesity
prevalence
(males) 2014
Overweight 71% 74% 69% 75% 72% 66%
and obesity
prevalence
(females)
2014
An important body in the Saudi healthcare system is the Council of Health

Services (established in 2002) whose aim is to coordinate the MOH with other
governmental agencies and the private sector (ARAMCO hospitals, National Guard
Health Affairs, Armed Forces Medical Services, etc.) (Almalki et al. 2011; Saudi
Health Council n.d.).
Moreover, service provision in KSA is based on the PHC strategy and the use of a
referral system. The PHC (established in 1980) is the gatekeeper for the referrals to
general and specialized hospitals. There are 2325 PHC centers reported for 2016 that
provide general, child, maternal, preventive care, and school health services (Gen-
eral Authority for Statistics KSA 2016). A small number of diabetic clinics exist
(20 in 2011) and other services include awareness campaigns and early detection of
NCD risk factors that are not systematic (MOH KSA 2012c). Mental care is also part
of their services (WHO 2013d).
Services are free of charge for nationals and expatriates working within the public
sector. All other expatriates have private insurance schemes and do not have access
to public PHC and hospitals. Saudi nationals who work in the private sector also
have to have a private health insurance (WHO 2013d).
Accessibility to health services is of concern due to variations in distribution of
health services and health professionals in different areas. Some population groups
such as adolescents, elderly, and people with disabilities are also underserved,
especially in rural areas. There are also difficulties of accessing healthcare for people
living in border regions and remote areas (Almalki et al. 2011).
Agencies/Departments Involved in Health Promotion
Figure 1a shows the organizational structure of departments in the MOH that are
related to HP. There are two main departments in the MOH with important roles in
HP: the Nutrition General Department (MOH KSA n.d.-d) and the Health Programs
General Department (MOH KSA n.d.-a). A newly founded department is the
Awareness and Health Promotion General Department, and there is also a School
Health General Department (MOH KSA n.d.-c). We are not aware of the activities of
both these departments in relation to HP for nutrition and physical activity.
Nutrition General Department

The Nutrition General Department has a responsibility in educating professionals as
well as the public through awareness campaigns and nutrition programs (MOH KSA
n.d.-d). During 2012, when food-based dietary guidelines were published by the
Gulf States, KSA created its own set of dietary guidelines “The Healthy Food Palm”
initiated by the Nutrition General Department (General Directorate of Nutrition,
KSA 2012). The number of servings recommended is the same as in the Gulf
guidelines, with the exception of the meat/legumes category in which the Saudi
guidelines suggest 2–3 servings/day instead of the meat/legumes/nuts category of
the Gulf States recommending 2–4 servings/day. There are some differences in terms
of the quantity that each serving represents (for meat = 60–90 gr for Saudi Palm and
50–80 gr for Gulf guidelines). Finally, both guidelines also include recommenda-
tions for 30–60 min of PA daily.
The Saudi guidelines were created to serve as an educational tool for health
professionals and nutritionists and also for guiding the public. It was advised that
these guidelines are (1) circulated in all official agencies, (2) printed and given to
Saudi families, (3) spread using mass media, (4) included in awareness campaigns
and HE efforts in the community and in healthcare places, and (5) included in school
curricula.
While the distribution plans for these guidelines as educational material are
promising, there also are some important challenges, including a need for
intersectoral collaboration and willingness to promote the material; further, dissem-
ination requires a deeper level of education of the population on eating habits and
food as many are unaware of the category to place foods they regularly consume (the
guidelines only give examples). Other concerns are increasing in understanding of
measuring units (cup, spoon, etc.) and serving sizes usually found in dietary
guidelines.
These concerns are common to creating guidelines in all countries and require a
dedicated effort to implement successfully. To our knowledge, there is no report/
document related to the dissemination and implementation of these guidelines
in KSA.
Health Programs Department

There were two major programs that had been developed under the Health Pro-
grams Department as shown in Fig. 1a: the Diet and PA Program and the Obesity
a
Ministry of
Tax on soft drinks
Finance
General
Presidency for
Youth Welfare
MOE PE Program
Agency for Assistant Agency

Nutrition General
Therapeutic for Supportive
Department
Services Medical Services
Awareness and
MOH HP General
Department
School Health
Assistant Agency
Agency of PH General
for PHC
Department
Diet and PA
Program
Health Programs
General
Department
Obesity Control
Program
b
Department of
Ministry of Youth National Nutrition
Research and Studies
Affairs Surveillance Program
of Nutrition
Department of Food
and Nutrition
PAYS
Management and
Control
Department of
Nutrition and Feeding
Assistant
Division of Outpatient
MOH Undersecretary Undersecretary for
Clinics in PHC Centers
PH
Department of PH
Department of
Nutrition Awareness
of the Community
c
MOE HPS Program
Assistant
Undersecretary
of PHC Adolescent and
Nutrition Section Adult Nutrition
Unit
MOH HP Directorate
Assistant NCDs Unit
Undersecretary Undersecretary
of PH
PH Directorate
School Health
nurse group Youth and
Adolescent
Health Program
School Section
School HP
Program
Prevention and
PHC group Surveillance
Program
HPS Program
Fig. 1 (a) KSA agencies/departments involved in health promotion for nutrition and physical
activity. PH public health, PHC primary healthcare, HP health promotion, PA physical activity, PE
physical education, MOE Ministry of Education, MOH Ministry of Health. (b) Kuwait agencies/
Control Program. The first one was established in 2006, with the aim to follow the
recommendations for the Global Strategy on Diet, PA, and Health developed by
WHO, so formalizing the principles of HP (MOH KSA n.d.-e). The major
objectives of the program were to raise health awareness, to enact legislation
related to health, to create health through community partnership, and to create an
action plan for the National Strategy for Diet and Physical Activity 2014–2025 for
KSA (no detailed action plan exists). Activities of the program in line with the
National Strategy for Diet and Physical Activity 2014–2025 were mainly related
to (1) awareness through the creation of educational material for the public,
(2) early screening of chronic diseases (“Your Health Comes 1st” and “Change
Your Lifestyle” in 20 cities in the country where approximately 9400 people were
screened), (3) community activities such as marathons and walks (e.g., the
marathon for female students at the Princess Nourah Bint Abdulrahman Univer-
sity in 2014), (4) community contests to lose weight, (5) workshops on nutrition
and PA (around 1400 trainees), and (6) community seminars on nutrition and PA
(around 2980 trainees). Nevertheless, these activities do not reflect supportive
environments or encourage intersectoral work or community participation in
creating health which are main principles in HP.
The second program was introduced as a resolution of the MOH executive
council in 2013 and was created in affiliation with the agency for PHC (MOH
KSA n.d.-f). However, this program is only indirectly related to HP through its
educational aspect. Their objectives were the early detection of cases, prevention, and
management of obesity through improved health services as well as family involve-
ment and community participation. Major activities included educational material and
educating health professionals in PHC clinics (1.600 professionals) as well as creating
40 sites (schools, malls, etc.) in 20 cities for the early detection of obesity (around
10,000 participants screened and referred to PHC clinics for follow-up). However, the
early screening was not systematic or permanent.
A recent initiative of the program was the training of 295 healthcare staff and
health educators on obesity in the Eastern Region, as a preliminary step of a 4-year
joint initiative between the MOH and MOE to reduce obesity in schools in this
region (“Rashaqa” meaning agility) (MOH KSA news 2017a). This initiative would
include 1000 schools in 6 regions of KSA and target 6000 schools in 5 years (20% of
total in country). The aim was to increase awareness on obesity, improve food habits,
and increase PA for male and female schoolchildren (MOH KSA news 2017b).
However, the initiative did not provide specific information on actions/policies to
achieve this goal.
Fig. 1 (continued) departments involved in health promotion for nutrition and physical activity.
PAYS Public Authority for Youth and Sport, PH public health, MOH Ministry of Health. (c) Bahrain
agencies/departments involved in health promotion for nutrition and physical activity. PH public
health, HP health promotion, NCDs noncommunicable diseases, PHC primary healthcare, MOH
Ministry of Health, MOE Ministry of Education
Overview of National Plans and Health Promotion
The KSA Vision 2030 has three main themes of which the first, a vibrant society,
emphasizes living healthy lives and particularly promoting PA and sports through
creating more facilities and programs for the whole population. Improvement of
cities and increases in landscaped areas are also deemed important for recreational
activities in the community (Vision 2030 KSA n.d.-a).
In the National Transformation Program 2020, a program for achieving the goals
of the 2030 Vision of KSA, obesity is considered an important target for the MOH.
Additional targets of other ministries related to HP are (1) increasing the national
park area per capita from only 2.9sqm currently to 14.9sqm and increasing the
number of visitors to national parks (Ministry of Environment, Water and Agricul-
ture) and (2) promoting PA and sports especially for youth (General Presidency for
Youth Welfare). At the same time, there are no relevant initiatives from other entities
such as Ministry of Transportation, Ministry of Municipal and Rural Affairs, etc. For
the MOH, important priority areas were reforming the PHC and interventions to
combat obesity among others (Vision 2030 KSA n.d.-b). The General Presidency for
Youth Welfare also suggested initiatives such as extracurricular school sport pro-
grams such as summer clubs initiated by the MOE (Al-Ghamdi 2017), implemen-
tation of licensed women sports halls, creation of neighborhood clubs, development
of campaigns for awareness on PA, development of PE classes, etc. (Vision 2030
KSA n.d.-b). These initiatives were launched in 2016 but are still not in the spirit of
HiAP and do not show a strong intersectoral action for promoting health and
combating obesity.
In relation to nutrition, the MOH, the Ministry of Commerce and Industry, and the
Ministry of Finance have developed some regulations. The Ministry of Finance had
announced a tax of 50% for soft drinks. The decision (signed end of 2016) came after
a proposal for taxation at the GCC (December 2015) (‘Saudi says soft drinks’ 2017).
The tax was to be implemented in June 2017 (Deulgaonkar 2017b).
A new law was issued by the MOH through the Ministry of Commerce and
Industry to levy a fine to restaurants that offer soft drinks as reported in April 2016
(Saudi to fine restaurants serving soft drinks 2016). We are not aware if this law has
been implemented.
The Minister of Health decided to ban candies, soft drinks, and all sales of
“junk food” in hospitals in KSA, an action that was praised by the Gulf Health
Ministers’ Council (Rasooldeen 2016). It is unclear if the decision has been
implemented yet.
The Ninth National Development Plan 2010–2014 (5-year plans established
in 1970) did not include any goals related to HP or HiAP (WHO 2013d). The
Tenth National Development Plan 2015–2019 mentioned the standard of living
and good life (as part of its social development component), with one
action being PH awareness programs (‘Objectives of the Tenth Development
Plan’ n.d.).
Healthcare Strategic Plan 2011–2020 and Health Promotion
In the Healthcare Strategic Plan developed by the MOH, the reforming and improve-
ment of the PHC were extensively discussed. There are increasing numbers of PHC
centers, with improvements in infrastructure and activities, but there are also chal-
lenges such as the lack of early screening for chronic conditions and education
programs for the population at the PHC level.
Other actions and projects were to develop a HE and HP strategy. The strategy
gave details on specific actions/indicators for achieving the desired goals and
provided detailed timetables and allocation of funds as well as the organizational
structure to execute the strategy (MOH KSA 2012c). By indicators are meant
specific, pre-defined measurements of change and they are essential to the imple-
mentation and evaluation process of a health promotion project or program. Lack of
explicit indicators signifies a project that is not well designed or that does not have
specific targets or plan. To our knowledge, there are no reports on the implementa-
tion of the strategy.
The news section of the MOH provided some updates on advancements related to
HP: (1) new nutrition clinics at referential PHC centers for promoting healthier
eating through HE (MOH KSA news 2016) and (2) a National Strategy for the
Health of Youth and Adolescents (not known if implemented) (MOH KSA news
2012a).
National Strategy for Diet and Physical Activity 2014–2025
The National Strategy for Diet and PA for the years 2014–2025 considered HP as
a main goal (‘National diet and PA strategy’ n.d.). It is not clear if this strategy was
the intended HE and HP strategy mentioned in the Healthcare Strategic Plan
above. The objectives of the strategy included reducing the risk factors for
NCDs and increasing their surveillance, developing intersectoral collaboration
for health, enhancing human and organizational resources, and raising public
awareness on the significance of diet and PA. Particular attention focused on
children, adolescents, females, health workers, etc. The specific strategies aimed
at the national level, settings/supportive environments, policy level, and support-
ive programs.
At the national level, the following actions were proposed: (1) issuing laws/
legislations on nutrition and PA and coordination with other sectors, (2) creating a
committee under the MOH for executing and monitoring the strategy, and (3) creat-
ing and implementing an action plan through the Diet and PA Program.
At the policy level, the main focus was on (1) reducing advertisement directed to
children and reducing advertisement of beverages and fast-food products and
(2) educating the population on food labels and adding nutritional and health
information to food labels.
At the level of supportive programs, some important targets were (1) training of
health educators on diet and PA, (2) participation of media in educating the public on
diet and PA in an effective and continuous way, and (3) making health educators/
nutrition and PA specialists available in all PHC centers.
At the settings/supportive environment level, the suggestions were (1) taking
actions at schools such as information on diet and PA in the curriculum, PA pro-
grams, healthy food available in the canteens, using sports yards and halls after
school hours, and screening of children for obesity; (2) improving the workplace
environment through availability of healthy food in the canteens and making avail-
able small sports halls for PA and creating sports clubs in every ministry for the
employees; (3) developing workshops for educating mothers/children on healthy
cooking and healthy food options at home; and (4) providing information on
balanced diets and displaying information on fruits and vegetables in restaurants
and supermarket premises.
According to a report by WHO (WHO EMRO 2014), KSA had a policy man-
dating the inclusion of physical education (PE) for boys and girls. PE was so far
available for boys but with no gym classes and was the only course in the curriculum
differing by gender. PE for girls has been allowed since 2013 in private schools
(‘Physical exercise’ 2013). The MOE decided to launch a PE program for girls as
well from the academic year 2017 to 2018 with plans to introduce university degrees
in PE in the future (Al-Suraihi 2017). An early example was the Prince Muqrin Bin
Abdulaziz University in Madinah that offered sports classes for girls and women
already during the summer of 2017, with the intention to hold a further series of
sports programs. The university also intended to establish a sports academy to train
the trainers (Al-Sharqawi 2017).
The Shura Council rejected a proposal to create sport education colleges for
women (Al-Qahtani 2017). Saudi women can only have a diploma on sport educa-
tion from foreign universities, with the only exception so far being a major in PE for
women at Taif University (Muhammad 2017). This lack of female sport educators
hampers the introduction of PE for females in schools.
The strategy represented preliminary and generic plans on nutrition and PA that
were not detailed enough for a sustainable long-term solution with defined out-
comes. The strategy lacked detailed actions or a list of indicators such as percentage
of projects achieved, number of policies created/implemented, number of new parks,
places for PA, etc. with specific budgets and timelines.
Health Education and Health Promotion Professionals
There is a general shortage of health professionals in all areas as well as of highly

qualified health professionals, due to the high demands resulting from a fast eco-
nomic development and a large growth in the population. A large part of the
workforce comprises expatriates who eventually need to be replaced by Saudi
nationals, as part of the “Saudization process” (General Authority for Statistics
KSA 2016). In addition, the size of the country as well as the existence of remote/
isolated areas makes the coverage of these areas by health professionals challenging.
This problem is addressed as a main issue in the Healthcare Strategic Plan
2011–2020 (MOH KSA 2012c). The ratios of physicians and nurses to the popula-
tion in KSA are 16 and 36, respectively, per 10,000 population, which is lower than
in other Gulf States such as Bahrain (30 and 58 per 10,000) and Kuwait (18 and
37 per 10,000) (Almalki et al. 2011).
HE is a very important component of HP, and KSA currently lacks enough
properly trained staff to benefit from this approach (Al-Hashem 2016). The MOH
is responsible for coordinating/funding HE programs but also for training health
professionals in HE. Health educators are not a stand-alone professional category in
KSA (such as allied health professionals in other countries). A major challenge is the
greater distribution of HE programs for professionals and the public in large cities,
resulting in neglect of more rural areas. Another concern is that HE programs in the
PHC clinics are not theory-based, due in large part to poor/no training of health
educators or due to other health professionals assuming the role of health educators.
This shortage in HE/HP professionals represents a major challenge for HP activities
in the population.
The Charitable Society for Health Communication was established in 2006 and
was the first HE association. In 2013, the National Committee for HE was founded in
Riyadh under the Ministry of Information and Culture. There are currently a total of
69 health associations in KSA tasked with working on health awareness for pro-
fessionals and the public (Al-Hashem 2016).
There are currently two universities offering bachelor’s degrees in HE/HP: the
College of Applied Medical Sciences of King Saud University was the first to offer a
degree in HE that is also available for females, and more recently, the College of
Health and Rehabilitation Sciences of Princess Nourah Bint Abdulrahman Univer-
sity also offers a degree in HE and HP; the program was initiated in collaboration
with the University of Southern Denmark (Princess Nourah Bint Abdulrahman
University KSA n.d.; University of Southern Denmark n.d.).
Examples of Specific Interventions and Initiatives
Ministerial committees to develop intersectoral action and achieve HiAP do exist for
KSA (WHO 2013d). However, the principle of HiAP is not yet an integral part of the
strategies in the country and very few, mostly local, examples of effective
intersectoral work exist, such as the Healthy Cities (HC) Project, which was
established in 1999 by WHO and the MOH of KSA and involved (1) HE, (2) active
citizen participation, (3) participation of institutions such as universities, and
(4) development of supportive environments (MOH KSA n.d.-b). One example
was in the city of Abha (population around 200.00 in 2011) in the southern
mountainous region of KSA between 2007 and 2011 (WHO 2011b), where a PA
program in the city was the creation of a safe walking track with water supplies,
benches, and green areas through collaborations between the directorates of Health,
Agriculture, Water, and Electricity and the Governorate. The city committee
included the local city council, the private sector, education, agriculture, etc., in
order to achieve strong and coordinated change for the community. The track was
increasingly used by the citizens.
Another intersectoral effort was the urban design/urban planning of Wadi Hanifa
in Riyadh (WHO EMRO 2014). Wadi Hanifa is a valley spanning over 100 km in
Riyadh that started by restoring the natural environment and that later allowed the
community to enjoy the area through a recreational area available for PA.
A whole-of-school program to promote PA called “Al Haraka Baraka” (“in
movement there is blessing”) was implemented in primary schools in Riyadh for
2 years as an initiative of King Saud University and in collaboration with the Arab
Center of Nutrition. The program was designed to enhance HE for teachers and
children as well as the children’s families through educational audiovisual material
(WHO EMRO n.d.-a). The material was given during regular HE classes, and all
parties benefited from the added knowledge. Unfortunately, there was no support to
continue the program after the period of intervention of 4–6 weeks, in spite of the
interest in HP in school programs. This was an isolated program that did not have
multilevel interventions such as extracurricular activities, walking to and from
school, etc.
Even though there are no national policies regarding workplace HP, Saudi
ARAMCO is an example of a company supporting employee well-being through
creating small fitness centers for its firefighters (Razavi and Kirsten 2012).
Implementation
Figure 2 shows the main intended actions of the national strategies/plans related to
HP.
A follow-up report summarizing the advancements of the National Healthcare
Strategic Plan 2011–2020 is not available. It is unclear which parts of this reform
initiative are being implemented and to what degree of success. Some aspects of the
National Diet and PA Strategy 2014–2025 have been implemented through the Diet
and PA Program and with the introduction of PE for all in schools in 2017 by the
MOE. This strategy is a long-term proposal with no specific action plan, and its
success will be known in the future.
Main Results
KSA is both the largest in size and population of countries in the Gulf States and has
achieved significant advancements in health in some areas (e.g., eradicating infec-
tious diseases, infant and maternal mortality) but continues to have a high prevalence
of NCDs (MOH KSA news 2012b). Due to an increasing population, rapid lifestyle
changes, and geographical considerations (many isolated/remote areas), there is a
need to redesign and enhance its health services.
38
Healthcare Strategic Plan 2011-2020

-Develop a HE and HP strategy
-Develop a national Strategy for the health of Youth and Adolescents
KSA Vision 2030 HP

-Promote PA and sports especially for youth (PE in
schools, extra-curricular activities, implementation of
licenced women sports halls, PA in the community etc)
-Built environment and parks
National Strategy for Diet and PA 2014-2025

- Promote HE on nutrition and PA through awareness campaigns
- Reduce advertisement on junk food and soft drinks
- Improve food labelling (nutritional information)
-PE in schools
- Provide healthy food in school canteens
- Develop workplace health promotion
- Develop HE on nutrition in restaurants and supermarkets
Health Promotion for Preventing Obesity in the Arab Gulf States
Fig. 2 Activities/actions related to HP intended by KSA strategies/plans (in colored bold appear the actions that were implemented). PE physical education, PA
physical activity, HE health education, HP health promotion
911
Reform of the Saudi health system is underway, with the aim of an integrated and
comprehensive healthcare system in the future and which places the PHC centers as
centerpieces with clear referral systems. Training of additional health professionals
at all levels is also a task facing KSA. However, there is no clearly defined strategy
that describes the actions for achieving greater numbers of locally trained health
educators/health promoters. A National Strategy for Diet and PA is in place, but an
action plan needs to be developed with targeted actions for settings, policies, and
intersectoral work.
It is clear that the country recognizes the importance of HP and has a new
department in the MOH. The Minister of Health recently announced that the MOH
is “seeking to become a health promoting entity” and not an entity that only provides
health services (MOH KSA news 2017c). However, there is a lack of a well-
articulated national HP plan and little intersectoral work.
Current Challenges
The healthcare system in KSA faces some important challenges:

First is the need to fully implement reforms without much further delays, while at
the same time focusing on HP and HE. The former task is constrained by the need for
coordinated efforts related to improvements in infrastructure, quality of services,
training of professionals, a meaningful referral system and a transport system for
patients, especially in rural areas, etc. Therefore, work on HP is an additional,
heavy task.
A second important challenge is the lack of locally trained health educators/health
promoters and also a plan for ensuring a sustainable effort by creating a self-
sufficient overall health workforce throughout the country.
A third factor to consider is the absence of intersectoral work in order to achieve
HiAP for supporting HP. One example for this would be a joint effort between MOH
and MOE for health-promoting activities in schools.
Kuwait
The total population, surface area, and percentage of expatriates for Kuwait (Central
Statistics Bureau Kuwait 2015, 2016) are shown in Table 1. Kuwait is divided into
six governorates, and population is mostly located in urban areas in and around
Kuwait City (WHO 2014a). The Kuwaiti citizens enjoy a high standard of
healthcare, where everyone has access to local health services (WHO 2014a). The
country has a similar burden of diseases as in highly developed countries, with the
main health concern being NCDs (WHO, Kuwait 2014a). The prevalence of over-
weight and obesity for males/females is presented in Table 1 (WHO 2014b).
The healthcare system in Kuwait is decentralized into six health regions, with
each region being financially and administratively independent, in addition to
regulating its own management of training personnel and health delivery. Each
region has a number of PHC centers (92 PHC centers in total reported in 2014)
and one general hospital (WHO 2014a). The PHC is a cornerstone of the healthcare
system in Kuwait, with three levels of health delivery: primary, secondary, and
tertiary care (available in general hospitals and specialized hospitals/clinics). Efforts
are underway to establish the PHC as the exclusive entry point for healthcare needs.
The PHC centers include general, child, maternal, diabetic, and dental clinics and
offer preventive care and school health services and, more recently, also mental
health services (WHO 2014a).
Expatriates in Kuwait pay an annual fee of 48 Kuwaiti dinars and have access to
public PHC and hospitals. However, due to the large number of expatriates in the
country, there would be some significant changes that would include increasing the
fee to 133 Kuwait dinars and the creation of three hospitals and 15 PHC centers for
use only by expatriates. This independent healthcare system for expatriates would
occur in two phases, with the first phase starting in 2017 in PHC centers (‘Health
insurance for expats’ 2016).
The MOH website provides information on the available departments/administration

(MOH Kuwait n.d.-a). Figure 1b shows the different departments related to HP for
nutrition and PA.
The mandate of the Department of PH in relation to HP is the development of
awareness campaigns on nutrition and PA to fight obesity (MOH Kuwait n.d.-b). The
Nutrition Department (ND) and Feeding includes the following departments that
contribute to HP: (1) Department of Food and Nutrition Management and Control,
(2) Division of Outpatient Clinics in PHC Centers, and (3) Department of Nutrition
Awareness of the Community. The first department has a managerial role and is
responsible for the development and implementation of policies and programs on
nutrition for HP and also participates in developing health awareness on nutrition in
the community. The division supervises the work of the external nutrition clinics
available in PHC centers and monitors the promotion of nutrition in the community
through awareness programs. Finally, the third department has as a main role to
develop nutritional awareness programs in the population. In addition, the Depart-
ment of Research and Studies of Nutrition is responsible for the National Nutrition
Surveillance Program (MOH Kuwait n.d.-c).
Kuwait has established a nutrition surveillance system that regularly monitors
nutrition, PA, and obesity levels of Kuwaiti nationals (AlSumaie 2011). This project
was initiated in 2001 with the support of WHO and is funded by the MOH Kuwait. A
national survey is performed annually, and reports are published and disseminated to
relevant agencies. The project serves to inform interventions and policy choices
based on the health status of the population. However, efforts are required for
achieving a unified health information system that connects different sources of

health information and statistics in the country (WHO 2014a). Kuwait is currently
the only country among the Gulf States with a systematic surveillance system on
obesity, nutrition, and PA.
The Kuwait long-term strategy for 2035 had five objectives, of which the third was
related to human development and included the development of healthcare. To
achieve these long-term goals, a 5-year strategy had been developed, and important
actions related to PHC were included in the 2010–2014 plan; however, they did not
have elements on HP (General Secretary for Supreme Council for Planning and
Development Kuwait n.d.).
A new Development Plan for 2015–2020 was created to improve and enhance the
actions according to the 2035 Vision of Kuwait (General Secretary for Supreme
Council for Planning and Development Kuwait 2015). The plan for 2015–2020
contained a stated policy on HP: “Encourage many good practices (sports, health
food, early screening and periodic screening, etc.).” The Development Plan
2015–2020 was more focused, with specific projects related to the vision of each
sector. The plan included seven pillars, one of which was healthcare with an
emphasis focus to decrease the prevalence of diabetes and other related health
conditions. Among proposed actions were improving regulations targeting
unhealthy food. Specific projects related to HP included (1) building more public
sports centers/facilities (Public Authority for Youth and Sport (PAYS)), (2) greater
public participation through increased awareness on PA and building sports arenas
(PAYS), (3) HC initiative with a plan to build five HC with the support of the WHO,
and (4) sports support in schools, colleges, and universities (PAYS). These projects
were suggested by the MOH and have been approved by the General Secretary for
Planning and Development as being relevant to the objectives of the
Development Plan.
There are no reports on the advancement of these projects as these efforts will
continue to 2020. As for regulations targeting unhealthy food, Kuwait has subsidized
healthy oils (sunflower oil, canola oil, olive oil, etc.), therefore discouraging the use
of unhealthy oils (palm oil, coconut oil, etc.) (WHO EMRO 2015). The MOH of
Kuwait has also reduced the salt consumption in the population by 30% and has
recently made agreements with the Kuwait Flour Mills and Bakeries Company to
reduce the salt content in bread by 20% (Qudaih 2017).
National Health Development Plan 2010–2014 and Health

Promotion
The National Health Development Plan developed by the MOH for 2010–2014
included among others programs on nutrition and obesity prevention (no more detail
is given), whereas programs for PA were not developed. According to the WHO
report, progress was made in relation to NCDs but a report on the achievements of
the plan is unavailable. Important targets for the National Health Development Plan
for 2010–2014 related to HP were (1) revisiting and updating health legislation,
(2) human resource development including training of health promoters, and
(3) community HP (WHO 2014a). To our knowledge, there is no report on the
2010–2014 Health Plan.
National Framework for Youth Empowerment and Mainstreaming
A National Framework for Youth Empowerment and Mainstreaming targeting youth

development and well-being was created in the same year that the Ministry of Youth
Affairs was established (Jamjoom 2013). The framework discussed challenges and
possibilities such as (1) creating PHC centers with health prevention/promotion
aimed specifically at youth; (2) increasing the number of gyms/clubs, especially in
rural areas; (3) updating and increasing relevance of youth centers to make them
more appealing to youth (the existing centers only attracting 2% of youth); and
(4) involving different sectors to improve the well-being of the youth. The “Kuwait
Listens” was a National Youth Project aimed to partner with youth and incorporate
their needs, ideas, and visions.
The operational objectives of the framework related to HP were the following:
(1) create environments that support healthy choices (awareness on healthy lifestyle
through media, enhancing community healthcare through the family unit, providing
support to young populations at risk); (2) support participation in sporting and
leisure activities (raise awareness and interest in sporting and leisure activities,
enhance school facilities, include sports in a national campaign, create opportunities
for sports for the young); and (3) create more facilities for sports, walking, etc.
As part of this framework, the Health Empowerment Youth Association launched
a national awareness campaign on childhood obesity in 2014 (Bhacker and Mehrtash
2014). The initiative was supported by the MOH and the Ministry of Youth Affairs
(other participants included social marketing agencies, a nonprofit organization, and
other relevant parties from the public/private sector) and was founded on a solid
methodology. The awareness campaign proposed a 1-year period for awareness and
planning, allowing for additional stakeholders to also be engaged, and a subsequent
2–5-year phase of intervention that included 6 months mini campaigns for specific
target interventions (such as sugary beverages). The intervention would not only
have an educational but also a facilitating/empowering role with strategies such as
providing incentives to schools for stocking water and healthy food and drink
alternatives. In addition, the campaign would also target the general public through
effective educational materials such as visual and social media that go beyond
leaflets and brochures. As pointed out by researchers in relation to mass media and
awareness campaigns, the intensity of a campaign, working with opinion leaders, the
use of different voices to promote the campaign, and also the use of multicomponent
media (printed material, mass media, and interpersonal interactions) are very
important for the impact of a campaign (Aldoory and Bonzo 2005). Although this
was an intersectoral approach based on solid methodology, results on the evaluation
of the campaign or the implementation of other objectives of the framework are not
known.
Strategies and Visions for Nutrition and Physical Activity
National Program for Healthy Living 2013–2017

The aim of the National Program for Healthy Living: First 5-Year Plan for
2013–2017 was to reduce the prevalence of obesity, inactivity, and high-calorie
intake through HP activities in people of different ages and various segments of the
population (Behbehani 2014). The plan was published by the Dasman Diabetes
Institute in 2014, with preparations starting in 2010 through consultations with the
media, supermarket cooperatives, malls, universities, schools, workplace, and peo-
ple in places of worship. Stakeholders from the MOH, the MOE, the Ministry of
Commerce, the Ministry of Information, the Ministry of Public Works, the Ministry
of Labor and Social Affairs, the Kuwait Institute for Scientific Research (Kuwait
Institute for Scientific Research n.d.), NGOs, the Public Authority of Youth and
Sports, the PA society, private school councils, private gym facilities, etc. were all
part of the plan. In addition, representatives of the population were also part of the
process, providing an example of empowerment of the individual and the commu-
nity through participatory approaches in HP.
The main actions related to HP and social support (which is important for
developing HP in the community) considered for the elderly were to (1) educate
the elderly on PA, supplements, and nutrition, (2) encourage the elderly to participate
in social activities, and (3) educate the population on the health of elderly through the
use of media, conferences, seminars, etc. Actions proposed in the workplace were
(1) policy advice/guidelines to organizations on overweight/obesity; (2) increasing
employee awareness on obesity, diet, and PA; (3) skill building/environmental
support for employees; and (4) a healthy workplace policy. Some actions were
also suggested for schools: (1) introduce information on obesity/nutrition/PA in
the curriculum, (2) evaluate the nutritional value of food served in schools, and
(3) provide healthy food options at schools.
To the best of our knowledge, PE in schools in Kuwait is available for both
genders, with optional participation by children (Behbehani 2014). The Municipality
of Kuwait in collaboration with the MOH and MOE had banned selling soft drinks in
school canteens in 2004 but allowed sales of fresh fruit beverages and milk
containing no preservatives (Kuwait News Agency 2004). However, there was
evidence that unhealthy food practices (soft drinks, potato chips, chocolate, etc.)
were still common in Kuwaiti schools (‘Unhealthy food sold’ 2014), implying a lack
of governmental oversight ensuring implementation.
Shopping malls are often used as a venue for PA, particularly in warm countries
such as Kuwait. The action items related to PA in malls were to (1) create point-of-
decision prompts to encourage using stairs and walking instead of elevators,
(2) encourage the use of indoor spaces for walking, and (3) use the mall to provide
information on HE on nutrition and PA. Proposals for implementation at universities
were to (1) encourage practicing PA through the use of stairs and gymnasiums and
promote participating in sporting activities, (2) increase the variety of healthy food
options available on campus, and (3) develop awareness campaigns. Indicators
included changes in PA and food choices of the students on campus. Food cooper-
atives and supermarkets are available in each neighborhood, where suggested
actions were to (1) promote awareness campaigns on healthy living/healthy food
options, (2) promote advertisements of healthy food, and (3) promote improvements
in food labeling in terms of contents and nutritional value. Actions related to the
media included (1) regulating advertising on TV, radio, and street signs and (2) cre-
ating awareness campaigns on healthy living.
The program suggested the creation of a steering committee and taskforces;
setting timetables and training different professionals involved; measuring baseline
risk factors for obesity, behaviors, nutritional and PA habits, etc.; and evaluating the
current situation and readiness for the different projects. Another important aspect of
the program was the use of mostly short-term indicators to evaluate the impact of the
interventions and to test acceptability and willingness from the citizens. Using short-
term indicators is useful for monitoring a step-by-step evolution of the program (for
instance, comparing the use of stairs and elevators) or for evaluating how partici-
pants respond to interventions (for instance, number of elderly who participate in
social activities). Some of the suggested actions also seemed imprecise, such as
encouraging PA in the universities without specifying the actions to be taken. In
addition, many of the actions focused on providing information but not on changing
the environment.
Overall, this was an ambitious program both in scope and in delivery over 4 years.
The program would benefit from detailed documentation on the different phases,
actions, indicators, budget, etc., and a more complete account of the actions taken
and their outcomes.
National Physical Activity Plan

Kuwait has also developed a National PA Plan with a “top-down” approach, and the
first draft of the principles and background was published in 2010 (Ramadan et al.
2010). A significant event was the creation of the National PA Committee in March
2007, the members of which were MOH representatives and also NGOs, university
deans, PA specialists and physicians, media figures, and representatives of
governorates.
The objectives of the plan were to increase awareness of PA in the population; to
encourage community members to participate in PA by using existing facilities in the
country; to develop policies for schools/worksites and the built environment
(human-made surroundings, from buildings to parks) by supporting PA; to contrib-
ute to the monitoring and evaluation of activities of PA programs; to decrease the
levels of physical inactivity every year; and to build capacity through training
workshops. The plan underlined the use of media, multicultural activities, PA
education through the curriculum and through in and after school activities, and
multisite community programs. More specifically, the strategy proposed environ-

mental policies to promote walking spaces, the use of incentives for worksites to
establish PA programs, school policies, and the use of malls, cooperatives, beach-
fronts, desert camps, and dewaniyas (social gatherings) for promoting PA and
providing educational material for the public.
The plan incorporated multiple governmental and nongovernmental agencies,
which promoted a consensus on implementation, avoidance of duplication,
establishing an intersectoral approach, and creating commitment to the process.
Nevertheless, the plan as presented required details on the creation of a specific
plan/project and the outcomes resulting from their implementation. There is no
information available on the implementation and outcomes of this plan.
Kuwait relies heavily on migrant workers in the healthcare system, with the
“Kuwaitization” policy leading to them to be eventually replaced by nationals in
the long term. A comprehensive evaluation is needed on the assessment and man-
agement of human resources. There is also expertise needed in policy, strategy, and
plan development. Better qualified social workers and professionals which connect
PHC to the community are also needed (WHO 2014a).
There is also a great need to increase the number of trained professionals in
HE/HP. However, based on the mid-range Development Plan for 2015–2020, there
appears to be no specific plans to increase the number of health professionals or
trained health educators/health promoters (General Secretary for Supreme Council
for Planning and Development Kuwait 2015).
To the best of our knowledge, there is currently no HE/HP undergraduate or
postgraduate degree program offered in Kuwait. Kuwait University offers a bache-
lor’s degree in Health and Community Studies through the Faculty of PH (Health
Science Center Kuwait n.d.). The program focuses on PH, HP, and community
health assessment and also offers certificates for professionals trained on topics
such as HP, policy, biostatistics, etc.
Another effort underway is the “Exercise is Medicine” organization that was initi-
ated in the USA by the American College of Sports Medicine in order to promote PA
for secondary and tertiary care patients (Exercise is Medicine n.d.). The role of an
“Exercise is Medicine” national center is to connect healthcare with facilities that
promote PA (such as community activities, fitness centers); to support the education
of physicians in prescribing PA to patients and giving referrals to other health
professionals and fitness facilities; as well as to assist in the implementation of the
“Exercise is Medicine” national decisions. Kuwait had established a taskforce and is
at the initial stages of creating a national center at Kuwait University in collaboration
with the MOH (WHO 2014a; Exercise is Medicine 2015). This holistic approach
fosters HP and benefits healthy individuals and patients.
Implementation
HP. As it can be seen, very few actions have been implemented (at least published).
The most recent mid-range Development Plan for 2015–2020 discussed projects
on HP; however, the evolution of these plans is unclear since this plan has a long
timeline (to 2020). We are also unaware of the implementation/outcomes for the
Healthy Living Plan 2013–2017 and for the PA Plan as well as if a strategy for youth
has been created as a result of the National Framework for Youth Empowerment and
Mainstreaming.
Main Results
Kuwait is a relatively small country and has the advantage of a decentralized

healthcare system. However, there is great need to strengthen decision-making at
the local level (WHO 2014a). There are currently sophisticated surveillance systems
for nutrition and health information systems at different levels.
An important project for HP (PC Project) was initiated by the MOH for
2015–2020, but it is not clear if this project has been developed. There is a lack
of strategies on intersectoral approaches or the development of a HiAP approach
by the MOH. It is not clear whether the plans on nutrition and PA, which are not
detailed enough in terms of actions, timetables, resources, etc., are implemented;
further, there is no HP strategy for the country. While there is an interest in
improving PA and nutrition in schools, the workplace, and the community and
in developing related policies, these are not yet in place. Finally, significant effort
is still needed to increase the number of health educators/health promoters in the
country.
Current Challenges
Kuwait, as is the case also for KSA, faces the double burden of improving the
healthcare system in addition to supporting HP initiatives and programs. Kuwait has
a decentralized healthcare system, and its relatively small size allows for rapid
changes in the healthcare system to be made.
An area of particular need in Kuwait is in training sufficient numbers of health
professionals, especially in the areas of HE/HP; this will require significant invest-
ment. Having such professionals will guide the creation of sound policies and
strategies/plans in HP programs. As is also the case for to KSA, intersectoral work
is not yet part of the national healthcare plans in Kuwait.
920
National PA Plan (2010) Development Plan 2015-2020

-Increase awareness of PA in the population -Improve regulations to target unhealthy food
-Develop environmental policies to promote walking spaces -Promote PA through awareness campaigns, building sports arenas and
-Introduce PE in the curriculum public sports centers, support PA in schools, colleges and universities
-Create in and after school activities -Build 5 Healthy Cities
-Develop multi -site community programs for encouraging PA
-Provide incentives for worksites to establish PA programs
-Use of malls, cooperatives, beachfronts, desert camps for
promoting PA and providing educational material for the public
National Health Development Plan 2010-2014
HP -Develop programs on nutrition and obesity
-Provide training of health promoters
National Program for Healthy Living 2013-2017

-Educate the elderly on PA and nutrition
-Increase employee awareness on nutrition and PA
-Develop a healthy workplace policy National Framework for Youth Empowerment and
-Introduce information on nutrition and PA in the curriculum Mainstreaming (2013)
-Provide healthy food options at schools -Create PHC centers with HP activities aimed at youth
-Use of malls for walking and information on nutrition and PA -Increase number of gyms/clubs in rural areas
-Increase the variety of healthy food options in campus -Focus on intersectoral work to improve youth wellbeing
-Encourage practicing sports in the gymnasiums -Create environments that support healthy choices
-Promote awareness campaigns on healthy options in supermarkets
-Support participation in sports (raise awareness in sports, improve
-Promote advertisements of healthy food school facilities, create more facilites for sports and walking)
-Improve food labelling (nutritional information) -Develop a national awareness campaign on childhood obesity
-Create awareness campaigns on nutrition and PA through media
-Regulate advertising of food on media
Fig. 3 Activities/actions related to HP intended by Kuwait strategies/plans (in colored bold appear the actions that were implemented). PE physical education,
PA physical activity, HE health education, HP health promotion, PHC primary healthcare
A. Samara et al.
Bahrain
The total population, surface area, and percentage of expatriates for Bahrain are
shown in Table 1 (Open Data Portal Bahrain 2016). Large parts of the population
live in the capital region and neighboring governorates such as the Northern and the
part of the Muharraq governorate that borders the Capital governorate. The Capital,
Northern, and Muharraq governorates represent about 32% of the total surface area
of Bahrain (Open Data Portal Bahrain 2012).
The Bahraini population enjoys comprehensive health services, where patients
have 100% access and coverage at no cost (WHO 2013c). Bahrain has a high burden
of NCDs but has reduced infectious diseases and maternal/child mortality rates
(WHO 2013c). The prevalence of overweight and obesity for males/females is
presented in Table 1 (WHO 2014b).
Bahrain has eight governmental hospitals, and three hospitals are in the
Muharraq governorate, four in the Capital governorate, and one in the Southern
governorate. There are also a total of 28 PHC centers, of which 5 are in the
Muharraq governorate, 11 in the Capital governorate, 7 in the Northern gover-
norate, and 5 in the Southern governorate (Open Data Portal Bahrain 2014; MOH
Bahrain 2014).
The PHC is the cornerstone of healthcare in Bahrain and is the entry point to more
specialized care. Efforts are ongoing for maintaining the PHC as the gatekeeper of
healthcare. The PHC centers offer general, maternal, child, and dental care, with clinics
for the youth/adolescents, elderly, and diabetic patients (MOH Bahrain n.d.-d).
They also provide HP services through HE and collaborate with the MOE in providing
healthcare and HP activities in schools (MOH Bahrain n.d.-g).
Nationals in the public sector receive health services free of charge, but Bahrainis
working in private sectors need to be insured by their company. Expatriates
employed by the Bahrain government have access to governmental hospitals, but
those working in private sectors need to be insured by their employers at a cost of
72 Bahraini dinars/year (for 2017). Insurance fees are higher for expatriates com-
pared to nationals (‘Bahrain launches new medical plan’ 2015).
The Public Health Directorate (PHD) has a central role in PH-related matters and in
the overall well-being of the Bahraini population. The PHD and the PHC are mainly
responsible for disease prevention and HP in the country, and these two entities are a
priority for MOH. Among key functions of the directorate are HP, reducing inequal-
ities in health, community participation in health, creating and reinforcing health
policies, development and training of human resources in PH, and surveillance of the
health status of the population (PHD Bahrain 2016). There is also a HP Directorate,
but we are not aware of its specific roles and strategy (MOH Bahrain n.d.-h).
Figure 1c shows the organizational structure of departments related to obesity and

HP (MOH n.d.-e).
The Health Promotion Directorate

The HP Directorate has not been considered significantly in report/strategy/plan
documents. However, a number of activities have been initiated by this directorate.
The directorate initiated in January 2017 an activity in malls. Malls choosing to
participate were labeled as “health-promoting shopping malls” if eight criteria were
fulfilled or as “health-friendly shopping malls” if four criteria were fulfilled. The
criteria were to (1) provide a convenient place for breastfeeding, (2) monitor
smoking ban implementation, (3) provide options for healthy food in the restaurants,
(4) distribute a satisfaction questionnaire to the public about the project, (5) display
health messages through posters/screens, (6) implement two events/year related to
health, (7) provide containers for recycling, and (8) open the mall 1 h before the
official time for those who wish to exercise (walk, use the stairs, etc.) (MOH Bahrain
n.d.-a).
Other examples of HP projects by the HP Directorate published by the WHO
EMRO were (1) a mass media campaign initiated in 2012 (ongoing) (WHO EMRO
n.d.-g) and (2) promotion of PA in schools initiated in 2010 (ongoing) (WHO EMRO
n.d.-c). The first intervention targeted smoking, stress, diet, and PA for the whole
population but also for specific age groups and groups with specific needs and was
communicated through radio, newspapers, TV, as well as social media. Daily pro-
grams on nutrition and PA were broadcast on radio and TV as part of the program.
The Information Affairs Authority and the MOH funded the initiative and facilitated
collaboration between sectors.
The second program focused on PA in children and consisted of one equipment
mobile unit (bus) visiting each school. A health promoter also provided children and
parents with advice on PA, and the bus also visited parks and other public spaces.
This initiative was reported as successful (66 visits between 2010 and 2013) and
received positive feedback.
The Public Health Directorate

The NCD Unit under the PHD has a role in HP through national awareness
campaigns and is also responsible for the early detection of NCDs and evaluation
of risk factors in the population. According to the most recent report of the direc-
torate in 2014, the unit required further improvement in relation to HP: (1) enactment
of regulations and development of policies related to a healthy lifestyle, (2) imple-
mentation of awareness campaigns, (3) development of community initiatives for
early detection of NCDs, and (4) strengthening intra- and intersectoral collaboration.
The unit initiated 15 “Protect your Heart” campaigns in governmental sites for 2014
(4 for 2013, 14 for 2012, 5 for 2011, and 15 for 2010). It also initiated three
campaigns in 2014 in nongovernmental sites (nine for 2013 and four for 2012)
(PHD Bahrain 2016).
The Nutrition Section

The Nutrition Section of the Directorate supports HP through community nutritional
awareness including healthy food choices for all age groups. Key functions of the
section were to develop policies for promoting a healthier lifestyle, to establish
nutrition projects that address nutrition-related health problems, and to give lectures,
seminars, and develop educational material on nutrition. Goals of the section were to
integrate nutrition in all general health services and also to emphasize the role of the
individual in their own health (PHD Bahrain 2016). The idea that the individual is
mainly responsible for their health is known as “victim-blaming” and goes against
HP which considers that the environment has a major influence on the health of the
individual (Petersen and Lupton 1996).
Experts from the Nutrition Section suggested banning unhealthy food and soft
drinks in hospital canteens and vending machines in 2015. They also suggested
substituting such machines with ones that offer healthier options for patients and
medical staff (Trade Arabia 2015). It is unclear if the decision has been
implemented yet.
The Adolescent and Adult Nutrition Unit (NU) in the Nutrition Section had a
goal to improve the nutritional status of young and schoolchildren and adults, with
four programs connected to this goal: (1) evaluate the current list of food and
beverages in school canteens; (2) nutritional, PA, and weight surveillance of
schoolchildren (6–18 years old); (3) healthy food management in MOH canteens;
and (4) nutrition awareness programs and activities. There are some key perfor-
mance indicators mentioned in the programs, but they are very generic (PHD
Bahrain 2016).
According to the directorate’s 2014 report, achievements related to these pro-
grams included updated schools meal menus for suppliers and nutrition surveillance
but only for students aged 13–15 years. Nutrition awareness campaigns and produc-
tion of educational material were also performed during 2014 for workplaces,
schools, and health centers, but we are not aware of the evolution/implementation
phase of the programs on healthy food management of MOH canteens (PHD
Bahrain 2016).
The School Section

The vision of the School Section under the PHD included health awareness for
students and school employees and also for the surrounding community and the
parents, so creating a conducive environment for HP for children. Among its
objectives were (1) development of school health programs, (2) increase of health
awareness in schools, (3) strengthening of legislation on school health, (4) manage-
ment of human resources and school health services, (5) weight surveillance, and
(6) expansion and strengthening of HPS and adding other schools under their
umbrella. Important needs in the section were to strengthen the partnership with
media and to increase the number of personnel trained in school health (PHD
Bahrain 2016).
One of the clusters of the School Section was the PHC group. This group focused
on HP and included the School HP Program and the Prevention and Surveillance
Program. The first program involved actions such as competitions for the network of
HPS, a schools’ canteen project, and a health facilities project. The second program
included mandatory health evaluations for new students for early detection of risk
factors for NCDs, surveillance of children’s health, training and educational work-
shops on NCDs, and nutrition and PA for nurses and healthcare providers in schools.
Both these programs had some key indicators with the second program having more
specific indicators such as a documented annual health examination, number of
workshops provided for nurses, etc. (PHD Bahrain 2016).
Another cluster was the School Health nurse group which has a complementary
program to the School HP Program, as it offered school workshops and lectures on
nutrition, PA, and health for students and school staff and surveillance of the
anthropometric indices of the students including a health examination of school
employees. Part of this program included the training of nurses themselves (“train
the trainer”). Specific program dissemination/implementation indicators included the
percentage of employees benefiting from annual examinations, number of lectures
and workshops provided by nurses in schools, number of courses attended by school
nurses, etc. (PHD Bahrain 2016).
Finally, the Youth and Adolescent Health Program (established in 2012) sought to
establish a national health plan for youth, to implement legislation related to youth,
and to coordinate different sectors providing youth services. The program had
initiatives similar to those available to other school-age groups (e.g., awareness
campaigns on nutrition and PA, improvement of food in canteens, and inclusion of
PA in schools as a main subject) and also some additional components such as to
increase organized walking tracks/spaces in the community. Specific key indicators
were the number of organized tracks/spaces created, percentage of schools offering
healthy food in the canteens, etc. We are not aware whether these initiatives were
implemented (PHD Bahrain 2016).
Further to the above, the PHD report of 2014 described the achievements for the
different groups. These achievements included surveillance of health and weight of
students, follow-up with the HPS program, and HE activities on NCDs, nutrition,
and PA. No information was provided on other programs in relation to nutrition and
PA, including the training of healthcare providers and nurses (PHD Bahrain 2016).
Bahrain had developed the National Economic Vision 2030 in 2008, and since then a
National Development Strategy (NDS) was proposed every few years (2008–2014
and 2015–2018) to achieve the vision. The National Economic Vision 2030 had an
aim of “promoting and encouraging a healthy lifestyle” (Economic Development
Board Bahrain 2008).
A strategic priority of the NDS 2015–2018 was related to HP: (1) maintain a safe
and pleasant environment (access to public spaces, expansion of community parks
and recreation facilities in residential areas, street beautification with walking paths
and outside sitting areas). In addition, hosting cultural events and festivals, which are
a part of the priorities to maintain a safe and pleasant environment, can enhance
social bonds and create additional opportunities for awareness campaigns, social
activities, etc.
Another priority was healthcare, and the components related to HP were (1) con-
tinuation and expansion of health awareness campaigns especially in relation to
healthy life choices (including exercise), (2) increasing preventive programs through
screening for NCDs, and (3) directing the PHC toward preventive programs and
early screening of NCDs (Economic Development Board Bahrain n.d.).
National Health Strategies and Health Promotion
Health Strategy 2002–2010 and Strategic Directions

Two important health-related documents were released in Bahrain in 2002: the MOH
Strategic Directions and the National Health Strategy (NHS) – Framework for
Action 2002–2010. The first document had included many of the goals and recom-
mendations of the NHS. The Strategic Directions underlined the importance of
collaboration between sectors and with the community as well as of equality in
health as detailed in the section “Health Services Without Walls: A Community
Partnership for Health.” In these documents the important proposal for a “commu-
nity partnership for health” was also very crucial. The main focus in the MOH’s
philosophy was on HP (healthier communities and lifestyle-related programs) and
PHC (MOH Bahrain n.d.-f).
The NHS 2002–2010 had 12 strategic goals of which the first focused on NCD
prevention and management and the sixth and seventh on intersectoral work. The
first goal had as one of its aims to promote a healthy lifestyle through increased
awareness and collaboration with other sectors (MOH Bahrain n.d.-c). This strategy
document provided only the outlines of planned activities and the general outputs
expected.
Health Improvement Strategy 2011–2014

A health agenda for health improvement for 2011–2014 was published in 2012 by
the MOH with the aim of developing an improved healthcare sector. This Health
Improvement Strategy (HIS) was in line with the Economic Vision 2030 and also
with the NDS 2008–2014. The HIS specified some strategic objectives which
included actions related to HP. The first strategic objective was to sustain the
population’s health through HP and prevention, under the responsibility of the
Assistant Undersecretary for PH. Screening programs aimed at asymptomatic
patients, awareness of NCDs for health professionals and the public, and well-
being clinics to be established in every governorate were important actions aimed
at redirecting the PHC to prevention and HP (timeline 2011–2016) (MOH Bahrain
2012a). To our knowledge, screening programs are not yet in place and at least one
well-being clinic was created in 2012, with no information on the proposed
expansion to all six governorates (MOH Bahrain 2012b). Other actions under the
first objective included health policies such as fiscal policies encouraging the
consumption of healthy foods and policies for improving food labeling and also
controlling advertisement of unhealthy food especially for children and youth
(timeline 2011–2014). However, to our knowledge there is no published document
to date on the success of these policies. On the other hand, regulations on removal of
trans fat and decrease of salt content in prepared food products were submitted for
approval as reported in the 2014 report of the directorate of PH. Another important
action was to develop a national HP action plan (timeline 2011–2016) aimed to last
for 15 years, having specific programs and initiatives for supporting healthy life-
styles in the population (MOH Bahrain 2012a).
The fifth strategic objective was to enhance the MOH’s role in policy-making and
governance and to collaborate with different stakeholders for establishing HiAP.
Thus the MOH would be restructured to become the main governmental body
responsible for developing, implementing, and evaluating health policies (MOH
Bahrain 2012a).
Health Improvement Strategy 2015–2018

This document is the continuation of the HIS for 2011–2014 and discussed the
advancements of the same objectives as well as further work to be done. Unfortu-
nately, this document did not provide information on the advancements of the period
2011–2014 but rather mentioned that the HIS for 2015–2018 was the continuation of
efforts from 2011–2014. The initiatives remained to a large extent the same, with
some indicators added for each objective. However, the indicators for NCD preven-
tion and HP were long-term indicators such as prevalence of NCDs, mortality rates
due to NCDs, etc. For the first objective, which was to sustain the population’s health
through HP and prevention, the partners suggested were all governorates and the
municipal councils (important for tailored approaches and local leadership in pro-
jects), the General Organization for Youth and Sports, the MOE, the Private Health
Sector (important for participation of NGOs in community projects), the Ministry of
Social Development (to facilitate community participation in health), and the Infor-
mation Affairs Authority (to support awareness campaigns and educational pro-
grams) (MOH Bahrain n.d.-b). This was an important initiative to develop HiAP and
intersectoral action.
A National Health Plan was recently launched by the Supreme Council for Health
(SCH) for 2016–2025 (Bahrain News Agency 2017). The plan will continue in the
same direction as the NHS objectives and within the targets of the Economic Vision
2030. The Supreme Council was established in 2003; its members represent the
MOH, the Ministry of Finance, the Ministry of Interior, the private sector, etc., and
aimed to develop the plan and supervise its implementation.
National Plan of Action for Nutrition in Bahrain (1995)
In 1995, the NU published a National Plan of Action for Nutrition in Bahrain

(PHD Bahrain 1995) with the main objectives to promote educational activities on
nutrition and to develop nutrition policies for healthy living. The plan suggested
to formulate a national food and nutrition committee and to implement educa-
tional programs on nutrition in schools and also in the community with PHC as a
main actor. The plan did not sufficiently elaborate on specific strategies and
actions but remains significant in acknowledging the importance of policy and
education. Since then, the PHD has performed significant work in education on
nutrition and PA in schools especially through the HPS program. We were not able
to find subsequent national plans on nutrition, PA, and HP. This important issue
needs to be addressed in order to achieve unified and effective actions at the
national level.
According to the HIS 2015–2018, the government had reached its targeted levels of
“Bahrainization” (82%). However, these levels may not be insufficient especially
when it comes to the needs for some medical sub-specialties. At the same time,
Bahrain has highly qualified PH professionals (MOH Bahrain n.d.-b).
There is little discussion on whether there is a lack in health educators/health
promoters in Bahrain. The PHD 2014 report discussed the training of nurses and
other healthcare professionals in awareness in NCDs, obesity, nutrition, and
PA. However, there was no specific target for increasing their skills in HE/HP in
school programs (PHD Bahrain 2016).
The College of Health Sciences of the University of Bahrain offers a bachelor’s
degree in PH and a 1-year diploma in Community Health Nursing. The latter is the
only program that provides some training of nurses in HP/HE (University of Bahrain
n.d.). To our knowledge, there is no undergraduate or graduate degree in HP/HE
offered in Bahrain.
The HPS, which was developed by the WHO in 1995, has only been
implemented in Bahrain and Oman in the Gulf States. A main responsibility of
the HPS was to create healthier lifestyles in schools and the community. The
HPS had six strategies: (1) engagement of staff, students, parents, and commu-
nities, (2) creation of safe and healthy environments, (3) promotion of skills-
based HE, (4) provision of health services, (5) development of HP policies and
practices, and (6) focus on community health practices as an integral component
of HP (WHO n.d.-b).
A high-level joint committee between the MOH and MOE was developed in
2000, with the aim of creating a strategic plan for Bahrain. In 2002, the Bahrain
National School Health Program was developed with a focus on intersectoral
collaboration and HP. Key strategies of the MOE were (1) enhancing HE, (2) creating
healthy school environments, (3) promoting sports and recreation, (4) encouraging
community participation, and (5) promoting the health of workers. Key strategies at
the MOH were (1) training teachers, (2) providing resources, (3) evaluating the
programs, and (4) management and planning (MOH Bahrain 2003). The HPS
program was in line with the above strategies and started in 2004, in cooperation
with the GCC School Health Committee and the WHO EMRO. Initially, 11 schools
were selected in the Muharraq governorate for the 2004–2005 school year. The
program expanded to 50 schools in all 5 governorates for the 2005–2006 school year
(WHO EMRO 2007).
Meetings were held with community leaders to discuss the basic principles of
the program. A local planning process was then established, a school team was
created, and HP activities were developed. An action plan was also developed as
well as a mechanism for monitoring implementation and success. Some of the
factors contributing to a successful work in the HPS program included the
support by the GCC School Committee and the WHO EMRO, the strong
collaboration between MOH and MOE, as well as a developed school infra-
structure and the existence of health committees in all schools in Bahrain (WHO
EMRO 2007).
However, some important obstacles remained: (1) school administrators were
occupied with another national project (Future Schools Project, which does not focus
on health) that was supported by the government and (2) participation in the HPS
was not compulsory. These factors affected the implementation process of the
project, and this lack of implementation led to another strategy launched in 2007,
which also suggested school HP initiatives in all governmental schools (Whitman
and Aldinger 2009).
We are currently unable to report on the number of schools that have
implemented the HPS. It is clear that Bahrain has focused on school health for
many years, involving different sectors (MOH and MOE). However, based on the
2014 report of the PHD, which is not clear on school health work performed, it
seems that the HPS program needs further implementation efforts and expansion
and that there are no HP strategies/policies with clear directions to be
implemented in all governmental schools (canteens, PE, school environment,
etc.) (PHD Bahrain 2016).
Implementation
HP.
The HIS 2015–2018 did not report on specific advancements in HP. According to
the PHD report for 2014, some actions on policy have made progress (policy on trans
fat and decrease of salt content submitted) in addition to activities performed on
health in schools. Important initiatives such as the development of a long-term HP
strategy/action plan or the development of screening programs to asymptomatic
38
National Development Strategy 2015-2018

-Expand of community parks, walking paths and recreational
facilities in residential areas
-Develop health awareness campaigns on nutrition and PA
HP
Health Improvement Strategy 2011-2014
-Develop screening programs for asymptomatic patients
-Develop awareness work on nutrition and PA for health professionals,
nurses and school staff (workplace) and the population
-Create wellbeing clinics
-Develop fiscal policies for consumption of healthy food
-Improve food labeling
Health Improvement Strategy 2015-
-Control advertisement of unhealthy food
2018
-Multiple partners invited for achieving
-Impose salt reduction and removal of trans-fat use in prepared food products intersectorral work and HiAP for HP
-Develop a national HP action plan
-Develop HiAP and strengthen the policy-making role of the MOH
Fig. 4 Activities/actions related to HP intended by Bahrain strategies/plans (in colored bold appear the actions that were implemented). PHC primary
healthcare, HP health promotion, PA physical activity, HiAP Health in All Policies
929
patients have not yet been accomplished. The directorate’s report also listed goals
that have been successfully reached (school canteens, workplace HP, nutrition
surveillance for children).
Main Results
Bahrain is the smallest country in the Gulf States, both in size and population. The
country significantly reduced the prevalence of infectious disease and maternal/child
mortality. However, the burden of CVDs remains high in the country.
Unlike other GCC countries, there is no detailed CCS between WHO and Bahrain
but rather a short report for 2012–2016. One of the targets of WHO for Bahrain is to
strengthen the HP strategies for combatting NCDs (WHO 2013c).
HP and the importance of HiAP and intersectoral collaboration as well as the
involvement of the community were discussed in the health strategies of Bahrain
first released in 2002. These were also the priorities listed in the Vision 2030
document, and some actions toward this direction had been taken during the HIS
2015–2018. However, no strategy or action plan has been published on nutrition
and/or PA since 1995, and the suggested HP plan is yet to be created or published. A
HP Directorate also exists but with limited roles.
The PHC has contributed significantly in projects for nutrition and PA in schools
and also in educating the population through awareness work and has been involved
in the HPS program.
Concrete actions and advancements in HP in Bahrain were (1) collaboration
between the MOH and MOE to improve school health and the implementation of
the HPS; (2) the screening of children for nutrition, PA, and weight at schools and
updated school meal menus for suppliers; and (3) awareness work in the workplace
(health professionals, nurses, and school staff) and the whole population.
Current Challenges
An important challenge for Bahrain is to further develop its health-promoting

strategies for decreasing the burden of NCDs. A large part of the HP actions are
still at the level of awareness campaigns (even though they need continuation and
expansion), and this needs to lead to actions that change the environment, such as
increasing the numbers of walking tracks, parks, etc. The plans to screen the adult
population is yet to be developed, as is the case for creation of well-being clinics in
all governorates and the training of health professionals and nurses for school
programs related to health.
Significant efforts are still needed for school HP, health-promoting policies,
screening of the population, training of health educators/health promoters, increase
in HiAP actions, and more intersectoral work.
Qatar
Table 1 gives information on the total population, surface area, and percentage of
expatriates for Qatar (Ministry of Development Planning and Statistics Qatar 2016,
2017; WHO 2006). Qatar is divided into eight municipalities, and Doha Municipal-
ity has the biggest population and the smallest surface area. The second biggest in
population is the Al-Rayyan Municipality. The distribution of the population among
municipalities is not equal with Al-Shamal Municipality having as little as about
9.000 inhabitants. The highest population density is in the Doha Municipality and
around it (east part of the Al-Rayyan Municipality). In general, the east part of the
island is mostly populated (Census 2015) (Ministry of Development Planning and
Statistics Qatar 2016).
Qatar has a high quality of services offered to the population with a full coverage,
and there is a decrease in the incidence of communicable diseases but also a rise of
NCDs as in all other Gulf States (WHO 2006). The prevalence of overweight and
obesity for males/females is presented in Table 1 (WHO 2014b).
Qatar has 14 hospitals and specialized centers under the Hamad Medical Corpo-
ration (HMC) and 23 PHC centers under the Primary Healthcare Corporation
(PHCC) (in the North, Central, and West regions) (MOPH Qatar n.d.-d).
The PHC is the cornerstone of the healthcare system, and efforts are being made
for establishing it as the only entry point to the healthcare system. The PHC centers
provide general, maternal, child, and dental care, dietician and NCD clinics, mental
health, and HP services through HE. They are also involved in school health (PHCC
Qatar n.d.-b).
In Qatar, all nationals and nonnationals enjoy free healthcare in public hospitals
after they obtain a health card for which they pay a yearly fee of 100 Qatari riyals
(only nonnationals) (HMC n.d.).
According to the CCS report for WHO and Qatar for the period 2005–2009 (the
latest available), there was a lack of clarity on the roles and coordination of tasks
among the MOH, the HMC, and the Planning Council and also a weakness in
developing long-term policies/strategies for the healthcare system in the country
(WHO 2006).
In an effort to overcome the problem of coordination, the National Health
Authority (NHA) was established in 2005 with the aim to lead and guide the health
system reform in Qatar; this authority was foundational for developing a clear
direction of healthcare for the country. The NHA was appointed responsible for
supervising the PHC and also hospitals, whereas the HMC (established in 1982) was
ultimately responsible for clinical care. One of the main objectives of the NHA was
HP, and in that context, a HP Division was established under the PH Department.
The division comprised NCD and HE teams (NHA Qatar n.d.).
Figure 5a shows the organizational structure of departments involved in HP. The
HE Unit (which is currently under the Ministry of Public Health – MOPH) is
responsible for creating material, developing and supervising HE programs, partic-
ipating in media and health awareness campaigns, and training staff of different
disciplines in HE (MOPH Qatar n.d.-a).
One of the objectives of the NHA was to create an independent organization for
PHCC (NHA Qatar n.d.). The PHCC was established in 2012 and has health-
preventive and health-promoting activities (Fig. 5a) (PHCC Qatar n.d.-b).
a
'We are Healthy
SEC
Kids' Program
'Health at
QOC Worksites'
Program
'We are Healthy

Kids' Program
MOPH PH Department HP Division
National
Healthy Schools'
Program
Healthcare
PHCC
Clinics
HE Unit
b
DHA ADEC
Dubai
DSC
Abu ADSC
Dhabi Schools for Health
Program
HAAD PH Department
Weqaya Program
National Olympic
Committee
GAYSW
Healthcare Service
MOE
Nutrition Service
PHC Department
Assistant
Undersecretary for
Health Centers and
Clinics HE and HP
MOHP Department
Assistant
Undersecretary for
Health Policies PH Policies
Department
Fig. 5 (continued)
MOE HPS Program
OOC
Department for
School and HPS Program
University Health
Wilayat and local
governance
Department of HE
and Awareness
Programs
Directorate
General of PHC
The CBIs
CBI Programs
Department
Nutrition
Fig. 5 (a) Qatar agencies/departments involved in health promotion for nutrition and physical
activity. QOC Qatar Olympic Committee, MOPH Ministry of Public Health, PHCC Primary Health
Care Corporation, PH public health, HP health promotion, HE health education. (b) UAE agencies/
departments involved in health promotion for nutrition and physical activity. DSC Dubai Sports
Council, ADSC Abu Dhabi Sports Council, ADEC Abu Dhabi Education Council, DHA Dubai
Health Authority, HAAD Abu Dhabi Health Authority, GAYSW General Authority for Youth and
Sports Welfare, MOE Ministry of Education, MOHP Ministry of Health and Prevention, PH public
health, HE health education, HP health promotion, PHC primary healthcare. (c) Oman agencies/
departments involved in health promotion for nutrition and physical activity. OOC Oman Olympic
Committee, PHC primary healthcare, HE health education, CBIs community-based initiatives
The Qatar Olympic Committee (QOC) is a major actor for promoting sports for
all ages, through awareness campaigns and PA education, community activities, and
programs. The committee had also developed the “Schools Olympic Program”
(established in 2007 and ongoing) (Ministry of Development Planning and Statistics
2008) and works together with the MOE for promoting PA and sports in schools
through competition. Among the objectives of the program were (1) to create an
environment for PA for both genders, (2) to promote all sports at schools, (3) to
encourage the values and principles of the Olympic movement, (4) to make sure that
the highest possible number of students participated in sports, (5) to increase the
interest of the whole community in participating in sports, and (6) to support the
program with financial and human resources (QOC n.d.). The Schools Olympic
Program focuses on annual competitions among schools, and in that sense, it
encourages PA in schools, not directly through the school PE curriculum. This
program has achieved increased numbers of participation of students (age
5–18 years) for school competitions and has proven very successful in increasing
PA in schools and also developing a pool of talents in sports from young ages (Qatar
Fencing Federation n.d.; QOC n.d.).
Another interesting PA initiative for the whole population was the Al Dana Green
Run, a yearly event since 2005 that includes different categories of runners based on
age and skills. Around 5.000 participants of both genders joined the program funded
by the Doha Bank and the Qatar Olympic Committee (MOPH NHS news Qatar
2016a).
The National Vision for 2030 for Qatar, published in 2008, defined four pillars of
which the human development mentioned the improvement of the healthcare
system. The NDS 2011–2016 derived from the Vision 2030 for Qatar (Ministry of
Development Planning and Statistics 2008). The objectives for the healthcare
sector in relation to HP were to (1) shift PHC responsibility to more preventive
and health-promoting activities, (2) develop programs for prevention and early
detection of disease including obesity, and (3) develop a comprehensive nutrition
and PA program, e.g., establish HP in schools, establish wellness promotion in
the workplace, implement awareness campaigns through media on nutrition and
PA, develop policies to reduce fast-food consumption, and promote healthy
options at restaurants and retail outlets. Targets were (1) early detection/screen-
ing programs that would cover at least 50% of the targeted population and (2) a
nutrition and PA program that would lead to a decrease in the prevalence of
obesity by 3%. The above-described programs and actions reflect the National
Health Strategy 2011–2016 for Qatar (Ministry of Development Planning and
Statistics 2011).
The need for cross government collaboration was underlined in relation to
healthcare. One very important action showing an effort for intersectoral collabora-
tion and involvement of the community was the numerous agencies participating in
developing the strategy for healthcare: Ministry of Interior, Permanent Population
Committee, Supreme Council for Family Affairs, and all health-related agencies
such as the SCH, the HMC, the PHCC, etc. (Ministry of Development Planning and
Statistics 2011).
Under the social development pillar, the strategy discussed the promotion of
sports and PA in the community, especially for youth. The strategy had as objectives
to educate the population on sports and PA, to create and enhance existing facilities
that support sports and PA, and to enhance talent development programs. A national
sports curriculum project was suggested to be developed and implemented for
enhancing the existing PE curriculum (PE is compulsory in schools from kindergar-

ten to 12 years old and developed by the Supreme Education Council – SEC) and for
supporting the training of teachers and staff in sports and PA (Ministry of Develop-
ment Planning and Statistics 2011). The target for the PE curriculum in schools
included also activities for children with disabilities (Ministry of Development
Planning and Statistics 2011). This demonstrates an effort toward equity: “the
absence of avoidable, unfair, or remediable differences among groups of people,
whether those groups are defined socially, economically, demographically or geo-
graphically or by other means of stratification” which is a very important principle in
HP (WHO n.d.-a).
The QOC has shown interest in developing PA and sports in the society. Under
the social development pillar in the NDS 2011–2016, other main targets for sports
were a national sports and recreation facilities master plan and the Active Qatar
campaign (General Secretariat for Development Planning Qatar 2011). These targets
were part of the Sports Sector Strategy 2011–2016 developed by the QOC (2011).
There were three key aims in this strategy: (1) greater community participation in
sports and PA, (2) improved and integrated planning for community and elite sports
facilities, and (3) increased and improved sports talent development, management,
and performance.
The Active Qatar campaign developed by the QOC was launched in 2014 aiming
to support PA education, community activities, and programs. It would be followed
by targeted campaigns for specific groups of the population (large-scale mass media,
individual behavior change interventions, social support interventions through social
networks such as working environment) (QOC news 2014).
The national sports and recreation facilities master plan was an ambitious plan
that aimed to support the creation of new spaces (parks, bicycle, and walking lanes)
and facilitate their access as well as repurpose and update existing spaces such as
spaces in schools and in the community. Urban planning and adopting an
eco-friendly approach are parts of this master plan (QOC 2011).
The above plan set concrete objectives together with a timeline for different
actions that need to be accomplished by 2016. However, no information could be
found about the advancements of this strategy, in relation to the development of the
facilities master plan.
For promoting culture and sports, agencies such as the Supreme Education
Council (SEC), the SCH, the Supreme Council for Family Affairs, the QOC, the
Permanent Population Committee, etc. would be involved.
Moreover, a healthier urban living environment was another objective for the
strategy under the environmental development pillar, going also in the direction of
HiAP. Creation of green spaces especially in Doha was one very important project
with the target to establish three green space tree corridors in the city.
Agencies involved in the development of the projects for the environmental
development would be the Ministry of Environment, the Ministry of Municipality
and Urban Planning, the SCH, the Permanent Population Committee, the Public
Works Authority, etc.
“Caring for the Future” (2007)

The 2006 report of the WHO for Qatar (WHO 2006) had underlined the following
areas of development for HP: (1) coordination among agencies within the health
sector and (2) shifting the role of PHC toward more preventive and promoting
activities.
In 2007, the NHA published a 3-year strategic direction “Caring for the Future”
with the following goals related to HP: (1) building a healthy place to live and work
through programs such as in PH and (2) ensuring a healthy population – the wellness
model (create an independent institution to oversee PHC, build new wellness
centers) (NHA Qatar n.d.). Most of the objectives of the NDS 2011–2016 have
taken into account the challenges pointed out by WHO. Important improvements
have happened in the healthcare system such as the independent governance of the
PHC through the PHCC, but other areas need continuous work such as the shift of
the PHC toward HP.
National Health Strategy 2011–2016

The NHS 2011–2016 was an integral part of the NDS 2011–2016 and was based on
the SCH’s Qatar National Health Vision 2020: “Caring for the Future – Establishing
a Healthy, Vibrant Society.” This vision among others highlighted encouraging
healthy lifestyles and providing community-based PHC.
The NHS 2011–2016, developed and supervised by the MOPH, was a compre-
hensive strategy with specific projects, indicators, main actors involved, expected
outcomes, etc. The NHS 2011–2016 was an integral part of the NDS 2011–2016 (the
main objectives of the NHS have been adopted from the NDS section on healthcare
under the human development pillar) (MOPH Qatar n.d.-b).
For nutrition and PA (the duration of the program was 5 years), some main
objectives were (1) to develop HP programs in schools, (2) to develop workplace
HP programs (with a policy to enforce them in all government departments and
agencies), (3) to develop nutrition and PA awareness campaigns, (4) to develop and
implement policies to reduce fast-food consumption, (5) to develop and implement a
strategy to promote healthy food options (e.g., healthy options in fast-food menu),
and (6) to improve food labeling for providing better information on the healthy
aspects of the products. The main actor was the MOPH together with the SEC for
school HP, with the Ministry of Labor for workplace HP, and with the Ministry of
Municipality and Agriculture and the Ministry of Business and Trade for policies
of fast-food consumption and healthy food options. This is a great example of
intersectoral work.
Primary Health Care Corporation Strategy 2013–2018

In 2012, the PHCC was established as part of the NHS 2011–2016 to set the PHC as
the foundation for healthcare. In 2013 the PHCC developed the PHC Strategy for
2013–2018 (PHCC Qatar n.d.-c). The PHC Strategy had set HP as one of the main
services for the PHC centers. Important planned activities (five key components) in
relation to HP were (1) HP in the workplace (e.g., vending machines in PHCC would
stock only healthy food), (2) risk factor assessment for visiting patients in PHC
centers, (3) HE for visiting patients and families, (4) a health-promoting environment
for PHCC staff, and (5) PHCC work with community organizations to promote
health at the local level. The strategy also committed in introducing a yearly “health
check” (on diet, PA, blood pressure, and smoking) for those who would benefit.
Workplace health and wellness was an important target for the PHC Strategy, starting
with the government departments and agencies by developing healthy workplace
action plans. Moreover, the PHCC would work with sports clubs and societies to
encourage people to practice more sports and PA. The PHCC would also work with
the MOPH for developing yearly HP campaigns and disseminating HP messages to
the population through multiple media. In addition, an expansion of clinics for
weight management and nutrition was planned. Another very interesting initiative
would be the development of four community health centers that aimed to provide
the following additionally to a regular healthcare center: (1) nutrition counseling,
(2) healthy cooking classes, and (3) HP and education rooms. In addition, two of the
wellness centers were supposed to provide a gymnasium, pool, and sauna in addition
to the above. Furthermore, in an effort to achieve the specific goals in HP, new
professions such as community workers and nutritionists were required as part of the
PHC reform.
Finally, the strategy underlined the importance of having a 100% coverage of
nurses for schools, and the activities related to HP for government schools for 6 to
19 year olds suggested were weight and height measurement and HP through
nutrition and PA (not clear if it refers to awareness/education or regulation/school
environment). Nongovernmental schools would be encouraged to also participate in
preventive and health-promoting programs. All the above were very promising
initiatives and highlighted the importance that would be given to the PHC in relation
to HP.
As for the deadlines, half of the actions needed to be adopted fully or in part by
2013. Among them were the five key components for HP described above, the
expansion of clinics for weight management and nutrition (only available for
employees at the Ministry of Interior at the time) and the work of the PHC with
sports clubs and gyms. With regard to the end of 2014, the recommended actions to
be performed were to develop a monitoring system for all schools, the MOPH, and
the SEC to require all schools to be involved in HP/health prevention (20% of
governmental schools in HPS initiatives so far), to develop workplace health action
plans for governmental departments and agencies (2015 for private sector), and to
establish a program for community health educators. Finally, the expansion of PHC
centers was estimated to be delivered for 2015/2016.
There was some information available from the NHS 2015 update report (SCH
Qatar 2015) on the progress of the PHCC Strategy. According to the report,
advancements were made on the creation of wellness centers. Other aspects of the
PHC reform were discussed but not in relation to nutrition and PA or to screening.
The 2014–2015 report of the PHCC also provided information on advancements
in PHC even though they were not presented as in the strategy (deadlines achieved,
which projects pending, etc.). At this point, school health, HE, and HP in schools
were part of the activities of the PHC centers. A very important action was the
interaction with the local community, and a session was held to inform and educate
the community on the PHCC tasks in relation to the community. The community was
also participating in decision-making (constructive discussions on the services of the
PHCC and their performance) and the PHCC collaborated with different partners for
adding value to the community (through education and activities).
Specifically in relation to HP, the following achievements were reported: (1) par-
ticipation of the PHCC in sport events and providing advice on nutrition and PA and
biometrics tests (blood pressure, lipids, weight, height, etc.), (2) PHCC is sponsoring
the HPS initiative (with 105 schools included so far), (3) HE through the media, and
(4) a plan for 20 new facilities mostly community health centers and wellness centers
to be delivered between 2015 and 2019 (PHCC Qatar n.d.-a).
Based on the above report, there were some achievements in relation to HP for
schools (even though we do not know which were the exact improvements and
actions), the expansion of health centers, recruitment of allied health professionals
(even though no specific information provided on health educators), awareness
campaigns, and participation in events. Other plans of the PHCC Strategy such as
workplace HP especially in government departments and agencies, a “yearly
checkup” for people at risk or regular screening for risk factors, and consultation
in PHC centers for visiting patients were not discussed. Definitely there is progress
made in PHC. The strategy was very ambitious, and that may explain the delays for
some actions and the postponing or lack of completion of certain parts. Yet, the PHC
is certainly heading to the direction given by the strategy.
National Public Health Strategy 2017–2022

In May 2017, the MOPH launched the PH Strategy consultation, which was the start
of an online PH survey, seeking residents’ opinions on health issues. The strategy
was planned to be launched at the end of the year and would address 16 key areas
including healthy lifestyle (MOPH Qatar news 2017b).
The survey was open online, and the “healthy lifestyle” area had six objectives:
(1) reduce unhealthy nutrition and physical inactivity; (2) increase public awareness
about healthy lifestyle; (3) introduce policies and legislation targeting nutrition and
PA; (4) stimulate the practice of PA particularly in schools, workplaces, and the
community; (5) establish wellness centers and health coaches in PHC centers, and
(6) collaborate with the private sector to promote the importation, production, and
distribution of healthy food products (MOPH Qatar n.d.-c).
National Nutrition and PA Action Plan 2011–2016
The NDS 2011–2016 had as one of the main objectives in relation to healthcare to
develop a comprehensive nutrition and PA program, and as a response to this
objective, a National Nutrition and PA Action Plan 2011–2016 had been developed.
The overall expected outcomes of the Action Plan were to (1) reduce the rates of
obesity and overweight by 1% yearly, (2) increase the levels of PA by 1% yearly,

(3) increase the proportion of the population consuming five servings of fruits and
vegetables by 10% in 5 years, and (4) increase the level of public awareness on
nutrition and PA by 25% in 5 years (SCH n.d.).
The Action Plan had seven action areas: (1) national policies and legislation;
(2) national coordination mechanism; (3) national nutrition programs; (4) national
PA programs; (5) promotion and advocacy; (6) surveillance, monitoring, and eval-
uation; (7) capacity building; and (8) partnership with academic institutions and the
private sector. Every action area had one or more objectives, which were further
divided intro short- (6–12 months), mid- (1–3 years), and long- (3–5 years) term
objectives.
For the first action area, the short-term objectives were to develop national dietary
(MOPH Qatar 2015a) and PA guidelines (published in 2014) (Aspire Zone Foun-
dation 2014). The PA guidelines that were developed (in collaboration with Qatar
University, HMC, PHCC, ASPETAR-a sports medicine hospital in Qatar) were very
elaborate and included also recommendations for chronic conditions (e.g., patients
with heart disease). Some basic information on PA, which is nonetheless informative
for the population, can be found in the dietary guidelines. The midterm objectives
were to develop regulations for marketing food and sugar-sweetened beverages to
children and updating legislation on food labeling, including food served in restau-
rants and fast-food chains. The long-term objectives were the establishment and
implementation of the regulations/legislation.
In 2017, the MOPH decided as mandatory the presence of nutritional facts on all
products in Qatar (‘Nutrition labels’ 2017). The MOPH also mentioned that the
dietary guidelines would be used to guide policy and also nutrition labeling, mar-
keting of food and beverages, school meals and snacks, workplace programs, and the
food industry (Fahmy 2015). Qatar was also in the process of subsidizing healthy
oils (sunflower oil, canola oil, olive oil) in order to discourage the use of unhealthy
oils (palm oil, coconut oil) (WHO EMRO 2015). According to WHO, Qatar reduced
the salt content in bread by 20% through the public bread suppliers (WHO EMRO
2015). In February 2017, the MOPH provided guidelines for available food in
healthcare facilities (cafeterias, restaurants, vending machines). The ministry spe-
cifically suggested to avoid selling food high in calories and soft drinks in vending
machines. The target was reducing the selling to 20% in the restaurants of healthcare
cafeterias. It also recommended 50% of healthy food in the cafeterias and a proper
display for these types of food. Food and beverages were also required to be
classified in one of three categories based on their nutritional value (healthy,
moderate, unhealthy), and the ministry required the cafeterias to use these labels.
The guidelines were aimed to be implemented in all healthcare facilities by the end
of 2017 or the first quarter of 2018, and teams were expected to monitor the
implementation process (some facilities have already started the process of imple-
mentation) (Saleem 2017).
The second action area had as objectives to create and strengthen the national
coordinating mechanisms on nutrition and PA as well as to promote the participation
of academia, media, civil society, etc., in activities related to nutrition and
PA. According to the NHS updated summary of 2015, the objective related to
nutrition and PA mentioned the collaboration with universities and the “Healthy
Lifestyle Campaign/Our Future Lies in Our Health” supported by the media (SCH
Qatar 2015).
The third action area on national nutrition programs had as objectives to promote
nutrition at schools and for adults at the workplace. The short-term objectives for
schools were the (1) creation of guidelines for a national snack program, (2) the
creation of a nutrition element for the school curriculum, and (3) the planning of HP
programs. The long-term goals were the implementation of the area’s objectives in
all schools and the presence of ongoing school healthy eating promotion programs.
Similarly, for the workplace, the objective was to create guidelines for healthy eating
at work and to implement them.
Indeed, in the NHS updated summary of 2015 (SCH Qatar 2015), a workplace
wellness program was launched, and in 2014 it was in its second phase for Qatar
Tourism Authority staff (screening for obesity and NCD risk factors). The first phase
was to collect general lifestyle information. The following phase was to evaluate the
health status of the employees, provide consultation, and also develop a plan for the
first year of implementation that would include proposed activities to raise
employees’ awareness on nutrition and PA (use of stairs, healthy nutrition at work,
healthy cooking). In addition, in 2014, the third phase of the program was launched
for the MOPH staff (MOPH Qatar news 2014). In addition, in 2016 the MOE banned
the selling of junk food and food with high caloric content and soft drinks in
governmental school canteens. The Ministry of Municipality and Environment
inspected the school canteens and restaurants for implementation (Sharma 2016).
No information was found about possible introduction of the nutrition topic in the
school curriculum or a national snack program.
The fourth action area on PA had as objectives to enhance PA at schools and at the
workplace. For school, the short-term goals were to introduce PA in the curriculum
and to promote PA in the schools, whereas the long-term objectives were to establish
regular PE in all schools and PA programs.
At the workplace, the short-term goals were to evaluate existing PA guide-
lines for the workplace, and the long-term goals were to promote PA in the
workplace and through community facilities. The “Health at Worksites” was a
program with more than 20 institutions from the public and private sector
participating till 2016, established by the HP Division (MOPH NHS Qatar
news 2016c). The “We are Healthy Kids,” an awareness program, started in
2010–2011 and was piloted in 15 schools, and in 2011–2012 it was piloted in
35 schools. The awareness program focused on primary schools with duration of
8 weeks, each with a different theme (MOPH NHS Qatar news 2013). Since
then, according to the NHS updated summary of 2015, the program had reached
in total 94 primary schools and also 65 preparatory schools. It was expected to
extend to private primary schools and even preschools. Work was also underway
for secondary schools (SCH Qatar 2015). The program increased students’
awareness in the benefits of exercise and PA by 40% (MOPH NHS Qatar news
2013). This program was initiated by the HP Division and in collaboration with
the SEC. Finally, healthy snack guidelines for schools were launched but we are
not aware whether it is implemented (SCH Qatar 2015). PE is compulsory in
schools from kindergarten to 12 years old. No further information or any specific
policies/programs related to PA in schools have been available to be reported.
Regarding school initiatives, in 2015 the MOPH announced the National Healthy
Schools Programme with an aim to unite all existing initiatives in schools under the
same program and to support also the surrounding communities in health. The
program is a collaboration of the MOPH (the HP being a main actor, the SEC, the
QOC, the PHCC, the directors of schools, Weill Cornell Medical School, and
ASPETAR). Besides the health, nutrition, and PA awareness aspects of the program,
it is not clear which other actions were planned (school environment, curriculum,
etc.). Teams were also planned for follow-up to ensure the implementation of the
program (MOPH Qatar news 2015b).
The fifth action area on promotion and advocacy targeted mostly the collabo-
ration with media and the development and use of national awareness campaigns
on nutrition and PA. There are some good examples of such efforts in Qatar, such
as the “Healthy Lifestyle Campaign/Our Future Lies in Our Health” (‘SCH
launches second phase’ 2015) addressing nutrition, PA, and smoking; the “Start
Now/Eat Healthy” campaign on nutrition awareness initiated by the HP Division
(MOPH Qatar news 2017a); and “Your Healthy Choice” initiative at Al Meera
supermarkets for educating the consumers through nutritional information on
printed material and health educators available at the premises for suggesting
healthy choices to the consumers as well as school visits at the supermarkets. The
“Your Healthy Choice” project was initiated in June 2016 by the Weill Cornell
Medical College in Qatar and in collaboration with the MOPH and four Al Meera
supermarkets. It was part of a wider awareness campaign called Sahtak Awalan –
“Your Health First” initiated by the Weill Cornell Medical College in Qatar
(MOPH NHS Qatar news 2016b).
Based on the above, significant work has been undertaken so far in the field of
nutrition and PA with interesting initiatives such as those in the workplace, in
collaboration with the supermarkets, enhancement of the existing food labeling
and valuable awareness campaigns in schools and the community, and the ban-
ning of fast food in the school canteens. An important achievement is that
intersectoral efforts have been established both for developing the plan and for
implementing it.
In March 2017, it was reported that the NHS 2011–2016 had achieved in total
80% of its goals, and a NHS 2017–2022 was heading/on the planning phase as a
continuation of the previous work. Advancements were reported in areas such as in
disease prevention (screening programs) and HP (dietary and PA guidelines), six
new PHC centers (including three wellness centers), etc. In addition, a National
Nutrition and PA Action Plan for 2017–2022 is underway (MOPH NHS Qatar news
2017). The text above shows a continuation and the buildup on the achieved work
and a willingness for a true change in healthcare.
According to the NDS 2011–2016, a target for workforce was to have a qualified
workforce by increasing the number of allied health professionals (no specific infor-
mation about health educators/health promoters was provided) from 0.4 per 1000
people to 4%. However, it is not specified which categories of allied health profes-
sionals were involved (General Secretariat for Development Planning Qatar 2011). In
addition, based on the NHS 2011–2016, Qatar had an increased need of workforce that
was impossible to be catered by the local workforce. Expatriates continue to be a very
important component in the health workforce. “Qatarization” of healthcare providers
was not achieved (Qataris find working in the health sector of limited appeal, due to low
levels of compensation compared to other sectors). The shortage and need for devel-
opment for allied health professionals had been noticed in different sectors such as PH,
occupational health, nutrition, HE, etc. (MOPH Qatar n.d.-b).
At the capacity building action area 7 of the Nutrition and PA Action Plan
2011–2016 (SCH n.d.), nutritionists and nurses in the PHC were the spine for
conducting HP programs at schools, the workplace, and the community. The plan
had the following targets for workforce: (1) recruit nutritionists at eight PHC centers
(short-term), at 15 PHC centers (midterm) and at all PHC centers (long-term),
(2) strengthen human resources and infrastructure in relation to nutrition in the
MOPH, and (3) train healthcare workers on nutrition. Unfortunately, the focus
seemed to be only on nutritionists since no specific information regarding health
educators or health promoters was provided.
In the PHCC Strategy 2013–2018, it was reported for 2013 that only 2 nutrition-
ists were available in 5 of the 23 available healthcare centers. The lack of health
educators and the lack of a clear, feasible and implementable educational program
for these professionals were discussed. It was declared that to achieve the specific
goals in HP, community workers and nutritionists were required professions as part
of the PHC reform, and it was recommended to develop a HE program in Qatar. The
strategy also suggested that PHC providers should work in collaboration with the
Faculty of Family and Community Medicine in Qatar University and the Calgary
Nursing College to enhance the focus on HP within curricula. No information was
given in the PHCC report of 2015 about the advancements on recruiting nutritionists,
health educators, etc., or about training on HP (PHCC Qatar n.d.-c).
To our knowledge, Qatar University, under the College of Health Sciences,
Department of PH, offers a bachelor in PH with courses on HE and HP (established
in 2012) (Qatar University n.d.). A new College of PH also opened since fall 2016 in
the Hamad Bin Khalifa University, but its program’s content was not available on
their homepage (Hamad Bin Khalifa University 2015).
Implementation
HP.
38
National Nutrition and PA Action Plan 2011-

National Health Strategy 2011-2016 2016
-Create HP in schools and workplace -Develop national PA and dietary guidelines
-Develop awareness campaigns on nutrition and PA for the -Introduce nutritional information on food labeling
population -Intersectoral work
-Create policies to reduce fast food consumption -Create guidelines for a national school snack
-Introduce healthy options at restaurants and retail shops -Create a nutrition element in the school curriculum
-Improve food labelling on healthy aspects of the products -Establish regular PE and PA programs in schools
HP -Create guidelines for healthy eating in the workplace
-Promote PA in the workplace and through community
facilities
-Develop awareness campaigns on nutrition and PA
National Development Strategy 2011-2016

-Increase PHC responsibility towards more HP activities Primary Health Care Corporation Strategy 2013-
-Develop programs for prevention of obesity 2018
-Develop a nutrition and PA program: -Improve HP in the workplace
HP in schools and workplace -Provide HE for visiting patients in PHC centers
Awareness campaigns on nutrition and PA for the population -Create partnership with the local community for HP
Policies to reduce fast food consumption -Develop HP environment for PHCC staff
Healthy options at restaurants and retail shops -Screen the population at risk on diet, PA blood pressure
-Promote intersectoral collaboration -Develop healthy workplace action plans for HP in the workplace
-Promote community participation (government departments)
-Promote sports and PA in the community (through education on PA) -PHCC collaboration with sports clubs to encourage PA in the population
-Create and enhance facilities for sports (sports and recreation facilities master plan) -Develop yearly HP campaigns
-Develop a sports national curriculum project (to support PE in schools and train teachers -Screening of weight and height in schools
and staff on PA and sports) -Encourage HP trough nutrition and PA in schools
-Enhance built environment and green spaces -Develop community health centers and wellness centers
-Recruit community workers/nutritionists for PHC
Fig. 6 Activities/actions related to HP intended by Qatar strategies/plans (in colored bold appear the actions that were implemented). PE physical education, PA
physical activity, HE health education, HP health promotion, PHC primary healthcare
943
The report for the NHS 2011–2016 in 2015 gave some information on
implemented actions, but these were not very detailed. However, there was no
systematic presentation of the suggested actions in the strategy that were
implemented and/or evaluated. Similarly for the National Nutrition and PA Action
Plan of 2011–2016, only part of the projects and programs was implemented within
the recommended deadlines. Finally, the 2015 report for PHCC did not give an
update on the achievement of targets of the PHCC Strategy of 2013–2018.
However, some important suggested programs/projects have been implemented,
and the new strategies (NHS 2017–2022, National Nutrition and PA Action Plan
2017–2022) show a continuation of the work in HP.
Main Results
Qatar has achieved significant advancements in (1) the establishment of the PHCC,
(2) the focus of the PHC as a main actor for prevention and HP, (3) the creation of
long-term strategies/action plans/policies, etc.
There were many intersectoral collaborations for achieving the targets of the
healthcare strategy with the SEC being a main partner for schools. The HP Division
had an active role in HP programs such as important initiatives for schools and
workplace in relation to nutrition and PA. Community was considered in the
development of programs and in decision-making which is very unique and a pillar
for developing HP in the community. The PHCC was involved in most HP activities
in the country, and this is also very unique since in most GCC countries, the PHC
does not contribute much in HP activities. Beyond awareness campaigns and HE on
nutrition and PA, interesting and innovative initiatives such as the creation of
wellness and community health centers, healthy eating in the hospitals and
healthcare facilities, and a national healthy school program have been developed.
At the same time, further work in schools is needed in order to achieve coordi-
nated action in all governmental and nongovernmental schools; the PHC’s role needs
further strengthening and more set goals to be achieved in relation to HP; and
additional policies are also needed, especially targeting fast food and advertisements
of junk food and soft drinks for children and important enhancement in the work-
force with a much needed focus on health educators and health promoters. Some of
the suggested programs in the strategies are pending or not fully implemented.
However, the MOPH is continuing its work with the strategies for 2017–2022.
Current Challenges
Qatar is undergoing a health reform, and actions are taken on different administrative
levels together with HP projects/programs. The country is paving the way for a
healthier lifestyle, but continuous work is challenging yet needed for achieving the
country’s visions. Another major challenge is the lack of workforce at the level of
HE/HP.
expatriates for UAE (Federal Competitiveness and Statistics Authority UAE
2011, 2016). The population of Abu Dhabi (the capital) for 2016 was estimated
to 2.908.173 inhabitants (Statistics Center Abu Dhabi n.d.), the population of
Dubai in September 2017 was estimated to 2.847.854 inhabitants (Statistics
Center Dubai n.d.), whereas Sharjah was the third in the list with 1.405.849
inhabitants, according to the 2015 Sharjah census (‘Sharjah’s population’ 2017).
Abu Dhabi occupies the biggest surface area (67.340sqk) (87% of the mainland
area). Dubai occupies 3.885sqk and Sharjah 2.590sqk. Eighty percent of the land
is desert, especially in the western part (Abu Dhabi Emirate). Around 85% of the
population lived in urban areas already in 2005 (Food and Agriculture Organisa-
tion n.d.).
UAE has a very good level of health services and has eradicated communicable
diseases (WHO 2012). The burden of NCDs is still high: the prevalence of over-
weight and obesity for males/females is presented in Table 1 (WHO 2014b).
The health sector is administered by different authorities in UAE: the Ministry of
Health and Prevention (MOHP) (regulatory role) and the Emirates Health Authority
(service delivery) (federal level) and the Health Authority-Abu Dhabi (HAAD) and
Dubai Health Authority (DHA) (emirate level) (WHO 2012).
Based on the Abu Dhabi Health Services Company SEHA, responsible for health
services delivery, there are 12 hospitals and 46 PHC clinics, 10 prevention and
screening clinics, 1 school clinic, etc. This is the biggest healthcare network in the
UAE. The Dubai Emirate comprises 6 hospitals and 20 PHC centers/peripheral
clinics (one for each 30.000 inhabitants) [DHA n.d.-c.; MOHP UAE n.d.-c]. Based
on information from the list of hospitals and PHC centers from the MOHP, there are
14 hospitals for the remaining 5 emirates (5 in Sharjah, 4 in Ras Al Khaimah, 2 in
Ajman, 2 in Fujairah, and 1 in Umm Al-Quwain) and 35 PHC centers (15 in Sharjah,
10 in Ras Al Khaimah, 5 in Ajman, 1 in Fujairah, and 4 in Umm Al-Quwain)
(MOHP UAE n.d.-c).
The PHC approach is used in UAE with PHC centers as the entry point to the
system. The centers in Abu Dhabi provide general, maternal, child, geriatric and
dental care, diabetes and weight management clinics, screening services, and HP
through school health and HE (Abu Dhabi Health Services Company SEHA n.d.). In
Dubai, the centers provide general, maternal, child, geriatric and dental care, HE, and
nutrition clinics (DHA n.d.-d).
There is free health coverage for nationals in all emirates (WHO 2012). Dubai
and the other five emirates offer free access to healthcare after they obtain a
health card through the MOH, renewed yearly (100 dirhams for nationals and
505 dirhams for nonnationals) (MOHP UAE n.d.-a). In Abu Dhabi, all non-
nationals have to be insured by their employers in order to receive healthcare
(WHO 2012).
In 2001, the government of Abu Dhabi established the General Authority for Health
Services, which was later restructured into the HAAD and the SEHA. At the time of
creation of the HAAD in 2007, similarly, the DHA was created. The MOHP is
mostly coordinating the remaining five emirates (Al Qasimi Foundation for Policy
Research 2015b). Figure 5b gives an overview of the departments and agencies
involved in HP.
Ministry of Health and Prevention

Among the most important programs/initiatives of the MOHP is to raise awareness
for a healthier lifestyle (MOHP UAE n.d.-e). Under the Assistant Undersecretary for
Health Policies and Licensing, the PH Policies Department is responsible for
developing projects/programs and policies for NCDs among others (MOHP UAE
n.d.-f). Furthermore, under the Assistant Undersecretary for Health Centers and
Clinics, the PHC Department is responsible for school health among others
(MOHP UAE n.d.-d). The HE and HP Department is responsible for establishing
strategies and programs on health awareness in the country (MOHP UAE n.d.-b).
Unfortunately, no specific programs initiated by these departments are available.
Table 2 describes briefly all the programs and campaigns of the MOHP for schools.
Among the activities of the MOHP in relation to HP, an anti-obesity campaign at
schools took place in Dubai and Ajman. The campaign showed very positive results
for schoolchildren (40% average weight loss for Dubai and 46% average weight loss
for Ajman). The success of this program would be continued by a national program
for schools that would be included in the NNS that would be developed (Qabbani
2011). The NNS is discussed below and focuses on educating the population on
nutrition.
In addition, a collaboration between the MOHP, UNICEF, and Dubai Sports
Council had led to a 3-month awareness campaign for the whole population in
2009. However, important downfalls of this initiative were that the main activities
were held in Dubai and also the short duration of the program (Emirates News
Agency 2009).
In 2013 and as part of the national UAE campaign “Every Step Counts,” the
“School HE Project” was launched and aimed to increase health awareness. Health
knowledge of children increased among students (by 15% for girls and 12% for
boys). This program would lead to the development of a plan for implementation in
all governmental schools across UAE (Emirates News Agency 2014). One of the
outcomes of this pilot project was the creation of the Health Skills manual, directed
to health educators and nurses for children at secondary schools. The manual
included many tools, activities, and methods for delivering HE through an interac-
tive approach (‘UNICEF and DU team up’ 2014).
The “Every Step Counts” initiative was a national wellness campaign launched in
2013 with the support of the telecommunications company DU and in order to
answer the HH Mohammed Bin Rashid Al Maktoum’s call to adopt positive energy.
The company itself had adopted a wellness program (fitness equipment on all
38
Table 2 Programs and activities of the MOHP and MOE in UAE for school nutrition and physical activity
Participating
schools Who was
Authority Title Scope Duration (governmental) Activities involved? References
MOHP Anti- Create a supportive 2 years 9 Dubai Not clear School nurses Qabbani
obesity environment for (2009–2011) 153 participants PE trainers (2011)
campaign significant change in (2009–2010) –Nutritionists
obesity through 4 Ajman School
nutrition and physical 144 participants employees
activity in schools (2009–2010) Parents
9 + 2 Dubai
(2010–2011)
4 + 2 Ajman
(2010–2011)
MOHP + “Fat Truth” Develop an awareness 3 months NA Educating schools in NA Emirates
UNICEF + campaign campaign in Dubai on (2009) Dubai News
Dubai obesity for the whole Inviting stakeholders Agency
Sports population from different sectors (2009)
Council Distributing material in
malls and clinics
National media
campaign (workshops at
school, PHC, and
corporate level)
Sports activities in
schools, parks, and
public spaces
(continued)
947
948
Table 2 (continued)
Participating
schools Who was
Authority Title Scope Duration (governmental) Activities involved? References
UNIFEC + “School Develop HE on a 1 year (2013) 18 secondary HE through innovative School Emirates
MOE + HE national level in schools schools around active learning and teaching staff News
MOHP Project” UAE participatory School nurses Agency
+SEHA approaches (trained with a (2014)
“Health Skills”
Manual)
MOE NA Improve the nutritional 1 year (2012) All schools of Introduction of healthy NA Ahmed
environment of children Dubai and five guidelines for (2012)
in schools (canteens and other emirates (1) removing junk food
cafeterias) (not Abu Dhabi) from the canteens and
cafeterias and
(2) substitute with
healthier options
Letters sent to parents to
advise them on avoiding
packing junk food for
their children
Scrutinizing of the work
of all school suppliers
and dismissal of the
ones who did not follow
the guidelines
Inspections at school
canteens
A. Samara et al.
38
MOE Connected Improve eating habits 1 year (2013) 54 schools from Daily supply of fresh NA Pennington
to the for schoolchildren Dubai and 5 other food to schools (2014)
above emirates (not Abu All junk food removed
initiative Dhabi) from canteens and
cafeterias
Students provided with
healthy snacks and
lunch boxes (water, one
serving of fruit and one
of vegetable, fresh juice,
and one whole wheat
product)
Organic farming was
implemented (one
school)
MOE MOE Create a curriculum that Continuously All government PE and HE (awareness Parents MOE UAE
reform for supports and enhances schools on obesity, nutrition, School staff news
HE and PE physical and health and PA, reading food (2017)
literacy labels, sports activities)
MOE NA Enhance students’ Annually All schools of Developing and NA MOE UAE
Healthcare nutritional habits Dubai and five implementing HE (n.d.-a)
Service other emirates programs in schools
(not Abu Dhabi)
MOE NA Enhancing students’ Continuously All schools of Applying guidelines for NA MOE UAE
Nutrition nutritional habits Dubai and five food in the school (n.d.-a)
Service other emirates canteens and cafeterias
(not Abu Dhabi)
MOE Ministry of Education, NA not available, HE health education, PE physical education, UAE United Arab Emirates, PA physical activity, MOHP Ministry of
Health and Prevention, PHC primary healthcare
949
premises, healthy options in the restaurant, etc.). Major objectives for the years
2014–2015 were (1) raising awareness for the individuals and for institutions on a
healthier lifestyle and (2) rewarding individuals and institutions which have contrib-
uted to positive change (DU UAE 2013). It is not clear what were the specific
activities of the campaign.
Ministry of Education
Table 2 shows programs and activities of the MOE in relation to nutrition and
physical activity in schools in Dubai and the other five emirates (not Abu Dhabi).
The MOE has a dedicated healthcare and a nutrition service which both focus on
nutrition in schools (MOE UAE n.d.-a). In 2012 the MOE had introduced health
guidelines in schools (Ahmed 2012). As part of this initiative, in 2013 another
program was launched. A year of success was celebrated for the program (reduction
in obesity for the children from 17.5% to 12.5% and an increase in fruit consumption
from 1% to 19%). The ministry’s aim was to increase the school participation to
321 schools, but we are not aware if this program has been implemented in school
since (Pennington 2014).
The “UAE School Specification for Healthy Foods Committee” (DHA, HAAD,
MOHP, MOE, Dubai Municipality (DM), and some universities) has worked to
implement nutritional guidelines across UAE schools, and for the academic year of
2014, all schools in UAE had to ensure that both suppliers and canteens offer healthy
food for children. Dubai also informed that there will be penalties for failure to abide
by the rules (‘School canteens’ 2014).
The above shows that implementing policies in settings such as schools can be
time-consuming, but with persistence and continuous follow-up, preferred results
can be achieved.
General Authority for Youth and Sports Welfare and National Olympic
Committee
The General Authority for Youth and Sports Welfare (GAYSW) was established in
1999, and it is the supreme governmental authority responsible for the welfare of
youth and for the sport sector. The chairman of the authority is the Minister of
Culture and Knowledge Development of UAE. Major roles of the authority at the
sports level are to implement the government’s policies and create a sports culture in
the community (GAYSW UAE n.d.).
Examples are the “I dare you” program that aimed to promote sports culture and
increase awareness on importance of exercise and the environment in Al Ain through
various activities (GAYSW UAE news 2016f); the “Happiness in sports” that
included a marathon, an educational lecture, and competitions in the Fujairah
emirate at a high school (GAYSW UAE news 2016e); the “Sports in your house”
in Abu Dhabi (GAYSW UAE news 2016d), Sharjah (GAYSW UAE news 2016b),
Ras Al Khaimah (GAYSW UAE news 2016c), and Ajman (GAYSW UAE news
2016a) in collaboration with the MOHP for providing sports equipment to diabetic
patients and other categories of patients; the creation of a sports map that includes
more than 1500 sports facilities around the country and promotes community sports;
summer programs for children that can be used through a website or a phone
application (GAYSW UAE news 2015); etc. The GAYSW is very active in promot-
ing sports in the population and has developed its own strategy for 2017–2021 that
will be presented further below.
The National Olympic Committee was established in 2012 and is also an orga-
nization promoting PA in the community and sports in youth but focuses more on the
competitive aspect of sports. The School Olympic Program initiated since 2011
promotes competition in sports among school students (Gomes 2016).
Health Authority – Abu Dhabi

The HAAD has a PH Department (HAAD n.d.-b) with a focus among others on
CVD (including obesity) prevention and management and on school health (HAAD
n.d.-c). Important PH programs related to HP are the “Schools for Health” and the
“Weqaya” (HAAD n.d.-d). The HAAD collaborates with many other agencies such
as the Abu Dhabi Police, the UAE Football Association, the Abu Dhabi Media
Company, the Environmental Agency of Abu Dhabi, the Abu Dhabi Education
Council (ADEC), the Ministry of Labor, the Abu Dhabi Food Control Authority
(ADFCA), the MOHP, etc. (HAAD n.d.-g).
Weqaya Program Screening

In 2008, all nationals living in Abu Dhabi had to be screened for NCD risk factors
in order to enroll to the thiqa (trust) insurance system and were followed since
(HAAD news 2008b). The Weqaya program was a combination of screening of
the population (18–75 years old) and of interventions at the individual and at the
community levels. The screening comprised a questionnaire, physiological mea-
surements, and a blood test. A personal risk score was created for every individ-
ual, and the individuals were followed up. Screening occurred at the PHC centers
of SEHA and was enforced through linking the screening with the issuance of a
free comprehensive health insurance card (HAAD n.d.-h). Compliance was
achieved through encouragement from media and community campaigns. Results
then were sent to individuals as health reports evaluating their risk and using a
clear color-coding. In the health report, specific actions were suggested such as
seeking support from a doctor and/or receiving more information on a healthier
lifestyle through the educational material in the Weqaya website. There are
available Weqaya clinics for appointments as well as diabetes clinics and weight
management clinics. The health report was confidential, and every individual had
access to his/her report in the Weqaya website. Ninety-four percent of adults over
18 years of age had been screened since the beginning of the program (2009).
Results showed that 2/3 are overweight or obese, 44% are either diabetic or
prediabetic, almost 50% had abnormal cholesterol, and 71% had at least one
risk factor for CVD. Definitely the program is a great tool also for surveillance
of the population on NCDs and future research and intervention programs (HAAD
n.d.-i).
Weqaya Program Interventions

The Weqaya program was also an intervention program both at the individual level
(consultation through a doctor) and at the workplace, school, and community.
Important actors from the non-health sector that had been proposed by the HAAD
as “Health Guardians” were the (1) ADFCA and (2) the Abu Dhabi Environmental
Agency. The role of the ADFCA would be to educate on food and on the nutritional
value of products, to ban trans fat, to develop clear traffic lights on food labeling, to
reduce salt in bread and cereal, etc. The Abu Dhabi Environmental Agency together
with the Municipality and the Urban Planning Council would be major actors for
improving “walkability” through pedestrian-friendly environments (including shop-
ping malls) and open attractive staircases, extracurricular sports activities, open
school facilities in evenings and vacation (especially summer), community leagues,
etc. (HAAD n.d.-i).
Besides the above “Health Guardians,” other entities will support the initiatives of
the Weqaya program. Through “Weqaya in the Workplace” program, employers
would receive anonymous feedback of reports of their staff and plan interventions
for creating a healthier working environment. Through the “Healthy Schools”
initiatives, which was a partnership between HAAD and ADEC, schools would
implement clear standards on food and PA in schools, and results will be measured
through annual health checkups for the students. The “Weqaya in the Community”
program will encourage local government to play a role through opening of parks
and open spaces, etc. (HAAD n.d.-i). A Weqaya advisory taskforce was established
in 2011 with the aim to work closely in collaboration with the HAAD (HAAD news
2011a).
Weqaya Program Specific Actions

In 2012, the “Weqaya workplace wellness” HP project was launched (pilot phase for
1 year) and was well received by many employers. Among the main factors that
would be targeted were nutrition and PA. This pilot project aimed to build capacity
for future development, implementation, and evaluation of HP programs in the
workplace. Some participating organizations were the HAAD itself, the UAE Uni-
versity, the National Bank of Abu Dhabi, the Emirates Foundation, etc. The organi-
zations were provided with guides and support material and would be supported
closely by the HAAD, in order to create healthier environments for employees
(HAAD news 2012).
At the national level, an increasing number of companies are implementing
wellness programs across UAE. A survey of 136 companies showed that 66% of
respondents implement programs (45% in 2014), and the Daman Corporate Health
Awards encourages companies to participate. The winner for 2016, the Dubai
Chamber of Commerce and Industry, showed positive results: a 10% increase in
employees’ health and a reduction in absenteeism by 56% (‘Workplace wellness
programs’ 2017).
In 2013, the “Weqaya Healthy Nutrition” program was launched with the aim to
raise awareness on healthy food options by adding a logo to pre-approved healthy
menu items (low-fat, low-sodium, high-fiber food, etc.) in restaurants. The pilot
phase was implemented in 11 restaurants in collaboration with the ADFCA (HAAD

news 2013b). In 2016, 11 more restaurants/food outlets added healthy food options
in their menus (HAAD news 2016d). As a continuation of this project, in 2015,
additional initiatives were launched that included activities, events, a health maga-
zine, and competitions as well as participation of chefs for increasing the public
awareness on healthy food and its preparation (HAAD news 2015d).
As part of the same program, the HAAD together with the ADFCA and Abu
Dhabi Quality and Conformity Council (Abu Dhabi Quality and Conformity Coun-
cil 2015) created the Abu Dhabi certification scheme for prepackaged food in 2016.
In a preliminary phase, the dairy and bakery product manufacturers were urged to
produce their products in a healthier way (low in fat, salt, etc.) and to apply for the
label “Weqaya” and “Abu Dhabi Trustmark.” The label would be further applied to
other prepackaged products following the standards for healthy food (HAAD news
2016c). Recently, a workshop was organized in order to inform manufacturers on
healthy prepackaged food standards and train them in preparing their products
according to these standards (HAAD news 2017).
Even though the UAE government has not enforced the addition of nutritional
value on the products imported, the ADFCA encourages manufacturers to provide
nutritional and health information on the food labels (ADFCA news 2015).
Finally, the Abu Dhabi Municipality (ADM), majorly through the Division of
Health, Safety and Environment and the Division of Community Services, has also
supported the Weqaya program through various activities. To mention some, they
have (1) initiated awareness campaigns on nutrition, PA, and health (ADM news
2012, 2014c), (2) promoted sport events (ADM news 2009, 2011a, c), (3) supported
efforts on urban planning that allow for walking and jogging spaces (ADM news
2010e, 2013a, 2015) and greenery all around the city (ADM news 2010a, b, 2014a,
2017b), (4) introduced gym and sports equipment in parks (ADM news 2010c),
(5) created playgrounds (ADM news 2010d, 2014d), and (6) organized cultural and
social events that create the sense of a community, supporting social capital (ADM
news 2011b, 2013b, 2014b, 2017a). The ADM initiated some of the activities,
whereas others are in collaboration with the HAAD, the ADEC, etc.
Schools for Health Program

This program was in collaboration between the HAAD and the ADEC, ADFCA, and
SEHA and was in connection with the vision of the Weqaya program for a healthier
lifestyle in schools. The “Eat right get active” campaign was part of the program and
focused on nutrition and PA among others. The campaign included (1) the creation
of a series of educational material for children/adolescents and parents (a food dome,
advice on eating and PA, healthy recipes, games to increase PA) and (2) canteen
guidelines which do not allow junk food and other types of processed food (fruit
syrup, soft drinks, energy drinks, candies, sweets, chips, etc.). The school clinics
provided a yearly screening program for all children (medical history and body mass
index) (HAAD n.d.-e). The “Eat right get active” campaign produced a manual for
the academic year 2010–2011 describing the aim of the campaign and the interven-
tions to be considered by schools. The aim was to establish enough awareness about
nutrition and PA in schools to promote PA also outside the school and to encourage
the participation of parents in a healthier lifestyle. The manual was a guide to schools
for developing their own policies and programs (evaluated by the HAAD) and
provided suggestions for reaching these goals (e.g., create a school policy, family,
and community involvement, nutrition education classes, etc.) (HAAD n.d.-a).
In 2011–2012 the program was piloted in 25 public schools, and for the year
2012, 50 private schools also joined. The program showed promising results during
the pilot phase (increase of fruit consumption, increasing availability of policies on
nutrition and PA, and increased use of tools promoting healthy eating) (HAAD news
2010). Follow-up of the program showed many improvements: (1) availability of a
nutrition policy in schools from 36% to 79%, (2) implementation of school canteens
guidelines from 86% to 100%, (3) availability of healthy eating options in school
from 64% to 71%, (4) adaptation of a PA policy from 47% to 80%, (5) at least three
physical exercise sessions of 40 min each per week from 33% to 60%, and (6) sports
outside the school hours from 26% to 46% (HAAD news 2013a). The participating
schools were honored at different occasions, encouraging their continuous efforts
(HAAD news 2015a). Finally, in the same direction of efforts, parents were given
advice on food items to choose for their children when they prepare their lunchboxes
(HAAD news 2015b).
Based on the above, the Weqaya program is fulfilling its promises in
implementing interventions at different levels for promoting the health of Abu
Dhabi citizens.
Abu Dhabi Education Council

Besides its very significant role in the “Eat right get active” campaign, the ADEC has
produced other important actions. One initiative was the Iftah Ya Simsim (Open
Sesame-TV cartoon characters), an awareness campaign at schools throughout the
emirate that was launched in 2015 and was addressed to children, their parents, and
the teachers as well. Educational material was created (book, short stories, video
games), and the initiative was in collaboration with the HAAD, SEHA, and Bidaya
Media (HAAD news 2016a).
The HAAD together with ADEC decided to introduce a HE course focusing on
healthy lifestyle in the curriculum (kindergarten to 12 years old) for all public
schools and was expected to be in place for the academic year 2016–2017 with the
aim to create more sensitive citizens, oriented toward healthy choices in life (Rizvi
2015).
The ADEC has also published school policy documents for public and private
schools yearly, since 2012 yearly. The most recent regulations were published for
public schools in September 2015 for the academic year 2015–2016 (ADEC 2015b),
whereas for the private schools, one document was published in 2013 (Arabic and
later English version) for the academic year 2014–2015 (ADEC 2015a).
Among the mandatory policies for the public schools, there is a policy related to
school canteens and healthy eating as well as a policy for parents’ involvement in
activities at schools as well as a policy on partnership with the community for
activities in art, sports, and culture. According to the policy, the school canteens
should follow the existing standards at the level of facilities, hygiene, and products
(food allowed in schools, availability of low-fat products, availability of fruit and
vegetables, etc.), and principals as well as parents will be introduced to these
standards. The school principals are responsible for the implementation of the policy
and are accountable to the ADEC, and also, they are responsible for developing a
healthy eating policy and distributing it to the school community. Similarly, the
ADEC requested from private schools to follow the existing school canteen stan-
dards. These standards had been initially published in 2013 by the ADFCA and the
Abu Dhabi Quality and Conformity Council and were later updated in 2015. There is
a strict monitoring of the conditions/suppliers at public and private schools to make
sure that the policy is enforced (‘New school canteen rules’ 2015; ADFCA 2015).
Abu Dhabi Sports Council

Abu Dhabi has its own Sports Council with the aim to create an environment that
supports sport practicing and sport programs and to promote Abu Dhabi at a national
and international level (Abu Dhabi Sports Council n.d.). The council supports
various sports and is in partnership with the ADM. The council is also a member
of the Childhood Obesity Taskforce and a partner in the Weqaya program for a
healthier Abu Dhabi. The council initiates many events such as the Abu Dhabi sports
festival with duration of 2 months (Abu Dhabi Sports Council news 2016) and the
StartYAS which together with the GoYAS and the TrainYAS offers opportunities for
the Abu Dhabi residents to train in the well-known Formula 1 circuit. This initiative
was launched in October 2015 in collaboration with the HAAD (HAAD news
2015c).
Dubai Health Authority

The DHA underlines its continuous focus on PH awareness through media such as
newspapers, radio, TV shows, campaigns, and even phone applications with valu-
able health information. In addition, the “Leaders at Your Service” initiative pro-
vides a direct communication platform for the public to DHA leaders for feedback,
suggestions, and complains which shows an interest in the community participation
(DHA news 2017).
The DHA has a Clinical ND with the role to support both patients and healthy
individuals in nutrition. Important roles include the development of educational
material and nutrition awareness campaigns for the population (DHA n.d.-a).
Some efforts of the department during 2016 were a short campaign on raising
awareness on obesity (DHA news 2016g) and a nutritional awareness campaign
for the third consecutive year (DHA news 2016b). Other nutrition awareness efforts
have been performed through a “smart clinic” at various occasions (DHA news
2015, 2016d). Other initiatives of the DHA were the Diabetes Walkathon (DHA
news 2016f) and the participation of around 2000 employees of DHA in the Dubai
Marathon (DHA news 2016a). At the PHC level, there are dieticians and HE clinics
in Dubai (DHA n.d.-d).
In 2011, the Clinical ND and the Sector of Policies and Strategies in collaboration
with the Food Control Department of the DM published the Guide of Health and
Nutrition practices in school canteens (DHA and DM n.d.). The document provided
recommendations for healthy food choices, food groups included in a healthy
lunchbox, as well as food allowed/prohibited in the school canteens and premises.
The prohibited items were soft drinks, energy drinks, fruit drinks, milk and yogurt
with synthetic flavors, chewing gums and candies, chips, high-fat food, and sweets
with excessive sugar. The DM was a major actor in approving food suppliers as well
as requirements for the school canteens/restaurants. A tight surveillance and regular
inspection were proposed in order for the guidelines to be fully implemented.
Recently, the nutritional guidelines were updated to include portion sizes and
nutritional labeling for the food provided in all governmental and private schools
with the DM as the major actor and implementing body (Saseendran 2017). This is
the most advanced step any Gulf State has taken in school nutrition policies.
According to a survey (208 governmental and private schools) conducted in
December 2011 on PA and PE programs, there was a need to make PE in the
school mandatory both for primary and secondary schools for both genders. The
survey that aimed to describe the existing school facilities and training of staff
showed that around 60% of students get a PE class 2–3 times/week; 50% of the
schools allow substitution of the course, even though it is prohibited; around 80%
of teachers participate in training at least once a year; and around 90% of teachers
keep students vigorously active for 50% of the total class time. The Sector of
Health Policies and Strategies of the DHA suggested that (1) HE should be daily
for primary and secondary schools, (2) it should be a core/compulsory subject,
(3) it should not be substituted by another subject, and (4) all PE teachers should
participate in continuous development/training (‘Physical education should be
compulsory’ 2012).
In 2017, the DHA announced a structured program in schools for combating
obesity in children. The DHA targeted social mobilization, partnership with stake-
holders, as well as interventional steps in schools. The Dubai Sports Council would
be a partner for creating PA programs that will reach all children in public and private
schools (targeting also obese children), and a screening for obesity in schools would
be performed for all children with a follow-up until the end of school (from lowest
class to the senior-most class). The program would be launched in the academic year
2017–2018 (Chaudhary 2017).
Another effort of the DHA together with the DM announced in 2013 was the
incorporation of nutritional information on menus and food packages of all food
establishments. However, the mandatory information is on the presence of gluten,
nuts, fish, and dairy products that can cause allergies, but the calories and nutritional
value of packaged food and menus in restaurants is in their discretion (Al Serkal
2013).
Dubai Sports Council

Finally, it is important to mention the Dubai Sports Council, which was founded in
2005 with the aim to support sports in the whole population and especially for youth
and to create PA opportunities and supportive environments. The council is highly
active, has organized various sports events in the city, has an important role in
women’s sports, and also focuses on Dubai’s sports tourism. The council has signed
in 2016 a memorandum of understanding with the DHA (DHA news 2016c).
A very important community initiative of the council was the “Dubai Pulse”
initiated in 2009, which is ongoing yearly in collaboration with the DHA targeting
all the segments of the population (children, elderly, employees, low socioeconomic
status, etc.). Its purpose is to promote PA as a lifestyle through educational material
and various events (marathons, walk, swims, etc.). The success of the program was
due to the participation of different Dubai government departments (DM, schools,
etc.), engagement of different community groups, and availability of high-quality
facilities (WHO EMRO n.d.-b).
Recently in 2016 was also launched the “Hamdan Bin Mohammed Community
Sports Initiative” with an aim also to support a healthy lifestyle and enhance social
bonds through many activities in the Dubai and surrounding areas such as the city of
Hatta of the Dubai Emirate (‘Three thousand people joined Hatta walk’ 2017).
In the 2021 UAE Vision, a world-class healthcare is a major target (Vision 2021
UAE n.d.). The agenda on healthcare underlines the importance of preventive
medicine especially for NCDs, and one key target is to decrease the prevalence of
childhood obesity. Some achievements by the MOHP included activities and pro-
grams for awareness such as the WHO initiative of “1000 cities 1000 lives” that tried
to open up public spaces for health (e.g., activities in parks) with the participation of
five emirates (Dubai, Sharjah, Ajman, Ras Al Khaimah, and Fujairah). In addition,
the MOHP included event days (World Diabetes Day, World Heart Day, World Food
Day, etc.) (Vision 2021 UAE news 2013).
In accordance with the 2021 Vision, the government has created the National
Program for Government Communication with seven pillars. One of the pillars was
the “2021 Healthy Children” national campaign aiming to reduce childhood obesity
to 12% by the year 2021 (Government of UAE National Program for Government
Communication 2021 n.d.). One of the initiatives was the “Healthy restaurants” that
was suggested by MOHP to restaurants for creating healthy menus for children and
adults (Achkhanian 2015). Other activities under the “2021 Healthy children”
campaign were the “2021 steps” walkathon in Dubai mall; the “Let’s walk” march
in Dubai, Abu Dhabi, and Sharjah; health information distributed in Dubai, Sharjah,
Ajman, Abu Dhabi, and Ras Al Khaimah; and the “Let’s run” activity for schools
that included some HE and nutrition elements. These activities took place in spring
2015 and were also majorly organized by the MOHP (Government of UAE NPGC
2021 2015).
Like Saudi Arabia, UAE has also announced a tax of 50% for soft drinks expected
to be implemented in the fourth quarter of 2017. The decision was announced in May
2017 (Deulgaonkar 2017a).
The MOHP announced a 2014–2016 strategy with different targets including
(1) a national awareness program (restrictions on commercials for unhealthy food,
caloric content on food tags, etc.) and (2) a health checkup for all Emiratis. The
strategy is in line with the 2021 Vision for UAE (Bell 2014). This strategy was very
promising but was only set for 2 years, and we are not aware of its achievements
since 2014.
The MOE 2010–2020 strategy addressed health and PE and underlined the role
and training of staff as well as the contribution of parents in PA and in their children’s
healthy lifestyle and of the community in supporting schools’ activities (MOE UAE
n.d.-b).
The MOE had announced an innovative reform of the physical and HE system in
schools in UAE (MOE UAE news 2017). The reform in the curriculum was
implemented since January 2017 in all government schools and for all grades and
aimed at creating a curriculum tailored to the local needs that would support
students’ well-being. It also aimed at empowering students and creating health and
physical literacy instead of simply providing them with information. The curriculum
encompassed subjects such as awareness on obesity, nutrition, reading nutritional
information on food labels, PA, and sports activities. The participation of parents
was encouraged, and about 500 staff members were trained to the curriculum before
its implementation.
Overview of Abu Dhabi and Dubai Plans and Health Promotion
In 2014, Abu Dhabi published the Abu Dhabi Plan with 25 goals, one of which was
to improve the health services in Abu Dhabi government including promoting PH
(Our Abu Dhabi n.d.). The HAAD had set seven priorities (as part of the 5-year
strategic plan) for improvement and had developed a Capacity Building Plan, and
wellness and prevention through community initiatives was one of these priorities
(HAAD n.d.-f). As for the prevention and wellness priority, the Weqaya program is
the most important, and as we have described above, this program has seen many
achievements so far (HAAD news 2014).
In 2007, Dubai had launched its first long-term plan, the Dubai Strategic Plan
2015, with five pillars. Under the social development pillar, “Availability of Quality
Health” was one objective (Government of Dubai 2021 Dubai Plan n.d.). In contin-
uation, the Dubai Strategic Plan 2021 underlined also health, PA, and healthy
environments for the community. The plan mentioned the importance of
intersectoral collaboration and of community participation (Government of Dubai
2014). In accordance with the Dubai Plans, the city has provided many green spaces,
beaches, neighborhood parks, walking and running tracks in collaboration with the
DM, supporting health, and PA (Dubai Government n.d.; DM n.d.).
The DHA developed its own HS for 2016–2021 in the same direction with the
Dubai Plan (DHA n.d.-b). The strategy was developed after consultation with
government employees and the contribution of different community sectors and
also many stakeholders. This approach was very much in agreement with the
principles of HP on community participation already at the development level,
empowerment, and intersectoral collaboration.
The strategy provided only the general lines of projects to be developed. Among
the 15 strategic programs of the strategy were prevention and healthy lifestyle.
Specific initiatives for the prevention and healthy lifestyle program were to
(1) develop policies and guidelines for NCDs and their risk factors, (2) enhance
school health programs, (3) develop various health awareness programs, and
(4) improve HE in the curriculum. Dubai has already implemented important pro-
grams in schools, health awareness programs, and sports activities and events and is
continuing its significant efforts.
Overview of Strategies on Nutrition and Physical Activity
The MOHP in collaboration with WHO developed its first 5-year NNS 2010–2015
with a focus on educating the population on nutrition and creating nutritional
information for fast food (Saberi 2010). One of the objectives of the strategy was
the National Nutrition Survey performed between 2010 and 2012, interested in the
nutritional status of children and youth (up to 19 years old) as well as of adult
females (Ng et al. 2011). We are not aware of other specific targets of this strategy.
The GAYSW Strategy is in its fourth cycle (for 2017–2021) and is following the
Vision 2021 for UAE. The strategy included the following main projects: (1) Com-
munity Sports Programs, (2) Supporting and Motivating Women’s sports, (3) Sports
Facilities Needed, (4) 2020 Olympics, etc. (GAYSW UAE news 2017).
Abu Dhabi has also established its own Childhood Obesity Taskforce which
announced in 2016 its key strategies that included the implementation of programs
to promote PA and a healthy diet, providing services for the families to support
healthy lifestyles for their children, etc. The emirate focused on efforts in schools,
awareness campaigns in the community, and urban planning. The government
agencies involved in the taskforce are the HAAD, the ADEC, the ADFCA, the
SEHA, the ADM, the Urban Planning Council, the ADSC, etc. (HAAD news
2016b).
As reported by the WHO in 2012, UAE had an increasing need in health pro-
fessionals with 80–90% of them being expatriates. The medical schools and colleges
available were not enough to cover the current professional education needs
(WHO 2012).
The MOHP HS as well as the Health Strategy developed by Dubai and the 5-year
strategic plan for Abu Dhabi all highlighted the need for more health professionals
and more training of the workforce. However, they did not particularly discuss the
need for health educators/health promoters. In the Capacity Building Plan of the
HAAD, in the category of allied health professionals, nutritionists and social
workers but not health educators/health promoters were included in relation to
HE/HP, and there was an urgent need to increase their numbers (HAAD 2016e).
Some universities in the country offer degrees in PH. Under the College of
Medicine and Health Sciences, in the United Arab Emirates University, the Institute
of PH offers a master’s degree in PH with a course in HP (UAEU n.d.). In Dubai, the
Hamdan Bin Mohammad Smart University offers also a master’s degree in PH with
the following core areas: epidemiology, biostatistics, behavioral sciences, environ-
mental health, and healthcare management (HBMSU n.d.). Abu Dhabi offers a
bachelor in PH in Abu Dhabi University (ADU n.d.). In addition, in 2008 HAAD
signed an agreement with the Johns Hopkins Bloomberg School of PH for
supporting the healthcare system of Abu Dhabi. Master and doctoral degrees in
PH were planned (HAAD, news 2008a). In 2011, the first 11 Emirati students in the
master of PH graduated (HAAD news 2011b), but we do not know if the program is
still active today. To our knowledge, UAE does not offer any university programs
with training in HP/health education.
Example of Specific Interventions and Initiatives
The ruler of Ras Al Khaimah, HH Sheikh Saud bin Saqr Al Qasimi, founded in 2009
the Al Qasimi Foundation for Policy Research.
Ras Al Khaimah is under the Federal MOH, but there are some independent
initiatives in the emirate. Ras Al Khaimah is interested in preserving its heritage and
natural beauty as well as in creating parks among others for the community
(Al Qasimi Foundation for Policy Research 2015c). The foundation focused on
research, but it has also been part of events and initiatives supporting health and
well-being. In 2014 and 2015, the foundation supported a monthly event on nutrition
and PA awareness, various activities, urban planning initiatives, and activities related
to arts and culture (Al Qasimi Foundation for Policy Research 2015a; Al Qasimi
Foundation for Policy Research 2016).
Implementation
HP.
The Health Strategy for Dubai and the 5-year strategic plan for Abu Dhabi, as
well as the Abu Dhabi Obesity Taskforce, reflect the intentions of these emirates
which have been very active with initiatives to promote healthy nutrition and
PA. The Weqaya program is fulfilling its goals and implementing different initia-
tives in schools, workplace, and the community as well as in screening programs.
As for Dubai, there are also many actions in the same direction, such as
intersectoral work, programs in schools, and awareness campaigns on nutrition
and PA.
The MOE has also implemented initiatives on promoting PA with the 2017 PE
and PA reform for all schools in the UAE, and the GAYSW is constantly supporting
PA in the schools and the community through various activities.
MOHP 2014-2016 Strategy

MOE 2010-2020 Strategy
-Develop a national awareness program (restrictions on
commercials for unhealthy food, caloric content on food -Develop HE and HP in schools
tags etc) (training of staff, contribution
of parents and community)
-Establish a health check-up for all Emiratis
National Program for Government
Communication 2021 UAE Vision 2021
-‘2021 Healthy Children’ campaign: -Preventive medicine (reduce
-Healthy restaurants childhood obesity)
-2021 Steps’, Let’s Walk’, ‘Let’s run’ activities
on PA HP
Abu Dhabi Plan 2014
-Promote wellness and prevention
through community initiatives
(Weqaya Program)
Dubai Health Strategy 2016-2021

-Enhance school health programs Dubai Strategic plan 2021
-Develop various health awareness programs -Develop PA and healthy environments
for the community
-Improve HE in the curriculum
-Develop intersectoral collaborations
-Focus on community participation
GAYSW Strategy 2017-2021

-Develop community sports programs
-Support and motivate women’s sports
-Develop more sports facilities
Abu Dhabi childhood obesity taskforce strategy

HP
2016
-Implement programs to promote PA and nutrition National Nutrition Strategy 2010-
-Support healthy lifestyles for families and children 2015
-Develop awareness campaigns in the community -Educate the population on nutrition
-Focus on school programs -Create nutritional information on fast food
-Urban planning
Fig. 7 Activities/actions related to HP intended by UAE strategies/plans (in colored bold appear
the actions that were implemented). PE physical education, PA physical activity, HE health
education, HP health promotion, PHC primary healthcare, MOE Ministry of Education, MOHP
Ministry of Health and Prevention
However, at the national level, we are not aware whether the health checkup for
the whole population has been implemented. In addition, policies need to be
developed for fast food (advertisement, restaurants, labeling, etc.), and there is a
general need to increase the efforts on promoting especially healthy nutrition in the
community, in the whole country.
Main Results
According to the CCS for WHO and UAE for 2012–2017, there was a need to create
a national health policy and strategy, beyond the health policies of the independent
health authorities of HAAD and DHA. At the MOHP level, there were also require-
ments for development of a national surveillance system for risk factors of NCDs, for
putting more efforts on HP initiatives, etc. (WHO 2012). We were not able to find a
long-term HS or a HP strategy or a recent national strategy on nutrition and PA.
On the other hand, significant efforts of the MOHP have been made at the policy
level for schools, mostly through the MOE. The GAYSW also has its own strategy
and has contributed enormously on sports and PA at the national level.
At the individual health authority level, both HAAD and DHA have done
significant work in HP through awareness work, policies in schools on nutrition
and PA and serious efforts to implement these policies, urban planning and PA
activities through their sports councils, etc.
The HAAD has been leading the way with the Weqaya program that included a
comprehensive surveillance system for the population, surveillance for obesity in
schools, workplace HP, and a unique to the Gulf States labeling system to encourage
manufacturers to produce healthier food for the emirate.
Current Challenges
A major challenge for UAE and for the HAAD and DHA is the shortage of health
professionals with different specializations. Another challenge is the MOHP’s need
to create more policies/regulations on nutrition and PA and to work on HP in order to
provide healthier lifestyles for the Northern Emirates.
Oman
expatriates for Oman (National Center for Statistics and Information Oman 2017).
Oman is divided into 11 governorates with 61 wilayats (districts) (MOH Oman
2014). The Dhofar governorate, the biggest in size at the south part of the country,
together with the Ad Dakhiliyah and the Al Batinah North governorate have each a
population of more than 430.000 inhabitants. The Muscat governorate (where the
capital is) has around 1.5 million inhabitants even though it is not a big governorate
in size. There are two governorates with less than 47.000 inhabitants, and one of
them is the Al Wusta governorate, which is a big area separating the Dhofar
governorate in the south from the Northern Oman (all other governorates) (National
Center for Statistics and Information Oman 2017).
According to the WHO (WHO 2010b), Oman was among the eight best
performing countries in healthcare quality worldwide, and this is a huge success
for a country whose healthcare system has only started being developed in the 1970s,
as an initiative of Sultan Qaboos (WHO 2010b). Oman has eradicated most com-
municable disease (WHO 2010a). However, there is a burden of NCDs with a
prevalence of overweight and obesity for males/females that is comparable to other

Gulf States, as presented in Table 1 (WHO 2014b).
The healthcare system in Oman is decentralized. Each of the Oman governorates
is a health region with the wilayat being the smallest basic unit in the health system
(since 1993). The MOH has delegated to each health region financial and adminis-
trative authority. In addition, the “Hospital Autonomy Initiative” in 2001 has further
decentralized the healthcare system. The decentralization has allowed local initia-
tives, planning, and budget management, resulting in health developments (MOH
Oman 2014).
Oman has 49 public hospitals (National Center for Statistics and Information Oman
2017). Of these, 14 are classified as governorate (regional) hospitals with tertiary and/or
secondary care, 5 wilayat hospitals with secondary care, and 30 local hospitals that
provide PHC. The country has 192 PHC centers in total (MOH Oman 2014).
The PHC is the cornerstone of the healthcare system and is the entry point for
healthcare. The PHC centers provide general, maternal, child care, dietician, and
NCD clinics and HP services through HE. They are also involved in school health
(MOH Oman n.d.-a).
In Oman, all nationals and nonnationals working in the public sector enjoy free
healthcare in public hospitals. For expatriates working in the private sector, their
employers cover their health insurance for having access to healthcare
(WHO 2010a).
Accessibility to health services can be a challenge for Oman, which consists of
81% desert and wadis (dry river beds) that are not inhabited. Mountain (mountain
area 15% and inhabited by 5% of the population) barriers create also problems for
transportation and communication between areas (MOH Oman 2014).
Directorate General of Primary Healthcare

The directorate of PHC includes several departments in relation to HP as shown in
Fig. 5c (MOH Oman n.d.-a).
The ND was established in 2000. The Community Nutrition Section is responsi-
ble both for malnutrition problems in the country as well as for healthy nutrition and
combating obesity in the population. The section develops dietary guidelines and
programs related to nutrition (MOH Oman n.d.-a).
The HE and Awareness Department was established in 1975 as HE Division, and
in 1976 a health educator joined the division. In 1990 it changed into a department.
The department acknowledges HE as not only health information to the public but
education as skill development. The department is responsible for developing and
monitoring programs in the MOH and following up activities, programs, campaigns,
and exhibitions at the governorate level. The department is well equipped for
developing health educational media programs and publications. The department
in collaboration with the media creates also the agenda for TV, radio, and newspaper
presentations and programs related to health (MOH Oman n.d.-a).
The MOH also supports community-based initiatives (CBIs) in the country. A CBI
Department under the General Directorate of PHC exists since 2006 (CBI n.d.-c).
The CBI Department is responsible for (1) creating policies for CBIs and connecting
the programs with the health sector, (2) monitoring the implementation of the yearly
plan for CBIs, (3) supporting them financially and technically, (4) training personnel
for management positions in the CBIs, and (5) developing guidelines for the imple-
mentation of the CBIs (MOH Oman n.d.-a).
Successful examples of CBIs that have worked on health problems included
(1) Wadi Ma’awel Healthy wilayat project in 1994, (2) Healthy Lifestyle program
in Nizwa in 1999, (3) Healthy City in Sur in 2002, (4) Healthy Village in Qalahat in
2002, and (5) Healthy Villages and Neighborhoods programs in four wilayats of
Muscat governorate in 2004. Other examples were the Healthy City in Sohar and the
Healthy Lifestyle program in Salalah in 2006 (MOH Oman 2014).
The CBIs are an important strategy for promoting health through intersectoral
work and community participation. The government of Oman has created the
Healthy Cities projects, the Healthy lifestyle projects, and the Healthy Villages
and Neighborhoods projects.
Department for School and University Health

The Department of School and University Health (established in 1991) provides
health to schoolchildren and health in the community through schools. The major
roles of the department are to (1) develop policies and strategies for school and
university health at the preventive, curative, and health-promoting level, (2) prepare
and monitor the HPS in collaboration with the MOE, (3) integrate health in the
school curriculum together with the MOE, and (4) survey the knowledge, practices,
and attitudes toward health in schools and universities (MOH Oman n.d.-a).
The HPS was introduced in 2004 in Oman, and during the academic year
2004–2005, a plan was developed. In total, 19 schools (2 from each governorate,
8 from urban, and 11 from rural areas) participated for the duration of 2004–2005 to
2008–2009. This program had been a good example of intersectoral collaboration,
and this was largely due to an existing culture of an intersectoral approach in the
MOH and the government.
A central School Joint Committee existed since 1992 that included the MOH, the
MOE, the Ministry of Municipalities, and Muscat Municipality that hold regular
meetings. School Joint Committees had also been created at the governorate level.
The Department of School and University Health was in close collaboration with the
Department of Activities and Students Education at the MOE in particular for
developing and monitoring programs. Nurses were the backbone for school health
and were responsible for implementing HP activities, performing a needs assessment
and a plan of action for health-related issues. A national HPS taskforce was created
as well as a taskforce at each governorate and school level. The national taskforce
was responsible for developing a plan and guidelines, creating material and
launching the initiative at a national level, building capacity of school teams,
conducting a training staff, and monitoring system. At the governorate level, the
responsibilities were to assist schools in planning, training, and monitoring the
initiatives. In addition, parents’ councils played a key role in the implementation of

the programs.
Components of the HPS included skill-based HE, health services and screening,
school physical environment, psychological support, nutrition, PA education and HP
of school staff, and community participation. Raising awareness on health issues and
creating health-supportive environments were major parts of the program for most
schools.
In addition, in order to support each other’s efforts, a network of the partici-
pating schools was created. Both process and impact evaluation revealed positive
results, and schools received a gold, silver, or bronze certificate according to their
performance. The success of the program was due to several factors: existing
intersectoral approach, decentralized system, committed communities, and well-
established parents’ councils. Two major challenges were that schools were
simultaneously involved in similar activities (as initiatives of the MOH and
MOE) and there was a high turnover of the working teams resulting in repeated
training for every new team (WHO 2013a). Due to the success of the HPS, the
program continued and more than 200 governmental schools are currently part of
this network, as reported for 2013.
Wilayat and Local Governance

In 1992, a Community Support Group was created by volunteers. The aim was to
promote breastfeeding. The Community Support Group was a connection between
the community and the health sector. It was followed by the creation of the Wilayat
Health Committees in 1999 with members from different health-related sectors
working to serve the needs of the local community. The Wilayat Health Committees
are headed by the wilayat leader (Wali), and the members from different health-
related sectors are assigned by the director/supervisor of the health services of the
wilayat. These committees identify health problems at the local community level,
support communication between health and other sectors, and raise health awareness
at the community level. Intersectoral players are municipalities, youth, media,
agricultural sector, etc. (MOH Oman 2014).
Oman Olympic Committee

Like some of the other Gulf States, Oman has an Olympic Committee since 2005,
which among others seeks to promote PA and sports in the community as part of
daily life, to support the concept of sports for all, and to involve the media, academia,
and other sectors to achieve these goals (OOC n.d.).
National 5-Year Health Plan 2011–2015

In the Oman Vision 2020, one of the main objectives was to enhance the standard of
living of the citizens and reduce disparities among regions and different income
groups (Supreme Council for Planning Oman n.d.).
The MOH had a national health policy created in November 1992 that underlined
equity, HP initiatives, intersectoral collaboration, the PHC system as a cornerstone,
responsiveness to the needs of the community, and community involvement in the
planning and development of the healthcare (MOH Oman 2014).
The health development plans of Oman have seen three major phases of which
the first (1976–1990) focused on building the health infrastructure from zero, the
second (1991–2005) was the phase that saw the decentralization to health regions/
governorates and wilayats, and the third phase still continues and builds upon the
existing knowledge of the previous phases. The seventh plan (2006–2010) and the
eighth plan (2011–2015) are the two plans of the third phase. Every Health Plan is a
5-year plan, and the planning is happening at the national (overall goals and
objectives), regional (more specific health projects), and local (Wilayat) (short-
term 1 year health projects) level (MOH Oman 2014).
The eighth 5-year plan of 2011–2015 had the following strategic objectives in
relation to HP: (1) strengthen the prevention and control of NCDs and encourage
healthy lifestyles and (2) strengthen and spread the concept of HP. This plan
developed 12 visions. Among the visions, 5 and 6 were the dissemination of healthy
lifestyles in the community and better nutrition for all. In order to define specific
actions, 35 domains of interest were developed, among which were NCDs (part of
vision 3), HE and communication, adolescent and youth health, school and college
health (part of vision 5), nutrition (part of vision 6), and community participation
(part of vision 7).
Noncommunicable Diseases (Vision 3)

For the NCDs some of the targets were to reduce the risk factors of NCDs and to
achieve early detection. The country had already taken actions such as the creation of
a national screening program in all PHC centers for early detection of chronic
disease in 2007. Some of the strategies during the Plan 2011–2016 were the
implementation of the National Diet, PA, and HS, to activate the national screening
program for early detection of NCDs with media coverage, to include individuals of
30–40 with obesity or family history of disease in the screening program, to increase
manpower in nutrition and HE, to expand the well-being clinics in the PHC system,
and to expand the Healthy Villages and Cities programs from four to eight. Among
the indicators for the strategies were the banning of trans fat, regulation of the
amount of salt in food, expansion of the well-being clinics in the PHC system
(from 15 to 50), expansion of the Healthy Villages and Cities programs (from 4 to
8), number of regions which implemented the National Nutrition, PA, and HS
program (0 to all), and percentage of annual coverage of the target group in the
national screening program in group age 40 and above (from 37% to 70%) (MOH
Oman n.d.-b).
To our knowledge, Oman has not yet banned trans fat from products. As for salt
reduction, Oman has reduced the salt content in bread by 10% through the public
bread suppliers (WHO EMRO 2015). In addition, the Ministry of Manpower had
issued since 2008 a regulation at the workplace with a healthy nutrition and PA
promoting component, but we have no evidence of its implementation in different

organizations/agencies (Ministry of Manpower Oman 2008).
Health Education and Communication (Vision 5)

For the HE and communication, the targets were to develop and improve the HE
services, capacity building, and skill development of the MOH staff that work on HE
and to increase health awareness in the population for achieving a healthier lifestyle.
The specific strategies included the expansion of the number of health educators;
updating the curriculum of health educators; training healthcare workers on HE,
social marketing, and communication; studying the existing knowledge and attitudes
of the community; unifying health messages across sectors; and evaluating the
impact of HE and awareness programs. Some important dissemination/implementa-
tion indicators were the creation of a comprehensive HE and a communication
strategy; the number of health educators enrolled in the MOH annually (from 2 to
30); the number of HE material printed (from 27 to 70 yearly); audio (from
0–5 yearly); the number of health messages broadcasted in the media in TV (from
60 to 100), radio (not available to 100), and press (from four to 150); the number of
health programs implemented in the media on TV (from 51 to 100) and radio (from
99 to 150); and the number of health messages developed in collaboration with other
sectors (from 27 to 50) (MOH Oman n.d.-b).
In 2016, the MOH had suggested banning advertisement of junk food as another
measure to combat obesity, but the regulation was at its first phase and would need
2 years to be fully implemented (‘Junk food ads could be banned’ 2016).
Adolescent and Youth Health (Vision 5)

For the adolescent and youth health, the targets were to promote the role of PHC as
an actor for health for them at the regional level and to increase health awareness for
them. A study by the MOH revealed that there were no dedicated health services for
this age group and that HE programs should be created that are costume-made to the
needs of this part of the population. The strategies suggested were training of health
workers in adolescents’ health; provision of health counseling for them; develop-
ment of educational packages on PA, nutrition, etc.; and strengthening the partici-
pation of CBIs in supporting adolescents’ health. Some indicators suggested were
the number of adolescents’ clinics in PHC (11 to 61), the percentage of health
educators trained for adolescents’ health (from 9% to 80%), the percentage of health
institutions providing counseling (from 6% to 80%), the number of educational
material published at the PHC level (from 1–2 to 5–7 activities per institution
annually), the number of educational material published at the regional level (from
0 to 1–2 per region), and the number of wilayats including adolescents in their health
activities (from 50 to 61) (MOH Oman n.d.-b).
School and College Health (Vision 5)

For the school and college health, the targets were to promote healthy lifestyles in the
school community for all regions, to develop and expand health services at schools,
and to promote health of students at higher educational institutions for all regions.
According to the MOH, a comprehensive school health program includes “HE,

school health services, a healthy, safe and supportive environment, nutrition promo-
tion, PA and mental HP as well as promotion of school staff health and community
participation.” In 2008, the Department of School and University Health developed
the National School HS. In 2010, 100% of schools had comprehensive school health
services.
The strategies included expansion of the national HPS initiative network and
implementation of HP for students, implementation of peer education for children
and students, monitoring of high-risk behaviors in schools and higher educational
institutions, training and HE programs for school staff, HE programs for parents,
continuous implementation of the national school HS in collaboration with other
sectors, and strengthening the structure of the Department of School and University
Health and school sections in all regions in order to supervise and monitor health
programs. Important indicators suggested were the percentage of schools joining the
national HPS network (from 20% to 60%), the number of HE sessions conducted for
school staff (from 3 sessions for 20% of the schools to at least 3–5 session for all
schools annually), the number of HE sessions conducted for parents (from 2 sessions
for 20% of the schools to at least 2–4 session for all schools annually), the number of
training courses on peer education (from 46 to 165), periodic monitoring system for
risk factors among students (present but incomplete), the percentage of schools with
a full-time school nurse (from 0% to 100%), the percentage of higher education
institutions that were declared health-promoting institutions (from 0% to 25%), the
percentage of schools with comprehensive health services for school staff (20% to
100%), and the percentage of high education institutions with HE programs (80% to
100%) (MOH Oman n.d.-b).
A healthy eating pilot scheme was tested in 2017 in three governmental schools,
where healthy meal options were provided until the end of the school year. If
successful, it would be implemented in all schools in Oman (Al Haremi 2017).
Nutrition (Vision 6)
For nutrition the targets in relation to HP were to promote food and nutrition policies
and strategies. In 2010 there was no national food and nutrition policy; no protocol
determining the nutritional part in the National Diet, PA, and HS; no protocol
determining nutrition programs in the Healthy Lifestyle projects; and no protocol
to control overweight and obesity in the community. Strategies included the creation
of a taskforce to establish a national nutrition policy; the implementation of nutri-
tional activities in the National Diet, PA, and HS; the incorporation of nutritional
objectives in the Healthy Lifestyle projects; and a focus on obesity prevention and
implementation of the communication strategy of the Omani food-based nutritional
guidelines. Some indictors were the percentage of qualified dieticians in PHC (0% to
20%), the number of institutions with nutrition clinics (20% to 50%), and
the percentage of governorates implementing the communication strategy for
the Omani food-based nutritional guidelines (not available to 100%) (MOH Oman
n.d.-b).
The nutritional guidelines were created in 2009 and were mainly addressed to
health workers/professionals rather than to the public (Alasfoor et al. n.d.). A similar
document was also published in 2009 called the Omani Guide to Healthy Eating
(ND MOH Oman 2009). In addition, a National Long-Term Nutrition Strategy
2014–2050 was developed by the ND that we will discuss below.
Community Participation (Vision 7)

For the community participation, the targets were the implementation of the HP
strategy and the improvement of the mechanisms for community participation. In
2010 there was no intersectoral plan of action related to the HP Strategy 2010–2015.
The HP strategy was established by the CBI Department with the following main
aims: (1) to develop an organized leadership that supports HP programs, (2) to build
HP capacity at multiple sectors, and (3) to monitor the different programs and
policies (particularly on diet, tobacco, and PA) created and implemented by different
sectors (CBI Oman n.d.-b). Strategies in the plan included the creation of a National
HP Committee, capacity building of health workers on HP, the development of
evaluation mechanisms for HP activities, the establishment of community informa-
tion centers in all Healthy Villages, following up implementation of plans at the
wilayat and community levels, and training members of the Wilayat Health Com-
mittees on CBI. The indicators for this domain were the percentage of educational
institutions that include HP in the curriculum (from 0% to 20%), the percentage of
activities carried out from the HP Strategy (from 0% to 60%), the number of CBIs
implemented (13 to 25), the percentage that completed all implementation stages
(from 5% to 100%), the number of trained people for managing CBIs (from 20 to
50), the number of villages that have a community information center (from four to
25), and the number of CBIs (from 35 to 60) (MOH Oman n.d.-b).
The above strategy is very explicit on the targets/indicators it wants to achieve
(the most specific of all the Health Strategies in the Gulf States). Unfortunately, we
were not able to find a report that would document the advancements for process
(e.g., capacity building on HP) and outcome indicators (e.g., number of CBIs) at the
end of the 2015 Strategy.
However, based on information given on the situation in 2010 and on the
indicators that need to be improved, we can conclude the following: (1) continuous
improvement of the existing good PHC system in order to reach the whole popula-
tion; (2) enhancement of the national screening program for risk factors of CVD in
order to reach a good part of the population; (3) increase of the number of wellness
clinics and CBIs; (4) acknowledgment of the lack of health educators/health pro-
moters and of their importance; (5) expansion of the existing HPS initiative and
focus also on school staff and parents, as well as on a better monitoring system of
risk factors for children; and (6) enhancement of the existing CBI network in terms
of follow-up, evaluation of health-promoting activities, etc.
Oman Health Vision 2050

The MOH of Oman published in 2014 the Health Vision 2050 for the country, which
is the most long-term vision any of the Gulf countries has published (MOH Oman
2014). Five-year Health Plans would implement the different suggestions/actions of

the vision (continuation of the previous 5-year plans).
As for the specific visions related to HP, they were identified in (1) the health
services and (2) the intersectoral partnership and collaboration sections.
As for the health services, the PHC was already established as the cornerstone of
the system but still needs to direct itself more toward HP and prevention to combat
NCDs. Among the four visions, Vision 1 was a “Strong, responsive and sustainable
PHC system as the main entry point and backbone of Healthcare.” Actions included
adding elements of promoting and preventive nature in the PHC centers, enhancing
community participation, incentivizing and budgeting PHC centers individually
according to needs and achievements, etc.
Concerning the section on intersectoral partnership and collaboration, all
three visions were relevant to HP. Vision 1 “Intersectoral partnership is a vehicle
for health development,” Vision 2 “Intersectoral and population health approach
institutionalized,” and Vision 3 “Health is the responsibility of everyone” all
included actions that support HP. Vision 1 suggested building trust and strong
working relationships among sectors, involving politicians in health and well-
being, as well as building public awareness on health and well-being. Vision
2 included actions such as to create a specialized body in the health system that
would develop and supervise intersectoral collaborations (MOH Oman news
2017) and to develop PH policies and health goals for every governorate. Vision
3 actions were to develop policies that would ensure that the private and PH
sector take responsible actions for ensuring the well-being of the community and
the protection of the environment (in areas of industry, agriculture, etc.); to
adopt strategies to encourage the individuals to be active in seeking health
information and to participate in community-organized events and initiatives;
and also to introduce and emphasize health beliefs as early as in school (MOH
Oman 2014).
National Nutrition Strategy 2014–2050
A need for a plan with a focus on nutrition has been mentioned in the recent Health
Plan of 2011–2015. A long-term NNS for 2014–2050 was created by the ND (ND
MOH Oman 2014). However, we were unable to find the National Nutrition, PA, and
HS that was mentioned in the Health Plan.
In the 2014–2050 Strategy, there were three main domains outlined: (1) health
and nutrition, (2) food security and quality, and (3) physical fitness through active
living. The first was concerned with obesity among others, and an intersectoral
approach involving different agencies such as the MOE, Commerce, Agriculture,
etc., was pointed out as important for fighting the obesity epidemic. The second
domain focused on decreasing the importation of processed food to <30% by 2050
(through cooperative agreements) and introducing fees for non-healthy food and on
local food self-sufficiency and diversity (through organically grown fruit and veg-
etables) with rural and urban gardens for up to 80% of the households. The third
domain was interested in creating urban green spaces and pedestrian routes in all
cities as well as in intracity travel.
In order to implement the above, the government needed to (1) develop an
intersectoral approach, (2) create a public nutrition knowledge base, and (3) improve
national and local capacity in public nutrition. For the intersectoral approach, a
National Board of Public Nutrition as well as an intersectoral Public Nutrition
Technical Committee needed to be created and establish a national nutrition policy.
The board would also be responsible for funding nutrition interventions. For the
nutrition knowledge base, a national nutrition survey was needed. In 2016, a survey
was initiated and focused on children under 5-years old and women at reproductive
age, probably as a starting point for a bigger nutrition survey (MOH Oman news
2016a). As for capacity in public nutrition, there was a limited availability of
nutritionists trained for public nutrition mostly there is an expertise in clinical
nutrition.
In the Nutrition Strategy, some suggestions during a short workshop for
intersectoral action were provided: MOE (education activities and awareness pro-
grams on nutrition), Ministry of Commerce and Industry (regarding importation of
food and importation fees for unhealthy food), Ministry of Social Development
(access to organizations and research on social determinants of nutrition), Ministry
of Regional Municipalities and Water Resources (food safety, parks and green areas),
and Ministry of Agriculture (National Nutrition Survey with MOH; monitoring and
evaluation of nutrition programs, farm schools, school gardens, and home gardens;
marketing of food to influence consumption patterns). Other ministries were to join
the effort such as the Ministry of Sports Affairs responsible for promoting sports for
the whole population and especially for youth and for implementing sports facilities
and creating sports events in the country.
As part of improving nutrition and increasing PA, recent efforts were the national
campaign on PA launched in 2016 called “Health begins with one step” that lasted
1 year and would (1) increase awareness on PA and existing PA/sports facilities,
(2) encourage the community to participate in sports programs, and (3) develop a
number of activities in schools, malls, etc. (MOH Oman news 2016b). Another
example was the already existing outdoor PA facilities in Muscat (hiking, biking,
running and walking tracks, beach volley, etc.) (Nair 2016).
The Nutrition Strategy was ambitious and acknowledged the importance of
assessing the current situation, creating a national plan of action, and establishing
committees dedicated to nutrition programs. The strategy gave some concrete
examples of actions but did not go as far as developing indicators, expected out-
comes, setting a timeline for actions/programs, etc.
Oman is like all Gulf States in the “Omanization” process that is difficult to achieve
considering also the increasing needs of the country in healthcare manpower and
specialized workforce. However, the country is achieving results with (1) a total
Omanization of 70% in 2010 and (2) for different health professions such as health
administrators (98% Omani), dieticians (99% Omani), health educators (100%
Omani), nurses (67% Omani), etc. The Health Plan 2011–2016 also provided
strategies to achieve better results and indicators to be reached but did not have
any specific indicators on health educators/nutritionists/health promoters. Some
important actions were also highlighted in relation to human resources and HP:
(1) capacity building of health workers in HP, (2) expansion of the number of health
educators in the MOH (from 2 to 30), and (3) increase of the manpower in nutrition
(MOH Oman n.d.-b).
The MOH had developed a plan for education and training in basic educational
programs for health professions by establishing educational institutes in most of the
governorates. In addition, the MOH supported the specialized postgraduate education
programs for nurses (since 2001) such as nursing management, HE, etc. (MOH Oman
n.d.-b). The Oman Institute of PH (since 1991) had been created to support this
discipline (MOH Oman 2014). Finally, the College of Medicine and Health Sciences
has a Department of Family Medicine and PH (Sultan Qaboos University n.d.).
To our knowledge, there are no bachelor programs in HE/PH/HP in Oman. It is
unclear to us whether there are master programs in these specialization (for nurses it
is not specified if the postgraduate program is a master degree or not).
The Health Vision 2050 discussed the upcoming University of Oman with
“Faculty of Medical Sciences and PH” and the establishment of “School of PH”
(unclear under which institution) and also suggested a bachelor in PH in the
proposed educational framework for the future (MOH Oman 2014).
At the governorate level, the “Let’s rise” project in the governorate of the South
Sharqiyah that comprises five wilayats (administrative division) and has around
360.000 inhabitants was initiated in 2013. The communication campaign finished
in 2013 but the PA activities are ongoing. The project focused on PA, tobacco
consumption, healthy nutrition, and accidents. The project included the following
components: (1) HE of PHC professionals, (2) school interventions, and (3) commu-
nity interventions. For the schools there were open days for sports in schools, cycle
race, volleyball competition, and HE activities. Community interventions included
competition for ideal body weight (wilayat of Sur), open days for sports in commu-
nity leisure centers, and a local football league for youth. The evaluation was based
on annual reports from each of the five wilayats. Overall 70 schools and 20 PHC
centers participated in the project, and more than 350 lectures were delivered. Major
advantages of the project were the involvement of community leaders and stake-
holders, the work in partnership to implement the activities, a good planning of the
project with the best use of available resources, and the inclusion of the activities as
part of the daily activities of schools and PHC centers. Some challenges of the
project were the high burden of interventions in schools, a limited budget, and an
overwhelming number of activities (WHO EMRO n.d.-d).
One very known project is the Nizwa Healthy Lifestyles project at the Nizwa
wilayat district (Ad Dakhiliyah governorate) that is inhabited by over 80.000
people and comprises 120 communities. The project started in 1999 and is
ongoing. In the direction of PA the following was done: (1) the “Move for
Health” program was integrated into the primary schools curriculum (both gen-
ders) and included training of teachers (teaching modules, teachers’ and parents’
guide), (2) supportive environments (two gymnasiums were built in schools, one
in the women association, and three walking pathways in different communities),
(3) awareness-raising campaigns (events in the community, newspapers, radio
interviews, etc.), and (4) increasing capacity of health professionals (training and
skill development, together with guidelines for better serving the population at
high risk for NCDs). Results from 2001 to 2010 included an increased partici-
pation in PA (from 40% to 71%) and awareness of PA as a risk factor (from 7% to
93%), and about 50% of the participants reported to have changed their lifestyle
because of the project. However, some of the challenges of the project were the
limited decision-making authority in some cases, limited experience in commu-
nity management, and a big volume of interventions for schools (WHO EMRO
n.d.-f).
Another successful example at the wilayat level was at the Al Khaboura
wilayat (Al Batinah governorate) for combating obesity. This district is
inhabited by about 5.000 people, and a survey on obesity was performed in
2007 on a small sample since this area seemed to have particularly high levels of
obesity. The survey showed that 57% of the population was either overweight or
obese. The project intended to raise awareness on PA and diet, assess the
availability of food in the local supermarkets and substitute with better choices
and encourage PA in the community, establish walking paths, create supportive
environments for PA especially for women, and improve the health of obese and
diabetics in the wilayat. Many of the above targets have been already achieved
(CBI n.d.-a).
At the local level, an example is the Qualhat Healthy Village project and was
initiated in 2002. Key intervention activities were at schools, raising awareness on
PA in sablla (where people gather in the village), the development of a walking
pathway, competition on football and cycling, etc. (WHO EMRO n.d.-e).
Implementation
HP.
The main document on health planning was for 2011–2015, and there is no report
stating the advancements in that period. Certainly, important achievements have
happened, since this 5-year Health Plan is the continuation of work that has been
started previously (CBIs, wilayat decentralization, school health, etc.).
In addition, we do not have any information on the progress of the brief HP
Strategy 2010–2015 neither on the NNS 2014–2050 which is a long-term strategy.
Oman national health policy-1992 8th health 5-year plan 2011-2015

-Equity -Adolescent and youth health (vision 5):
-HP initiatives Train health workers in adolescents health
Expand the number of adolescents clinics in the PHC
-Intersectoral work
Create educational packages for adolescents on nutrition and PA
-Community involvement
Strengthen the participation of CBIs in adolescent health
-PHC as cornerstone -School and college health (vision 5):
Expand the HPS initiative
Develop HE programs for school staff
Continuous implementation of the national school HS
Strengthen the Department of School and University Health
-Nutrition (vision 6):
8th health 5-year plan 2011-2015 HP Develop food and nutrition policies
-NCDs (vision 3): Establish a national nutrition policy
Screening program in PHC centers for the whole population Implement the nutritional objectives of the Nutrition, PA and Health
on NCDs Strategy
Implement the national nutrition, PA and health strategy Implement the communication strategy for the Omani food -based
nutritional guidelines
Expand the wellbeing clinics in the PHC
-Community participation (vision 7):
Expand the Healthy Cities and Villages programs
Implement the HP strategy
Ban trans-fat
Focus on capacity building of health workers on HP
Regulate salt in food
Establish community information centers in all Healthy Villages
-HE and communication (vision 5):
Follow-up implementation plans at the local and wilayat level
Increase the number of health educators
Develop evaluation mechanisms for HP activities
Improve the HE programs
Unify health messages across sectors
Evaluate the impact of HE and awareness programs
Create a comprehensive HE strategy
National Nutrition Strategy 2014-2050

-Reduce obesity Health Vision 2050
-Decrease processed food import to less than 30% -Add elements of HP in PHC
-Increase local produce of vegetables and fruit
-Enhance community participation
-Introduce fees for non-healthy food
-Develop rural and urban gardens
-Create more urban green spaces and pedestrian routes
HP -Develop intersectoral work
-Build public awareness on health and
wellbeing
-Create a national board of public nutrition
-Create a specialized body that will supervise
-Develop a national nutrition survey
intersectoral work
-Increase the number of nutritionists trained in nutrition
for the general population -Develop PH policies and goals for all governorates
-Promote PA (schools, community, malls etc) -Develop HiAP
-Enhance HE in school and community
Fig. 8 Activities/actions related to HP intended by Oman strategies/plans (in colored bold appear
the actions that were implemented). PE physical education, PA physical activity, HE health
education, HP health promotion, PHC primary healthcare, HiAP Health in All Policies, NCDs
noncommunicable diseases, CBIs community-based initiatives
Main Results
The MOH has achieved important health advancements since 1970. However, due to
the country’s topography, significant efforts are still needed to reach remote and
isolated areas. The establishment of the wilayat system with local health governance
is a great example of a tailor-made approach that can serve the local needs of each
community. CBIs are also a part of this work, and a considerable number of such
projects have been successful. At the same time, there is a continuous effort to equip
and enhance the wilayat as independent entities through improved local manage-
ment, additional financial support, local information centers, health educators, and
nutritionists at the wilayat level. This decentralized system is also the best frame-
work for applying HP strategies.
Oman has shown already extensive intersectoral work and is the only Gulf State
with 5-year Health Plans since 1970. In its plan for 2011–2015, the importance of HP
is discussed in detail, and specific, measurable actions are suggested. In addition, the
expansion of the HPS initiative is highlighted. A HP strategy has also been devel-
oped, but there is no detailed action plan. Similarly, an action plan for the coming
years needs to be developed for nutrition and PA. Policies for schools and for fast-
food consumption/food labeling also are needed. Finally, significant work needs to
be done to reach the required numbers of health educators, health promoters, and
nutritionists in the country through the development of new bachelor/master degrees
provided by public universities in the country.
Current Challenges
Oman has an established healthcare system offering high quality of care. However,
the existing decentralized system needs further support on levels such as leadership
and management, funding at the local level, capacity building of health educators
and nutritionists at the wilayat level, supervision of the implementation of projects at
the wilayat level, etc.
Another important challenge is the reform in the educational institutions to
achieve appropriate workforce for HP/HE and achieve high levels of “Omanization.”
Summary and Conclusions
All Gulf States according to data from 2014 have a serious obesity problem with
obesity prevalence being from 23% in Oman to 34% in Qatar for males, from 34% in
Oman to 45% in Qatar for females, and with women having higher prevalence
compared to men in all Gulf countries. For overweight and obesity together, again
Oman had the lowest prevalence for men (61%) and women (66%) and Kuwait and
Qatar the highest prevalence for men (73% and 72%, respectively) and for women
(74% and 75%, respectively) (Table 1).
All of the Gulf States focus to some degree on prevention and have implemented
different programs related to HP, as have been suggested in the action plans and
strategies for the Eastern Mediterranean Region and in the Political Declaration of
the High-level Meeting of the General Assembly on the Prevention and Control of
NCDs. However, some of them largely focus on awareness campaigns and HE work
in the form of information such as Saudi Arabia, Kuwait, and Bahrain. This might be
due to the dominant concept of risk as a property of the individual and the individual
responsibility to reduce the exposure to risk.
HP using policies and environmental changes is still weak, especially

in Saudi Arabia, Kuwait, and Bahrain which largely rely on information
campaigns targeting individuals.
At the same time, Gulf States have the advantage of being wealthy societies
allowing for multiple actions on HP at different levels. Such examples are the
Weqaya program in Abu Dhabi; an initiative with health-promoting activities in
malls in Bahrain; wellness health centers with available gyms, cooking classes, etc.;
an initiative in supermarkets for educating the consumers; an online PH survey in
2017 on residents’ opinion on health issues in Qatar; the program “Health in your
House” in different UAE emirates where diabetic patients are provided with devices
at home for exercising; the creation of a sports map with available sport facilities for
UAE; gym and sports equipment in parks and tracks in Abu Dhabi and Dubai;
“Healthy restaurants” with restaurants voluntarily developing healthy menus for
children and adults; and well-being clinics in Oman.
Multiple original HP initiatives are developed especially in Qatar

and UAE.
Among Gulf States, Oman has achieved a very quick development in healthcare,
as in the “WHO Health Report 2010” it was the eighth best performing country
among 100 countries in total.
Oman is also the only Gulf State with a 5-year Health Plan that includes regional
and local planning (with 1-year projects for wilayats) since the 1970s, showing a
close focus and care on healthcare progress and improvement. Oman is also the Gulf
State with the longest health vision (until 2050). Qatar and Oman are the two
countries with the most extended health plans (indicators, specific projects, and
actions) in relation to HP. In addition, the Oman Vision 2050 is the only health-
related document among all Gulf States that discusses specific actions that need to be
taken for HP: (1) intersectoral work supervision, (2) development of PH policies for
every governorate, (3) development of policies that ensure that there is HiAP in the
private and public sector, and (4) evaluation of the impact of applying a
decentralized system for 20 years.
Oman has (to a degree also Qatar) extended plans on HP and

discusses specific and important actions such as the creation of a body that
supervises intersectoral work across different sectors.
Oman and Kuwait have a decentralized healthcare system, and in UAE, Abu
Dhabi and Dubai have their own health governance (Table 3). Oman had developed
a system as early as 1993 with the wilayats (districts). Saudi Arabia is the other big
Gulf State together with Oman that would benefit from decentralization because of
the presence of remote/isolated areas and especially for Saudi Arabia because of big
population demands.
Table 3 Health promotion-related activities/functions in the Gulf States
38
KSA Kuwait Bahrain Qatar United Arab Emirates Oman

Responsibility No Yes No No Yes (Dubai, Abu Dhabi) Yes
delegated to
regional/
municipality level
National strategy on Yes (2014–2025 Yes (2013–2017 very No Yes No (Abu Dhabi with Yes
nutrition and/or PA very preliminary) preliminary) (2011–2016 Weqaya-2008) (2014–2050
and very
2017–2022) preliminary)
Health promotion/ Yes, health Yes, health Yes, health Yes, health Yes, health education Yes, health
health education promotion promotion promotion promotion department under MOHP education
department department department department department department
Intersectoral work No Yes, partially Yes, partially Yes Yes Yes
(2013–2017 project) (schools)
Health education/ Yes (bachelor in Yes, partially Yes, partially Yes partially Yes partially No
health promotion Health Education/ (bachelor in Health (bachelor in (bachelor in (bachelor and Master in
university programs Health Promotion) and Community Community Health Public Health) Public Health)
Studies) Nursing)
Health educators/ Insufficient Insufficient Not clear Insufficient Insufficient Insufficient
health promoters
Healthy Cities Yes No No No No Yes
project
Community Yes, partially Yes, partially (in the Yes Yes Yes Yes
participation (in the Healthy 2013–2017 project)
Cities projects)
Systematic nutrition No Yes No No No No
surveillance system
Obesity No No Yes, partially Not clear Yes (Abu Dhabi) No
surveillance at (children
school 13–15 years old)
977
Oman has a decentralized system with wilayats as the smallest

administrative units.
As for PHC, all Gulf States are putting efforts in integrating health-
promoting activities in the PHC and in making the PHC centers the only
point of entry in healthcare which is already established for Oman and UAE.
In Bahrain, PHC is a main actor for the school health programs. In Qatar, there
is a separate entity, the PHCC with its own strategy for 2013–2018. The
strategy suggested various interesting actions of the PHC such as workplace
HP for the MOH and PHCC, school health, the development of community
health centers and wellness centers, a patient consultative council, screening of
the population for risk factors of NCDs, etc. Some of them have been
implemented (school health, community health and wellness centers, and
interaction with the community).
More work is needed in PHC for integrating health-promoting

activities in PHC clinics; Qatar shows some good examples.
A very important aspect of HP is intersectoral work. Saudi Arabia and Kuwait
do not yet present such efforts with the exception of suggestions for improve-
ment in urban planning. All other Gulf States underline the importance of
intersectoral work in their strategies and implement it in various degrees with
Abu Dhabi, Dubai, Oman, and Qatar being very good examples of applying
HiAP:
1. The development of the national healthcare strategy 2011–2016 for Qatar as a

common effort of many actors (Ministry of Interior, Supreme Council for Family
Affairs, Permanent Population Committee, etc.)
2. The collaboration of academia and media for HP work in Qatar
3. Various collaborations of the HAAD, the Abu Dhabi Police, the UAE Football
Association, the Abu Dhabi Media Company, the Environmental Agency of Abu
Dhabi, the Abu Dhabi Education Council, the Ministry of Labor, the Abu Dhabi
Food Control Authority (ADFCA), the MOPH, etc. on HP such as for the Weqaya
programs
4. The development of the Dubai HS 2016–2021 in collaboration with community
sectors and many stakeholders
5. The “UAE School Specification for Healthy Foods Committee” with DHA,
HAAD, MOHP, MOE, DM, and some universities for the implementation of
nutritional guidelines in the schools and canteens in UAE
6. A School Joint Committee (since 1992) of the MOH, the MOE, the Ministry of
Municipalities, and Muscat Municipality that hold meetings in relation to school
health in Oman
7. The Wilayat Health Committees that are the connection between the community
and the government and are the ones responsible for intersectoral work at the
local/wilayat level in Oman
Abu Dhabi, Dubai, Qatar, and Oman show the best examples of
intersectoral work.
Some of the Gulf States do not have a national HP strategy or a national strategy on
nutrition and PA. Saudi Arabia and Kuwait have done some efforts toward this
direction, although not sufficient (very preliminary, very general, with no specific
programs, or short-term programs). Bahrain has not developed such a strategy neither
has UAE nor Dubai. On the other hand, Abu Dhabi (Weqaya program) and Qatar have
developed more elaborate strategies and have to some degree implemented them.
Finally, Oman has developed specific projects and actions for HP, within its Health
Plan for 2011–2015, but there is no extensive, independent work/strategy on HP or
nutrition and PA. A common problem in Gulf States is the lack of (1) specific actions/
programs described, (2) specific governmental actors/participators, (3) implementation
indicators, and (4) follow-up of all the initial targets. More policy-related professionals
might be needed in order to develop elaborate HP strategies.
On the other hand, all Gulf States have a HP/HE department, but in Saudi Arabia,
Kuwait, and Bahrain, there is no major involvement of the department in HP. Oman
is the only country that has a CBI Department due to its numerous initiatives through
the wilayats and governorates.
Abu Dhabi, Qatar, and Oman have strategies on HP, but there is a
need for more elaborate efforts in all Gulf States (implementation indicators,
follow-up, etc.) for strengthening the role of the HP departments.
All Gulf States face problems in nationalizing their health professionals and in
particular their health educators/health promoters. Most significant efforts have been
achieved in Saudi Arabia, but the country has also higher demands compared to all
other countries in the region. Saudi Arabia is the only country that offers a bachelor
in HE/HP, whereas the other Gulf States (with the exception of Oman) offer a
bachelor in PH/Community Health. However, these are broader fields of knowledge,
and more specialized bachelor/master degrees are needed in order to deliver com-
prehensive HP strategies/programs for each country.
Among the Gulf States, the need for health educators/health promoters is often
not a target in their strategies, nor is there a plan for achieving higher numbers/better
professionals in these fields (with the exception of Oman). Instead, other health
professionals receive training (seminars, workshops, diplomas), but in reality, they
cannot offer the same quality of work.
There is an increased need in health educators/health promoters in

all Gulf States, and more efforts should be put in developing strategies and
developing more academic departments on HP/HE.
Community participation is another very important indicator for HP. Some Gulf
States have invested in community participation. Such examples are the National
Program for Healthy Living 2013–2017 in Kuwait where representatives of the

population were part of the decision-making process, participation in decision-
making for the PHC in Qatar, parents’ involvement and community participation
for PA in schools and sports for children in Abu Dhabi, activities of the Dubai Sports
Council that involve community groups/volunteering, the development of the Dubai
HS 2016–2021 after consultation with community sectors and government
employees, and the wilayat system in Oman through citizens participating in and
developing projects/activities.
As presented in Table 3, only Oman and Saudi Arabia to a small degree have
developed Healthy Cities (Kuwait is interested in developing Healthy Cities as well),
which are HP initiatives at the whole-of-community level. Oman has an extended
network of local initiatives due to its decentralized system through wilayats. These
include Healthy Wilayats, Healthy Villages, and Neighborhoods and Healthy Cities.
Community participation is still weak in most Gulf States, but in

Oman it is facilitated through the wilayat system.
Healthy Cities exist in Saudi Arabia and more extensively in Oman.

Kuwait is the only Gulf State that performs a yearly national nutrition survey.
This kind of survey is not a common survey not even among European countries and
provides a wealth of information on obesity levels, PA, and nutrition and also
evaluates the impact on obesity of different measures/policies implemented. Another
very important initiative in surveillance is the Weqaya program in Abu Dhabi with a
screening for risk factors for NCDs for all nationals of the emirate. The Weqaya also
incorporates interventions and provide a good model of health-promoting activities
and subsequent evaluation of them. Finally, Oman had in 2007 a national screening
program for the early detection of NCDs but is not currently active.
Some important follow-up/surveillance initiatives are the National

Nutrition Survey in Kuwait and the screening for risk factors for NCDs in Abu
Dhabi.
Table 4 summarizes different policies related to nutrition and PA:
• An interesting initiative was the suggestion for banning of soft drinks and junk
food in hospitals for patients and the personnel in Saudi Arabia, Bahrain, and
Qatar. The latter has put an effort in implementing the policy.
• All Gulf States have had a suggestion for banning advertisement of junk food
especially for children, but none has implemented it yet. Promotion of healthy
food and PA through various activities in schools has been either suggested
(Saudi Arabia and Kuwait), partially implemented (Bahrain, Qatar, and Oman),
or fully implemented (Abu Dhabi and Dubai) by the Gulf States. Abu Dhabi and
Dubai are the only two examples with an implemented health screening policy in
38
Table 4 Policies/regulations on nutrition and physical activity being implemented in the Gulf States
Hospitals
Regulation on junk food Yes (suggested, No Yes (suggested, Yes No No
and healthy options in 2016) 2015) (healthcare
hospitals implemented, NA implemented, facilities,
NA 2017) and
implemented
Schoolchildren
Regulation on Yes (suggested, Yes (suggested, Yes (suggested, Yes Yes (suggested by the Yes
advertisement of junk 2014) 2013) 2011) (suggested, MOHP, 2014) (suggested,
food/soft drinks for implemented, NA implemented, NA implemented, 2017) implemented, NA 2016)
children NA implemented, implemented,
NA NA
Promotion of healthy Yes (suggested for Yes (suggested, Yes (2014) Yes (2013) Yes (Abu Dhabi, 2011) Yes (HPS
food and PA in school 20% of the total 2010) partially partially and implemented schools, 2004
policy through various schools, 2017) implemented, NA implemented implemented Yes (Dubai-2017) and and CBIs)
activities (including implemented, NA implemented partially
educational) implemented
Health screening policy No No Yes (2014) Yes Yes (Abu Dhabi, 2011) Yes (date, NA)
in schools partially (suggested, and implemented partially
implemented 2013) Yes (Dubai, 2017) and implemented
implemented, implemented
NA
Regulation on HE No No Yes (suggested, No Yes (Abu Dhabi, 2016) Yes
course in schools 2014) and implemented (HPS-2004)
implemented, Yes (MOE reform, 2017) partially
NA and implemented implemented
(continued)
981
982
Table 4 (continued)
Regulation on PE Yes (launched in Yes (suggested, Yes (suggested Yes (date, Yes (MOE reform, 2017) Yes (HPS
course in schools 2017 for girls) 2010) HPS schools) NA) and and implemented schools, 2004)
implemented implemented, NA implemented, implemented partially
NA implemented
Regulation on junk food Yes (suggested, Yes (suggested, Yes (suggested, Yes (2016) Yes (Dubai and other Yes (suggested
and healthy options in 2014) 2013) 2014) and Emirates, 2012; Abu pilot scheme,
school canteens/ implemented, NA implemented, NA implemented, implemented Dhabi, 2013) and 2017)
cafeterias, healthy NA implemented implemented,
guidelines for schools Yes (Dubai nutritional NA
labeling and portion
sizes for food provided
in schools, 2017) and
implemented
Workplace
Workplace health Yes (suggested, Yes (suggested, Yes (awareness Yes (2014) Yes (Abu Dhabi, 2014) Yes
promotion policy 2014) 2013) work in partially partially implemented (suggested,
implemented, NA implemented, NA workplaces, implemented Yes (across UAE, 2014) 2008)
2014) partially partially implemented implemented,
implemented NA
Community
PA in the community Yes (suggested, Yes (suggested, Yes (suggested, Yes (2013) Yes (Dubai through Yes (Healthy
policy Vision 2030) 2010) 2014) partially DHA and DSC Cities and
implemented, NA implemented, NA implemented, implemented Abu Dhabi through Villages)
NA ADSC, HAAD, and partially
ADM) and implemented
implemented
Yes (through GAYSW)
and implemented
A. Samara et al.
38
Primary healthcare
Create wellness clinics No No Yes (2012) Yes (2013) No Yes (date, NA)
within the PHC partially and and
implemented implemented implemented
Food labels
Regulation on food Yes (suggested Yes (suggested No No Yes (Abu Dhabi logo to No
labeling and healthy banning of soft food labeling for pre-approved healthy
options in restaurants drinks, 2017) supermarkets, items and addition of
implemented, NA 2013) healthy options, 2013/
implemented, NA 2016) partially
implemented
Yes (suggested for UAE
healthy menus for
children and adults,
2015) implemented, NA
Regulation on nutrition Yes (suggested, Yes (suggested, Yes (suggested, Yes (2017) Yes (suggested by the No
information on food 2014) 2014) 2011) and MOHP, 2014)
labeling implemented, NA implemented, NA implemented, implemented implemented, NA
NA Yes (suggested by the
MOHP for fast food,
2010/2015)
implemented, NA
Regulation on food No No No Yes Yes (Abu Dhabi No
labeling (low salt, sugar, (healthcare certification scheme for

fat, etc.) facilities, prepackaged food, 2016)
2017) and implemented
partially
implemented
(continued)
983
984
Table 4 (continued)
Policies on food
Soft drinks tax Yes (2017) and No No No Yes (2017) and No
implemented implemented
Salt reduction in food No Yes (2015) and Yes (suggested, Yes (2015) Yes (Abu Dhabi, 2016) Yes (2015) and
such as bakery goods implemented 2011) and and implemented implemented
locally produced implemented, implemented
NA
Oils subsidies No Yes (2015) No Yes (2015) No No
implemented and
implemented
Removal of trans fat No No Yes (suggested, No No No
from food 2011)
implemented,
NA
PA physical activity, NA not available, MOHP Ministry of Health and Prevention, DHA Dubai Health Authority, DSC Dubai Sports Council, ADSC Abu Dhabi
Sports Council, HAAD Health Authority-Abu Dhabi, ADM Abu Dhabi Municipality, GAYSW General Authority for Youth and Sports Welfare, PHC primary
healthcare, HE health education, PE physical education
A. Samara et al.
schools for children. UAE is the only country with an available HE course
implemented for the whole country. As for PE, in addition to UAE, Saudi Arabia
and Qatar have a PE course in the curriculum. Banning junk food in school
canteens is available in Qatar, Abu Dhabi (school principals responsible for the
implementation of the policy), Dubai, and all the other emirates.
• Qatar has a policy on workplace HP starting from governmental institutions. The
Weqaya workplace wellness program is another initiative that focuses on the
workplace in Abu Dhabi. UAE is a leader in workplace HP compared to the other
Gulf States. Finally, Bahrain has also developed a policy for workplace HP.
• UAE promotes actively PA through different agencies and multiple actions and is
the most active country among the Gulf States.
• Another particular effort is the creation of wellness clinics within the PHC, and
Qatar and Oman are the two countries which are leading on this.
• None of the countries has initiated an effort to regulate food labeling and provide
healthy options in restaurants. The GCC approved in 2015 food labeling stan-
dards for reporting the amount of trans and saturated fat in all food, but most of
the Gulf States have not yet fully adopted this policy at the national level. Qatar is
the only Gulf State that has made mandatory the presence of nutritional facts on
food labels for all products. The “Abu Dhabi Trustmark” for healthy food (low in
fat, salt, etc.) is a good way of providing nutritional information/claims on food
and promoting healthier options for consumers, but no other efforts in other
countries have been suggested or implemented.
• There is a policy on the soft drinks tax that has been adopted both by Saudi Arabia
and UAE (Saudi Arabia and UAE have already implemented the tax), after a
proposal of the Gulf Cooperation Council, but has not been yet adopted by the
other Gulf States. There is also a salt reduction policy for goods locally produced
that has been implemented for Kuwait, Qatar, UAE, and Oman. Another impor-
tant policy action for unhealthy food is the subsidizing of healthy oils by Kuwait
and Qatar, which is implemented. Finally, on the trans fat in food, there is yet no
regulation from any of the Gulf States (Bahrain has suggested but not known if
implemented).
Qatar and UAE have developed and implemented significant poli-

cies in the workplace and in food labeling as well as in the school setting,
together also with Bahrain and Oman.
Urban planning is a good example of HiAP efforts, and most of the Gulf States
have either suggested such initiatives in their national strategies (Saudi Arabia,
Bahrain, Qatar) or have been actively creating urban environments that support
health and PA/sports through parks, walking tracks, cycling tracks, etc. (UAE,
Oman at the Healthy Cities level). Saudi Arabia due to its size needs definitely a
plan/strategy for developing urban planning throughout the whole country. A sug-
gestion has also come from Oman to increase food self-sufficiency and diversity
through rural and urban gardens by 2050.
Specifically for PA, Oman, Qatar, and UAE have dedicated organizations that are
very active: QOC, the Abu Dhabi Sports Council, the Dubai Sports Council, and the
GAYSW for sports for the whole UAE. The QOC has set as a project to develop a
master plan for the country’s sports and leisure facilities, the GAYSW has its own
strategy for 2017–2021, the Abu Dhabi Sports Council which is a member of the
Childhood Obesity Taskforce, and the Dubai Sports Council with multilevel inter-
ventions/activities such as the “Dubai Pulse.”
On nutrition, one common action was the development of the food-based nutri-
tional guidelines for the Gulf States, even though Saudi Arabia, Oman (addressed to
health professionals), and Qatar have also developed their own. In addition, Qatar
has developed elaborate PA guidelines, covering needs on PA for chronic disease
patients.
UAE and Oman have invested in urban planning, and UAE, Oman,
and Qatar have organizations that support PA through various activities.
Food-based nutrition guidelines are available for the Gulf States.
Conclusion
As a conclusion, all Gulf States are having a health reform and are trying to shift
toward more HP initiatives. They are on their way and, in some areas, have come a
long way in terms of HP efforts and policies.
At the same time, there are many challenges, and therefore it is crucial that there is
continuous development, capacity building, and increasing implementation of HP
policies, systems, and efforts in the coming years. A big challenge for all of them is
the lack of health educators/health promoters. For some of them, intersectoral work
is still not an integral part of their strategies, and their strategies on nutrition, PA, and
HP are not enough focused and explicit. The principle of HiAP is also very
important, in order to improve/modify the environment and create the condition to
support healthier lifestyles for the population. There is a need to shift the under-
standing of HP from awareness work to multilevel, intersectoral approaches with
main actor professionals in policy and HE/HP. There is also a need to prioritize HP
promotion efforts to overcome increasing costs due to the rising burden of NCDs,
especially in the Gulf States.
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A Perspective on Female Obesity and Body
Image in Middle Eastern Countries 39
Rabab B. Alkutbe
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1004
Obesity in Middle Eastern Populations and Prevalence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1005
Body Composition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1008
Obesity-Related Diseases and Health Consequences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1009
Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1009
Cardiovascular Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1010
Obesity and Cancers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1011
Determinant Factors Contributing to Obesity in Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1013
Genetic Influences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1013
Socioeconomic Determinants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1014
Age, Gender, and Body Image . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1016
Physical Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1017
Dietary Consumption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1020
Obesity and Its Relation to Body Image Perception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1022
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1023
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1023
Abstract
Obesity has become a serious health problem particularly in Middle Eastern
countries because of the recent rapid changes in lifestyles of the populations.
The various methods for measuring body mass and body composition are
explained, and the prevalence of obesity among females in different countries
of the region is detailed. This chapter outlines the many factors that have
contributed to the rise in obesity, and it shows that there is not one single
cause; rather, there is an interplay between genetic and environmental factors
R. B. Alkutbe (*)
School of Biomedical Sciences (Faculty of Health: Medicine, Dentistry and Human Sciences),
University of Plymouth , Plymouth, UK
e-mail: rababalkutbe5@gmail.com; rabab.alkutbe@plymouth.ac.uk

https://doi.org/10.1007/978-3-030-36811-1_38
1004 R. B. Alkutbe
and personal behaviors. The consequences are discussed, with particular empha-
sis on serious life-threatening conditions such as diabetes, cardiovascular disease,
and cancers.
Keywords
Body image · Middle East · Arabs · Obesity-related disease · Physical activity ·
Diet
Introduction
A key determinant of health is body composition and in particular the proportion and
distribution of fat within the body. “Overweight” and “obesity” are two terms which
are frequently used to describe the excessive accumulation of fat in the body. The
medical significance of excessive body fat is that it usually contributes to impaired
health in the individual. There are various methods to measure and calculate the
proportion of fat in the body (CDC 2016).
The usual and commonly cited measure of the risk of obesity is the body mass
index (BMI) (CDC 2016; World Health Organization (WHO) 2017). This is a simple
index that estimates the ratio of weight in relation to height using a formula to
calculate an individual’s weight in kilograms divided by the square of the height in
meters (kg/m2). The WHO has adopted the following descriptive classifications
using the BMI: for normal weight is a BMI of 18.5–24.9. Grade 1 overweight
(usually as “pre-obese” or simply as being overweight) refers to a BMI of
25–29.9 kg/m. Grade 2 overweight (usually referred to as obesity) is a BMI of
30–39.9 kg/m. Grade 3 overweight (referred to as morbid obesity) when BMI is
greater than or equal to 40 kg/m (WHO 2017).
The BMI classification is generally accepted by health authorities globally; however,
it is not regarded as a definitive measure of “fatness” because there are several important
factors that can influence the results, for example, differences arising from ethnicity and
age; likewise, a very active person may have a relatively high BMI due to the
development of muscle rather than the accumulation of fat; nor does it take account of
the distribution of fat throughout the body (Heymsfield et al. 2016). Nevertheless, it is
regarded as a useful screening tool and as such it is suitable for large-scale population-
level surveys. It has the advantages of being applicable equally to both genders and to all
ages of adults, but it is not useful as a means of medical diagnosis.
Other measures of overweight and obesity focus on abdominal circumference;
these different measures of fatness entail relating the circumference to other anthro-
pometric indices such as hip circumference, and height, which is closely associated
with health morbidities (Bosy-Westphal et al. 2006; Amato et al. 2010).
A range of other techniques are also available to researchers that tend to be used
only in specific small-scale localized studies because of cost and because of the
limited availability of such hospital /laboratory-based equipment (Duren et al.
2008).
39 A Perspective on Female Obesity and Body Image in Middle Eastern Countries 1005
In the Middle East, increasing attention has been given to the issue of obesity due
to its serious consequences for the health of populations as well as the ability of
health services to provide assistance (Musaiger 2011). A special focus has been on
obesity in children and adolescents, with many studies confirming that obesity in
young people often continues into adulthood and that, in later years, it is extremely
difficult to reduce body mass and to sustain any loss. It has been estimated that in
developed countries, more than 300 million women are considered clinically obese
(Templeton 2014). Similarly, there is increasing attention to obesity in women in
Middle Eastern nations, where according to the World Obesity Federation (2018),
the overall levels of overweight and obesity have risen in all countries since the
1970s according to all studies. Despite efforts by health agencies to raise awareness
of the problem and to provide guidance on matters such as eating habits, nutrition,
and exercise, obesity levels keep escalating.
Obesity not only affects women and their body image, but it has been correlated
with other health issues such as an increase in gynecological cancer associated with a
high BMI. Moreover, maternal obesity raises the risk of congenital abnormalities and
difficulties with breastfeeding (Poston et al. 2016). This chapter addresses several
major gaps in our knowledge and the understanding of these issues. Researchers in
most Middle Eastern nations have surveyed obesity levels within their jurisdictions,
and many studies have focused on obesity rates in young people. However, there has
been less attention paid to obesity in adult women, and programs to help women
address the problems of obesity have been few – or absent. Survey methodologies
have varied considerably and so it can be difficult to make accurate comparisons
between studies; thus, when analyzing this subject, researchers are also confounded
by variations in sampling procedures, age ranges, and year of data collection (Zyoud
et al. 2014). Nevertheless, this chapter uses the data that is available to provide an
overview of health determinants and consequences and to identify issues linked to
obesity in women in Middle Eastern nations.
Obesity in Middle Eastern Populations and Prevalence
The region generally referred to as the Middle East comprises about 17 nations
(Bahrain, Cyprus, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi
Arabia, Syria, Turkey, United Arab Emirates, Yemen, Libya, Tunisia) with a com-
bined population of about 410 million people (UN 2017). (This figure does not
include countries in North Africa or those from the former contiguous regions of the
Soviet Union.) The people are not homogeneous, instead being diverse in terms of
ethnicity, culture, tradition, language, and religion – all of these factors strongly
influence behavior and attitudes on matters such as food and exercise. Some nations
have large populations (Iran and Turkey each have more than 80 million), while
others are small (Kuwait 1.1 m and Bahrain 1.5 m) (UN 2017). But it is not absolute
population size that determines obesity; rather, it is the lifestyles that have been
adopted in recent decades as national prosperity has risen. Some Middle Eastern
countries have enjoyed the benefits of income from oil resources with the result that
1006 R. B. Alkutbe
within a generation, lifestyle has moved from traditional farming and herding to
urban and industrial settings.
Overweight and obesity cause, or are associated with, a number of severe
morbidities. The term “metabolic syndrome” is a medical terminology used to
refer to a combination of health conditions; it is not a medical disorder itself; rather,
it is a general term which describes a number of linked medical conditions which
together contribute to serious illnesses (Kaur 2014). The most common elements of
metabolic syndrome are obesity, hypertension, increasing in the triglycerides, insulin
resistance, and decrease of high-density lipoprotein cholesterol. Initially, the major-
ity of the disorders associated with metabolic syndrome are asymptomatic, despite
the fact of a large waist circumference is an apparent sign (Kaur 2014). There are
several conditions stemming from metabolic syndrome, and especially from obesity,
with the main ones being diabetes, cardiovascular disease, and cancers. Both males
and females in the region experience these diseases, and while the affected pro-
portions of the population may vary slightly between nations and between genders,
there is clear evidence that these and other related illnesses are on the rise (Afshin
et al. 2015).
Most countries in the Middle East have recorded rising levels of obesity, and
viewed from a global perspective, they are now recording rates that are among the
highest in the world (Nikoloski and Williams 2014). Several surveys have been
conducted in the Gulf States, and while each records slightly different figures
(usually due to survey methodology), the overall trend is clear: that obesity rates
for young and old and male and female have risen rapidly since the 1970s – and they
continue to rise. In relative terms, the Pacific Island nations record the highest rates,
but these are followed closely by countries in the Middle East. One study by
Dillinger (2017) lists about 37.9% of adult Kuwaitis as being obese, followed closely
by adults in Jordan (35.5%), Saudi Arabia (35.4%), Qatar (35.1%), Egypt and
Lebanon (32.0%), UAE (31.7%), and Bahrain (29.8%).
Two recent reports confirm these patterns. A systematic analysis by Ng et al.
(2014) and a meta-analysis by Abarca-Gómez et al. (2017) both noted the changes
that have occurred, though like other such surveys, they found some marked
variations between countries, and within countries, in regard to the levels and trends
in overweight and obesity, with distinct regional patterns. The figures quoted by Ng
et al. (2014) and Abarca-Gómez (2017) which exceeded 50% differ slightly from
those cited above by Dillinger (2017) (74.2% (72.3–76.0)), but they show that, in
general, the rates are broadly similar in most Middle Eastern nations. However, what
these respective studies highlight are regional variations and in particular the differ-
ences between rural and urban groups. In the Gulf countries, a significant increase in
the prevalence of obesity has been reported in adult females and males, and the
averages are between 2–55% and 1–30%, respectively, and while urban lifestyles
have changed swiftly, some rural towns and districts have retained traditional
customs and cuisines, and at the same time, people have continued to perform
work that entails physical activity (Alnohair, 2014).
The figures listed above are an overall rate but it is important to consider gender
differences. The various regional and nation-specific surveys in the Middle East
show similar patterns, and several conclusions can be drawn from the data. Firstly,
that men are generally more likely to be overweight than women; secondly, women
with obesity are more predominant in most of the Middle Eastern countries; and
thirdly, women have higher BMI than men in the Middle Eastern countries (Alzaman
and Ali 2016; Dillinger 2017; Alnohair 2014; Abarca-Gómez et al. 2017). Tables 1
illustrates the relative proportion of overweight and obese males and females in
several Middle Eastern nations.
The significance of the data shown in Table 1 is that it illustrates the disparity
between the genders, highlighting that obesity in females is more common than in
males. The causes of the disparity have been well documented (Abarca-Gómez et al.
2017; Alnohair 2014; Alzaman and Ali 2016; Alqarni 2016). The pattern of change
is perhaps best illustrated with reference to Saudi Arabia, a large country with an
increasing population that has benefited from substantial oil revenues since the late
1960s. Work by Alqarni (2016), and others shows the profound effects of social
change on females. For example, Table 2 shows the percentages of men and women
classified as overweight and obese in Saudi Arabia.
A distinctive feature of Table 2 is the large differences in the rates for obesity in
men and women. The pattern is similar in other Gulf States and illustrates the health
burden being experienced by females in the Middle East. As discussed below, this
Table 1 Percentage of obesity in the populationa

Males Females
Kuwait 30 55
UAE 25 42
KSA 23 36
Egypt 22 48
Bahrain 21 38
Jordan 20 38
Qatar 19 32
Lebanon 15 27
Syria 12 25
Libya 12 25
Iraq 8 19
Oman 8 17
Tunisia 8 33
Yemen 2 2
Cyprus NA NA
Iran NA NA
Turkey NA NA
a
Source: Alzaman and Ali (2016)
Note that these figures were based on a WHO survey, and the percentages would be even higher
now. Note also that these figures vary from some other survey results primarily due to differences in
methodology and whether children and adolescents are included. It does not include all ME nations
or Iran and for the sake of brevity neither does it include some other Arabic-speaking Mediterranean
countries.
1008 R. B. Alkutbe
Table 2 Percentages of overweight and obese men and women in Saudi Arabiaa
Year Men Women
1992 12 20.7
2002 29.3 26.3
2012 35.1 58.7
2017 38.2 67.5
a
Source: Alqarni (2016)
burden is evidenced by higher rates of diabetes, cardiovascular diseases, and other

weight-related conditions.
Body Composition
Being overweight or obese is not an absolute indicator of an individual’s ill-health;

other factors need to be taken into consideration including the nature and source of
the weight. Excessive body fat contributes to impaired health, but when assessing the
well-being of individuals, it is equally important to consider the composition of
the body and in particular the distribution of fat (Shah et al. 2014). Excess food can
be stored as fat in different locations, often in the form of adipose tissue (which is
fatty connective tissue within a structural network of fibers and is mainly found
mainly beneath the skin, between muscles, in the intestines, etc.) Also, males and
females tend to store excess food in different locations, thus creating slightly
different body profiles. There are several different types of fat deposits, and while
it is not possible to consider them all in this chapter, it must be noted that the different
fat deposits have unique characteristics which can have differing health effects.
There have been numerous studies which have confirmed that the distribution of
body fat is more important than merely excess adiposity when considering the under-
lying causes of the metabolic syndrome (Kwon et al. 2017). Although the distribution of
fat is different between males and females, the females usually have 10% more fat than
the males even when they have similar BMI values (Jackson et al. 2002).
There is a positive association between body weight and lean mass in males,
which is in contrast to the findings in females where the increase in body weight is
due to fat mass (Karastergiou et al. 2012). Moreover, a study conducted by Farooq
et al. (2013) on Qatari people to determine the effects of gender on fat distributions
and body compositions showed that females had significantly more adipose tissues
in the total abdominal and abdominal subcutaneous in comparison to males.
Consequently, the variability in fat distribution in different parts of the body could
play functional implications such as adipokine production and development of
insulin sensitivity (Manolopoulos et al. 2010). Therefore, further research is required
to understand the reason for the greater accumulation of adipose tissue in females
than in males and its effects on metabolic consequences.
The quantity and location of the fat deposits can have different consequences
(Jensen 2008). Central adiposity (i.e., fat that accumulates around the center of the
body) is defined as a combination of both subcutaneous fat, which is located

underneath the skin, and visceral fat, which is found around the internal organs in
the peritoneal cavity. It is the latter which reportedly contributes most to the
metabolic syndrome, but the task of identifying, locating, and quantifying the fat
surrounding internal organs has, until now, proved to be very challenging.
Fat deposited mainly in the upper torso, such as the abdomen, chest, shoulder, and
nape of the neck, produces an apple-shaped body and is more common in males.
Referred to as android obesity, it is characterized by elevated metrics such as
abdomen-to-thigh skin-fold ratio, waist-to-hip circumference ratio, and waist cir-
cumference. More common in females is the pear-shaped body termed “gynoid.” In
this case, fat is distributed primarily in the lower half of the body, especially around
the hips, buttocks, and thighs. Assessing the extent of gynoid distribution entails
measurements of the abdomen and hip, but of particular importance as an indicator
of metabolic syndrome and various comorbidities is waist circumference (Kwon
et al. 2017). Measurements will vary with ethnicity, but as a rough guide waist
circumference in both gender as >102 cm in male and >88 cm in female is
associated with many health complications such as cardiovascular disease, high
blood pressure, diabetes, and several malignancies including prostate, breast, and
colorectal cancers.
Skin-fold measurements are a simple and easy technique for assessing subcuta-
neous fat, but the task of assessing visceral fat has been difficult. In recent decades,
however, the development of various noninvasive imaging processes has enabled
this work to be undertaken with considerable accuracy (Shuster et al. 2012). Com-
puted tomography (CT) uses X-rays to examine very specific regions by means of
cross-sectional and multi-angle views of internal features, including soft tissue.
Though accurate and reliable for locating and quantifying fat deposits, it is limited
in use by an individual’s exposure to radiation. Magnetic resonance imaging (MRI)
is likewise a process for examining internal features by means of radio waves within
magnetic fields. The MRI produces accurate and specific cross-sectional views like
in a CT scan, but it has the advantage of not requiring exposure to radiation.
Obesity-Related Diseases and Health Consequences
Diabetes
The increase of diabetes has risen fast in the Middle Eastern and North African
regions, and it has been rated as the second highest worldwide (IDF 2013), with
Abuyassin and Laher (2016) asserting that some of the risk factors that associated
with type 2 diabetes appear more in the Arab world because of the pace of change.
Abuyassin and Laher (2016) acknowledge the likely influence of genetic risk factors,
but they stress that obesity, rapid urbanization, dietary changes, and sedentary
lifestyles are the key determinants that cause the increase of the prevalence of
T2DM in the Middle Eastern region – even among adolescents and young adults.
According to the International Diabetes Federation (IDF 2013) estimates, for the rate
1010 R. B. Alkutbe
of the prevalence of T2DM, international rankings reported that Saudi Arabia,

Kuwait, and Qatar are rated in the top ten countries worldwide. For instance, studies
from Saudi Arabia in the 1980s found prevalence level of diabetes in adult males and
females in rural areas was 4.3% and that 41.2% of the diabetic subjects were obese
(Fatani et al. 1987). Another study conducted a decade later showed increases in
diabetes in the rural areas in both males and females (7.0–7.7%, respectively) (Al-
Nuaim et al. 1996). In addition, a recent study in Saudi Arabia indicated a dramatic
increase with an estimated prevalence of 25.4% (Al-Rubeaan et al. 2015). This
pattern of substantial increases mirrors those of Bahrain, Oman, and other countries
within the Arabic-speaking world (Abuyassin and Laher 2016). The figures resulting
from Middle Eastern research studies vary because of differences in methodology,
but nevertheless a trend is evident in the Gulf States where it is estimated that about
10% and 20% of the adult population are diabetic, with even higher rates for older
cohorts in some large urban areas. To date, there have been relatively few surveys of
T2DM among children <18 years in Middle East, and the figures reported have been
low (Abuyassin and Laher 2016). Nevertheless, the existence of diabetes in children
is still a cause for concern.
The link between body mass and prevalence of obesity was strong, with 88% of
those with diabetes having a BMI of 25, while the prevalence of obesity (BMI 25)
was slightly higher in females (88%) in comparison to males (83%). Accordingly,
the findings of Alqurashi et al. (2011) showed that one of the main factors closely
associated with women being borderline diabetic or diabetic is the high BMI and
obesity. Some reasons for this prevalence were that Saudi women with diabetes
mellitus do not have periodic medical examinations, and this helps explain why a
significant percentage (48.4%) of women with diabetes had not been previously
diagnosed and that 27.8% of these women who are obtaining treatment had previ-
ously uncontrolled diabetes (Alqurashi et al. 2011).
Similarly, a study carried out in the UAE by Sulaiman et al. (2018) reported that
both genders have similar percentages of prevalence in total diabetes, whereas
females have a higher percentage of known diabetes mellitus (KDM). Moreover,
regression analysis shows that obesity was a cofounder in association with diabetes
( p < 0.0005) (Sulaiman et al. 2018). This suggests that obesity plays a key role in
diabetes, and since the prevalence of obesity is higher in females, they are more
susceptible to diabetes.
Cardiovascular disease (CVD) includes many disorders, most commonly angina,

myocardial infarction (usually described as a heart attack), heart failure, stroke, and
hypertensive heart disease. Stroke, coronary artery disease, and peripheral artery
disease involve atherosclerosis which, in turn, arises primarily from the effects of
obesity, high blood pressure, diabetes, insufficient exercise, smoking, poor diet, and
excessive alcohol consumption, among others.
Moreover, in 2015, Iran and Oman were included in the list of countries with the
highest age-standardized prevalence of cardiovascular disease, which is defined as
>9000 cases per 100,000 capita. Saudi Arabia had a prevalence of between 5600
and 6600 per 100,000, Jordan, Kuwait, and UAE being slightly lower. CVD is one of
the major reasons that causes human death in Saudi Arabia; in particular, Saudi
women are prone and more likely to die from CVD due to the social and cultural
restrictions on females engaging in physical activities (Roth et al. 2017). The main
risks for Saudi women derive from obesity and physical inactivity (Alshaikh et al.
2016). A systematic review by Alshaikh et al. (2016) examined the prevalence of
CVD risk factors in Saudi women and noted that in addition to obesity and diabetes,
1.1–9.1% smoked, 21.8% experienced hypertension, an average of 24.5% recorded
hypercholesterolemia, and between 53.2% and 98.1% were physically inactive.
The consequences for females with CVD may, in some settings, be more serious
than for men. A comparative study of both genders with CVD in six Middle Eastern
countries was conducted by El-Menyar et al. (2009), and the results confirmed that in
general women fared worse than men. The study, though small in scope, found that
at the time of presentation with myocardial infarction, women were more likely to
have T2DM, high blood pressure, unstable angina, and dyslipidemia. Compared to
men, women were significantly less likely to be treated with beta-blockers and
antiplatelet therapy (common treatments for heart attacks). In all patients with
CVD, the Middle Eastern women not only ranked higher in risk in global terms
but also had increased inhospital mortality (1.75 times that of men). El-Menyar et al.
(2009) concluded that in addition to presenting with higher risk factors, females were
experiencing poorer outcomes from their treatments.
When reviewing prevalence and causes of CVD, it is difficult to make absolute
comparisons between Middle Eastern nations because of different approaches to data
collection, but nevertheless, there are close similarities between these populations
with regard to factors such as body mass, diabetes, hypertension, and smoking.
Almahmeed et al. (2012) examined coronary artery disease across the Middle East,
with the trends being similar across the region; for instance, in Lebanon, age, body
mass, dysglycemia, high blood pressure, dyslipidemia, and having a close relative
diagnosed with coronary heart diseases were the main predictors of the development
of CVD. As noted, CVD must be seen within a broader lifestyle context, leading
Roth et al. (2017) to use a sociodemographic index (SDI) to identify correlations
between CVD and social influences. As low-income countries become more pros-
perous (achieve a higher SDI), the level of CVD for women increases, but CVD
decreases slightly at higher SDI (Roth et al. 2017), possibly because of education
and awareness of health issues. This pattern is evident in North America and Western
Europe; however, the trend is not evident in most Middle Eastern countries due to the
social restrictions on women described above, and there is no discernible or
sustained decline in CVD rates in the Gulf States.
Obesity and Cancers
Obesity has long been shown to contribute to many types of cancers (Nimptsch and
Pischon 2016). Excessive body mass is not in itself a direct cause of cancer; rather, it
provides opportunities and mechanisms for cancers to develop. While some are
1012 R. B. Alkutbe
common to both males and females, several cancers are specific to females. Breast,
cervical, and ovarian cancers are among the most common female-only cancers, and
in general the rates are higher in developed nations (WCRF 2007).
As noted, countries in the Middle East generally have a high prevalence of
obesity in their female populations, and there is considerable quantitative informa-
tion on cancer rates. But as yet there are not any nation-specific data linking the
effects of elevated body mass on the different forms of cancer. In discussing this
issue, it must be noted that in the Middle East, there are some social reservations that
impede women’s medical examinations, in particular tests for breast, ovarian, and
cervical cancers. Additionally, an investigation was done in Qatar to illustrate an
approach to breast cancer screening. It reported that males acknowledged the
importance of regular breast cancer screening (BCS) for the female members in
their family on condition that a female health professional conducts the examination
for their female family members (Donnelly et al. 2017). Other concerns were
detected from a survey conducted in the UAE regarding breast cancer in that some
women worried about their spouses’ reactions, and they expressed fears about being
negligent about screening because of their husband’s concerns. The religious and
cultural embargo also was another concern highlighted in this survey, which restricts
or delays some females getting regular examinations if a male medical professional
will be examining them (Elobaid et al. 2016).
Because so much global research is focused on this issue, it has been possible for
international monitoring agencies (such as the International Agency for Research on
Cancer and the World Cancer Research Fund) to quantify the global prevalence of
cancers, with their conclusion being that the proportion of all cancer cases attribut-
able to high BMI is about 20%. These agencies, together with many other research
programs, have confirmed the strong link between obesity and such common cancers
as colorectal, prostate, postmenopausal breast, renal, endometrial, and esophageal
adenocarcinoma (Nimptsch and Pischon 2016).
The Million Women Study (Shapiro et al. (2012) and others have also indicated
that the risk of breast cancer in premenopausal female falls when body mass index
rises. On the other hand, there is a positive correlation between the risk of breast
cancer and the body mass index in postmenopausal female who receive no hormone
replacement therapy. This could be argued because of the high levels of sex hormone
in the blood.
One systematic review, meta-analysis, and follow-up of cancer cases showed that
the relationship between obesity and cancer is gender-specific, and this concept is
applicable for people from different regions worldwide (De Pergola and Silvestris
2013). On the other hand, these reviews comment that the risk of obesity-induced
cancer can vary among various ethnic populations; some communities from Africa
seem to be more prone to cancers, whereas Hispanic populations appear to be less
vulnerable; however, there is a strong correlation between risen body mass index and
breast cancer in both Asian and Pacific communities.
Various research projects on the subject of cancers in women in Middle Eastern
countries highlight the need for increased education and for a change in attitude
(Metwali et al. 2015). It is vital for women to willingly participate in the cancer
screening programs where available. While cancers cannot yet be fully cured,
healthcare practitioners point out that early detection is essential for reducing
mortality. However, changes in societal attitudes are occurring far too slowly.
Determinant Factors Contributing to Obesity in Women
The determinants of overweight and obesity in the Middle East are essentially the
same as those identified in other settings. However, several factors, such as cultural
traditions and social norms, accentuate those determinants and create conditions
which contribute to women having greater difficulty in controlling their weight.
At one level, obesity seems a simple matter of excessive food intake and
insufficient expenditure of energy by way of physical activity. And while this
remains broadly true, in reality, the issue is far more complicated. Indeed, the
etiology of obesity is complex and has many determining factors from various
aspects, the first being genetics with some individuals being predisposed to respond
to conditions in ways that cause them to become overweight. But numerous other
influences contribute to this problem – political, socioeconomic, environmental,
educational, cultural, historical, gender, religious, lifestyle, and many more. These
factors cannot be considered in isolation, and the interactions between them need to
be better understood.
Genetic Influences
Genes define the boundary conditions or ability of the human system that determines
body mass and composition to react to the environment, and nongenetic forces
determine at what point within these boundaries the system operates. That is, the
genotype determines what can happen and the environment determines what does
happen (Loos 2012). The genetic influences of Middle Eastern populations have
been shaped to a considerable extent by historic migrations, the main components
being Bedouin, African, Persian, and South Asian. Another important regional
determinant has been the practice of consanguinity – that is, the marriage of family
members such as first and second cousins (Loos 2012). Moreover, consanguinity
marriages are widely spread in some of the Middle Eastern countries with rates
higher than 50% in Kuwait and Saudi Arabia and between 40% and 49% in Turkey
and Lebanon and 29% in Egypt.
This type of marriages could lead to increased risks of inheriting undesirable
genes and a reduction in genetic diversity for the offspring such as monogenetic
forms of obesity (Kapoor et al. 2019). A review by Saeed et al. (2018) focusing on
the genetic associations of obesity showed that 3% and 12% of consanguineous
marriages in Egypt and Turkey, respectively, inherited genes causing obesity.
Since the completion of the sequencing of the human genome in 2003, it has
become possible to closely scrutinize individual genetic factors. Genome-wide
studies have identified many genetic factors which shape human lives. Studies of
1014 R. B. Alkutbe
the interactions between genes and lifestyle have shown that genetic factors predis-
pose individuals to obesity, though this susceptibility can be reduced by making
healthy lifestyle choices (Hruby et al. 2016). Despite the fact that the environmental
and lifestyle changes are mainly the critical role of the prevalence of obesity
worldwide, where the dietary habits and patterns are the main contributors, the
interaction with genetic factors can accelerate the propensity for human body to
develop obesity. Over the past decade, large-scale genome tests for a range of
adiposity traits, such as BMI, extreme obesity, and body fat percentage, have
identified several 100 genetic markers for obesity, and while the contribution of
each marker might be slight (and not yet properly understood), they shed new light
on the complex physiology, biochemical activities, and regulatory processes that
determine energy balance and fat distribution (Soldati et al. 2016). Although
genome-wide studies have identified candidate genes, they do not yet fully explain
the pathway of genes that triggers the onset of obesity.
Increasing numbers of studies are exploring the genetic links to obesity, and
recent studies in the Gulf States have confirmed some associations. One such
study in Saudi Arabia shows correlations between obesity-related genes and
glucose biochemical markers in young Saudi women (El Nashar et al. 2017).
That work confirmed that the participants were susceptible to accumulating
excess mass, which most did because of their diets and lack of exercise. A project
by Mezzavilla et al. (2015) used genetic analysis to show that within the popu-
lation of Qatar, mapping characteristics was used to detect the functional path-
ways of the carbohydrate metabolism that contributes to high BMI. Other work
(Bener et al. 2011) explored possible candidate genes that cause obesity in the
Qatari population, and the association between a particular gene variant and its
contribution to obesity and hypertension was specified. However, they also
concluded that the variant was not solely responsible and that other genes (as
yet unidentified) were involved.
The process of genome analysis is continuing to gain pace, and an increasing
number of studies show the overriding influence of genetics on body composition. It
is not yet possible, however, to thoroughly identify the relevant characteristic
genomes for the body composition of individuals. When that point is reached, it
may then be possible to determine strategies for helping each individual person to
control their weight.
Socioeconomic Determinants
Genetic factors can set the parameters for body composition, but it is also important
to appreciate that there are many socioeconomic factors that contribute to being
overweight and obese. Socioeconomic influences entail many aspects of life, and the
interactions between them combine to shape human lives. Socioeconomic factors
include work, transport, leisure, housing, income, education, the natural and built
environments, family life, religion, culture, and of course food – what is eaten, when,
and how (Hruby et al. 2016).
Socioeconomic determinants have been particularly important in the rapid trans-

formation of the lifestyles of people in the Middle East, and these factors largely
explain the increase in obesity and consequent health problems (Alzaman and Ali
2016). Many studies have been undertaken in the Middle East to explain the rise of
obesity, and all these determinants vary from country to country, and while it is not
possible to explain them all in detail, several key points can be highlighted.
For instance, women in Middle Eastern countries are encountering some of the
traditional cultural restrictions in their lifestyles, resulting in an increase in the risk of
obesity. That is, the opportunities for females to perform vigorous exercise activities
are limited considering the small number of female gymnasiums and sports clubs;
moreover, most oil-rich societies now have readily available affordable foreign labor
to perform household work. Families in Kuwait, Qatar, Bahrain, UAE, and Saudi
Arabia commonly employ chefs and servants, thus leaving the women to experience
sedentary lifestyles. Television and the Internet are main leisure activities, and
restrictions on outdoor activities mean that women cannot readily walk anywhere
– instead are always driven even for short distances. Multiple pregnancies are also an
important factor of increasing obesity in women, and this consists of a combination
of factors such as less physical activity with high dietary intake and gestational
weight gain which could result in gaining 4.5 kg or more in 1 year (Farpour-Lambert
et al. 2018). Perhaps the most documented change in lifestyle leading to obesity
concerns food. The availability of processed food, which is high in salt and fats, the
availability of energy-dense snack food at all hours, the consumption of large
quantities of sugary soft drinks, and changes to family mealtime arrangements are
all contributing factors.
While food consumption patterns have changed, so have associated lifestyles. In
most oil-rich Gulf states, women’s daily lives have been transformed by the avail-
ability of cheap domestic help (Hruby et al. 2016). Numerous studies have shown
that women who transferred their food consumption behavior to a Western pattern
(high intake of red and processed meats, consumption of readily available “fast
foods,” refined grains, sweets or desserts, sugar-sweetened beverages, and potatoes)
gained weight, while those who adhered to a fairly traditional Middle Eastern cuisine
(high intake of fruits, vegetables, whole grains, fish, poultry, and salads) gain little
(Hruby et al. 2016; Musaiger 2011; AlNohair 2014).
Considerable research undertaken recently has explored the behavioral influences
on obesity, in particular, behaviors that cause an energy imbalance which could be
manifested in overeating or reduced physical activity, and this will consequently lead
to weight gain taking into account environmental factors (AlNohair 2014). In UAE,
Qatar and Kuwait women, who in many settings cannot drive and are limited in their
physical activities, now have little housework to perform, do not necessarily have to
prepare meals, and can be driven to shopping venues; they may have little work to do
and are unable to expend excess energy by other means – much like the case in KSA
(Mozaffarian et al. 2011).
Like the physical environment, the sociocultural setting of Middle Eastern com-
munities (how people relate to each other) influences lifestyle and health (Alqarni
2016). While social and cultural influences are evident in all societies, they are
1016 R. B. Alkutbe
probably more pronounced in Middle Eastern settings because of very strong

traditional and especially religious rules about behavior; and these rules act as firm
constraints on the activities of females and on the public image which females are
expected to adopt (Alqarni 2016; Al Alhareth et al. 2015).
The contribution of income and education on obesity in females has been noted in
a number of studies, and it has been reported that as incomes rise, women are able to
enjoy wider (and better) choices, thus leading to less obesity (Conklin and Monsivais
2017). An alternative approach was adopted in an interesting study by Kim and von
dem Knesebeck (2018) who reviewed the relationship between obesity and low
incomes. Although they did not use data from a Middle Eastern country (no data
being available), they reported a relationship between obesity and income; more-
over, the association is influenced by obesity measurement and gender. That is, the
more obese a person is, then the less likely he/she is to obtain a well-paid position;
negative stereotypes and stigma were identified as causes, and obese women were
more affected.
Moreover, marriage and the number of pregnancies have been correlated with
weight gain. These complications in the marital state influence the body status as
well as cultural concepts of having many children (Badr et al. 2012). In some rural
areas in Egypt, it is acceptable for women to be overweight or obese as this is
associated with a wealthy lifestyle, and even 40% of women with a high level of
education tend to be obese (Aitsi-Selmi 2012).
Nongenetic factors such as lifestyle choices can improve the maintenance of
healthy weight and ameliorate the risk of obesity. But as discussed here, there are
scores of interrelated factors that shape our daily choices; there are upstream
environmental, social, cultural, and political forces (laws, culture, traditions, and
religion) within which families and individuals have to function but over which they
have little control. Then there are countless downstream elements that can also lead
to obesity – these include income, social milieu, housing, work, education, culture,
sleep, and leisure. These can affect males and females in different ways, but in
general, in Middle Eastern countries, it is far more difficult for females than males to
sustain a healthy weight and lifestyle.
Age, Gender, and Body Image
It is not possible to make definitive global generalizations about links between age
and obesity because patterns vary in different settings. High body mass should not be
considered as a problem only for older people, as surveys in numerous countries
clearly confirm that increasing numbers of children and adolescents are becoming
obese and seemingly at ever-younger ages. This is certainly true in the Middle East,
where numerous reports stress the serious extent of childhood obesity (e.g., Farrag
et al. 2017). An analysis of Middle Eastern countries by Musaiger (2011) noted that
in many countries, overweight and obesity increased with age until age 60, thereafter
declining steadily. This phenomenon was perceived in both genders, but the pattern
is not uniform across all countries. While the age profile in the Middle East is quite
young, a greater proportion are living into old age (>65) because of improved
medical services.
However, with increasing lifespan come all the physical afflictions of aging, such
as the increased lifetime cumulative risk for many conditions such as cancers
(Musaiger 2011). In general, women in Arab and nearby countries tend to increase
in body mass after middle age (Abuyassin and Laher 2016). While there are some
regional variations in survey results, most studies confirm that in general, women in
the Middle East develop higher levels of BMI than men in their later years (Al
Alhareth et al. 2015). There are several possible explanations for this: one is
physiological, another is lifestyle, and a third is cultural perceptions. The proportion
of subcutaneous fat in women increases with age as sex hormones decrease; more-
over, the amount of subcutaneous fat is greater in women at all ages compared to
men (Lizcano and Guzmán 2014). Other studies on the influence of clothing suggest
that females who tend to wear trousers and skirts would observe any increase in their
waist circumference that bring their attentions to any change in their body weight (Al
Tawil et al. 2007). A project by Al Tawil et al. (2007) reported that the percentage of
overweight women (BMI 25) who prefer to wear a loose gown at home was
greater than women who tend to wear pajamas, the reason being that trousers with a
tied waistband readily indicate any change in waist circumference. Similarly, the
proportion of obese women (BMI > 30) was higher among those who wore gowns
or abayas outside the home.
Physical Activity
Physical activity and eating are two modifiable factors that regulate weight balance.
Expressed in very simple terms, if expenditure of energy by means of physical
activity is less than the consumption of energy from food, then weight gain will
likely occur. Before discussing the scenarios in the Middle East, it is relevant to note
the levels of physical activity that are needed for weight control. To help counter the
global epidemic of obesity, the WHO has developed guidelines for recommended
physical activity for three age groups: 5–17, 18–64, and >65 (WHO 2010) years.
For the following two age groups, the recommendations are:
Adults aged 18–64 and >65 should spend at least 2 h and 30 min in moderate
aerobic physical activity per week or spend a minimum of 1 h and 25 min in vigorous
aerobic physical activity per week or combined both intensities of moderate and
vigorous activity. It has been recommended that the minimum aerobic epoch should
be at least 10 min in duration.
Firstly, special attention has been devoted to quantifying physical activity in
children and adolescents, driven by the burden of obesity-related diseases that
progresses into adulthood. As a useful point of comparison, Al-Nakeeb et al.
(2012) compared the physical activity of adolescents in the UK and KSA. Both
are prosperous communities with well-developed urban facilities, and both have
been increasing rates of obesity. There were similar patterns in both cohorts; firstly,
that physical activity was negatively associated with BMI (i.e., the higher the
1018 R. B. Alkutbe
physical activity, the lower the BMI). Second, that in all age groups, males were
significantly more active than females and that, during adolescence, physical activity
among females reduced BMI markedly (Al-Nakeeb et al. 2012). However, a major
difference was that in the KSA, the participants were generally much less active and
had higher overall levels of BMI. The authors noted that physical activities by young
people in KSA have not been considered as desirable pursuits due to cultural
attitudes and beliefs. Until recently, physical activity was not encouraged; instead,
the pursuit of academic excellence and Islamic scholarship held greater status. In
cities and towns, there is a general lack of parks, open-space areas, and facilities
suitable for youths to engage in sports and games. Moreover, the climate is not
conducive to PA in the outdoors for part of each year in the KSA, a problem
highlighted by the harsh desert environment and the absence of outdoor walking
spaces. Al-Nakeeb et al. (2012) found that the participants were mainly using
computers or watching television for recreation – passive activities commonly
accompanied by casual snacking.
Al-Hazzaa et al. (2011) stated that males and females in KSA had comparable
amounts of moderate physical activity but that few females experienced vigorous
physical activity. He also reported that in Riyadh, nearly 81% of men are inactive,
whereas the majority of women (99.5%) in Asir province do not participate in
physical activity of any type. The same pattern has been described in other Middle
Eastern countries: for instance, describing the setting in Iran, Kelishadi et al. (2010)
reported that there are relatively few open spaces or dedicated sports grounds, and
while boys can use any empty space to play ball games, the situation for girls is
different because of social reservations which are strictly enforced. Another study
conducted in Al Ain (UAE) on the barriers in the physical activity environment for
Emirati women concluded that the shortage of culturally sensitive exercise facilities
restricts outdoor physical activities and the great need for social support, such as
accompany with other women for walk activity (Ali et al. 2010).
While acknowledging the lack of physical activity in people in Middle Eastern
countries, Musaiger (Director of Arab Center for Nutrition in Bahrain) explained the
rise in obesity as due primarily to the use of cars (Taylor 2009). Similarly, in Kuwait,
a study conducted among Kuwaiti female college students found that the lack of
physical activity contributed to the increase in the level of obesity (Al-Isa et al.
2013). These situations were also reported in some other Middle Eastern countries
such as Lebanon, where female students aged >18 years reported less exercise than
males, where the reasons of this low level of activity are similar to other countries in
the Middle East (Shediac-Rizkallah et al. 2000).
A review conducted by AlQuaiz et al. (2014) to investigate changes in chronic
diseases in women in Saudi Arabia used data from national studies that tested over
17,000 Saudi men and women aged between 30 and 70. Using data on sporting
activities, leisure activities, and walking, they found that 96.1% were very inactive,
with the figure being even worse for females (98.1%) than for males (93.9%). This
observation is confirmed by WHO figures which reported that the ranges of inac-
tivity among the adults of both genders in Arab countries are between 80% and 95%
(Taylor 2009). These observations and figures were supported by Al-Nozha et al.
(2007) who reach the conclusion that most men and women did not reach the
recommended physical activity levels which are essential to promote health and
prevent diseases.
As Musaiger explains (cited in Taylor 2009), world weight control across the
Arab is especially difficult for women since in some of the Middle Eastern countries,
mixing between women and men in exercise is considered as an unacceptable
violation. However, wealthy women only can afford to exercise in exclusive
female’s gym centers; most other women have no such options. Even something
as simple as walking is challenging because where and how women can walk is
limited. In some countries such as Qatar, new programs have been established in
Aspire Zone (also known as Doha Sports City) to encourage women to be active
more freely. One solution, which has readily been adopted, is air-conditioned
shopping malls, but they are designed for strolling, not exercising. Musaiger stated
that in Bahrain, there are allocated parks that specify some days for women and
families that allow women to exercise freely, while it is open to the public during the
rest of the week (Taylor 2009). However, he admits that it is of little value as it is
available for women only on certain days, and the requirement for traditional cover-
all clothing continues to be a serious impediment in all public venues, including
malls.
Few people in the Middle East exercise, and most continue to eat large quantities
of fast food, energy-dense snacks, and sugar-rich soft drinks. Very similar outcomes
were recorded in other investigations by Donnelly et al. (2018), who found that there
was a significant correlation between obesity and inactivity in Qatari females; a high
prevalence of inactivity was reported also in Oman and many other countries in the
region.
Moreover, the weather conditions also contribute to the lack of activity as most of
these countries experience extremely hot weather, and there is a lack of outdoor
facilities; this recurring theme is noticeably more difficult for females of all ages in
the Middle East. Females in most countries have freedom and are permitted to
exercise in groups in public. In discussing the situation in the Gulf States, Jawad
(2014) said that the lack of facilities for outdoor activities is not the only factor
limiting against physical activity; parental attitudes are also a strong impediment,
with most parents failing to encourage sports or outdoor games, but demanding
instead attention to academic studies.
Another aspect of this issue concerns the time spent in sedentary behavior. In
Middle Eastern countries, the range of occupations available to women has, until
recently, been relatively limited, with the main areas of employment being teaching/
education, healthcare, and office work. Albawardi et al. (2017) examined the
sedentary routines of office workers in several locations across Riyadh, finding
that their median sitting time on work days was 690 min (11.5 h), half of which
was spent at work. However, on nonwork days, the amount of sedentary time was
not much less at 575 min (9.6 h).
The lack of facilities and limited opportunities is a recurring theme in reports on
this topic, and it is noticeably more difficult for females of all ages to be active in any
settings in the Middle East. But attitudes must also be mentioned, with Mabry et al.
1020 R. B. Alkutbe
(2010) commenting that there is not a strong culture of physical activity in the Gulf
States. But a detailed survey by Al-Haramlah et al. (2016) concluded that while there
might not currently be a culture of physical activity by females, nevertheless Saudi
women in general would like to be much more active if they had opportunities and
suitable locations. Moreover, the survey participants strongly supported proposals
for women’s sport clubs and for the inclusion of physical activity in schools for girls.
It was evident from that study that women in the Middle East realize the health and
lifestyle benefits of vigorous games, sports, and physical exercises.
Despite all the negative images and the many critical reports cited above, it must
be noted that changes are occurring in the lives of females in the Middle East – albeit
slowly. In 2017 and 2018, the governing council of KSA eased restrictions on
women’s activities, allowing women to drive by themselves, although this does
not redress the problem of physical inactivity; nevertheless, it does indicate the
possibility that other changes could follow. Another important freedom is that
women are permitted to run together in public. This latter relaxation followed the
adoption of a full-length style of loose clothing suitable for vigorous activity. Also,
the recent development of wrist-mounted monitoring devices could offer a limited
opportunity for individuals to better manage their own exercise regimens because it
encourages the wearer to complete a certain number of steps (usually 10,000) daily,
and the steps could be adopted easily during housework, shopping, or either walking
to the local mosque.
Although factors such as marriage, weather, facilities, and culture have been
addressed as reasons for high levels of inactivity among females in Middle Eastern
countries, women have positive attitudes about physical activity and fully recognize
the importance of energetic activities for themselves and their daughters. They
clearly want, and need, more opportunities and facilities in which to exercise without
restrictions or inhibitions (Al-Bakr et al. 2016).
Dietary Consumption
Much has been made of changes in eating habits in the Middle East, with studies
uniformly pointing to the rampant adoption of energy-dense, high-fat, sugary foods.
Numerous studies have identified this pattern as being one of the defining determi-
nants of obesity throughout the Middle East. While the issue of food consumption
tends to focus mostly on the composition of the food that is eaten, there are other
considerations too. For example, when and how food is eaten, portion sizes, social
settings, education, and social status – all have impacted daily lives and contributed
in some ways to the obesity problem.
As would be expected, traditional foods have been influenced by a number of
factors, the main one being the availability of raw materials. For example, across the
inland deserts of the various Arabic-speaking countries, traditional foods were
restricted to cereals, dates, and dairy products. By comparison, the coastal commu-
nities had more diverse and plentiful sources of food from the sea and by way of the
coastal trade (Alalwan et al. 2017). Better watered regions such as western KSA and
coastal Lebanon had greater access to imported vegetable and animal products.
Some commonly used ingredients have included olives and olive oil, honey, pita
bread, sesame seeds, and dates. In many regions, grains were important too, includ-
ing rice which figures prominently in Iranian dishes (Karizaki 2016).
Over the last half-century, dietary habits and food choices have changed signif-
icantly in most of the Middle Eastern countries, with a noticeable increase in an
individual’s energy intake and fat daily consumptions (Taylor 2009). Aboul-Enein
et al. (2016) conducted a large-scale systematic review of food consumption in the
Middle East. Their findings are especially interesting because while half of the
research projects reported a transition to Western-style foods, the other half did not
but instead report popular transitions to other non-Western cuisines such as Asian or
Mediterranean foods. Importantly, the studies concluded that changes in dietary
composition was not the sole cause of obesity; it was not just a matter of what was
eaten; it included other associated transitions. It was when accompanied by
decreased physical activity, the movement of populations from rural to urban
settings, changes in food preparation methods, and snacking that weight gain was
most marked.
Numerous studies have highlighted the alterations to the diets of young people.
Amin (2008) described the pattern of increasing consumption of saturated fats, meat,
bread, and rice. The issue of snacking is a key element in the transition, and most
studies have stressed the profound importance of highly sweetened carbonated soft
drinks. Patterns of food consumption learned in childhood often continue into
adolescence and into young adulthood. Abdel-Megeid (2011) concluded that uni-
versity students in various Middle Eastern nations have tended to adopt unhealthy
diets which suit their academic lifestyles. The pressures of their work plus their move
to the independence of full adulthood enable them to purchase whichever food they
like, and young people tend to favor fast foods and snacks which can be taken while
studying at their desks. This situation is partly explained by the habit of skipping
breakfast – a practice that has been reported in a number of studies and which is
associated with obesity. Musaiger cites a study of three Gulf countries where 59% of
Bahraini adolescent students tend to skip their breakfast, and the number was slightly
higher in Oman of 66% and 74% in Saudi Arabia. The result is that they become very
hungry by midmorning and consequently binge on high-energy snacks (Farrag et al.
2017).
Fast food is not unhealthy because it is prepared quickly; it is intentionally made
to be attractive to younger people because it is tasty and satisfying, but nevertheless
much of it is unhealthy because it is deep-fried and of limited nutritional value
(Abdel-Megeid et al. 2011). Moreover, eating behaviors have been investigated in
several studies and in both genders. A study in Qatar reported that females had a
significantly higher rate of weekly consumption of doughnuts, sweets, French fries,
and cake, whereas males had a higher rate of fruit and milk consumption (Daradkeh
et al. 2015). A study conducted in Bahrain to examine the dietary habits of both
genders found that more than 50% of females consume fast foods daily, and 60% of
females do not eat breakfast daily. Also, females reported significantly lower intakes
of fruits and vegetables every day (Musaiger 2011). Furthermore, Emirati university
1022 R. B. Alkutbe
students consumed more diets high in fat, and 50% of them skipped the breakfast
meal, with many using a perceived shortage of food choices in the university
(Kerkadi 2003).
Additionally, most (70%) Arabs prefer a sweet taste, causing soft drinks manu-
facturers to increase the amount of sugar in their products in Arab countries.
According to the International Sugar-Sweetened Soft Drink Survey (2015), some
of the fizzy drinks in some Middle Eastern countries like Qatar, Kuwait, and Turkey
contain 38–40 g of sugar per serving which is classified in red category
(Actiononsugar.org 2019).
Indeed, countries in the Middle East are major consumers of soft drinks, and
despite the availability of low-calorie alternatives, there is no sign that this pattern of
consumption is changing. Accordingly, a study has found that Emirati females
consumed (40–71%) sugary drinks for the majority of their daily liquid beverages,
and these added-sugar drinks are associated with obesity (Ng et al. 2011). Further-
more, Australian females reported a moderate consumption of 35% of their weekly
intake of sugary drinks which is less than the percentage in Arab countries (Miller
et al. 2019). Moreover, Saudi adult females consume 69% of their daily calorie
intake from carbohydrate which exceeds the World Health Organization (WHO)
recommendations of 50% (Al-Daghri et al. 2013).
The result is that children grow up being used to a sweet taste, which affects their
dietary preferences into their adult years.
Obesity and Its Relation to Body Image Perception
How individuals perceive their own body shape, and images of what constitutes
desirable beauty, is a key role underlying psychological factors that influence body
weight status. An emphasis on slimness in Western societies is a major cause leading
to unconsciously having unhealthy diets and eating disorders, but conversely,
underestimation of body weight may cause individuals to neglect their own condi-
tion and thus increase the risk of developing obesity. Perception of body shape is
strongly influenced by social and cultural factors, and in the Middle East, images of
what constitutes desirable beauty appear to be changing.
Incorrect self-assessment of body shape is a recurring theme in many surveys
both in the West and in the Middle East. That is, thin females (BMI < 18) often
perceive that they are too fat (and so take unnecessary steps to reduce weight), and
those who are overweight (BMI > 25) can perceive themselves to be thin (thus
failing to reduce weight). Studies cited by Musaiger (2011) and Shaban et al. (2016)
suggest that body image dissatisfaction is a negative appraisal on a person’s bodily
appearance; they state that studies in countries such as the UAE and Jordan reported
high percentages of adolescent girls being dissatisfied with their body shapes
(usually seeing themselves as too fat) and expressing a desire to be thin. A Saudi
study showed that just above 20% of healthy weight women considered themselves
as overweight, whereas 6.6% thought themselves obese; however, 36.8% of
overweight women and 28% of obese women considered themselves as having

normal weight (Musaiger 2011).
A study in Bahrain found that the adolescent girls are more likely to discontent
with their body weight than boys; more than 50% of the girls and about 33% of boys
expressed that regarding their weight (Al-Sendi 2004). The study showed that self-
assessment of body size was often incorrect; moreover, the assessment of survey
participants by peers and parents was often incorrect as well, usually
underestimating those who were markedly overweight. It is clear from this and
similar studies in the Middle East that there are distorted weight-related attitudes
among Middle Eastern adolescents; at one end of the spectrum (i.e., BMI > 25),
there exists a tolerance of obesity, while at the other end (BMI < 18), there is an
unnecessary and exaggerated concern for being fat.
Concepts of beauty and notions of the ideal attractive body size are firmly
influenced by culture and tradition, but in the Middle East, there is evidently a
clash between traditional and Western images. On the one hand, the Western image
stresses the appeal of slimness. On the other hand, there is a long-held belief among
Arab women that Arab men prefer women to be plump. It has been proposed that in
some Arab countries, the Western standard of beauty has contributed to a sense of
conflict between new and old, a preoccupation among women with thinness and
body image dissatisfaction (Al Alhareth et al. 2015; Shaban et al. 2016). The
purported indirect influence of men is an essential issue that determines women’s
perspective regarding their body size in some of the Middle Eastern countries. In
some of the Gulf States, Arab women surveyed believe that men preferred large
women (Musaiger et al. 2011; Kabir et al. 2013). Although the prevalence of obesity
has risen among them, some communities still maintain a cultural perspective of the
appeal of large body sizes positively, and body fatness is considered a beauty
criterion and sexually attractive (Al Alhareth et al. 2015). But this belief is
compounding the problem of obesity, and it is contributing to the rising epidemic
of weight-related illnesses.
Conclusion
In summary, the Ministries of Health and any other health-related facilities in Arab
countries should raise public health awareness among increasing obesity, especially
in women. There should be a greater focus on the health and social consequences of
this epidemic. These measures could lead to useful interventions, encourage health-
ier lifestyles, and promote more physical activity.
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Diabetes in the Arab World
40
Rabia Khan, Ammar Ahmed Siddiqui, Freah Alshammary,
Sameer Shaikh, Junaid Amin, and Hassaan Anwer Rathore
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1030
Epidemiology in the Arab World . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1031
Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1031
Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1032
Fast Urbanization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1032
Nutritional Habits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1033
Sedentary Lifestyle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1033
Other Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1033
Complications of Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1034
Macrovascular Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1034
R. Khan
Department of Bio Engineering, Lancaster University, Lancaster, UK
e-mail: r.s.khan@lancaster.ac.uk
A. A. Siddiqui (*)
F. Alshammary
e-mail: a.siddiqui@uoh.edu.sa
S. Shaikh
Divisions of Oral Diagnosis and Oral Medicine, Department of OMFS and Diagnostic Sciences,
J. Amin
Department of Physiotherapy, College of Applied Medical Sciences, University of Ha’il, Ha’il,
Saudi Arabia
H. A. Rathore
College of Pharmacy, University of Ha’il, Ha’il, Saudi Arabia
e-mail: Ha.Rathore@uoh.edu.sa; hassaan@usm.my

https://doi.org/10.1007/978-3-030-36811-1_41
1030 R. Khan et al.
Microvascular Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1039

Diabetes and Oral Health Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1042
Dental Caries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1043
Oral Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1043
Xerostomia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1043
Oral Mucosal Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1043
Taste and Neurosensory Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1044
Gingivitis and Periodontitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1044
Miscellaneous Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1044
Treatment of Chronic Complications in Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1045
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1045
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1046
Abstract
The prevalence of diabetes in the Arab world increased greatly during the past two
decades, largely due to adaptation to Western lifestyles and poor dietary choices.
Diabetes in the Arab world is estimated to double in 2035. Hereditary risk factors
play a key role in the uncontrolled prevalence of diabetes in the Middle East.
However, obesity and a lack of exercise cannot be ignored as factors in the swift
rise of diabetes in the Arab world. Half of the patients suffering from diabetes are
unaware of their condition and are at great risk of diabetic complications; such
patients are a large component of the high rates of morbidity and mortality in diabetic
patients in the Arab world. The majority of costs associated with diabetes relate to
treatments of diabetic complications. Therefore, early treatment in diabetes is impor-
tant both for health as well as in reducing long-term costs. This chapter discusses the
chronic complications of diabetes by dividing them into microvascular and macro-
vascular diseases, where microvascular complications have a higher prevalence.
Microvascular complications involve nephropathy, neuropathy, and retinopathy,
while macrovascular complications include stroke, cardiovascular diseases, and
peripheral artery diseases. There is an urgent need to fight the spread of diabetes in
the Arab world considering the epidemic of diabetes in the region.
Keywords
Diabetes · Prevalence · Risk factors · Arab world · Complications ·
Microvascular · Macrovascular
Introduction
Diabetes mellitus is a global public health issue that impacts every age group and all
economies of the world. The disease develops when blood glucose levels are
uncontrolled (WHO 1999a). Diabetes is often diagnosed by its presenting symptoms
such as polyuria, polyphagia, polydipsia, and associated complications such as blurred
vision. In severe cases of uncontrolled blood sugar levels, ketoacidosis or a nonketotic
hyperosmolar syndrome can lead to coma and even death in complicated cases. There
are three main forms of diabetes: type 1 diabetes (T1DM), type 2 diabetes (T2DM), and
40 Diabetes in the Arab World 1031
gestational diabetes (GDM). T1DM has an absolute requirement for treatment with
insulin because of the destruction of pancreatic islet beta cells (β cells). In T2DM,
there is impaired insulin action or insufficient insulin secretion. Family history, physical
activity, and ethnicity are associated with T2DM. GDM develops due to variations in
insulin levels during pregnancy (2009; American Diabetes Association 2012b; Lester
2019).
According to the International Diabetes Federation, nearly 463 million adults
suffered from diabetes in 2019, and this figure is estimated to increase to 640 million
by 2040 (International Diabetes Federation 2019). Half of diabetic patients remain
undiagnosed, are unaware of the condition, and are more prone to the progression of
diabetic complications. Nevertheless, for most people, the cost of living with
diabetes is often unaffordable. More than 12% of global expenditure in 2015 was
spent on treating the complications of diabetes. The prevalence of diabetes is also
increasing rapidly in developing countries, with the rates of diabetes in South Asia
and the Middle East being higher than in other parts of the world. The prevalence of
obesity for people in their 60s in the United States has risen from 30% (in 2003) to
60% (in 2006) (Boutayeb et al. 2012; Rahim et al. 2014; Zayed 2016).
Epidemiology in the Arab World
The Arab world is not exempt from the prevalence of diabetes. The Middle-Eastern
and North-African region is projected to have the second highest rates of diabetes
around the globe (Abuyassin and Laher 2016). Increases in diabetes place a burden
in Arab countries due to the enormous financial costs of managing the disease and its
complications. This suggests a need for greater efforts to control the intense escala-
tion in diabetes that is affecting the health of children and adults (Epidemiology
1990; Jaber et al. 2003; Abdullah 2005; Haslam et al. 2006; Boutayeb et al. 2012).
According to the International Diabetes Federation, three countries from the Arab
world (Saudi Arabia, Qatar, and Kuwait) are among the top ten countries worldwide
for the prevalence of diabetes. The increase in the incidence of diabetes is due to
lifestyle risk factors and increases in BMI in the Arab world as shown in Fig. 1. The
prevalence of diabetes was relatively low in Saudi Arabia in the 1980s (2.4–4.3%),
and there were similar low rates in Oman, Iraq, and other countries in the Arab World
(International Diabetes Federation 2013, 2017; Carracher et al. 2018).
Risk Factors
There are several risk factors that account for the unrestrained increase in diabetes in
the Arab world, where heritable aspects play a substantial role. In terms of evaluating
the etiology of diabetes, there are modifiable risk factors related to poor nutritional
choices and lack of exercise (Rahim et al. 2014; Mokdad et al. 2014; World Health
Organization 2016a, b; Bondi et al. 2018). Other considerations could be multiple
pregnancies, lack of health education, and other unique cultural challenges in the
Arab world.
1032 R. Khan et al.
Fig. 1 Incidence of diabetes in the Arab world (Meo et al. 2017)
Obesity
Obesity is key in the pathogenesis of diabetes, and particularly in the alarming

increases in diabetes in the Arab world. Obesity not only increases the chances of
developing diabetes, but people suffering from obesity and diabetes also have
increased microvascular complications. A study from Saudi Arabia on 14,252
patients reported poor glycemic control in more than half of the patients who were
overweight and suffering from diabetes. The first national survey conducted in
Kuwait suggests that 77% of obese females and 48% of obese males were diabetic.
Similarly, 59% of diabetic patients in Qatar and 60% of such patients in Oman were
obese (Alaboud et al. 2016; Almetwazi et al. 2019). Moreover, females in the Middle
East are more obese than males (42% vs. 33%) (World Health Organization 1999b;
Deckelbaum and Williams 2001; Baumgart et al. 2015; Hegazi et al. 2015; Boles
et al. 2017; Bondi et al. 2018).
Fast Urbanization
Many rural areas had been urbanized in the Arab world; this has benefits when it
comes to access to medical services, education, and modern public services and
convenience. A significant difference in the rates of diabetes occurs when comparing
rural and urban communities. For instance, the prevalence of diabetes in urban
residents in Oman is 17% while it is 10% in rural areas. Large differences were also
observed in the communities of Saudi Arabia where those from urban communities
had a higher prevalence of diabetes (12% in males and 14% in females) while it was
7% in rural communities (Abuyassin and Laher 2016; Chatterjee et al. 2020).
Nutritional Habits
The Mediterranean diet is one of the healthiest diets as it includes a range of

vegetables, fruits, olive oil, and grains. However, attaining the maximum advantage
from the Mediterranean diet is unlikely in the Arab world because of cultural habits.
The United Food and Agriculture Organization studied the dietary habits in 20 coun-
tries of the Middle East and North Africa (Iraq, Bahrain, Turkey, Egypt, Iran, Jordan,
Lebanon, Libya, Morocco, Oman, Afghanistan, Palestine, Qatar, Saudi Arabia,
Syria, Tunisia, the United Arab Emirates (UAE), Algeria, Kuwait, and Yemen).
The estimates were conducted in order to gather cardiometabolic disease mortality
rates specific to each country in relation to metabolic risk factors (Afshin et al. 2015).
The results of the analysis reported a suboptimal intake of a healthy diet and a high
consumption of harmful/dangerous diets (Hurt et al. 2010). The high
cardiometabolic disease mortality rates and nonoptimal BMI values were second
in the metabolic risk factors for the cardiometabolic disease mortality; increased
fasting blood glucose levels accounted for 17% of all cardiometabolic disease deaths
(Kastorini and Panagiotakos 2009; Kontogianni et al. 2012).
Sedentary Lifestyle
Several studies confirm that physical activity reduces the incidence of diabetes. It has
been estimated that 6 years of active life along with consuming a healthy diet can
reduce the risk of diabetes by 43% in individuals with impaired glucose tolerance
when followed for 20 years. Another study showed that physical activity and
exercise reduced glycosylated hemoglobin levels in diabetic patients by up to
0.66%, which is a sufficient change to reduce the complications of diabetes
(Adamo et al. 2017; Cirilli et al. 2019). Therefore, changes in modifiable risk factors
in the Arab world can help to reduce the prevalence of diabetes. Saudi Arabia has
26% of its population as being physically active while only 9% of the population in
Egypt is physically active (Oggioni et al. 2014).
Other Risk Factors
Several other risk factors could explain the dramatic increase of diabetes in the Arab
world including cultural aspects, for instance, multiple pregnancies, cultural barriers
that discourage women from being physically active, etc. Even though traditional
risk factors remain the same, alarming increases in the prevalence of diabetes
1034 R. Khan et al.
occurred during the past two decades, suggesting that recent lifestyle changes
impacted the prevalence rates (Mokdad et al. 2003; Galtier 2010; Wu et al. 2014).
Besides, global warming and increased dust and pollution levels further discouraged
engaging in outdoor activities regardless of age or gender. In addition, the political
instability in many Arab countries also affected access to medical care and
healthy food.
Newer risk factors for diabetes have recently been proposed, such as insomnia,
which could be a novel risk factor for the development of type 2 diabetes, as the
incidence of diabetes in people with insomnia is estimated to be 17% (Yuan and
Larsson 2020). The researchers evaluated 74,124 patients with type 2 diabetes and
824,006 control patients with a mean age of 55 years, of which 55% were males. The
analysis included 40 individual research studies that listed 19 risk factors from a list
of 97. Other risk factors included skipping breakfast, daytime napping, alcohol
consumption, inflammatory factors, etc. The study indicated that prevention strate-
gies should include perspectives on sleep quality, obesity, smoking, mental health,
birth weight, and education level (Yuan and Larsson 2020).
Complications of Diabetes
Diabetes is the eighth leading cause of death in the world according to the World
Health Organization. Data from the Arab world indicates that diabetes is currently
the fifth leading cause of death in the region, a change from being the eleventh
leading cause of death in 1990 (Deshpande et al. 2008; Forbes and Cooper 2013;
Gowan and Roller 2013). The complications of living with diabetes are summarized
in Table 1. Other complications related with diabetes include decreased resistance to
infections, more dental diseases, and birth complications.
Macrovascular Complications
Diabetes is linked with complications causing tissue and organ damage in patients
with T1DM and T2DM. The complications of diabetes are broadly divided into
macrovascular and microvascular complications (Chawla et al. 2016). Microvascu-
lar complications can induce atherosclerosis, cerebrovascular disease, and ischemic
heart disease. Cardiovascular disease is the main cause of death in patients with
diabetes and includes cerebrovascular diseases such as stroke. High blood glucose
levels and insulin concentrations cause structural and functional changes related to
chronic inflammation of arterial walls. An invasion of macrophages leads to plaque
formation and atherosclerosis (Forbes and Cooper 2013; Huang et al. 2017). Patients
with diabetes have a two- to fourfold higher risk of developing stroke and also have
an increased probability of its recurrence. Moreover, occlusion of arteries, specifi-
cally in the limb region, causes peripheral arterial disease and functional disability,
pain, and claudication. There is a 25 times higher risk of amputation in diabetic
patients (King et al. 2005). Diabetic patients from Asia and the Middle East are at
Table 1 Complications of diabetes in the Arab world. (Adapted from Abuyassin and Laher 2016)
Sample
Country Year size Prevalence of complications References
Saudi 2015 50,464 Retinopathy: 19.7% Al-Rubeaan et al. (2015)
Arabia 2015 3800 Blindness: 33% Hajar et al. (2015)
2014 54,670 Nephropathy: 10.8% Al-Rubeaan et al. (2015)
2015 62,681 Diabetic foot: 3.3% Al-Rubeaan et al. (2015)
Foot ulcer: 2.05%
Gangrene: 0.19%
Amputation: 1.06%
2014 552 Peripheral neuropathy: 19.9% Wang et al. (2014)
Kuwait 2007 165 Retinopathy: 40% Al-Adsani (2007)
Emirates 2007 513 Retinopathy: 19% Al-Maskari and El-Sadig
(2007)
2007 2455 Retinopathy: 54.2% Saadi et al. (2007)
Nephropathy: 40.8%
Neuropathy: 34.7%
Peripheral vascular disease:
11.1%
Bahrain 2009 712 Microalbuminuria: 27.9%
2007 1477 Neuropathy: 36.6% Al-Mahroos and Al-Roomi
Foot ulcer: 5.9% (2007)
11.8%
Qatar 2011 540 Retinopathy: 23.5% Bener et al. (2014)
2014 1633 Retinopathy: 12.5% Elshafei et al. (2011)
Nephropathy: 12.4%
Neuropathy: 9.5%
Oman 2003 2249 Retinopathy: 14.9% Khandekar et al. (2003)
2009 418 Retinopathy: 7.9%
2012 2551 Microalbuminuria: 37% Al-Lawati et al. (2012)
Nephropathy: 5%
2012 699 Nephropathy: 42.5% Alrawahi et al. (2012)
Yemen 2011 694 Blindness: 15.7% Al-Akily et al. (2011)
2009 350 Retinopathy: 55% Bamashmus et al. (2009)
1997 1095 Peripheral neuropathy: 40.7% Gunaid et al. (1997)
2010 311 Peripheral vascular disease: Al-Khawlani et al. (2010)
9.1%
Jordan 2015 3638 Blindness: 1.3% Rabiu et al. (2015)
Severe visual impairment:
1.82%
Correctable visual
impairment: 9.49%
2008 986 Retinopathy: 64.1%
2005 986 Blindness: 7.4% Al-Till et al. (2005)
2003 1142 Microalbuminuria: 33% Jbour et al. (2003)
(continued)
1036 R. Khan et al.
Table 1 (continued)
Sample
Country Year size Prevalence of complications References
Ulceration: 4%
Amputation: 5%
Egypt 2011 1325 Retinopathy: 20.5% MacKy et al. (2011)
2015 2000 Neuropathy: 29.3% Assaad-Khalil et al. (2015)
11%
1988 4600 Retinopathy: 42% Herman et al. (1998)
Blindness: 5%
Nephropathy: 7%
much higher risk of developing macrovascular complications, especially cardiovas-

cular disease, than patients from other ethnicities (Huang et al. 2017). A study by
Awad et al. (2013) concluded that there were more young adult Asian patients
diagnosed with stroke than in Western societies. Another study from Sri Lanka
reported that 5% of stroke patients were under 45 years of age (Perera et al. 2015).
Hyperglycemia initiates direct and indirect effects on the vascular tree and is the
major reason for the mortality and morbidity in T1DM, T2DM, and GDM. It is
essential for physicians to understand the association between vascular disease and
diabetes because of the significant need for preventive measures to control diabetic
complications arising from both macro- and microvessels (Laakso and Kuusisto
2014; Jovanovič et al. 2015; Napoli et al. 2017).
Insulin resistance and hyperglycemia contribute to atherosclerotic alterations and
vascular complications in diabetes. Hyperglycemia and insulin resistance are com-
monly observed in patients with diabetes, but insulin resistance may develop far
earlier then hyperglycemia.
Insulin Resistance
The major factor in insulin resistance is obesity as is common in type T2DM. By the
release of free fatty acids, adipose tissue, and inflammatory mediators, the lipid
metabolism gets altered and increases systemic inflammation and reactive oxygen
species (Reaven 1988; Kahn and Flier 2000; Courtney and Olefsky 2007). Type
4 glucose transporters (GLUT-4) are expressed in muscle cells and adipose cells. The
expression of GLUT-4 is reduced by fatty acids. The decreases in Akt and P13K
activity in diabetes inactivate endothelial nitric oxide synthase and reduce nitric
oxide levels (see Fig. 2). Insulin resistance and decreases in nitric oxide activity
contribute to endothelial dysfunction that precedes atherosclerotic changes. In addi-
tion to atherosclerotic changes, thrombosis also plays a significant role in the
development of macrovascular complications in patients with diabetes. Insulin
normally inhibits thrombosis; insulin resistance increases fibrinolysis and a pro-
thrombotic state. A lack of insulin activity causes boosts in the aggregation of
platelets and contributes to cardiovascular disease (Huang et al. 2017).
Fig. 2 Insulin resistance and hyperglycemia in diabetes (Huang et al. 2017)
Hyperglycemia
Hyperglycemia plays a significant role in the pathogenesis of diabetic complications
by increasing reactive oxygen species production, which then inactivates the nitric
oxide. Increased production of reactive oxygen species also activates protein kinases
that can affect other cellular proteins and alter vascular cell growth, cytokine
production, apoptosis, and extracellular matrix synthesis. The increased levels of
reactive oxygen species upregulate nuclear factor subunit p65 expression to increase
gene transcription of inflammatory factors. The increased production of inflamma-
tory mediators causes the adherence of monocytes, extravasation, foam cell forma-
tion, and the formation of atherosclerosis. Hyperglycemia activates biochemical
pathways causing an increased polyol flux and elevates levels of advanced glycation
end products and increased activity of hexose amine pathway (Huang et al. 2017).
1038 R. Khan et al.
Heart Disease in Diabetes

Diabetes increases the risk of heart disease. The spectrum of heart disease is complex
and broad in people with diabetes. The 7-year risk for myocardial infarction for patients
with diabetes (with no previous history of myocardial infarction) is 20.2%, compared to
a risk of 3.5% for patients with no diabetes (Emerging Risk Factors Collaboration et al.
2010; Müller-Nordhorn and Willich 2016). However, a study from Denmark concluded
that diabetic adults who were 30 years and older were at increased risk of coronary heart
disease. Men with diabetes had a hazard ratio of 2.30 for developing myocardial
infarction, which when compared to the nondiabetic men, was a lower risk compared
to those with a history of myocardial infarction where their hazard ratio was 3.97
(Kannel and McGee 1979; Alberti et al. 2009). Several other studies suggest that platelet
activation and aggregation have important roles in the progression of coronary heart
disease in patients with diabetes (Kannel et al. 1974; Wilson et al. 1998; Micha et al.
2010). Plasma cholesterol levels are a strong indicator for developing cardiovascular
disease in people with diabetes and a leading cause of mortality and morbidity.
Stroke in Diabetes
Being a diabetic patient increases the ratio of getting inflicted with many illnesses
including having a stroke; patients with diabetes are at increased risk (2.3 times
higher) of getting a stroke (Wolf et al. 1991; Luitse et al. 2012; Boehme et al. 2017).
Even after recovering from a stroke, patients can experience lifelong disabilities.
According to the Australian Stroke Unit Registry, 3 months after having a stroke, a
diabetic patient has far worse outcomes compared with the outcomes of nondiabetic
patients. The worst-case scenario for diabetic patients who have a stroke is that they
are likely to experience another stroke, which in many cases could be life-
threatening (Luitse et al. 2012).
Peripheral Arterial Disease in Diabetes

Adding to the complications that can create difficulty for diabetic patients is periph-
eral arterial disease that occurs most commonly in patients with diabetes; this disease
is associated with large blood vessel complications in patients over 65 years of age,
who have a twofold higher rate of peripheral arterial disease compared with non-
diabetic patients (Clark et al. 2003; American Diabetes Association 2003; Marso and
Hiatt 2006). Peripheral arterial disease needs to be identified as soon as possible
using tests such as the ankle brachial index, bearing in mind that while this test is a
simple and reliable test for the diagnosis of peripheral artery disease, it has limited
value in patients with diabetes due to its low sensitivity in such patients, in part due
to arterial calcifications. Diabetic patients also experience worse revascularization
outcomes (Marso and Hiatt 2006; Bosevski 2012).
Atherosclerosis and cardiovascular disease are caused mainly by prolonged
hyperglycemic conditions. A prediabetic state is characterized by impaired fasting
glucose levels of 5.6–6.9 mmol/l; impaired glucose tolerance (2-h postglucose load)
is seen at 7.8–11.0 mmol/l, and with HbA1c levels of 5.7–6.4% (Okeda 1996;
Bornfeldt and Tabas 2011).
Normal fasting glucose levels are 3.90–5.59 mmol/l, and levels higher than
5.60 mmol/l occur in diabetic patients, who are also at danger of developing cardiovas-
cular complications (Brownlee 2001; Singh et al. 2002; Prenner and Chirinos 2015). In
addition, according to the Hoorn study that was supported by deVegt et al., cardiovas-
cular mortality is associated with fasting glucose levels (de Vegt et al. 1999).
Recent Trends in Complications of Diabetes

Recent trends report improved outcomes in the complications for diabetic patients
(such as stroke and coronary heart disease) due to improved pharmacological
treatments. Unlike other major complications, peripheral artery disease is still a
life-threatening disease for diabetic patients. Improvements in coronary heart disease
have been reported in various parts of the globe such as in Sweden, where the rate of
coronary heart disease has fallen from 37.7% to 19.1% in a span of 5 years from
2003 to 2008, whereas in UK it has fallen from 21.1% to 16.4%. Complications of
stroke for diabetic patients have also improved, for example, there are fewer patients
having ischemic strokes in Finland. However, these improved outcomes do not seem
to apply to peripheral artery disease. The frequency of peripheral artery disease
differed among countries. In Queensland (Australia), hospitalization due to periph-
eral artery disease in diabetic patients was reduced by 43% between 2005 and 2010
(Méndez et al. 2010; Harding et al. 2019). The relationship between diabetes and
prediabetes with cardiovascular disease suggests opportunities for reducing compli-
cations due to cardiovascular disease by improved management of diabetes
(Wu et al. 2014; Beckman and Creager 2016; Harding et al. 2019). There is need
to make lifestyle modifications, in order to reduce and control the glycemic levels,
which will in turn decrease the cardiovascular diseases associated with diabetes and
other complications (Tyagi 2000; Tiganis 2011; Cannon et al. 2018).
Microvascular Complications
Diabetic Retinopathy
Complications in diabetic patients related to the dysfunction of eyes, nerves, and
kidneys are usually due to alterations in microvascular structure and function.
Chronic insulin resistance and elevated glucose blood concentrations can lead to
diabetic retinopathy especially in overweight patients. Retinopathy causes acute
damage in the retina of eye and is divided into two types: background and prolifer-
ative retinopathy. In proliferative retinopathy, new blood vessels are formed on the
surface of the retina as indicated by the formation of white regions on the retina
(Fig. 3). This vascularization leads to hemorrhaging of the vitreous of the eye that
can lead to vision impairment if not treated (Forbes and Cooper 2013; Nentwich and
Ulbig 2015). In background retinopathy, there appears to be a slight hemorrhage that
appears as dots in the middle layer of the retina. There is 11-fold-increased risk in
retinopathy due to the chronic hyperglycemia which can sometimes develop at quite
an early stage. The earliest histopathological sign of retinopathy in diabetes is
associated with the loss of pericytes, which wrap around the capillary, and
1040 R. Khan et al.
Fig. 3 Hallmarks of retinopathy
dysfunction of arterial endothelial cells, capillary growth, tone, and resistance, and
provides protection from damage due to the oxidative stress in diabetes mellitus.
There is thickening of basement membrane during retinopathy, changes in perme-
ability of endothelial cells, and the development of microaneurysms (King et al.
2005; Behnam-Rassouli et al. 2010).
Cell apoptosis is caused by activation of protein kinases, abnormal glucose
metabolism, increased production of reactive oxygen species, formation of advanced
glycation end products, release of proinflammatory cytokines from leukocytes in the
retina, and by the loss of signaling by platelet-derived growth factor and
upregulation of Tie-2 (receptors for angiopoietin, which are growth factors required
for the formation of new blood vessels (Kowluru and Chan 2007).
Diabetic retinopathy is the leading cause of blindness around the globe. According to
the National Health and Nutrition Survey, the prevalence of retinopathy in diabetic
patients is close to 30% (Zhang et al. 2010; Wang et al. 2016). Patients at high risk of
vision loss are diabetic patients with a long duration of hyperglycemia, male sex, high
blood pressure, and insulin usage. Microvascular disease also indicates diffuse vascular
disease in diabetic patients that is characterized with an increased rate of atherosclerosis
in patients with retinopathy (compared to diabetic patients without retinopathy). Retinal
ischemia and impaired perfusion upregulate angiogenic molecules, including erythro-
poietin, vascular endothelial growth factor, and other vascular growth factors. These
vascular growth factors in turn promote proliferative diabetic retinopathy, which conse-
quently increases vascular leakage. Preretinal angiogenesis has the ability to cause
bleeding in the vitreous of the eye, and form epiretinal membranes, and loss of vision
(Zhang et al. 2010; Lee et al. 2015).
Diabetic Nephropathy
An equally serious and common complication of diabetes is nephropathy. The
increase in blood pressure caused by atherosclerosis and greater adipose tissue
function causes dysfunction of renal tissue in the early stages of diabetic
nephropathy, where the excretion of albumin in urine is 30–299 mg/24 h and is
known as microalbuminuria which leads to the final stages of renal failure. A
study by Uwaezuoke (2017) reported that microalbuminuria is more common in
T1DM, and the first stages of microalbuminuria are evident in about a quarter of
patients with T2DM. Microalbuminuria also causes nerve dysfunction, and
almost half of diabetic patients subsequently develop diabetic neuropathy. Dia-
betic neuropathy and its symptoms can lead to the loss of vascular control,
abnormal heart rate, and cardiovascular dysfunction (Tervaert et al. 2010; Lim
2014).
Diabetic Neuropathy
According to the American Diabetes Association, diabetic neuropathy is “the pres-
ence of symptoms and/or signs of peripheral nerve dysfunction in the people with
diabetes after the exclusion of other causes” (American Diabetes Association
2012a). The risk of developing diabetic neuropathy (as with other diabetic compli-
cations) is directly related to both the duration and magnitude of hyperglycemia. In
addition, some genetic attributes can also predispose to such types of complications.
Although reasons for the injury from hyperglycemia to peripheral nerves are unclear,
some suggested mechanisms are associated with oxidative stress, polyol accumula-
tion, and injury from advanced glycation products. Peripheral neuropathy is
manifested in various forms such as autonomic, focal/multifocal, and sensory. Foot
injuries due to diabetic neuropathy can lead to an 80% increased risk of amputations
(Vinik et al. 2003; Edwards et al. 2008; Zakin et al. 2019).
The most frequent form of neuropathy in diabetic patients is chronic sensory
motor distal symmetric polyneuropathy. Diabetic patients experience a burning and
tingling pain in combination with numbness that often gets worse at nighttime.
Hence, patients with numbness present with foot ulceration, and the absence of
signs does not eliminate neuropathy. Patients with neuropathy lose sensory light
touch, and responses to increases in temperature and vibration. Loss of ankle
reflexes is also experienced; patients who lose the sensation to a10 g monofilament
are at higher risk for the development of foot ulceration (Boulton 2005; Juster-
Switlyk and Smith 2016; Volmer-Thole and Lobmann 2016). Mononeuropathies
have an abrupt onset and can involve almost any nerve but usually affect the ulnar,
median, and radial nerves. It is important to evaluate diabetic neuropathy using
electrophysical tests that can reveal decreases in the conduction and amplitude of
nerve impulses for the identification of particular nerve damage. One manifestation
of diabetic mononeuropathy is diabetic amyptrophy, which involves the large
muscles of the thighs, buttocks, and legs, and causes severe pain with muscle
atrophy and weakness. Diabetic autonomic neuropathy also triggers mobility and
mortality concerns in patients (Vincent et al. 2004; Rogers and Malik 2010; Russell
and Zilliox 2014).
1042 R. Khan et al.
Diabetes and Oral Health Complications
There are a range of oral disorders associated with diabetes. Oral disorders such as
gingivitis and periodontitis have received great attention due to the inflammatory
response caused by diabetes. In addition, salivary dysfunction, dryness of mouth
(xerostomia), oral mucosal and fungal infections, dental caries, risk of oral cancer
dentine hypersensitivity, neurosensory, and taste disorders (Lamster et al. 2008) can
also occur in patients with diabetes. In the Arab world, communication between the
patient and dentist should be improved with detailed medical updated history of
patient. Poor oral health is significant and is associated with the income and the
educational background of the patient. Moreover, dental health awareness will help
to improve dental care (Mian et al. 2020). An overview of dental health concerns in
diabetes is summarized in Fig. 4.
Fig. 4 Oral manifestations of diabetes

Dental Caries
Diabetes and dental caries have complex associations. Salivary flow rate reductions
contributes significantly to dental caries development. Other factors include a low buffer
capacity, and bacterial infections. Reductions in salivary flow rates which is associated
with hyperglycemia increases the levels of acidogenic bacteria in oral cavity which
induces the dental caries in children and adults with diabetes (Latti et al. 2018).
Oral Cancer
A common theme in the risk factors of both oral cancer and diabetes appears to be
dietary; however, there is not necessarily a correlation between the dietary factors
that increase the risk of oral cancer and those that increase the risk of diabetes.
Viral infections also pose a risk for both oral cancer and diabetes, but again, these
appear to be different viral infections. The consumption of alcohol is a risk for
oral cancer (especially for those who consume alcohol and smoke tobacco), and
alcohol also raises blood glucose levels, suggesting a correlation between alcohol
consumption and diabetes. Some studies seem not to support this hypothesis
when considering drinking in moderation, while “excessive” drinking is thought
to increase the incidence of diabetes (Al-Maskari et al. 2011). Other studies on
the incidence of oral cancer and diabetes mellitus have largely been inconclusive
and conflicting.
Xerostomia
Salivary dysfunction is commonly reported by people with diabetes. Dry mouth or

xerostomia and the salivary dysfunction are experienced in adults, and the causes
may be related to polyuria or alterations in the salivary gland basement membrane.
Xerostomia causes thirst that increases the susceptibility of acquiring bacterial, oral
mucosal, and fungal infections (Hoseini et al. 2017).
Oral Mucosal Diseases
There is a greater likelihood of developing oral mucosal lesions in individuals with

diabetes, with reports of high prevalence of lichen planus, fungal infections, and
aphthous stomatitis. This could be due to chronic immunosuppression and acute
hyperglycemia. Fungal infections such as oral candidiasis are common in individuals
with diabetes, those who smoke cigarettes, and those who wear dentures and with
poor oral hygiene. Salivary dysfunction also contributes to the fungal infections
(Al-Maskari et al. 2011).
1044 R. Khan et al.
Taste and Neurosensory Disorders
Some neurosensory disorders include the burning mouth syndrome, dysphagia, and
glossodynia (spontaneous burning sensation, discomfort, pain, irritation or rawness
of the tongue and lips, or oral cavity). Individuals with poor glycemic control are
severely affected and experience altered taste due to underlying conditions including
peripheral neuropathies and diabetic retinopathies (Al-Maskari et al. 2011).
Gingivitis and Periodontitis
Gingivitis and periodontitis are well-recognized complications of diabetes. Increases

in periodontal disease are due to poor glycemic control, as shown in epidemiological
data and from animal models (Preshaw et al. 2012).
Periodontitis is due to an exaggerated inflammatory response of periodontal
microflora in people with diabetes. There are several mechanisms proposed for the
susceptibility of diabetic individuals to periodontal diseases. One mechanism is
related to activated glycation end products that form when excess levels of glucose
interact with structural and other proteins. This event triggers a series of pro-
inflammatory and inflammatory responses that cause periodontal tissue destruction
in patients with diabetes (Preshaw and Taylor 2011).
Alterations in the host response, collagen metabolism, subgingival microflora,
vascularity, hereditary patterns, and gingival crevicular fluid are other contributing
factors that may be involved. The loss of alveolar bone is thought to be caused by
compromised neutrophil function, leukotaxis, and decreased phagocytosis. It is
important to treat chronic periodontitis and related infections as these can lead to
periodontitis-induced bacteremia and increases in proinflammatory cytokines in the
serum; this in turn can lead to hyperlipidemia, insulin resistance, and destruction of
pancreatic beta cells (Khader et al. 2006).
Miscellaneous Complications
As discussed earlier in the chapter, patients with diabetes who experience large
hypoglycemic episodes are at higher risk of developing cardiovascular disease. A
retrospective study analyzed data on insulin-treated T1DM and T2DM patients,
with self-monitored blood glucose and HbA1C levels, and reported that hypo-
glycemia was more common in patients with T1DM and that there was a positive
association between glycemic variability and the frequency hypoglycemia in
patients with T1DM and T2DM (Canivell and Gomis 2014). Hence, there
needs to be a strategy to avoid hypoglycemia by targeting glycemic variability,
particularly in insulin-treated patients (Schalkwijk and Stehouwer 2005; Zheng
et al. 2018).
Advanced glycation end products also play a significant role in impaired wound
healing in diabetic patients. Receptors for activated glycation end product (RAGE)
mediate poor wound healing in diabetic mice, as shown by the use of anti-RAGE
antibodies that improved wound healing (Bierhaus et al. 2005; Xie et al. 2013). In
addition, the phagocytic function of macrophages was improved based on immuno-
histochemical staining. These findings could be used in clinics for the treatment of
wounds in diabetic patients (Yao and Brownlee 2010).
Hypothyroidism can also occur in T1DM and T2DM patients. Hypothyroidism in
T2DM patients was more common in patients with higher levels of HbA1c and total
cholesterol levels when compared to euthyroid diabetic patients. This suggests that
there should be screening of thyroid dysfunction in patients with diabetes patients as
these types of comorbidities can worsen diabetic control (Brenta 2010; Zimmermann
and Boelaert 2015).
Treatment of Chronic Complications in Diabetes
Achieving proper metabolic glucose control in diabetes and avoiding diabetic

complications require alterations in lifestyles and pharmacological treatment. The
risks of microvascular and microvascular complication of diabetes are significantly
decreased when near-normal HbA1C levels are achieved. There are several different
treatments for diabetes available, including a combination of oral and injectable
drugs. The treatment algorithms are designed to reduce complications of diabetes.
There are both benefits and limitations for the different drugs for the treatment of
diabetes. However, the preliminary focus remains changes in lifestyle such as
nutritional intervention and exercise.
Metformin is frequently used first in the treatment for patients with diabetes.
Metformin has different mechanisms of actions and contraindications that physicians
should be aware of prescribing the drug. The second line of treatment is individu-
alized and it depends upon the variety of characteristics each patient having diabetes.
Insulin secretagogues, sulfonylureas and meglitinides, alpha glucosidase inhibitors,
thiazolidinediones, dipeptidyl peptidase-4 inhibitors, sodium glucose cotransporter-
2 inhibitor, and insulin are some commonly used therapies in the management of
diabetes. Insulin is used for the treatment of patients with all types of diabetes and
comes in many formulations that determine onset and duration of action (Rother
2007; Marín-Peñalver et al. 2016).
Conclusions
There is an unrestrained increase in diabetes and related complications over the

previous two decades in the Arab world, particularly within the Gulf cooperation
countries. There is an urgent need to better understand the disease and its compli-
cations in the Arab world, due to its unique features in lifestyle, and cultural and
genetic influences. The interaction between these factors in the Arab world is
unknown.
1046 R. Khan et al.
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Current Status of Diabetes in Palestine:
Epidemiology, Management, and 41
Healthcare System
Nuha El Sharif and Asma Imam
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1054
Aim and Scope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1055
The Palestinian Healthcare System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1055
Extent and Magnitude of the Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1056
Prevalence and Incidence of T2DM in Palestine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1059
Controlling the Modified Risk Factors for Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1060
Metabolic Syndrome (MetS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1060
Overweight and Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1060
Diet and Physical Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1063
Tobacco Smoking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1064
Quality of Life (QoL) in Patients with Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1064
Diabetes Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1065
Managing Diabetes Through Lifestyle Modifications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1066
Medications Adherence Among Patients with T2DM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1068
Palestinian Diabetes Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1069
Monitoring NCDs Including Diabetes by the PMoH and UNRWA . . . . . . . . . . . . . . . . . . . . . . . 1071
Prevention of Diabetes Complications Using the Glycemic Control (HbA1c) . . . . . . . . . . . . 1072
Challenges and Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1074
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1074
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1075
Abstract
This chapter reviews the epidemic of diabetes mellitus (DM) that is affecting the
Palestinian population, the extent and magnitude of the problem, risk factors and
complications, management protocols and compliance, and patients’ quality
of life (QoL). Moreover, the challenges and problems facing the Palestinian
community in prevention and control of diabetes are discussed. The authors
N. El Sharif (*) · A. Imam

Faculty of Public Health, Al Quds University, Jerusalem, Palestine
e-mail: nsharif@staff.alquds.edu; aimam@staff.alquds.edu

https://doi.org/10.1007/978-3-030-36811-1_43
1054 N. El Sharif and A. Imam
focus on the published literature from the past two decades, and incorporate data
from research studies in the field of diabetes and metabolic syndrome. It is worth
noting here that most work done in Palestine in the field are evaluative studies,
and that there are no prevention or intervention studies focused on diabetes
prevention or control.
DM is considered the fourth leading cause of death in Palestine, with
a prevalence of 9.1% in patients aged 20–79 years and is predicted to increase to
20.6% by 2020. Lifestyle changes and uncontrolled glycemic levels are associated
with an increased risk of developing type 2 DM (T2DM) and its complications.
All Health-related quality of life (HRQoL) domains of Palestinian patients
with DM are negatively affected by its incidence. Moreover, longer duration
of DM (>10 years), presence of chronic diseases and comorbidities, and the
existence of one or more DM complications negatively impact HRQoL.
T2DM patients’ adherence to anti-diabetic medications in Palestine is sub-
optimal compared to international studies. The overall adherence levels to the
diabetic clinical guidelines are disappointingly suboptimal within the Palestinian
Primary Healthcare Centers of both the Ministry of Health and the United Nations
Relief and Work Agency (UNRWA).
Keywords
Epidemiology · Risk factors · Prevention · Complications · Management
protocols · Compliance · Quality of life · Diabetes strategy · Challenges · Arabs ·
Palestine · Diabetes management · Medication adherence
Introduction
Diabetes is one of the four priority non-communicable diseases (NCDs) identified by

the World Health Organization (WHO) along with cardiovascular disease (CVD,
which includes heart attack and stroke), cancer, and chronic respiratory disease.
Diabetes is a group of disorders with common features, of which raised blood
glucose is the most evident. It is a chronic disease which can cause substantial
premature morbidity and mortality (WHO 2014).
Diabetes is subcategorized into diabetes type 1 or what was formerly called
juvenile diabetes (T1DM), diabetes type 2 (T2DM), as well as specific types, e.g.,
drug-induced and gestational diabetes mellitus (GDM). It is a common, chronic,
and a costly disease (IDF 2015). Many factors affect its prevalence and identification
of those factors is necessary to facilitate change when facing health challenges.
An increased number of early-onset DM is also responsible for the development
of various diabetic complications due to longer disease duration that is largely due
to better disease management (Hillier and Pedula 2003).
The diagnosis of diabetes is based on clinical symptoms and/or measurements of
plasma glucose. Glycocylated hemoglobin A1c (HbA1c) is accepted as an additional
diagnostic test for DM (WHO 2011a). The American Diabetes Association (ADA) has
also suggested a revision by incorporating impaired glucose tolerance (IGT) and
41 Current Status of Diabetes in Palestine: Epidemiology, Management. . . 1055
impaired fasting glucose (IFG) tests as indicators of increased risk of diabetes (American
Diabetes Association 2010). The definition of gestational diabetes mellitus (GDM) is
controversial although guidelines for its detection and diagnosis are available.
The etiology of DM is multifactorial and includes genetic factors coupled with
environmental influences such as obesity associated with modern living standards,
the steady stream of urban migration, and lifestyle changes. In the Arab region, rapid
urbanization and lack of exercise are among other key determinants of this increase
in T2DM (Laher 2014).
Developing T2DM and its complications can cause severe problems for affected
individuals and their families, in addition to increasing the burden on health services.
Primary prevention of T2DM is potentially feasible, but has yet to be implemented
as a public health measure. The organization of services for the care of people with
diabetes is complex, involving hospital-based diabetes teams, community services,
those working in primary care, patients, and their families (McGill et al. 2017).
Much as in other developing countries, Palestine is also experiencing a rapid
epidemiological transition which leads to a rapid change in lifestyles, nutritional
behaviors, and environmental conditions. It was estimated that nearly two-thirds of
elderly Palestinians complain from chronic diseases. However, there is insufficient
or incomplete national data on the quantity, quality, and scope on the burden of
chronic non-communicable diseases (NCDs) (Musleh et al. 2016).
Some studies were conducted on diabetes management in Palestine, with reports
on self-management or management by healthcare providers and the type of the
healthcare provided. Also, protocols used for diagnosis, treatment, and follow-up are
areas of intense investigation. Another research interest is the quality of life (QoL)
and satisfaction with services provided for diabetic patients’ illness.
Aim and Scope
This chapter reviews the most recent published studies in the area of epidemiology
and management of diabetes in Palestine. Also, it highlights areas and suggests
issues, in particularly in the domain of health services, where more information is
needed. The chapter includes a review of the Palestinian health system; the extent
and magnitude of DM; the epidemiology of DM in the following order: incidence
and prevalence and controlling the modified risk factors (metabolic syndrome,
overweight and obesity, diet and physical activity, and tobacco smoking); QoL
of diabetic patients; and diabetes management (glycemic control and diabetes
complications, medications adherence among patients with T2DM, and healthcare
professionals adherence to Palestinian diabetes guidelines).
The Palestinian Healthcare System
The Palestinian Healthcare System is a mixture of governmental, nongovernmental

(NGOs), United Nations Relief and Work Agency (UNRWA), Palestinian Military
Medical Services (PMMS), and private (profit and nonprofit) services delivery. These
health providers provide overlapping services, although none of these sectors deliver
comprehensive health services. The Palestinian Ministry of Health (PMoH) endures the
heaviest load of the health services responsibility. It provides primary healthcare (PHC)
and secondary and tertiary healthcare for the entire population, and the UNRWA, which
is the other healthcare provider in Palestine, provides services at the primary level of
healthcare. There are 669 primary health clinics and 51 hospitals in the West Bank,
including those of the UNRWA and nongovernmental organizations (see Map 1). There
are 223 primary healthcare facilities and 28 hospitals in the Gaza Strip (WHO EMRO
2010) (see Map 2). However, specialized care is not available in the public health
system, and patients in need are referred to private nongovernmental organization-
managed hospitals in the West Bank, Gaza, or abroad; a significant portion is referred
to Israeli hospitals. The cost of this referral is entirely covered by the national govern-
mental insurance. This referral imposed a large burden on the Palestinian Healthcare
System, which recently adapted a multifaceted performance improvement approach to
reduce the cost of referrals (Bitar 2016). In East Jerusalem, the six Palestinian-operated
hospitals – Maqassed Islamic Hospital, the Red Crescent Society (PRCS) maternity
hospital, Augusta Victoria Hospital, St. John’s Ophthalmic Hospital, St. Joseph’s
Hospital, and Princess Basma Rehabilitation Center – have served for decades as the
main referral centers for the Palestinian population in the West Bank and Gaza Strip and
the central medical training facilities for Palestinian health professionals. Egypt, Israel,
and Jordan also provide important referral centers for treatment for Palestinians with
either government insurance or private patients.
In its latest annual report, “Right to Health: Crossing barriers to access health in the
occupied Palestinian territory,” the World Health Organization (WHO 2016a) draws
attention to a concerning and continuing decline in the approval rates for patient
permits to access healthcare outside of the West Bank and Gaza Strip. Historical
reliance on hospitals and referral centers that now require permits to access, especially
those in occupied East Jerusalem, means that patients must navigate burdensome
permit application processes and security procedures that result in delays and denial of
care for thousands of Palestinian patients every year. In 2016, the permit approval rate
for patients was the lowest recorded by WHO since it started monitoring in 2008, with
two in every five patients encountering delays or denial of care.
Extent and Magnitude of the Problem
The prevalence of T2DM is increasing in developing countries because of the ageing

population, adopting a sedentary life, changing lifestyles, and the increase in the
prevalence of several risk factors such as the metabolic syndrome factors, particu-
larly obesity (Maruthur 2013). In addition, the noticeable increase in the incidence
of childhood diabetes also contributes to the rise of diabetes incidence and preva-
lence (Cizza et al. 2012). There are a limited number of published studies on
the incidence and prevalence of diabetes in Palestine, with the most recent data
derived from projection models (Abu-Rmeileh et al. 2013). Similarly, there are
a limited number investigations on the risk factors and complications for T1DM
Map 1 Healthcare facilities distribution in the West Bank – Palestine 2017. (Source: Palestinian
Ministry of Health, Palestinian Health Information Center (PHIC))
Map 2 Healthcare facilities distribution in Gaza Strip – Palestine 2010. (Source: World Health
Organization, Jerusalem, Palestine)
(Khdour and El Sharif 2007) and GDM (AlKasseh et al. 2014; Smak et al. 2014;
Titi and El Sharif 2013). Most studies have focused on the risk factors for T2DM,
which will be presented in the following sections.
Prevalence and Incidence of T2DM in Palestine
The most recent findings rank T2DM as the fifth leading cause of disability in the
Arab world which is a significant deterioration from being ranked 10th as recently as
1990 (Abuyassin and Laher 2016). This is very similar to the Palestinian case, where
the Palestinian Ministry of Health (PMoH) ranked T2DM as the fourth leading cause
of death and represented 8.9% of all deaths in 2014 (PMoH 2016a).
The incidence of T2DM in Palestine is not reported accurately. In the Palestinian
national population-based survey (STEPwise 2010/2011) on risk factors of T2DM
of adults aged 15–64, the annual incidence rate ranged from 150 to 220 per 100,000
population. However, the reported cases may represent half of actual cases, as there is
currently no screening program in place for the early detection of diabetes. Another
potential explanation is the underreporting of cases since there is no real-time electronic
medical record system at the point of care (e-Health) for monitoring incidence, preva-
lence, and treatment outcomes in the PMOH primary healthcare clinics (Khader et al.
2013). Most diagnosed cases that are registered were insulin-resistant T2DM (WHO
2011a). In 2016, in the annual PMoH report, the newly reported DM cases in primary
healthcare diabetes clinics in West Bank were 5,148 cases. The incidence in males was
174.6 per 100,000 population and 211.5 per 100,000 for females. However, the
prevalence rate of T2DM was highly variable in the various studies and reports. The
International Diabetes Federation (IDF) reported the prevalence in diabetic patients aged
20–79 years in Palestine to be 9.1% (IDF 2015). In the national STEPwise survey, 8.5%
were diabetics and 5.8% had impaired glucose levels (WHO 2011b), while insulin-
dependent T1DM was about 5% of diagnosed cases (WHO 2016b). The rate of diabetes
as reported by the United Nations Relief and Works Agency (UNRWA) was 5 million
(or 11%) of the Palestinian-registered refugees living in Palestine and in the other Arab
countries (Jordan, Lebanon, and Syria) aged 40 years and older (UNRWA 2014).
Data on T1DM in Palestine is very limited. No data is available for T2DM in
children, and diabetes in childhood is entirely due to T1DM. In Saudi Arabia, the
age-specific prevalence of T2DM in children less than 18 years old is 1 per 1000 (Zeitler
et al. 2014). Similarly, the UNRWA annual report (2016) reported that T1DM is about
2.6% of patients diagnosed with diabetes (with an estimated prevalence of 1.5%), but
accurate national incidence and prevalence rates are not available. In the STEPwise
national survey (2010/2011), the mean fasting blood glucose, including those currently
on medication for raised blood glucose, was 98 mg/dl. The percentage of patients with
impaired fasting glycemia [IFG, defined as the percentage below plasma venous values
of 6.1 mmol/L (110 mg/dl) and <7.0 mmol/L, and capillary whole blood values of
5.6 mmol/L (100 mg/dl) and <6.1 mmol/L (110 mg/dl)] was 5.8% (3.7–5.8%). The
percentage with increased fasting blood glucose, defined as percentages below or
currently on medication for raised blood glucose [plasma venous value 7.0 mmol/L
(126 mg/dl), or capillary whole blood value 6.1 mmol/L (110 mg/dl)] was 8.5%
(6.5–10.5%) (WHO 2011b).
In a recent modeling for diabetes projections, diabetes prevalence (for those aged
25 years or more) is predicted to reach 20.6% in 2020 and 21.5% in 2030,
representing a predicted increase of 35% from 2000 to 2030. The estimated number
of patients with diabetes is thus expected to reach 289,000 in 2020 and 444,000 in
2030. Prevalence in men increased from 9.1% to 16.9% and in women from 10.2%
to 13.6% (Abu-Rmeileh et al. 2013).
Controlling the Modified Risk Factors for Diabetes
Diabetes can be prevented with effective lifestyle changes, including maintaining

a healthy diet, regular physical activity, normal body weight, and avoiding tobacco.
However, these measures are not widely implemented by the public. According to
STEPwise national survey (2010/2011), nine out of every ten Palestinians living in
Palestine have at least one risk factor for NCDs, whether diabetes, heart disease,
cerebrovascular disease, or cancer (WHO 2011b).
Metabolic Syndrome (MetS)
MetS is also a constellation of abnormal cardiometabolic factors that increase the

risk of CVD and T2DM. It is characterized as having three or more of the following:
central obesity (large waist), high blood pressure, altered fasting blood glucose, and
high cholesterol level (Kaur 2014). These factors are present in 20–40% of
Palestinians. In Palestinians older than 20 years in the Jerusalem area, the prevalence
of MetS was 33.6%, of which 27% had insulin resistance and 67% had high levels of
central obesity (Abu Sham’a et al. 2009). In Gaza, those older than 20 years of age
had prevalence rates of MetS of 23.0%, which was associated with physical inac-
tivity (Sirdah et al. 2011). Therefore, obesity and physical inactivity are of great
concern when setting policies for control of T2DM. A recent estimation model to
prevent and control diabetes in Palestine showed that increases in obesity and
smoking, the major lifestyle factors associated with diabetes, will affect T2DM
over ten years (Abu-Rmeileh et al. 2013).
The first line of therapy for the treatment of T2DM is weight loss with lifestyle
modifications such as a healthy diet and increased exercise levels, as obesity
increases the probability of developing diabetes and its complications (Masuo
et al. 2010; Masuo et al. 2011). Not only does the total body fat matter but also
the pattern of its distribution. Excess visceral fat, also referred to as central obesity,
has a stronger association with chronic diseases than does subcutaneous fat, which is
deposited mainly around the hips and buttocks (Segula 2014). Epidemiological
studies across the world shows that body mass index (BMI) positively correlates
with the chance of developing T2DM. The Health Professionals’ Follow-up Study
of 51,529 US male dentists, veterinarians, osteopaths, podiatrists, optometrists, and
pharmacists aged 40–75 years reported that the risk of DM increased with greater
levels of body mass index (Chan et al. 1994). The Nurses’ Health Study of 113,861
US female nurses aged 30–55 years also reported similar results in women with
a BMI of 22 or greater (Colditz et al. 1990). Therefore, examining the modifiable
risk factors for DM, including obesity, is important because of its public health
implications (CDC 2018a).
Treating long-term DM is costly, and the best approach to control diabetes is
primary prevention. In some Arab countries where diabetes prevalence is relatively
low, such as Sudan and Tunisia, the Relative Risk (RR) of developing T2DM was
1.74 (95%CI: 1.32–2.28) and 1.61 (95%CI: 1.34–1.93), respectively (Laher 2014).
However, the prevalence of obesity in adults (15–100 years old) in other Arabian
countries such as Kuwait (29.5–55%) and the United Arabs of Emirates
(24.5–42%) were considered relatively high when compared to Palestine
(19.6–37.9%) (Badran and Laher 2011). The situation in Palestine may be even
worse than in Sudan and Tunisia, since obesity is relatively high in Palestine at
about 25% of the adult population (Abu-Rmeileh et al. 2013). The national
STEPwise survey reported 57.8% of adults aged 15–64 years as overweight and
26.8% as obese (WHO 2011b).
Obesity is becoming pandemic in Palestine, in particular among adult females
over age 40 and is more preventable among those living in cities and refugee
camps compared to those living in rural areas both in Gaza Strip and
West Bank (see Table 1). The two major healthcare providers, i.e., PMoH and
UNRWA, reported a high prevalence of obesity in diabetic patients, leading both
agencies to include obesity in the national strategy to combat NCDs – particularly
diabetes. The PMoH reported that over half of diabetic patients have obesity
(PMoH 2005). The UNRWA reported that 90% of DM patients are obese or
overweight. These “dangerous” rates require a long-term action plan which includes
an emphasis on comprehensive medical treatment and lifestyle support for patients
living with T1DM and updating technical instructions to introduce modern technol-
ogies and medicines for care of T2DM, expanding comprehensive prevention
activities for at-risk populations, and developing partnerships with local, national,
and international stakeholders (UNRWA 2014).
Therefore, obesity should be targeted to reduce the prevalence of T2DM.
The EMRO-WHO targets a 35% reduction in obesity over 10 years, which could
lower diabetes prevalence by 20.2%. In Palestine, a suggested policy scenario to
control diabetes expects a decline in obesity by 10% in 10 years, which could
produce a 5.3% reduction in diabetes prevalence (Abu-Rmeileh et al. 2013).
Table 1 Two-decade data on overweight and obesity in Palestine

Year Population Locationa Gender Overweight Obese
Abdul-Rahim 2001 Urban WB F 49
et al. 2001 population M 3
Abdeen et al. 1999–2000 18–64 years WB F 33.5 31.5
2012 M 40.3 17.5
Abdeen et al. 2003 Children WB Both 14.9 5.9
2003 <59
months
Al-Rifai 2006 Rural WB F 37
& Roudi-Fahimi M 18
2006
Ellulu et al. 2007 Adults WB F 52.6
2014 M 28.7
GS F 41.6
M 34.1
Kanoa et al. 2008 University GS F 17.3 3
2008 students
Husseini et al. 2009 Adults All F 71.3
2009 M 58.7
Al Sabbah et al. 2009 Adolescents WB Both 13.3 3.2
2009
Obaid et al. 2010 > = 60 Gaza Both 29.4 41.0
2010 years
Al-Sabbah 2012 2012 University WB Both 20.1 4.6
students
Musaiger et al. 2011 Adolescents WB F 12.5 3.5
2011 M 12.7 5
Bayyari et al. 2013 University WB F 12.4 1.7
2013 students
Lubbad et al. 2011 University GS F 7.1 0
2011 students M 17.1 2.9
Kishawi et al. 2014 18–28 years GS Both 31.3 15.6
2014 29–39 years Both 37.6 35.8
40–50 years Both 32.4 56.8
City GS Both 26 31
Rural Both 47 20
Refugee Both 35.9 30.9
camps
Kishawi et al. 2016 18–50 years GS F 64.1 –
2016
Massad et al. 2010 Refugee WB F 30% 39%
2018 camps
a
WB West Bank including Jerusalem, GS Gaza Strip
Diet and Physical Activity
A healthy diet has an important role in preventing and managing diabetes

complications (Ley et al. 2014). Changing dietary habits is an important strategy
that targets diabetes prevention and control of its complications (Ley et al. 2014).
Some food groups are associated with diabetes complications such diabetic
retinopathy in patients with T2DM (Cundiff and Nigg 2013). For example,
increased fruit intakes in ranges commonly consumed are associated with
reduced incidence of diabetic retinopathy inpatients adhering to a low-fat
energy-restricted diet (Tanaka et al. 2013a, b). Diabetic retinopathy, sight-threat-
ening diabetic retinopathy, and micro-albuminuria are also associated with a
lower dietary-fiber intake (Ganesan et al. 2012). Understanding dietary patterns
can be used to test the role of the overall diet on nutrition-related diseases. Most
of these dietary patterns are characterized by high consumption of plant-based
foods and low consumption of animal-based, high-fat, and processed food
(Lazarou et al. 2012). Plant-based dietary patterns, which are rich in fruits,
vegetables, and whole grains, are valuable in preventing various chronic dis-
eases, whereas a diet high in red and processed meat, refined grains, and added
sugar increases the risk of developing T2DM and the metabolic syndrome
(Medina-Remon et al. 2018). Several of dietary patterns are beneficial both for
the prevention and management of T2DM (Ley et al. 2014). The Mediterranean
diet, which is a plant-based diet, significantly reduces the rate of T2DM
(Georgoulis et al. 2014). There is a noticeable increase in the consumption of
fast foods such as hamburgers, pizza, etc. in Palestine during the past decade
(Abudayya et al. 2011). A recent study in Gaza showed that an “Asian-like” diet,
which is characterized by a high intake of whole grains, potatoes, beans, legumes,
vegetables, tomatoes, and fruits, as well as a low intake of refined grains, sugar,
sweets, and desserts, lowered the prevalence of T2DM complications, i.e., high
blood pressure, kidney injury, heart diseases, peripheral organ injury, and neu-
rological complications (El Bilbeisi et al. 2017).
Regular physical activity helps to maintain weight loss and prevent weight
regain, and also decreases the risk of developing T2DM. Regular exercise and
fitness improve insulin sensitivity that persists for 72 h or longer after training
(Way et al. 2016). Only about 19% of the adolescent population in Arab engages in
physical activity (Abuyassin and Laher 2016). A limited number of studies exam-
ined the activity levels of the Palestinian community. The STEPwise national
survey (2011/2012) reported that Palestinian men spent more time on physical
activity than women. The percentage with low levels of activity (defined as
<600 MET/metabolic equivalents-minutes per week) was 46.5% (33.8% in
males versus 59.2% in females) (WHO 2011b). The community-based study of
30 diabetic women aged from 40 to 70 years in Gaza that included a health
awareness and education program on changing lifestyle (diet and daily physical
activity) produced a significant reduction in HbA1c mean after 3 months of
intervention (9.16 (SD 1.15) before versus 8.033 (SD 1.21) after intervention)
(Arafat et al. 2016).
Tobacco Smoking
There is much evidence that smoking increases the risk of diabetes and its compli-
cations. Smokers are 30–40% more likely to develop T2DM than non-smokers
(CDC 2018a). Smokers who are also diabetic are more likely than non-smokers to
have difficulty with insulin dosing and with controlling their disease. The exact
mechanism of how smoking increases the risk of diabetes and deteriorates glucose
homeostasis has not been fully elucidated, but the available evidence indicates that
smoking increases insulin resistance (CDC 2018a). Smoking makes glucose control
more difficult, regardless of the type of diabetes. Moreover, smokers with diabetes
have higher risks for serious complications (Seet et al. 2012).
Smoking prevalence in Palestine is very high, where 53.7% of men are smokers
compared to 5.2% of women (Abu-Rmeileh et al. 2013). The STEPwise national
survey reported that about 20% were current smokers (36% in men and 2.2% in
women (WHO 2011b). The UNRWA reported that 20% of the refugee population
with T2DM were also smokers (34.1% males and 11.3% females) (UNRWA 2014).
Data on smoking in females may be underestimated. “Nirgelia” or water pipe
smoking is not considered as tobacco smoking but a social habit which is common
in females. However, other methods of tobacco smoking, such as cigarette or pipe
smoking, by females is a stigma in Palestinian society. Therefore, the published
smoking rates and its association with diabetes in Palestinian women should be
treated with caution. The association between tobacco smoking, in particular water
pipe “Nirgelia” smoking, and health effects (especially diabetes) has not been
examined in Palestine. It is important to stress that use of the water pipe is not
without health risk. In a review by Golbidi et al. (2018), the authors concluded that
understanding the cellular redox balance in conditions such as diabetes and smoking
would help in providing a new treatment strategy that might minimize the side
effects of treatments in these conditions.
Quality of Life (QoL) in Patients with Diabetes
WHO defines QoL as “an individual’s perception of their position in life in the
context of the culture and value systems in which they live and in relation to their
goals, expectations, and standards and concerns. It is a broad-ranging concept
affected in a complex way by the person’s physical health, psychological state,
level of independence, social relationships, and their relationships to salient features
of their environment” (Bowling 2003; WHO 1997). Health-related quality of life
(HRQoL) is a multi-dimensional concept and its determinants have developed since
the 1980s to include domains related to physical, mental, emotional, and social
functioning (CDC 2018b). HRQoL has been used to differentiate the different
patients or groups of patients, to predict individual outcomes, and to evaluate the
effectiveness of therapeutic interventions (Guyatt et al. 1993). EQ-5D is a standard-
ized measure of health status developed by the EuroQol Group in order to provide a
simple, generic measure of health for clinical and economic appraisal (EuroQol
Group 1990). The scale comprises five domains (mobility, self-care, usual activities,
pain, and anxiety/depression).
Health-Related Quality of Life (HRQoL) is a relatively new research field in
Palestine. In reviewing the literature, there are three published studies conducted
on QoL in Palestinian patients with DM and one unpublished doctoral dissertation.
These studies concluded that all domains of HRQoL (physical, emotional, and
psychological) were negatively affected by diabetes (Abu Awad 2013, and Eljedi
et al. 2006, Khatib et al. 2018). Studies by Zyoud et al. (2015) found the mean
of European Quality of Life Scale (EQ-5D) score for diabetic patients in Palestine
was 0.7 (SD 0.20), while studies by Khatib et al. (2018) reported that the mean EQ-
5D score in hemodialysis patients with DM was 0.314 (SD 0.4). This low score may
reflect the impact of complications resulting from both DM and hemodialysis. Data
by Eljedi et al. (2006) suggest that all domains of World Health Organization Quality
of Life-short version (WHOQOL-BREF) were substantially reduced in diabetic
patients as compared to controls, with stronger effects on physical health (36.7 vs.
75.9 points in the 0–100 score) and psychological domains (34.8 vs. 70.0) and
weaker effects in social relationships (52.4 vs. 71.4) and environment domains (23.4
vs. 36.2).
Moreover, longer duration of DM (>10 years) and existence of one or more DM
complications negatively impact HRQOL (AbuAwad 2013). Patients with more
chronic diseases and comorbidities have significant poorer HRQOL scores (Khatib
et al. 2018). Moreover, patients who were on oral hypoglycemic agents (OHAs) had
a better HRQOL score than patients treated with insulin, but this difference did not
reach significant levels (AbuAwad 2013).
Diabetes Management
“Disease Management” is the goal in caring for patients with DM and aims
to eliminate symptoms and to prevent, or at least slow, the development of compli-
cations. Microvascular (i.e., eye and kidney disease) risk reduction is accomplished
through control of hyperglycemia and blood pressure, while macrovascular (i.e.,
coronary, cerebrovascular, peripheral vascular) risk reduction occurs through control
of lipids and hypertension, smoking cessation, and aspirin therapy and metabolic and
neurologic risk reduction by control of hyperglycemia (Chawla et al. 2016).
A team-based management strategy is crucial in the treatment of diabetes – the
disease should be managed by the patient, the physician, the nurse, the healthcare
system, and the sociocultural environment as a whole. Defects in any of these
components would lead to less than optimal results in the fight against diabetes
The essential components of disease management are (1) identification of indi-
viduals or populations with diabetes (or a subset with certain risk factors); (2) use
of guidelines or performance standards to manage those identified; (3) informa-
tion systems to track and monitor interventions and patient-, practice-, or popu-
lation-based outcomes; and (4) measurement and management of patient and
population outcomes (Huber 2005). This approach to diabetes management
involves lifestyle modifications, proper use of medication, appropriate self-mon-

itoring of blood glucose (SMBG), regular monitoring for complications, and
laboratory assessment which should be applied for diabetes management and
control (WU et al. 2014). We next discuss diabetes management and its applica-
tions in Palestine.
Managing Diabetes Through Lifestyle Modifications
The Palestinian healthcare system is mostly physician-centered and with a focus-

prescribing medications. Dieticians are not part of the care team in the primary
healthcare clinics, and nutrition counseling is performed mainly through the distri-
bution of printed materials by either nurse/nurse educator or clinic physicians
who usually have many other priorities in terms of urgent patient care (WHO 2016c).
There is substantial evidence that leading a healthy lifestyle, including following
a healthy diet, achieving modest weight loss, and performing regular physical
activity can maintain healthy blood glucose levels and reduce the risk of complica-
tions of T2DM (Klein et al. 2004). Intensive lifestyle interventions reduced a weight
loss of more than 5%, which was maintained at the fourth year in the Look AHEAD
(Action for Health in Diabetes) study (Wadden et al. 2011).
The PMoH constructed a national NCD center that is responsible for conducting
health education and health promotion campaigns and maintaining a surveillance
system in Palestine. Further, the PMoH NCD department, in collaboration with
technical assistance from the WHO, has developed a national strategy for the
prevention and management of NCDs. The results of the STEPwise survey on
non-communicable disease risk factors (2010–2011) guided the PMoH in formulat-
ing the National Policy and Strategic Plan for Preventing and Management of NCDs
for 2010–2014 (PMoH 2010). In the Palestinian National Strategy 2017–2022, one
of the main strategies is to promote the management of non-communicable diseases,
preventive healthcare approaches, community health awareness, and gender-related
programs (PMoH 2016b). However, the action plan for this strategy for 2017–2022
is still in preparation.
The Augusta Victoria Hospital (AVH) in East Jerusalem initiated a diabetes
project in 2003 with the purpose of establishing a diabetes center at AVH. The aim
was to create a center of excellence for the introduction of holistic approaches to
diabetes care and prevention, thus challenging the biomedical approach that has
dominated diabetes care in the Palestinian areas for decades. In this program,
patients who have access to the center are assessed by a team of health profes-
sionals that include a diabetologist (who prescribes the proper treatment according
to patient’s condition and diabetes control), a dietitian (for individual nutrition
assessment and counseling), and specialized diabetes care nurses. Healthy lifestyle
strategies are discussed with all diabetics and their families. Group education
sessions on topics related to diabetes self-management, complications, treatment,
and control are held regularly. All necessary laboratory tests (mainly HbA1c and
creatinine-albumin ratio) are performed on all diabetic patients (Khatib and El
Sharif 2012). Due to the political situation that prevents Palestinians from
accessing the center services in Jerusalem, AVH initiated in 2014 a new community
health program targeting diabetes. Mobile units run by AVH medical specialists
and nurses who travel daily to key locations in southern Palestine provide high-
quality diabetic care to 154 communities. In cooperation with the Palestinian
Ministry of Health, AVH staff treats patients seeking eye, foot, and diabetes care
(LWF 2015). Abu Al-Halaweh et al. (2017) assessed the prevalence of microvas-
cular and macrovascular complications of T2DM in 1308 patients examined by the
AVH Mobile Diabetes Clinic. The mean HbA1c (tested in 1221 patients) was 9.21
(standard deviation = 2), and only 16.1% of patients had HbA1c <7%. The authors
concluded from this survey and other surveys that were done on the same database
of AVH that the provision of diabetes services, including diabetes medications,
health education, monitoring, and supportive supervision, is still insufficient to
improve diabetes control through diabetic patients’ education and awareness (Abu
Al-Halaweh et al. 2017).
The UNRWA conducted a clinical Audit of Diabetes in 2012 and in 2015 for
Palestinian Refugees. The purpose of the audit was to evaluate the technical instruc-
tions on treatment and monitoring of diabetes (UNRWA 1997) and the health
education program that was implemented in the PHC of the UNRWA to control
diabetes and its complications. The results of the first and the second UNRWA
clinical audits reported that around 90.0% of the patients registered in the non-
communicable diseases (NCD) program were either obese (~ 64.0%) or overweight
(~26.0%). The 2015 audit showed that low control rates and poor health lifestyle
remained the major problem facing diabetes care in UNRWA. Control rates were
only ~25%. Obesity and overweight remained prevalent (~91%). The program of
controlling diabetes using lifestyle approaches was successful in only 2.5% of
patients. Routine measuring of HbA1c was introduced in 2015, and the NCD
technical instructions was updated accordingly (UNRWA 2016). In addition, the
UNRWA implemented a “Risk scoring” system, which is a risk assessment system
for patients with NCD who are registered refugees at the UNRWA health centers.
The presence of modifiable risk factors for NCD (such as smoking, hyperlipidemia,
physical inactivity, blood pressure, blood sugar) and non-modifiable risk factors
(such as age and family history of the disease) are recorded. The system helps health
staff to manage patients according to their risk score and to refer them for specialist
care as necessary. All patients registered with the NCD program in 2015 at an
UNRWA health center were assessed using the risk scoring assessment system,
and revealed that an average of ~25% of patients were considered to be at high
risk (UNRWA 2016).
Registered Palestinian refugees in Syria, Jordan, Lebanon, Gaza, and the West
Bank receive food aids containing grain, flour, and rice, i.e., “traditional food
parcel delivery” (“in-kind” food aid). A recent study by Basu and colleagues
(2018) indicates that a shift in the content of these food parcels to an alternative
parcel with less grain and more fruits and vegetables affects the morbidity and
mortality of several NCDs such as T2DM and hypertension. They showed a
decreased incidence of T2DM by 0.18 per 1,000 person-years and by 0.02 per
1,000 person-years all-cause mortality (95% CI 0.01 decrease to 0.04 increase) for
those receiving aid. The authors also reported that engaging in compensatory
behavior by recipients of food aid through the additional consumption of as little
as a 2% increase in refined grains, fats, and oils neutralized the positive effects of
the fruit- and vegetable-rich parcels. The researchers therefore recommend offering
a larger alternative parcel but this would require an increase in total food aid
expenditure of 27%.
Most diabetes awareness campaigns in Palestine are always done in cooperation
with the PMoH and the UNRWA. Juzoor for health and social development
(Juzoor), which is a Palestinian nongovernmental organization, had two projects
on diabetes in cooperation with the PMoH, UNRWA, AVH, and the DAN Church
AID (DCA). The first project aims in implementing the Diabetes Comprehensive
Care Model in the North of the West Bank (Qalqilya, Toulkarem, and Nablus) and
was funded by the World Diabetes Foundation. It is a national community-based
approach to diabetes care and prevention. One of its objectives was to raise
awareness of preventive measures for diabetes and NCDs within the community
(Juzoor 2018). In addition, in year 2017, they run a 1-year program on lifestyle
modifications in Al-Jalazoon refugee camp in Ramallah governorate. The Diabetes
Prevention Program (DPP) project was funded by Portland Trust. It targeted the
Palestinian pre-diabetic refugee women. The intervention is composed of nutrition,
physical education, and yoga sessions. The program showed an impact of the
women’s weight and HbA1c. The body Mass Index (BMI) decreased for a total
of 100% of participants. HbA1c was reduced in a percentage of 67%, and none of
the participants reached the diabetic stage. This program is extended for another 3
years 2018–2021 and will include 300 pre-diabetic refugee women in Al-Amary,
Qalandia, Qadoura, Jalazoon, and Shufat refugee camps within the Ramallah
governorate (Juzoor 2017).
Medications Adherence Among Patients with T2DM
Adherence to prescribed medications is defined as the proportion of prescribed doses

of medications actually taken by a patient over a specified period of time (Osterberg
and Blaschke 2005). It is one of the key elements of healthcare quality, and
it has significant economic and therapeutic consequences (Ho et al. 2006). Patient’s
adherence to anti-diabetic medications is important in preventing serious detrimental
complications and minimizing utilization of healthcare resources. Thus, achieving
glycemic control and preventing early diabetes complications depend on patient’s
adherence to therapies (Farsaei et al. 2011). Several factors can influence
a patient’s adherence to treatment plans, including provider-patient relationship,
patient-centered factors, therapy-related factors, healthcare system factors, social
and economic factors, and disease-related factors (Wong et al. 2011).
According to the PMoH reports (PMoH 2016a, 2017, 2018), Fig. 1 shows the
trend of diabetes medications use between years 2015 and 2017. The figure shows
that there is an increase in the percentage of patients using medications which might
Year 2015 Year 2016 Year 2017

66.50%
61.20% 63%
20% 21.10%
15.50%
13.10% 13.10% 14.80%
0.50% 1% 0.60%
Of clinic attendance Tablets & Insulin Tablets Diet
Fig. 1 Trend on diabetes medications use at the PMoH primary healthcare clinics. (Source: PMoH
annual Health reports, 2015, 2016, 2017)
reflect better compliance, better diagnosis, better patients-physician communication,

or better awareness.
Published studies on adherence to anti-diabetic medications in T2DM patients in
Palestine are few and show that adherence was suboptimal compared to international
studies. Elsous et al. (2017) report that 42% of the participants had a compliance
that was medium to low adherence, while Sweileh et al. (2014) indicate that 42.7%
of the study sample were considered non-adherent, and Jamous et al. (2011) suggest
that 44.6% had a medium adherence and 16.9% had low adherence rates. The low-
medium level of adherence to medications in these studies was attributed to the
healthcare settings mainly related to provider-patient relationships and the socioeco-
nomic status of patients. Moreover, the level of adherence to medications was
associated with patient-specific factors, patient’s disease-related knowledge,
and their knowledge of the severity and seriousness of disease and the benefit
and consequences of treatments. In the Gaza Strip specifically, an important consid-
eration is the inconsistent availability of medications due to the political conditions.
It can be concluded that the Palestinian PMoH should further develop policies
and take steps to boost the adherence to medications for type 2 DM, including
measures that promote the provider-patient relationship, making the treatments
accessible at the time of use and enhancing the self-management and self-monitoring
of blood glucose. Moreover, healthcare providers should address the patient’s beliefs
through assessment and education on medications in the hope of improving adher-
ence and consequently therapeutic outcomes. Medication adherence has important
therapeutic and economic consequences (Ho et al. 2006; Sokol et al. 2005).
Palestinian Diabetes Guidelines
Several international organizations have published guidelines for the care of patients
with DM to help practitioners and patients choose appropriate care and improve
treatment outcomes. Guidelines for the care of patients with DM help to improve
clinical practice and patient care (Sharif et al. 2016). To improve the quality of care
of diabetes patients, the Palestinian Ministry of Health (PMoH) and the United
Nations Relief and Works Agency for Palestine Refugees in the Near East
(UNRWA), the two major stakeholders in Palestine, have developed guidelines for
the management of diabetes. The PMoH guide is devoted to the management
and care of DM, while the UNRWA provides technical instructions and management
protocols on the prevention and control of non-communicable diseases. Both pro-
tocols are based on the World Health Organization (WHO) diabetes care guidelines
of 2006, with some differences between the two protocols, and sometimes also from
the WHO guidelines (WHO 2006). The PMoH guide was developed in 2008, in
cooperation with WHO and the Austrian Development Cooperation. The PMoH
adopted the Quick reference guide for the management and care of diabetes mellitus,
also called the Quick Guide. The Quick Guide targets areas of screening, diagnosis,
and treatment in order to standardize the care provided to patients withT1DM and
T2DM (WHO 2006).
Technical guidelines on surveillance, monitoring and management of DM in
UNRWA covers the following: diagnostic criteria for DM, case assessment (risk
assessment and physical examination, basic investigations, and health status in terms
of control and complications), management of DM (lifestyle modifications, insulin
therapy, therapy by oral hypoglycemic agents (OHA), and combined insulin and
OHA therapy), management of diabetic emergencies (hypoglycemia, hyperglyce-
mia, and diabetic ketoacidosis), monitoring (control criteria, and follow-up), referral
to specialists, self-care (enhancing self-reliance, teaching basic skills, and monitor-
ing of glucose level), diagnosis, management, and monitoring of diabetes in
pregnancy (pre-existing DM and preconception care of women with diabetes, and
gestational DM), and surveillance (UNRWA 2009).
The following management standards for T2DM were developed by the MoH
primary healthcare centers in 2012: screening and diabetes, early detection, diabetes
diagnostic criteria, management of diabetes, complications monitoring, nutrition
therapy and lifestyle changes, pharmacotherapy, diabetes self-management educa-
tion and self-monitoring of blood glucose, testing (HbA1c, cholesterol, renal eval-
uation, and eye examination and foot examination), and referral criteria and
indicators (screening indicators, clinical assessment indicators, treatment indicators,
outcome indicators, chronic complications indicators) (USAID 2012).
The main roles of physicians include taking a medical history (personal, family,
and past history, symptoms related to DM, frequency of acute complications,
symptoms of chronic complications and medications use), physical examination
(chest and heart, abdomen, mouth examination, skin, peripheral pulses, neurological
foot examination), treatment and patient education (nutrition therapy and lifestyle
changes, pharmacotherapy), and referral to other healthcare specialists (referral to
ophthalmologist, nephrologist, etc.) (USAID 2012).
The roles of the nurses include the following: blood pressure, height, and weight
measurement and recording, providing nursing care, and providing patient education
regarding DM general information, diet, exercise, DM chronic complications, DM
acute complications, patient’s risk for having CVD, taking medications, self-moni-
toring of blood glucose, foot care, and tobacco use (USAID 2012).
A study by EL Sharif et al. (2015) in the West Bank analyzed the pattern of DM
care by physicians and nurses in PHC clinics, and their self-reported compliance
with the PMoH and UNRWA guidelines. Their study showed that only half of the
physicians and one-third of nurses were familiar with local guidelines at their
disposal. Around half of the physicians and nurses did not adhere to Palestinian
diabetes guidelines because of lack of interest, making it challenging to the
healthcare services and proper diabetes management. In total, 46.0% of participants
knew of the existence of Palestinian guidelines and about 60% believed these
were partially used; 32.7% received training on implementation of the guidelines.
The poor adherence to guidelines by physicians and nurses is related to time
constraints and work overload, lack of the guideline trustworthiness, lack of incen-
tives, lack of resources for laboratory testing, and lack of training on how to apply
the guidelines (El Sharif et al. 2015; Radwan et al. 2017).
A recent study by Radwan et al. (2017) in Gaza to identify the predominant
culture within the Palestinian Primary Healthcare Centers of the Ministry of Health
(PHC-PMoH) and the Primary Healthcare Centers of the United Nations Relief and
Works Agency for Palestine Refugees (PHC-UNRWA) used the competing values
framework (CVF) and examining its influence on the adherence to the Clinical
Practice Guideline (CPG) for DM. The overall adherence levels to the diabetic
clinical guideline were disappointingly suboptimal within the PHC-PMoH and
the PHC-UNRWA. The organizational culture had a marginal influence on the
adherence to diabetes treatment guidelines. The lowest adherence was on
the recommendation to perform screening for type 2 DM in all individuals at the
age of 45 years in both PHC-PMoH and PHC-UNRWA. These findings were
congruent with several systematic reviews which also indicated that most of
the adherence-enhancing interventions had only modest-to-moderate effects (Bero
et al. 1998; Grimshaw et al. 2004).
In conclusion, there is a great need to effectively consider the factors that are
associated with successful implementation of clinical guidelines, including the
availability and affordability of resources and updating and training on guidelines
and the characteristics of the patients, providers, and healthcare organizations.
Monitoring NCDs Including Diabetes by the PMoH and UNRWA
According to the Palestinian National Policy and Strategy for Prevention

and Management, the burden of NCDs and the health outcomes of people with
NCDs within the National Health Information system should be monitored.
The PMoH is planning a legislative and regulatory policy framework to combat
smoking, and promote a healthy diet and physical activity. In addition, the PMoH is
working to strengthen health promotion and education programs in schools, the
workplace, and at a community level. Such health promotion and education pro-
grams are aimed at preventing and decreasing levels of smoking, physical inactivity,
obesity, and the consumption of foods rich in salt, sugar, and calories. In addition,
the PMoH is working to strengthen the early detection of NCDs and their risk factors
in an effort to reduce and prevent complications (PMoH 2010). At the PHC level,
the PMoH is implementing the WHO Package of Essential Noncommunicable

Disease Interventions for primary healthcare (PEN) approach to improve health
outcomes and to reduce rising healthcare costs due to NCDs and their preventable
complications (WHO 2010). In 2011, the WHO Package PEN led to introducing
evidence-based and cost-effective interventions for NCDs. The PEN interventions
are for detection, prevention, treatment, and care of NCDs approach. From January
2013 to June 2013, a pilot project for the PEN approach was implemented in 14
primary care clinics in Salfit District, West Bank and assessment made after a 6-
month pilot project. Patients who participated in this qualitative study perceived
positive changes in the quality of NCD services since the introduction of the PEN –
such as having a more thorough physical examination by a doctor, more time with
the doctor, perceived improvement in prescription of drugs, and better organization
of laboratory tests (Barghouthi et al. 2017).
The UNRWA began developing and piloting the use of electronic medical records
(EMRs), named as “the classical e-health system, in its health centers, transitioning
away from a time consuming, costly and labor-intensive imprecise paper-based
system” for Palestinian refugees in 2009. One of these modules is the NCDs e-
health (UNRWA 2015). In 2012, and due to continuous political conflicts and lack of
justice especially in Palestine (which affects the population’s physical, social and
mental health), the UNRWA set a strategy that focuses on “improving the quality of
healthcare delivered through a Family Health Team (FHT) model; improving the
quality of medical consultations and care for NCDs; providing staff with training in
family health; integrating Mental Health and Psychosocial Support (MHPSS) and
protection into the day-to-day activities of health centers; engaging the community
in health prevention and promotion activities; and improving hospitalization support
to ensure financial protection for the most vulnerable.” This strategy helped in
supporting the e-health system, and strengthening the FHT primary healthcare
model (UNRWA 2015). Following the FHT approach implementation in 2012,
a new FHT-based e-health system was developed which led to better documentation
and follow-up of referrals. It reduced patient waiting times and increased provider-
patient contact time, thereby increasing opportunities for the delivery of important
health education messages (UNRWA 2017).
Prevention of Diabetes Complications Using the Glycemic Control

(HbA1c)
Several factors have been suggested to be of importance for the development

of short-term and long-term complications in diabetes such as metabolic syndrome
factors (Wu et al. 2014). Some associations have asserted that the duration
of diabetes and other metabolic syndrome factors are well-established risk factors,
while others have been more controversial with partly contradictory findings
in different studies (Wu et al. 2014). The importance of different risk factors also
differs in patients with short- or long-term durations of diabetes (Karamanos et al.
2000). Chronic complications of diabetes include microvascular and macrovascular
complications. Microvascular complications include retinopathy, nephropathy, and

neuropathy. The risk of developing microvascular complications of diabetes depends
on both the duration and the severity of hyperglycemia (The American Diabetes
Association 2010).
The risk of diabetic complications is dependent on the degree of glycemic control
in patients. The main goal of pharmacological treatment of DM is to achieve
a target level of HbA1c, with an attempt to prevent the development of diabetes-
related complications (WHO 2011b). As recommended by the 2009 consensus
statement of the American Diabetes Association and the European Association for
the Study of Diabetes, a HbA1c level of 7% calls for initiation, combination,
or change of therapy with the aim of achieving an optimal glycemic control, i.e.,
HbA1c level below 7% (Nathan et al. 2009). Clinical trials such as the Diabetes
Control and Complications Trial (DCCT) demonstrate that tight glycemic control
achieved with intensive insulin regimens can reduce the risk of developing
or progressing retinopathy, nephropathy, or neuropathy in patients with T1DM or
T2DM. The Epidemiology of Diabetes Interventions and Complications (EDIC)
trial, a follow-up to the DCCT, indicates that the previous degree and duration
of glycemic exposure are also important determinants of risk of developing micro-
vascular diabetic complications (American Association of Diabetes Educators 2002;
Cundiff and Nigg 2005).
Studies in Palestine show poor glycemic control in diabetic patients, which is
associated with several complications. A study in Gaza reports that good glycemic
control is determined by the patients’ age, high medication adherence, and better
health literacy. Duration of DM (DM >7 years) was inversely related to good
glycemic control (Radwan et al. 2018). In a community-based study in the Ramallah
governorate, 35% of T1DM patients had HbA1c measurement over 8.5%.
The prevalence of diabetic complications was as follows: retinopathy 36.4%,
neuropathy 26.2%, and nephropathy 7.5%. The study results show a significant
association between retinopathy and neuropathy with HbA1c and diabetes duration
(Suman and El Sharif 2009). In patients with T2DM with a mean level of HbA1c
of 8.27, rates of complications were as follows: 54% had hypertension, 6.7% had
kidney problems, 28% had cardiac problems, and 62% had retinopathy (Suman and
El Sharif 2009). Similarly, a hospital-based study showed that in patients with
a mean HbA1c of 9.2%, the prevalence of microvascular complications was 16%,
and myocardial infarction and stroke was 26% (Abu Al-Halaweh et al. 2017).
However, other studies show lower prevalence of these complications. In a “Rapid
Assessment of Avoidable Blindness (RAAB)” survey in Gaza, which included
diabetic patients aged 50 years or more, the prevalence of blindness suggests
that significant numbers of people (predominantly female) in Palestine do not have
access to eye care services The prevalence of blindness was higher in Gaza (4.9%,
95%CI: 3.7–6.1%) than in the West Bank (2.5%, 95%CI: 1.9–3.1%) and greater
in women (4.3%, 95%CI: 3.3–5.2%) than in men (2.2%, 95%CI:1.5–2.9%) (Chiang
et al. 2010).
In conclusion, adherence to medication, patient literacy, and duration of diabetes
are key factors for improving glycemic control and preventing diabetes-related
complications. In Palestine, strategies have been suggested for improving the quality
of diabetes education to make it more effective and enhancing glycemic control
(UNRWA 2016; El Sharif et al. 2015), but these strategies are still not implemented.
Challenges and Problems
Political Situation and Access to Care: Palestine is a country in conflict and under
occupation. Israeli authorities restrict the free movement of Palestinians between the
Gaza Strip and the West Bank, between East Jerusalem and the rest of the West
Bank, and between rural areas and their traditional service centers. In the West Bank,
movement restrictions are implemented through military orders, regulations, policies
and practices, as well as physical obstacles such as the separation wall, countless
barriers, gates and fences, and Israeli settlements and their separate system of road
networks. Palestinian patients may travel to East Jerusalem only by permit and
are restricted in their mode and point of entry at the 16 checkpoints around the
city. Palestinians can also exit the West Bank directly via the Allenby Bridge,
contingent on an Israeli permit, as well as a Palestinian passport or Jordanian travel
document. In the Gaza Strip, there are just two exits for patients (at Rafah to Egypt),
and at Erez (to Israel and for access to the West Bank, including East Jerusalem, or to
Jordan).
Political Situation and Quality of Services: In the Gaza Strip, the long durable
siege and the severe constrains executed by the Israeli occupation since 2006 (and
before with the beginning of the second Intifada in 2000) severely impact the
development of quality healthcare services in Gaza. This has been intensified
by the internal Palestinian political separation and the economic crisis in Gaza.
The health system had been impacted severely in the previous three wars (2008/
2009, 2012 and 2014), the last of which severely affected the social and economic
conditions of the Gaza Strip population and the health sector.
Conclusions
DM is rapidly reaching epidemic proportions in Palestine. The levels of morbidity

and mortality due to diabetes and its potential complications are enormous and pose
significant healthcare burdens on individuals, families, and society. Of concerns are
that diabetes is associated with a spectrum of complications and is occurring at
a relatively younger age within the country. The steady migration of people from
rural to urban areas and changes in the economic situation lead to lifestyle changes
which impact susceptibility to DM. Despite the increased incidence in diabetes, there
remains a paucity of studies investigating the prevalence and management of the
disease, largely due to the political and socioeconomic vulnerability in the country.
Given that the disease is now highly visible across all sections of Palestinian society,
there is an urgent need for more research and intervention – at regional and national
levels – to mitigate the potentially catastrophic increase in diabetes predicted to

occur in the near future.
In addition, screening studies related to lifestyle choices, levels of physical
activity, diet, and environmental factors as well as culturally sensitive community-
based strategies aimed at prevention and management of obesity and its metabolic
complications are crucial for effective strategies. Moreover, it is essential to stabilize
healthcare-based interventions and strategies to support patients with diabetes
through improvement of follow-up, adherence to the national diabetes management
guidelines, patients’ adherence to medication use, and patients’ education on diabe-
tes complications.
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Diabetes Mellitus in Saudi Arabia
Challenges and Possible Solutions
42
Mohamed Abdulaziz Al Dawish and Asirvatham Alwin Robert
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1084
What Is the Problem? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1085
Burden and Current Status of Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1085
Economic Burden . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1086
What Are the Key Challenges? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1087
Growing Prevalence of Diabetes and Prediabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1087
Rising Prevalence in Adolescents and Young Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1089
Lifestyle-Associated Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1089
Delay in Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1090
Low Awareness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1090
Possible Solutions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1091
Education and Awareness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1091
Self-Care Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1093
Collective Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1093
Comprehensive Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1094
Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1094
Ministry of Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1094
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1096
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1097
Abstract
According to the World Health Organization rankings, Saudi Arabia stands
second among the Middle East countries, and seventh globally, for the prevalence
Mohamed Abdulaziz Al Dawish and Asirvatham Alwin Robert contributed equally with all other
contributors.
M. A. Al Dawish (*) · A. A. Robert

Department of Endocrinology and Diabetes, Diabetes Treatment Center,
Prince Sultan Military Medical City, Riyadh, Saudi Arabia
e-mail: maldawish@psmmc.med.sa; aalwinrobert@gmail.com

https://doi.org/10.1007/978-3-030-36811-1_45
1084 M. A. Al Dawish and A. A. Robert
of diabetes mellitus. An estimated seven million of the population are diabetic,

with a further three million being prediabetic. Of even greater concern
perhaps is the alarming increase in diabetes in Saudi Arabia in recent years.
In fact, diabetes has increased by tenfold during the past three decades in
Saudi Arabia. Furthermore, the management of diabetes faces many challenges
in Saudi Arabia, including the rising prevalence (principally among children and
young adults), micro- and macrovascular complications, lifestyle alterations,
delayed diagnosis, low degree of awareness, and expensive treatment costs.
There has been a huge acceleration (more than 500%) in the expenses incurred
for healthcare and treatment of diabetes during the last two decades. The
healthcare budget of Saudi Arabia in 2014 was 180 billion (Saudi Riyal), of
which roughly 25 billion used exclusively for the management of diabetes.
Therefore, a comprehensive program/multidisciplinary approach on a national
level is urgently required before the treatment of diabetes mellitus becomes an
even greater burden on the health of the population and also the health budget. In
this chapter we discuss the significant and chief threats due to diabetes mellitus in
the Saudi population and propose solutions to delay/prevent this further increase
in diabetes in Saudi Arabia.
Keywords
Diabetes · Diabetes complications · Prediabetes · Healthcare · Quality of life ·
Prevalence of diabetes · Incidence of diabetes · Public health · Saudi Arabia
Introduction
Diabetes is a group of metabolic diseases characterized by hyperglycemia resulting

from defects in insulin secretion, insulin action, or both (American Diabetes
Association 2009). The International Diabetes Federation (IDF) estimates that the
total number of diabetes mellitus (DM) cases globally would increase from 171
million in 2000 to 366 million by 2030. Sadly, the worldwide prevalence of DM
already approached 366 million already in 2011 (Wild et al. 2004; Al Dawish et al.
2016). Diabetes is currently among the most prominent global health emergencies of
the twenty-first century, with increasing numbers of people emerging with this health
condition and its consequent life-altering complications (Jaacks et al. 2016; Al-
Lawati 2017). Besides the 415 million adults (1 in every 11 adults have diabetes)
currently recorded with diabetes, there are another 318 million adults with impaired
glucose tolerance that are at high risk of developing the full-blown disease in the
future. It has been projected that by 2040, 642 million (1 in every 10 adults) will
have diabetes (International Diabetes Federation (IDF) 2015). Important is that
another 50% of the adult population are undiagnosed with diabetes and there are
5.0 million deaths a year resulting from diabetes (one individual succumbs every
6 s). Type 2 diabetes mellitus (T2DM) is predominant, while type 1 diabetes mellitus
(T1DM) remains an important public issue with an annual increase of 3%, especially
in children. Each year nearly 86,000 children develop type 1 diabetes, and in
42 Diabetes Mellitus in Saudi Arabia 1085
instances of the unavailability of insulin, their life expectancy is dramatically

shortened (International Diabetes Federation 2015; Uddin et al. 2001).
The number of children with T1DM exceeded the half a million mark (542,000)
for the very first time in 2015. The lack of awareness of diabetes and its vicious
social and economic impacts makes it the greatest barrier to implementing effective
prevention strategies stem the tide of T2DM emerging in several countries (IDF
2015; Uddin et al. 2001). While diabetes-related research in Saudi Arabia is increas-
ing, most of the efforts focused on the incidence of diabetes throughout the region,
with fewer studies on other aspects such as diabetes education and self-care man-
agement (Robert et al. 2016). In this chapter, we review diabetes mellitus in the
Saudi population and discuss strategies to delay/prevent DM in the country.
What Is the Problem?
Burden and Current Status of Diabetes
The rapid urbanization of Saudi Arabia had two measurable consequences: the
first being causing subtle increases in the prevalence and incidence of DM and,
second, significant improvements in living standards and the adoption of more
“Westernized” lifestyles (Alnuaim 2014; Al Dawish et al. 2016). The unhealthy
dietary choices and reduced physical activity levels across Saudi Arabia activated an
unprecedented spike in the diabetes level of up to 25% in the adult population. This
rate is expected to double or even more by 2030 (Alotaibi et al. 2017; Naeem 2015).
The World Health Organization (WHO) ranks Saudi Arabia as second in the Middle
East region for the prevalence of diabetes and seventh in the world (Mokdad et al.
2015). More alarming though is the rapid increase (of nearly tenfold over the last
three decades) in diabetes in Saudi Arabia (Al Dawish et al. 2016). Previous studies
first published in 2004 reported that one in every five Saudi adults had DM (Al-
Daghri et al. 2011; Al-Nozha et al. 2004). A recent study indicates the incidence of
diabetes at 34.1% in males and 27.6% in females. The mean age for the onset of
diabetes was reported as 57.5and 53.4 years in males and females, respectively
(Alqurashi et al. 2011). Another study suggested that the occurrence of DM in the
central region of Riyadh was 23.7% (age group 30–70 years) with an additional
14.1% having impaired fasting glucose regulation. Furthermore, the authors indi-
cated that diabetes was more prevalent in urban areas (26% versus 20% in rural
regions) (Al-Nozha et al. 2004).
A recent study indicates that more than 50% of the Saudi population aged
30 years or more were identified as either diabetic (25%) or prediabetic (26%) and
that another ~40% of patients of being unaware of having the condition (Al-Rubeaan
et al. 2015a). Assuming that current trends remain unaltered, it can be estimated that
at least 45% of the adult population will have DM by 2030 (Al-Rubeaan et al.
2015a). There is little information available on the epidemiology of T1DM in Saudi
Arabia. Reports in the literature suggest steady increases in the incidence of T1DM
over the last 30 years, with an incidence rate of 109.5 per 100,000 in Saudi children,
a figure that is much higher than in some developed countries (Al-Herbish et al.
2008; Cherian et al. 2010). The city of Medina has the highest prevalence of T1DM
of all the major cities in the Middle East. Moreover, the annual mean incidence of
T1DM (per 100,000 individuals) has nearly doubled in Eastern Saudi Arabia,
increasing from 18.05 in 1990–1998 to 36.99 in 1999–2007 (Al-Herbish et al.
2008; Cherian et al. 2010). The most recent Diabetes Atlas (8th edition) reported
that 35,000 children and adolescents in Saudi Arabia suffer from T1DM, making
Saudi Arabia rank the 8th in terms of numbers of TIDM patients and 4th in the world
in terms of global rankings of the incidence (33.5 per 100,000 persons) of TIDM
(International Diabetes Federation 2017).
The IDF 2015 reported that in the Middle East and North Africa Region,
countries with high diabetes prevalence include Saudi Arabia (raw diabetes preva-
lence of 17.6%), Bahrain (15.6%), Egypt (14.9%), Kuwait (14.3%), Qatar (13.5%),
Lebanon (12.2%), Oman (9.9%), Jordan (9.1%), Iran (8.5%), Iraq (7.2%), and
Yemen (3.8%). The countries with the largest number of adults with diabetes are
Saudi Arabia (20%), Bahrain (19.6%), Egypt (16.7%), Kuwait (20%), Qatar (20%),
Lebanon (13%), Oman (14.8%), Jordan (11.7%), Iran (10.1%), Iraq (9.3%), and
Yemen (5.1%) (International Diabetes Federation 2015; Alanazi et al. 2017). How-
ever, variations in reported prevalence of T2DM within each country can be attrib-
uted to the study design, population, and diagnostic methods used to acquire these
data (Table 1). It is evident that diabetes in Saudi Arabia is likely to reach devastating
levels, which can only be mitigated by implementing a long-term comprehensive
epidemic control program and promoting a healthy diet, active lifestyle, and exercise
and reducing levels of obesity/overweight in children and adults (Hussain et al.
2007; Memish et al. 2014; Swinburn 2002). Recent studies report that the prevalence
of T2DM has increased dramatically during the last two decades, with diabetes in the
Arab world estimated to increase by 96.2% by 2035 (Abuyassin and Laher 2016).
This substantial upsurge in the rate of T2DM is similar to that in Oman, Iraq, Qatar,
and some other countries within the Arabic world (Abuyassin and Laher 2016).
Economic Burden
Recent research in Saudi Arabia makes it clear that of the 180 billion Riyals
healthcare budget, approximately 25 billion used to manage the population with
DM (Mokdad et al. 2015). If patients with glucose intolerance (prediabetes)
progressed at the present rate, treatment costs would increase to 43 billion Riyals.
The 2014 census estimated the diabetic population would reach 20 million Saudis
and 9.5 million non-Saudis. Therefore, the projected expenses likely to be incurred
for the treatment of DM would be 25, 39.8, and 63.4 billion Riyals, assuming that
both non-Saudis and Saudis experience similar disease patterns (Mokdad et al.
2015). Healthcare costs for the treatment of DM over the last two decades burgeoned
by more than 500%. In 2010, on average, those with DM incurred a tenfold increase
in medical healthcare expenses ($3,686 vs. $380, 21%) (Sherif and Sumpio 2015;
Alhowaish 2013). There is a lack of further information on the economic burden of
Table 1 Country summary: estimates for 2015
Country/territory Diabetes (20–79) national Diabetes age-adjusted (20–79) Adults with diabetes(20–79) in
prevalence (%) [uncertainty comparative prevalence (%) 1,000s [uncertainty range]
range] uncertainty range]
MIDDLE EAST AND NORTH 9.1 [6.29–12.24] 10.7 [7.39–14.20] 35 381.2 [24,318.55–47,366.10]
Afghanistan 6.6 [5.2–9.1] 8.8 [6.9–12.0] 935.8 [741.3–1,295.8]
Algeria 6.8 [4.7–9.5] 7.5 [5.1–10.3] 1 679.5 [1,157.6–2,359.5]
Bahrain 15.6 [14.3–17.3] 19.6 [17.9–21.6] 154.3 [141.6–170.4]
Egypt 14.9 [7.2–17.1] 16.7 [8.1–19.2] 7 809.7 [3,759.2–8,972.4]
Iran [Islamic Republic of] 8.5 [6.6–11.5] 10.1 [7.7–13.5] 4 602.2 [3,571.6–6,256.6]
Iraq 7.2 [4.9–9.5] 9.3 [6.6–12.0] 1 261.9 [857.5–1,665.0]
Jordan 9.1 [7.5–15.6] 11.7 [9.8–19.1] 374.1 [307.6–641.3]
Kuwait 14.3 [11.7–19.4] 20.0 [15.7–28.0] 399.9 [325.8–541.2]
Lebanon 12.2 [10.0–15.2] 13.0 [10.6 - 16.1] 464.2 [378.2–579.0]
Libya 9.2 [6.4–11.9] 10.4 [7.2–13.3] 354.0 [247.9–456.5]
Morocco 7.7 [6.0–11.5] 8.1 [6.3–12.1] 1 671.4 [1,291.3–2,495.5]
Oman 9.9 [7.4–12.2] 14.8 [10.9–18.1] 325.9 [243.9–402.3]
Pakistan 6.9 [5.0–9.8] 8.1 [6.1–11.3] 7 028.1 [5,141.3–10,034.2]
Qatar 13.5 [12.4–15.0] 20.0 [18.4–22.1] 239.1 [220.3–265.8]
Saudi Arabia 17.6 [13.5–19.6] 20.0 [15.7–22.5] 3 487.3 [2,682.2–3,897.5]
State of Palestine 6.5 [3.6–13.8] 9.4 [5.1–19.3] 146.7 [81.6–309.1]
Sudan 7.7 [4.2–15.6] 8.9 [5.0–17.6] 1 490.4 [815.4–3,030.4]
Syrian Arab Republic 7.0 [5.7–9.3] 8.1 [6.5–10.7] 652.8 [530.0–867.9]
Tunisia 9.5 [6.3–13.4] 9.6 [6.4–13.6] 725.9 [477.0–1,023.1]
United Arab Emirates 14.6 [13.0–17.1] 19.3 [16.9–22.4] 1 086.3 [966.3–1,270.5]
Yemen 3.8 [3.0–6.4] 5.1 [3.9–8.8] 491.8 [381.3–831.9]
World and regional estimates; Adult diabetes estimate based on oral glucose tolerance tests;
Adult diabetes estimate based on HbA1c, fasting blood glucose, or self-report; Adult
diabetes estimate based on extrapolation from similar country
Adapted from International Diabetes Federation (IDF) (2015)
T2DM in Saudi Arabia. The only option seems to improve health and related quality
of life outcomes as a means to reduce social and personal costs of the DM. It is clear
that the mortality and morbidity associated with diabetes has reached a crises level in
Saudi Arabia and that it can no longer be ignored. If insufficient or no measures are
taken, Saudi Arabia can easily reach levels of diabetes seen in some populations
(e.g., Pima Indians), where nearly 50% of the adult population have DM
(Al-Rubeaan et al. 2015b).
What Are the Key Challenges?
Growing Prevalence of Diabetes and Prediabetes
The main challenges facing the Saudi healthcare division involve sustained moni-
toring of the incidence and prevalence of DM in the country. Based on the findings of
the WHO Regional Office for the Eastern Mediterranean, six of the ten countries
with the highest prevalence of diabetes across the world are situated in the
Middle East, these being Bahrain, Kuwait, Lebanon, Oman, Saudi Arabia, and the
United Arab Emirates (Robert et al. 2016). The IDF statistics (2011) for T2DM
indicates that an estimated 9.1% of the Middle Eastern-North African (MENA)
populations had DM (32.8 million). If this trend continues, the IDF projects that the
diabetic population in the MENA region will be double (reaching 59.7 million) by
2030 (International Diabetes Federation 2012).
The high occurrence of diabetes in Saudi Arabia is of serious clinical and public
health concern. Based on a study from 1982, only 2.5% of the 1,387 males surveyed
in the Al-Kharj region were diagnosed with DM; this increased to 30% in a survey
performed at a primary care clinic in June 2009 (Alqurashi et al. 2011). Another
study ranks Saudi Arabia as a leader in the overall incidence by registering 17,817
cases per 100,000 people in 2013, which is more than twice that in China
which reported 6,480 per 100,000 and the United States with 6,630 per 100,000
(Global Burden of Disease Study 2013 2015). A recent study reports that abnormal
glucose metabolism in the Saudi population has epidemic levels, with more than
50% of 30-year-old Saudi’s males and females being diagnosed as either diabetic
(25.4%) or prediabetic (25.5%) (Al-Rubeaan et al. 2015a). An additional 40.3% of
diabetic were being unaware of their disease, this being among the highest reported
percentages globally (Al-Rubeaan et al. 2015a). Most of the studies emphasize that
the increasing incidence of diabetes in the Saudi community is among males than
females. A recent study (in 2015) recorded a tenfold increase in DM over the past
40 years in the Saudi community, with a high incidence of between 12 and 20% (i.e.,
nearly one million people) (Al Dawish et al. 2016). The current estimates of T2DM
in Saudi Arabia are 32.8% of the population, with the projected prevalence for 2020
to be 35.37%, for 2025 to be 40.8%, and for 2030 to be 45.8% (Meo 2016) (Fig. 1).
These projections confirm that diabetes mellitus is increasing rapidly in Saudi Arabia
and that the incidence of T2DM in Saudi Arabia may be more serious than assumed
thus far and importantly that these patterns represent a real and imminent challenge
to the Saudi healthcare system (Meo 2016). Of importance is a study noting that both
Fig. 1 Prevalence and future prediction of diabetes mellitus in Saudi Arabia (Wild et al. 2004; Al-
Lawati 2017; International Diabetes Federation 2012; Meo 2016; Robert and Dawish 2019; Al
Dawish et al. 2016)
DM and prediabetes increased with age – with rates of DM increasing exponentially

(Bahijri et al. 2016). Prediabetes was slightly more frequent than DM in the
population aged between 18 and 39 years, while DM was more prevalent in
individuals 40 years or more, with 46.1% of men and 44.4% of women 50 years
or above being diagnosed with DM (Bahijri et al. 2016).
Rising Prevalence in Adolescents and Young Adults
According to the most recent statistics reported by the National Information Center
of the Ministry of Interior, nearly 67% of the Saudi population is below 30 years of
age, with at least 80% of the population being younger than 40 years old. The
diagnosis of T2DM was generally made mostly in the middle-aged and elderly (Al
Dawish et al. 2016). While this age group continues to face a higher risk of DM than
the younger adult population, DM is becoming increasingly frequent in those
younger than 30 years old. In addition, unlike the increased prevalence of T1DM
in children, there is now a surge in the diagnosis of T2DM in young patients
(Braham et al. 2016; Diabetes 2010; Pozzilli and Buzzetti 2007; Alberti et al.
2004; Al-Rubeaan 2015).
While T1DM is still the most prevalent in children worldwide, it is likely that
levels of T2DM will surpass this in several countries over the next 10 years. For
example, T2DM accounts for 80% of childhood diabetes in Japan (Patterson et al.
2014; World Health Organization and Asian-Pacific Type 2 Diabetes Policy Group
2005). The age of onset of T2DM in Saudi Arabia is generally low, with previous
studies from Saudi Arabia reporting many young adults developing diabetes
(Alqurashi et al. 2011), leading to the recommendation that every Saudi 30 years
or above be screened for both T2DM and prediabetes. The recommendation of
the American Association of Clinical Endocrinologists is also to annually screen
high-risk adults aged 30 years or more (American Diabetes Association 2015).
Lifestyle-Associated Risk Factors
Two principal drivers propelling this epidemic in Saudi Arabia are demographic
changes with longer life expectancies and changing lifestyles arising from increased
urbanization and industrialization (Sherif and Sumpio 2015). Several reports suggest
that implementing healthy lifestyles can greatly reduce the risk of T2DM and/or
retard its onset in genetically susceptible groups (Robert et al. 2016; Al Dawish et al.
2016; Bellou et al. 2018). Moreover, T2DM is more effectively controlled when
patients deliberately maintain healthy lifestyles that include exercise and weight
management, especially when having a family history of diabetes (Robert et al.
2016). Fresh vegetable and fruit consumption is infrequent in the Saudi population,
with greater leanings toward meat and carbohydrates such as dates. This dietary
imbalance has been replaced with greater consumption of carbonated drinks and
processed food (Sherif and Sumpio 2015).
The past 40 years has witnessed rapid economic growth in Saudi Arabia, coupled
with a striking rise in the living standards and the adoption of “Westernized”
lifestyles that features unhealthy dietary choices and low levels of physical activity
(Al Dawish et al. 2016). Increases of T2DM in Saudi Arabia parallels the adoption of
“Westernized” lifestyles, which added to the inherent high genetic predisposition to
diabetes as a result of the high frequency of consanguineous marriages (Al Dawish
et al. 2016). Several recent reports suggest a positive relation between the increased
per capita income and economic development on the incidence of diabetes (Sherif
and Sumpio 2015; Alhowaish 2013). Urbanization and economic development in
emerging economies like China and Nigeria have also reduced levels of the overall
and occupational physical activity and increased the incidence of DM in the popu-
lation (Sherif and Sumpio 2015; Alhowaish 2013). Weight loss and physical activity
are the primary management tools in diabetes, where a loss of 5–10% of total body
weight and 30 min of daily exercise are recommended (Laditka and Laditka 2015;
Colberg et al. 2010; Jokela et al. 2014).
Delay in Diagnosis
T2DM often develops over several years, during which time the individual may
show no symptoms until complications emerge. Thus, many opportunities to treat
and control diabetes (e.g., with lifestyle modifications) are often missed. Early
identification of high-risk groups and providing suitable intervention that includes
diet alterations and increased physical activity would enable the prevention, or at
least delay of the onset, of diabetes (International Diabetes Federation 2011; Charfen
et al. 2009). In some cases, patients were undiagnosed for more than 7 years, and the
large numbers of undiagnosed diabetes in Saudi Arabia (International Diabetic
Federation 2012) increases the frequency of diabetes-related complications and the
resultant higher healthcare costs (Samuels et al. 2006). As the symptoms of diabetes
are generally unknown to the Saudi population, delays in the diagnosis of the disease
can last several years and lead to discovery of vascular complications at the time of
diagnosis. Strong recommendations are in place that all healthcare providers in the
government and nongovernment sectors perform opportunistic screening for the
nondiabetic subjects who present for a medical checkup (Al Dawish et al. 2016).
Low Awareness
Unless urgent actions are taken to prevent DM, about three new persons will
suffer from diabetes every 10 s, resulting in the diagnosis of nearly ten million
new cases per year around the world. The IDF predicts that about 183 million
individuals may be unaware of being affected with DM (International Diabetic
Federation 2012). Even policy makers at international and national levels reveal a
marginal level of awareness regarding public health and clinical significance of
diabetes (Amanda and Nigel 2004).
Populations in low- and middle-income countries are most often ignorant of

diabetes and its effects (International Diabetes Federation). Some efforts are under-
way in Saudi Arabia to evaluate the levels of awareness and knowledge of the
population on DM risk factors and preventative measures (Aljoudi and Taha 2009).
A study of 300 participants at a primary care center in eastern Saudi Arabia
reported low poor knowledge of DM risk factors and preventive measures (Aljoudi
and Taha 2009). Another recent survey of 1530 Saudis in the city of Hail (Northern
Saudi Arabia) reported that more than 60% were unaware of DM and that about
48% were not aware about its symptoms (Ahmed et al. 2018). About 40% of diabetic
patients in Saudi Arabia were ignorant of the disease (Al-Rubeaan et al. 2015a).
Another study reported that the diabetes knowledge score of the Al-Qassim region;
with scores for general knowledge regarding the disease (71%), risk factors (63%),
and symptoms and complications (81%) (Mohieldien et al. 2011). Males have a
twofold increased likelihood of having greater knowledge of the disease, and nearly
two-thirds of all participants in the study believed that diabetes was curable. Only
19% of the participants received an understanding on diabetes from the healthcare
professionals, suggesting a great need to educate the general population on diabetes
and its associated complications (Mohieldien et al. 2011).
A recent study suggests (1) that the health ministry lacked initiatives on
awareness of T1DM and its related complications and also failed to provide
proper infrastructure in the healthcare centers, (2) schools had only limited
success in offering additional care for children with T1DM, and (3) children
were unaware of the T1DM self-management techniques, and were unsure of the
disease management process, and in fact were wholly dependent on their parents
for disease management (Alotaibi et al. 2016). Similarly, there is a strong
unwillingness to begin insulin use by about one-third (35%) of the Saudi partic-
ipants with T2DM. Concerns expressed by the participants regarding insulin
therapy were insulin was a last resort for treatment (57%), insulin restricted
normal lifestyles (49%), hypoglycemia was a hindrance (45%), insulin use
implied a failure in the early management of diabetes (45%), and weight gain
(41%) (Batais and Schantter 2016). A recent study from Al-Jouf and Hail
province of Saudi Arabia indicated that while 24% of diabetics were ignorant
that diabetes could cause eye disorders, 27% were unaware of the need for regular
eye examinations, with 35% not knowing that they needed to have an ophthal-
mologist to check and examine their eyes and 31% unaware that timely interven-
tion could prevent or retard eye damage (Al Zarea 2016).
Possible Solutions
Education and Awareness
Correct awareness and education on the implications of diabetes and its management
are an important added component to drug treatments currently available. Evidence
from several studies confirms that education on diabetes leads to overall
improvements in diabetic care, as well as a reduction in hospitalizations (Skyler and

Ricordi 2011; Al Hayek et al. 2013; Jamal et al. 2015). A trial on diabetes control
and complications shows improved glycemic control and reductions in diabetic-
associated complications through intensive education programs (The Diabetes
Control and Complications Trial Research Group 1993). Individuals with lower
education levels encounter greater risks, likely due to their low degree of awareness
on the disease risk factors and systemic complications. The lifetime costs associated
with diabetes could be reduced by 8% if T2DM patients were appropriately informed
about the disease and its management (Diabetes 2010). Health education is provided
in primary healthcare centers and rarely in the government hospitals. Important to
this is that diabetes patients were more willing to receive health education than
the nondiabetic patients visiting the health facilities (Diabetes 2010). An accurate
understanding of diabetes, its risk factors, and complications will greatly impact
treatment outcomes, so that when individuals with diabetes are taught clearly about
the disease, their HbA1c levels and related complications are attenuated. An educa-
tion program for Saudi nationals reports significant improvements in glycemic
control, regardless of gender, age, and educational level (Uddin et al. 2001). Another
study showed that a 6-month diabetes education program resulted in remarkable
improvement of the patients’ dietary choices, physical exercise, self-monitoring of
blood glucose (SMBG) , HbA1c, careful adherence to medication, and depression
(Al Hayek et al. 2013). A recent cross-sectional study conducted in 702 participants
in Arar city (Northern Province of Saudi Arabia) reported that 25% of these patients
were aware of retinopathy and loss of vision, 8% were aware of complications in
addition to retinopathy and loss of vision, such as reduced sensation and numbness
in extremities, while 25% reported that symptoms of DM were thirst and frequent
urination (Al-Rubeaan et al. 2014).
The IDF assessment indicates that nearly 183 million people are unaware that
they suffer from diabetes, with some policy makers at both international and
national levels also having limited awareness of the clinical significance of
diabetes and its impact on public health (Robert et al. 2016; Al Dawish et al.
2016). A recent report from Saudi Arabia reported that about 40% of diabetic
patients did not realize that they had DM (Al-Rubeaan et al. 2014). Another study
from Saudi Arabia discussed the effectiveness of an intensive education training
provided by professional healthcare teams and emphasized the necessity for
mandatory delivery of such educational programs on metabolic control for
diabetic patients (Ahmed et al. 2018). The average score for diabetes knowledge
in the Saudi population was 67%, and scores for general knowledge about the
disease, its risk factors, symptoms, and complications were 71.1, 63.4, 80.8, and
47.7%, respectively (Jokela et al. 2014). Males were nearly twice as likely to
have knowledge of this disease than the females, and nearly two-thirds of patients
believed that diabetes was curable. More alarming was the ignorance of diabetes-
related secondary complications, with only 19% of the participants understand-
ing the disease and its complications at a basic level. Thus there is a clear and
urgent need to provide more education to the general population on diabetes and
its complications (Mohieldein et al. 2011).
Self-Care Management
Both the Veterans Health Administration (VHA) and American Diabetes Associa-
tion (ADA) emphasize the importance of self-management skills in diabetes care.
The ability of patients to understand and carry out their individual treatment pro-
tocols is vital in the control of DM. Each treating institution must promote self-
management by developing a statement of short-term and long-term goals suitable
for the individual patient needs and must clarify medication use by the patient, the
dietary plan, possible lifestyle alterations, required monitoring, and need for annual
comprehensive examinations of the eyes and feet (Al Zarea 2016; Sabbah and Al-
Shehri; West and Goldberg 2002). Such a written management plan should be
handed to each patient with input from the patient, family, and healthcare team.
The key of the management plan is to deliver self-management education of diabetes
and continued diabetes support (American Diabetes Association 2015; Al Hayek
et al. 2013).
A study of 123 patients with diabetes reported that the most frequent diabetes
self-management behaviors were foot care followed by self-medicating behavior,
while the least often stated diabetes self-management behaviors were blood sugar
testing and exercise self-management (Saad et al. 2018). Another study conducted of
210 diabetes patients surveyed in primary healthcare centers in Medina reported that
only 15% of patients achieved adequate glycemic control; those with low poor self-
management practices were mostly males and those with low incomes (Al Johani
et al. 2015). Another study of 75 diabetic patients in the Riyadh region reported that
the majority of these patients had poor diabetes self-care behaviors (ALAboudi et al.
2016). It has been suggested that healthcare providers in Saudi Arabia that design
educational programs led to improved self-care behaviors and better glycemic
control (ALAboudi et al. 2016).
Collective Action
As diabetes impacts society as a whole, the solutions and responses must of necessity
be multi-sectoral and well coordinated (Jamal et al. 2015; Robert et al. 2016). As the
complications due to diabetes continue to inexorably increase, greater efforts are
needed to improve the health and well-being in Saudi Arabia. It would seem that
many organized public responses, research studies, and conferences have produced
little benefits. The IDF also invites participation by governments, businesses, the
United Nations and other international bodies, civil organizations, health profes-
sionals, researchers, philanthropic organizations, and the general public to work
together in a coordinated manner to conquer diabetes and its related non-
communicable diseases. Despite the intense efforts of the public and private orga-
nizations across Saudi to positively influence the burgeoning diabetes crisis, it is
obvious that greater efforts are required to raise the awareness in the country (Jamal
et al. 2015; Robert et al. 2016). The combined efforts of a network of stakeholders
will help to identify interventions that are appropriate for the country culturally and
also ensure participation of a greater number of sectors of the Saudi society

to produce an immediate and sustainable influence on the country as a whole.
Multidisciplinary care teams of nurses, clinicians, dietitians, psychologists, physio-
therapists, and health educators are well suited to provide more intensive counseling
and increase motivation levels of diabetic individuals to achieve their health goals
(Jamal et al. 2015; Robert et al. 2016).
Comprehensive Evaluation
A comprehensive and organized patient evaluation at each clinical visit has been
shown to ensure long-term benefits in controlling the onset and complications of
diabetes (Robert et al. 2016). The American Diabetes Association recommends a
mandatory thorough medical evaluation during the patient’s initial visit, during
which the type of diabetes and its associated complications could be determined
prior to providing treatment (American Diabetes Association 2017; Al-Aboudi et al.
2016). It is also suggested that patients be assisted in creating a management plan for
continuing care. The ADA 2015 and 2017 guidelines are promoted for all Saudi
diabetes clinics (American Diabetes Association 2017; Al-Aboudi et al. 2016)
(Table 2).
Previous studies from Saudi Arabia reported that diabetes is prevalent in young
adults, leading to the suggestion that every Saudi 30 years should be screened
for both prediabetes and T2DM (Alqurashi et al. 2011). The American Association
of Clinical Endocrinologists has also recommended persons aged 30 years or
more should undergo annual screening, especially in high-risk groups (American
Diabetes Association 2017).
Research
Our improved understanding of the pathophysiology and effects of the diabetes has
led to improved therapies (Robert et al. 2016). However, there is limited research on
diabetes in Saudi Arabia. While a lot is known about the incidence of diabetes in the
country, we know less about other aspects such as diabetes education and self-care
management (Al Dawish et al. 2016). Innovative research related evidence-based
care and prevention is needed to facilitate appropriate planning of management
programs. (Robert et al. 2016).
Ministry of Health
The Ministry of Health of Saudi Arabia not only provides treatment to all
patients with diabetes but also provides education on the disease and its complica-
tion, although there is clearly much more to accomplish (Robert et al. 2016; Al
Dawish et al. 2016; Alotaibi et al. 2016). Recruiting and training health professionals
Table 2 Components of the comprehensive diabetes medical evaluation

Medical history
Age and characteristics of onset of diabetes (e.g., diabetic ketoacidosis, asymptomatic
laboratory finding)
Eating patterns, nutritional status, weight history, sleep behaviors (pattern and duration), and
physical activity habits; nutrition education and behavioral support history and needs
Complementary and alternative medicine use
Presence of common comorbidities and dental disease
Screen for depression, anxiety, and disordered eating using validated and appropriate
measures
Screen for diabetes distress using validated and appropriate measures
Screen for psychosocial problems and other barriers to diabetes self-management, such as
limited financial, logistical, and support resources
History of tobacco use, alcohol consumption, and substance use
Diabetes education, self-management, and support history and needs
Review of previous treatment regimens and response to therapy (A1C records)
Assess medication-taking behaviors and barriers to medication adherence
Results of glucose monitoring and patient’s use of data
Diabetic ketoacidosis frequency, severity, and cause
Hypoglycemia episodes, awareness, and frequency and causes
History of increased blood pressure, abnormal lipids
Microvascular complications: retinopathy, nephropathy, and neuropathy (sensory, including
history of foot lesions; autonomic, including sexual dysfunction and gastroparesis)
Macrovascular complications: coronary heart disease, cerebrovascular disease, and
peripheral arterial disease
For women with childbearing capacity, review contraception and preconception planning
Physical examination
Height, weight, and BMI; growth and pubertal development in children and adolescents
Blood pressure determination, including orthostatic measurements when indicated
Fundoscopic examination
Thyroid palpation
Skin examination (e.g., for acanthosis nigricans, insulin injection, or infusion set insertion sites)
Comprehensive foot examination
Inspection
Palpation of dorsalis pedis and posterior tibial pulses
Presence/absence of patellar and Achilles reflexes
Determination of proprioception, vibration, and monofilament sensation
Laboratory evaluation
A1C, if the results are not available within the past 3 months
If not performed/available within the past year
Fasting lipid profile, including total, LDL, and HDL cholesterol and triglycerides, as
needed
Liver function tests
Spot urinary albumin-to-creatinine ratio
Serum creatinine and estimated glomerular filtration rate
Thyroid-stimulating hormone in patients with type 1 diabetes
Adapted from American Diabetes Association (2017)
* The comprehensive medical evaluation should all ideally be done on the initial visit, but if
time is limited different components can be done as appropriate on follow-up visits
** Refer to the ADA position statement “Psychosocial Care for People With Diabetes” for
additional details on diabetes-specific screening measures
in diabetes facilities should be in line with internationally accepted levels.

Collaborative efforts are needed from all members of the diabetes community of
scientists, clinical trialists, patients, families, funding agencies, education institu-
tions, and the regulatory agencies of Saudi Arabia (Skyler and Ricordi 2011).
Furthermore, it is also essential to raise awareness of the importance of a healthy
diet, increased physical activity, and creating healthy environments as parts of urban
planning.
Diabetic patients in Saudi Arabia are currently managed at primary, secondary,
and tertiary level healthcare centers by general practitioners, internists, and endocri-
nologists. Most healthcare services delivered to Saudi citizens with diabetes are
without any cost. The private healthcare sector plays a minor role in diabetes care in
Saudi Arabia, although greater opportunities arise and are available due to the
rapidly increasing needs of a growing population of patients with diabetes, many
of whom are in a position to afford to be patients at private healthcare clinics. Health
insurance provides a small component of healthcare expenses by Saudi, possibly for
cultural and religious reasons. Thus, adopting innovative approaches to medical
insurance will help to deliver healthcare to diabetic patients in administrative health
regions (Al-Rubeaan et al. 2015c). The MOH intends to update its plans for
providing diabetes awareness education at the community level, targeting those
individuals with unhealthy lifestyles, diabetic patients, and their families
(The Ministry of Health, Saudi Arabia 2017).
Conclusions
The incidence of diabetes in the Saudi population is rapidly increasing and

continues to be a significant public health challenge in the country. Most cases of
diabetes are preventable or can be delayed. Early diagnosis and accurate manage-
ment can ensure that individuals with diabetes can live longer and healthier and
lead more productive lives. Health systems can minimize their costs if related
complications such as renal failure, blindness, and amputations can be averted.
Greater efforts using education and awareness programs will facilitate the diagno-
sis and management of both T1DM and T2DM. Innovative approaches to encour-
age lifestyle changes needed to delay the onset of type 2 diabetes should be
considered at the individual, family, and community level. While educational
programs can refine disease management in individuals with diabetes, public
health education at the population level will stimulate behavioral changes aimed
at preventing or delaying the onset of T2DM. Similarly, prompt implementation of
prevention programs at a national level is needed to detect and monitor progression
of diabetes, education on modifiable risk factors at the community level with
focused high-risk groups. Incentive schemes for regular use of gymnasium or
memberships in sports groups (for cycling, swimming, walking, etc.) are additional
approaches to be considered. Implementation of proper policies with dedication,
investment, and perseverance will undoubtedly lead to great health benefits in
Saudi Arabia and the neighboring Gulf countries.
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Type 2 Diabetes Mellitus (T2DM) in the
Arab Society of Israel 43
Abdelnaser Zalan and Rajech Sharkia
Contents
Diabetes Worldwide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1103
History and Origin of Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1103
Epidemics and Global Burden of Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1103
Risk Factors of Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1105
Diabetes: Complications, Prevention, and Future Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1107
Diabetes in the Arab Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1108
Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1108
Obesity Related to Diabetes and Other Comorbidities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1109
Diabetes in Israel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1110
Introductory Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1110
Characteristics of the Arab Society in Israel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1111
Epidemiology of Diabetes in Various Ethnic Groups of Israel . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1111
Diabetes in Palestine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1119
Historical Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1119
Noncommunicable Diseases, Lifestyle, and Risk Factors for Diabetes in Arabs and
Palestinians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1120
Our Recommendations, Suggestions, and Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1122
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1123
Abstract
The ancient Egyptians described clinical features similar to diabetes mellitus
about 3000 years ago. In recent years, diabetes had become a worrying pandemic
A. Zalan (*)
Human Biology Department, The Triangle Research and Development Center, Kfar-Qari, Israel
e-mail: dr.zalan@hotmail.com
R. Sharkia
Human Biology Department, The Triangle Research and Development Center, Kfar-Qari, Israel
Beit-Berl Academic College, Beit-Berl, Israel
e-mail: rajachsharkia@hotmail.com

https://doi.org/10.1007/978-3-030-36811-1_162
1102 A. Zalan and R. Sharkia
disease. It has increased dramatically worldwide during the last decades and it
affects more than 382 million people around the world, of whom 90% are
diagnosed with type-2 DM (T2DM). It is rapidly increasing in developing as
well as developed countries; moreover, it is even found to be increasing to a
higher extent in the Arab world. Behavioral and sociodemographic factors asso-
ciated with T2DM vary within different societies.
The aim of our current study is to shed a considerable amount of light on the
status of diabetes in the Arab society of Israel, in relation to the various risk
factors that are associated with T2DM. As this community has certain unique
characteristics in relation to other residents of this country, lots of studies had
been undertaken to explore and compare the incidence, prevalence, and trends of
T2DM between all the residing communities in this holy land. Furthermore, in
this book chapter we also attempted to shed light on the current status of diabetes
in the Palestinian population living in the same holy land and abroad. In the end
of this chapter, our recommendations, suggestions, and conclusions in relation to
diabetes prevailing in our society are also included. We hope this chapter to
constitute beneficiary information to all readers and knowledge seekers from all
over the world.
Keywords
Arab society in Israel · Lifestyle · Physical activity · Risk factors ·
Sociodemographic factors · Type 2 diabetes mellitus (T2DM)
AD Anno Domini
AIDS Acquired immune-deficiency syndrome
BMI Body mass index
CAD Coronary artery disease
CBS Central Bureau of Statistics
CGT Combined glucose tolerance
CHD Coronary heart disease
CVD Cardiovascular disease
DN Diabetic nephropathy
DPP Diabetes Prevention Program
DR Diabetic retinopathy
ESRD End-stage renal disease
GDM Gestational diabetes mellitus
HbA1c Hemoglobin bound with glucose
HDL High-density lipoprotein
HIV Human immunodeficiency virus
HMO Health Ministry Organization
IDF International Diabetes Federation
IFG Impaired fasting glucose
IGT Impaired glucose tolerance
43 Type 2 Diabetes Mellitus (T2DM) in the Arab Society of Israel 1103
IR Insulin resistance
LNCS Low- and no-calorie sweeteners
MENA Middle East and North Africa
NCD Noncommunicable disease
NGT Normal glucose tolerance
OECD Organization for Economic Co-operation and Development
OGTT Oral glucose tolerance test
OR Odds ratio
PA Physical activity
T1DM Type 1 diabetes mellitus
T2DM Type 2 Diabetes Mellitus
UKPDS UK Prospective Diabetes Study
UNRWA United Nations Relief and Works Agency
USA United States of America
USD United States Dollar
Diabetes Worldwide
History and Origin of Diabetes
Ancient Egyptians described clinical features similar to diabetes mellitus about

3000 years ago. “Diabetes” as a term was firstly coined by Araetus of Cappodocia
(81–133 AD), while, the word “mellitus” meaning honey sweet was added in 1675
by the English physician Thomas Willis after rediscovering the sweetness of urine
and blood of patients (first noticed by the ancient Indians). In modern time, the
history of diabetes coincided with the emergence of experimental medicine. An
important milestone in the history of diabetes is the establishment of the role of the
liver in glycogenesis, and the concept that diabetes is due to excess glucose produc-
tion Claude Bernard (France) in 1857. Mering and Minkowski (Austria) in 1889,
discovered the role of the pancreas in pathogenesis of diabetes. Later, this discovery
constituted the basis of insulin isolation and clinical use by Banting and Best
(Canada) in 1921. Trials to prepare an orally administrated hypoglycemic agent
ended successfully by first marketing of tolbutamide and carbutamide in 1955
(Ahmed 2002). The discovery of insulin and the ability to produce it commercially
has been a great achievement in both the therapy and the prognosis of the diabetes
(Vecchio et al. 2018).
Epidemics and Global Burden of Diabetes
Definitions and General Descriptions

Noncommunicable diseases (NCDs) have become a significant global burden on
health due to the rise in rates of conditions such as cardiovascular disease (CVD),
cancer, and diabetes. NCDs now form one of the major causes of mortality and
morbidity globally, with 38 million deaths worldwide (Naseem et al. 2016). NCDs
currently account for almost 70% of all deaths worldwide; ischemic heart disease,
cancer, and stroke are among the leading causes (Abubakar et al. 2015).
Diabetes is a well-known chronic disease that occurs when the pancreas cannot
make insulin (Type 1), or when the body cannot make good use of the insulin it
produces (Type 2). There are more than 542,000 children in the world who live with
type 1 diabetes, which is an autoimmune condition where the body attacks its own
insulin-making cells. The pancreas is a large gland behind the stomach that secretes
digestive enzymes into the duodenum. Embedded in the pancreas are the islets of
Langerhans, which secrete into the blood the hormone insulin that regulates blood
sugar-glucose (Ogurtsova et al. 2017; Jaacks et al. 2016). Gestational diabetes
mellitus (GDM) is defined as any degree of glucose intolerance with onset or first
recognition during pregnancy. It usually disappears after the pregnancy is over.
Diabetes in pregnancy may give rise to several adverse outcomes, including con-
genital malformations, increased birth weight, and an elevated risk of prenatal
mortality (American Diabetes Association 2014).
Epidemiology of Diabetes
Diabetes Mellitus (DM) is considered to be one of the major public health threats
with an increasing prevalence rates among the general population worldwide
(Dijkstra et al. 2013). It has increased dramatically during the last decades, and it
affects more than 382 million people around the world, of whom 90% are diagnosed
with type 2 DM (Atlas 2013). The causes of this epidemic are a complex interaction
between genetic and epigenetic factors and societal influences that determine diet
and levels of physical activity (Chatterjee et al. 2017). A recent report indicates that
there were about 422 million people aged 18 years who were living with diabetes
in 2014 worldwide. This is almost equivalent to 8.5% of the world’s population. The
prevalence of T2DM was highest in the eastern part of the Mediterranean region
increasing from 5.9% (6 million) to 13.7% (43 million) in 1980 and 2014, respec-
tively. About 43% of people with diabetes will succumb to complications of the
disease before the age of 70 years. The highest proportion of deaths occurred in low-
and middle-income countries (WHO 2016).
It is a well-known fact that the prevalence of type 2 diabetes mellitus (T2DM) has
risen sharply worldwide and so have the associated health consequences and
healthcare costs (Ogurtsova et al. 2017). Evidence shows that the prevalence of
T2DM is higher in obese, overweight, and physically inactive individuals (Sullivan
et al. 2005). An increase in physical activity, healthy nutrition, and weight loss may
prevent or delay T2DM manifestation (Cefalu et al. 2016). However, it is challeng-
ing to reach certain populations, in particular so-called vulnerable groups that
include individuals with a migration background and/or low socioeconomic status.
Those patients are disproportionally affected by T2DM and diabetes-related com-
plications (Connolly et al. 2000). Language, cultural perception, shame, and lower
health literacy often play an important role in nonparticipation (Patel et al. 2017).
Research suggests that behavioral change is possible, but this change generally
requires comprehensive approaches tailored to specific settings and target groups

(Grol and Grimshaw 2003).
Global Burden of Diabetes

Diabetes is the leading cause of heart disease, stroke, kidney failure, nontraumatic
lower-limb amputations, and new cases of blindness among adults. Those with
diabetes have twice the normal risk of death; in 2014, diabetes was listed as the
seventh leading cause of death in the United States. As of 2015, approximately 415
million persons aging 20–79 years (1 in 11 adults) in the world have diabetes and that
number is expected to rise to 642 million by 2040, and that five million deaths are
attributable to diabetes (Ogurtsova et al. 2017; Jaacks et al. 2016). Therefore, this
chronic disease not only affects the patients themselves but it also causes a consider-
able suffering emotionally and financially for their families, relatives, and the whole
society (Seuring et al. 2015). A recent study in the USA demonstrated that cancer
histories as well as short or long sleep durations are independently associated with DM
and might increase an individual’s likelihood of having DM (Seixas et al. 2018).
It was estimated that 382 million people live with diabetes mellitus worldwide
and a further 316 million have impaired glucose tolerance making them high-risk for
the disease. In 2013, diabetes caused 5.1 million deaths and cost USD 548 billion in
healthcare spending about 30% of the total healthcare expenditure (Williams 2015).
Type 2 diabetes mellitus (T2DM) accounts for 90% of all diabetes cases with its
incidence increasing and mirroring the worldwide increase in levels of obesity in
adults and children (Danaei et al. 2011).
Globally, the burden of diabetes is estimated to constitute about 12% of the global
healthcare expenditures, corresponding to about $800 billion. Drivers of this pan-
demic include increased global obesity which, in turn, is driven by increased
standards of living, increased availability, affordability, consumption of non-nutri-
tive foods, and mass urbanization of the global population, in the context of an
overall decrease in per capita physical activity (Swinburn et al. 2011; Ladabaum
et al. 2014). On the other hand, a recent systematic review estimated the global
economic burden of diabetes and its complications to be US$ 825 billion, about 60%
of these costs are borne by low-income and middle-income countries (NCD Risk
Factor Collaboration 2016). Therefore, it is evident that diabetes and its complica-
tions impact harshly on the finances of individuals and their families and to health
systems and national economies through direct medical costs and loss of work and
wages (Zimmet et al. 2016).
Risk Factors of Diabetes
Diabetes, type 2 Diabetes Mellitus (T2DM), is a polygenic disorder involving

interactions between genetic and environmental risk factors that result in the under-
lying pathophysiology of hepatic and muscle insulin resistance, and subsequent
beta-cell failure (Prasad and Groop 2015). Many studies showed that T2DM is
more likely to be an outcome of the interaction of environmental, biological, and
behavioral risk factors (Kahn et al. 2014; Chatterjee et al. 2017). There are various
studies that suggest a link between the environment and health outcomes that are
closely related to T2DM such as obesity, cardiovascular diseases, hypertension,
metabolic syndrome, and physical inactivity (Schulz et al. 2016; Feng et al. 2010).
It was shown that individual-level socioeconomic, demographic, and behavioral
factors are important predictors of T2DM (Akter et al. 2017).
There is a dramatic increase in overweight and obesity worldwide. The WHO
estimates that 39% of adults worldwide are overweight and 13% are obese (World
Health Organization 2006). It is widely known that obesity is associated with numerous
comorbidities such as hypertension, musculoskeletal disorders, cancer, and type 2
diabetes (Jensen et al. 2014; Fried et al. 2014). Likewise, overweight or obese pregnant
women show an increased risk for gestational diabetes (Catalano and Shankar 2017).
The prevalence of prediabetes, which is a precursor to T2DM, has increased
globally. Prediabetes is characterized by impaired glucose tolerance (IGT) and/or
impaired fasting glucose (IFG) and is a condition closely tied to obesity, which is one
of the most important risk factors for T2DM (Mainous et al. 2014). Overweight and
obesity constitute a global pandemic with devastating consequences that affect over
two billion people worldwide. Obesity plays a central role in morbidity and mortality
of diseases of multiple organs and systems, and it is a major contributor to the
growing incidence of cancer. T2DM is another global health threat closely associated
with obesity that boosts the risk of cancer driven by high BMI (Suárez 2018).
A recent study was carried out to identify demographic and social-cognitive
factors that were associated with weight loss in overweight and obese participants.
The study found out that, being male, having a higher baseline BMI, having a higher
income, perceiving fewer disadvantages of a healthy diet, experiencing less discour-
agement for healthy eating by family and friends, and lower education were inde-
pendently linked to greater weight loss. The study concluded that, weight loss
programs should always address the social environment of persons who try to lose
body weight as family members and friends can be important supporters in reaching
a weight loss goal (Hansen et al. 2018).
Role of Diet in Diabetes

There are some epidemiological studies that have reported associations between
potato intake and obesity, type 2 diabetes, and cardiovascular disease. However,
results are contradictory and confounded by lack of detail on cooking methods
(Robertson et al. 2018; Churuangsuk et al. 2018). On the other hand, the role of
red meat consumption as a risk factor for diabetes and its comorbidities was studied
previously. It was documented that nitrites and nitrates in red meat can lead to
increased insulin resistance, dysregulated blood glucose levels, and elevated oxida-
tive stress all leading to chronic diseases (Misra et al. 2018).
Recently, international scientific experts in food, nutrition, dietetics, endocrinol-
ogy, physical activity, pediatrics, nursing, toxicology, and public health met in order
to develop a consensus on the use of low- and no-calorie sweeteners (LNCS) as
substitutes for sugars and other caloric sweeteners. The use of LNCS in weight
reduction programs that involve replacing caloric sweeteners with LNCS in the
context of structured diet plans may favor sustainable weight reduction. Further-
more, their use in diabetes management programs may contribute to a better glyce-
mic control in patients, albeit with modest results (Serra-Majem et al. 2018).
Dietary Patterns in Relation to Diabetes

Dietary pattern is an approach that has been used to investigate diet-disease relations
(Hu 2002; Kant 2004). The pattern of diet is potentially useful in making dietary
recommendations because overall dietary patterns might be easy for the public to
interpret or translate into diets (National Research Council 1989). The exact etiology
of T2DM complications is poorly understood (Díaz-López et al. 2015). Diet is one of
the lifestyle factors that may play an important role in preventing and managing
these conditions (American Diabetes Association 2002; Mirmiran et al. 2014).
However, few studies have explored the relationship between dietary patterns and
diabetes complications. Most studies have examined the associations between indi-
vidual foods or food groups and nutrients and diabetes complications (Mahoney and
Loprinzi 2014; Horikawa et al. 2014; Tanaka et al. 2013). Various studies have
documented that many chronic diseases such as diabetes, cardiovascular disease, and
some cancers are preventable through life-long practices of adhering to healthy
dietary patterns, engaging in physical activity, and maintaining acceptable weight
(Suárez 2018; Neuhouser 2018). Healthy dietary patterns were defined in the 2015
Dietary Guidelines Advisory Committee Scientific Report as diets that are high in
fruits, vegetables, whole grains, low and non-fat dairy and lean protein. Other
characteristics of healthy dietary patterns are that they are low in saturated fat,
trans fat, sodium, and added sugars (Millen et al. 2016).
Diabetes: Complications, Prevention, and Future Therapy
Compared with the general nondiabetic population in the USA, persons with T2DM
have approximately a 7-year shorter life expectancy, an effect directly related to the
major diabetic complications (Morgan et al. 2000). Patients with diabetes develop
macrovascular complications (including coronary artery disease (CAD), peripheral
vascular disease, and stroke) and microvascular complications (including diabetic
nephropathy (DN), diabetic retinopathy (DR), and peripheral neuropathy), which are
collectively known as diabetic vascular complications. Worldwide, diabetes is the
major cause of CAD, limb amputations, end-stage renal disease (ESRD), and
blindness. Compared to nondiabetic individuals, adults with diabetes have a two to
fourfold higher death rate from CAD, and those with ESRD on dialysis have a
fourfold reduction in life expectancy (Haffner et al. 1998; Goodkin et al. 2003). A
recent study investigated the association of diabetes with a broad range of health
conditions. People with diabetes had a 25–75% higher risk of dying from cancer,
infections, liver disease, lung disease, mental disorders, intentional self-harm, exter-
nal causes, and falls, independent of other risk factors (such as age, gender, smoking,
and weight). Overall, approximately 40% of the excess deaths in diabetic patients
appears to be due to nonvascular events (Seshasai 2011).
The individuals affected with diabetes are at an increasing risk for developing
microvascular and macrovascular diseases. Such diabetics who cannot maintain ade-
quate glycemic control (such as the failure to reach the recommended target level of
HbA1c < 7%) are at a higher risk and predisposed to develop neuropathy, retinopathy,
nephropathy, cardiovascular disease, cerebrovascular disease, and premature death
(Evans and Goldfine 2016). The deaths from diabetes-associated complications (~5
million cases) account for more deaths than combined deaths caused by HIV/AIDS (1.5
million), tuberculosis (1.5 million), and malaria (0.6 million) (Atlas 2015). In response
to the enormity of this medical catastrophe, there have been major initiatives on the part
of global health organizations, national diabetes associations, and primary caregivers to
educate patients about the benefits of appropriate nutrition and physical activity (Evans
and Goldfine 2016). Since dietary modification and increased physical activity provide
insufficient glucose control over the long-term course of the disease, many individuals
will require some type of medication for glycemic control and ultimately address their
complications (Turner et al. 1999). Therefore, continuous search for better possible
solutions is always encouraged. A promising strategy for the prevention of T2DM is
adherence to a healthy lifestyle, mainly addressing diet and physical activity (Balk et al.
2015). Research has shown that reducing body weight can be effective in preventing and
delaying the onset and deterioration of both prediabetes and T2DM (Feldman et al.
2017). The US Diabetes Prevention Program (DPP) has indicated that participants with
impaired glucose tolerance (IGT) who participated in a lifestyle intervention group
reduced their diabetes risk by 58% (Knowler et al. 2002). Another strategy used for the
treatment of T2DM depends on a dual combination of insulin secretagogue and an
insulin sensitizer, and despite reasonable glycemic control provided by these drugs
initially, over time their efficacy tends to diminish. Moreover, side-effects such as severe
hypoglycemia, lacticacidosis, idiosyncratic liver cell injury, digestive discomfort, dizzi-
ness, and even death are recognized and can limit their use (UK Prospective Diabetes
Study (UKPDS) Group 1998; Action to Control Cardiovascular Risk in Diabetes Study
Group 2008). Therefore, utilizing different approaches to address this problem remains a
challenging issue, thus, a recent study revealed that metabolic disorders such as obesity
and diabetes could be resulted from alterations in the diversity or structure of gut
microbiota. Thus, the role of prebiotics, probiotics, genetically modified bacteria, and
fecal microbiota transplantation could be explored as potential therapeutic challenges for
type 2 diabetes (Vallianou et al. 2018).
Diabetes in the Arab Countries
Background
The Arab world contains 22 countries with a total population of 362.5 million people
with a $2.55 trillion economy (World Bank 2015). Type 2 diabetes mellitus (T2DM)
is spreading fast in developing as well as developed countries; however, it is
observed to be more increasingly in Arab countries. Its incidence is rapidly increas-
ing in both developing and developed countries; furthermore, it is even found to be
increasing to a higher extent in the Arab world (Meo et al. 2017). Some of the Arab
countries are considered to occupy the highest prevalence of diabetes (in adults aged
20–79 years) ranging from 19% to 21% (Atlas 2011).
Diabetes is a major public health concern that every nation and society suffer
from. It has an increasing prevalence and long-lasting complications. Even with
great developments in various medical technologies and diabetes science, it is still an
incurable life-long disease, which is swiftly growing among different age groups of
men and women. It engages various physiological functions, organs, and multiple
systems resulting in extensive ranging and highly damaging complications (Meo
et al. 2006; Gavin et al. 1997). In the past few decades, there has been a drastic
change in the socioeconomic condition, particularly in the oil and gas-rich Gulf
countries, that has resulted in huge changes, both in the patterns of health and
disease. It brought about unexpected changes to life styles. Excess wealth and
rapid growth in urbanization caused a drastic change in traditional diet habits, resting
tendency, and a lavish lifestyle that expanded in these societies. Additionally, people
quickly embraced fast food and a “remote-control” culture, which are the two main
causes of physical inactivity leading to obesity and diabetes mellitus as the people
started eating excessively and exercising rarely (Musaiger 1992; Meo et al. 2006).
It has become an established fact that physical inactivity and unhealthy diets are
major health and economic problems worldwide and are important modifiable risk
factors for noncommunicable diseases such as type 2 diabetes, cardiovascular
disease, and some cancers (Ding et al. 2016; Lee et al. 2012). The rapid socioeco-
nomic development of the Gulf countries has resulted in major demographic and
epidemiological transitions, with obesity, a high prevalence of diabetes, and chronic
diseases becoming the leading causes of morbidity and mortality (Nikoloski and
Williams 2016). Factors underpinning this increasing prevalence of obesity and type
2 diabetes mellitus (T2DM) are multifactorial and primarily related to economic
development, and the parallel shift in culture, lifestyle, and dietary habits. Obesity is
the most important risk factor for developing glucose intolerance. The high preva-
lence of obesity in the Gulf countries has led to a marked rise in the prevalence of
prediabetes and diabetes (Alharbi et al. 2014). The various components of metabolic
syndrome are established risk factors among patients presenting for coronary artery
bypass grafting in one study from the region (Pieris et al. 2014). The prevalence of
obesity in Gulf countries among children and adolescents ranges from 5% to 14% in
males and 3% to 18% in females. In adult women, there is a significant increase of
obesity with a prevalence of 8–36% in men and 17–48% in women (ALNohair
2014). The International Diabetes Federation (IDF) reported high prevalence rates of
more than 20% for diabetes and more than 15% for prediabetes in most Gulf
countries. These are among the highest rates worldwide (Atlas 2017).
Obesity Related to Diabetes and Other Comorbidities
The world is affected by a global rise in the prevalence of obesity. The burden of
obesity-driven morbidity is affecting developed as well as developing countries
(James 2008). The mechanism linking obesity with several related co-morbidities
such as hypertension, type 2 diabetes, and cardiovascular disease is postulated to be
obesity-driven peripheral insulin resistance (IR) (Reaven 1995). The Middle East is
also affected by alarming increases in the prevalence of obesity both in children and
adults and of diabetes which have been documented in several Arab countries (Ng
et al. 2011; Ali et al. 2013). Similarly, in the Arabian Gulf countries, the most
eminent risk factors of noncommunicable diseases were known as inadequate intake
of fruit and vegetables, being overweight or obese, physical inactivity, high blood
pressure, high blood cholesterol, and tobacco use (WHO 2014). Therefore, in the
Arab societies, the behavioral and sociodemographic factors play a vital role for the
increasing rate of T2DM. It was found that obesity, fast urbanization, and lack of
exercise are key determinants of the rapid increase in the rate of T2DM among the
Arab world. This is believed to be a logical outcome of the rapid economic growth
that carried with it the burden of greater reliance on mechanization, a proliferation of
western-style fast food, and access to cheap migrant labor, thus, resulting to greater
opportunities for sedentary lifestyles, especially in the young. These environmental
factors fuel the emerging epidemic of type 2 diabetes in the Arab countries (Kahn
et al. 2014; Badran and Laher 2011). Furthermore, the enormous changes in the
lifestyle of the people in Gulf countries specifically, often described as “westerniza-
tion,” due to the shift in the socioeconomic condition, are leading to rapid changes in
their way of life. This includes rapid growth in urbanization and a change in the
traditional diet habits, thus, embracing fast food with deskbound lifestyle that is the
main causes of obesity and diabetes mellitus (Musaiger 1992; Meo et al. 2006; Atlas
2015). Among the top 10 countries with the highest prevalence of diabetes (in adults
aged 20 to 79 years), six of them are Arab countries, viz, Kuwait (21.1%), Lebanon
(20.2%), Qatar (20.2%), Saudi Arabia (20.0), Bahrain (19.9%), and UAE (19.2%)
(Atlas 2011).
Diabetes in Israel
Introductory Background
When the State of Israel was created in 1948, the majority of Palestinian Arabs were
forced out of their homeland to live either in Gaza Strip, the West Bank, or
surrounding Arab countries (Zlotogora 2002). Those who remained in Israel at
that time numbered about 156,000, but currently there are in excess of 1.6 million
Arabs living in the country (Central Bureau of Statistics, Israel 2013, 2014). The
Palestinians who remained in their homeland were later named by different names
such as: Israeli Arabs, 1948 Arabs, Israeli Palestinians, or Arab community in Israel.
Most of the Arab population in Israel lives in predominantly Arab cities and small
tows or in mixed cities (Arabs and Jews) which are close to Jewish cities and towns;
therefore, they have high exposure to westernized foods and eating habits (Yitzhaki
2010). The Arabs’ sudden and fast involvement in the urbanization process has been
accompanied by a nutrition transition that yielded a sluggish lifestyle with lower
levels of physical activity, and the exchange of traditional foods high in complex
carbohydrates for new foods high in refined carbohydrates (Abu-Saad et al. 2012;
Baron-Epel et al. 2005). These changes could explain the high prevalence of obesity
among Arabs in Israel (Kalter-Leibovici et al. 2007).
Characteristics of the Arab Society in Israel
The Arab population in Israel, which today counts about 1.8 million (Central Bureau
of Statistics, Israel 2016) is an ethnic group with some unique cultural, religious, and
social characteristics, which differ from those of the general population in Israel.
This population belongs to various religions: Muslims (83.9%), Christians (8.3%),
and Druze (7.8%). The Arab communities are still undergoing a transition from a
mainly agrarian society, to a more urbanized one. On the whole, compared to the
Jewish population, Arabs in Israel have lower socioeconomic status and poorer
health awareness (Daoud 2008). The community is characterized by a high rate of
consanguineous marriages with a common founder effect (Central Bureau of Statis-
tics, Israel 2016; Sharkia et al. 2016). Recently, a westernized lifestyle was adopted
by most of the Arab population of Israel (Treister-Goltzman and Peleg 2015). It was
found that the main causes of death that might contribute to the lower age of Arabs
than Jews could be due to chronic diseases, especially ischemic heart disease and
diabetes (Na’amnih et al. 2010).
Epidemiology of Diabetes in Various Ethnic Groups of Israel
General Background
Israel is considered to be a modern, industrialized, multi-ethnic state, currently
classified as a high-income country. Israel’s high Human Development Index reflects
achievements in key dimensions of human development, namely, a long and healthy
life, high educational attainment, and a decent standard of living (Sagar and Najam
1998). On the other hand, Israel’s high Gini index reflects high income inequality
(Yitzhaki 1983). The population has grown rapidly as a result of both immigration
and high fertility, and presently constitutes about 8.5 million people (Central Bureau
of Statistics, Israel 2016). The two main population groups are Jews (74.8%) and
Arabs (20.8%). Israeli Jews are customarily classified by regions of origin: Europe,
America, Asia, North Africa, and native-born. Israeli Arabs include Muslims, Druze,
and Christians. Between and within these groups, wide cultural, lifestyle, and
socioeconomic variations exist. 12% of Jews were aged 65 years or older compared
with 4% of Arabs (Central Bureau of Statistics, Israel 2016; Dwolatzky et al. 2017).
A substantially higher proportion of Arabs live in areas peripheral to the main
urban centers, mainly in the northern and southern parts of Israel. The Bedouin
Arabs are a distinct Muslim subgroup (about 13.4% of Israeli Arabs), most of whom
reside in the southern part of the country. About half of them live in unauthorized
villages, without access to water in their homes and sanitation infrastructure, but
with access to health services. In general, important determinants of health inequal-

ities have been shown to be income, education, sex, and ethnicity (Marmot 2005;
Link and Phelan 1995; Blane 1995; Cassel 1976). The association between socio-
economic position and mortality has been suggested to be mediated through
resources such as money, knowledge, prestige, power, and beneficial social connec-
tions that protect health, regardless of the specific mechanisms operating at any time
(Link and Phelan 1995). Additional determinants of health inequalities include
biological variation, free choice (i.e., behaviors), and environmental conditions
that are mainly beyond the control of the individual and that characterize the
conditions in which people are born, grow, live, work, and age (Marmot 2005;
Link and Phelan 1995; Blane 1995; Cassel 1976).
In Israel, despite an overall increase in educational and economic status, the
average educational attainment and income of Arabs remains below that of Jews.
Additionally, participation of Arab women in the labor force is around 25%,
compared with 70% among Jewish women (Central Bureau of Statistics, Israel
2016). In 2014, 22% of the Israeli population lived under the national poverty
line, the second highest among the Organization for Economic Co-operation and
Development (OECD) countries. Poverty is particularly high among ultra-Orthodox
Israeli Jews (59%) and Israeli Arabs (54%). Inequality levels, measured by the Gini
coefficient (in which higher values reflect greater inequality), increased from 0.353
in 1998, to 0.371 in 2014, fourth in rank among OECD countries (OECD average
0.308) (National Insurance Institute, Israel 2015).
All permanent residents, in Israel, are medically insured under the National
Health Insurance Law and are members of one of the four Health Ministry Organi-
zations (HMOs) that supply health services in the community that are included in a
nationally determined basket of services. All HMOs support and cooperate with the
program, including in the development, assessment, and publication of quality
indicators (Gross et al. 2001).
In a population-based cross-sectional survey among 1100 adult Jewish and Arab
Israelis, the prevalence of diabetes was higher among Arab participants than among
Jewish participants (21.0% vs. 11.9%), respectively. However, Arabs developed
diabetes 11 years earlier than Jews. Diabetes risk calculation was based on self-
reported age at diabetes diagnosis. The excess diabetes risk among Arabs was
independent of body mass index, family history of diabetes, and consumption of
energy-dense foods (Kalter-Leibovici et al. 2012). Another study confirmed the
difference in the prevalence of diabetes between Arabs and Jews (Zucker et al.
2016). Although prevalence data are crucial for appreciation of disease burden, they
reflect both disease risk and survival. Indeed, diabetes-related mortality accounts for
a significant part of the disparity in longevity among Arabs and Jews in Israel
(Saabneh 2015).
A recent study pointed out that even the Bedouins living in Israel were found to
be severely affected by diabetes and obesity. The cross-sectional study was initiated
to update the prevalence of diabetes among Bedouins in the Negev and to observe
differences in this population in comparison with non-Bedouins in Israel. The age-
adjusted prevalence of diabetes was 12.3% in the Bedouin population versus 8.2% in
the non-Arab population in southern Israel. The prevalence of diabetes among

Bedouins and other Arabs in Israel was similar (12.0%). In all of Israel, age-adjusted
diabetes prevalence for men and women was 8.8% and 7.5%, respectively, while in
Bedouin population it was higher, i.e., 12.0% and 12.5%, respectively. On the other
hand, there was a difference in diabetes prevalence among the Bedouin population in
planned cities compared to those in unrecognized villages (12.5% vs. 10.5%,
respectively). The study concluded that the increasing urbanization of the Bedouin
population with their higher diabetes prevalence indicates the need for increased
medical intervention as well as continuing investigation into the causes (Amkraut
et al. 2018).
A recently published research work demonstrated an annual decrease in mortality
from diabetes in both men and women, particularly in the Israeli Arab population
(Calderon-Margalit et al. 2018). A study in one of the Israeli HMOs demonstrated an
association between glycemic control and mortality (Wilf-Miron et al. 2014).
Another study indicated that improvements in diabetes care in the community
were associated with improved health. Specifically, these achievements consisted
of accelerated decreases in lower limb amputations in men and in mortality due to
diabetes in the Arab population (Calderon-Margalit et al. 2018). The same study also
reported a decline in diabetes-related blindness in Israel, which also supported and
extended a previous local report (Skaat et al. 2012). On the other hand, the same
study could not support a decrease in diabetes-related end-stage renal disease
incidence (Calderon-Margalit et al. 2018).
A study showed that the prevalence of T2DM is much higher among the Arab
population compared to the Jewish population in Israel (Kalter-Leibovici et al.
2012). This was partly explained by the higher prevalence of obesity among Israeli
Arab population (especially women) compared with Jews (Kalter-Leibovici et al.
2007; Keinan-Boker et al. 2005). It was documented that mortality related to T2DM
is one of the leading contributors to gaps in life expectancy between Israeli Arabs
and Jews, with increasing gaps attributed to diabetes mortality in the years
1980–2004. Additionally, it was also demonstrated that there were very low rates
of diabetes mortality in the 1980s that increased drastically in the 1990s and 2000s,
in both Jews and non-Jews. However, steeper increases were shown among Arab
men and women. Diabetes mortality among Arab women became the major con-
tributor to the Arab-Jewish gap in life expectancy at 45 years of age (Na’amnih et al.
2010). The Israeli Central Bureau of Statistics, in its report has demonstrated the
smallest Jewish-Arab gap in life expectancy at age 45 among women since 2000
(Israel Central Bureau of Statistics, 2015).
There were few evaluating studies from Israel’s two largest HMOs that described
the efforts invested in improving the quality of primary healthcare supplied non-
Jewish populations such as Arabs and individuals of low socioeconomic status to
minimize inequalities (Cohen et al. 2010; Wilf-Miron et al. 2010a, b). In one of our
recent studies, we found that the incidence rate of T2DM was increasing signifi-
cantly from 11.3% to 17.7% in the years 2005 and 2015, respectively, with a
progressive increase with age in both genders (Sharkia et al. 2018). A recent local
study indicated that the Israeli adults aged 18–74 years, numbered 4.25 million to
4.76 million during 2002 and 2010. During this period, the numbers of patients with
diabetes increased from 205,725 to 352,747, yielding an increase in prevalence from
4.8% to 7.4%. This study concluded that Israel’s national program for quality
indicators in diabetes care in the community has probably had a significant impact
on the health status of the whole population and may have contributed to narrowing
gaps in life expectancy between Israeli Jews and Arabs. (Calderon-Margalit et al.
2018).
Our latest research work on diabetes was conducted with the aim of determining
the various behavioral and sociodemographic factors associated with T2DM in the
Arab society in Israel. This cross-sectional study was conducted based on data from
1894 residents over the age of 21 years. The study found that 13.7% were affected
with T2DM. The prevalence of T2DM increased sharply in the successive age
groups of both men and women. About 85% of the men affected with T2DM were
physically inactive, while 97% of the affected women were physically inactive.
Almost half of the participants with diabetes have a family history of the disease in
both genders. The study concluded that age, obesity, family history of diabetes, and
physical inactivity were the significant factors associated with the prevalence of
T2DM within the Arab society in Israel (Sharkia et al. 2019).
The various latest studies on diabetes and its risk factors in the Arab society of
Israel are presented in Table 1.
The Risk Factors for Diabetes in Israel

There is evidence that Israeli Arabs have a higher prevalence of obesity and
metabolic syndrome (Abdul-Ghani et al. 2005b) and diabetes, including an earlier
age of onset than Israeli Jews (Kalter-Leibovici et al. 2012). Urban Palestinian Arabs
have been shown to suffer from a greater incidence of coronary heart disease (CHD)
(Kark et al. 2006) and higher CHD mortality than Israelis (Kark et al. 2000). The
question arises whether there is a specific ethnic predisposition for the development
of adverse glucose metabolism and insulin resistance in Palestinians that can be
demonstrated using a simple biomarker. It has been shown that overweight and
obese individuals from specific ethnic backgrounds, such as Hispanics and East
Asians, manifest lower insulin sensitivity and greater metabolic risk relative to
Whites of similar anthropometric dimensions (Palaniappan et al. 2002). Such dif-
ferences render these individuals prone to develop diabetes and CHD at a lower BMI
(Fujimoto et al. 1995). The Jerusalem Palestinian-Israeli Risk Factor Study was
designed to assess differences in the distribution of cardiovascular risk factors
between urban Palestinians and Israelis, following the evidence for substantial
disparity in the incidence of myocardial infarction between these two populations
(Kark et al. 2000, 2006).
There are some local studies that compared many aspects of lifestyle and various
diseases susceptibility between Israeli Arabs and Jews. It was found that there are
certain differences in risk factors between Israeli Arab and Jewish women have been
reported: Arab women are more obese, have a greater prevalence of diabetes,
exercise less, are less educated, and have a lower socioeconomic status than Jewish
women, nevertheless, they smoke less. With respect to diet, a salient difference is the
Table 1 Summary of studies on the prevalence of diabetes and risk factors in the Arab society of
Israel
Reference/
Number Year Subjects Study results
1 Sharkia A total of 1894 residents over the It was found that 13.7% of the
et al. age of 21 belonging to the Arab studied samples were found to be
(2019) population in Israel was included affected with T2DM. It was also
in the study found that age, obesity, family
history, and physical inactivity
were the significant factors
associated with the prevalence of
T2DM within the Arab society in
Israel
2 Calderon- During the study period, the The numbers of patients with
Margalit Israeli adults aged 18–74 diabetes increased from 205,725
et al. numbered 4.25 million to 4.76 to 352,747, yielding an increase
(2018) million in prevalence from 4.8% to 7.4%
3 Sharkia The samples size was estimated It was found that the incidence
et al. to be 3173 households in the first rate of T2DM was increasing
(2018) period and 2250 households in significantly from 11.3% to
the second period 17.7% in the years 2005 and
2015, respectively
4 Jaffe et al. The total study population The incidence rates of diabetes
(2017) included 17,044 Arabs (49% per 100 persons were higher
males; mean age 39.4 17.3) and among Arabs 2.9 than among
16,012 Jews (50% males; mean Jews 1.8. Furthermore, Arabs had
age 40.5 17.6) a much higher diabetes
prevalence than Jews; 18.4 and
10.3, respectively
5 Weiss Participants (968 Palestinians, Prevalence of diabetes was 2.4-
et al. 707 Israelis) and 4-fold higher among
(2015) Palestinian men and women,
respectively ( p < 0.001)
6 Idilbi et al. Review of official health statistics The incidence rate of diabetes in
(2012) the Israeli Arab population
increased by 9.1 per 1000 persons
annually. In contrast, it decreased
among Jews
7 Merom A total of 970 Palestinians and 26% of Palestinian women were
et al. 712 Israelis aged 25–74 years classified as insufficiently active
(2012) living in east and West Jerusalem versus 13% of Palestinian men
participated in the study who did not differ from the Israeli
sample (14%)
8 Kalter- Participants (n = 1100) Arabs The prevalence of adult-onset
Leibovici and Jews patients were randomly diabetes was 21% among Arabs
et al. selected from the urban and 12% among Jews. Arab
(2012) population of the Hadera District participants were younger than
Jews at diabetes presentation by
11 years
(continued)
Table 1 (continued)
Reference/
Number Year Subjects Study results
9 Jabara The study includes 546 women Arab women (compared to
et al. (444 Jews and 102 Arabs) who Jewish women) had a higher
(2007) had coronary heart diseases prevalence of diabetes (61%:
46%), had borne more children,
were younger, had a lower
socioeconomic status, consumed
less alcohol and more olive oil,
suffered more passive smoking,
and were less physically active
than Jewish women. Whereas
rates of dyslipidemia and
hypertension were higher in the
Jewish patients
10 Kalter- The study included 880 randomly The prevalence of obesity was
Leibovici selected participants (Arabs and 52% in Arab women compared to
et al. Jews) from the urban population 31% in Jewish women and 25%
(2007) of the Hadera District in Arab men compared to 23% in
Jewish men
11 Abdul- Medical records of 7434 patients T2DM was diagnosed in 323
Ghani from an outpatient clinic in an patients of whom 63% were
et al. Arab village women. The prevalence of
(2005a) diabetes was significantly higher
among women than men younger
than the age of 65 years. Diabetic
women were younger than men at
diagnosis (48y vs. 59y) and had a
higher BMI
12 Abdul- Randomly recruited 95 Arab In the tested subjects 27% had
Ghani subjects who were overweight undiagnosed T2DM, 42% had
et al. and above 40 years old impaired fasting glucose and/or
(2005b) impaired glucose tolerance, 48%
metabolic syndrome
13 Keinan- Representative sample of 3246 Obesity rates increased with age
Boker participants from the general and reached 22.4% for men and
et al. Israeli population aged 40.4% for women aged
(2005) 25–64 years 55–64 years
higher olive oil intake among Arabs (The Israel Center for Disease Control 2006;
Keinan-Boker et al. 2005; Baron-Epel et al. 2004; Troen et al. 2006). A further, local
study compared Jewish women with Arab women. It found that Arab women had a
higher prevalence of diabetes, had borne more children, were younger, had a lower
socioeconomic status, consumed less alcohol and more olive oil, suffered more
passive smoking, and were less physically active. Compared to Jewish women,
Palestinian Arab women in Jerusalem appear to have more diabetes. The study
concluded that greater attention to primary prevention in this ethnic group is needed
(Jabara et al. 2007). Type 1 diabetes mellitus (T1DM) is a chronic disease
characterized by the destruction of insulin-producing β-cells of the pancreas. The

current paradigm in this disease’s etiopathogenesis points toward the interplay of
genetic and environmental factors. Among the environmental variables, dietary
factors, intestinal microbiota, toxins, and psychological stress have been implicated
in its onset. This recent local study aims to investigate the relationship between
psychological stress and T1DM by presenting evidence from epidemiological stud-
ies, animal models, and to provide the mechanism involved in this association. It was
found that there was a wide array of evidence, ranging from epidemiological to
animal models, that points toward the role of psychological stressors in T1DM
pathogenesis. It was suggested that further research could investigate the gene-stress
interactions to evaluate the risk of T1DM development (Sharif et al. 2018).
An observational study was carried out in five countries that determined the
incidence of hypoglycemia during the holiday month of Ramadan among Muslim
subjects with T2DM treated with a sulfonylurea, the highest incidence of hypoglyce-
mia (40%) was reported by patients from Israel (Aravind et al. 2011). In a recent study
among patients in hospitals that had predominantly Arab patients (more than 90%),
the proportion of diabetics was 39%. There was a female preponderance among
patients admitted with diabetes (52.9%), while only 45% of hospitalized patients
without diabetes were women. A difference was found in the reasons for hospitaliza-
tion between patients with diabetes and those without. In the diabetic group, there
were more hospitalizations 37% and 27%, respectively, while urinary tract infections
had rates of 7.7% and 6.9%, respectively. The authors recommended that the preven-
tion of cardiovascular disease and urinary tract infections among the diabetic popula-
tion should be a priority, particularly for Arab women over 40 years of age, who have a
high risk for morbidity and a high rate of hospitalizations (Nseir et al. 2013).
A study that evaluated risk factors among Arab and Jewish patients who underwent
rehabilitation for a first stroke, revealed that a high percentage of Arab patients have
hypertension and T2DM. The prevalence of diabetes among Arabs, non-immigrant
Jews, and immigrant Jews patients was 51.4%, 38.5%, and 39.1%, respectively
(Greenberg et al. 2011). In another study that evaluated ethnic disparities between
patients with a first episode of primary intra-cerebral hemorrhage in northern Israel,
the Arab patients were found to be younger and to have a higher prevalence of
diabetes (Telman et al. 2010a). A national survey among 28 hospitals in Israel that
assessed ethnic variations in acute ischemic stroke showed that the mean age of Arab
patients was 9 years younger than Jewish patients; Arabs were more likely to be obese
and to have diabetes (Gross et al. 2011). A higher prevalence of diabetes among Arabs
than Jews was also found in a study that compared ethnic differences in ischemic
stroke in patients of working age 65 years and lower (Telman et al. 2010b).
In two studies that examined risk factors in hospitalized Arab and Jewish women
with coronary heart disease who underwent cardiac catheterization, a higher preva-
lence of diabetes was found among the Arab compared to Jewish women. Such
differences should be taken into consideration at the time of developing stroke and
coronary artery disease preventative strategies, planning healthcare services, and
designing culturally relevant public education programs (Jabara et al. 2007; Salameh
et al. 2008).
Genetics of Diabetes and Prediabetes in the Arab Population of Israel

It was known that the Arab community of Israel is characterized by a high rate of
consanguinity (Sharkia et al. 2016). A study investigated the effect of consanguinity on
multifactorial common adult morbidity, including T2DM. The study found that there
was no significant difference in T2DM between patients with and without consanguinity
(Jaber et al. 1997). There is another study on the Israeli Arab society that examined the
existence of a direct genetic association that affects the development of diabetes. It
elucidated that distinct genetic backgrounds were responsible for the development of
beta-cell dysfunction and insulin resistance among Arabs (Shalata et al. 2013).
It was previously known that obesity constitutes one of the major factors in the
development of T2DM and the risk of diabetes increases substantially with increased
BMI (Abdul-Ghani et al. 2005a). A study from central Israel showed that the mean
BMI of 18-year-old Jews and Arabs is similar. This finding changes with age so that
52% of Arab women are classified as obese compared with 31% of Jewish women
and 25% of Arab men compared to 23% of Jewish men. On the other hand,
surprisingly a group of Arab women aged 55–64 years had an obesity rate of 70%
(Keinan-Boker et al. 2005).
A study of randomly recruited healthy, overweight Arabs (BMI > 27) attending a
primary healthcare clinic in Israel revealed that 27% of them had undiagnosed
T2DM, 42% had impaired glucose tolerance (IGT), and only 31% had a normal
oral glucose tolerance test (OGTT). The metabolic syndrome was diagnosed in 48%
of them (Abdul-Ghani et al. 2005b). There is evidence from various populations that
IGT and impaired fasting glucose (IFG) often are associated with different groups of
patients (Bardini et al. 2014). The study from Israel assessed insulin resistance and
impaired pancreatic function among overweight Arab patients with IFG only, IGT
only, or IFG and IGT (combined glucose intolerance-CGT) compared to those with a
normal glucose tolerance (NGT). Patients with IFG and CGT were more obese and
had higher values of insulin resistance compared to those with IGT only or normal
fasting glucose. There was no statistically significant difference in insulin resistance
between patients with IGT only and those with NGT. Beta-cell function was
depressed in patients with IGT only and CGT compared to those with IFG and
NGT, while beta-cell function indices in patients with IFG were similar to those with
NGT (Abdul-Ghani et al. 2006).
There are large numbers of studies in the recent decades that focused on T2DM in
Israel, a study found that the incidence rate of diabetes in the Israeli Arab population
has increased by 9.1 per 1000 persons annually (Idilbi et al. 2012). While another
study on the urban Jewish and Arab population from the central area of Israel found
that the prevalence rates for adult-onset diabetes were higher in Arabs than in Jews
(21% and 12%, respectively). The Arabs had diabetes at a younger age than the Jews
and 25% of the Arab population was diagnosed with diabetes by age 57 compared to
age 68 in the Jewish population (Kalter-Leibovici et al. 2012). A worrying finding
could be observed as high prevalence of diabetes was found in Israeli Arab women
over 50 years, reaching 50% (Kalter-Leibovici et al. 2010). Another study found that
the prevalence of diabetes among women younger than 65 years old was signifi-
cantly higher compared to men. The mean age at which women developed diabetes
was 48.3 compared to 59.5 for men, while women had a higher BMI (34.5 vs. 30.04,
respectively) at diagnosis. The age of diabetes diagnosis correlated significantly with
BMI (Abdul-Ghani et al. 2005a).
Despite the high prevalence of obesity, metabolic syndrome, and overt diabetes
among Arabs, there is evidence of inadequate care for diabetes in this population.
More than a third of respondents reported that they did not receive any counseling on
issues such as foot care or the effects of smoking on diabetes. Misconceptions,
attributable to social norms, are common and more than a third forgo taking
medications because they cannot afford them (Khatib et al. 2007). Arab diabetics
received less nutritional counseling, less counseling on physical activity, and less
advice on self-testing of the feet than Jewish patients (Tirosh et al. 2008). There is
poor diabetes control and suboptimal follow-up care among Arab patients with
diabetes (Wilf-Miron et al. 2010b).
A recent Israeli study was conducted to evaluate the effect of a herbal composi-
tion (denoted as SR2004) on HbA1c, fasting blood glucose levels, and the blood
lipid profile in patients with T2DM. It was found that this supplementation (SR2004)
significantly reduced HbA1c, blood glucose, and lipids with good tolerability and no
observed adverse interactions with conventional medications. Some interesting
findings relating to the reversal of microvascular phenomena warrant further
research to elucidate the mechanisms of action of this novel composition (Chatterji
and Fogel 2018).
Diabetes in Palestine
Historical Background
The number of Palestinians worldwide recently reached 11 million. Fewer than half
(4.2 million) live in the occupied Palestinian territory. Of these, two millions are
refugees, the majority living in camps (Statistics UNRWA 2010). As only 1.3 million
Palestinians live in Israel, 5.5 million of the Palestinian population lives abroad. The
total area of historical Palestine is 27,000 km2. Nearly 6% of this area was controlled
by Jewish immigrants prior to the United Nations resolution on the partition of
Palestine in 1947. Today, Israel controls 85% of the total area of historical Palestine.
The Gaza Strip is one of the most densely populated parts of the world, with about
4300 individuals/km2 (Qlalweh et al. 2012). Continued land confiscation and inten-
sified tightening of the closure system have increased the prevalence of economic
crises, unemployment, and poverty, thereby strengthening dependency on donor
financing (World Bank 2010). Restrictions on freedom of movement, trading,
employment, living a healthy life, access to healthcare, etc. threaten welfare and
public health (Giacaman et al. 2009; Batniji et al. 2009; Rytter et al. 2006).
The United Nations Relief and Works Agency for Palestine Refugees (UNRWA)
has been working in the Near East for over 62 years, and provides health, education
and social services for over five million Palestinian refugees in Jordan, Lebanon,
Syria, the West Bank, and Gaza Strip. It currently delivers health services through
138 primary healthcare (PHC) centers and one hospital in the West Bank, and the main
focus of its health work is the provision of general medical care, maternal and child
health care, and diagnosis and treatment of noncommunicable diseases, particularly
diabetes mellitus (DM) and hypertension. Prevalence of DM and hypertension among
the served population aged 40 years and above attending the health facilities is 11.4%
and 17.5%, respectively, and in 2011, almost 211,000 people with DM and / or
hypertension were being cared for at UNRWA clinics in the region (Custer 2010).
Noncommunicable Diseases, Lifestyle, and Risk Factors for Diabetes

in Arabs and Palestinians
In the Middle East and North African region (MENA),the noncommunicable dis-
eases (NCD) include cardiovascular disease (CVD), cancer, and diabetes. It was
found that their mortality rates vary, with Lebanon experiencing an 85% NCD
mortality rate and Jordan experiencing a 76% NCD mortality rate (World Health
Organization 2014). A cross-sectional study conducted between 1996 and 1998
documented alarming high prevalence rates of obesity (42%), hypertriglyceridemia
(35%), and low HDL-cholesterol (61%) among urban Palestinians living in the city
of Ramallah, whereas the corresponding rates in a nearby rural community were
28%, 23%, and 28%, respectively (Abdul-Rahim et al. 2001). The reported preva-
lence of type 2 diabetes mellitus (T2DM) was 12% in both communities, while 21%
had hypertension and 17% were classified as having the metabolic syndrome
(Abdul-Rahim et al. 2001). In this region, too, high levels of behavioral risk factors
have been discerned such as daily tobacco smoking (26.3% in Jordan, 18.9% in
Egypt, 37.6% in Lebanon, and 19.3% in Palestine); insufficient physical activity
(46.8% in Lebanon and 46.5% in Palestine); and obesity (34.3% in Jordan, 28.2% in
Lebanon, 34.6% in Egypt, and 26.8% in Palestine) (Rahim et al. 2014). It is
documented that active lifestyle can help prevent much of the above mentioned
diseases in the Palestinian community. Little is known about the physical activity
(PA) behavior of the Palestinians. A study was conducted to determine the preva-
lence of insufficient PA and its sociodemographic correlates among urban
Palestinians in comparison with Israelis. It was found that Israelis are more physi-
cally active than Palestinians; furthermore, substantial proportions of Palestinian
women, and subgroups of Palestinian men, are insufficiently active. Culturally
appropriate intervention strategies are warranted, particularly for this vulnerable
population (Merom et al. 2012)
Health and Diabetes Status in Palestine

In one of the UNRWA-primary healthcare clinics in Jordan, a study was conducted
on a cohort of Palestinian refugees with hypertension (Khader et al. 2012a). From the
same clinic, another study described the use of quarterly reporting for cases and
treatment outcomes to assess the burden of disease and management of patients with
DM. Such an analysis needs to be more widely applied for the monitoring and
management of noncommunicable chronic diseases (Khader et al. 2012b).
A recently published article described the general health situation and the health-
related hardships of the Palestinians living in the occupied Palestinian territories
(Waterston and Nasser 2017). In Palestine, the prevalence rate of type 2 DM (T2DM)
was 10.5% in the West Bank and 11.8% in the Gaza Strip among the registered
Palestinian refugees (Relief, U.N. 2007). It was estimated that the prevalence rate of
T2DM in Palestine will be 20.8% and 23.4% during the years 2020 and 2030,
respectively (Abu-Rmeileh et al. 2012). Previous Palestinian studies have shown a
high burden of T2DM. Its prevalence in the West Bank was 10% in the year 2000
and 15% in 2010 (Abu-Rmeileh et al. 2013).
In 2015, diabetes was the fifth leading cause of death (Palestinian Ministry of
Health, 2016). Despite this high burden in Palestine, little is known about diabetes
mellitus complications and its determinants. A review published in the Lancet in
2009 indicated the scarcity of data on complications of diabetes in Palestine
(Husseini et al. 2009).
A latest local study was carried out on 517 T2DM patients, in order to estimate
the prevalence of T2DM complications in Ramallah and al-Bireh governorate of
Palestine. It found that the prevalence of diagnosed microvascular and macro-
vascular complications was 67.2% and 28.6%, respectively. On the other hand, the
study found that 78.2% of the participants had poor glycemic control (Ghandour
et al. 2018).
Dietary Patterns in Relation to Diabetes Complications in Palestine

A unique study was conducted to identify major dietary patterns among 1200 T2DM
patients and its association with diabetes complications in Gaza Strip, Palestine. The
study identified two major dietary patterns, namely: Asian-like pattern and sweet-
soft drinks-snacks pattern. The study found that there is no significant association
between the sweet-soft drinks snacks pattern and diabetes complications. It was
concluded that Asian-like dietary pattern may be associated with a lower prevalence
of diabetes complications among T2DM patients (el Bilbeisi et al. 2017).
A recent comprehensive study was carried out in order to estimate changes in
T2DM and cardiovascular disease morbidity and mortality, among Palestinian
refugees in the Middle East, attributable to a transition from traditional food aid to
either (i) a debit card restricted to food purchases, (ii) cash, or (iii) an alternative food
parcel with less grain and more fruits and vegetables. The results obtained did not
robustly support the theory that transitioning from traditional food aid to either debit
card or cash delivery alone would necessarily reduce chronic disease outcomes.
Rather, an alternative food parcel would be more effective (Basu et al. 2018).
Complications of Diabetes in Palestine

T2DM and cardiovascular disease have become leading causes of morbidity and
mortality among refugees in the Middle East (Gersh 2012; Mokdad 2018). They are
also prevalent among over five million registered Palestinian refugees living in
Syria, Jordan, Lebanon, Gaza, and the West Bank, with a prevalence of 12.1% for
T2DM and 18.6% for hypertension among adults over 40 years old (United Nations
Relief and Works Agency 2018).
Complications can arise as T2DM progresses. Long-term complications such as

coronary heart disease which can lead to a heart attack, cerebrovascular disease
which can lead to stroke, retinopathy (disease of the eye) which can lead to
blindness, nephropathy (disease of the kidney)which can lead to kidney failure and
the need for dialysis, and neuropathy (disease of the nerves) which increases the
chance of foot ulcers, infection, and the eventual need for limb amputation may be
attenuated by dietary interventions (American Diabetes Association, 2014).
A recent cross-sectional study was carried out on 1308 patients diagnosed T2DM
and attending four main Primary Health Care Clinics in the Southern West Bank of
Palestine. It was found that 95.3% of the patients were overweight or obese. The
mean HbA1c was 9.21, hypertension was found in 23%, and dyslipidemia was
present in 37.3% of the patients. About 42% of them had a history of macrovascular
and microvascular complications (Al-Halaweh et al. 2017).
The majority of T2DM complications studies come from high-income countries
and results vary greatly between countries (WHO 2016). Furthermore, another recent
study was carried out to examine prevalence of complications related to T2DM in 385
patients. The study also aimed to investigate association between clinical variables and
biochemical factors with complications of T2DM in patients treated in primary
healthcare settings in the West Bank of Palestine. It found that the prevalence of
complications related to diabetes was high among the patients treated in primary
healthcare practice. These complications and risk factors were predicted by certain
clinical characteristics and biochemical factors. It was concluded that policies and
programs are needed to manage these modifiable risk factors (Shawahna et al. 2018).
In cases when T2DM is uncontrolled, it will have horrible consequences on health
and well-being (Zimmet et al. 2016). A study was conducted in Gaza Strip of Palestine
to evaluate the adherence to anti-diabetic medications among 369 patients with T2DM
seeking medical care in the Gaza Strip, Palestine. It was found that the level of
complete adherence to anti-diabetic medications was suboptimal. Thus, it was con-
cluded that new strategies that aim to improve patients’ adherence to their therapies are
necessarily needed, taking into consideration the influencing factors and the impor-
tance of having diabetes educators in the primary care centers (Elsous et al. 2017).
Our Recommendations, Suggestions, and Conclusions
From the above mentioned review about the current status of type 2 diabetes mellitus
(T2DM), and its future speculations, this establishes its seriousness that causes a
growing public health concern in almost all countries. Furthermore, it is now a
leading cause of death, disability, and high health care cost. It is considered to be one
of the most intimidating challenges posed today by virtue of its frequency, its costs,
and suffering imposed by its related-complications (affecting the eyes, kidneys, and
nerves, as well as causing delayed wound healing). It becomes of crucial importance
to defend ourselves (and the whole humans) against it in a variety of means;
therefore, there must be serious and strict efforts to organize and implement a unified
strategy for the prevention and control of diabetes.
What is currently seen now (from the incidence and prevalence of T2DM) is just
the tip of the iceberg, while the hidden portion is much greater in size than expected;
therefore, more surveillance programs are needed in many hidden places in the world
which are the low-income societies in south America, Africa, India, China, south
east Asia, etc., in order to unveil the hidden cases of diabetes for immediate action.
Our opinion about the various aspects of diabetes could be summarized as
follows:
1. Comprehensive preventive plans must be initiated at the earliest, such as educa-

tive programs for increasing the people’s knowledge and awareness about this
dread disease.
2. Timely prevention of diabetes is of utmost importance in order to minimize its
vast burdens on individuals and societies.
3. Continuous searching for possible therapies.
4. Helping low-income countries in fighting this epidemic by supporting their health
systems for protecting their general population.
5. Properly managing patients with diabetes begins with understanding the disease,
the treatments, and lifestyle changes that can allow patients to live longer with
T2DM with fewer complications. For those who already suffer from diabetes, it
becomes very important to manage their lives accordingly. These patients must
seriously take the proper measures such as: measure their insulin levels; take oral
medications, insulin injections, with continuous medical supervision; and mon-
itor their diets and exercise levels each day.
In summary, we recommend continuous physician consultation, particularly those

at high risk for diabetes (overweight or with a family history of the disease or over
45 years of age). These actions include: losing weight (for those who are overweight
and obese), minimizing fat and calories from the diet, minimizing sugar and high-
protein diet, maximizing high-fiber diet, increasing whole-grain diet, increasing
physical activity, and refraining from alcohol consumption and smoking.
Finally, in simple and common man’s language an attempt to prevent diabetes at a
personal level should be adopted as a common old proverb says: “Prevention is
better than cure.” People are advised to eat healthy, natural, and fiber-rich diet on
their daily basis, as it surely affects their wellbeing. Furthermore, everyone is
advised to use active lifestyle, eat proper food at definite times, and sleep at regular
times (as there is a saying: “early to bed, early to rise, makes man healthy, wealthy
and wise”). Lastly, every person’s ultimate goal should be in their wellbeing in both
the short and long term.
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Diabetes and Obesity
Harms of Lifestyle and Diet in the Arab World
44
Nawar M. Shara
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1134
Scope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1135
Obesity-Associated Complications in T2DM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1136
Other Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1137
Lack of Arab World Data Collection Causes Barriers to Uniform Policy . . . . . . . . . . . . . . . . . 1138
State of Health and Disease in the Arab World . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1139
Gulf Council Cooperation Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1140
Non-GCC Arab Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1140
Policy Design and Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1141
Obesity and Type 2 Diabetes Mellitus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1141
Obesity on the Rise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1143
Women Versus Men . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1143
Childhood Obesity and Type 2 Diabetes Mellitus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1144
Childhood Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1144
Type 2 Diabetes Mellitus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1146
Diet and Lifestyle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1147
Causes for Obesity and T2DM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1147
Solutions to Reduce Obesity and T2DM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1148
Public Awareness Using Public Relations for National Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1149
Physical Activity and Accessible Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1150
Analyzing Supporting Data in Support of Modification of Diet and Lifestyle . . . . . . . . . . . . 1150
Consequences of Obesity and T2DM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1150
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1151
Simultaneous Economic Growth and Health Decline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1151
Public Health Initiative Possibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1151
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1152
N. M. Shara (*)
Department of Biostatistics and Biomedical Informatics, Georgetown University, BERD-CTSA
(Georgetown-Howard), MedStar Health Research Institute, Hyattsville, MD, USA
e-mail: Nawar.Shara@Medstar.net

https://doi.org/10.1007/978-3-030-36811-1_148
1134 N. M. Shara
Abstract
Type 2 diabetes mellitus (T2DM) is the fifth leading cause of death in the Arab
world. The International Diabetes Federation’s data suggests that the region has
the second highest rate of T2DM in the world with a projected increase of 110%
by 2045. Modifiable determinants of obesity, including harmful trends in diet and
sedentary lifestyle behaviors, must be addressed to reduce its frequency. Comor-
bid illnesses accompanying T2DM are swelling the economic burden on health
agencies and Arab world infrastructures. Rapid urbanization in the Arab countries
has accommodated the introduction of diets saturated with fat and sugar over the
last two decades increasing the incidence of T2DM, while stronger economies led
to improved transportation and technology, exacerbating the ills of a sedentary
lifestyle. Harmful effects of an inactive lifestyle and poor dietary intake lead to
cardiovascular disease (CVD) as a common comorbidity of T2DM. These neg-
ative behaviors may be adopted during formative years increasing the risks of
childhood obesity that is associated with adult health complications. The Gulf
Cooperation Council (GCC) countries have seen the highest increase in T2DM,
because of their strong economies and over-indulgence, while other war-torn or
politically unstable Arab countries struggle with undernutrition and lifestyle-
related illnesses due to unhealthy diets and a lack of safe or temperate exercise
locations. The widespread epidemic of obesity and T2DM can be reversed by
government initiatives that include public education on active lifestyles and the
identification of formidable access points for nutritious food supplies based on
individual country requirements within the Arab world.
Keywords
Diabetes · Obesity · Diet · Lifestyle · Nutrition · Arab world · Middle East ·
Metabolic syndrome · Sedentary lifestyle · Childhood obesity · Cardiovascular
disease
Introduction
Life expectancy is increasing in the Arab world but the quality of those increased
years is peppered with chronic and debilitating disease processes burdening
healthcare agencies and economies. There is a decline in deaths related to infectious
diseases but an increase in deaths related to noninfectious and chronic disease
processes. Common chronic diseases placing a heavy burden on health care delivery
agencies include (1) type 2 diabetes mellitus (T2DM), (2) obesity, (3) childhood
obesity, and (4) cardiovascular disease (CVD). Economic infrastructures are charged
with developing approaches to increase services, data collection, and research
activity as the base for a uniform public health policy across the region. The Center
for Disease Control defines obesity as weight that is higher than what is considered
healthy for a given height. A body mass index over 30 is considered obese. The
44 Diabetes and Obesity 1135
prevalence of obesity is high in the Arab world and has direct associations with
metabolic syndrome (MetS) conditions including: (1) high blood pressure, (2) poor
blood lipid profiles, and (3) elevated blood sugar, increasing the prevalence of
cardiovascular disease (CVD) and other prominent risk factors for adult mortality
in developed and developing countries (Gunnars 2018).
Obesity is one of the largest health problems in the world and a key public health
concern in all 22 Arab countries, although its severity varies from one country to
another in that region, based on economic factors and political stability (Badran and
Laher 2011). Disease manifestations may have slight variations based on each
country and the population, but all of the Arab countries are revealing upward trends
in poor health. Current changes in lifestyle have resulted in the large and expanding
burden of chronic disease rooted in obesity, primarily type 2 diabetes mellitus,
whereby the body does not produce or utilize insulin well. Secondary disease
processes involve cardiovascular malfunction leading to persistent poor health
even though mortality, due to acute coronary syndrome conditions such as a heart
attack, has declined.
Scope
This chapter summarizes the current national health decline in Arab countries and
the impact of rising obesity on the worldwide healthcare delivery platform. Obesity
is one cause for an increase of T2DM with comorbid diseases and is a modifiable risk
factor in the Arab population. The T2DM epidemic in the Arab world with its
comorbid CVD complications can be addressed by utilizing similar initiatives to
those already in play in other parts of the world that measure direct impacts to
mortality rates. Measuring successful treatment modalities of comorbid illnesses of
obesity including T2DM and introducing modifiable determinants that decrease
related chronic illnesses must be the goal of a formal Arab health organization.
Rapid urbanization in prosperous countries has fueled poor eating habits and sed-
entary lifestyles, and reversing this trend requires reeducation and increasing access
and availability of nutritious food supplies and safe places to engage in regular
exercise.
This chapter also introduces the need for uniform health policies and healthcare
support options in each of the 22 countries of the Arab world. Due to difficulties in
uniform health information data collection, and the insufficient and inaccurate group
health data to be analyzed for the 22 countries of the Arab world, coupled with the
instability of some government infrastructures, public health policies will be difficult
to draft and adopt until the importance of reversing the obesity epidemic and its
negative impact of T2DM on the overall health of the Arab world population
becomes a priority for those in power. The wealth and political stability of the
Gulf Council Cooperation (GCC) countries, including Bahrain, Kuwait, Oman,
Qatar, Saudi, Arabia, and the United Arab Emirates, affords them great influence
on stabilization policy for other individual Arab country’s infrastructures, through
the development and implementation of initiatives that will improve the health of all
1136 N. M. Shara
citizens. The GCC governments have advanced their healthcare systems with the use
of electronic medical records for patient data and actively conduct clinical studies
creating a fertile ground for multigroup patient data collection to complete a baseline
meta-analysis of common disease processes related to T2DM in the region. Their
leadership in a national health services campaign should: (1) identify a data collec-
tion method to compare and contrast variations in disease processes related to
T2DM, (2) develop healthy initiative proposals specific to the variations identified,
and (3) deliver country-specific healthy lifestyle educational programs including the
identification of access points to quality nutritional food sources that will improve
overall health outcomes in the Arab world.
One of the most significant problems in creating a unified Arab world health
facility might present itself in the disparities of record keeping in non-GCC coun-
tries. Examples of these disparities are seen in Yemen through reductions in acces-
sible health care facilities due to corruption and economic downturn, and in Syria
because of the civil wars that have caused citizens to flee the unstable government
infrastructure negatively impacting health care systems and valid data storage.
Utilizing the existing health systems platform in the GCC Countries of the Arab
world and relying on their economic stability and increased technological advance-
ment could help to create a basic comprehensive policy. Once drafted, that general
policy could be used as a template to add country-specific language regarding
geographical, political, and resource access against actionable policies and proce-
dures that target successful outcomes in each country. Implementation of those
policies must occur in a timely manner to address the increasing prevalence of
obesity and chronic diseases, specifically diabetes (Mattke et al. 2015).
The design and implementation of an Arab health policy constructs an Arab
world platform to measure and treat chronic illnesses driven by the negative effects
of obesity and T2DM. Viable formal health data collection systems have been
delayed due to underreported or absent regional data that can be addressed through
sampling methods and data analysis standards used in Arab American studies that
identify common disease processes based on ethnicity, internal and external envi-
ronments, genetics and consanguinity prevalent in Arab countries, endogamy, family
history, poor diet, lifestyle, and risky behaviors.
Obesity-Associated Complications in T2DM
The Arab world has seen dramatic increases of T2DM with current projections climbing
to 110% by 2045 (International Diabetes Federation 2017), largely because of poor
dietary choices and decreased physical activity, actions that negatively impact insulin
resistance causing deficiencies that allow disease processes to take over. Obesity has
increased to dangerous levels worldwide, affecting both developed and advanced
countries, with the rates doubling between 1980 and 2014 (Alqarni 2016). Obesity is
a major contributor to CVD and is a leading risk factor for developing the metabolic
syndrome (MetS) condition that has the following hallmarks: (1) high blood pressure,
(2) poor blood lipid profiles, and (3) elevated blood sugar (Hebert et al. 2013). MetS
represents a bundle of cardiovascular risk factors where patients carry three or more
dysmetabolic abnormal health problems, including increased weight around the middle
(central adiposity) evident from waist circumference measurements, high fasting blood
sugar, elevated triglycerides, and high blood pressure that often result in serious
complications of CVD and T2DM. It is a concern for public health officials who want
to impose the value of healthy lifestyles supporting a reduction in obesity and drops in
comorbid disease processes. According to a 2008 World Health Organization study,
CVD was estimated to have caused about 49% of the deaths in Oman and 46% of the
deaths in Kuwait. The rate of deaths caused by CVD was high in the UAE, Bahrain,
Qatar, and Saudi Arabia (Ahmed et al. 2017). The Gulf RACE and INTERHEART
study has found that patients in the Middle East have heart attacks earlier in life than
Westerners. Genetics may be partially to blame, but changes in lifestyle and the lack of
uniform public health care policies addressing poor diet and inactive lifestyle have
contributed to increased risk factors of cardiac events in this region.
Other Risk Factors
Obesity is not the only risk factor for T2DM. Other risk factors for T2DM in Arab
countries include: (1) genetic predisposition, (2) environmental factors, (3) family
history, (4) old age, (5) physical inactivity, and (6) ethnicity (Ng et al. 2011).
Genetic predisposition. Genetic diseases are most commonly inherited from
parents through a mutation of the DNA sequence, or a germ cell mutation. When a
gene code is mutated, it cannot perform its normal function and a predisposition to a
disease may be the consequence. The high rate of consanguinity in the Arab
countries predisposes children to disease processes held by one or both parents
because they share blood lines. Several studies on the association of consanguinity
to noncommunicable disorders such as diabetes, hypertension, and psychiatric
disorders among Arabs are presently nonconclusive (Tadmouri et al. 2009). Children
born from consanguineous marriages in Saudi Arabia and Qatar revealed an
increased risk of T2DM. Rare diseases reveal themselves through Mendelian disor-
ders in which a single gene is mutated, but many genetic diseases have multiple
factors such as mutations in more than one gene exacerbated by lifestyle and
environmental factors as modifiers that increase susceptibility toward a disease
such as CVD or T2DM. Arab populations exhibit many rare, Mendelian, and
familial genetic disorders (Blair et al. 2013). To address the national crisis on the
harmful effects of fast-food consumption and sedentary lifestyles, scientists studied
metabolic traits through a review of published reports on T2DM genetics in the Arab
population originating in Kuwait, Lebanon, Saudi Arabia, Qatar, the UAE, Oman,
and Tunisia and determined established risk in some studies but not all (Hebbar et al.
2019). Findings in one Qatar study revealed the development of T2DM complica-
tions in patients with either paternal or maternal history of diabetes mellitus were
more common than those without. Hypertension was the only significant difference
in patients with or without a family history of diabetes mellitus (Bener et al. 2013).
1138 N. M. Shara
Environmental factors. It is thought that obesity gene variants interact with

multiple environmental factors and increase susceptibility to metabolic diseases
(Castillo et al. 2017). Environmental factors include air, water quality, sanitary living
conditions and stress, and the impact of personal choices including smoking ciga-
rettes, drinking alcohol, making unhealthy food choices, engaging in low levels of
physical activity, and participating in other risky behaviors.
Family history and old age. Family history is based on past mental health or
medical occurrences in family members and behaviors to which a person may be
prone. Old age is the time that a person nears or surpasses life expectancy. Family
history considerations related to T2DM and CVD can include: lifestyle; anthropo-
metric facets comprised of body fat composition, height, weight, and hip, waist, and
chest circumference measurements; and genetic risk factors, but they are only part of
the risks for T2DM. Being aware of relational tendencies allows an individual to
embrace a healthy diet and exercise regimen (InterAct Consortium et al. 2012).
Metabolic rates slow during aging, and insulin levels become unstable when a
person is sedentary, causing weight gain and ineffective use of insulin.
Physical inactivity. The World Health Organization (WHO) confirms that people
are less active worldwide, and that there are increased risk factors for non-
communicable diseases (NCDs), including T2DM, CV, cancer, and respiratory
illnesses (WHO 2015).
Ethnicity. The Arab world encompasses a large social group with origins in 22
nations, where the ancestry is diverse and the people have differences in physical
features, lifestyles, languages and are cast in a wide geographical net due to a shared
history, language, and culture. Because the governing bodies, politics, health facil-
ities, physical features, diets, and activities in each of the 22 nations are unique,
systemic grouping for health care sampling based on ethnic impact contributing to
T2DM and comorbid illnesses can be challenging. One example where culture has
played a part in the negative effects of obesity as reflected by the World Health
Organization’s estimate that a quarter of the 1.5 million women in Mauritania are
obese without the effects of fast food but because of practices of forced feeding and
being looked down upon by relatives if they are of a healthy weight.
Lack of Arab World Data Collection Causes Barriers to Uniform Policy
Rapid growth and political crises have gripped the Arab world, leading to drastic
transformations in diet and lifestyle behaviors that are causing poor health. This
dynamic has increased demands on governments and health agencies for orga-
nized support and deliverables in all 22 countries in the Arab world. While some
countries in the Arab world have ongoing political turmoil (such as Libya, Syria,
and Yemen), other regions, such as Egypt and Saudi Arabia, have experienced
economic transformation impacting socioeconomic and political growth, and
technological advancement through rapid urbanization. Causal effects of both
situations have led to a transformation in dietary habits, resulting in illnesses
from undernutrition, infant catch-up growth causing metabolic disturbances later
in life, and overnutrition resulting in obesity (Musaiger et al. 2011).
Minimal data is available to indicate the level of obesity in the poor countries of the
Arab world, but the incidence of T2DM reported over a period of 13 years in various
studies was recorded as follows: 2007 for Lebanon was 18.9%; 2010 for Libya was
18.8%; 2008 for Jordan was 17.4%; 2012 for Egypt was 17%; 2010 for Syria was
15.6%; 2014 for Tunisia was 15.1%; 2007 for Algeria was 20.14%; 2001 for Palestine
was 12.0%; 2008 for Yemen was 10.4%; 2001 for Sudan was 10.4%; 2012 for
Comoros was 8.4%; 2009 for Morocco was 8%; 2008 for Iraq was 7.43%; 2012 for
Djibouti was 7.43%; 2013 for Mauritania was 4.7%; and 2012 for Somalia was 3.9%.
The mean prevalence of T2DM in GCC countries was 25.45% and the mean preva-
lence of T2DM in non-GCC Arab countries was 12.69% equaling a combined mean
prevalence of T2DM in all the Arab world countries at 16.17% (Meo et al. 2017).
Chronic disease patterns are associated with comorbid health issues associated with
obesity. Strategic steps utilizing global data on similar disease markers can be the base
of actionable policies and procedures that can benefit the Arab world’s public health
education, including promotion of healthy diets and increased physical activity in the
region. Standard treatment policy may benefit wealthy individuals with a higher
standard of living. The wealth of the individual cohorts impacts the severity of CVD
and other comorbid disease factors (Shara et al. 2010). The comorbid disease pro-
cesses experienced in relation to CVD support an increased need for health services
that are disease specific in the Arab population (Radwan et al. 2018). Each country in
the Arab world should identify and address the changes in diet, exercise, and health
care delivery to reverse obesity trends in adults and children.
State of Health and Disease in the Arab World
The total population of the Arab world is approximately 345 million with origins
from 22 nations including the 10 Arab countries in Africa: Algeria, Comoros,
Djibouti, Egypt, Libya, Mauritania, Morocco, Somalia, Sudan, and Tunisia; and
the 12 countries in Asia: Bahrain, Iraq, Jordan, Kuwait, Lebanon, Oman, Palestine,
Qatar, Saudi Arabia, Syria, the United Arab Emirates, and Yemen. The term Arab is
a classification based mainly on common language (Arabic) and a shared sense of
geographic, historical, and cultural identity. It is not a racial classification and
includes persons with wide-ranging physical features. The Arab world is experienc-
ing an interesting demographic phenomenon characterized by natural growth and
migration based on fertility, mortality, and migration. These advances beg for
uniform public health policies and initiatives with concerted efforts toward improv-
ing living conditions that support healthy life expectancy (Abdul Salam et al. 2015).
In 2010, the Global Burden of Disease study showed that the Arab world is
experiencing an alarming high prevalence of several chronic diseases including
diabetes and cardiovascular disease resulting from risk factors such as tobacco use,
inactivity, and unhealthy diets in adults and children. Despite the health crisis and the
identified cost-effective treatment interventions, governments in the Arab countries
have not prioritized policies to address these risk factors to contain and reverse this
new epidemic (Rahim et al. 2014). The Middle Eastern and North African regions
reveal a potential for a 110% projected increase in diabetes by 2045 reflecting the
1140 N. M. Shara
second highest rate in the world (International Diabetes Federation 2017). Economic
burden will be experienced through carrying the costs of treatments, managing
disease complications, loss of productivity, and costs of disability for individuals
in these regions (Al-Maskari et al. 2010).
While countries in the region share social, cultural, and economic characteristics,
many differ in their historical and geopolitical stances, creating a highly diversified
profile for health outcomes and disease burdens in each of those 22 countries. This
diversity has complicated evidence-based health outcome comparisons generated from
studies undertaken in the Arab world and globally. Arab country governmental priorities
must include tailored regional public policy addressing positive changes necessary to
decrease the obesity epidemic by showcasing the importance of healthy diets and
increased physical activity; including healthy food access and safe exercise spaces.
Gulf Council Cooperation Countries
The Gulf Council Cooperation (GCC) countries, including Bahrain, Kuwait, Oman,
Qatar, Saudi, Arabia, and the United Arab Emirates, are experiencing the largest impact
from economic prosperity, coupled with the increased availability of technology and
transportation, promoting a sedentary lifestyle and Western-influenced fast food dietary
changes saturated with fat and sugar. Kuwait has been rated number one in the world
among countries who are experiencing the obesity crisis, and Saudi Arabia falls in
second place. Egypt falls at number four on the list, representing the highest diabetes
rates in the world, while Jordan is number five with two times as many obese women,
compared to men. The United Arab Emirates is number six with more obese women
than men, suggesting that being fat is a sign of wealth, and Qatar falls at number eight on
the list as they are suffering a childhood diabetes crisis (Carlson 2018).
While these regions are experiencing superior wealth, the overall health condition
of Arab countries is spiraling downward due to obesity and its comorbidities. The
rapid economic growth reflected in some parts of the Arab world such as in the GCC
has led to dramatic transformations translated into sedentary lifestyles with poor
nutrition and a decline in health (Mattke et al. 2015). The lifestyle of the Arab
populations can be described as sedentary, reliant on high caloric food intake with
poor nutritional value and rapid economic growth with migration from rural to urban
areas (Mattke et al. 2015). Moving from a rural area to an urban area decreases
activity levels at the outset because walking and traveling distances will become
shorter and variations in food sources and amounts will be readily available in urban
areas, gradually changing an individual’s overall eating habits.
Non-GCC Arab Countries
Much of the Arab world continues to benefit from strong economic growth, while
other countries in the region such as Libya, Syria, and Yemen are plagued by war and
political instability shifting the focus of government resources and priorities to
secure basic needs in those areas as the population seeks refuge in other countries.
Measuring the incidence of disease and addressing diet and lifestyle changes in these
regions is not as high a priority as stabilizing government and insuring basic needs
for people who live there. Deaths related to T2DM from 2017 revealed 10,859 or
6.25% of all deaths in Algeria; 123 or 2.40% of all deaths in Comoros; 243 or 3.78%
of all deaths in Djibouti; 21,045 or 4.10% of all deaths in Egypt; 1,221 or 4.12% of
all deaths in Libya; 888 or 3.15% of all deaths in Mauritania; 20,285 or 11.54% of all
deaths in Morocco; 1,109 or 0.81% of all deaths in Somalia; 5,179 or 1.93% of all
deaths in Sudan; 7,965 or 12.04% of all deaths in Tunisia; 6,382 or 3.62% of all
deaths in Iraq; 1,874 or 7.08% of all deaths in Jordon; 1,972 or 5.83% of all deaths in
Lebanon; 1,289 or 0.94% of all deaths in Syria; and 3,359 or 2.31% of all deaths in
Yemen. These totals are significant as they show the impact diabetes has on middle-
to lower-income countries of the Arab world.
Policy Design and Development
Arab countries lack cumulative crossover vital statistics data, complicated by weak
health information systems that cannot be trusted or used to support reasonable
projections of disease burdens and risk factors specific to each Arab country, partially
due to government instability in certain countries where there are limited resources to
track disease processes based on nutritional deficits and lack of physical activity and
doing so is not a government priority. The GCC countries have the ability to compare
data trends via use of patient data stored electronically as well as clinical studies being
conducted in the organized healthcare facilities available in those countries.
Obesity and Type 2 Diabetes Mellitus
The following tables reflect upward trends in adult obesity and increased diabetes in
the GCC Countries of the Arab world, with global target probability projections for
2025. The data suggests a higher rate of obesity for women but reveals a higher rate
of diabetes for men in the case of all but the United Arab Emirates where the percent
of men to women is the same. The projected trends in obesity and diabetes in the
following charts were estimated for adults 20 years and older for obesity and
18 years and older for diabetes.
Bahrain
Estimated prevalence in Probability of
2010 Projection for 2025 meeting global target
Women Men Women Men Women Men
Obesity 35.6% 23.0% 42.3% 32.9% 4% 1%
(29.3–42.0) (17.1–29.1) (31.3–53.4) (21.7–44.8)
Diabetes 10.4% 11.6% 12.0% 14.1% 43% 35%
(7.1–14.4) (8.0–16.0) (4.3–26.1) (5.3–29.8)
1142 N. M. Shara
Kuwait
Obesity 44.6% 30.4% 51.0% 41.2% 4% 0%
(39.5–49.8) (25.5–35.3) (41.2–60.8) (30.8–52.2)
Diabetes 18.3% 18.4% 24.9% 25.4% 15% 14%
(13.4–24.2) (13.4–24.4) (11.3–46.8) (11.6–48.1)
Oman
Obesity 31.0% 19.3% 41.6% 32.5% 0% 0%
(25.0–37.0) (14.4–24.4) (30.5–53.0) (21.8–44.9)
Diabetes 11.6% 13.1% 15.7% 20.1% 21% 11%
(8.3–15.6) (9.4–17.6) (6.0–32.3) (7.7–42.2)
Qatar
Obesity 41.8% 29.3% 49.2% 41.2% 2% 0%
(35.3–48.2) (23.1–35.8) (38.3–60.0) (29.8–53.2)
Diabetes 17.3% 17.3% 24.9% 26.0% 12% 10%
(12.9–22.8) (12.6–22.9) (11.0–48.7) (11.2–50.0)
Saudi Arabia
Obesity 40.5% 27.2% 49.1% 40.0% 1% 0%
(35.6–45.3) (22.7–32.0) (39.3–58.7) (29.7–50.9)
Diabetes 15.7% 16.1% 22.1% 23.5% 14% 12%
(11.7–20.6) (12.0–21.3) (9.8–43.6) (10.3–45.7)
The United Arab Emirates

Obesity 39.2% 24.3% 47.8% 36.3% 1% 0%
(32.9–45.6) (18.4–30.6) (37.1–58.9) (25.0–48.5)
Diabetes 14.9% 14.7% 19.9% 19.9% 22% 21%
(11.1–19.7) (10.7–19.6) (8.0–40.4) (8.0–41.1)
• Age-standardized estimates for adults 20 years and older for obesity and 18 years
and older for diabetes were used.
• Global target for obesity and diabetes is to halt, by 2025, the rise in the age-
standardized adult prevalence at their 2010 levels.
Obesity is a serious and dangerous medical disorder that is impacting the world
with epidemic rates doubling between 1980 and 2014 and quickly unfolding as one
of the most serious public health problems of the twenty-first century. Type 2
diabetes mellitus is a condition that does not allow the proper manufacture or use
of insulin in a person’s body and can occur at any age. Economic stressors negatively
impacting national infrastructures and health outcomes for persons around the world
have increased in tandem with obesity rates due to health care costs associated with
comorbid disease processes associated with obesity.
Obesity on the Rise
According to the WHO, worldwide obesity has nearly tripled since 1975; 1.9 billion
adults were overweight with 650 million considered obese in 2016, 41 million
children under the age of 5, and 340 million children/adolescents aged 5–19 were
considered overweight or obese during that same period (World Health Organization
2018). Recent studies have shown that the etiology of obesity is more complex than
just a simple imbalance in energy intake and output, with a predisposition to factors
including (1) endocrine, (2) metabolic, (3) genetic, (4) lifestyle, (5) diet, (6) race, and
(7) gender (Alzaman and Ali 2016).
Women Versus Men
Arab women reveal a higher incidence of obesity compared to their male counter-
parts; with causes varying in relation to their socioeconomic status, cultural differ-
ences, and geography. Possible culprits to this increase have been the introduction of
the Western diet; a lack of physical activity, blamed partly on restrictions of women
exercising in public; family commitments; and the idea that being plump is a sign of
beauty and wealth (Sarant 2013). In a study conducted among Arab females, a strong
association between breast cancer and obesity was detected revealing the proportion
of overweight/obese females to be significantly higher among breast cancer patients
(75.8%) than among healthy controls (61.3%). Obesity was just one of the contrib-
uting factors identified but influenced other listed factors, such as early menarche,
late age for giving birth to first child, and lack of physical activity (Elkum et al.
2014).
A study conducted in the United Arab Emirates showed that many patients with
obstructive sleep apnea and obesity hypoventilation syndrome were at risk for
cardiovascular disease as well as pulmonary hypertension negatively impacting
overall health and increasing the country’s burden to develop preventive strategies
1144 N. M. Shara
and uniform policies for healthy diet and physical activity (Mahboud et al. 2013).
Obesity in Arab countries is widespread among urban-living, higher class women
and reveals a trend in Egypt, Jordan, Morocco, Oman, and Tunisia where urban
women experience higher rates of obesity than their rural counterparts in those
regions (Musaiger et al. 2011). The International Association for the Study of
Obesity has conducted surveys that reveal rates of obesity in women to be signifi-
cantly higher than their male counterparts and is a health crisis threatening Arab
women and family life due to a higher incidence of infertility and miscarriage in
obese women (Sarant 2013). The common denominator for the increased weight
gain in areas of Kuwait, Qatar, and Saudi Arabia, where between 40% and 50% of
women are obese, has been identified as higher intakes of animal fats and sugars, and
the cultural, socioeconomic, and geographical factors that impact lifestyle and
physical activity (Sarant 2013). Detrimental consequences of obesity in Arab
women can include negative effects on reproduction through polycystic ovary
syndrome (PCOS) (Al-Jefout et al. 2017), which is the main cause of infertility
due to anovulation, or pregnancy complications such as gestational diabetes due to
abnormal fluctuations in insulin levels caused by obesity. The hormone adipokine is
also associated with obesity and T2DM causing reproductive issues. Children whose
mother has had gestational diabetes are at risk for diabetes and obesity later in life,
and child-rearing activities may be distorted toward unhealthy eating habits as a sign
of economic prosperity, setting children up for harmful lifestyles regarding dietary
intake and limited exercise as adults.
Strategic steps utilizing global data gleaned by similar disease markers can be the
base of actionable policies and procedures to increase healthy diets and physical
activity to the region. A review of current literature speaks to increased negative
impacts to women versus their male counterparts regarding costly health trends and
fertility risks due to disease processes rooted in obesity. Peer partnerships to jump
start physical activity can be community-based in order that women and children
(who are most often in the care of the women) will adopt healthy living through
exercise, coupled with dietary support from government and health care agencies.
Figure 1 shows a significant upward trend in adult obesity from 1975 to 2015
whereby females have a higher rate of obesity than their male counterparts. GCC
incidents of obesity are the highest with the Arab world almost half way between the
world and the GCC. The GCC rates of obesity increased approximately 20% over
the 40-year span and are significantly higher than the world rates which increased
almost 10%.
Childhood Obesity and Type 2 Diabetes Mellitus
Childhood Obesity
Childhood obesity in the Arab world is due to an epidemiological transition, a phase

of development where infectious disease processes become replaced with chronic
disease processes, due to changes in population demography. Childhood obesity
40%
30%
Adult Obesity
Female
Male
20% Arab World

GCC
World
10%
1975 1985 1995 2005 2015

Year
Fig. 1 Adult obesity in the Arab world, the GCC, and the world stratified by gender from
1975–2015
negatively impacts disease processes in early development of children, persisting

into adulthood and manifesting in a series of health-related disorders including
CVD, T2DM, and premature death. Nutrition transfer seems to be at the root of
the childhood epidemic of obesity in the Eastern Mediterranean countries, coupled
with a more sedentary lifestyle.
Nutrition transfer occurs in concert with an epidemiological transition such as the
one that has occurred in the Arab world. The shift in childhood obesity is an
epidemiological transition in the Arab world caused by urbanization, modern life-
styles, decline in diet quality with the introduction of fast food, and increased use of
modern transportation and technology creating a sedentary existence (World Health
Organization 2018). Obesity in children is attributed to diet and physical inactivity
and has a direct correlation to obesity in women because children are more often in
their care, and women have a much higher rate of obesity than their male counter-
parts in the Arab countries. Approximately 40–50% of women in some regions put
their children at risk by offering poor food choices at home and allowing sedentary
lifestyles that limit opportunities for physical movement to burn calories associated
with high fat content and sugar intake. Cross-sectional data suggesting obesity trends
in the urban areas, such as Khartoum, revealed school children aged 6–12 to be
14.8% overweight and 10.5% obese (Abdul Salam et al. 2015). Arab children,
1146 N. M. Shara
adolescents, and adults have replaced the once healthy traditional diet found in most
parts of the Arab world with high-caloric diets that are low in nutrients and filled
with fats and sugar.
Cardiovascular risks, dental decay, prediabetes, disturbances in eating behavior,
hypertension, and metabolic syndrome are just a few of the negative health impli-
cations related to childhood obesity. Active lifestyles exhibited by children in less
wealthy regions and genetics also play a significant part in the variations of child-
hood obesity rates. One such example is showcased by a study conducted in the
Kingdom of Saudi Arabia (KSA) where children in the rural southwestern region of
KSA have a lower rate of obesity (4%) which may be attributed to an active lifestyle,
such as fishing and farming (El Mouzan et al. 2012).
Results from genetic studies suggest significant genetic contributions and pre-
dispositions to obesity with some markers showing maternal BMI having a stronger
influence on childhood adiposity, which is a concern in all parts of the world,
because it is much harder to reverse obesity once it has been established, leading
to other comorbid illnesses (Linabery et al. 2013). Preventive treatment measures
should be undertaken before the ages of 5–7 years (Evensen et al. 2016). The field of
genetics is underdeveloped in the Arab world and more studies are needed to tease
out genetic factors predisposing children to obesity and diabetes. Diet and lifestyle
are measurable factors to obesity and they are also modifiable risk factors that can be
targeted and managed through youth-focused initiatives regarding physical activity
through sports and play and changes in dietary intake.
Type 2 Diabetes Mellitus
Children with severe obesity are at risk for T2DM, hypertension, sleep apnea, and
liver diseases. Adequate sleep improves cardiometabolic health and may help with a
reduction in obesity among adolescents. Several studies have been conducted
throughout the Arab world investigating the outcomes of surgical interventions for
weight loss. Addressing T2DM through weight loss has addressed the increased
obesity rates among children and adolescents in the Middle East and Saudi Arabia by
supporting a shift to young patients having bariatric surgery (Bell 2018). The most
frequent procedure was a Roux-en-Y gastric bypass, and the outcomes showed
improvement in the triglyceride levels, like the heated hemoglobin levels, with
expected weight loss. Obese children and adolescents undergoing sleeve gastrec-
tomy showed no recurrence up to 3 years after surgery and only some comorbidities.
There was resolution, remission, or improvement in more than 90% of comorbidities
including T2DM at 2 years with few complications, no mortality, and normal growth
(Alzaman and Ali 2016).
The foundation for the obesity problem in children is that it is not seen as an
illness and dire consequences ensue with negative symptomology setting the chil-
dren up for future illness in adulthood. As it is easy for a child to embrace unhealthy
eating choices and lifestyles, it is just as easy to set them up for success with proper
health choices and structured activities. To reduce the trend toward epidemic obesity
20%
15%
Childhood Obesity
Female
Male
10%
Arab World
GCC
World
5%
0%
1975 1985 1995 2005 2015

Year
Fig. 2 Childhood obesity in the Arab world, the GCC, and the world stratified by gender
1975–2015
numbers in the GCC population that were created with urbanization, disposable
income, and processed food consumption, negative factors must be addressed by
parents, teachers, and health care officials.
Figure 2 reflects the upward trend in childhood obesity in the Arab world, the
GCC, and the world with an apparent upshot for higher childhood obesity rates for
both males and females in the GCC as compared to the rest of the Arab countries and
the world. The upward trend from 1975 to 2015 shows GCC obesity rates are
increased approximately 10% over the 40-year span and are significantly higher
than the world rates.
Diet and Lifestyle
Causes for Obesity and T2DM
The World Health Organization (WHO) and the American Heart Association (AHA)
recognize diabetes, obesity, hypertension, and MetS as major risk factors for CVD
and lifestyle behaviors such as smoking, physical inactivity, unhealthy diet as
modifiable risk factors (Chomistek et al. 2015). Poor diet and sedentary lifestyles
1148 N. M. Shara
are both important facets of health that can be modified to reflect individual health
benefits and lower costs to regional government economies and infrastructures
including health care delivery institutions. In 2007, a study showed that physical
inactivity from a large national health survey in the KSA was as high as 96% in both
men and women (Ng et al. 2013). A study conducted in 38 Muslim countries on
163,556 participants revealed Arab women to be less physically active than non-
Arab women (Benjamin and Donnelly 2013). There are major variations in the
prevalence of physical inactivity in the Arab world and a combination of risk factors
related to emerging lifestyle changes and its health consequences are alarming (Aune
et al. 2016; IHME 2015).
By comparison, non-modifiable barriers to an active lifestyle include global
change in the Arab nations that causes increased higher temperatures for longe r
periods, increased polluted and dusty air quality, and political instability in many of
the countries which can deter individuals from outdoor activities. Access to healthy
food and medical care can also be harder to reach due to obstacles including weather
and political climates (Abuyassin and Laher 2016). Culturally, parents, peers, and
teachers favor educational and spiritual activities over physical activity in the KSA,
Egypt, and Jordan. Inactivity is very high, around 80% in all national surveys except
Tunisia. Women are found to be more physically inactive and are attributed to gender
norms and regional conservative attire (Sharara et al. 2018). Religious interpretation
plays a role in discouraging physical activities in portions of the Muslim world
(Kahan 2015).
The diet and nutritional status of Arab countries changed along with growth of the
nation to the detriment of the health of its people because of socioeconomic changes.
Disease processes include those related to inadequate nutrient intake sometimes
causing growth retardation in children in less wealthy regions and alternate illnesses
from poor nutrient, high-caloric intake causing CVD, T2DM, osteoporosis, cancer,
and other diet-related noncommunicable diseases in wealthier regions. Variations in
nutritional problems stem from socioeconomic status and the overall wealth of the
country. There are currently not enough programs to control or prevent nutrition-
related diseases because of the lack of epidemiological studies, national interest, low
nutrition information, cost-effective health care, and dietary intervention program-
ming (Musaiger et al. 2011).
Solutions to Reduce Obesity and T2DM
Addressing the obesity epidemic and its association with T2DM through transfor-
mations in diet and lifestyle is the most cost effective, far reaching blanket tool
available. The underpinning of physical activity as part of the lifestyle in the Arab
world is complex and differs between its 22-member countries due to socioeconomic
factors, religion, and tradition, considering individual cultural aspects pertaining to
each region. Similarities in the Arab world give way to a starting point to develop
healthy living initiatives but individual distinctions within communities must be
addressed when considering physical activity patterns in each region. It is important
at the societal level to support individuals with evidence-based policies tailored

toward regional populations. Policies must be actionable including availability of
healthy food options and providing an atmosphere open to regular physical activity,
with both facets being affordable and accessible. When policies and initiatives are in
place, responsibility falls to the individual to effectuate a healthy lifestyle outcome
with decreased illnesses and costs related to medical care, disability, disease, and
early death.
National policy should emergently act in the health interests of the Arab world
and incorporate modifiable strategies that will reduce obesity and T2DM, simulta-
neously reducing and reversing poor health conditions overall. The fast-moving
epidemic of obesity sweeping the Arab world can be reduced and removed once the
22 governments within develop common health goals that will supersede geography,
culture, religion, and wealth in the best interests of health care and interactive public
education that will decrease current and future economic burdens caused by poor
health and comorbid diseases resulting from obesity, including T2DM and CVD.
Alternate food parcels might be an effective means of introducing healthy diets back
to the Arab region while lessening the consumption of a diet mostly comprised of
grain, flour, and rice through the availability of more fruits and vegetables as a step to
lessen the negative impacts of hypertension and T2DM (Basu et al. 2018).
Proponents of uniform treatment directives that address obesity must develop
health-conscious policies and programs to control CVD and T2DM in Arab coun-
tries and showcase the value of traditional diets in concert with the importance of
using existing food supplies and engaging in daily physical activity. Collaborative
international efforts will be necessary to slow the disease process through compar-
ative study analyses utilizing similar data sets, while the collection of Arab-focused
data sets is fortified specific to each country’s region to develop evidence-based
health care protocols and programs to tailor toward obesity with a focus on T2DM
and CVD reduction (Abuyassin and Laher 2016).
Public Awareness Using Public Relations for National Events
Recognition from Qatar’s winning bid to host the 2022 International Federation
of Association Football (FIFA) World Cup will spotlight the region and create an
opportunity to highlight the value of sports, especially among children and young
adults as they become engaged with the country’s activities leading up to the
World Cup. This excitement will hopefully fortify efforts to promote physical
activities as they gain momentum in the regions where societal constraints
previously hindered women from participating as needed. Educational cam-
paigns that promote healthy living and nutritional intake among the youth are
imperative in this region, and the media has opportunity to partner with govern-
ment and health care agencies to play a vital role in raising awareness about the
importance of active living and a healthy diet, as they piggyback public service
regarding health and wellness on the back of public relations campaigns promot-
ing World Cup activities.
1150 N. M. Shara
Physical Activity and Accessible Nutrition
A multifaceted approach is necessary for the development of public health policy

and procedure to address challenges regarding healthy eating through access and
affordability in Arab countries due to difficulty transporting healthy food supplies,
and to promote physical activity in safe environmentally friendly venues supporting
equal participation for men, women, and children. Peer partnerships to jump start
physical activity can be community-based in order that women and children (who
are most often in the care of the women) will adopt healthy living through exercise,
coupled with dietary support from government and health care agencies.
Recent projects have been initiated in Saudi Arabia and Bahrain to promote
physical activity for women to address the concern that gender discrimination causes
them to be more sedentary because they carry the bulk of the family-related activities
and have not had welcome venues to exercise in. The project mission is to open the
schools at night where women might be able to exercise together. The idea of
building muscle is not something women have a great interest in, because plumpness
is seen as physical beauty and an indication of wealth as noted by study results from
2010 in the United Arab Emirates Philips Center for Health.
Analyzing Supporting Data in Support of Modification of Diet and

Lifestyle
Adapting data collection methods similar to the “depression, metabolic syndrome

(MetS) and locus of control (LOC)” study undertaken in the D.C. Metropolitan area
to screen Arab persons through: (1) physical exam including weight and measure-
ments, (2) blood work to benchmark comorbid disease possibilities, (3) question-
naire completion related to depression and lifestyle, and (4) assessment of wealth
would be a mildly invasive broad-base screening tool to reach a larger cohort of at-
risk individuals in the Arab regions. These methods would increase data yield to
support development of regionally focused national policy to diagnose and support
obesity and its comorbid components (Shara et al. 2018).
Consequences of Obesity and T2DM
If the Arab world does not address its current epidemic of obesity and T2DM
because of poor diet and inactive lifestyles, it will continue to exacerbate
increases in comorbid disease processes that will debilitate individuals and
hinder growth and expansive public health services by government health care
outlets as they will have to absorb the high costs associated with comorbid
diseases and disability of its citizens.
Conclusions
Simultaneous Economic Growth and Health Decline
The Arab world is experiencing dynamic changes in growth of its economy and
concurrent decline of the health of its people. In 2016, the Arab world contributed
3.31% to the world gross domestic product (GDP) and made up 5.5% of the world’s
population (Population Reference Bureau 2016). In contrast, Arab countries con-
tinue to lag in biomedical research even as there has been advancement in under-
graduate and postgraduate education and an increase in the number of journals
published. The publications have not been embraced by the scientific community
worldwide resulting in limited contributions to biomedical research literature
(Bredan et al. 2011). The absence of verifiable research and statistics make it difficult
to comprise blanket policy for all 22 Arab countries, but if a comparison to the
disease process itself is undertaken analyzing tangible outcomes for diet and activity
initiatives in other countries, it may be used as a starting place to develop policy
while embracing the national diversity and individual country parameters in the Arab
world.
Public Health Initiative Possibilities
Sports and exercise implications to health and wellness are new areas of interest in
the Arab world but lack evidence-based intimate subject research. Proponents who
are charged with building a case for physical activity initiative development will
have to defer to worldwide research on the topic and tailor specifics toward each
Arab country. Lack of physical activity or physical inactivity has been identified as
the fourth leading risk factor for global mortality, leading to approximately 3.2
million deaths globally.
The World Health Organization estimated that 87% of children and adolescents
and 33.2% of adults in the Arab world and the Middle East were insufficiently active
in 2010 (World Health Organization 2018). Physical inactivity is associated with an
increased risk of cardiovascular diseases, diabetes, colon and breast cancer, hip or
vertebral fractures, obesity, and depression (Fares et al. 2017). Public health chal-
lenges marking physical inactivity and poor nutrition are recognized as the highest
contributing factors to the obesity epidemic and the increase in CVD and T2DM
among Arab adults and children and must be addressed expediently. Obesity and
diabetes are sweeping the Arab world, with some of the highest rates identified
globally, while several Arab countries in the GCC, including Saudi Arabia, Oman,
Kuwait, Bahrain, and the United Arab Emirates, reflect the highest obesity rates in
the world, with less prevalent occurrences in Mauritania and Somalia. Conversely,
Arab countries who are not enjoying great wealth have diet and lifestyle harms
associated with diabetes.
1152 N. M. Shara
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Overweight and Obesity Among Saudi
Children: Prevalence, Lifestyle Factors, 45
and Health Impacts
Abeer M. Aljaadi and Mashael Alharbi
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1156
Definitions of Overweight and Obesity in Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1157
Prevalence of Overweight and Obesity Among Saudi Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1159
Regional Differences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1164
Sex Differences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1166
Health Impacts of Overweight and Obesity in Saudi Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1166
Risk Factors of Childhood Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1169
Early-Life Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1169
Lifestyle Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1170
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1173
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1174
Abstract
The rate of overweight and obesity among children and adolescents has increased
worldwide and is a significant public health concern. The Kingdom of Saudi
Arabia (KSA) has experienced a large increase in obesity prevalence over the past
three decades. The World Health Organization reported that the prevalence of
A. M. Aljaadi (*)
Department of Food, Nutrition, and Health, Faculty of Land and Food Systems, University of
British Columbia, Vancouver, BC, Canada
Department of Clinical Nutrition, Faculty of Applied Medical Sciences, Umm Al-Qura University,
Makkah, Saudi Arabia
e-mail: abeera@mail.ubc.ca; amjaadi@uqu.edu.sa
M. Alharbi
Curriculum and Pedagogy Department, Faculty of Education, University of British Columbia,
e-mail: mashael.alharbi@alumni.ubc.ca

https://doi.org/10.1007/978-3-030-36811-1_187
1156 A. M. Aljaadi and M. Alharbi
obesity has increased from 14.3% in 2010 to 17.4% in 2016 among children aged
5–19 years in the KSA. Childhood obesity is linked to adult morbidity and
obesity, which is associated with several adverse health, social, and economical
outcomes. This chapter reviews the published data on the prevalence of over-
weight and obesity in children and adolescents in the KSA, along with the
potential health impacts and associated lifestyle factors. Overall, the prevalence
of childhood obesity in the KSA continues to increase. It varies by sex, region,
and definition criteria. Childhood obesity in the KSA is associated with
cardiometabolic risk factors and might be associated with psychological and
social outcomes. Research is needed to study society-specific risk factors of
obesity in more depth to inform targeted, effective interventions. Additionally,
health programs need to be endorsed in schools and beyond schooling for the
prevention and management of childhood obesity in the region.
Keywords
Child · Adolescent · Obesity · Health · Saudi Arabia · Body mass index ·
Overweight · Prevalence · Childhood obesity
Abbreviations
BMI body mass index
CDC US Centers for Disease Control
HDL-C high-density lipoprotein cholesterol
HOMA-IR homeostatic model assessment of insulin resistance
IOTF International Obesity Task Force
KSA the Kingdom of Saudi Arabia
LDL-C low-density lipoprotein cholesterol
TG triglyceride
US United States
Introduction
Childhood obesity is a major public health concern in the twenty-first century. The
global prevalence of overweight and obesity among children 5–19 years old was over
18% in 2016, more than four times higher than in 1975 (4%) (World Health Organi-
zation 2017a). In 2016, the World Health Organization (WHO) reported that almost
half of all overweight children (<5 years) were in Asia (World Health Organization
2017a). The rapid economic growth in the Arabian Gulf States following the discovery
of oil in the 1960s has been associated with an increase in the prevalence of overweight
and obesity. Compared to other countries in the WHO Eastern Mediterranean Region,
the Kingdom of Saudi Arabia (KSA) is one of the Gulf Countries with a higher
prevalence of obesity (World Health Organization 2015, 2018).
Over 30% of the population in Saudi Arabia is aged 19 years or younger (General
Authority for Statistics 2019). Childhood obesity is associated with greater adult
45 Overweight and Obesity Among Saudi Children: Prevalence, Lifestyle. . . 1157
morbidity and obesity (Mahan and Escott-Stump 2008). A systematic review of data
from 33 years prior to 2014 reported that the KSA was among the top seven countries
with the most significant increases in the rate of obesity in both men and women (Ng
et al. 2014). Nearly 35% of Saudi adults are obese, with higher rates in women than
men (41% versus 31%) (World Health Organization 2018). Excess weight in adults
is associated with noncommunicable chronic diseases such as cardiovascular dis-
ease, type II diabetes, musculoskeletal disorders, and some types of cancer (Obesity
Control Program 2016). Cardiovascular disease is the leading cause of death in
Saudi Arabia (37% of total deaths), and the prevalence of high blood pressure in
adults is estimated at 19% (World Health Organization 2018). Although cardiovas-
cular events occur most frequently during or after the fifth decade of life, risk factors
can originate in childhood (Agirbasli et al. 2015). This review provides updates on
the prevalence of childhood obesity in the KSA, discusses lifestyle factors, and
reviews the potential health impacts associated with childhood obesity in the region.
Definitions of Overweight and Obesity in Children
Body mass index (BMI) is a surrogate measure of adiposity and is used to define
overweight and obesity. BMI is calculated by dividing a person’s weight in kilo-
grams by the square of height in meters [BMI ¼ kg/m2] (Mahan and Escott-Stump
2008). In adults, a normal BMI ranges from 18.5 to 24.9 kg/m2, whereas a BMI of
25.0–29.9 kg/m2 is considered overweight and a BMI of 30 kg/m2 is obese. In
children, there are different approaches to define overweight and obesity. Growth
charts are tools used for evaluating a child’s physical growth and development, and
they vary based on the child’s age and sex. Table 1 provides a summary of some
definitions of overweight and obesity in children that have been used in studies
conducted on Saudi children.
The 2006 WHO growth charts were developed for children under 5 years of age,
using data collected from the WHO Multicentre Growth Reference Study (2006).
The WHO Multicentre Growth Reference Study followed the growth of infants and
children (0–5 years) from six cities in different countries, including one Arabic
country (Oman). Overweight or obesity in children under 5 years is determined
using the weight-for-height 2006 WHO growth standards as shown in Table 1. For
children over 5 years, the WHO created growth references in 2007 that were
constructed using the original sample used in developing the 1977 National Center
for Health Statistics (NCHS)/WHO international growth reference, taking into
consideration data from the 2006 WHO growth standards to provide a smooth
transition between the under 5-year growth standards and the 5–19 years growth
reference (de Onis et al. 2007). Overweight or obesity in children over 5 years is
determined using the BMI-for-age 2007 WHO growth reference as shown in Table 1.
The US Centers for Disease Control (CDC) has developed growth charts for two
age groups: birth to 24 months and 2–20 years. The CDC currently recommends the
use of the WHO growth standards for children under the age of 2 years (Center for
Chronic Disease Prevention 2000). For ages 2–20 years, the CDC has developed the
Table 1 Definition of overweight and obesity in children based on BMI

Age group Overweight Obesity
WHO 2006 (WHO <5 years Weight-for-height greater Weight-for-height greater
Multicentre Growth than 2 standard deviations than 3 standard deviations
Reference Study above the WHO Child above the WHO Child
Group 2006) Growth Standards median Growth Standards median
WHO Growth 5–19 years BMI-for-age greater than 1 Greater than 2 standard
Charts (de Onis standard deviation above deviations above the WHO
et al. 2007) the WHO Growth Growth Reference median
Reference median
CDC Growth 2–20 years BMI-for-age ¼ 85th–< BMI-for-age 95th
Charts (Center for 95th percentile percentile, or BMI
Chronic Disease 30 kg/m2 whichever
Prevention 2000) smaller
Saudi Growth 0–18 years BMI-for-age percentile BMI-for-age percentile
Charts (Al Herbish >85th–<95th centile >95th centile
et al. 2009)
IOTF (Cole and 2–18 years Age- and sex-specific BMI Age- and sex-specific BMI
Lobstein 2012) cutoff pointsa correspond to cutoff pointsa correspond to
an adult BMI of 25 kg/m2 an adult BMI of 30 kg/m2
BMI body mass index, WHO World Health Organization, IOTF International Obesity Task Force,
CDC US Centers for Disease Control
a
For children younger than 2 years, the indicator is weight-for-length
BMI-for-age charts for males and females based on anthropometric measurements

performed between 1963 and 1994 on nationally representative samples from the US
population. The International Obesity Task Force (IOTF) used a different approach
than the WHO and the CDC for creating growth charts to define overweight and
obesity. The adult BMI cutoffs were used to develop corresponding age- and sex-
specific BMI cutoffs in children using data obtained from six large nationally
representative cross-sectional surveys on growth from Brazil, Great Britain, Hong
Kong, the Netherlands, Singapore, and the USA (Cole et al. 2000; Cole and Lobstein
2012). Recent Saudi guidelines on the prevention and management of obesity
suggest the use of Saudi Growth Charts (Obesity Control Program 2016), but
these charts are not commonly used by clinicians and researchers to define over-
weight and obesity in children. The charts were created in 2007 based on data
collected from 35,275 full-term and healthy children and adolescents from the 13
regions of the KSA (El-Mouzan et al. 2007; Al Herbish et al. 2009). The charts were
developed for two age groups: birth to 36 months and 2–18 years.
Although BMI is widely used to measure obesity in population-based studies and
clinical practice, it does not take into consideration differences in body composition.
The BMI is calculated from total body weight without distinction between fat mass
and lean (muscle) mass or body fat distribution, and there are no ethnic-specific
cutoffs (Mahan and Escott-Stump 2008). Obesity by definition is the increase in fat
mass that imposes health risk. Regional distribution of body fat is also an important
factor to consider when assessing obesity-related health issues. There are two major
types of fat deposition: the android “apple-shape” and the gynoid “pear-shape.”
Android obesity is characterized by excess subcutaneous fat on the trunk/abdominal
region and is more common in males, while gynoid fat distribution is characterized
by excess fat in the thighs and buttocks and is more common in females (Mahan and
Escott-Stump 2008). The android type of obesity is more often associated with
metabolic disturbances (such as glucose intolerance, hypertension, and hyperlipid-
emia) than the gynoid type in both adults and children (Daniels et al. 1999; Hamdy
et al. 2006; Mahan and Escott-Stump 2008). Simple methods of measurement such
as waist circumference, skinfold thickness, and calculation of waist-to-hip circum-
ference ratio are available to estimate body fat and body fat distribution (Mahan and
Escott-Stump 2008). Waist circumference is the most practical surrogate indicator of
abdominal fat and one of the best anthropometric predictors of cardiometabolic risk
(Janssen et al. 2002; Wang et al. 2005), and healthy ranges based on sex and
ethnicity have been established (Leiter et al. 2011). However, the use of waist
circumference to predict cardiometabolic dysfunction still has some limitations, as
it cannot distinguish between visceral and subcutaneous adipose tissue. Visceral
adipose tissue is the fat that surrounds abdominal organs such as the liver, kidneys,
and pancreas and is associated with greater cardiometabolic risk (Hamdy et al.
2006), whereas subcutaneous adipose tissue is the fat located between the skin and
muscles. Skinfold measurement is the most widely used method to estimate percent
body fat. Although skinfold thickness provides an indirect estimate of total body fat,
it is inexpensive and easy to use in clinical settings (Lee and Nieman 2013). There
are also more accurate, but complex and expensive, techniques to assess body
composition and fat distribution, such as magnetic resonance imaging, bioelectrical
impedance analysis, dual-energy X-ray absorptiometry machines, and computed
tomography (Lee and Nieman 2013). Although these instruments are not easily
available in clinical settings, studies in Saudi children using more advanced tech-
niques to assess body composition are warranted.
Prevalence of Overweight and Obesity Among Saudi Children
The prevalence of obesity and overweight among children and adolescents has
increased at an alarming rate in recent years in Saudi Arabia, making it one of the
Middle Eastern countries that has the highest rates of overweight and obesity (NCD
Risk Factor Collaboration 2017). The WHO has issued data in its Global Health
Observatory on the prevalence of overweight/obesity between 1975 and 2016
among both adults and children, using data from several countries including the
KSA (World Health Organization 2017b). In 2010, the rates of overweight and of
obesity in Saudi children (5–19 years) were 31.6% and 14.3%, respectively. In 2016,
the rates of overweight and of obesity in Saudi children (5–19 years) increased to
35.6% and 17.4%, respectively (World Health Organization 2017b). The rates of
overweight and obesity in Saudi children are shown in Figs. 1 and 2, respectively, for
both females and males, from 2010 to 2016 (World Health Organization 2017b).
45
40
35
30
Percent
25
20
15
10
0
2010 2011 2012 2013 2014 2015 2016 2010 2011 2012 2013 2014 2015 2016
5 - 9 years 10 - 19 years
Both Male Female
Fig. 1 The WHO estimates of the prevalence of overweight among Saudi children 2010–2016.
Overweight was estimated using the BMI greater than 1 standard deviation above the median,
according to the WHO child growth standards (World Health Organization 2017b)
A summary of studies since 2010, conducted on apparently healthy male and

female children in Saudi Arabia from different regions, and the criteria used to
define overweight and obesity, is provided in Table 2. Most studies in Saudi Arabia
since 2010 defined obesity and overweight using the CDC or the recent WHO
criteria. Other studies have used the IOTF criteria, and a few studies have used the
Saudi BMI percentiles to define overweight or obesity in children. One study did
not specify which standard was used. A survey published in 2010, conducted on
a national representative sample, reported that the overall rates of overweight
and obesity among children (5–18 years) were 24% and 9%, respectively,
using the 2007 WHO reference (El Mouzan et al. 2010). However, the
rates were slightly lower when the CDC criteria were used (Table 2). The
same survey reported lower rates of overweight and obesity among younger
children (5–12 years) compared to older children (13–18 years), regardless of
the reference used to define overweight or obesity (El Mouzan et al. 2010).
Similarly, a survey of different regions that included younger children
reported that the prevalence of obesity was 6% in children 2–<6 years compared
to 8% and 11% in children 6–<13 years and 13–18 years, respectively (El Mouzan
et al. 2012). This is in line with other studies that reported lower rates of obesity
among younger children (Al Alwan et al. 2013; Al-Muhaimeed et al. 2015;
25
20
15
Percent
10
0
2010 2011 2012 2013 2014 2015 2016 2010 2011 2012 2013 2014 2015 2016
5 - 9 years 10 - 19 years
Both Male Female
Fig. 2 The WHO estimates of the prevalence of obesity among Saudi children 2010–2016. Obesity
was estimated using the BMI greater than 2 standard deviation above the median, according to the
WHO child growth standards (World Health Organization 2017b)
Elkhodary and Farsi 2017; Al-Hussaini et al. 2019), but the WHO data illustrated
in Fig. 2 show a different pattern, as children 5–9 years seem to have a higher rate
of obesity than children 10–19 years.
Data from a national survey published in 2010 show that the rate of obesity was
6% in adolescents using the CDC criteria and 9% using the WHO criteria (El
Mouzan et al. 2010). A subsequent national survey published in 2015 on adolescent
students (n ¼ 12,575 students) reported that 16% of adolescents were obese and 14%
were overweight (AlBuhairan et al. 2015), suggesting an increase in the rate of
obesity in adolescents. However, another survey published in 2012 that covered
seven regions of the country reported a much lower prevalence of obesity: 11% of
adolescents (13–<18 years) were obese, whereas 25% were overweight (El Mouzan
et al. 2012). In this 2012 survey, overweight was defined as BMI-for-age >85th
centile without specifying the end of the overweight range at <95th centile in the
CDC charts, suggesting that the 25% included both overweight and obesity (El
Mouzan et al. 2012). Accordingly, the actual prevalence of overweight was 14%,
after excluding the 11% obese adolescents, which is similar to the 2015 survey
(AlBuhairan et al. 2015). It is important to note that data in the earlier survey (El
Mouzan et al. 2012) were collected between 2004 and 2005 and did not include
some of the more urbanized regions in the KSA, such as the western and eastern
regions, which were reported to have high rates of overweight and obesity (Al-
Hazzaa et al. 2014). A survey from three major urbanized cities in the KSA (Riyadh,
Jeddah, and Al Khobar) reported a slightly higher prevalence of obesity (19%) and
overweight (20%) among adolescents (Al-Hazzaa et al. 2014). It appears that
1162
Table 2 Summary of recent published studies on the prevalence of overweight and obesity in Saudi Arabia
Classification Overweight (%) Obesity (%)

Study/author Region/city Population Setting method All M F All M F
El Mouzan et al. Seven regions n ¼ 11,112 (49.4% girls) House visits CDC 18.2 17.6 18.8 8.1 8.6 7.7
(2012) Age: 2–17 years
Al-Hussaini Riyadh n ¼ 7931 (67% girls) Schools WHO 2007 13.4 12.0 14.2 18.2 18.4 18.0
et al. (2019) Age: 6–15 years
AlBuhairan et al. National n ¼ 12,575 (49% girls) Schools CDC 14.1 13.9 14.5 15.9 20.2 11.0
(2015) Age:
Mean SD ¼ 15.8 3.4 years
Al-Hazzaa et al. Riyadh, Jeddah, n ¼ 2881 (52% girls) Schools IOTF 20.2 19.5 20.8 19.1 24.1 14.0
(2014) and Al Khobar Age: 14–19 years
El Mouzan et al. National n ¼ 19,317 (49% girls) House visits WHO 2007 23.9 22.4 23.8 9.3 10.6 8.5
(2010) Age: 5–18 years CDC 20.4 20.3 20.4 5.7 6.6 4.7
Al-Muhaimeed Qassim region n ¼ 601 (31% girls) Schools IOTF 19.1 12.0 26.1 – – –
et al. (2015) (Buraidah and Age: 6–10 years
Unaizah)
Al-Dossary et al. Alkhobar n ¼ 7056 (44.3% girls) Private CDC 19.2 18.0 20.3 22.9 26.4 19.3
(2010) Age: 2–18 years school and
hospital
El-Sayed El- Shaqra n ¼ 200 (all girls) Schools Not specified – N/A 13.5 – N/A 11.0
Sayed Amr et al. Age: 12–20 years
(2012)
Al-Nakeeb et al. Al-Ahsa n ¼ 1118 (48%) Schools IOTF 18.2 16.9 19.5 18.3 19.5 17.1
(2012) Age:15–17 years
A. M. Aljaadi and M. Alharbi
45
Mahfouz et al. Abha and Ahad n ¼ 1869 (33.2% girls) Schools NCHS/WHO 13.5 11.5 15.5 12.9 11.8 13.9
(2011) Rufeida Age: 11–19 years 1995
Al Alwan et al. Riyadh n ¼ 1212 (57.8% girls) Schools WHO 2007 21.4 21.5 21.3 13.4 17.4 9.3
(2013) Age: 6–16 years
Alazzeh et al. Hail region n ¼ 1495 (all boys) Schools WHO 2007 – 21.3 N/A – 27.0 N/A
(2018) Age: 12–19 years
Al-Hussein et al. Riyadh n ¼ 2149 (47% girls) Schools CDC 13.8 12.1 15.7 14.8 14.2 15.5
(2014) Age: 6–17 years
Elkhodary and Jeddah n ¼ 1523 (49.2% girls) Schools Saudi growth 16.9 16.3 17.6 20.7 25.8 15.6
Farsi (2017) Age: 7–19 years reference
Farsi and Jeddah n ¼ 801 (52% girls) Schools Saudi growth 16.0 18.0 14.0 25.8 51.0 0.5
Elkhodary Age: 15–18 years reference
(2017)
Al-Kutbe et al. Makkah n ¼ 266 (all girls) Schools CDC – – 12.8 – – 17.3
(2017) Age: 8–11 years
CDC Centers for Disease Control and Prevention, WHO World Health Organization, IOTF International Obesity Task Force, NCHS, National Center for Health
Statistics, y years
Overweight and Obesity Among Saudi Children: Prevalence, Lifestyle. . .
1163
differences in the prevalence of overweight and obesity in Saudi adolescents are

partially explained by variances in the definitions and differences in the regions
where the population was selected.
Regional Differences
The 13 administrative regions of the KSA are shown in Map 1. Cultural practices
differ among these regions. There are two studies published in the KSA since 2010
that explored regional variation in childhood obesity (El Mouzan et al. 2012; Al-
Hazzaa et al. 2014). The first survey compared central (Riyadh and Qassim),
southwest (Jizan and Asir), and northern (Hail, Jouf, and Northern Borders) regions
and reported a lower prevalence of overweight and obesity in the southwest regions
compared to central and northern regions; there were no significant differences
between central and northern regions in overweight or obesity rates (El Mouzan
et al. 2012). A second survey explored differences among three cities from the
Riyadh, Makkah, and eastern regions (Al-Hazzaa et al. 2014). All of these cities
are urban and highly populated. Although there were no significant differences in
prevalence of overweight/obesity among the three cities, abdominal obesity
Al-Jawf Northern Borders
Tabuk
Hail
Al-Qassim
Madinah
Riyadh Eastern Province
Makkah
Al-Bahah
Asir
Najran
Jizan
Map 1 Administrative regions of Saudi Arabia (GeoCurrents 2016)

(assessed by waist circumference and waist-to-hip ratio) was different among the
adolescents (14–19 years) from these cities; post hoc analyses were not conducted,
but abdominal obesity appeared to be highest among females in Jeddah (Makkah
region) (Al-Hazzaa et al. 2014).
Five individual studies conducted in central regions (Riyadh and Qassim) from
2010 to 2019 reported an average of 28% for both overweight and obesity (El-Sayed
El-Sayed Amr et al. 2012; Al Alwan et al. 2013; Al-Hussein et al. 2014; Al-
Muhaimeed et al. 2015; Al-Hussaini et al. 2019). The lowest prevalence of over-
weight and obesity occurred in the central regions as reported in a study conducted in
two cities, Buraidah and Unaizah (Qassim region); the prevalence of overweight was
12% for males and 26% for females (Al-Muhaimeed et al. 2015); the authors did not
state the prevalence of obesity, but proportions reported appear to include both
overweight and obesity rates. The low prevalence might be due to the younger age
of the children (6–10 years) or perhaps because it was the only study of the five that
used the IOTF definition (Al-Muhaimeed et al. 2015). The prevalence of overweight/
obesity has been reported to be lower when using the IOTF definition compared to
the use of definitions by the CDC and the WHO (Hammad and Berry 2017).
A study carried out in 2002 showed that the eastern region had the highest
percentage of obesity and overweight among male children and adolescents:
27.4% of boys were overweight and 10.4% were obese, compared to 12% and
6.1%, respectively, in western regions (El-Hazmi and Warsy 2002). However, the
current prevalence of overweight and obesity in western and eastern regions has
become comparable. Two recent studies conducted in Jeddah (Makkah region)
reported an average of 40% of overweight and obesity among male and female
children (Farsi and Elkhodary 2017; Elkhodary and Farsi 2017). One of the studies
included a wider age range and reported that 18% of the children (7–10 years) and
16% of the adolescents (15–19 years) were overweight (Elkhodary and Farsi 2017).
A similar rate was reported for obesity among the children (18%), but there was a
higher rate among the adolescents: 23% were classified as obese (Elkhodary and
Farsi 2017). A second study was conducted by the same research group and included
adolescents only, which partially explains the higher overall prevalence of obesity
(25% vs. 21%) (Farsi and Elkhodary 2017). These are the only two studies in Table 2
that reported the prevalence of overweight and obesity using the Saudi growth
reference (Farsi and Elkhodary 2017). A third study conducted in Makkah city
included girls only (8–11 years) and reported a prevalence of 30% of overweight
and obesity, using the CDC charts (Al-Kutbe et al. 2017).
The two studies conducted on children in two cities in the eastern region of the KSA
reported an average prevalence of overweight and obesity of 39% (Al-Dossary et al.
2010; Al-Nakeeb et al. 2012). One of these studies included children 2–18 years and
reported that the rate of obesity among preschool students (20%) was lower than among
adolescents (27%) (Al-Dossary et al. 2010). However, the second of these two studies
included adolescents only and reported a lower prevalence of obesity (18%), using the
IOTF definition (Al-Nakeeb et al. 2012). In addition, the former study recruited children
from a private school and from an outpatient department of a private hospital (Al-
Dossary et al. 2010), which might explain the generally higher rates reported.
Some studies were conducted in cities from other regions, such as the Asir and
Hail regions. The study conducted in Abha and Ahad Rufeida cities (Asir region)
reported the lowest prevalence of overweight and obesity (26%), despite the fact that
only adolescents were included (Mahfouz et al. 2011); these cities are generally less
urbanized. The only study conducted in the Hail region included male adolescents
from 12 schools and reported the highest prevalence of overweight and obesity
(48%) of all the studies shown in Table 2 (Alazzeh et al. 2018). The high prevalence
of overweight/obesity in the Hail region is concerning and requires further
investigation.
Sex Differences
Contrary to data reported on Saudi adults (World Health Organization 2018), the
rates of both overweight and obesity in Saudi children appears to be higher for males
than for females. According to data from the WHO, boys have higher rates of
overweight and obesity than girls in Saudi Arabia, as shown in Figs. 1 and 2. For
example, the prevalence of overweight among Saudi boys aged 5–9 years was 40%,
while the prevalence among girls of the same age was 33% (World Health Organi-
zation 2017b). Similarly, the obesity prevalence among Saudi boys aged 5–9 years
was 21%, while the prevalence among girls of the same age was 15% (World Health
Organization 2017b). Other discrepancies in rates between boys and girls have been
reported: a survey on a national sample of Saudi children 5–18 years published in
2010 reported that the rates of overweight were higher among girls than boys,
whereas the pattern for obesity was similar to the WHO findings (i.e., obesity rates
were higher among boys than girls) (El Mouzan et al. 2010). Other studies that
addressed sex differences in overweight among children reported higher rates of
overweight in females than in males (Al-Muhaimeed et al. 2015; Elkhodary and
Farsi 2017; Al-Hussaini et al. 2019), whereas sex differences in obesity are consis-
tent with the WHO data that reports higher rates of obesity in male children (Al-
Dossary et al. 2010; Al-Hussein et al. 2014; Elkhodary and Farsi 2017).
Health Impacts of Overweight and Obesity in Saudi Children
There is a greater likelihood of developing chronic diseases in individuals with

obesity. An estimated 39% of deaths among adults worldwide in 2015 (four million
deaths) were attributable to overweight and obesity (The GBD 2015 Obesity Col-
laborators 2017). A pooled analysis of 97 prospective cohorts on adults found that
both overweight and obesity were associated with higher risk for coronary heart
disease and stroke than that of normal weight individuals (Lu et al. 2014). Several
adult diseases and their risk factors originate in early life, and strategies for preven-
tion and treatment should ideally target both children and adults (World Health
Organization 2016).
Although several studies have assessed cardiometabolic risk factors in Saudi

children (El-Hazmi and Warsy 2001; Mahfouz et al. 2012; Alkahtani 2015; Al-
Daghri et al. 2016), very few have studied these outcomes in relation to overweight
and obesity. The term “cardiometabolic risk” covers a wide range of risk factors for
the development of type II diabetes mellitus as well as cardiovascular disease (Leiter
et al. 2011). Important elements of increased cardiometabolic risk include abdominal
obesity, smoking, insulin resistance, high blood pressure, high low-density lipopro-
tein cholesterol (LDL-C), low high-density lipoprotein cholesterol (HDL-C), high
triglycerides (TG), high fasting blood glucose, and disturbed inflammatory profile.
Preventing or reducing these risk factors would result in a substantial reduction in the
burden of noncommunicable diseases, such as cardiovascular disease and type II
diabetes mellitus (Leiter et al. 2011).
A cross-sectional study on school children from ten schools in Riyadh (6–17 years;
n ¼ 2149) reported that 51.5% of the children had elevated blood pressure (>90th
percentile) and 13.6% had elevated TG 1.1 mmol/L; prevalence did not differ
between males and females (Al-Hussein et al. 2014). The study also reported that
elevated blood pressure was positively associated with quartiles of BMI and waist
circumference. It is not clear, however, whether single or multiple blood pressure
measurements were performed, if right or left arm was used for measurement, and
whether the children had time to rest prior to blood pressure measurements in this
study, so the findings should be interpreted with caution. Further, waist circumference
(>75th percentile, using US reference data (de Ferranti et al. 2004)) predicted elevated
TG 1.1 mmol/L in Saudi children after adjustments for age, sex, and activity level (it
was unclear how physical activity was determined) (Al-Hussein et al. 2014). The
prevalence of elevated fasting blood glucose (6.1 mmol/L) was <1%. Using the
CDC 2000 growth charts, there was no significant difference between males and
females in the prevalence of overweight (BMI-for-age 85th and <95th percentile)
and obesity (BMI-for-age 95th percentile) (Al-Hussein et al. 2014).
Another cross-sectional study of 542 Saudi children (4–17 years) from Riyadh
explored the relationship between adiposity indices (BMI and waist circumference) and
metabolic and hormonal markers (Al-Daghri et al. 2014). The study reported significant
differences in insulin resistance as estimated by homeostatic model assessment of insulin
resistance (HOMA-IR), LDL-cholesterol, HDL-cholesterol, TG, and systolic and dia-
stolic blood pressure between normal, overweight, and obese children (Al-Daghri et al.
2014). Further analyses showed that children with higher BMI had lower HOMA-IR,
indicating higher insulin resistance. Another study conducted on apparently healthy
adolescents (13–17 years; 1187 males and 1038 females) recruited from public and
private schools in Riyadh reported that nearly 20% of adolescents had elevated blood
glucose concentrations (5.6 mmol/L), over 60% had low HDL-C concentrations
(<1.03 mmol/L), and 15% had elevated TG concentrations 1.7 mmol/L (Al-Daghri
et al. 2015); over 30% of these adolescents were overweight or obese in the study, and
10% had abdominal obesity (>92 cm for boys and >86 cm for girls). The study did not
examine the association between overweight and obesity with the assessed
cardiometabolic risk factors, but higher BMI in males was associated with lower serum
25-hydroxyvitamin D, an indicator of vitamin D inadequacy (Al-Daghri et al. 2015).
Although not all individuals with obesity have metabolic complications, which is
partially attributed to lower visceral fat deposition (Karelis et al. 2004), this “healthy
obesity” phenotype may change over time and eventually lead to adverse health
outcomes. A study reported that metabolically healthy subjects with obesity had a
higher risk for cardiovascular events and all-cause mortality in the long term
(10 years), compared to subjects with healthy BMI (Kramer et al. 2013). There-
fore, tackling obesity as early as possible is critical for long-term health.
A review of three studies conducted on Saudi school boys (7–12 years) in Riyadh
reported that boys with fat 25% (measured or estimated from skinfold thickness)
had significantly higher mean systolic and diastolic blood pressure and TG com-
pared with boys with <25% fat (Al-Hazzaa 2002). Total cholesterol did not differ,
but boys with fat >25% had lower mean HDL-C concentrations than boys with
<25% fat. Altogether, these studies suggest a potential role of obesity in the
observed adverse cardiometabolic health of Saudi children. Other regions in the
KSA reported high rates of childhood obesity, but the lack of research from other
regions than Riyadh makes it difficult to draw definite conclusions. This emphasizes
the need for a national survey similar to that reported by AlBuhairan et al. (2015) to
explore the health outcomes of obesity in Saudi children.
Childhood obesity is also associated with sleep-disordered breathing, a term that
covers a range of conditions in which there are episodes of complete or partial
obstruction of the upper airway during sleep (Redline et al. 1999; Verhulst et al.
2008; Arens and Muzumdar 2010). Sleep-disordered breathing can affect a child’s
behavioral and emotional regulation, learning abilities, and alertness (Beebe 2006).
Sleep-disordered breathing is also associated with hypertension in children (Flynn
et al. 2017). A cross-sectional study conducted on 1350 Saudi children (6–12 years;
46% girls) reported that being overweight was positively associated with reported
sleep-disordered breathing; overweight children had significantly higher odds of
reporting sleep-disordered breathing symptoms compared to normal weight children
(adjusted OR ¼ 3.3; 95% CI, 2.1–5.2) (Baidas et al. 2019). It is not clear, however,
how overweight status was measured or defined in this study; and sleep-disordered
breathing was determined based on symptoms reported by parents using a question-
naire. Studies using objective tools to assess sleep-disordered breathing, such as
polysomnography, are warranted in Saudi children to provide more accurate results.
A cross-sectional study of 2868 adolescents (15–19 years) from three major cities
in Saudi Arabia (Al Khobar, Jeddah, and Riyadh) reported a higher prevalence of
short sleep duration among overweight or obese adolescents, compared to adoles-
cents with normal BMI, as determined by the IOTF age- and sex-specific BMI cutoff
reference standards (Al-Hazzaa et al. 2012). Similar results were reported in a study
that included younger Saudi children (10–19 years), and additionally more over-
weight and obese children reported sleeping intermittently rather than continuously,
suggesting lower sleep quality (Bawazeer et al. 2009). It is important to note that
short sleep duration and/or poor sleep quality are implicated in childhood obesity as
risk factors and as consequences of excess weight gain.
In addition to the adverse health outcomes of childhood obesity, several social
and psychological concerns related to overweight/obesity have been raised. In a
recent survey, nearly 45% of Saudi adolescents reported the need to lose weight,
suggesting a negative body image; these adolescents were more likely to feel sad and
hopeless (adjusted OR ¼ 1.38; 95% CI, 1.22–1.56) compared to those who reported
being happy with their bodies (Abou Abbas and AlBuhairan 2017). Evidence from
prospective studies suggests that obese adolescents (12–18 years), particularly
females, were at higher risk for anxiety disorders and major depressive disorders
later in life (Anderson et al. 2007). Overweight children (8–18 years) from ten
European countries scored lower in social acceptance and bullying dimensions,
suggesting an impairment in this domain of the health-related quality of life, than
normal weight children and adolescents, using a validated instrument in assessing
health-related quality of life (Ottova et al. 2012). A meta-analysis of cross-sectional
studies reported that bullying victimization was associated with higher likelihood of
being overweight or obese (OR ¼ 1.68; 95% CI, 1.21–2.33 and OR ¼ 1.78; 95% CI,
1.42–2.21, respectively) (Moore et al. 2017). However, the cross-sectional design of
most studies makes it challenging to distinguish whether bullying victimization is a
cause or a result of obesity in children.
There is no data on bullying in the KSA related to overweight or obesity, but
bullying rates in Saudi schools are not low. A national survey on Saudi adolescents
reported that 27% of male and 23% of female adolescents were exposed to bullying
during the past 30 days prior to administering the survey (AlBuhairan et al. 2015),
which is higher than the 21% reported by US adolescents (Lebrun-Harris et al. 2019)
and higher than the 19% reported by Australian children and adolescents (Jadambaa
et al. 2019). Data from the 2016 National Survey of Children’s Health in the USA
suggest that bullying victimization is higher among younger children (6–11 years)
than adolescents (12–17 years) (Lebrun-Harris et al. 2019). These differences in the
prevalence of bullying in children can be due to differences in the conceptual
definition of bullying or in the measurement approach.
Risk Factors of Childhood Obesity
Early-Life Factors
The etiology of obesity is still a highly active area of research as multiple factors are
believed to contribute to obesity, making it a complex phenomenon. Genetic,
environmental, and physiological influences play a causative role in obesity and
frequently interact with each other on many occasions (Mahan and Escott-Stump
2008). Growing evidence supports the role of developmental programming, which
suggests that maternal and early-life environmental stressors play a role in excess
weight gain later in life. These can drive an individual’s disposition to gain excess
weight and fat starting as early as in utero and within the first few years of life.
During pregnancy, maternal smoking habits, weight gain, and gestational diabetes
can have profound effects on the growing fetus, including the obesity risk. These
factors have not been studied in the Saudi population, but this does not rule out the
possibility that they are also contributors to childhood obesity in Saudi Arabia. In a
meta-analysis of 14 studies conducted in 84,563 children, mothers who smoked

during pregnancy had children with higher risk of being overweight (at ages
3–33 years) compared to children of mothers who were non-smokers (Oken et al.
2008). Although some studies found this association to be independent of the timing
of smoking exposure (Leary et al. 2006), other studies reported that smoking
throughout pregnancy was associated with higher risk of overweight in children in
comparison to smoking only during the early stages of pregnancy (Power and
Jefferis 2002; Chen et al. 2006).
Moreover, a prospective cohort study of pregnant women and their children
(1044 mother-child pairs) found that greater gestational weight gain was associated
with increased adiposity in children at 3 years of age, as determined by skinfold
thickness and BMI, regardless of factors such as maternal and paternal BMI,
breastfeeding duration, and infant growth (Schack-Nielsen et al. 2010). In this
study, mothers with excess gestational weight gain had children who were at four
times greater risk to be overweight at 3 years, compared to children of mothers who
gained inadequate weight during pregnancy, based on the 1990 Institute of Medicine
guidelines (Oken et al. 2007). The positive association between gestational weight
gain and offspring BMI has also been observed in adults at 42 years of age
(OR ¼ 1.08; CI, 1.03–1.14 per kg of gestational weight gain), as reported by the
Copenhagen Perinatal Cohort study (n ¼ 1540) (Schack-Nielsen et al. 2010).
In addition to the intrauterine environment, early-life influences can shape the
trajectory of weight gain and adiposity later in life. Birth weight and rapid weight
gain early in life are two examples of possible postnatal influences on obesity. Data
from the National Longitudinal Study of Adolescent to Adult Health revealed that
elevated birth weight (>4 kg) was positively associated with obesity later in life,
unlike normal birth weight in participants (2.5–4 kg) (The et al. 2010). Other
studies have reported a similar trend, but this association can be partially attributed to
confounding factors related to maternal characteristics, such as maternal obesity
(Fall et al. 1995; Curhan et al. 1996; Eriksson et al. 2001; Parsons et al. 2001; Loos
et al. 2002). Excess weight gain early in life was also reported to be associated with
developing further obesity and rapid weight gain (Singhal et al. 2010). In particular,
rapid weight gain during the first 3 months of life was positively associated with
central adiposity in early adulthood (Leunissen et al. 2009). There is a possibility that
increased weight gain in early childhood is only an early expression of obesity
phenotype as a result of genetic predisposition (Elks et al. 2010).
Lifestyle Factors
Even though genetics and environmental factors can lead to obesity, a genetic
element alone is unlikely to explain the rapid rise in the obesity rate in Saudi Arabia
(Mahfouz et al. 2011). Environmental factors have been widely studied and have
been suggested to play an important role in the current rise in the obesity rate
worldwide (Badran and Laher 2011). Several studies in Saudi Arabia have explored
a variety of obesity modifiable risk factors, such as sleep duration (Al-Hazzaa et al.
2012), physical activity (Al-Nuaim et al. 2012; Ahmed et al. 2016), screen time (Al-
Ghamdi 2013), socioeconomic factors (Alazzeh et al. 2018), and nutrition and food
choices (Farghaly et al. 2007; Mahfouz et al. 2011). The KSA has changed in many
aspects over the last three decades, including economic and social developments
such as an increased number of women entering the workforce, which has improved
people’s standard of living. However, this positive transformation in lifestyles has
also been associated with physical inactivity and an overall increase in the rate of
overweight/obesity (Al-Nuaim et al. 2012). The available evidence in the KSA has
mainly discussed physical activity and diet as risk factors for obesity in the region.
A study in Riyadh reported that 21% of adolescents (n ¼ 107) do not consume
fruits and vegetables daily, and 32% reported that they do not exercise daily, but
there was no significant association between the students’ BMIs and their lifestyles
and eating habits (Al-Muammar et al. 2014). However, a study on children from the
Qassim region reported that children who ate restaurant food 2 times per week
were 2.4 times more likely to become overweight (Al-Muhaimeed et al. 2015). In
addition, consumption of sugary drinks is associated with higher BMI in children
(12–16 years) from Riyadh (Alghadir et al. 2016) and in girls 8–11 years from
Makkah (Al-Kutbe et al. 2017). A recent review examined 23 studies published
between 2003 and 2016 on childhood obesity in the KSA (Hammad and Berry 2017)
and revealed that several factors related to eating habits and food choices have
contributed to the prevalence of obesity/overweight among children. For example,
skipping breakfast and the consumption of soft drinks and fast food were associated
with overweight and obesity. Specific risk factors for obesity identified in the review
included the amount of physical activity, frequency of skipping breakfast, consump-
tion of sugar-sweetened beverages, fruit and vegetable consumption, sweet and
candy consumption, and television watching (Hammad and Berry 2017). The review
stressed the urgent need to initiate interventions and national programs, especially at
the school level, to manage the obesity epidemic that the country is facing today
(Hammad and Berry 2017).
Physical activity is an important factor contributing to obesity, particularly in
children, and can be understood in terms of the average walking time spent per day
by individuals (Al-Nuaim et al. 2012) and average time engaging in exercise and
sports (Alazzeh et al. 2018). A study in Qassim region reported that children who
were engaged in sport activity 2 h per day were less likely to be overweight (Al-
Muhaimeed et al. 2015). A study of 1270 students (15–19 years; 48% girls) in the
eastern region reported a negative association between BMI and physical activity
among males only (Al-Nuaim et al. 2012). Similarly, a study in Makkah that
included girls only (8–11 years; n ¼ 78) reported no significant difference between
the number of average daily steps (using an accelerometer) and BMI categories, but
less than 10% of all the girls met the recommended 10,000–12,000 steps per day (Al-
Kutbe et al. 2017). Waist circumference has been reported to be inversely associated
with reported physical activity among both males and females in the eastern region
(Al-Nuaim et al. 2012). It is speculated that a cause of reduced engagement in
physical activity could be living in the desert where the weather is mostly extremely
warm during the summer and very cold and windy in winter. Lack of facilities and
equipment for exercise in different locations could also be a related issue. The lack of
physical activity in class was also associated with greater likelihood of obesity
among students (Mahfouz et al. 2011). Although several studies explored physical
activity as a risk factor for obesity in Saudi children, there is a lack of emphasis on
the role of schools in providing physical education.
Television viewing and the use of electronic devices are also implicated in
childhood obesity in the KSA (Al-Ghamdi 2013; Al-Agha et al. 2016; Alghadir
et al. 2016). Watching television could contribute to the increasing rate of over-
weight/obesity by replacing the time of physical activity and increasing food con-
sumption (Al-Agha et al. 2016; Alghadir et al. 2016). In a case-control study
investigating the association between watching television and obesity among 397
children (9–14 years; 50% girls) in Riyadh city, time spent watching television in the
weekend was associated with higher risk for obesity (Al-Ghamdi 2013). The study
also reported that children with obesity were more likely to watch television at night
(Al-Ghamdi 2013). However, the children whose mothers determined how much
television they could watch were less likely to be obese (Al-Ghamdi 2013). The
availability of television in the child’s bedroom has been also linked to increased risk
for obesity (Al-Ghamdi 2013). Children (12–16 years; n ¼ 214) who reported
watching television more than 2 h per day had higher BMI than those who watched
television less than 1 h per day (Alghadir et al. 2016). Similarly, children
(2–18 years; n ¼ 541) who spent 2 h daily on electronic devices had higher
BMI, although no relationship was observed between watching television and
BMI (Al-Agha et al. 2016).
Another lifestyle factor that has been studied in association with obesity/over-
weight in Saudi Arabia is sleep duration (Al-Hazzaa et al. 2012; Ahmed et al. 2016;
Al-Hazzaa and Albawardi 2019). A cross-sectional study that looked at the preva-
lence of short sleep duration in relation to overweight and obesity was conducted on
2868 students (51.9% females) in 3 cities (Al Khobar, Jeddah, and Riyadh) in 3
different regions in Saudi Arabia (Al-Hazzaa et al. 2012). The study reported that the
average sleep duration among Saudi adolescents was 7.2 h per day, and 50% of the
participants had less than 8 h per day, which was lower than the average sleep hours
per day in other countries such as Germany, India, and Australia. The higher
prevalence of short sleep duration per day was associated with a risk of increased
overweight and obesity among students (Al-Hazzaa et al. 2012). A similar result was
reported in a study conducted on students (10–19 years) in Riyadh city, which
showed that sleeping 7 h per day or less was associated with a higher risk of
overweight and obesity (Bawazeer et al. 2009). A recent study also reported a
positive association between obesity and sleeping <6 h per day (Alazzeh et al.
2018). Even though several studies reported a relationship between short sleep
duration and the risk of overweight and obesity, the reasons for this relation are
still under investigation by researchers in the KSA.
Currently, more studies are attributing changes in sleep patterns to the increased
rates in overweight and obesity in Saudi Arabia. With regard to irregularity in
sleeping patterns as a factor in rising levels of overweight and obesity, modern
lifestyles provide access to television, smartphones, and video games around the
clock for children, which can seriously affect their sleep health. This is of particular
importance in the KSA, where schools start at 7 am and have a high demand for
schoolwork. Having a lot of homework can keep students working late rather than
going to bed early, which also results in reduced sleep time at night (Al-Hazzaa et al.
2012; Al-Hazzaa and Albawardi 2019).
There is an association between the prevalence of overweight/obesity and a
family’s socioeconomic status in the KSA (Al Alwan et al. 2013; Alazzeh et al.
2018). A study in Jeddah reported that obesity was more prevalent in students
attending private schools than those attending public schools (Farsi and Elkhodary
2017). Similarly, a study on adolescents from three cities reported a higher preva-
lence of obesity and abdominal obesity (based on waist-to-hip ratio) among students
from private schools compared to students from public schools (Al-Hazzaa et al.
2014). Attending a private school in the KSA is linked to higher socioeconomic
status and fewer restrictions on food choices. A study in children from Riyadh
reported that children were more likely to be overweight when their families had
higher incomes and when their mothers had higher levels of education (Al Alwan
et al. 2013). A cross-sectional study in the Hail region reported a positive association
between working mothers and obesity in their children (OR ¼ 1.43; 95% CI, 1.03–
1.99) (Alazzeh et al. 2018). The authors argued that in recent years, obesity resulted
from different factors, including the change in the number of educated and working
mothers, since working women may need to eat away from home and spend less time
on healthy food preparation at home, which could influence a child’s weight. The
authors suggested that working mothers reflected the change that is happening in
Saudi society and ties in with the government orientation of setting a strategy to be
one of the strongest economies by 2030 by increasing the number of women in the
workforce by 22–30%.
Conclusions
The prevalence of childhood obesity in the KSA has increased in the past three
decades and is still on the rise. Several health groups in the KSA recognize the
increased rate of obesity and its associated health consequences. The cause of
overweight and obesity among children can be a contentious issue in the KSA:
while some point to the connection between overweight/obesity and sedentary
lifestyles, other advocacy groups pace the widespread consumption of fast food
and junk food consumption by children as the main culprit. Although there are
different factors being studied to understand the rapid increase in obesity and
overweight among children, there is a lack of in-depth research in Saudi Arabia;
there are few qualitative studies that explore eating habits and physical activity in
association with childhood obesity. There are rapid changes in family and individual
lifestyles in today’s society in the KSA, including changes in food preparation,
marketing, and choices. Regardless of the outcomes of the debate over what causes
obesity and overweight and how these factors play a role in the prevalence of obesity
and overweight among children, it is important to mention the need for creating
awareness among parents and children in schools and beyond schooling. Given the
significant amount of time spent in schools, health education in schools should
advocate for a healthy lifestyle among the young generation. Health education
programs in schools have the potential to control the obesity epidemic in children
by empowering children to establish healthy eating habits and to be physically active
(World Health Organization 2016). The Ministry of Health in Saudi Arabia released
the Saudi Guidelines on the prevention and management of obesity in 2016, with an
emphasis to start weight management as early as possible (Obesity Control Program
2016). Further, a program named Rashaka (an Arabic word for fitness) has been
launched (Al Eid et al. 2017), and it has been introduced to some schools in the
country. Hence, beyond the current attempts to face the issue of overweight and
obesity, there is a need to promote for these programs among the youth and to
monitor their effectiveness.
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Part VI
Mass Gatherings and Infectious Diseases
Health Issues of Mass Gatherings
in the Middle East 46
Amani Salem Alqahtani, Amal Mohammed Alshahrani, and
Harunor Rashid
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1184
Hajj Pilgrimage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1186
Hajj Rites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1186
Circumambulation of the Ka’abah . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1186
Mina Stay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1188
Arafah Daylong Stay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1188
Stopover at Muzdalifah . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1189
Jamarat Stoning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1189
Shaving Hair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1189
Other Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1189
Health Risks at Hajj . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1191
Health Risks at Ashura and Arbaeen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1191
Health Risks of Aqaba Gathering . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1192
Health Risks of the Sixth Francophone Games in Lebanon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1193
Health Risks of Other MGs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1193
Healthcare at MGs in the Middle East . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1193
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1195
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1195
A. S. Alqahtani
Saudi Food and Drug Authority, Riyadh, Saudi Arabia
e-mail: amani.shelwa@gmail.com
A. M. Alshahrani
Armed Forced Hospitals Southern Region, Khamis Mushayt, Saudi Arabia
e-mail: amal.jrais@gmail.com
H. Rashid (*)
National Centre for Immunisation Research and Surveillance (NCIRS), The Children’s Hospital at
Westmead, Westmead, NSW, Australia
The Discipline of Child and Adolescent Health, Faculty of Medicine and Health, Sydney Medical
School, University of Sydney, Sydney, NSW, Australia
e-mail: harunor.rashid@health.nsw.gov.au

https://doi.org/10.1007/978-3-030-36811-1_46
1184 A. S. Alqahtani et al.
Abstract
The Middle East is host to some of the world’s most crowded mass gatherings
(MGs) including Hajj and Arbaeen pilgrimages. These MGs can strain the health
system of the host countries and at the same time can pose significant threat to
global health security through the spread of infectious agents with epidemic
potential. Large intercontinental outbreaks of meningococcal disease in recent
past are a testament to this fact. A range of viral and bacterial infections of the
upper and lower respiratory tract can occur during Hajj and Arbaeen, and the risk
of diarrhea, a common travel morbidity, increases significantly at Arbaeen and to
a smaller extent at Hajj. Stampedes with high fatalities have occurred in those
gatherings. The risk of health hazards can be minimized by following host
country’s guidance that include stringent compliance with vaccination recom-
mendations, food and water safety practices, adhering hygienic principles,
maintaining hydration, risk awareness and avoidance of high-risk behaviors
such as walking against the traffic in a crowded place or drinking raw camel milk.
Keywords
Arbaeen · Ashura · GITEX · Hajj · Makkah · Mass gathering · Middle East
Introduction
A mass gathering (MG) is defined as an event involving large number of participants

(1000) at a specific location for a specific purpose for a defined period of time.
Thus, a planned or unplanned large event is classified as MG if the number of people
attending is sufficient to strain the planning and response resources of the commu-
nity, state, or nation hosting the event (WHO 2016).
Health risks at MGs differ by types, e.g., every religious, cultural, sport, enter-
tainment, trade, social, educational, or political MG has distinctive features, and
attract attendees with certain common characteristics; consequently, their medical
risks vary. Some events occur regularly in the same location (e.g., Hajj pilgrimage),
some others take place regularly in different locations (e.g., Olympic Games, FIFA
World Cup), others irregularly at different locations (music events), and many other
MGs occur spontaneously (e.g., funeral event of an influential person, political
rallies, mass displacement due to natural or man-made disasters) (Memish et al.
2012, 2019).
The Middle East occupies a unique position in the world map because of its
pivotal role in geopolitics, trade, and religion. It gave birth to several mainstream
religions or their offshoots including Zoroastrianism, Judaism, Christianity, Islam,
Druze, Zaidism, Baha’ism, and several others. The region is a host to various MGs
(AlNsour and Fleischauer 2013; Memish et al. 2012); notable ones are listed in
46 Health Issues of Mass Gatherings in the Middle East 1185
Table 1. MGs in the Middle East can be roughly divided into four groups: religious
(e.g., Hajj, Arbaeen), cultural (e.g., camel festival in Riyadh), trade fair or expo (e.g.,
Saudi International Motor Show in Jeddah, Gulf Information Technology Exhibition
in Dubai [GITEX] in Dubai), or sport gatherings (e.g., Asian Football Confederation
[AFC] AFC Asian Cup 2011 in Qatar and the AFC Asian Cup 2019 in UAE).
Extreme crowding is considered to be the most important factor responsible for
amplified transmission of diseases at MGs; however, other factors such as close
contact, compromised hygiene, and the stress of travel may also play important roles
Table 1 Major mass gatherings (MGs) in the Middle East

MG
Comment Name of MG Country Attendance category
Religious Hajj Saudi Arabia 2–3 million Annual
pilgrimage
Ashura Iraq 5–6 million Annual
Arbaeen Iraq Up to 14 million Annual
Death anniversary of Iraq 5–6 million Annual
Imam al-Kadhim
Birthday of Imam Iran 5–6 million Annual
Muhammad al-Mahdi
Mohammed’s (BPUH) Egypt 3 million Annual
birthday celebration
Cultural King Abdulaziz Camel Saudi Arabia >300,000 Annual
Festival
Al Janadriyah Heritage Saudi Arabia >500,000 Annual
and Cultural Festival
Jerash Festival of Jordan 100,000 Annual
Culture and Arts
Religious Aqaba Eid Event Jordan 100,000 Annual
and cultural
Sport 2019 AFC Asian Cup UAE 650,000 One off
2011 AFC Asian Cup Qatar 400,000 One off
1988 AFC Asian Cup Qatar 300,000 One off
Arabian Gulf Cup Occurs across Arab 300,000 Biennial
states of the Persian Gulf
Expo GITEX UAE 150,000 Annual
Dubai International UAE >100,000 Annual
Motor Show
Tehran International Iran 2,000,000 Annual
Book Fair
Saudi International Saudi Arabia >100,000 Annual
Motor Show, Jeddah
Riyadh Motor Show Saudi Arabia 97,000 Annual
(Al-Tawfiq and Memish 2014). The participants are not only at risk of suffering from
endemic diseases of the host country which they can then return with to their home
countries but can also import endemic and epidemic diseases of their native countries
and may spread globally (Abubakar et al. 2012).
Hajj Pilgrimage
Hajj pilgrimage in Makkah, Saudi Arabia is the most notable MG in the Middle East.
Considered to be one of the five basic tenets of Islam, Hajj pilgrimage is obligatory
for every able adult practicing Muslim at least once in lifetime (Shafi et al. 2008).
Each year, over two million Muslims from around the world assemble in Makkah
(also spelled as Mecca) in Saudi Arabia, considered by Muslims as their holiest
place, to perform the pilgrimage. Hajj assembly takes place on specific dates of the
last month (called Dhul-Hijjah) of the Islamic lunar calendar year and advances by
10 or 11 days in the Gregorian calendar; thus Hajj date rotates across the seasons
(Gatrad and Sheikh 2005). In 2019, it took place during mid-August, and in 2020 it
will take place in late July.
Muslims have been gathering on Hajj since 632 AD (Memish 2018), when tens of
thousands of people were known to attend. In the past, pilgrims used to arrive at
Makkah on camels and donkeys or by ship after an arduous journey of months, if not
years. Since the advancement of air travel, the majority of international pilgrims and
a large proportion of domestic pilgrims travel by air; the ease and speed of travel
have made Hajj a highly crowded gathering (Memish and Ahmed 2002). In recent
decades, up to three million Muslims have attended Hajj each year from over
180 countries, and despite quota reduction since 2013, approximately 2.2 million
pilgrims have attended Hajj in recent years.
Hajj Rites
There are several major and minor rites of Hajj (Fig. 1) that are observed over
5–6 days, beginning on the eighth day of the Dhul-Hijjah month (the ninth lunar
month of the Arabic calendar) (Gatrad and Sheikh 2005). The rites of Hajj are
described below.
Circumambulation of the Ka’abah
On the first day of arrival, all male pilgrims don a pair of unstitched white sheets as a
symbol of denouncing the mundane world, and females wear simple plain garments
and then make seven circuits around the Ka’abah (Fig. 2), the huge cube-shaped
black monolith at the Holy Mosque (Step 1, Fig. 1). It may take between 1 and 4 h to
complete all turns depending on the length of the radius on which the circumambu-
lation progresses. Pilgrims also need to make similar circuits once more in the period
Fig. 1 The major rites of Hajj [the steps are shown in numbers in parenthesis (x) in chronological
order; Courtesy of Mr Kamil Rauf, Sydney, NSW, Australia]
Fig. 2 Pilgrims making circumambulations around the Ka’abah
mid-Hajj and immediately before departing from Makkah, amounting to at least

21 circuits by the conclusion of Hajj (Gatrad and Sheikh 2005). Respiratory illnesses
can spread very easily during this prolonged close contact in that semi-closed milieu
(Benkouiten et al. 2013b; Alqahtani et al. 2015).
Fig. 3 Mina tent city
Mina Stay
Following circumambulation pilgrims stay in the tents of Mina (Step 2 in Fig. 1), an
uninhabited valley several miles east of Makkah, for at least three to four nights
(Fig. 3). Each large tent accommodates as many as 100 to 150 pilgrims (Memish and
Ahmed 2002). Crowding and prolonged close contact among pilgrims in Mina
facilitate easy spread of respiratory infections. During their stay at Mina, many
pilgrims rely on prepared foods from vendors, resulting in an increased risk of
food-borne illnesses (Gautret et al. 2015). In addition, on day 3 of Hajj, pilgrims
are required to sacrifice quadruped animals such as sheep or camels. In modern days
this is done mostly by proxy at abattoirs, and the occupational workers can be at risk
of zoonotic diseases like brucellosis (Kalimuddin et al. 2010) (Almasri et al. 2019).
Arafah Daylong Stay
On the second day of Hajj, pilgrims travel to Arafah, also spelt as Arafat, (Step 3 in
Fig. 1), a nearby hillside and plain in Greater Makkah. They must reach Arafah by
the afternoon and stay until the sunset.
Stopover at Muzdalifah
After sundown on the second day, pilgrims head from Arafah to a place called
Muzdalifah (Step 4, Fig. 1) located between Mina and Arafah. They rest/sleep under
the sky in Muzdalifah for about 3–4 h in the open which is dusty.
Jamarat Stoning
For three consecutive days (third, fourth, and fifth day of Hajj), pilgrims perform the
stoning ritual at a place called Jamarat (Step 5, Fig. 1). They throw pebbles at a
symbolic pillar representing the devil. Because this ritual is performed within a
specified time, often it can be extremely crowded; consequently, several major
stampedes occurred in recent past resulting in large number of casualties (Alqahtani
et al. 2017; Alaska et al. 2017).
Shaving Hair
To mark the end of the main rituals of Hajj, male pilgrims shave their head or at least
trim it, and females cut short a single lock of hair. Saudi authorities require all
barbers serving the pilgrims to be licensed. However, many pilgrims use the services
of opportunistic unlicensed barbers in makeshift roadside salons, of whom an
estimated 10% are chronic carriers of hepatitis C and 4% are carriers of hepatitis B
(Rafiq et al. 2009; Ahmed et al. 2006). Pilgrims may also shave each other’s heads,
often by reusing razors. These practices place male pilgrims at risk of acquiring
blood-borne infections such as hepatitis B and C (Ahmed et al. 2006).
Other Activities
Although Hajj rituals are completed in 5–6 days, most overseas pilgrims stay in
Makkah for a month or longer. During this time pilgrims visit historical sites in
Makkah and perform supplementary rituals. These include additional circumambu-
lations around the Ka’abah and shaving their heads (or at least trimming hair) if they
have not already done so. A visit to the shrine of the Prophet Muhammad (peace be
upon him [PBUH]) in Madinah (also spelled Medina), north of Makkah, is not an
essential part of Hajj, but many pilgrims who can afford it make a weeklong visit to
the tomb.
Pilgrims who are not fortunate enough to make the Hajj trip can travel to Makkah
any time during the year on Umrah pilgrimage, but the peak time is in Ramadan
(Muslims’ fasting month) which attracts about four million visitors to Makkah but is
projected to rise to 30 million per year by 2030 (Memish and Ahmed 2002; Yezli
et al. 2017).
Table 2 Major health risks at Hajj

Health
condition Category Brief description
Infectious Respiratory Compared to community settings, the risk of respiratory
infections infection at Hajj increases by several folds. Both viral
(influenza, rhino, RSV, adeno) and bacterial
(pneumococcal, pertussis, and tuberculosis) infections
are common (Benkouiten et al. 2014, 2013a; Barasheed
et al. 2014; Alqahtani et al. 2015)
Gastroenteritis Diarrhea and food poisoning continue to occur among
pilgrims at a mean prevalence of 2% to 23% (Gautret
et al. 2015)
Meningococcal Brought largely under control (Wilder-Smith et al. 2010;
disease Memish et al. 2013), sporadic cases still occur (Zumla
and Memish 2019). Meningitis caused by other
organisms (e.g., pneumococcus) have been reported
(Madani et al. 2006)
Noninfectious Cardiac and vascular Cardiovascular diseases (including myocardial
events infarction) are the leading causes of ICU admission and
fatalities during Hajj (Al Shimemeri 2012). The
incidence of stroke at Hajj is estimated to be about
9/100,000 (Almekhlafi et al. 2017)
Renal disorders One-tenth of the hospitalized Hajj pilgrims suffer from
acute kidney injury (or acute renal failure). Those with
hypertension or diabetes are at higher risk (Elrewihby
et al. 2018)
Exacerbation of Acute severe asthma and uncontrolled diabetes or
pre-existing diseases hypertension are common at Hajj (Mirza et al. 2011;
Algeffari 2019). Poor compliance with medications is
the main reason (Algeffari 2019; Zhang et al. 2019)
Psychological Anxiety, mood disorders, insomnia, apprehension
disorders (of being lost), and even psychosis have been reported
among pilgrims, exclusively among first-time Hajj
attendees (Masood et al. 2007; Hankir et al. 2019)
Accidental Mass causalities Stampedes constitute the major bulk of these; building/
injuries crane collapse, blaze, and bomb explosion have been
reported (Alqahtani et al. 2017). The last major casualty
happened in 2015, thousands died (Khan and Noji 2016)
Other traumas Superficial cuts or burns and soft tissue contusion are
common injuries at Hajj. Limb fractures and head
injuries also occur often following major road traffic
accidents (Al-Harthi and Al-Harbi 2001)
Infectious and Skin diseases Dermatological conditions account for about 5% of all
noninfectious diseases seen during Hajj (Mimesh et al. 2008);
dermatitis, intertrigo, pyoderma, and fungal infections
are the common ones (Samdani 2004)
Foot wounds Blisters and sore feet are common among diabetic and
nondiabetic pilgrims (Alfelali et al. 2014; Sridhar et al.
2015)
Health Risks at Hajj
Health risks at Hajj can be divided into three groups: (1) infectious, (2) noninfectious,
and (3) injuries, including mass casualties (Table 2). Infectious diseases include
respiratory viral and bacterial infections, meningococcal diseases, gastroenteritis,
and food poisoning; noninfectious diseases include exacerbation of bronchial
asthma, diabetes mellitus, cardiovascular events, and mental disorders. Stampedes
are the most notable mass causalities at Hajj (Khan and Noji 2016; Alqahtani et al.
2017). This is an arbitrary classification; some illnesses at Hajj have both infectious
and noninfectious components (e.g., certain dermatological conditions or foot
wounds) (Mimesh et al. 2008; Alfelali et al. 2014).
Health Risks at Ashura and Arbaeen
Muslims, mostly Shiites, assemble in Karbala, Iraq, in Muharram, the first month of
Arabic calendar, to celebrate Ashura, a mourning event to commemorate the mar-
tyrdom of Hussein ibn Ali, the grandson of the Prophet Muhammad (PBUH) at the
Battle of Karbala in 680 AD. Visiting the shrine of Hussein is the key part of the
event (Fig. 4). It is followed by a 40-day period of mourning. The “Arbaeen” marks
the end of this 40-day period attracting millions of pilgrims from inside and outside
Iraq. A procession on foot for about a 100 km to Karbala is a unique part of this
pilgrimage. About 14 million people from 60 countries are known to attend Arbaeen.
Unlike Hajj, literature on the health risks of Arbaeen is scanty. From the available
data, the risks seem to be similar to that of Hajj with respiratory infections being the
dominant cause of healthcare visits (Lami et al. 2019a), but the pattern of hospital-
izations, however, seems to be different with cardiovascular diseases being the
leading cause of hospital admission at Arbaeen, while pneumonia is the leading
cause of hospitalization at Hajj (Sadeghi et al. 2015; Madani et al. 2006); neverthe-
less cardiovascular diseases are the leading causes of intensive care unit (ICU)
admission and fatalities during Hajj (Al Shimemeri 2012).
During the 2010 Ashura day, a sevenfold increase in emergency room (ER) visit
for febrile disorders and twofold increase for chronic diseases and injuries were
noted during the event compared to the baseline activity in ER (Al-Lami et al. 2013).
A larger cross-sectional survey conducted in 2014 showed 5% attendees had com-
municable disease syndromes: fever and cough (42%), acute diarrhea (29%),
vomiting with/without diarrhea (27%), and blood-stained diarrhea (2%) (Lami
et al. 2019a). In the same year, daily average for noncommunicable disease (NCD)
emergencies increased by fourfold during the event with twofold increase in ische-
mic heart disease and asthma and a threefold increase in severe hypertension and
diabetes complications (Lami et al. 2019d). A subsequent survey showed about 59%
pilgrims visit health centers for acute or infectious conditions, 33% for chronic
conditions, 24% for injuries, and 28% for joint pains (Lami et al. 2019c).
Fig. 4 The shrine of Hussein ibn Ali in Karbala [Courtesy of Mr Mustafa Alansari, Sydney, NSW,
Australia]
The attack rate of influenza among Iranian pilgrims returning from Karbala was
14% in the years 2013–2016; this compares with the attack rate of 12% among
Iranian pilgrims returning from Mecca and of 9% among Iranian general population
(Yavarian et al. 2018; Gautret 2018), indicating a higher risk of influenza acquisition
at Karbala than in community setting or even Mecca pilgrimage (Gautret 2018).
Several cases of hepatitis A among Iranian pilgrims have been attributed to Karbala
attendance (Ghasemian et al. 2016).
Stampedes also occurred at Karbala. In 2019, at least 31 people have died and
hundreds injured in a stampede incident in Karbala (Anon. 2019).
Health Risks of Aqaba Gathering
Aqaba in Jordan is a yearly cultural-religious gathering corresponding with Eid-al-

Adha (as well as Hajj) where about 100,000 people attend. A cross-sectional
surveillance study carried out 14 days before, during, and 10 days after the
“Aqaba 2010” event showed that the number of drownings increased from 0 in the
previous week to 7 during the event and injuries by marine creatures increased from
0 before to 22 during the event and there was a more than threefold increase in road
traffic accidents during the event (Abdullah et al. 2013).
Health Risks of the Sixth Francophone Games in Lebanon
In 2009, Lebanon hosted the Sixth Francophone Games from 27 September to

6 October amidst the global pandemic influenza. About 3000 artists and athletes
from 46 countries and many more local and international spectators attended. About
3000 medical consultations were reported during the event, 29% of which related to
infectious diseases including 10 cases of acute respiratory infections but no case of
influenza A(H1N1)2009 and another 23 cases of gastroenteritis (Haddad et al. 2017).
Health Risks of Other MGs
In 2005, about 1000 people died following a stampede on Al-Aaimmah bridge,

which crosses the Tigris River in the Iraqi capital of Baghdad during an assembly to
celebrate the death anniversary of Imam Musa al-Kadhim (Worth 2005).
The King Abdulaziz Camel Festival in Riyadh attracts on average about 300,000
visitors (may be up to two million over 1 month) and brings them in close proximity
to camels increasing the risk of zoonotic diseases. A health emergency risk assess-
ment conducted in 2017 identified both zoonotic, foodborne illnesses, bites, and
trauma to be important public health hazards of the event (Bieh et al. 2019).
Qatar is hosting the FIFA 2022. It will be the first time football’s biggest tourna-
ment will be held in the Middle East. One million international visitors and many more
local visitors from the Gulf countries are expected to attend the games. An external
evaluation carried by a World Health Organization (WHO) team identified rooms for
improvement in Qatar’s capacity to fight antimicrobial resistance, real-time detection
of a disease signal, and its ability and agility to respond to the signal, but Qatar is
stepping up global health security (Bala et al. 2017) and has already shifted the event
date from typical June to July timeframe to late November and December to reduce the
incidence of heat-related events (Matzarakis and Frohlich 2015).
Healthcare at MGs in the Middle East
The Middle East people are traditionally known as hospitable nations. The host
countries do their best to ensure health and well-being of the attendees, mostly pro
bono, as Good Samaritans. This is more true for religious gatherings where helping
pilgrims is considered as an act of piety.
The Saudi government invests enormous resources for the welfare of Hajj and
Umrah pilgrims including creating health facilities, ensuring qualified healthcare, pro-
viding logistics to serve the pilgrims, and disseminating health messages. At least
14 permanent hospitals, 80 seasonal health centers and 34 permanent health centers
provide dedicated medical service to pilgrims, and 96 cooling units are available for
management of heat exhaustion and stroke (Almalki et al. 2011). About 6500 extra beds
are prepared in Makkah and Medinah for regular and emergency cases during the Hajj
seasons; about a third of that are ICU beds (Arabi and Al Shimemeri 2006). About
18,000 healthcare workforces, including anesthesia/intensive care residents, are mobi-

lized to pilgrimage areas. On average, each physician treats about 600 patients, while a
nurse cares for about 370 pilgrims (Boker 2016; Almalki et al. 2011).
In Makkah at least four large tertiary care hospitals (Al Noor, Hera, King Faisal,
and King Abdulaziz) cater for pilgrims; patients needing advanced cardiac, neuro-
logical, and oncological support are sent to King Abdullah Medical City. Also Ajyad
Hospital, a 50-bedded hospital close to the Holy Mosque in Makkah, caters for
medical and surgical emergency needs and supports two other health centers located
inside the Holy Mosque.
Also some countries like Turkey, Malaysia, and Iran have medical missions run
by their own medics. Many other voluntary missions like British Hajj Delegation,
Council of European Jamaats, and US-based Imamia Medics International Hajj
Medical Mission, just to name a few, provide walk-in care to pilgrims.
For Ashura and Arbaeen, about 500 established or temporary healthcare centers/
clinics are made available along the pilgrimage routes. Most of these healthcare
facilities are understaffed and unlicensed and provide only care for minor ailments
or injuries (Lami et al. 2019b). The challenges of providing medical care in Karbala
gatherings have been explored. The ineffectiveness of health training, low perception
of risk in pilgrims, poor control of the effective factors on infectious diseases, and
deficient health infrastructure in Iraq were considered important challenges, and the
need for multi-sectoral and international planning was felt (Karampourian et al. 2018).
Prevention remains the mainstay of control of health hazards at MGs in the
Middle East. If available, travellers should follow health advice from the host
country. Saudi Ministry of Health annually publishes guidelines for Hajj and
Umrah pilgrims advising them on vaccination requirements and hygienic measures
(Table 3); some of those (but not all) are applicable to other religious MGs of the
Middle East. Participants should also remain aware of medical guidelines published
by international bodies such as WHO, FIFA, and International Olympic Committee.
Table 3 Summary of the health recommendations to prevent Hajj health hazards

Preventive measures Remarks
Compulsory vaccines
Quadrivalent meningococcal Compulsory for all pilgrims; administered not <10 days
vaccine (ACYW) before arrival, the conjugate vaccine is preferable
Oral polio (OPV) or inactivated Compulsory for pilgrims from endemic countries;
poliovirus (IPV) administered at least 4 weeks before arrival
Yellow fever vaccine Compulsory for pilgrims from endemic countries or those
transiting through endemic countries; administered at least
10 days before arrival
Recommended vaccines
Seasonal influenza vaccine Recommended for all, in particular at-risk pilgrims;
quadrivalent vaccine is preferred
Pneumococcal vaccine Particularly indicated for high-risk pilgrims
Diphtheria, tetanus, and acellular Remain up to date
pertussis (DTaP) vaccine
(continued)
Table 3 (continued)
Preventive measures Remarks
Measles containing vaccine Remain up to date
Hepatitis A vaccine Pilgrims aged 1 year are recommended to receive at least
one dose of monovalent hepatitis A vaccine. A second dose
6 to 12 months later will provide longer-term protection
Hepatitis B vaccine Adult formulation is given in a three-dose schedule over
6 months, but a “rapid schedule” is also available if there is
limited time before departure
Typhoid vaccine Three doses of oral vaccine given at 0, 3, and 5 days or a
single dose of parenteral vaccine confer protection for at
least 3 years
Non-pharmaceutical measures
Wash hands with soap and water or disinfectant, especially after coughing and sneezing, after
using toilet, before handling and consuming food, and after touching animals. Observe cough
etiquette
Wearing face masks may help in avoiding hand contact with nose and mouth
Avoid contact with sick animals; avoid drinking raw camel milk or camel urine or eating
improperly cooked meat
To minimize the risk of stampede, understand the “mode” of the crowd; know the peak hours. Try
to follow the traffic; avoid going against the traffic. Wear fitting shoes; do not carry overhead
luggage
Prevent heat stroke by avoiding sun exposure and maintaining hydration. Use sunscreen to
prevent sunburn
Conclusion
The Middle East hosts some of the world’s largest MGs. Host countries do their best to
ensure safety of attendees and mitigate health risks from these gatherings by escalating
health workforces and mobilizing resources, yet these gatherings often pose major
health threats of international scale. Crowded religious gatherings like Hajj, Arbaeen,
and Assembly at the Shrine of Imam al-Kadhim are linked to mass casualty events and
amplified risks of infectious diseases. Management and prevention of those hazards
are a shared responsibility: while countries hosting those events should scale up public
health preparedness for MGs, attendees should be aware about the risks and comply
with prevention guidelines, and above all, countries sending travellers/pilgrims should
ensure the latter comply with the health recommendations.
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The Rise of Antimicrobial Resistance in
Mass Gatherings 47
Hamid Bokhary, Harunor Rashid, Grant A. Hill-Cawthorne, and
Moataz Abd El Ghany
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1200
Mass Gatherings and Public Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1200
Global Concern of Antimicrobial Resistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1201
Arab World, Antimicrobial Resistance, and Mass Gatherings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1202
Infectious Diseases in the Arab World . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1202
The Rise of Antimicrobial Resistance in Mass Gatherings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1204
Impact of Hajj on the Transmission of Drug-Resistant Infections . . . . . . . . . . . . . . . . . . . . . . . . . 1205
Drug-Resistant Enteric Infections at Hajj . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1206
H. Bokhary (*)
Umm Al-Qura University, Makkah, Saudi Arabia
e-mail: hamid.bokhary@sydney.edu.au; hamidbokhary@outlook.com
H. Rashid
National Centre for Immunisation Research and Surveillance (NCIRS),
The Children’s Hospital at Westmead, Westmead, NSW, Australia
e-mail: harunor.rashid@sydney.edu.au
G. A. Hill-Cawthorne
e-mail: grant.hill-cawthorne@sydney.edu.au
M. Abd El Ghany
The Westmead Institute for Medical Research, The University of Sydney, Sydney, Australia
The Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney,
Sydney, Australia
e-mail: moataz.mohamed19@outlook.com; moataz.mohamed@sydney.edu.au

https://doi.org/10.1007/978-3-030-36811-1_47
1200 H. Bokhary et al.
Mobile Nature of Resistance Genes Found in Hajj Mass Gathering . . . . . . . . . . . . . . . . . . . . . . 1207

Drug-Resistant Respiratory Infections in Hajj . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1208
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1209
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1210
Abstract
Mass gatherings (MGs) are a common human group behavior. Antimicrobial
resistance (AMR) is a major public health issue. The Arab world hosts the annual
Hajj pilgrimage, a MG with diverse attendees, and the region is also a layover hub
for global travels. Although AMR surveillance is still insufficient, the available
data on Hajj reveal that the AMR rate is generally high and is increasing each
year. Enteric infections are common in Hajj and provide grounds for AMR
acquisition and transmission, including emerging resistance to β-lactams. Respi-
ratory infections are a major concern in Hajj, where incidences of outbreaks such
as meningococcal disease being documented during the pilgrimage. With the
recorded high usage of antimicrobials during Hajj, including mandatory prophy-
laxis for high-risk travelers and the availability of over-the-counter antimicro-
bials, the risk of AMR development is likely to increase.
Keywords
Mass gathering · Antimicrobial resistance · Arab · Health · Hajj
Introduction
Mass Gatherings and Public Health
The tendency to gather in large numbers is an ancient human behavior, driven by a

collective desire to express presence in unity. Mass gatherings (MGs) have long been
documented to have an impact on the health of participants and on the host country’s
infrastructure and economy (Horwitz et al. 1977). Managing health risks that MGs
pose is a long-known practice for health authorities, such as the temporary suspension
of pilgrimage for British Hajj participants as a preventive measure against cholera at
the end of the nineteenth century (Vintras 1894). The term “Mass Gathering Medicine”
(MGM) has appeared more frequently in recent years in medical and public health
literature (De Lorenzo et al. 1993). Many peaceful MGs have attracted millions of
people: the largest peaceful gatherings in history have been the 2013 Kumbh Mela
pilgrimage (India, ~30 million participants); the 2014 Arbaeen festival (Iraq, ~20
million participants); the funeral of CN Annadurai, 1969 (India, ~15 million partici-
pants); the funeral of Ayatollah Khomeini, 1989 (Iran, ~10 million participants); the
Papal Mass in the Philippines (2015, ~6 million participants); the 1995 World Youth
Day (the Philippines, ~5 million participants); the funeral of Egyptian President Gamal
Abdel Nasser, 1970 (Egypt, ~5 million participants); the funeral of Pope John Paul II,
2005 (Italy, ~4 million participants); Rod Stewart concert, 1994 (Brazil, ~3.5 million
47 The Rise of Antimicrobial Resistance in Mass Gatherings 1201
participants); the 2012 Hajj pilgrimage (KSA, ~3 million participants), and an anti-war
march, 2003 (Italy, ~3 million participants).
The World Health Organization (WHO) has defined MG as a gathering of “more
than a specified number of persons (which may be as few as 1000 persons although
much of the available literature describes gatherings exceeding 25,000 persons) at a
specific location for a specific purpose (a social function, large public event or sports
competition) for a defined period of time” (Michael and Barbera 1997; WHO 2008).
MGs have been associated with changes in population dynamics that strain the
existing infrastructures that in turn can result in changes in the health and behavior
of participants (WHO 2015a). MGs represent a platform for varied health risks,
including the transmission of infectious diseases (e.g., foodborne outbreaks), adverse
effects associated with environmental exposure (e.g., heat exhaustion and stroke), and
other noncommunicable health risks (e.g., crushes, stampedes, cardiovascular events).
Many studies have highlighted the emergence and transmission of infectious
diseases during planned MGs, including sporting (Gautret and Steffen 2016; Pesola
et al. 2015), cultural events (Gautret and Steffen 2016; Grgic-Vitek et al. 2015), and
religious events (Gautret and Steffen 2016; Pfaff et al. 2010). Although all types of
planned MGs can raise public health threats, the implications on public health vary
depending upon a multitude of interrelated factors. The key factors that determine the
potential impact of a MG on public health include: type of the event; duration; origin,
density, and health status of the participants; venue characteristics; demographics of
participants and activities performed; and status of public health in the host commu-
nity/country. For instance, MGs that attract international participants can increase the
risk of importing infectious diseases into the host country and the risk of exporting
such infectious agents when the participants return to their countries of origin. The
magnitude of this impact depends on the number of participants, their countries of
origin, their background immunity, and the health risks endemic to the host country
(Abd El Ghany et al. 2018; Gautret et al. 2015; Gautret and Steffen 2016).
Therefore, the WHO has recommended that the activities of a planned MG should
meet the requirements of the International Health Regulations (IHR) 2005 for
enhancing global health security and preventing the transmission of infectious
diseases (WHO 2015a; WHO Secretariat 2011).
Recently, the WHO has reported on the high prevalence of antimicrobial resis-
tance (AMR) among pathogens responsible for the most common hospital- and
community-acquired infections in all regions of the world (WHO 2014). The global
transmission of AMR-pathogens is in turn fueled by AMR-carriage associated with
human displacement and international travel (de Smalen et al. 2017). A proportion of
this global travel includes the large numbers of domestic and international travelers
who participate in MGs (WHO 2016). Prolonged AMR-carriage, lasting up to 1 year
after returning from endemic regions, has been reported (Arcilla et al. 2017).
Global Concern of Antimicrobial Resistance
The discovery of penicillin in 1928 (Fleming 1929) and subsequent development of

other broad-spectrum antimicrobials revolutionized twentieth and twenty-first
century medicine. However, following the development of fluoroquinolones in the

early 1970s, no major groups of antibacterial drugs have been developed. This
paucity in development coincides with an increasing threat of antimicrobial resistant
organisms. Humans now face a significant risk of a post-antimicrobial era of
medicine, in which common infections can kill once more (Chan 2011).
AMR is a major threat to global public health. Every year, 700,000 deaths are
attributed to AMR-resistant infections (O’Neill 2016) with low- and middle-income
countries being the most affected, both in terms of impact on public health and
economic burden. The global mortality associated with drug resistance is projected
to be ten million per year by 2050 if the current prevalence rate remains unaltered,
with an economic loss of up to US$100 trillion (O’Neill 2014).
Antimicrobials are used in a variety of applications such as in agriculture
(Khachatourians 1998) and livestock farming (Pagel and Gautier 2012). Food
provision has always been a priority for humans and with a growing population
and industry demands, food providers use antimicrobials in the production process to
allow for fast, product-secure, and cost-effective production. This has led to the
acquisition or development of AMR in livestock animals’ flora (Brown et al. 2017).
Global efforts have risen to tackle this issue, such as the European Union ban on the
use of growth-promoting antibiotics in livestock (Phillips 2007). Moreover, for food
security, the WHO has issued guidelines on antimicrobial usage in food-producing
animals (WHO 2017c).
Arab World, Antimicrobial Resistance, and Mass Gatherings
Terms used for searching the literature for the “Arab world” were: Saudi Arabia or
United Arab Emirates or UAE or Dubai or Egypt or Arab or Algeria or Iraq or
Qatar or Kuwait or Morocco or Oman or Libya or Sudan or Syria or Tunisia
or Lebanon or Yemen or Jordan or Bahrain or Palestine or Mauritania or
Chad or Comoro or Djibouti or Eritrea or Israel or Somali or South Sudan.
Terms used for searching for “AMR” were: methicillin-resistant or drug
resistant or antimicrobial resistant or antibacteria or antimicrobial or resistant
or sensitive or super or bug or multiresistant or multi-resistant or virulant or
antibiotic resistant.
Terms used for searching for “MGs” were: Hajj or Arba’een or Haj or Hadj or
tourism or world cup or Olympic or mass gathering or pilgrim or Ziyar or
crowd or Imam Hussein.
Infectious Diseases in the Arab World
The Arab world refers to the geographic region in which Arabic is the primary
language, usually formed by northern Africa and western Asia. Recent conflicts in
the region and the unique social and political structures that are present have led to
the gradual deprioritization of healthcare services. Due to ongoing regional conflicts
and the effect of the so-called Arab Spring (Coutts et al. 2013), data reporting in the
region has been compromised (WHO 2014). In particular, infectious disease sur-
veillance requires considerable improvements in terms of breadth, depth, and
efficiency.
As in most low- and middle-income countries, the Arab world experiences a
significant health burden due to infectious diseases. Lower respiratory tract infec-
tions are the leading cause of death in low-income Arab countries and are within the
top three and top five in middle- and high-income Arab countries, respectively
(Rahim et al. 2014). Diarrheal diseases have been the second leading cause of
death in low-income Arab countries for the past 20 years (Rahim et al. 2014).
Tuberculosis (TB) is endemic in sub-Saharan Africa and southeast Asia. The
Arab world countries most affected by TB are Ethiopia, Somalia, Sudan, and South
Sudan (incidence ranges from 82 to 270 per 100,000 population, and mortality
ranges from 14 to 75 per 100,000 population), followed by Yemen and Algeria
(incidence: 48–70 per 100,000 population; mortality: 6.9–7.7 per 100,000 popula-
tion) (WHO 2017a). In contrast, the incidence of endemic malaria in the Arab world
is declining but imported malaria is a concern in some countries. However, certain
countries are going against this trend. For instance, Saudi Arabia’s autochthonous
cases increased from 29 in 2010 to 272 in 2016. The situation in Yemen has been
deteriorating since 2015 due to the ongoing civil war, and also in South Sudan due to
the cross-border displacement of refugees, which may be contributing to an increase
in malaria burden in neighboring countries (WHO 2017d). Viral infections are
usually self-limiting and associated with a lower fatality rate; however, the newly
emerged Middle East Respiratory Syndrome-coronavirus (MERS-CoV) in 2012 has
a high fatality rate and is threatening a public health crisis in the region. Around 82%
of reported cases have been from Saudi Arabia, with 31% of cases resulting from
transmission in healthcare settings (WHO 2017b).
The speed of emergence of AMR in the region has been as alarming as infectious
disease outbreaks. Even in the past year, strains of Klebsiella pneumoniae carrying
blaOXA-48-type and blaNDM gene for carbapenem-resistance have been detected in the
United Arab Emirates (Moubareck et al. 2018), Saudi Arabia (Al-Zahrani and Alsiri
2018), and Iraq (Hussein 2017). Other than the rapid emergence seen, most rates of
drug resistance are increasing, such as the annual rise in methicillin resistance among
Staphylococcus aureus isolates in Kuwaiti Hospitals from 906 in 2011 to 1771 in
2015 (Udo and Boswihi 2017). The Arab world is a geographic center for much of
the world’s trade, transport, and commercial lines. Moreover, the region hosts one of
the world’s largest annual MGs (Hajj), during which people come from every
continent to participate. The risk of importing and disseminating communicable
diseases is concerning. Furthermore, with infectious diseases and their endemic
profiles, the risk of AMR arises.
It is important to understand the AMR situation in the Arab world and in the MGs
hosted therein. The WHO reports that for its Eastern Mediterranean Regional Office
(EMRO), of which 19 of the 22 countries are from the Arab world, the rate of
resistance for Escherichia coli isolates to third-generation cephalosporins ranges
from 22% to 63%, and resistance to fluoroquinolones from 21% to 62%. Klebsiella
pneumoniae resistance to third-generation cephalosporins is 22–50% and to

carbapenems up to 54%. Staphylococcus aureus resistance to β-lactams was
10–53% and penicillin resistance in Streptococcus pneumoniae was 13–34%.
Rates of fluoroquinolone resistance for nontyphoidal Salmonella spp. ranged from
2% to 49% and for Shigella spp. ranged from 3% to 10%. Finally, soaring resistance
to third-generation cephalosporins is now being seen in Neisseria gonorrhoeae, with
up to 12% now displaying reduced susceptibility. No more than four countries in the
region reported their AMR rates to EMRO for any given organism; indicating a poor
reporting system (WHO 2014).
AMR surveillance in the Arab world is affected by regional insecurity and a
lack of governance and awareness. The region is known to be affected by civil
uprisings and wars with massive human displacements in the region (WHO
2014). This has resulted in shifting the priority in health programs to secondary
rather than primary and preventive health services. Until 2015, there was no
active national level action plans in any of the EMRO countries (WHO 2015b).
Moreover, some countries lack enforcement for their own prescription policies
(Nasr et al. 2017), such as the availability of antimicrobials without a prescription
(WHO 2015b). A general lack of national awareness of the risks of AMR is due to
poor health promotion and literacy (WHO 2015b). Poor health services infra-
structure contributes to the low quality of AMR surveillance, with little invest-
ment in AMR surveillance occurring in the region and laboratories not
adequately equipped with accurate and comprehensive instruments for antimi-
crobial testing, in addition to the presence of counterfeit antimicrobials (WHO
2015b). A lack of collaboration and transparency in the region is affecting the
sharing of AMR data and reporting processes (WHO 2015b), which needs to be
addressed and measures enforced.
The Rise of Antimicrobial Resistance in Mass Gatherings
Health issues in MGs vary depending on various factors intrinsic and extrinsic to the
events. Some factors are linked directly to health, such as the presence of
comorbidities among the attendees, and some are indirectly related, such as the
time of year the event takes place in and the level of environmental pollution in the
host city. Due to the increased risk to global public health, the hosts of MG events are
advised to collaborate with international stakeholders for a holistic approach to
tackle such issues. The main MGs in the region of public health significance are
Hajj and Arba’een, which are both annual. Arba’een in Karbala, Iraq, occurs 40 days
after the Day of Ashura, i.e., the day when Hussain ibn Ali, the grandson of Prophet
Mohammad (peace be upon him) was martyred. It is a key Shia religious observance
and attendees commemorate and mourn the loss of Hussain (Al-Lami et al. 2013).
Studies published thus far on Arba’een describe health issues other than AMR (Al-
Lami et al. 2013; Ghasemian et al. 2016). Infectious disease reports on other MGs in
the Arab world are scarce. The main body of literature available, although very
limited, focuses on AMR only at Hajj.
Impact of Hajj on the Transmission of Drug-Resistant Infections
Hajj, the annual pilgrimage by Muslims to Makkah, Saudi Arabia, attracts two to
three million pilgrims from 190 countries, together with hundreds of thousands of
Saudi Arabian residents every year, making it a unique MG event in terms of the
sheer number of attendees, ethnolinguistic diversity of pilgrims, nature of performed
activities, and the regularity of the event. These enormously diverse populations,
physically demanding rituals (e.g., circumambulation, marching between hillocks
and animal sacrificing) performed by them and the congested settings (crowded
accommodation, prolonged stay in tents, use of shared facilities) facilitate emergence
and dissemination of infectious diseases within the host country and beyond. Each
year, Makkah hosts multiple religious congregations: Umrah, the minor pilgrimage,
and Hajj, the major pilgrimage that takes place on specific days of the last month of
lunar calendar. Umrah pilgrimage, unlike Hajj, occurs throughout the year but most
festively during the month of Ramadan (the 9th month of the lunar year) and
involves fewer rites (e.g., visiting the Holy Mosque in Makkah). With a plan to go
up to 30 million in 2030, the number of offshore pilgrims for the Umrah season,
around six million during 2016, is greater than that of Hajj (around two million for
the same year) (Yezli et al. 2017a). The most intense congestion happens during the
last 10 days of Ramadan, creating a Hajj-like situation. However, the impact of
Umrah on the emergence and dissemination of infectious diseases is yet to be studied
(Yezli et al. 2017a).
Hajj has already been associated in the literature with an increased risk of
airborne, foodborne, bloodborne, and zoonotic infections (Ahmed et al. 2006).
For instance, the Hajj pilgrimage has been associated with major intercontinental
outbreaks of meningococcal diseases, first by serogroup A in 1987, and then by
serogroup W in 2000 and 2001 Hajj seasons (Moore et al. 1989). This triggered
the introduction of the mandatory meningococcal vaccination policy for all Hajj
pilgrims (Abd El Ghany et al. 2016). Previously, Hajj was also associated with
several major outbreaks of Vibrio cholerae, including the emergence of the
severe seventh pandemic of the El Tor strain (Hu et al. 2016). Recently, there
have been concerns that Hajj may act as a focal point for the acquisition,
emergence, and dissemination of AMR infections (Abd El Ghany et al. 2017;
Leangapichart et al. 2016b; Olaitan et al. 2015). Multiple studies have demon-
strated that pilgrims are at a higher risk of acquiring and transmitting AMR
pathogens, including multidrug-resistant Acinetobacter spp., carbapenemase-
producing E. coli (Leangapichart et al. 2016b), and extended-spectrum cephalo-
sporin- and colistin-resistant nontyphoidal Salmonella spp. (Olaitan et al. 2015).
Acinetobacter baumannii was isolated from 14.4% throat only, 25.6% rectal only,
and 3.3% of both throat and rectal swabs from French pilgrims returning after
Hajj. All A. baumannii isolated were found to be blaOXA-51-like gene positive and
therefore ceftriaxone-resistant (Leangapichart et al. 2016b). Acquisition of
blaCTX-M genes also occurred during Hajj, with 32.6% of French pilgrims’
stool samples being positive for this gene after Hajj compared to 5.5% before
(Leangapichart et al. 2017).
Drug-Resistant Enteric Infections at Hajj
A response to the 1997 Mina fire was for the Hajj authorities to ban pilgrims from
cooking their own food (Ahmed et al. 2006). Pilgrims’ meals are now arranged by
their tour operators, generally outsourced through a catering company. Pilgrims
whose tour operators do not organize their food often rely on street vendors and
gastroenteritis incidences have been reported, either as an outbreak (Emamian and
Mohammad Mohammadi 2013) or a clustering of reported cases (Al-Mazrou 2004).
Travelers’ diarrhea has been shown to be an independent risk factor for
contracting extended-spectrum ß-lactamase (ESBL)-producing Enterobacteriaceae
(ESBL-PE), with the rate of acquisition varying according to destination and age of
the travelers (Kantele et al. 2015). Both the host country, Saudi Arabia, and countries
that send pilgrims on Hajj are countries at higher risk for the acquisition of diarrheal
illnesses (Steffen 2005; Steffen et al. 2015) and ESBL-PE infections (Kantele et al.
2015).
Abd El Ghany et al. (2017) have conducted the first large-scale epidemiological
study to identify the etiologic agents of Hajj-associated diarrheal infections. The
investigators used integrated antigenic and molecular approaches to screen 544 fecal
samples from symptomatic pilgrims during three consecutive Hajj seasons for 16
pathogens associated with diarrheal infections. The data demonstrate that Hajj-
associated diarrheal disease is associated with mild illnesses caused mainly by a
single bacterial agent, with enterotoxigenic E. coli, Salmonella spp., and Shigella/
entero-invasive E. coli (EIEC) being the major causes. Of particular concern were
the presence of ESBL and carbapenemase genes in ~40% of Salmonella spp. and E.
coli-positive samples collected (Abd El Ghany et al. 2017).
In another study, an increase in the rate of carriage of third-generation cephalo-
sporin-, gentamicin-, and colistin-resistant nontyphoidal Salmonella spp. (NTS) has
been shown among French pilgrims on their return from performing Hajj (Olaitan
et al. 2015). This is a matter of concern; third generation cephalosporins are
considered the drug of choice in the treatment of many pediatric NTS infections
(Wen et al. 2017), and overall, they are used as second-line of treatment for most
typhoidal Salmonella spp. (WHO 2003). The proportion of third-generation cepha-
losporin-resistant NST in Hajj settings is 33.3% of isolated NTS (Olaitan et al. 2015)
and 40.3% of diarrhea-associated Salmonella spp. infections (Abd El Ghany et al.
2017), similar to what is recorded globally for NTS (31.2–55%) (Burke et al. 2014;
Murphy et al. 2018).
Enterotoxigenic E. coli (ETEC) is the most common serovar of E. coli and is
commonly associated with foodborne diarrheal infections during traveling to
endemic regions in Africa, Asia, and South America (Diemert 2006; Steffen 2017;
Steffen et al. 2015). Many studies have illustrated the role of ETEC and other
diarrheagenic E. coli strains in the occurrence of diarrheal infections and the
emergence of outbreaks in MGs through catering (Kim et al. 2017; Ochi et al.
2017; Park et al. 2018). Approximately 33.3% of the E. coli-positive samples from
symptomatic diarrheal cases at Hajj have been identified to contain blaCTX-M-15 and
blaNDM genes that are associated with resistance to third-generation cephalosporins
(Abd El Ghany et al. 2017). Such a high rate of third-generation cephalosporin

resistance to E. coli in Hajj is only comparable with the higher end of the global
range, which spans from as low as 3–7.8% (Randrianirina et al. 2014; Seiffert et al.
2013) to as high as 40–48% (Chagas et al. 2011; Lien et al. 2017; WHO 2003).
Another study found that 89% E. coli isolates during Hajj were resistant to
ampicillin, 9% to piperacillin/tazobactam, and 5% to imipenem (Asghar 2006). The
proportion of AMR E. coli at Hajj is greater than the global average. Globally, the
proportion of E. coli that are resistant to imipenem is 1% (Badura et al. 2015; Lien
et al. 2017), to piperacillin/tazobactam is 0.02–0.8% (Badura et al. 2015; Gonzalez and
Cortes 2014), and to ampicillin is 40–82.1% (Badura et al. 2015; Randrianirina
et al. 2014).
Mobile Nature of Resistance Genes Found in Hajj Mass Gathering
In Hajj, bla genes was found in Salmonella spp., E. coli, and A. baumannii with an
average acquisition rate of 33.4%, ranging from 22.2% to 40.3% (Abd El Ghany
et al. 2017; Alyamani et al. 2017; Leangapichart et al. 2016b). Moreover, a study
found that the bla gene was in 88.9% of amoxicillin-clavulanate and ampicillin-
resistant K. pneumoniae isolates (Al-Zahrani and Alsiri 2018). The most com-
monly mentioned bla gene in available literature in Hajj is the blaCTX-M-15 gene,
associated with Salmonella spp. and E. coli (Abd El Ghany et al. 2017; Alyamani
et al. 2017; Leangapichart et al. 2016b). Harboring other variations of blaCTX-M
gene (Alyamani et al. 2017; Leangapichart et al. 2016a, b, 2017), blaNDM (Abd El
Ghany et al. 2017; Al-Zahrani and Alsiri 2018; Leangapichart et al. 2016b), blaOXA
(Al-Zahrani and Alsiri 2018; Alyamani et al. 2017; Leangapichart et al. 2016b),
blaTEM (Alyamani et al. 2017; Leangapichart et al. 2016a, b), blaSHV (Alyamani
et al. 2017; Leangapichart et al. 2016a), and blaVIM (Al-Zahrani and Alsiri 2018)
are also found in Hajj. No documented findings on Enterobacteriaceae harboring
the blaKPC and blaIMP genes in Hajj (Abd El Ghany et al. 2017; Al-Zahrani and
Alsiri 2018).
During Hajj, of aminoglycoside-resistant E. coli isolates from hospitalized
patients with urinary tract infection from two general hospitals in Makkah: 44.8%
harbored the aac6 gene, 43% harbored the aac6Ib gene, 42% harbored the aadA4
gene, 36% harbored the strB gene, 15% harbored the aadA1 gene, 12% harbored the
aadA2 gene, 4% harbored the aadB gene, 4% harbored the ant2 gene, 12% harbored
the aphA gene, and 1% harbored the strA gene (Alyamani et al. 2017).
The studies demonstrated that many Enterobacteriaceae members carrying plas-
mid-mediated resistance genes including ESBLs (e.g., blaCTX-M), Carbapenemases
(e.g., blaNDM), and Colistin are the major contributors to Hajj-associated enteric
carriage and infections. This is not surprising considering the well-established fact
that AMR in Gram-negative bacteria is associated with horizontal gene transfer
mediated mainly by plasmids and conjugative transposons (Partridge 2011, 2015).
This allows for AMR transmission through the dissemination of resistance plasmids
among different strains and closely related species.
Drug-Resistant Respiratory Infections in Hajj
Unlike most other parts of Saudi Arabia, tuberculosis (TB) is considered endemic to
the Makkah region, with a 25% incidence rate compared to around 16% for the rest
of the country. While the incidence in most parts of the country has decreased, the
rate of TB in Makkah has increased since the start of the Millennium (Al-Orainey
2013). Consequently, the rate of multidrug-resistant (MDR) TB is higher in the
Makkah region (25%) compared to that in other regions of Saudi Arabia (Al-Orainey
2013). Available data show that 1.4% of pilgrims from TB endemic countries have
undiagnosed active TB (Yezli et al. 2017b) and a prospective study conducted in
2005 involving Singaporean pilgrims show that around 10% pilgrims acquire TB
following Hajj attendance (Wilder-Smith et al. 2005). In a study of hospitalized
patients diagnosed with pneumonia during Hajj 1994, TB was found to be the
leading cause, accounting for 20% of pneumonia cases (Alzeer et al. 1998). While
no drug resistance was reported (Yezli et al. 2017b), given the risk of transmission
from cases that are not being identified as TB and treated accordingly, the situation is
alarming.
The serogroup W Neisseria meningitidis strain responsible for the Hajj-associated
intercontinental meningococcal outbreak of 2000 and 2001 was resistant to several
antimicrobials, including sulfadiazine, cloxacillin, tetracycline, and cotrimoxazole
(trimethoprim/sulfamethoxazole) (Abd El Ghany et al. 2016; Molling et al. 2001;
Yousuf and Nadeem 1995). Reported levels of drug resistance for Neisseria
meningitidis infections related to Hajj were 10.3% for azithromycin, 5.9% for
ciprofloxacin, 4.4% for levofloxacin, 4.4% for rifampicin (Ashgar et al. 2013), and
66.6% for gentamycin (Karima et al. 2003). While Hajj-associated meningococcal
strains are still susceptible to penicillin, cephalosporins, ciprofloxacin (Karima et al.
2003), and cefotaxime (Ashgar et al. 2013), their epidemiology may change over
time. This is also true for Umrah pilgrimage; the meningococcal colonization rate
among Umrah visitors was found to have doubled by the end of the pilgrimage
compared with the beginning (Ashgar et al. 2013). Hence, alternative strategies, such
as the impact of vaccination on the meningococcal AMR profile, need to be
explored.
Streptococcus pneumoniae is a Gram-positive bacterium responsible for an array
of noninvasive and invasive diseases, including sepsis and meningitis. Pneumonia is
the leading cause of hospital admission during Hajj (Ridda et al. 2014). Different
pneumococcal vaccine types are available, with recommended target groups for each
type (Abd El Ghany et al. 2016; CDC 2012). Currently, pneumococcal vaccination is
not a visa requirement for Hajj attendance, but it is recommended for high-risk
pilgrims (Abd El Ghany et al. 2016). The carriage rate of Hajj-related S. pneumoniae
among international pilgrims was 5.4%, of which 76.7% of the isolates were
reported to be resistant to at least one drug and 22.9% to three or more drugs
(Memish et al. 2015, 2016). These rates are higher than what is reported globally
(5–50%) for at least one drug but on the upper end of the range of globally reported
MDR S. pneumoniae (9–24%) (Lynch and Zhanel 2010). In view of the much lower
carriage rates typically seen globally among community-dwelling adults, the levels
of drug resistance seen for S. pneumoniae during Hajj are alarming and require
further investigations.
Staphylococcus spp. are Gram-positive bacteria that usually colonize human skin
and nasal flora. Staphylococcus aureus is one of the leading causes of bacteremia and
is associated with skin and other related infections (Tong et al. 2015). Methicillin-
resistant S. aureus (MRSA) infections are more serious because they are typically
more difficult to treat. Globally, over 90% of Staphylococcus aureus are resistant to
penicillin (Lowy 2003). Globally for general communities, MRSA colonization rate
is 1.25%, accounting for 5.68% of isolated S. aureus (Shokouhi et al. 2017). In Hajj,
the reported rates are slightly higher; MRSA colonization is 1.46%, accounting for
7.1% of noninvasive S. aureus isolates in Hajj (Memish et al. 2006). Paradoxically,
MRSA colonization rates in Hajj are lower when compared to close-quarter living
communities; where MRSA colonization rate is 6.1%, accounting for 21.7% of
S. aureus isolates (Mobasherizadeh et al. 2016). This lower carriage rate has been
partially attributed to the prophylactic measures (including antimicrobial use) used
before the start of Hajj (Memish et al. 2006).
In Makkah hospitals, S. aureus bacteremia incidence increases during the Hajj
season compared with other parts of the year (Asghar 2006), with 43.3% of
bacteremia isolates been identified as Staphylococci spp., of which 43% were
identified as S. aureus (Asghar 2006). S. aureus isolates from bacteremia patients
during Hajj were resistant to several antimicrobials: 92% to penicillin, 79% to
ampicillin, 58% to cotrimoxazole, 56% to erythromycin, 53% to oxacillin, 49% to
cephalothin, 48% to clindamycin, 44% to gentamycin, 42% to cefoxitin, and 38% to
amoxicillin/clavulanate. MDR MRSA, resistance to three or more of the following
agents: erythromycin, clindamycin, gentamicin, and oxytetracycline was identified
in 30.7% of Staphylococcus aureus isolates (Asghar 2006). Moreover, the rate of
AMR Staphylococcus aureus responsible for causing bacteremia among Hajj pil-
grim is higher than the resistance rate found globally against oxacillin (36%) and
cotrimoxazole (43.7%) (Musicha et al. 2017). These data are alarming because
β-lactams, such as oxacillin, are the first line of drugs of choice when treating
S. aureus bacteremia (Thwaites et al. 2011).
S. aureus is a common organism for causing pyoderma, a skin infection, during
Hajj seasons (Fatani et al. 2002). Pyoderma accounts for 5.6% of dermatological
cases in Hajj, with 47.5% of pyoderma cases being caused by S. aureus. Many
pyoderma S. aureus isolates among Hajj pilgrims are resistant to a range of antimi-
crobials: 80.9% resistant to penicillin, 12.8% to tetracycline, 6.4% to gentamicin,
4.3% each to erythromycin, cotrimoxazole, and clindamycin, and 2.1% each to
cephalothin and oxacillin (Fatani et al. 2002).
Conclusions
The Arab world is a geographical hub in the flow of people, cash, and commodities.
The mass gathering (MG) events that occur in the region can greatly impact global
health. Antimicrobial resistance (AMR) during MG has been shown to affect both
home and guest countries, with pathogens and colonizers being freely transmitted
and, therefore, a risk of AMR acquisition and dissemination. The field of MGM is
still being established and there are limited data on AMR among attendees of MGs.
A combination of regional conflicts, a low scientific funding base, and restrictions on
foreign investigators into MG studies all contribute to this knowledge gap. The
available studies suggest that the rate of AMR among attendees of MGs in the Arab
region is high and increasing. Further studies are needed for a clear picture of the
AMR profile in MGs, and specifically in Hajj, and assess how the widespread use of
prophylactic and over-the-counter antimicrobials is impacting this. Evaluating the
effects of vaccination on AMR of both disease-causing and colonizing organisms is
also a research priority. Moving forward, the governments of the host countries of
MGs will need to work in a cross-government capacity, including the relevant
ministries of human and animal health, infrastructure, and planning, and will also
need to work in an inter-government capacity with supranational agencies and the
governments of participating travelers. This will require collaboration that goes
beyond the International Health Regulation requirements, with a focus on transpar-
ency and information-sharing.
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Preparedness for Mass Gathering During
Hajj and Umrah 48
Iman Ridda, Sarab Mansoor, Revlon Briggs, Jemal Gishe, and
Doaha Aatmn
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1216
Search Strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1217
Mass Gatherings and the Role of Public Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1217
A Framework for Public Health at Mass Gatherings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1218
Public Health Surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1219
Regulations, Legislation, and Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1219
Emergency Planning and Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1219
Environmental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1220
Public Health Awareness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1220
Strengthening Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1220
Internal Organizational and Capability Building . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1220
Hajj and Umrah . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1220
Outbreaks and Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1222
Hajj Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1223
How to Stay Safe: Individual Traveler . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1223
How to Stay Safe: Role of Health Authorities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1229
Government Preparedness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1230
Relevant Procedures Pertaining to Travel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1230
Health Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1231
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1231
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1232
I. Ridda (*) · R. Briggs · J. Gishe

Department of Public Health, Health Administration, and Health Sciences,
Tennessee State University, Nashville, TN, USA
e-mail: imrd512@hotmail.com; rbriggs@tnstate.edu; jgishe@tnstate.edu
S. Mansoor
The University of Sydney School of Pharmacy, NSW, Australia
e-mail: sarabmalikmansoor@hotmail.com
D. Aatmn
California University of Science and Medicine, San Bernardino,
CA, USA
e-mail: AtamnD@calmedu.org

https://doi.org/10.1007/978-3-030-36811-1_48
1216 I. Ridda et al.
Abstract
The role of public health preparedness at mass gatherings (MGs) and a framework
to ensure a safe and healthy mass gathering are provided in this chapter.
The unique aspects of Hajj and Umrah events, including their massive size and
the interplay of environmental conditions with the international nature of
attendees, require proper and thorough public health preparation.
The key aspects of a framework designed to promote public health at mass
gatherings are also outlined in this chapter. The key aspects include risk assess-
ment, public health surveillance; regulations, legislation and policy; emergency
planning and response; environmental health; public health awareness; strength-
ening communication; and internal organizational and capacity building.
Our search evaluates literatures pertaining to the frameworks of public health
concerns at mass gatherings and analyzes the preparedness and effectiveness of
such regulations and projections in current models of disaster preparedness
and public health promotion. Such a model is crucial for setting the stage for
decision-making and ensuring the safety of attendees; it should be implemented
before the commencement of the event.
Further, the health risks associated with attending a mass gathering such as
Hajj/Umrah are discussed. Clinicians and attendees have specific roles to play in
ensuring good public health during these pilgrimages. Clinicians have a role in
ensuring attendees are well equipped with the knowledge and resources to stay
healthy during Hajj/Umrah, which helps to protect the public from infectious
disease transmission. Attendees have a role in ensuring personal health and
maintaining hygiene standards. Infectious diseases of concern at such mass
gatherings include Middle East respiratory syndrome-coronavirus (MERS-
CoV), meningococcal disease, diarrheal disease and seasonal influenza. Other
diseases of concern include the potential for pilgrims to contract Zika due to local
populations of Zika vectors.
Specific vaccine requirements and knowledge regarding health warnings are
crucial to Hajj attendees when traveling to the Kingdom of Saudi Arabia (KSA).
In addition, pilgrims are encouraged to seek accurate information related to travel
and visas and requirements of Hajj-specific travel visas.
Keywords
Hajj · Public health · Mass gathering · Preparedness · Vaccine
Introduction
The World Health Organization (WHO) defines mass gatherings as a planned or

spontaneous event where at least 1000 individuals gather at a specific location for a
specific purpose and defined period of time. The size of such gatherings increases
the risk of certain public health issues and requires special attention to mitigate
48 Preparedness for Mass Gathering During Hajj and Umrah 1217
these risks (WHO 2005). Without proper planning and foresight, such events can
put a strain on the health response resources of the community or country hosting
the event, as well as a strain on global health responses, since these attendees are a
part of a global population with diverse countries of return and origin (Leangapichart
et al. 2017; Khan et al. 2017; Rahimian and Hosseini 2017; Cobbin et al. 2017;
WHO 2015). Events such as the Olympic Games, political rallies, and religious
assemblies like Hajj are examples of mass gatherings that attract a large number of
people (WHO 2015). Mass gatherings can also include displaced populations due to
natural disasters, conflicts, and wars.
This chapter examines available literature on the burden of mass gatherings
during Hajj as a case study and identifies health-related requirements and recom-
mendations for obtaining an entry visa to attend Hajj and Umrah. The information
provided in this document can be a source of information that will add to general
knowledge and is intended to be of assistance to governments at all levels and
communities involved in overseeing leading public health preparedness efforts.
Identifying public health risks associated with Hajj and Umrah, as well as the gaps
in current literatures and research, will mitigate shortcomings in procedures and
structures associated with disaster preparedness and the risks and hazards posed by
such mass gatherings.
Search Strategy
Key databases were searched from late mid-September 2016 to early- March 2018 to
identify items on Hajj, mass gathering, public health preparedness and/or outbreak
and responses in Hajj and in Umrah pilgrims. Our search focused only on planned
mass gatherings. Manuscripts were excluded if the focus of the mass gathering event
was outside Hajj and Umrah. Databases searched include the Centers for Disease
Control and Prevention (CDC), OVID Medline, OVID Em-base, and Web of
Science databases consisting of the Science Citation Index, Social Sciences Citation
Index, Conference Proceedings Citation Index-Science, and Conference Proceed-
ings Citation Index-Social Science and Humanities.
Mass Gatherings and the Role of Public Health
Public health plays an important strategic and technical role in keeping the public
safe and healthy during mass gatherings. Epidemiologic surveillance, environmental
management, emergency care, disease prevention, access to information, and strong
leadership are critical elements at mass gatherings (Tsouros and Efstathiou 2007;
Kazi et al. 2017). The role of public health officials at mass gatherings is to assure
conditions through which all attendees remain safe and healthy for the duration of
such gatherings.
While some gatherings are brief and may last for a day or less, most religious
gatherings for Muslims are usually longer. The focus of this chapter is to examine the
Fig. 1 Total pilgrims in 2016 by origin. (Hajj Statistics 2016. General Authority for Statistics,
Kingdom of Saudi Arabia. Accessed at https://www.stats.gov.sa/sites/default/files/hajj_1437_en.
pdf)
role of public health officials during the Hajj and Umrah events, which are annual
gatherings of Muslims: Hajj which occurs once a year and Umrah, which can be
performed at any time. Attendance during these events is massive as more than two
million Muslims from 183 countries perform Hajj each year (Fig. 1).
With these massive crowds, it is critical that health officials remain vigilant in
exploring all avenues to preserve health through reduction of risk for injury, institute
robust surveillance to avert the spread of disease among attendees, and treat
attendees who become ill. Mass gatherings have significant public health implica-
tions that extend beyond acute health events and require rapid detection and effective
management (Tsouros and Efstathiou 2007). Mass gatherings can increase health
security risks, raise social anxiety, political urgency, and cause economic disruption
if steps are not taken to organize and respond effectively.
To assure safety during a mass gathering, preparations and necessary precautions
must be taken not only by attendees but also by sponsors and leaders in host
countries. A general public health framework for keeping crowds safe, and historic
examples of Muslim gatherings with specific recommendations to Hajj pilgrims are
provided in this chapter.
A Framework for Public Health at Mass Gatherings
Historically, peer-reviewed literature has concentrated on Hajj and Umrah as exam-

ples of mass gatherings that require public health-related responses (Tsouros and
Efstathiou 2007). The size of the gathering, diversity of population, the climate,
health facilities around the Hajj sites, and emergency management systems
all make this gathering a special and unique opportunity for the public
health community to invest and play an essential role. Proper preparation for
mass gatherings requires a substantial investment and capacity built between the
local officials, the community, and the attendees (WHO 2015). Preparation should
start early and include detailed policies and procedures that involve health partners,
public health providers, and emergency services.
A framework that connects the psychosocial, biomedical, and environmental
domains of public health preparation and response for mass gatherings is a useful tool
to verify that proper steps have been taken to ensure a safe and healthy gathering (Arbon
2004). The framework described will help set the stage for a broader view of decision-
making while planning the safety of attendees. In addition to higher level organizational
and government requirements with a public health lens, the roles and responsibilities are
discussed for attendees to contribute to a safe and well-executed mass gathering. The
framework to reduce risks in mass gatherings includes the following:
Public Health Surveillance
A robust public health surveillance system on-site for attendees is key to keeping
crowds safe at mass gatherings, which allows faster notification and response to
potential hazards. A surveillance system is important because strengthened systems
will improve resiliency and allow for greater event capacity. This system requires
integration of data from multiple sources (such as surveillance data, laboratory
results, the intelligence community, and the media) into succinct and accessible
reports for decision-makers.
To achieve better public health surveillance, and thus improve global security,
implementers can build upon existing response services to identify gaps and effi-
ciently use the technology that is available. Use of technologies in an innovative
way, such as the use of Short Message Service (SMS) to distribute health messages
to attendees, is one example of this strategy (WHO 2015).
Regulations, Legislation, and Policy
The development of a public health surveillance system may seem like a large, daunting
task. However, this investment can effectively reduce overall costs and keep populations
safe over time. To achieve this, decision-makers must revise policy, regulation, and
legislation to create plans that are cost-effective and appropriate to improve health
outcomes at mass gatherings. Support of the government and cooperation between all
stakeholders, while learning from past incidents, is key to public health preparedness for
such mass gatherings (Aleeban and Mackey 2016; WHO 2015).
Emergency Planning and Response
The next step requires emergency planning and response arrangements that are both
coordinated and efficient. Key players must understand their roles and responsibil-
ities. A robust emergency response system is one that is tested, evaluated, adaptable,
and adjustable (Tsouros and Efstathiou 2007; WHO 2015).
Environmental Health
Attention to the environment where the mass gathering takes place is a critical
component for the health of gatherers. Air quality maintenance, frequent decontam-
ination of the event site, improved hygiene and waste disposal facilities, enforcement
of food safety practices, safe drinking water, and an infrastructure to reduce
foodborne diseases are all essential elements that impact the wellbeing of the public
(Tsouros and Efstathiou 2007; WHO 2015).
Public Health Awareness
The healthier and more prepared attendees are during the mass gathering, the more
likely the event will be successful. To ensure the success of a gathering, efforts should
be made to inform the public of imposing risks and actions they can take to prepare
before they attend. Examples of this include vaccination campaigns, information
about environmental conditions, as well as the level of fitness or stamina needed to
safely participate. Open access to health and safety information can enhance relation-
ships and trust between governments, health officials, and the people, thereby,
improving the credibility of health organizations as an authoritative voice for public
health issues (Alqahtani et al. 2015; Rahman et al. 2016; WHO 2015).
Strengthening Communication
Improved communications across all stakeholders, including the host country’s

government, agencies, the private sector, the public, and all the organizers increase
the understanding of roles and responsibilities toward reducing the risk associated
with mass gatherings and providing the best prevention (WHO 2015).
Internal Organizational and Capability Building
To ensure sustainable systems that can handle repeat mass gatherings and improve
the quality of future events, internal organizations must build capacity with all
stakeholders by working to improve working arrangements, ensure understanding
of roles and responsibilities, and improve the working arrangements for all
national and international partners (WHO 2015).
Hajj and Umrah
The Hajj and Umrah religious mass gatherings hosted by the Kingdom of Saudi
Arabia (KSA) have historically challenged the existing public health systems and
has provided important case studies for mass gathering preparedness. The largest
annual pilgrimage to Mecca KSA, is the Hajj, a geographically and ethnically
diverse mass gathering.
Performing Umrah is not obligatory and can be a smaller scale pilgrimage than
Hajj, but not necessarily. Unlike Hajj, Umrah does not have a fixed time or date to be
performed, but there are times when the gatherings rival those of the Hajj pilgrimage,
such as those pilgrimages which occur during the last 10 days of Ramadan. Hajj is
the fifth pillar of Islam and is a mandatory religious duty for financially and
physically able-bodied Muslims. In it, pilgrims follow the footsteps of Prophet
Ibrahim (one of the Prophets of Islam) and his family. The Hajj Pilgrimage occurs
from the 8th to the 12th of Dhul al-Hijah, the last (12th) month of the Islamic (lunar)
calendar. This holy journey requires pilgrims to perform 10 rituals before and during
Hajj.
Upon arrival at the entrance of the Holy City, pilgrims from more than 185
countries enter the state of ihram or state of purity where they remain throughout
the Hajj. Males in the state of ihram wear two white seamless sheets wrapped around
their bodies and sandals. This practice signifies the state of holiness and contributes
to the sense of equality through the removal of materialistic signs of wealth, class,
and culture. For women, during the state of ihram, normal white clothing is worn
with only their faces and hands uncovered. In the state of ihram, pilgrims are
prohibited from cutting their hair and nails, engaging in sexual activity, and acts of
violent behavior (Armstrong 2002).
Eid al-Adha is the 10th day of Hajj, a major holiday observed by all Muslims.
For Hajj participants, the day is spent in Mina. Pilgrims sacrifice an animal in
commemoration of Abraham’s sacrificing his son Ismail, along with throwing
seven small stones at each of the three pillars. The pillars are symbolic of the
devil, and pilgrims throw stones at the pillars for three consecutive days. The
pilgrims then return to Mecca where they perform Tawaf for the second time.
Pilgrims shave or trim their hair marking the completion and state of ihram (Arm-
strong 2002). This religious event lasts for 5 days and attracts over two million
Muslims from around the world.
The approximately three million pilgrims are hosted in a relatively small area,
many of whom are housed in the tent city of Mina. In the first place, this global mass
gathering poses a risk for transmission of infectious diseases on a mass scale.
The tent city also poses several serious public health concerns, for in addition to
the language barriers and sheer mass of the gathering, the gatherers are so focused on
their purpose that bodily or physical concerns may be put off or disregarded for the
duration of the pilgrimage. The diversity of the group creates a barrier for the
dissemination of knowledge and precautionary measures, thus an informational
dearth is automatically a cause for concern. In addition to that, however, there is
the practical issue of national origin. The transmission of diseases not picked up by
preliminary physical examinations will be carried from person to person and,
ultimately, from country to country. The way these pathogens and illnesses behave
in their new environments can be unpredictable, and the physical space of the
gathering becomes a concern for susceptible members of the groups, such as the
elderly and those without adequate prior protection against infection and disease.
In addition to the risk of imported pathogens heightening the risk of infectious
diseases spreading worldwide, the size of the gathering is at risk for various
structural dangers. Vehicular accidents, structural issues, and stampedes are
examples of risks posed by size and mass and close quarters. Stampedes, which can
be attributed to inaccurate transmissions of information and language barriers as well
as sheer size, are another risk posed by a mass gathering (Alaska et al. 2016). Due to
the size and scope of this event, prior incidents of infectious disease transmission,
injuries due to stampedes, and motor vehicle accidents, there is an important
opportunity for collaboration between the host country and pilgrims to minimize
the risk of illness and promote the best prevention and health promotion guidelines.
In regard to the public health issues relating to the Hajj and the Umrah and the
nature of mass gatherings, this chapter will address communicable issues such as the
transmission of infectious diseases, the preventative measures taken such as risk
assessments and disaster preparedness, and noninfectious or noncommunicable
issues such as structural failures and physical injury.
Outbreaks and Response
Like all mass gatherings, there is an increased risk for pilgrims to contract and spread
certain infectious diseases due to the environmental conditions at the Hajj.
The communicable risks associated with mass gatherings are less relevant to their
size and the population, and more a result of global travel and behavioral practices at
mass gathering events.
Several factors contribute to the prevalence of these transmittable diseases,
including direct contact with infected people, climatic conditions, overcrowding,
cigarette smoking, and exposure to allergens, which are the main contributing factors
present in the Hajj environment. Under these circumstances, it is not surprising to
find that a significant number of pilgrims have an attack of one or more infectious
disease during or immediately after the Hajj performance (Shafi et al. 2016). Such a
high incidence of illness causes a significant burden to Hajj pilgrims. In addition, it is
also important to consider that pilgrims can be a source of infectious disease
transmission on their return home, making the infectious transmission a global
health risk (Gautret et al. 2016; Shafi et al. 2016; Yezli et al. 2017; Abd El Ghany
et al. 2017; Shirah et al. 2017).
Historically, infectious disease outbreaks were common during Hajj in the nine-
teenth and twentieth centuries. For example, meningococcal diseases had large
outbreaks in the late 1980s and early 2000s (Lingappa et al. 2003). The outbreaks
prompted Saudi authorities to implement prevention efforts and policies, investing in
strict vaccination and chemoprophylaxis policies (Yezli et al. 2016). Although
improvements have been realized in some cases, proactive surveillance of the
transmission of potential epidemic threats at Hajj are critical and must be sustained
to continue to preserve global health at mass gatherings (Shafi et al. 2016).
The Middle East respiratory syndrome coronavirus (MERS-CoV), meningococ-
cal disease, diarrheal disease, and respiratory illnesses such as seasonal influenza and
pandemic H1N1 are the most common outbreaks that travelers and organizers need
to combat and protect against (US Centers for Disease Control and Prevention
(CDC) 2015; United States Department of State [Overseas Security Advisory
Council (OSAC)] 2015; Finger et al. 2016; Alqahtani et al. 2016a); Al-Tawfiq et al.
2016, and health officials are worried that pilgrims may acquire the coronavirus that
causes Middle East respiratory syndrome (MERS) when they travel to Mecca and
unknowingly take it back to their home country, thus, spreading it globally (Coghlan
2015).
A major historical concern at Hajj was an isolated case of MERS-CoV identified
in a 68-year-old patient, dying of pneumonia and multiorgan failure in Jeddah in
June 2012 (Zaki et al. 2012). While the concern of the virus becoming an epidemic is
low, there has been an increase in cases in the region (Zumla et al. 2016). Serological
studies show that MERS-CoV was a common infection in dromedary camels
approximately 20 years ago, and there is accumulating evidence that the sporadic
human outbreaks are seeded by zoonotic infection from camels.
The past three Hajj pilgrimages were completed without an increase in travel-
related MERS-CoV cases. However, KSA authorities prepared for the potential
emergence of MERS-CoV with existing healthcare systems in place and resources
to address such cases. Health officials of other healthcare institutions and countries
have been vigilant in their efforts advising pilgrims to take precautions to minimize
health risks. Pilgrims with chronic medical conditions such as diabetes or chronic
heart failure, or individuals, who are immune-compromised, are at an increased risk
of MERS-CoV disease and should seek medical consultation before performing
Hajj. The risk of MERS-CoV is more apparent after exposure to camels or camel
products. Therefore, pilgrims are advised to avoid visiting areas where camels
congregate, and avoid consuming camel products or foods contaminated with
camel secretions. Pilgrims exposed to the virus are advised to seek medical attention
promptly and should inform their clinician of their travel to KSA (Zumla et al. 2016).
Today, there are steps that authorities, clinicians, and pilgrims can take to reduce the
risks of these outbreaks.
Hajj Planning
How to Stay Safe: Individual Traveler
Pre-travel Preparation
While vaccination is an important control measure for the prevention of
disease outbreaks during Hajj, health education is also critical in preventing disease
(Ministry of Health Saudi Arabia 2017). Pilgrims should seek advice about the
health risks before traveling to the KSA for Hajj/Umrah. Health advice can be
provided by Hajj travel agents, tour guides, and healthcare professionals who are
involved in planning interventions to educate pilgrims about possible diseases and
how to avoid them (Shafi et al. 2016; Alqahtani et al. 2015, 2016a).
Pilgrims also should be up to date on routine vaccinations, and see their
healthcare professional before traveling to get advice on vaccinations, food and
water intake, best hygiene practices, and injury prevention (Ministry of Health Saudi
Arabia 2017). In addition, healthcare professionals should ensure that pilgrims are
Table 1 Common health recommendations to Hajj pilgrims to curb the spread of disease during
Hajj/Umrah
Personal Wash hands with soap and water or disinfectant, especially after coughing or
hygiene sneezing, after using the toilet, before handling and consuming food, and after
touching objects and animals
Use disposable tissues when coughing or sneezing and dispose of them in the
dustbin
Avoid touching the eyes, nose, and mouth with hands
In public Avoid direct contact with people who appear to be ill (i.e., who are coughing,
sneezing, vomiting, or have diarrhea)
Do not share personal belongings
Wear a mask when in crowded places
Around Avoid contact with animals
animals Avoid drinking raw camel milk or eating meat that has been cooked improperly
Ministry of Health Saudi Arabia (2017): Health Guidelines during Hajj
physically fit before traveling, discuss the suitability of travel with pilgrims who
have pre-existing medical conditions, and ensure that pilgrims have a sufficient
supply of their medications and carry a copy of necessary prescriptions (United
States Department of State 2015).
Healthcare professionals should emphasize the importance of pilgrims to adhere
to the Ministry of Health (MOH) of KSA recommendations (Table 1) and comply
with health guidelines to prevent the spread of diseases during Hajj/Umrah season:
Pilgrims also have an important role in maintaining public health during Hajj/
Umrah. Pilgrims must have their vaccination certificate ready for inspection by
Saudi authorities at the port of entry (Bowron and Salahudin 2015). In addition to
the standard vaccination requirements, there are additional vaccines necessary for
entry to Saudi Arabia particularly during Hajj and Umrah seasons. Vaccinations for
travelers are listed in Table 2.
Zika Virus and Dengue Fever

Zika virus infection was at its peak during Hajj season of 2016 presenting concerns
of the possibility of transmission of the infection due to the virus at Hajj. No
human infection from Zika virus was reported from countries in the WHO Eastern
Mediterranean Region, yet there has been serologic evidence of the circulation of the
Zika virus reported in at least two countries, Pakistan and Egypt (Ahmed et al. 2016).
Circulation of the virus is expected since various countries in the WHO Eastern
Mediterranean region, such as Saudi Arabia, have a heavy infestation of Aedes
aegypti and Aedes albopictus, which are the vectors responsible for the transmission
of Zika virus, dengue, and chikungunya (Ahmed et al. 2016).
During Hajj, women are fully clothed making mosquito bites unlikely in
comparison to Hajj attire for men, which is less restrictive. Attire for men leaves
the right shoulder, neck, and head exposed making mosquito bites a more likely
occurrence. Zika has been documented as being carried in semen; therefore, leaving
the potential to transmit the virus during post-Hajj sexual intercourse.
Table 2 Required and recommended vaccinations for Hajj attendees

Recommended Required
vaccines Description vaccines Description
Hepatitis A Hajj conditions (low food Meningococcal Visitors of the Umrah/Hajj
hygiene standards, sharing meningitis are required to receive the
common toilets), pilgrim tetravalent (ACYW135)
behaviors and ritual vaccine to protect against
activities (share/reuse of meningitis. It should be
razor blades for mandatory received no more than
head shaving for men, 3 years or less than 10 days
improper disposal of razor prior to arrival. KSA
blades, cuts when requires proof of all
sacrificing animals) lead to vaccination upon arrival
increase food-borne for Hajj pilgrims. Hajj has
(hepatitis A virus (HAV). been associated with
The WHO (2016a) outbreaks of
suggests inactivated meningococcal disease in
hepatitis A vaccines have a returning pilgrims and
long-lasting protective people in close contact
efficacy of 90–95% in both with them, making
children and adults. Two- vaccination crucial for all
dose vaccination schedule attendees.
is preferred, but one dose
also induces similar
responses (Abd El Ghany
et al. 2016); Rafiq et al.
2009).
Seasonal The Ministry of Health of Poliomyelitis Documentation is required
Influenza Saudi Arabia recommends for oral polio vaccine
receiving the most recent (OPV) or inactivated
influenza vaccine before poliovirus vaccine (IPV)
arrival to KSA. Influenza regardless of age and
vaccine is highly vaccination status
recommended for pregnant (Ministry of Health Saudi
women, children > Arabia 2017). This vaccine
5 years, elderly, and is required within 4 weeks
individuals who are to a year prior to departure
immune-compromised and for Saudi Arabia and entry
have pre-existing chronic visa for pilgrims arriving
conditions. The from the following
vaccination is further countries, territories or
recommended for internal areas:
pilgrims in Saudi Arabia 1. Populations with
who have the same pre- endemic virus
existing health conditions transmission: Afghanistan,
aforementioned as well as Nigeria, and Pakistan;
healthcare workers within 2. Populations with
the vicinity of Hajj and circulating vaccine-derived
Umrah (Algarni et al. poliovirus within the past
2016). 12 months: Cameroon and
Typhoid The Typhoid vaccine is Somalia;
recommended for almost 3. Populations that remain
(continued)
Table 2 (continued)
all international travelers. vulnerable to polio:
Hajj pilgrims can get Equatorial Guinea,
Typhoid through Ethiopia, Iraq, Palestine
contaminated food or water (the West Bank and Gaza
in Saudi Arabia. The CDC Strip), Syrian Arab
(2017) recommends this Republic and Yemen.
vaccine for most travelers, Travelers from these
especially if they are countries will receive an
staying with friends or additional dose of OPV at
relatives and/or visiting border checkpoints upon
smaller cities or rural areas. arrival in Saudi Arabia.
Varicella CDC (2017) recommends It is encouraged for
(chicken pox) that all travelers to Saudi travelers from polio-free
Arabia are up to date on countries to be vaccinated
their Varicella vaccines. as well as they may be at
Diphtheria The Centers for Disease particular risk of
Control and Prevention importation (Algarni et al.
(2017) recommends that all 2016).
travelers to Saudi Arabia
are up to date on their
Diphtheria vaccines.
Tetanus The CDC (2017)
recommends that all
travelers to Saudi Arabia
are up-to- date on their
Tetanus vaccines. If
pilgrims have not received
a Tetanus booster within
the past 10 years, it is
recommended that this is
received before travel to
Saudi Arabia.
Malaria Pilgrims may need to take Yellow fever All travelers from regions
prescription medication with yellow fever
before, during, and after prevalence are required to
their trip to prevent have yellow fever
malaria, depending on their vaccination certificates
travel plans. Hajj pilgrims (Ministry of Health Saudi
should consult their Arabia 2017). WHO
medical professional to regularly updates the list of
discuss where they are countries that are at risk for
traveling, when they are yellow fever. Travelers
traveling, and if they are should check this list or
spending a lot of time discuss with their health
outdoors or sleeping providers prior to traveling
outside. (WHO 2016b). As at 2017,
affected countries include:
(continued)
Table 2 (continued)
Pneumonia It is recommended that all Angola, Argentina, Benin,
children under the age of Bolivia, Brazil, Burkina
five and all adults over the Faso, Burundi, Cameroon,
age of 50 who are traveling Central African Republic,
to Saudi Arabia for Hajj Chad, Colombia, Congo,
receive the STS Cote d’Ivoire, Democratic
pneumococcal vaccination Republic of the Congo,
before traveling (Alharbi Ecuador, Equatorial Guinea,
et al. 2016). Ethiopia, French Guiana,
Measles/ With a recent resurgence in Gabon, Guinea, Guinea-
Mumps/ cases of Measles and Bissau, Gambia, Ghana,
Rubella Rubella cases in Saudi Guyana, Kenya, Liberia,
Arabia, it is recommended Mali, Mauritania, Niger,
that any travelers to the Nigeria, Panama, Paraguay,
country, including those Peru, Rwanda, Senegal,
traveling to Hajj, are up-to- Sierra Leone, Sudan, South
date on their MMR Sudan, Suriname, Trinidad
vaccines (CDC 2017). and Tobago, Togo, Uganda
and Venezuela.
Additionally, due to the dry climate in Saudi Arabia, it is a common practice for
families to store water in shady areas of their homes leaving a suitable environment
for mosquitoes to breed. Therefore, vector control is critical. Every Hajj season, the
environmental team of the Saudi Ministry of Health focuses strategies on curtailing
vector-human interfaces including indoor residual spraying, insecticide-treated nets,
and protected windows and doorways since Aedes aegyptei are known to bite during
the day. The precautions are conducted in advance of Hajj and after Hajj, in addition
to continued health education efforts run by the Ministry of Health providing best
practices for personal mosquito bite prevention and prevention of the emergence of a
potential Zika or Dengue outbreak in Hajj premises (Ahmed et al. 2016).
Other Considerations
In addition to seeking preventative medical care and ensuring proper vaccination,
pilgrims can take practical steps to stay safe and healthy during their journey.
The steps include attention to food safety, sanitary conditions, accidents and injuries,
and environmental hazards such as cold or heat exhaustion (Ministry of Health
Saudi Arabia 2017).
Food Safety
Acute food poisoning and gastroenteritis are common during Hajj (Abd El Ghany
et al. 2017). Risk factors for transmission of gastrointestinal (GI) diseases include
contaminated food through unhygienic preparation, improper food storage, contam-
inated water sources, and improper food handling. Hajj occurs during the extreme
heat of the summer season in the KSA, which increases the risk of dehydration for
pilgrims (Shafi et al. 2016).
To mitigate these risks, officials in the KSA have implemented measures to

ensure food safety. The Ministry of Health restricts pilgrims from bringing fresh
food and agricultural products into the country (Shafi et al. 2016). Approved sealed
or canned food and food stored in containers with easy access for inspection are
allowed in small quantities that are sufficient for one person for the duration of the
trip (Algarni et al. 2016). The pilgrim should make sure food is healthy and
free from microbes, bacteria, or parasites.
Contaminated food and water often pose a risk for pilgrims therefore food should
be selected with care. Undercooked or raw meat and fish (including shellfish) can
carry various intestinal and systemic pathogens. Pilgrims should also avoid consum-
ing salads, unpasteurized juices, and milk in areas where hygiene and sanitation are
inadequate or unknown. Perishable cooked food should always be refrigerated and
expiration date on canned items should also be checked.
Pilgrims should be aware not to consume exposed food, as the consumption of
food and beverages obtained from street vendors has been associated with an
increased risk of illness.
Proper food preparation and handling, washing fresh fruits and vegetables thor-
oughly, and cooking meat well reduces contamination. Adequate fluid intake of
minerals from trusted sources replenishes electrolytes throughout the body (United
State Department of State’s Bureau of Consular Affair 2017).
The Saudi Food and Drug Authority also recommends that pilgrims be aware of
street vendors as food is often prepared in unsanitary conditions causing the spread
of microbes that cause foodborne illnesses. When a foodborne illness situation
occurs, a pilgrim should look for symptoms of fever, nausea, vomiting, and diarrhea.
In such cases, the pilgrim should be taken to the nearest hospital for medical
attention, identify the food in question, and take the necessary precaution to prevent
recurrence and further transmission (Saudi Food and Drug Authority 2018).
In summary, food safety tips include washing fruits and vegetables, washing
hands before eating or preparing food, eating cooked food immediately, and
avoiding food storage on buses or other means of transportation for extended periods
of time. The aforementioned tips decrease the risk of food poisoning
significantly (Ministry of Health Saudi Arabia 2017).
General Hygiene and Cleanliness

Pilgrims can take simple steps to reduce the risk of infections by maintaining personal
hygiene and staying clean. Regular bathing and washing hands with soap and water can
reduce the risk of becoming ill. All individuals can use a face mask in crowded places,
properly dispose of waste in sanitary bins, and avoid spitting on the floor to reduce the
spread of potential infectious agents (Ministry of Health Saudi Arabia 2017).
Accidents and Injuries

Accidents and injuries are common among pilgrims. A large number of Hajj pilgrims
have to travel by foot walking long distances through dense traffic or motor vehicles.
Road traffic accidents are also a potential hazard, which contribute to causalities and
deaths during Hajj (Shujaa and Alhamid 2015; Dong et al. 2017; Alqahtani et al. 2017).
Minor injuries to the feet are relatively common, particularly among pilgrims
with diabetes, while walking long distances. All foot injuries associated with other
health conditions such as diabetes should be assessed carefully by healthcare pro-
fessionals (Ministry of Health Saudi Arabia 2017).
Stampede is perhaps the most serious injury-causing event that occurs during Hajj.
As pilgrims undertake the stoning rite or other mass activities, stampede can contribute
to fatalities. In such large crowds, causalities can result from asphyxiation or head
injuries in which emergency assistance is difficult to obtain quickly (Shujaa and
Alhamid 2015). Significant improvements and modifications have been made by the
Saudi Government to ensure the safety of pilgrims and reduce the risk of crowding
such as the use of crowd simulation models, assessment of the efficient ways of
grouping and scheduling pilgrims, luggage management, video monitoring, and
changes in the transport system are the latest measures to improve the management
of the pilgrimage event. (Klüpfel 2007; United States Department of State 2015).
Environmental Hazards
In summer, temperatures can rise higher than 45 C, which can put pilgrims at risk
for heat exhaustion, heat stroke, and dehydration (Shujaa and Alhamid 2015).
With the lack of acclimatization, inadequate rest, and exposed spaces with limited
or no shade, heat stroke can occur among many pilgrims. Hajj pilgrims should be
advised to have adequate rest, maintain hydration with safe liquids, seek shade or use
umbrellas, perform rituals at night, and wear high-sun protection factor (SPF)
sunblock (Ministry of Health Saudi Arabia 2017).
The Saudi Ministry of Health has endeavored to provide shade in most of the
crowded areas. Water mist sprays have been implemented for regular operation at
the time of high risk for heat stroke as pilgrims may stand for periods of time during
the day (Ministry of Health Saudi Arabia 2017).
Non-pharmaceutical Interventions
The use of face masks and other such non-pharmaceutical methods to combat and
mitigate the effects of exposure to pathogens and high-risk environments is a
common alternate route to preventative measures taken by pilgrims and travelers.
The face mask, an affordable and effective way to prevent and protect travelers and
visitors from risks associated with transmittable and infectious airborne diseases
(Wang et al. 2015).
How to Stay Safe: Role of Health Authorities
Travelers should consult with their medical provider at least 4–6 weeks in advance of
departure to allow for adequate time to receive the recommended and required
vaccinations for travel and discuss their medical history during their pre-travel
consultation. Clinicians should reiterate the risks associated with the mass gatherings
by identifying travel requirements and personal hygiene recommendations. For
example, individuals performing Hajj are required to receive the quadrivalent
meningococcal vaccine before traveling to the KSA, whereas other travelers to the
KSA are not required to receive the vaccine (Center for Disease Control 2016; Yezli
et al. 2016; Al-Tawfiq et al. 2018).
For many non-Muslim healthcare providers, the care of Muslim patients provides
challenges. Cultural competency is an important aspect to aid healthcare profes-
sionals in delivering appropriate healthcare in culturally sensitive manner. Through
understanding religious beliefs, health and illness as well as privacy concerns. All
healthcare providers should be able to provide culturally competent care and can
discuss travel itinerary, planned activities, and any travel recommendations provided
by host sites to ensure the health and safety of pilgrims. For example, in response to
the emergence in 2013 of MERS-CoV, health officials of Saudi Arabia
recommended that the elderly or individuals with an immune-compromised system
reschedule their pilgrimage. Clinicians should make pilgrims aware of preventive
measures during their travel, such as practicing good hand hygiene and choosing
safe food and water sources (United States Department of State 2015).
Government Preparedness
The KSA uses a well-coordinated, inter-sectoral approach to the planning, communi-

cations, public health, and safety issues of Hajj. Plans for Hajj begin immediately at
the end of the current Hajj and the KSA Ministry of Hajj and Ministry of Health liaise
along with government officials from the countries of pilgrims attending. Recommen-
dations are discussed for pre-travel health regulations, advice on vaccinations, health
checks, and specific immunizations required at the port of entry (Shafi et al. 2016).
Prior to the upcoming Hajj, the KSA Ministry of Health prepares public
health communications on the health requirements for the issuance of travel visas.
Health education campaigns are conducted through educational materials and
resources to travel agents, pilgrim group leaders, websites, and the media before and
during Hajj (Shafi et al. 2016; Alzahrani and Kyratsis 2017). The KSA Government
also provides regular updates on Hajj travel guidance and health regulations through
international public health agencies such as the WHO, Public Health England, the
Centers for Disease Control and Prevention (CDC), and Hajj travel agencies.
During Hajj, an additional 25,000 health workers are deployed, and eight
hospitals with state of-the-art equipment and intensive care units are made available
specifically for pilgrims (Ministry of Health Saudi Arabia 2017). All medical
facilities offer high-quality healthcare and services free to Hajj pilgrims to minimize
adverse health risks.
Relevant Procedures Pertaining to Travel
Travelers must ensure all immunizations and health records are up-to-date and
prepare an adequate supply of hand hygiene products and medications for any pre-
existing illnesses and prevention. Transportation is provided upon arrival, and
travelers must expect longer wait times for public transit. Pilgrims must also follow
the guidance on bringing religious articles back to their country of origin for their
own safety and health (United State Department of State’s Bureau of Consular
Affair 2017).
Health Education
Governments and health authorities are required to provide information to traveling

pilgrims on infectious diseases and noncommunicable diseases, modes of transmis-
sion, methods of prevention, and public health implications (Algarni et al. 2016;
Alqahtani et al. 2016a). For example, an article announced the Ministry of Health
and Prevention launched an awareness campaign focusing on health and safety for
Hajj pilgrims (MENA Herald 2016). The aim was to ensure the safety and health of
Hajj pilgrim in cooperation with the Health Authority-Abu Dhabi (HAAD) and the
Dubai Health Authority (DHA). The campaign focused on the well-being of pil-
grims; especially the elderly and individuals suffering from chronic illnesses regard-
less of age. The campaign included medical advice on heat exhaustion, awareness
about healthy foods, personal care, emergency medicine, and available vaccines
(MENA Herald 2016).
The KSA Ministry of Health represented by the Awareness and Health Promotion
General Department, in collaboration with the Sanofi Company, launched a similar
health campaign entitled “Together for a Healthy Pilgrimage.” The objective of
the campaign was to promote awareness among pilgrims about the health require-
ments during the 2016 Hajj season with a key focus on vaccinations and health
misconceptions among pilgrims performing Hajj rituals (Ministry of Health Saudi
Arabia 2017). The campaign was printed in 10 languages with numerous numbers of
publications for distribution to pilgrims inside and outside the KSA. Also, the
campaign produced four awareness films including health tips and guidelines on
heat exhaustion, sunstrokes, food poisoning, and infection control as well as an
awareness application about pilgrimage (Ministry of Health Saudi Arabia 2017).
Conclusion
Decision-makers, government officials, health service providers, and attendees all

play a role in the success, health, and safety of a mass gathering. For a mass
gathering to be successful in promoting and maintaining public health throughout
the event, a public health surveillance system; strong regulations, legislation, and
policies; and thorough emergency planning and response arrangements are needed.
Attention to the environment; strong communication systems taking advantage of
technology as well as ongoing capacity building are essential for public health
preparedness. The implementation of a framework that has a strong foundation
including these key aspects should be the top priority for individuals organizing
mass gatherings, including Hajj/Umrah.
The primary gap in knowledge according to the research is in the behavioral
effects of mass gatherings, rather than the dangers of having a large population
gathering in one area. The literature which does not take into account mass behavior
patterns associated with ritual, with religious pilgrimage, and with traditions tends to
prioritize a reading that emphasizes the gathering’s size over its behavioral aspect.
Pilgrims attending Hajj must make themselves aware of the necessary precautions
and discuss these issues with their healthcare provider. Such precautions include
maintaining routine hygiene including hand washing, taking care in food prepara-
tion, and accessing safe water sources. Such basic advice may seem commonplace
for any type of travel; however, the nature of attendance at such a mass gathering
such as Hajj can make basic travel precautions more difficult to maintain.
In knowing this, the KSA officials make every attempt to provide detailed public
health information to pilgrims attending Hajj, including familiarizing them with the
compliance that is expected before pilgrims begin their journey.
Pilgrims attending Hajj can take steps themselves to ensure they return home safe
and healthy. Receiving proper vaccinations, talking with a medical provider, and
bringing appropriate supplies before traveling will allow for a safer and healthier
experience. The ability to access information, taking steps to ensure health hygiene
habits, and being aware of exit avenues and emergency procedures and services
during the gathering will help ensure health and safety for all. Knowledge from past
situations and teaching future pilgrims can build upon the experiences of pilgrims
and translate that information to future attendees.
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Middle East Respiratory Syndrome
Coronavirus (MERS-CoV) and Hajj 49
Gatherings
Jaffar A. Al-Tawfiq, Mamunur Rahman Malik, and Ziad A. Memish
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1238
Middle East Respiratory Syndrome Coronavirus (MERS-CoV): The Virus . . . . . . . . . . . . . . . . . . 1239
Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1239
History of MERS-CoV in Relation to the Hajj . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1240
Systematic Screening for MERS-CoV Among Attendees of the Annual Hajj . . . . . . . . . . . . . . . . 1241
Recommendations for Pilgrims in Relation to MERS-CoV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1243
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1244
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1244
Abstract
Hajj, the Pilgrimage to the Holy City of Makkah, Saudi Arabia, is one of the
largest mass gatherings in the world. Due to overcrowding, there is a risk of the
transmission of infectious diseases from person to person, especially the risk of
respiratory diseases. Since the emergence of Middle East Respiratory Syndrome
Coronavirus, there was a significant interest in the risk that this posed to the Hajj.
J. A. Al-Tawfiq (*)
Specialty Internal Medicine and Quality Department, Johns Hopkins Aramco Healthcare,
Dhahran, Saudi Arabia
Indiana University School of Medicine, Indianapolis, IN, USA
Johns Hopkins University School of Medicine, Baltimore, MD, USA
e-mail: jaltawfi@yahoo.com
M. R. Malik
Eastern Mediterranean Regional Office of WHO, Cairo, Egypt
e-mail: malikm@who.int
Z. A. Memish
College of Medicine, AlFaisal University, Riyadh, Kingdom of Saudi Arabia
e-mail: zmemish@yahoo.com

https://doi.org/10.1007/978-3-030-36811-1_49
1238 J. A. Al-Tawfiq et al.
So far, there had been systematic surveillance of the virus among returning
pilgrims and no cases were identified in relation to the Hajj. However, there
were two reported MERS-CoV cases related to the mini-Hajj, Umrah, in May
2014. Continued surveillance and vigilance are required to monitor and evaluate
the risk in the future.
Keywords
Hajj · Pilgrimage · Mass gathering · MERS-CoV · Middle East respiratory
syndrome coronavirus
Introduction
Hajj, the pilgrimage to the holy city of Makkah, Saudi Arabia, is one of the largest
mass gatherings in the world. Due to overcrowding, there is a risk of the transmission
of infectious diseases from person-to-person, contaminated food or water, respira-
tory droplet, airborne transmission, and vector-borne transmission (Al-Tawfiq and
Memish 2012a, 2015a; Gautret et al. 2016a). The potential for outbreaks due to
person-to-person transmission, food and waterborne disease outbreak, fast and wide
geographic spread of diseases, and the introduction of non-endemic diseases are all
fearful events during mass gathering. Possible communicable diseases pattern during
mass gathering includes endemic diseases and imported and exported diseases.
The Hajj draws 3 million Muslims annually, and of these pilgrims, there are 2
million non-Saudis. The majority of 89% travel by air (Al-Tawfiq and Memish
2012a) from more than 180 countries. The Hajj journey is well described (Memish
et al. 2014a). Pilgrims visit the Holy mosque in Makkah, the Plain of Arafat,
Muzdaliffah, and Mina where pilgrims stay in tents made particularly for pilgrims
(Memish et al. 2014a).
The Saudi Ministry of Health pays particular attention to the Hajj with multiple
committees. The preventive medicine committee oversees all public health and
preventative matters during the Hajj (Memish et al. 2014a; Al-Tawfiq and Memish
2014a). The Kingdom of Saudi Arabia deploys a large number of public health
officers to ensure compliance with health requirements. Those healthcare workers
ensure compliance with required immunization and administer mandatory prophy-
lactic medications (Memish 2010). There are strong public health teams who
diligently monitor the occurrence of communicable diseases using an electronic
surveillance (Al-Tawfiq and Memish 2012b). The surveillance particularly monitors
influenza, influenza-like illness, meningococcal disease, food poisoning, viral hem-
orrhagic fevers, yellow fever, cholera, polio, and plague (Memish 2010; Al-Tawfiq
and Memish 2012b). With the emergence of Middle East respiratory syndrome
coronavirus (MERS-CoV), the disease became also a focus of surveillance espe-
cially during the Hajj. Coronaviruses other than MERS-CoV were detected in
49 Middle East Respiratory Syndrome Coronavirus (MERS-CoV) and Hajj Gatherings 1239
0.6–0.8% of the tested population in regard to the Hajj seasons (Al-Tawfiq and
Memish 2012b).
Middle East Respiratory Syndrome Coronavirus (MERS-CoV): The

Virus
Human coronaviruses cause acute respiratory illness in humans and include Alpha-
and Betacoronavirus genera. Betacoronaviruses are divided into four clades
(A–D). MERS-CoV is a member of the human betacoronaviruses MERS-CoV
and is classified in Clade C (lineage 3). Similar to the severe acute respiratory
syndrome (SARS)-CoV, MERS-CoV is a positive-strand RNA virus. MERS-CoV
genome has more than 30,000 nucleotides with 7 predicted open reading frames
(ORFs) and 4 structural genes expressing 4 proteins, namely the spike (S) protein,
nucleocapsid (N), membrane (M), and envelope (E) proteins (Cotten et al. 2013,
2014). The closest coronavirus to MERS-CoV are Clade C betacoronaviruses,
Tylonycteris bat virus HKU4, Neoromicia zuluensis bat in South Africa, and
Pipistrellus bat HKU5 virus (Corman et al. 2014; Ithete et al. 2013; van Boheemen
et al. 2012).
Clinical Presentation
MERS-CoV causes a range of respiratory illness from a mild disease to a severe and
life threatening infection. In one study, a three-phase illness was described and
included the initial phase of fever and clinical stability probably representing viral
replication, followed by an immunologic phase with clinical and radiographic
deterioration and subsequent improvement (Al-Tawfiq and Hinedi 2018). In addi-
tion, asymptomatic cases had been described. Asymptomatic cases were reported
in 12.5% of 144 confirmed MERS-CoV cases in 2012, and this rate was 25.1%
among 255 confirmed cases (Al-Tawfiq and Gautret 2018). In children, the rate of
asymptomatic cases ranged between 41.9% and 81.8% (Al-Tawfiq and Gautret
2018; Alfaraj et al. 2018; Al-Tawfiq et al. 2016a; Thabet et al. 2015; Memish et al.
2014b). There are three patterns of MERS-CoV infection: isolated sporadic cases,
intra-family clusters, and healthcare-associated infections (Al-Tawfiq and Auwaerter
2018). The clinical presentation of most cases is consistent with respiratory illness
and 33% of patients may have nausea, vomiting, or diarrhea (Al-Tawfiq et al.
2016b). Early symptoms are mild and nonspecific which last several days prior to
progressing to severe pneumonia. There are no predictive signs or symptoms to
differentiate MERS-CoV from community acquired pneumonia in hospitalized
patients (World Health Organization 2015). There is an apparent heterogeneity
in transmission. Severe disease is usually seen in primary or index cases, immuno-
compromised, and people with underlying comorbidities. Mild or asymptomatic
disease usually occurs in secondary cases and was initially thought to be only in the
young and previously healthy individuals. However, mortalities and severe cases
were seen among primary cases and among young individuals (Corman et al. 2014).
Although person-to-person transmission is definite, the route of transmission is still
not clear. The median incubation period was 5.2 days (95% CI, 1.9–14.7), and the
serial interval was 7.6 days (95% CI, 2.5–23.1) (Assiri et al. 2013b).
There are few studies describing co-infection of MERS-CoV with influenza A,
parainfluenza, herpes simplex, and Streptococcus pneumonia and tuberculosis
(Alfaraj et al. 2017a, b; World Health Organization 2013).
MERS-CoV infection carries a case fatality rate of 40–60% (Al-Tawfiq and
Memish 2014b; Assiri et al. 2013a, b; Penttinen et al. 2013). Lower case-fatality
rates of 20% were reported in two studies from Saudi Arabia and South Korea. The
current study included a larger number of patients spanning a longer duration and the
case fatality rate was only 20% (Al-Tawfiq et al. 2017; Ki 2015). Variable laboratory
findings were reported among MERS-CoV patients. Lymphopenia was described in
44–92% of patients (Assiri et al. 2013a, b; Zaki et al. 2012; Al-Tawfiq et al. 2014a;
Hijawi et al. 2013; Guery et al. 2013; Memish et al. 2013a; Arabi et al. 2014).
In addition, thrombocytopenia was also described in different studies (Assiri
et al. 2013a, b; Arabi et al. 2014; Al-Tawfiq and Memish 2015b).
The main diagnostic test for MERS-CoV is based on real-time reverse-
transcription polymerase chain reaction (PCR). The samples are either Dacron-
flocked nasopharyngeal swabs or sputum samples (Assiri et al. 2013b). The PCR
test amplifies both the upstream E protein (upE gene) and ORF1a for MERS-CoV.
The best samples for the diagnosis of MERS-CoV is lower respiratory samples as
these samples have lower Ct values (higher viral load) and were present later in the
course of the disease (Assiri et al. 2013b; Memish et al. 2014c). This also in line with
WHO recommendations (World Health Organization 2015).
History of MERS-CoV in Relation to the Hajj
In the recent years, two novel corona viruses emerged and posed a global threat.
These are SARS-CoV in 2003 and MERS-CoV in 2013. It was shown that there were
no cases of SARS linked to the Hajj (Al-Tawfiq et al. 2014b). The first two MERS-
CoV infections occurred weeks before the 2012 annual Muslim Hajj season. The first
MERS case was in a Saudi Arabian patient (Zaki et al. 2012) and the second was in
a patient from Qatar who was transferred to London (Pebody et al. 2012). The initial
2012 Hajj season started few weeks after the first case of MERS-CoV infection
was reported (Memish et al. 2014d). However, there were no reported cases among
pilgrims in 2012 (Kandeel et al. 2011; Rashid et al. 2008; Al-Tawfiq et al. 2013;
Memish et al. 2013b). Thus, the Saudi Ministry of Health (MoH) utilized the MERS-
CoV case definition for monitoring any occurrence of the disease during Hajj
for early detection of cases among pilgrims (Al-Tawfiq and Memish 2014a). An
enhanced surveillance system was established for the detection of MERS-CoV
cases. The disease remains limited to the Middle East with the exception of sporadic
travel-associated infections and the large outbreak in South Korea (Sridhar et al.
2015; Kim et al. 2016; Korea Centers for Disease Control and Prevention 2015;
Pavli et al. 2014). In one study conducted during September 2012–October 2013, 77
travelers from the Middle East met the possible case definition for MERS and 2
of them tested positive for MERS (Sridhar et al. 2015). In a small study of 14
retuning pilgrims, all patients were hospitalized for respiratory symptoms and none
of them tested positive for MERS-CoV in Marseille France in October 2013 (Gautret
et al. 2014). Furthermore, nasopharyngeal swabs were collected from suspected
cases and all samples tested negative for MERS-COV (Memish et al. 2014d).
Another small study of seven pilgrims was conducted in 2014 in Austria, and
none had MERS-CoV (Aberle et al. 2015).
Systematic Screening for MERS-CoV Among Attendees of the

Annual Hajj
Following that, there were systematic screening of pilgrims for MERS-CoV, and
none of the studies showed positive cases (Al-Tawfiq et al. 2013; Aberle et al. 2015;
Gautret et al. 2013; Barasheed et al. 2014; Baharoon et al. 2009; Memish et al.
2014e, 2015; Annan et al. 2015; Refaey et al. 2016; Atabani et al. 2016; ProMed
2013; Griffiths et al. 2016; Benkouiten et al. 2014; Ma et al. 2017; Al-Abdallat et al.
2017; Koul et al. 2017). Mathematical models estimated the risk of MERS-CoV
among pilgrims to be 1–7 cases per Hajj and 3–10 per Umrah per year (Gardner et
al. 2014). Early in the history of MERS-CoV, it was estimated that 6.2 pilgrims may
develop MERS-CoV symptoms during the Hajj, and 4 pilgrims may become
infected and return home before symptoms development (Lessler et al. 2014).
Systematic surveillance of returning pilgrims was done in several studies in
Egypt, Iran, France, and Ghana as well as studies in Saudi Arabia (Gautret et al.
2013, 2014; Memish et al. 2014e; Annan et al. 2015). The prevalence of non-MERS
coronavirus was detected in 1–21% of pilgrims (Gautret et al. 2013, 2014, 2016a, b;
Al-Tawfiq and Memish 2014a; Memish et al. 2012, 2014d, e, 2015; Kandeel et al.
2011; Al-Tawfiq et al. 2013, 2016c; Aberle et al. 2015; Barasheed et al. 2014;
Baharoon et al. 2009; Annan et al. 2015; Refaey et al. 2016; Atabani et al. 2016;
ProMed 2013; Griffiths et al. 2016; Benkouiten et al. 2014; Ma et al. 2017; Al-
Abdallat et al. 2017; Koul et al. 2017) (Table 1). Despite the extensive surveillance
and since the emergence of MERS-CoV, only four cases have been linked to Umrah
(Mini-Hajj) (Kraaij-Dirkzwager et al. 2014; Fanoy et al. 2014; ProMed 2014a, b, n.
d.). In addition, few studies examined MERS-CoV among symptomatic pilgrims,
and none was positive for MERS-CoV (Table 2, Fig. 1) (Memish et al. 2014d; Al-
Tawfiq et al. 2013; Aberle et al. 2015).
Table 1 Systematic screening of MERS-CoV among pilgrims

Year of the Study Number N (%)
Reference study population Method screened positive
Gautret 2012 French cohort Nasopharyngeal 154 0
et al. 2013 swab
Gautret 2013 Departing Nasal swabs 129 0
et al. 2014 pilgrims
Barasheed 2013 Pilgrims from Nasal swabs 1038 0
et al. 2014 Saudi Arabia,
Australia, and
Qatar
Refaey 2012–2015 Egyptian Nasopharyngeal and 484 0
et al. 2016 oropharyngeal swabs
Annan 2013 Adult African Nasopharyngeal 839 0
et al. 2015 Hajj pilgrims swab
returning to
Ghana, West
Africa
Memish 2013 Departing Nasal swabs 692 (paired 0
et al. 2015 pilgrims, cohort), 514
paired, and (non-paired
non-paired arriving
cohort cohorts),
and 470
(non-paired
departing
cohort)
Gautret 2013 French Nasal and throat 129 0
et al. 2014; pilgrims swab
Benkouiten
et al. 2014
Memish 2013 Multiple Nasopharyngeal 3210 0
et al. 2014e nationalities swab pre-Hajj
Memish 2013 Multiple Nasopharyngeal 2025 0
et al. 2014e nationalities swab post-Hajj
Atabani 2013–2015 Symptomatic Upper and lower 202 0
et al. 2016 British respiratory tract
pilgrims
Griffiths 2013–2015 Ill French Not indicated 33 0
et al. 2016 travelers
Ma et al. 2013–2015 Chinese Lower respiratory 847 0
2017 tract sputum, washes,
and upper respiratory
tract oropharyngeal
swab
Al-Abdallat 2015 Jordanian Nasopharyngeal and 125 0
et al. 2017 oropharyngeal
Koul et al. 2014–2015 Kashmir, Nasopharyngeal and 300 0
2017 north India throat swabs
Table 2 Screening of symptomatic pilgrims for MERS-CoV

Year of
the Number N (%)
Reference study Study population Method screened positive
Al-Tawfiq 2012 Symptomatic Nasopharyngeal swab 300 0
et al. 2013 French
Memish 2013 Admitted pilgrims Sputum 38 0
et al. 2014d with pneumonia
Aberle 2014 Symptomatic Sputum, throat swab, 7 0
et al. 2015 pilgrims returning or bronchoalveolar
to Austria lavage
3500
3000
2500
2000
1500
1000
500
Fig. 1 Histogram shows the number of systematic screened pilgrims for MERS-CoV and none of
them tested positive
Recommendations for Pilgrims in Relation to MERS-CoV
As MERS-CoV emerged in 2012, there were no specific recommendations targeting

the newly emerging virus. In October 2012, updated recommendations on health
hazards and recommendations for Hajj 2012 were published (Al-Tawfiq and Memish
2012b). The 2012 Hajj season was concluded with no cases of MERS-CoV among
pilgrims. More 300 ill pilgrims were tested for MERS-CoV and all were negative
(Al-Tawfiq et al. 2013). There are no special recommendations for pilgrims in regard
to MERS-CoV infection. Pilgrims are advised to practice proper hand hygiene,
protective behaviors, and cough etiquette. It is also recommended that pilgrims
avoid contacts with camels (Al-Tawfiq and Memish 2012b). In addition, in 2015,
Saudi Arabia banned the sacrifice of camels for Hajj and discouraged visits by
pilgrims to camel barns during Hajj activities (Gautret et al. 2016b).
Conclusion
MERS-CoV infection remains very rare among pilgrims. There was extensive
surveillance of pilgrims for the existence of MERS-CoV, but all were negative.
However, two cases were detected among returning travelers after performing
Umrah (mini-Hajj). Continued surveillance and vigilance are required to further
enhance public awareness and inform evidence-based practices.
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Pandemic Viruses at Hajj: Influenza and
COVID-19 50
Mohammad Alfelali, Parvaiz A. Koul, and Harunor Rashid
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1250
Burden of Influenza at Hajj . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1252
Prevention of Influenza . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1252
Influenza Vaccine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1252
Vaccine Uptake . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1252
Vaccine Effectiveness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1253
Quadrivalent Vaccine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1253
Facemasks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1254
Hand Hygiene . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1254
COVID-19 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1254
Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1255
Global Burden . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1255
Transmission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1255
Incubation Period and Virus Shedding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1255
Clinical Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1257
Diagnosis of COVID-19 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1258
M. Alfelali
Department of Family and Community Medicine, Faculty of Medicine in Rabigh, King Abdulaziz
University, Jeddah, Saudi Arabia
e-mail: malfelali@kau.edu.sa
P. A. Koul
Department of Internal and Pulmonary Medicine, Sher-i- Kashmir Institute of Medical Sciences
(SKIMS), Srinagar, India
H. Rashid (*)

https://doi.org/10.1007/978-3-030-36811-1_50
1250 M. Alfelali et al.
High Risk Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1258

Prevention and Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1259
COVID-19 Vaccine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1259
Other Preventive and Therapeutic Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1260
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1261
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1261
Abstract
Hajj is the largest annual mass gathering event on the planet and usually attracts
two to three million people from all over the world and is one of the most
significant events in the life of a practicing Muslim. Viruses that may cause
pandemic outbursts, such as influenza and COVID-19, are important public
health threats at Hajj. Influenza, both seasonal and pandemic, has been reported
at Hajj at variable frequencies. Preventive measures including vaccination and
hand hygiene are known to be beneficial. The vaccination uptake is still sub-
optimal but improving, and time is ripe to consider using quadrivalent influenza
vaccine that provides protection against both lineages of influenza B. In response
to COVID-19, Hajj pilgrimage was essentially cancelled in 2020, downscaling to
just a few thousand local pilgrims who were required to comply with strict
preventive measures including maintaining optimum physical distance from
fellow pilgrims, and no case of Hajj-associated COVID-19 has been reported.
To combat COVID-19 in the coming years, all evidence-based preventive mea-
sures, including hand hygiene and use of personal protective equipment, should
be considered for Hajj pilgrims in addition to limiting the number of attendees.
The recently approved and rolled out COVID-19 vaccines would be important
preventive measures for prospective Hajj pilgrims.
Keywords
COVID-19 · Influenza · Hajj · Mass gatherings · Pandemic · SARS-CoV-2
Introduction
Hajj pilgrimage is one of the largest annual mass gatherings in the world. Every able,
practicing Muslim is duty-bound by faith to perform Hajj at least once in life (Gatrad
and Sheikh 2005). Each year, in the last month of the Arabic lunar calendar, two to
three million Muslims from all corners of the world gather in Makkah (Fig. 1) to
perform Hajj pilgrimage that involves performing specific rituals at designated
places, such as contemplating and reflecting in the valley of Mina and in the plain
of Arafat while donned in a pair of unstitched sheets, and visiting various sites of
historical and religious significance in Makkah and Madinah (Ahmed et al. 2006).
Pilgrims stay in Makkah for variable periods; most local pilgrims stay for about a
week, while many overseas pilgrims spend 2–4 weeks, but some devotees and tour
organizers stay for longer periods. During the peak period of Hajj, pilgrims avoid
50 Pandemic Viruses at Hajj: Influenza and COVID-19 1251
Fig. 1 Picture of the Grand Mosque in Makkah during the Hajj of 2014. (Photo courtesy:
Mr. Maher M Alzahrani, Makkah, Saudi Arabia)
using scented toiletries, plucking hair, and trimming nails. As a consequence of

compromised hygiene, intense crowding and physical exertion from multiple rituals,
the incidence of infectious diseases, mainly air-borne/respiratory ones, is amplified
during the Hajj pilgrimage (Shafi et al. 2008).
The spectrum of respiratory infections among Hajj pilgrims includes bacterial,
viral, and fungal pathogens. The predominant bacterial respiratory infections are
caused by Streptococcus pneumoniae, Haemophilus influenzae, Klebsiella
pneumoniae, and Staphylococcus aureus (El-Sheikh et al. 1998). Other bacterial
pathogens including tuberculosis, pertussis, and other drug-resistant bacteria have
been reported among Hajj pilgrims (Al-Tawfiq et al. 2016). However, viral respira-
tory infections are more prevalent during Hajj. The commonest viruses detected at
Hajj, rhinovirus, influenza, adenovirus, and respiratory syncytial virus occur at
variable frequencies across years and pilgrim populations (Gautret et al. 2016).
Burden of Influenza at Hajj
Repercussions of several global pandemics of influenza over the last century have
been felt at Hajj, including the H1N1 Spanish influenza of 1918, H3N2 Hong Kong
influenza of 1968, and the pandemic influenza A(H1N1)pdm09 of 2009 (Ebrahim
et al. 2009). The first known report of influenza surveillance at Hajj was in 1975
among Tunisian pilgrims (Jeddi et al. 1978). In recent years, the MERS-CoVoutbreak
in the Middle East with its epicenter in Saudi Arabia has posed a public health threat at
Hajj, but interestingly, as yet no case has been reported (Al-Tawfiq et al. 2018).
The burden of clinical influenza was assessed in several studies, and the estimates
varied depending on study designs and the criteria used to define clinical influenza
(Alfelali and Rashid 2014). A recent systematic review indicated that cough and sore
throat were the commonest respiratory symptoms among Hajj pilgrims (Benkouiten et
al. 2019). The prevalence of syndromic influenza such as influenza-like illness ranged
between 8% and 78%, depending on study design and how influenza-like illness was
defined (Alfelali and Rashid 2014). The prevalence of laboratory-confirmed influenza
at Hajj ranged from 5% to 14%. Influenza A was more dominant, ranging between 5%
and 10%, than influenza B which ranged from 2% to 7% (Gautret et al. 2016).
Prevention of Influenza
Both pharmacological and non-pharmacological interventions are used to prevent

influenza at Hajj (Haworth et al. 2013). Although non-pharmacological measures
such as facemask, hand hygiene, and cough etiquette are recommended for Hajj
pilgrims, these are underutilized, and the evidence of effectiveness of facemask remains
inconclusive (Rashid et al. 2012; Memish and Al Rabeeah 2011). Pharmacological
measures such as antiviral drugs as prophylaxis are believed to reduce the illness
duration and severity, and improve recovery. Some have hypothesized that a combi-
nation of ring prophylaxis of contacts and treatment of cases in mass gatherings
including Hajj may yield clinical and economic benefits (Tashani et al. 2013). Never-
theless, antiviral drugs are not commonly used at Hajj due to concerns of cost, antiviral
resistance, and logistic issues. The primary preventive measure against influenza is
vaccination. Therefore, the Saudi Ministry of Health (MoH) along with international
public health bodies such as the World Health Organization (WHO) and the Centers for
Disease Control and Prevention (CDC) of the United States of America (USA)
recommend influenza vaccination for Hajj pilgrims, particularly for those at higher
risk to develop severe influenza disease (Memish and Al Rabeeah 2014).
Influenza Vaccine
Vaccine Uptake
The first Saudi MoH recommendation for the influenza vaccine for Hajj pilgrims was
in 2005, and vaccination uptake among pilgrims has been assessed periodically. The
coverage varied across Hajj years and pilgrims’ countries of origin. For instance,
pilgrims from Iran had a satisfactory vaccination uptake between 76% and 89%
reaching 100% in 2009 when the vaccine was offered officially free of cost to all
pilgrims (Moattari et al. 2012). Pilgrims from Malaysia and India achieved a
coverage of 65% and 72%, respectively (Hashim et al. 2016; Koul et al. 2017). In
contrast, vaccination uptake among pilgrims from some European countries fluctu-
ated over the years. For example, the influenza vaccination rate among French
pilgrims usually ranges between 26% and 46%, approached a peak of 97% in
2009 during the pandemic year, and reached a nadir of zero in 2013 when the
vaccine was not available before Hajj (Gautret et al. 2011; Benkouiten et al.
2014). Similarly, pilgrims from the United Kingdom (UK) had a vaccination cover-
age of 28% in 2005 and 37% in 2006 (Shafi et al. 2006). On the other hand,
vaccination rates among pilgrims from surrounding Arab countries was generally
around 30%, and even lower among domestic Saudi Arabian pilgrims who never
achieved an uptake beyond 14% before 2009 but has increased in recent years.
Influenza vaccination rates among domestic Saudi pilgrims in 2013, 2014, 2015, and
2017 were 21% (in 2013), 48% (in 2014), 58% (in 2015), and 67% (in 2017)
(Alfelali et al. 2018; Alqahtani et al. 2019).
Vaccine Effectiveness
A synthesis of raw and published data from 11 Hajj seasons between 2005 and 2014
involving 33,213 Hajj pilgrims showed the prevalence of influenza-like illness
decreased among Hajj pilgrims as vaccine coverage increased over years (relative
risk [RR] 0.2, P < 0.01) (Alfelali et al. 2015). Pooled data from six studies
conducted among the UK, Iranian, and Saudi Hajj pilgrims across different years
show the vaccine to be significantly effective against laboratory-confirmed influenza
(RR 0.56 [95% CI 0.41–0.75], P < 0.001) (Alqahtani et al. 2015). A “test-negative”
case-control analysis using data from individual studies conducted in participants
from Saudi Arabia, India, Australia, and the UK between 2005 and 2015 showed an
overall vaccine effectiveness of 43.4% (95% CI 11.4% – 63.9%, P ¼ 0.01) (Alfelali
et al. 2019).
Quadrivalent Vaccine
Since influenza B/Victoria and B/Yamagata lineages are antigenically distinct,

vaccination against one lineage would not necessarily provide cross-protection
against the other. To ensure a broader coverage of protection, it is sensible to
consider using a quadrivalent influenza vaccine routinely for Hajj pilgrims in place
of a trivalent vaccine. During the next decade, Hajj would fall between April and
August, a period when influenza activity is intense in the Southern Hemisphere, and
when the Northern Hemisphere influenza vaccine is not available; it is prudential to
use the Southern Hemisphere quadrivalent influenza vaccine for all prospective
pilgrims (Koul et al. 2019).
Facemasks
The use of facemasks, especially in crowded places, has been recommended since 2014
when the MERS-CoV epidemic spiked in Saudi Arabia (Memish and Al Rabeeah
2014). On average, just over 50% Hajj pilgrims use a facemask during a non-pandemic
year, the compliance rate, however, ranges from as low as 0.02% to as high as 92.8%,
and while compliance in pilgrims from Southeast Asia (e.g., Malaysia and Indonesia) is
generally better possibly because of cultural acceptance of facemask, the compliance
among the domestic Saudi Arabian pilgrims ranges from 35% to 57%, and among
Australian pilgrims from 53% to 57% (Barasheed et al. 2016; Alqahtani et al. 2019).
The effectiveness of facemasks was studied in a dozen observational studies, in a
pilot randomized controlled trial and in a large cluster randomized controlled trial. The
pooled data from observational studies reveal benefit of using facemasks against
respiratory infections in general at Hajj (RR 0.89 [95% CI 0.84–0.94], P < 0.01)
(Barasheed et al. 2016), but the cluster randomized controlled trial failed to show any
benefit either against clinical infection (odds ratio [OR] 1.1 [95% CI 0.9–1.4],
P ¼ 0.40) or against laboratory-proven viral infection (OR 1.4 [95% CI 0.9–2.1],
P ¼ 0.18). Compliance with facemask use among participants in the intervention arm
was unexpectedly low, with only 24.7% participants using facemasks daily and 47.7%
using facemasks intermittently (Alfelali et al. 2020). A recent observational study
reported that the frequency of changes of facemasks is important, and that replacing a
facemask every 4 h reduced upper respiratory tract infections (adjusted OR 0.56 [95%
CI 0.34–0.92], P ¼ 0.02) (Al-Asmary et al. 2007).
Hand Hygiene
The compliance of hand washing among Hajj pilgrims with nonalcoholic surfactants
is about 78% (ranges from 32% to 90%) and the compliance of hand hygiene with
alcoholic products is 45% (ranges from 30.7% to 67.4%) (Alqahtani et al. 2020).
Pilgrims often lack precise knowledge of hand hygiene technique including on
lathering and the correct concentration of alcohol that should be present in hand
hygiene products (Mahdi et al. 2020). Only a few studies assessed the effectiveness
of hand hygiene against clinical disease and/or laboratory-confirmed infection
(Alqahtani et al. 2020), and found it to be effective. No randomized controlled
trial has assessed the effectiveness of hand hygiene at Hajj.
COVID-19
An outbreak of cases with unexplained lower respiratory infections was detected in

Wuhan, the largest metropolitan area in China’s Hubei province, in December 2019.
The etiology of this illness was eventually attributed to a novel virus belonging to the
coronavirus family (SARS-CoV-2) and the disease caused was named “COVID-19,”
an acronym for “Coronavirus disease 2019” (Chen et al. 2020).
The first case of infection with this virus in Saudi Arabia was reported on 2 March
2020 (Alandijany et al. 2020), and the infection spread very rapidly to affect over
35,000 people within just 8 weeks. The Saudi authorities have adopted various
national response measures to halt the progress of the pandemic, including travel
suspension, school closures, limiting workspace access, cancellation of Umrah
pilgrimage (Fig. 2), and downscaling Hajj (Fig. 3), ultimately reducing imported
COVID-19 cases (Ebrahim and Memish 2020; Zumla et al. 2020).
Epidemiology
Global Burden
Since the first reports of cases from Wuhan in December 2019, about 95 million
cases have been reported worldwide, with more than two million deaths (as of 16
January 2021) (World Health Organization 2021). The case count is likely an
underestimate of the disease burden because only a proportion of the cases are
diagnosed and reported. Sero-surveys suggest that after accounting for potential
false positives or negatives, the rate of prior exposure to SARS-CoV-2, as reflected
by seropositivity, exceeds the incidence of reported cases, especially so in densely
populated countries where the testing rate is low and the actual burden may be 80–
100 fold higher (Stringhini et al. 2020).
Transmission
Human-to-human transmission is believed to primarily occur through respiratory

droplets (particles >5–10 μm in diameter) during coughing and sneezing. Droplet
nuclei are also increasingly recognized as a possible mechanism of spread, especially
during protracted exposure to high aerosol concentrations in closed spaces, in pro-
cedures like intubation, nebulization, and bronchoscopy (Chagla et al. 2020). Close
contact seems necessary for transmission of the disease and presymptomatic and
asymptomatic individuals can contribute to up 80% of COVID-19 transmission. The
spread, in fact, is primarily limited to family members, healthcare professionals, and
other close contacts. Given the uncertainty regarding the relative contribution of
different transmission mechanisms, precautions against airborne transmission are
recommended. SARS-CoV-2 has been detected in non-respiratory specimens,
including stool, blood, ocular secretions, and semen, but the role of non-respiratory
routes in transmission is uncertain (Kang et al. 2020).
Incubation Period and Virus Shedding
The incubation period is generally thought to be within 3–7 days, but ranges up
to 14 days; the basic reproduction number (R0) is 2.2 (Lauer et al. 2020; Katul
et al. 2020).
Fig. 2 A brief timeline of COVID-19 in relation to Hajj and Umrah pilgrimages
While the precise period of viral shedding is uncertain, transmission is highest

early in the course of illness, and but the risk of transmission decreases to nearly
unlikely levels after 7–10 days. Older patients and those with severe diseases may
have a more prolonged duration of viral shedding (Walsh et al. 2020). Viral RNA
Fig. 3 Picture of the Grand Mosque in Makkah during the Hajj of 2020 when Hajj was downscaled
due to COVID-19. (Photo courtesy: Dr. Usama Munir, Nepean Hospital, NSW, Australia)
shedding continues for 12–20 days in hospitalized patients, which is prolonged in

those with severe illnesses. Viral infection soon leads to an immune response against
SARS-CoV-2; animal studies suggest that the initial immune response may offer
some protection against reinfection, at least in the short term (Chandrashekar et al.
2020).
Clinical Features
Infected individuals can remain asymptomatic or present with various symptoms; up

to 45% of individuals can remain asymptomatic (Oran and Topol 2020). Most
patients develop symptoms within 11.5 days of the infection (Lauer et al. 2020).
Symptoms vary in frequency and severity, but most of patients develop the following
in isolation or combination: fever or chills, cough, shortness of breath, fatigue,
muscle or body aches, headache, sore throat, new loss of taste or smell, runny
nose, nausea or vomiting, and diarrhea (Guan et al. 2020).
Based on the clinical course, symptoms can be stratified into mild, severe, and
critical. Among patients who developed severe disease, the median time to dyspnea
from the onset of illness ranges from 5 to 8 days. In hospitalized patients, 26–32%
require intensive care unit (ICU) admission and 3–17% develop acute respiratory
distress syndrome (ARDS). The median duration of hospitalization of survivors
ranges from 10 to 13 days (Wang et al. 2020; Yang et al. 2020). Most patients with
COVID 19 have mild-to-moderate disease but about 5–10% progress to severe or
critical disease, including severe pneumonia and acute respiratory failure (Huang
et al. 2020).
There are several reports of hospitalized patients with thrombotic complications,
most frequently deep venous thrombosis and pulmonary embolism, myocardial
injury with ST-segment elevation, large vessel strokes, and acute kidney injury
(Helms et al. 2020; Ronco et al. 2020).
Illness among pediatric patients with COVID-19 is typically milder than
among adults; most children present with symptoms of upper respiratory tract
infection; however, severe outcomes, including deaths, have been reported in
children.
Diagnosis of COVID-19
The most common method for diagnosis is the detection of SARS-CoV-2 is by RT-
PCR in respiratory samples, generally in nasopharyngeal, oropharyngeal samples,
and lower respiratory tract samples (Young et al. 2020). Laboratory abnormalities
include mild thrombocytopenia, increased D-dimer levels, increased fibrin degrada-
tion products, and elevated prothrombin time. Procalcitonin is typically normal on
admission but can increase in those admitted to ICU. Patients with critical illness
have high plasma levels of inflammatory makers, suggesting potential immune
dysregulation (Huang et al. 2020). Elevated D-dimer levels and lymphopenia have
been associated with mortality (Wu et al. 2020). Chest radiographs of patients with
COVID-19 typically demonstrate bilateral air-space consolidation, though patients
may have unremarkable chest radiographs early in the disease. Computerized
tomography (CT) is the imaging modality of choice, given its high sensitivity and
can identify changes even when molecular diagnostic tests are negative (Bernheim
et al. 2020).
High Risk Conditions
Age is an important factor in COVID severity and fatality. Mortality is <1.1% in

patients aged <50 years, and increases after that age. Compared to patients
<80 years, those aged 80 years have over sixfold higher risk of fatality (Bonanad
et al. 2020). Males are more likely than females to develop serious complications and
progress to death (Su et al. 2020).
Patients with COVID often have comorbidities; about a third have hypertension,
one-fifth have a respiratory disease including bronchial asthma, one-eighth have
a cardiovascular disease, one-tenth have diabetes, and a small group have renal, liver
diseases, immunosuppressed conditions, and malignancies. These comorbidities
increase the risk of severity and/or fatality by two- to sevenfold (Lu et al. 2020).
Prevention and Therapy
COVID-19 Vaccine
The various vaccine platforms that are being explored for development of SARS-
CoV2 vaccines include: live attenuated virus vaccines, viral vectors-based vaccines,
inactivated virus vaccines, protein subunit vaccines, mRNA vaccines, and recombi-
nant DNA-based vaccines. The UK regulators issued emergency use authorization
(EUA) for an mRNA vaccine from Pfizer and BioNTech, based on data of >43,000
participants aged 16 years enrolled in randomized controlled trials wherein the
vaccine was found to be safe and 95% effective against COVID-19 through 7 days
after receipt of the second dose of the vaccine (Polack et al. 2020). Subsequently, the
US Food and Drug Administration (FDA) also issued EUA for the Pfizer/BioNTech
mRNA vaccine. However, following the vaccination rollout, a number of cases of
anaphylactic reactions were reported and as such participants with a previous history
of severe allergy were advised against vaccination (CDC COVID-19 Response
Team; FDA 2021). The US FDA issued EUA for another mRNA vaccine from
Moderna based on the review of the safety data of the use of the vaccine in >30,000
participants aged 18 years with an efficacy of 94% (Baden et al. 2020). Both the
Pfizer/BioNTech and Moderna vaccines have logistic issues for rolling out in
developing countries as they have to be stored at 70 °C and 20 °C, respectively.
Pfizer/BioNTech vaccine has been rolled out in Saudi Arabia, and Umrah pilgrims
are urged to get vaccinated. The University of Oxford, in collaboration with the drug
company AstraZeneca plc, developed ChAdOx1 nCoV-19, a replication-defective
chimpanzee adenovirus (Ad) vector-based vaccine expressing the full-length SARS-
CoV-2 spike glycoprotein gene. Results from the recently published phase 2/3 trial
show that the vaccine produces strong immune responses across all adult age groups,
including the elderly, with higher levels in boosted compared with non-boosted
groups. The vaccine also results in a cellular immune response across all age and
dose groups, peaking at day 14 following vaccination (Ramasamy et al. 2020;
Folegatti et al. 2020). The vaccine was issued EUA by the UK regulators based on
the interim analysis of data from four phase 3 randomized controlled trials conducted
on 11636 participants across UK, Brazil, and South Africa. The analysis of the
pooled data showed that the vaccine is >70% effective against COVID-19 occurring
>14 days after receiving two doses of the vaccine. No case of severe infection or
hospitalization was reported in the vaccine group. A further analysis shows partic-
ipants who were primed with half dose had a better efficacy (90%) than those who
were primed with full dose (62%) (Voysey et al. 2021). Two other recombinant viral
vectored vaccines have been tested in clinical trials. A single-dose Ad5 vector-based
vaccine (CanSino Biological/Beijing Institute of Biotechnology, China) elicits neu-
tralizing antibodies and T-cell responses in a dose-dependent manner, but is less
immunogenic in individuals aged >55 years (Zhou et al. 2020). A heterologous
prime-boost Ad5/Ad26-vectored vaccine schedule (Gamaleya Research Institute,
Russia) generates neutralizing antibody and cellular responses in adults <60 years
of age (Logunov et al. 2020).
Recent developments suggest some RNA vaccines as forerunners. Pfizer Inc. and
BioNTech (Germany) have already published their phase 1/2 trial data involving two
RNA vaccines (BNT162b1 and BNT162b2) showing both have a tolerability and
safety profile consistent with other mRNA-based vaccines, the latter having better
safety profile entered to phase 3 trial. So far, about 44,000 participants were recruited
and the preliminary analysis shows the vaccine to be about 95% effective. These
companies submitted their application to the US Food and Drug Administration
(FDA) for emergency use approval; authorization is also being sought from regula-
tory bodies in Europe, Australia, Canada, and Japan.
Moderna (a biotech company in the USA) has published its phase 1 trial data
showing the vaccine to induce anti-SARS-CoV-2 immune responses in all partici-
pants, and to have no trial-limiting safety concerns; the vaccine has completed its
phase 2 trial (as yet unpublished) and is currently undergoing phase 3 trial. An
interim analysis of its phase 3 trial shows the vaccine to be 94% effective in
preventing COVID-19 including severe disease.
Two inactivated viral vaccines also show neutralizing antibody responses in a
dose-dependent manner in adults aged 18–59 years (China National Biotec Group
Company Limited) (Xia et al. 2020) or adults aged 18–59 and 60 years (Beijing
Institute Biological products/SinoPharm, China), with the second showing lower
neutralizing antibody titers in older adults after two doses (Xia et al. 2021). Both
vaccines are safe and are well tolerated at all tested doses (Xia et al. 2020, 2021).
Finally, a clinical trial of a nanoparticle vaccine composed of adjuvanted trimeric
SARS-CoV-2 spike glycoproteins (Novavax, USA) reports on the results of a two-
dose schedule given 3 weeks apart in healthy adults aged <60 years. This vaccine
induces neutralization responses that exceeds those measured in serum samples from
convalescent symptomatic patients was well tolerated (Keech et al. 2020).
Other Preventive and Therapeutic Measures
Facemasks, hand hygiene, physical distancing, and reducing contact time (<15 min)
are standard measures of preventing COVID-19. For healthcare workers performing
aerosol-generating procedures, well fitted face-piece respirators, for example, N95 or
N99 masks, are recommended as part of personal protective equipment. Members of
the general public are also encouraged to wear a facemask and systematic reviews of
primarily observational studies report benefit from wearing facemasks (Chu et al.
2020). Mass transmission of COVID-19 in airlines among passengers who did not
wear facemasks has been reported (Freedman and Wilder-Smith 2020). However,
the certainty of the effectiveness of wearing facemasks against COVID-19 is mod-
erate (Chu et al. 2020). In the Hajj setting, a large facemask trial failed to prove the
efficacy of facemask against respiratory viruses (Alfelali et al. 2020). Lately, a large
trial conducted among community dwellers in Denmark reports that using surgical
facemasks to supplement other public health measures did not significantly reduce
COVID-19 infection among users (Bundgaard et al. 2020). Therefore, pilgrims are
encouraged to comply with other standard measures in addition to using facemasks.
Therapeutics including systematic steroids (e.g., dexamethasone), antivirals,

hydroxychloroquine with or without azithromycin, tocilizumab (an immunosup-
pressive agent), and convalescent plasma have been tried. The use of systematic
dexamethasone in patients with severe disease reduced all-cause mortality (RR
0.83 [95% CI 0.75–0.93]) and the need for mechanical ventilation (RR 0.77 [95%
CI 0.62–0.95]), but in contrast, systemic corticosteroids can increase the risk of
death in patients without severe COVID-19. Remdesivir reduces the risk of
serious adverse events (e.g., respiratory failure) with a relative risk reduction of
20%; however, it did not reduce all-cause mortality or nonserious adverse events
(Juul et al. 2020). Favipiravir provides faster symptomatic recovery from cough
and fever but had no effect on viral clearance or 7-day clinical recovery rates
(Siordia et al. 2020). Other antiviral drugs (e.g., lopinavir, ritonavir, arbidol,
umifenovir), tocilizumab, hydroxychloroquine with or without azithromycin and
ivermectin have no proven benefit. A meta-analysis reports no significant differ-
ence between convalescent plasma versus standard care on all-cause mortality (RR 0.60
[95% CI 0.33–1.10]), although some individual trials indicated benefit but were under-
powered to support or refute realistic effects (Siordia et al. 2020; Juul et al. 2020).
Conclusion
Pandemic viruses such as influenza and COVID-19 pose serious public health
threats to Hajj pilgrims. Influenza is common among pilgrims, and vaccination is
of proven benefit value and should be promoted. It is time to consider a quadrivalent
influenza vaccine for better protection. COVID-19 is currently the most important
public health threat in all parts of the world, but lower attendance levels at Hajj
should be considered until the pandemic is better controlled. Hajj pilgrims should be
encouraged to comply with all evidence-based preventive measures, including
maintaining optimum physical distances, vaccinations against influenza and
COVID-19, use of personal protective equipment, and hand hygiene.
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Mass Gatherings and Hazard Control:
Agenda for Education and Implementation 51
Francis T. Pleban
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1268
Control Hierarchy for Common Mass Gathering Hazards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1269
Immunizations as an Engineering Control for Infectious Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . 1271
Meningococcal Meningitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1271
Yellow Fever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1272
Poliomyelitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1272
Zika Virus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1273
Respiratory Tract Infections and MERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1274
Personal Hygiene as an Administrative Control for Infectious Diseases . . . . . . . . . . . . . . . . . . . . . 1275
Personal Protective Equipment as a Control for Respiratory and Infectious Diseases . . . . . . . 1276
Surgical Masks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1276
Disposable N95 Respirators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1277
Public Use N95 Respirators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1278
Controlling for Other Mass Gathering Hazards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1278
Other Health and Safety Hazards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1278
Personal Responsibility in Abiding by General Posted Health Guidelines as Engineering,
Administrative, and/or PPE Controls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1279
Public Health Education and the Hajj . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1280
Kingdom of Saudi Arabia Ministry of Health (MOH) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1280
During Hajj MOH Health Education Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1281
Pilgrims with Chronic Disease Conditions MOH Health Education Guidelines . . . . . . . . . . 1283
Women and Children Pilgrims MOH Health Education Guidelines . . . . . . . . . . . . . . . . . . . . . . 1284
After Hajj MOH Health Education Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1285
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1286
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1286
F. T. Pleban (*)
College of Health Sciences, Department of Public Health, Health Administration and Health
Sciences, Tennessee State University, Nashville, Tennessee, USA
e-mail: fpleban@tnstate.edu

https://doi.org/10.1007/978-3-030-36811-1_51
1268 F. T. Pleban
Abstract
The Hajj is an annual pilgrimage to Mecca, Saudi Arabia, attended by approxi-
mately two million Muslims. To promote a healthy pilgrimage, travelers should
proactively look to recognize, prevent, and control those health or environmental
stressors, arising in or from the Hajj. A hierarchy of controls to hazards has been
employed as a means of determining how to implement meaningful control
solutions. The Centers of Disease Control (CDC) and the National Institute for
Occupational Safety and Health (NIOSH) lists ordered hazard control measures
as: (1) Elimination, (2) Substitution, (3) Engineering Controls, (4) Administrative
Controls, and (5) Personal Protective Equipment (PPE). Elimination, substitution,
engineering, and administrative controls are favored over the use of PPE; how-
ever, specifically in the case of mass gatherings, those controls are not always
feasible. Administrative controls, such as behavioral personal hygiene interven-
tions, which include hand hygiene, proper cough etiquette, social distancing, and
contact avoidance, can be effective at mitigating respiratory illness and other
infectious diseases (Brunette and Centers for Disease Control and Prevention
[CDC], CDC health information for international travel 2016: the yellow book.
Oxford University Press, New York, 2016). Immunizations, as an engineering
control, are designed to remove the hazard at the source, before it comes in
contact with an individual (American Chemical Society [ACS], Control mea-
sures. Retrieved from https://www.acs.org/content/acs/en/about/governance/
committees/chemicalsafety/hazard-assessment/fundamentals/control-measures.
html, 2015). The initial cost of immunizations can be higher than the cost of
personal protective equipment; however, over time, they can produce a cost
saving in terms of reduced further medical care. For personal protective equip-
ment to be effective, PPE should be properly worn and maintained in a clean
and reliable fashion before, during, and after use (Occupational Safety and
Health Administration [OSHA] 2016). The Kingdom of Saudi Arabia Ministry
of Health established health guidelines, disseminated electronically through the
MOH portal, specific to the health education of Hajj pilgrims addressing: (1)
During Hajj, (2) Chronic Diseases, (3) Woman and Child, and (4) After Hajj
(Saudi Ministry of Health, Media center. Retrieved from https://www.moh.gov.
sa/en/Pages/Default.aspx, 2018a).
Keywords
Environmental health and safety · Hazard control · Mass gatherings
Introduction
The Hajj, part of the Islamic faith, is an annual pilgrimage to Mecca, Saudi Arabia.
For Muslims, Mecca is the most holy city and the site of the largest mass gathering in
the world (Brunette and Centers for Disease Control and Prevention [CDC] 2016).
Every adult Muslim, being physically and financially capable, is obligated to carry
51 Mass Gatherings and Hazard Control: Agenda for Education and Implementation 1269
out this religious pilgrimage at least once in his or her lifetime (Brunette and Centers
for Disease Control and Prevention [CDC] 2016). The Hajj takes place during the
last month, or Dhu al-Hijja, of the Islamic lunar year. In all, approximately two
million Muslims from nearly 183 countries attend the Hajj each year. In helping to
promote a successful and healthy pilgrimage, individuals should proactively look to
recognize, prevent, and control those health or environmental stressors, arising in
or from the Hajj, which may cause illness, significant discomfort, or diminished
health and well-being.
Historically during Hajj, pilgrims have had an increased risk of exposure to,
and subsequently experienced, a number of illnesses and injuries, including:
incidence of new respiratory disease and exacerbation of existing respiratory
conditions, increased cardiovascular disease and disability, food-borne illnesses;
diarrheal diseases; well as psychosocial stressors aggravating behavioral, mood,
and sleep disorders (Masood et al. 2007; Meysamie et al. 2006). During the Hajj,
respiratory tract infections are common, with pneumonia cited as the most
common respiratory tract infection leading to hospitalization (Brunette and Centers
for Disease Control and Prevention [CDC] 2016). As well, crowded conditions
created during the Hajj increase the risk of tuberculosis and influenza transmission
(Brunette and Centers for Disease Control and Prevention [CDC] 2016). Chronic
health conditions, specifically cardiovascular conditions, were associated with
46–66% of pilgrim deaths during the Hajj (Brunette and Centers for Disease Control
and Prevention [CDC] 2016). Factors associated with exacerbating illness and injury
during the Hajj include changes in sleep and diet; as well as increased physical
exertion in classically hot climate conditions (Meysamie et al. 2006).
Control Hierarchy for Common Mass Gathering Hazards
Traditionally, in occupational and environmental health, a hierarchy of control to

hazards has been employed as a means of determining how to implement meaningful
control solutions. The Centers of Disease Control (CDC) and the National Institute
for Occupational Safety and Health (NIOSH) lists ordered control measures to a
specific hazard as: (1) Elimination, (2) Substitution, (3) Engineering Controls, (4)
Administrative Controls, and (5) Personal Protective Equipment (PPE). Elimination,
substitution, engineering, and administrative control methods are theoretically more
effective and protective than PPE (i.e., gloves, safety glasses, earplugs or muffs, face
shields, or facemasks and/or respirators) (Centers for Disease Control and Preven-
tion [CDC] 2015). Elimination, substitution, engineering, and administrative con-
trols are favored over the use of PPE; however, especially in the case of mass
gatherings, those controls are not always feasible.
Elimination and substitution are typically most effective at reducing hazards,
but are sometimes difficult to implement within existing practices or situations.
As well, engineering and administrative controls are also preferred, because these
methods are designed to remove hazards at the source, before coming in contact
1270 F. T. Pleban
with the individual (American Chemical Society [ACS] 2015; Centers for Disease
Control and Prevention [CDC] 2015).
Engineering controls involve making changes to an individual’s environment
in order to reduce hazards. Engineering controls are favored over all other controls
because they make permanent changes that reduce hazard exposure; not
relying solely on personal behavior for protection (Occupational Safety and Health
Administration [OSHA] 2016; American Chemical Society [ACS] 2015).
Administrative controls modify schedules and tasks in ways that minimize
a person’s exposure to a particular hazard. Behavioral practices can be employed
to reduce the duration, frequency, or intensity of individual or collective exposure
to a hazard (Occupational Safety and Health Administration [OSHA] 2009a).
Providing resources and promoting personal hygiene are forms of administrative
controls. Examples of resources include providing: facial tissues, hand soap, dispos-
able towels, hand sanitizer, disinfectants, and no-touch waste containers (Centers
for Disease Control and Prevention [CDC] 2009). Examples of behavioral health
promotion include providing: up-to-date education and training on hazard risk
factors, protective personal hygiene education and instruction on proper hygiene
behaviors (i.e., cough etiquette, avoiding touching eyes, nose and mouth, and
social distancing) (Occupational Safety and Health Administration [OSHA] 2009a;
Occupational Safety and Health Administration [OSHA] 2016).
Public health surveillance and monitoring stations may also act as
administrative controls. Both permanent and Hajj seasonal event health
facilities have been established. Permanent and Hajj seasonal event hospitals,
health centers, cooling/rest stations, and medical transportation have been put
in place to address routine and emergency cases, as well as to monitor travelers,
during the pilgrimage (Eltahir 2000).
Personal protective equipment (PPE) is applied protective devices with the
intention of keeping individuals safe in the presence of a hazard (Occupational
Safety and Health Administration [OSHA] 2016). Examples of PPE include
facemasks (e.g., N95 respirators), face shields, goggles, and disposable gloves.
Personal protective equipment, although initially more cost efficient to implement,
requires a concerted individual effort for proper use and protection. If appropriately
used and maintained, PPE can help prevent some exposures. However, PPE should
not take the place of other prevention interventions, such as engineering controls or
administrative public health promotion interventions (i.e., cough etiquette and hand
hygiene). It is important to note that for personal protective equipment to be
effective, PPE should be maintained in a clean and reliable fashion before, during,
and after use (Occupational Safety and Health Administration [OSHA] 2016).
Important PPE considerations include (1) proper selection based on the specific
hazard; (2) proper size and fitting (e.g., respirators and gloves); (3) conscientious and
proper wearing; (4) regular servicing and replacing of PPE following manufacturer’s
specifications; (5) proper removal and disposal to avoid possible contamination of
self, others, or the environment; and (6) if it is a reusable device, to ensure it is
properly removed, cleaned, disinfected, and stored following the manufacturer’s
specifications (Occupational Safety and Health Administration [OSHA] 2009a).
Immunizations as an Engineering Control for Infectious Diseases
To help prevent and control for a variety of viral or bacterial infections, each
individual pilgrim should maintain a current immunization schedule during the
time leading up to the Hajj. Before travel, immunization can reduce a person’s risk
of contracting some diseases. In the United States, vaccines are categorized as
either routine or travel. Routine vaccines typically include tetanus, diphtheria,
flu, varicella, measles, mumps and rubella, polio, hepatitis B, meningococcal,
and pneumococcal. Travel vaccines are comprised of hepatitis A, typhoid, rabies,
Japanese encephalitis, and yellow fever (Vanderbilt Health 2017).
The CDC (Brunette and Centers for Disease Control and Prevention [CDC] 2016)
recommends that all Hajj pilgrims remain up-to-date with routine immunizations,
particularly for meningococcal meningitis. For U.S. pilgrims, travel vaccines for
hepatitis A and B and typhoid are recommended. The required polio vaccine does
not include adult Hajj pilgrims from the United States. However, it is best that
individuals confirm full vaccination against polio before travel (Brunette and Centers
for Disease Control and Prevention [CDC] 2016).
The Saudi Arabia Ministry of Health requires visitors from any country arriving for
the Hajj pilgrimage to produce documentation of vaccination against meningococcal
meningitis infection, protecting against quadrivalent serogroups A, C, W, and Y
(ACWY). Also, the Saudi Arabia Ministry of Health has additional vaccination
requirements for Hajj pilgrims entering from countries outside of the United Kingdom
(UK) which include yellow fever and poliomyelitis (Saudi Ministry of Health 2016).
Meningococcal Meningitis
Crowded conditions and the high carrier-rate risk of meningococcal disease

among pilgrims, have led to historical outbreaks during Hajj. After the 2000 and 2001
meningococcal disease outbreaks, the Saudi Ministry of Health began requiring all
pilgrims to show documentation of the quadrivalent (ACWY) meningococcal vaccine
(Brunette and Centers for Disease Control and Prevention [CDC] 2016). All adults and
children above 2 years of age must receive at least a single dose of tetravalent
(ACYW135) vaccine and provide valid administered vaccination documentation of
not more than 3 years and not less than 10 days prior to arrival in Saudi Arabia. Both
meningococcal polysaccharide and conjugate vaccines are considered valid options.
Polysaccharide meningococcal vaccination delivers protection of at least 3 years with
conjugate meningococcal vaccination providing at least 8 years of protection.
Pilgrims arriving from counties identified in the “African Meningitis Belt” have
been shown to have the highest Neisseria meningitidis incidence rates (Table 1)
(The Council of British Hajjis [CBHUK] 2010; Brunette and Centers for Disease
Control and Prevention [CDC] 2016). Pilgrims visiting or residing in this region
or countries where meningococcal disease is hyperendemic or epidemic, should
receive vaccination with a quadrivalent meningococcal vaccine before the date
of travel (Brunette and Centers for Disease Control and Prevention [CDC] 2016).
1272 F. T. Pleban
Table 1 Countries in the Benin

“African Meningitis Belt”
Burkina Faso
(Ministry of Health –
Kingdom of Saudi 2017a) Cameroon
Chad
Central African Republic
Côte d’Ivoire
Eritrea
Ethiopia
Gambia
Guinea
Guinea-Bissau
Mali
Niger
Nigeria
Senegal
Sudan
South Sudan
For pilgrims residing in these regions, either the MenACWY vaccine (people aged
2 months through 55 years and meningococcal vaccine non-naïve people aged
56 years) or MPSV4 (meningococcal vaccine-naïve people aged 56 years)
are recommended before travel (Brunette and Centers for Disease Control and
Prevention [CDC] 2016). In addition to the stated meningococcal vaccination
requirements, the additional application antibiotic prophylaxis regimen with cipro-
floxacin is recommended for administration to adults (excluding pregnant
women) and children over 12 years of age at the port of entry into Saudi Arabia
(World Health Organization [WHO] 2016).
Yellow Fever
Beginning in 2005, pilgrims arriving from countries or regions identified at risk of

yellow fever transmission must also provide valid documentation of yellow fever
vaccination (World Health Organization [WHO] 2016). For valid yellow fever
documentation, pilgrims must show that vaccination was administered at least
10 days before arrival in Saudi Arabia (Brunette and Centers for Disease Control
and Prevention [CDC] 2016). Table 2 lists countries and/or regions identified at
risk for yellow fever transmission (World Health Organization [WHO] 2016).
Poliomyelitis
As of 2017, regardless of age and vaccination status, pilgrims must also show proof
of receipt within the previous 12 months (and at least 4 weeks prior to departure)
Table 2 Counties and/or regions at risk for yellow fever

Africa Americas
Angola Argentina
Benin Bolivia
Burkina Faso Brazil
Burundi Colombia
Cameroon Ecuador
Chad French Guiana
Congo Guyana
Côte d’Ivoire Panama
Equatorial Guinea Paraguay
Ethiopia Peru
Gabon Suriname
Gambia Trinidad and Tobago
Ghana Venezuela
Guinea
Guinea-Bissau
Kenya
Liberia
Mali
Mauritania
Niger
Nigeria
Senegal
Sierra Leone
Sudan
South Sudan
Sudan
Togo
Uganda
of a dose of oral polio vaccine (OPV), or inactivated poliovirus vaccine (IPV),

before entry to Saudi Arabia (World Health Organization [WHO] 2016). Table 3
identifies (as of 2017) countries or regions require proof of vaccination receipt.
Pilgrims from listed countries (as of 2017) will also receive 1 dose of OPV on
arrival at Saudi Arabia point of entry (World Health Organization [WHO] 2016).
Zika Virus
As of 2017, the Aedes aegypti mosquito has not been found at either the Hajj or
Umra areas; however, the Aedes aegypti mosquito is present in surrounding
locales (World Health Organization [WHO] 2016). The Zika virus has not been
detected in Saudi Arabia. The Ministry of Health of Saudi Arabia recommends
1274 F. T. Pleban
Table 3 Countries Afghanistan

requiring proof of
Pakistan
poliomyelitis vaccination
Guinea
Laos
Madagascar
Myanmar
Nigeria
Ukraine
Somalia
Syria
Yemen
Hajj and Umra travelers to take measures to avoid insect bites during daytime
and nighttime hours to reduce the risk of infection of mosquito borne diseases
(World Health Organization [WHO] 2016). Insect bite avoidance measures include:
1. The use of insect repellent. Environmental Protection Agency (EPA)-registered

insect repellent with one of the following active ingredients (a. DEET; b.
Picaridin; c. Oil of lemon eucalyptus (OLE) or para-menthane-diol (PMD); d.
IR3535) is recommended (Centers for Disease Control and Prevention [CDC]
2017). Used as directed, EPA-registered insect repellents have been shown to be
safe and effective, even for pregnant and breastfeeding women (Centers for
Disease Control and Prevention [CDC] 2017).
2. Cover as much of the body as possible. Wear long-sleeved shirts and long pants.
3. Keep mosquitoes out of the living/sleeping environment. If inside, utilize
window and door screens. If outside, sleep under mosquito bed netting.
Respiratory Tract Infections and MERS
Respiratory tract infections are common during Hajj, with pneumonia documented
as the most common cause of hospital admission (Shafi et al. 2016). The pneumo-
coccal polysaccharide vaccine is recommended for those pilgrims over 65 years of
age, as well as for younger pilgrims with comorbidities (Shafi et al. 2016). As well,
the Ministry of Health of Saudi Arabia recommends the administration of the
most current seasonal influenza vaccine, including H1N1.
Crowded conditions created during the Hajj also increase the probability
of tuberculosis and Middle East respiratory syndrome (MERS) transmission
(Brunette and Centers for Disease Control and Prevention [CDC] 2016). Middle
East respiratory syndrome (MERS) was first identified in Saudi Arabia in 2012.
Cases of MERS have been identified in and around the Arabian Peninsula, with
the exportation of cases to other countries, including the United States.
MERS is caused by a unique coronavirus, similar to the severe acute respiratory

syndrome (SARS) virus responsible for the 2003 global outbreak (Centers for
Disease Control and Prevention [CDC] 2012). Severity of illness can range from
mild to severe, with fatality in approximately 35% of the reported cases (Brunette
and Centers for Disease Control and Prevention [CDC] 2016). Currently, no vaccine
or preventive drug is available for MERS. General personal hygiene precautions
against MERS are recommended for pilgrims, such as frequent handwashing;
avoid touching eyes, nose, and mouth; and avoiding contact with other sick travelers
(Brunette and Centers for Disease Control and Prevention [CDC] 2016).
Engineering controls, such as immunizations, are designed to remove the
hazard at the source, before it comes in contact with an individual (American
Chemical Society [ACS] 2015). A well-designed immunization schedule can
be highly effective in protecting individuals. Initial cost of immunizations can be
higher than the cost of personal protective equipment; however, over time, they can
produce a cost saving in terms of reduced further medical care.
Personal Hygiene as an Administrative Control for Infectious

Diseases
Standard public health personal hygiene practices can act as a general administrative
control for infectious disease. Behavioral interventions as administrative controls
such as hand hygiene, proper cough etiquette, social distancing, and contact avoid-
ance can be effective at mitigating respiratory illness and other infectious diseases
among Hajj pilgrims (Brunette and Centers for Disease Control and Prevention
[CDC] 2016).
The Ministry of Health of Saudi Arabia (Ministry of Health – Kingdom of Saudi
Arabia. 2017a) advises all pilgrims to apply recommended personal hygiene
procedures, particularly after coughing and sneezing, after using the toilet, before
handling and consuming food, and after handling animals: (1) wash hands with
soap and water and (2) if soap and water is not readily available, use sanitizers with a
form of alcohol, such as ethyl alcohol, as an active ingredient (World Health
Organization [WHO] 2016).
Additional personal hygiene recommendations (World Health Organization
[WHO] 2016) include:
1. Use of disposable tissues when coughing or sneezing and properly disposing

of them afterwards in appropriate waste containers.
2. Avoid hand contact with the eyes, nose, and mouth.
3. Avoid direct contact with persons who appear ill, exhibiting conditions exhibiting
coughing, sneezing, expectorating, vomiting, and/or diarrhea.
4. Avoid sharing of personal belongings.
5. Avoid close contact with animals or eating meat that has not been properly
prepared and cooked.
1276 F. T. Pleban
Personal Protective Equipment as a Control for Respiratory and

Infectious Diseases
The use of personal protective equipment (PPE) is a way of controlling hazards by

placing a protective barrier between the person and hazard (New York Committee
for Occupational Safety and Health n.d.). As noted, personal protective equipment is
the least effective method for protecting an individual from hazards and should be
utilized after all other effective mechanisms to control the hazard have been
exhausted. Caution is advised in utilizing PPE for hazard control because: (1) the
hazard itself is not eliminated or changed, (2) improper PPE may be inadequate or
fail, (3) PPE is not 100% effective in controlling a hazard, and (4) some personal
protective equipment may be uncomfortable and place additional physical stress on
an individual (Centers for Disease Control and Prevention [CDC] 2015). In helping
to decrease any potential body burden placed on an individual from PPE use, there is
one basic engineering control pilgrims can utilize before travel – immunizations
(New York Committee for Occupational Safety and Health n.d.).
The most common PPE devices for respiratory infection control are surgical masks
and disposable N95 respirators. There are significant differences between these two
types of personal protective equipment. However, in order to provide protection, both
surgical mask and N95 respirators need to be worn correctly and consistently (U.S.
Food and Drug Administration [FDA] 2015). Regardless of the type of PPE, surgical
masks or N95 respirators, both need to be used in combination with other public
health interventions that are known to prevent disease transmission, such as engi-
neering and administrative controls and personal hygiene practices (e.g., cough
etiquette, hand hygiene, and social distancing) (Occupational Safety and Health
Administration [OSHA] 2009a). If used properly and in conjunction with other
controls, surgical masks and respirators both have a role in preventing different
types of exposures (Occupational Safety and Health Administration [OSHA] 2009b).
Evidence suggests that some disease transmission may occur from the inhalation of
microscopic airborne particles (American Industrial Hygiene Association [AIHA]
2017). Infectious diseases, particularly influenza, can be spread several ways, including:
1. Airborne droplets or sprays

2. Hand to mouth/nose/eye contact
3. Direct surface contact
4. Combinations of above listed contamination methods (American Industrial
Hygiene Association [AIHA] 2017)
Surgical Masks
Surgical masks as a physical barrier are threefold: (1) to protect the user from large
droplets of blood or body fluids hazards; (2) worn to keep contaminated fingers/hands
away from the wear’s mouth and nose, and (3) protect pilgrims against infection from
the person wearing the surgical mask by trapping large particles of contaminated body
fluids expelled by the wearer (Occupational Safety and Health Administration [OSHA]
2009a; Occupational Safety and Health Administration [OSHA] 2009b).
Surgical masks are neither designed nor certified to prevent the inhalation of
small airborne viruses or bacteria (Occupational Safety and Health Administration
[OSHA] 2009b). Also, because surgical masks are not designed to provide a tight
seal around the wearer’s face, potentially contaminated air can pass through gaps
between the wearer’s face and the mask during inhalation (Occupational Safety and
Health Administration [OSHA] 2009b). Because the surgical mask’s ability to filter
small particles varies significantly based upon the type of material used in construc-
tion, they cannot be relied upon to protect against inhaling infectious organisms
(Occupational Safety and Health Administration [OSHA] 2009b). In the United
States, only surgical masks that are tested for their ability to resist blood and body
fluids and cleared by the U.S. Food and Drug Administration (FDA) can be legally
marketed in the United States (Occupational Safety and Health Administration
[OSHA] 2009b; Centers for Disease Control and Prevention [CDC] 2016).
Furthermore, surgical masks are not designed to be used more than once.
If a wearer’s surgical mask becomes damaged or soiled, or if breathing through
the mask becomes difficult, the mask should be removed, appropriately discarded,
and replaced with a new mask (U.S. Food and Drug Administration [FDA] 2015).
To safely discard a mask, place it in a plastic bag, and place the bag with the mask
in an appropriate waste container. To help prevent any further contamination,
the wearer should wash their hands with soap and water after handling the used
mask (U.S. Food and Drug Administration [FDA] 2015).
Disposable N95 Respirators
Disposable N95 respirators are designed and tested to filter small air particulates;
thus reducing the number of infectious particles inhaled and affording more protec-
tion than surgical masks. The “N95” designation means that when the respirator is
subjected to careful testing, it blocks at least 95% of very small (0.3 micron) test
particles (U.S. Food and Drug Administration [FDA] 2015). Respirators offer the
best protection when wearers are within 6 feet/1.8 meters of others who have
influenza-like symptoms (Occupational Safety and Health Administration [OSHA]
2009b). With proper fitting to the person, the filtration capabilities of N95 respirators
are greater than those of surgical masks (U.S. Food and Drug Administration [FDA]
2015). In order to provide optimal protection, respirators require a more concerted
effort by the wearer in regard to use, fit, and care. Disposable N95 respirators come
in various sizes and must be individually selected to fit the wearer’s face in order to
provide a tight seal and subsequent protection. A proper, tight seal between the
wearer’s face and respirator forces inhaled air to be pulled through the respirator’s
filter material and not through gaps between the wearer’s face and respirator during
inhalation (Occupational Safety and Health Administration [OSHA] 2009b). How-
ever, even properly fitted N95 respirators do not completely eliminate the risk for
disease transmission (U.S. Food and Drug Administration [FDA] 2015). Also, since
1278 F. T. Pleban
a proper fit is essential for protection, N95 respirators are not designed for children or
Hajj pilgrims with facial hair. Unfortunately, a pilgrim may derive little benefit from
wearing an N95 respirator that has not been properly fit-tested on the wearer. Outside
of use in the occupational setting, proper fit-testing may be difficult to obtain for
members of the general public (American Industrial Hygiene Association [AIHA]
2017; U.S. Food and Drug Administration [FDA] 2015).
Public Use N95 Respirators
Select filtering facepiece N95 respirators have been cleared by the FDA for use by the
general public. All FDA-cleared N95 respirators are labeled as “single-use,” disposable
devices (U.S. Food and Drug Administration [FDA] 2015). If the respirator becomes
damaged or soiled, or if breathing difficulty occurs, a person should remove the
respirator, discard it properly by placing it in a plastic bag and placing both in an
approved trash container, and replace it with a new one (U.S. Food and Drug Admin-
istration [FDA] 2015). Proper handwashing with soap and water after handling any
respirator is required. However, in general, the CDC does not recommend facemasks
and respirators for use in community settings (U.S. Food and Drug Administration
[FDA] 2015). But, facemasks and respirators may be appropriate for persons at risk for
severe illness from influenza or other respiratory diseases. The FDA has approved the
following list of N95 respirators for use by the general public:
• 3 M™ Particulate Respirator 8670F

• 3 M™ Particulate Respirator 8612F
• Pasture Tm F550G Respirator
• Pasture Tm A520G Respirator (U.S. Food and Drug Administration [FDA] 2015)
The proper use of surgical masks or N95 respirators is one practice, in conjunc-
tion with other environmental controls and personal hygiene practices, which may
reduce the risk of infectious disease transmission. There is limited historical
data (Occupational Safety and Health Administration [OSHA] 2009b) on the effec-
tiveness of either surgical masks or N95 respirators for the control of respiratory
diseases during past pandemics. The effectiveness of surgical masks and N95
respirators has been inferred based on the mode of disease transmission, (specifically
influenza), particle size, and professional judgment (Occupational Safety and Health
Administration [OSHA] 2009a; U.S. Food and Drug Administration [FDA] 2015).
Controlling for Other Mass Gathering Hazards
Other Health and Safety Hazards
Skin chafing may be caused by long periods of standing and walking in the heat
leading to fungal or bacterial skin infections (Brunette and Centers for Disease
Control and Prevention [CDC] 2016). To maintain personal hygiene, clothing should
be light, not restrictive, and changed often (Brunette and Centers for Disease Control
and Prevention [CDC] 2016). It is recommended that pilgrims should keep skin
dry, use talcum powder, and be aware of any pain or soreness caused by clothing
or garments. Any sores or blisters should be disinfected and kept covered with
sterile a dressing or bandage; with special attention paid to protect the feet, which
are bare when inside the Grand Mosque (Brunette and Centers for Disease Control
and Prevention [CDC] 2016).
When the Hajj occurs during the summer months, heat exhaustion and heatstroke
are leading causes of death and disability (Brunette and Centers for Disease Control
and Prevention [CDC] 2016). Pilgrims should be cognizant on minimizing the
risk of heat-related injuries and illnesses, as well as sun avoidance. Particularly at
dawn on the 9th day of Dhu al-Hijja, pilgrims will begin an 8.9 m/14.4 km walk
to the plain of Arafat (Brunette and Centers for Disease Control and Prevention
[CDC] 2016). Typically, the route is supplied with cool mist sprinklers to offset
the high daytime temperatures; however, the risk of heat-related illnesses increases
during this part of the journey (Brunette and Centers for Disease Control and
Prevention [CDC] 2016).
Pilgrims should stay hydrated with water, wear sunscreen with a minimum
sunscreen protection factor (SPF) of 30, and seek shade when possible. Umbrellas
may also be used to provide portable sun protection (Brunette and Centers for
Disease Control and Prevention [CDC] 2016). In order to avoid oppressive daytime
heat, some Hajj rituals may also be performed at night. Pilgrims can be reassured
that evening rituals have been advocated as both appropriate and legitimate by
religious clerics (Brunette and Centers for Disease Control and Prevention [CDC]
2016).
Personal Responsibility in Abiding by General Posted Health

Guidelines as Engineering, Administrative, and/or PPE Controls
The Ministry of Health of Saudi Arabia has published General Guide for Health of
Hajj and Umrah Pilgrims (3rd edition) for all pilgrims to review and follow before
partaking in the Hajj (Ministry of Health – Kingdom of Saudi Arabia. 2017b).
The document’s primary goal is providing Hajj and Umrah pilgrims with health
education concepts to improve personal prevention practices against disease, illness,
and injury. Listed are general guidelines that if administered individually and
collectively, serve as effective engineering, administrative, and/or PPE controls:
1. Receiving necessary vaccinations vaccines, particularly elderly and pilgrims with

chronic diseases;
2. Traveling with sufficient medications for health and/or environmental conditions.
3. Traveling with sufficient clothes appropriate for environmental conditions;
4. Traveling with sufficient detailed medical report outlining pre-existing illnesses
and any prescribed medications;
1280 F. T. Pleban
5. Maintaining in good working order personal hygiene equipment, such as towels,

shaving tools, soap, toothbrush and toothpaste, creams and moisturizing
ointments, and an umbrella;
6. Traveling with sufficient supply of essential disinfectants, hand sanitizers, anti-
pyretics, and painkillers;
7. For diabetics, traveling with and maintaining in good working order a reliable and
accurate glucose meter;
8. Walking or standing for short periods after remaining stationary for long periods
of time (1–2 h in length).
9. Acquiring a medical checkup before traveling to help ensure a successful Hajj
pilgrimage (Ministry of Health – Kingdom of Saudi Arabia. 2017b).
Public Health Education and the Hajj
Implementation of administrative, PPE, or personal hygiene hazard controls, in

part or in whole, will only be effective if properly communicated and followed.
Those hazards, as identified through public health surveillance and monitoring,
require proper health education dissemination to pilgrims. Proper health education
communication should take into consideration an appreciation of the diverse char-
acteristics of all Hajj travelers. Providing health education to travelers through
various modes of has been shown to improve short-term health knowledge which
may promote positive health behaviors (Turkestani et al. 2013). Even with an
increase in short or long-term health knowledge, proper behavior modification
occurs when a person believes that he or she is susceptible to a hazard or considers
a hazard serious to their health. As well, establishing a personal sense of self-
efficacy, empowering an individual to take control of his/her own health and health
outcomes, will ultimately decide the fate of any health education programming.
However, for health education to be effective, special consideration must be given to
modes of communication and the cultural appropriateness of that communication
(Nishtar et al. 2004; Saha et al. 2005). Those communication barriers (e.g., environ-
mental and cultural) and modes of communication (e.g., social media messages,
lectures, public addresses, posters, and leaflets); as well as group characteristics
(e.g., age, gender, and background) need to be factored into the health education
message (Abolfotouh 1995; Werner and Wilson 1981). Major limitations to
implementing health education to Hajj pilgrims are similar to health promotion
programming in other settings. Restricted time and available resources to conduct
proper and repeated health promotion programming presents significant limitations
(Shirah et al. 2017).
Kingdom of Saudi Arabia Ministry of Health (MOH)
Established in 1950, the Kingdom of Saudi Arabia Ministry of Health’s (MOH)

primary responsibility is delivering integrated and comprehensive healthcare
services for the citizens of Saudi Arabia; as well as Hajj travelers irrespective of
region or country (Saudi Ministry of Health 2018a). Since inception, top MOH
priorities have focused on inclusive public health and disease control measures.
These specific policies and projects focus on providing both general and specific
health services to address health conditions; specifically non-communicable
diseases, nutrition, reproductive health, smoking (tobacco-use), AIDS, traffic
accidents, and injuries. (Saudi Ministry of Health 2018a). Capacity-building
collaboration and cooperation with international organizations helped establish
an infrastructure for comprehensive health services, including care for Hajj and
Umrah pilgrims.
The Kingdom of Saudi Arabia Ministry of Health (MOH) publishes health
requirements and regulations for the care of all pilgrims before each Hajj season.
Pilgrims in their countries or origin should consult with their respective health
authorities prior to travel regarding pre-event, event, and post-event personal
health measures to prevent illness and injury. To be effective, public health
information and campaigns should be provided so as to be interpreted appropriately
and with cultural competency.
Finally, effective cooperation and communication between agencies,
both within and outside the Kingdom of Saudi Arabia, is paramount in the
health promotion and disease surveillance of pilgrims. Health, environmental,
transportation, and border security are some examples in which effective agency
collaboration and communication can together mitigate hazards and promote
traveler health (Shafi et al. 2016).
The Kingdom of Saudi Arabia Ministry of Health established health
guidelines, disseminated electronically through the MOH portal, specific to the
health education of Hajj pilgrims (Saudi Ministry of Health 2018b). Public health
guidelines for current Hajj pilgrims (Hajj 1439 H.) have been established for
travelers addressing: (1) During Hajj, (2) Chronic Diseases, (3) Woman and Child,
and (4) After Hajj (Saudi Ministry of Health 2018a). A more robust description of
health guidelines for each of these four areas may be accessed through the MOH
portal (www.moh.gov.sa/en/Hajj/HealthGuidelines/Pages/default.aspx).
In general, each pilgrim should ensure proper maintenance of pertinent
vaccinations prior to travel; as well as awareness of disease transmission and
disease symptoms; with special consideration given to the education of respiratory
diseases. Advice on standard personal hygiene measures and general food and
drink hygiene practices, to minimize food and waterborne diseases and gastrointes-
tinal illness should be provided. Special public health education consideration
should be given to those with preexisting conditions, older pilgrims, and first-time
travelers.
During Hajj MOH Health Education Guidelines
During Hajj, health guidelines have been established for protection against
infectious and communicable diseases, with a focus on five practice areas:
1282 F. T. Pleban
(1) General Hygiene and Cleanliness; (2) Shaving and Haircutting; (3) Food Poi-
soning Protection; (4) Heat Exhaustion and Sun Stroke Protection; and (5) Guide-
lines for Patients with Chronic Diseases.
Established hygiene and cleanliness health recommendations for bathing,
handwashing, cleanliness of person and personal surroundings, and proper facemask
donning and doffing hygiene practices are emphasized. Particular infection control
emphasis is given to coughing and sneezing etiquette, including the use of handker-
chiefs as a barrier, with proper trash disposal soon after use. In the event where no
handkerchief is available, sneezing or coughing into the upper arm as a barrier
method is recommended. Facemask use, particularly in crowded areas, is
recommended as an additional barrier method. As mentioned, an integral component
of facemask effectiveness is being mindful of routine facemask changing on a 6-h
basis, when dirty, or in accordance to manufacturer guidelines. Facemask recom-
mendations are expanding to include those population dense event areas (i.e., during
circumambulation of the Ka’ba (Tawaf), stoning (Rajm), and walking between Safa
and Marwa (Sa’i)) (Saudi Ministry of Health 2018a).
Shaving and haircutting health education hygiene practices established by MOH
stress individual self-care to protect against infectious diseases such as hepatitis (B),
hepatitis (C), and HIV/AIDS (Saudi Ministry of Health 2018a). It is recommended
that once-use shavers be utilized and to never share personal razors (or other
personal items), such as brushes, with other travelers. As well, if a pilgrim chooses
to use a barber, to be attentive of selecting a reputable barber and to resist the
services of street barbers during the course of the event (Saudi Ministry of Health
2018a).
Food poisoning protection guidelines established by MOH parallel general per-
sonal hygiene practices. In addition to the washing of hands with soap and water
before and after food preparation, guidelines for food selection, storing, and cooking
are outlined. Food selection should be performed with expiry dates in mind. Food
storage should be such as to keep foodstuffs out of the elements, away from insects,
and at proper temperature. It is recommended that cooked food is stored for no more
than 2 h at room/bus temperature, in order to deter from bacteria growth and food
poisoning (Saudi Ministry of Health 2018a).
Hazards from exposure to environmental elements, particularly prolonged
exposure to sun and heat, cannot be overstressed. The Kingdom of Saudi Arabia
Ministry of Health public health guidelines for the prevention of heat exhaustion and
sunstroke promote the adequate consumption of liquids, use of umbrellas, the
wearing of loose, light colored clothing, and the proper incorporation work (walk)/
rest periods. Avoidance measures include reducing prolonged sun exposure and
physical exertion for extended periods of time (Saudi Ministry of Health 2018a).
Noted areas and times of frequent heat injuries have been identified. The Saudi
Ministry of Health (2018a) identifies the Tawaf (circumambulation of the Ka’ba), at
midday, Sa’i (walking between Safa and Marwa), during crowding and at high
temperatures, Arafat at midday, and Mina (places of slaughtering the sacrificial
animals and stoning), due to long travel distance and congestion as areas of increased
risk for heat exhaustion and sunstroke.
Finally, The Saudi Ministry of Health (2018a) outlines health guidelines specific
to the signs and symptoms of heat exhaustion or sunstroke. Pilgrims should be
aware of high body temperature, as well as other traditional signs and symptoms of
heat exhaustion or sun stroke, such as headache, dizziness, nausea, fatigue, thirst,
and/or cramping of the abdominal and leg muscles. To combat heat related illness
and injury, guidelines established include (1) resting in shady areas; (2) cooling
the body with cold water; (3) acquiring adequate sleep; (4) when necessary, admin-
istration of antipyretics and painkillers; and (5) in severe cases, admission to the
nearest health center for further treatment.
Public health education guidelines during the Hajj for patients with chronic
diseases focus on proper preparation before travel and communication at the
event. Before Hajj, physician consultation to assess current health status is
recommended. Before travel, any prescribed medications should be inventoried,
packed, and properly stored. At Hajj, pilgrims on a medication regimen should
adhere to physician instruction and take medicines at the prescribed times (Saudi
Ministry of Health 2018a). As well, travels should communicate disease-specific
details while at Hajj to others in attendance. It is recommended to adhere to the
person an information card, outlining: name, age, disease, the kind of treatment,
address and contact information. Communication with fellow pilgrims regarding
disease condition and the use of Hajj legal concessions when warranted (e.g.,
assigning someone to do the stoning ritual on your behalf) are recommended
(Saudi Ministry of Health 2018a) aids in securing a productive and successful
Hajj pilgrimage.
Pilgrims with Chronic Disease Conditions MOH Health Education

Guidelines
During Hajj, the Saudi Ministry of Health (2018a) have designated health
guidelines through their electronic portal for five chronic disease areas: (1) Heart
and Hypertension, (2) Diabetes, (3) Asthma, (4) Kidney/Renal, and (5) Epilepsy/
Seizures. Due to the complex etiology of each chronic condition, it is paramount that
each pilgrim, diagnosed with these specific chronic disease conditions or other
illnesses, first consult with their physician prior to any travel. Health education
guidelines are similar to those during Hajj recommendations. Physician evaluation,
inventory, storage, and transportation of medications, timely medication administra-
tion, sign and symptom awareness, and health communication with other travelers
and Hajj health authorities is recommended. As before, a more detailed description
of health guidelines for these five specific chronic disease condition may be accessed
through the MOH portal (www.moh.gov.sa/en/Hajj/HealthGuidelines/Pages/default.
aspx). One other common theme in properly managing these listed conditions, or
others, is to seek assistance from nearest health center or hospital. Health centers
and stations are strategically positioned at Hajj and noted event areas for rapid
response and treatment of these and other health conditions (Saudi Ministry of
Health 2018a).
1284 F. T. Pleban
Women and Children Pilgrims MOH Health Education Guidelines
Guidelines for the health of women and children have also been taken into
account with specific notation regarding the physical effort required for the journey
(Saudi Ministry of Health 2018a). With reference to maternal (women’s)
health, recommendations are outlined addressing health during menstruation and
pregnancy. The Saudi Ministry of Health (2018a) recommends that women
pilgrims consult their obstetrician-gynecologist physician before travel in order to
properly perform Hajj rites. If pregnant, the MOH recommends postponement of
the Hajj for specific reasons and cases.
Specific reasons for pregnant women to postpone the Hajj include risk of:
1. Unexpected pregnancy complications;

2. Sun stroke;
3. Physical overexertion;
4. Physical injury from overcrowded conditions;
5. Dehydration or insufficient hydration (Saudi Ministry of Health 2018a).
Specific cases for pregnant women to postpone the Hajj include history of:
1. Preterm births;
2. Early miscarriage cases;
3. Diabetes during pregnancy;
4. Pilgrims with diagnosed heart, hypertension, or kidney disease (Saudi Ministry of
Health 2018a).
In the case of proper pre-travel medical clearance to attend Hajj, pregnant women
should be made aware of the following Saudi Ministry of Health (2018a) health
published guidelines:
1. Obstetrician-gynecologist physician consultation to minimize any health

complications from attending the Hajj.
2. Possible vaccination against meningitis and influenza at least 10 days before the
Hajj.
3. Inventory of all the necessary medicines.
4. Fitting and use of proper clothing and footwear.
5. Adequate fluid supply for entire Hajj attendance.
6. Walking for an hour to 2 h, to reduce the risk of leg deep vein thrombosis.
7. Avoid overcrowded areas and choose times of less crowding to perform Hajj rites.
8. Utilize the nearest health center, station, or hospital in the event of bleeding,
abdominal contractions, and migraine, or when high temperature occurs.
9. Avoid any excessive physical effort and to apply legal Hajj concessions and
license according to conditions when necessary such as the use of a wheelchair
during Tawaf (circumambulation) and Sa’i (walking) (Saudi Ministry of Health
2018a).
The Saudi Ministry of Health (2018a) recommends against prepubescent children

attending the Hajj for several reasons. Recommendations for prepubescent children
abstaining from the Hajj include the increased risk of:
1. Respiratory and digestive tract infections;

2. Fluid loss;
3. Physical exhaustion;
4. Getting lost in areas of overcrowding (Saudi Ministry of Health 2018a).
In cases in which children and in the accompaniment of mothers attending the

Hajj, the Saudi Ministry of Health (2018a) stresses adherence of children to all
general health guidelines for attendance. Other children-specific guidelines include:
1. Wearing identification with full name, place of residence, contact telephone

number, and convoy name and contact information.
2. Current and up-to-date vaccination schedule and Hajj-related vaccinations.
3. Administration of Escherichia coli bacterium (Haemophilus influenza) 10 days
before travel (if not already part of their vaccination schedule or Hajj-related
vaccinations).
4. Maintaining adequate fluid intake.
5. Educated in proper handwashing practices.
6. Maintaining proper skin care practices to prevent drying and chafing.
7. Educated in proper food hygiene practices.
8. Avoidance of overcrowded areas as much as possible.
9. Utilize the nearest health center, station, or hospital if and when any health
problems occur such as diarrhea, vomiting, or high body temperature (Saudi
Ministry of Health 2018a).
After Hajj MOH Health Education Guidelines
After Hajj health guidelines have been instituted by the Kingdom of Saudi Arabia
Ministry of Health (Saudi Ministry of Health 2018a) to address signs and
symptoms experienced post-Hajj. Commonly reported post-Hajj health concerns
include muscle strain and pain, headaches, cold symptoms, lethargy, irregular
sleep patterns, and skin complexion darkening. Common contributors to the listed
health conditions include physical exertion with or in the absence of proper physical
conditioning, excessive sun exposure, and coming in contact with pilgrims infected
with the cold and/or influenza virus.
After returning, the following post-Hajj health advice is recommended:
1. Adequate rest.
2. Proper fluid consumption.
3. Analgesic medications if needed and prescribed.
4. Those with preexisting chronic conditions exacerbated from Hajj travels should
see their physician for proper medical guidance (Saudi Ministry of Health 2018a).
1286 F. T. Pleban
The importance of proper physical fitness, along with maintaining an ideal

weight, is stressed, particularly in promoting a successful and healthy future Hajj
pilgrimage (Saudi Ministry of Health 2018a). The best time to prepare for the
subsequent Hajj pilgrimages is on return from present travels.
Conclusion
In order to promote a successful and healthy Hajj, pilgrims should prepare in

advance to anticipate and recognize common health or environmental hazards that
may be encountered during their journey. To this end, the Kingdom of Saudi Arabia
Ministry of Health established health guidelines, disseminated electronically through
the MOH portal, specific to the health education of Hajj pilgrims addressing: (1)
during Hajj, (2) chronic diseases, (3) woman and child, and (4) after Hajj tradition-
ally; established hazard control measures include: (1) elimination, (2) substitution,
(3) engineering controls, (4) administrative controls, and (5) personal protective
equipment (PPE), with maintaining a current immunization schedule as an important
engineering control. As well, on an individual level, attention to regimented personal
hygiene practices is shown to be an effective public health administrative control
measure. Preparation for a healthy pilgrimage should begin in earnest, with prepa-
ration for the subsequent Hajj pilgrimages after returning from recent Hajj travels.
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Meningococcal Disease During Hajj, Umrah,
and Other Mass Gatherings 52
Sergerard Sebastian, Al-Mamoon Badahdah, Ameneh Khatami, and
Harunor Rashid
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1291
Meningococcal Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1291
Global Epidemiology of Meningococcal Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1292
Mass Gatherings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1295
Hajj and Umrah . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1296
Meningococcal Disease at Hajj . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1296
Meningococcal Disease at Non-Hajj/Umrah Mass Gathering . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1301
Comparing and Contrasting Hajj Versus Non-Hajj Outbreaks . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1302
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1303
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1304
Sergerard Sebastian and Al-Mamoon Badahdah contributed equally with all other contributors.
S. Sebastian
e-mail: sebastiansergerard@gmail.com
A.-M. Badahdah (*)
Department of Family and Community Medicine, Faculty of Medicine in Rabigh, King Abdulaziz
University, Jeddah, Saudi Arabia
Discipline of Child and Adolescent Health, The Children’s Hospital Westmead Clinical School,
Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
e-mail: mbadahdah@hotmail.com
A. Khatami
Discipline of Child and Adolescent Health, The Children’s Hospital Westmead Clinical School,
Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
Department of Infectious Diseases and Microbiology, The Children’s Hospital at Westmead,
Westmead, Australia
e-mail: ameneh.khatami@gmail.com

https://doi.org/10.1007/978-3-030-36811-1_52
1290 S. Sebastian et al.
Abstract
Meningococcal disease is a systemic infection caused by a bacterium Neisseria
meningitidis. There are an estimated 1.2 million worldwide cases of invasive
meningococcal disease every year, resulting in up to 135,000 fatalities. Incidence
of meningococcal disease fluctuates globally, with the highest annual incidence
found in the African meningitis belt. High-risk behaviors such as active and
passive smoking, intimate relationships (e.g., kissing), and semi-closed crowded
settings (e.g., residence in university halls, military barracks, and bar patronage)
perpetuate transmission of the organism.
Mass gatherings can serve as epicenters for disease transmission. Hajj is the
largest annual mass gathering that brings millions of Muslim pilgrims from
around the world to amass in Makkah, Saudi Arabia. Intense congestion during
Hajj, as well as shared accommodation and high-risk personal behaviors, magnify
disease transmission including meningococcal disease. This pilgrimage is the
most notable mass gathering and frequently magnifies meningococcal transmis-
sion and outbreaks. An outbreak in 1987 caused by serogroup A affected nearly
2000 individuals globally. A second outbreak caused by serogroup W occurred in
2000–2001, affecting more than 2400 individuals across the globe. Invasive
meningococcal disease outbreaks in non-Hajj/Umrah mass gatherings have
been reported in university hall residents, military establishments, refugee
camps, and sports and leisure events; these were mainly caused by serogroups
A and C and also led to an international spread. Mass immunization with
multivariate vaccines and antibiotic chemoprophylaxis is a mainstay for invasive
meningococcal disease prevention, successfully reducing morbidity and mortal-
ity. Without prevention, such mass gatherings can influence global meningococ-
cal epidemiology, likely by introducing invasive N. meningitidis strains to other
regions.
Keywords
Meningococcal disease · Mass gathering · Hajj · Outbreak · Arab world
H. Rashid
52 Meningococcal Disease During Hajj, Umrah, and Other Mass Gatherings 1291
Introduction
Meningococcal Disease
Meningococcal disease is a systemic infection caused by Neisseria meningitidis. The

pathogen is a Gram-negative, aerobic bacterium of the Neisseriaceae family
(Rouphael and Stephens 2012). There are 13 identified serogroups of N.
meningitidis, with 6 serogroups (A, B, C, X, Y, and W) causing the majority of
invasive meningococcal disease (IMD) (Rouphael and Stephens 2012). There are an
estimated 1.2 million worldwide cases of IMD every year, resulting in up to 135,000
fatalities (Jafri et al. 2013); however, the incidence of meningococcal disease
fluctuates globally, with annual incidence rates of 2 per 100,000 in most developed
countries, and reaching up to 230 per 100,000 in the African meningitis belt (Fig. 1):
an endemic region in sub-Saharan Africa stretched from Senegal in the west of the
continent to Ethiopia (Jafri et al. 2013). N. meningitidis is transmitted by direct
contact with respiratory secretions, e.g., via sneezing. The pathogen usually colo-
nizes asymptomatically in the nasopharyngeal cavity of carriers. It is estimated that
up to 10% of the general population carry N. meningitidis, yet only 1% of carriers
develop meningococcal disease (Rosenstein et al. 2001; Yazdankhah 2004). High-
risk behaviors such as active and passive smoking (Cartwright et al. 1987; Stuart
et al. 1988; Stanwell et al. 1994; Fischer et al. 1997; Neal et al. 2000; MacLennan
et al. 2006; Rashid and Booy 2012) and intimate relationships (e.g., kissing) perpet-
uate transmission of the organism (Tully et al. 2006; MacLennan et al. 2006). The risk
of transmission is further augmented through close contact in crowded settings, e.g.,
Fig. 1 The first Hajj-related international outbreak in 1987 started in Nepal, reached Makkah, and
spread to other parts of the world
residence in university halls, military barracks, and bar patronage (Stuart et al. 1988;
Stanwell et al. 1994; Edmond et al. 1995; Imrey et al. 1995, 1996; Cookson et al.
1998; Neal et al. 2000; Nelson et al. 2001; MacLennan et al. 2006).
Invasive infection with N. meningitidis can cause a number of clinical presenta-
tions. Septicemia and meningitis are considered the most common, with meningitis
presenting in 80–85% of cases of IMD (Memish 2002). However, pneumonia
(Racoosin et al. 1998), septic arthritis (Schaad 1980), conjunctivitis (Barquet et al.
1990), urethritis (Miller et al. 1979), and pericarditis (Rosenstein et al. 1999) can
also occur rarely. Common symptoms of meningococcal meningitis and septicemia
include onset of fever, nausea, vomiting, and fatigue (Pace and Pollard 2012).
Early initiation of antibiotic therapy is the mainstay of clinical management of
IMD (Cartwright et al. 1992). However, despite access to highly effective beta-
lactam antibiotics, the case fatality of IMD has remained around 10% in treated cases
(Thorburn et al. 2001). Furthermore, even with aggressive circulatory support in
specialist centers, significant sequelae, including neurological damage, hearing loss,
and limb loss, still occur in up to 20% of survivors (Healy et al. 2002). Thus,
prevention remains the key goal in management of meningococcal disease. Antimi-
crobial chemoprophylaxis serves as the primary method for controlling outbreaks
and direct contact transmission (CDC 2001; WHO 2008; Kushwaha et al. 2010;
Yezli et al. 2016b). During the 1960s, high IMD rates within the US military
prompted the development of the meningococcal polysaccharide vaccine (Hankins
et al. 1982). Vaccination is proven efficacious against IMD, providing immunolog-
ical protection against major N. meningitidis serogroups for several years depending
on the formulation. Quadrivalent (e.g., A, C, W, and Y vaccine), bivalent (e.g., A/C
and B/Y vaccines), and serogroup-specific monovalent (e.g., meningococcal B
vaccine), in conjugate and polysaccharide forms, as well as recombinant protein
vaccines are used globally in different settings (Vuocolo et al. 2018). With respect to
meningococcal serogroups A, C, W, and Y, more immunogenic polysaccharide-
protein conjugate vaccines, compared to plain polysaccharide vaccines, are now
used more widely, especially in developed nations, and these have been vital in
controlling both endemic rates of IMD and outbreaks (Miller et al. 2001; Salleras
et al. 2003; De Wals et al. 2004).
Global Epidemiology of Meningococcal Disease
The landscape of global burden of IMD varies, contingent on populations and

settings, geographic area and climate, period, serogroup, and clonal types. Epide-
miology of IMD occurs in either epidemic or endemic and hyperendemic rates
(Harrison et al. 2009). Lack of data on meningococcal disease epidemiology from
several countries hinders an accurate understanding of the magnitude of the world-
wide burden of IMD; however, it is known that very high incidence rates occur in the
African meningitis belt (Lapeyssonnie 1963). Most other countries in Africa, the
Pacific, and Western Europe have moderate incidence rates, while low incidence
rates are predominantly found in Americas and Eastern Europe (Jafri et al. 2013).
Africa
Meningococcal disease has existed in the African region for more than 100 years.
The highest global annual rates of IMD occur in the sub-Saharan countries of the
African meningitis belt, with attack rates peaking up to 1000/100,000 population.
Meningococcal meningitis is endemic in this region, and epidemics occur periodi-
cally during extremely hot and dry seasons. Crowded living conditions facilitate
transmission and colonization of the meningococci, and then the decreased air
humidity during the dry season is likely to damage the pharyngeal mucosa enough
to promote colonization of the epithelium by the invading meningococci (Green-
wood 1999). Serogroup A predominately causes IMD outbreaks in the region
(Harrison et al. 2009), although smaller outbreaks in the 1970s were caused by
serogroup C (Broome et al. 1983). Serogroup C outbreaks still continue to occur in
this region, with the 2015 Niger outbreak being the most recent, understood to be the
largest serogroup C outbreak in the meningitis belt (WHO 2015). In recent years
sporadic cases of serogroup X IMD have affected up to 6700 individuals annually
across Niger, Kenya, Togo, Burkina Faso, and Uganda (Xie et al. 2013). In African
countries outside the meningitis belt, meningitis rates are relatively low at 0.14 cases
per 100,000 population (Coulson et al. 2007). The incidence of the disease in the
African meningitis belt is summarized in Table 1.
Americas
Early outbreaks recorded during the twentieth century were believed to be caused by
serogroup A (Rouphael and Stephens 2012). Incidence of IMD prior to World War II
was high at 14/100,000 population but decreased to 0.5–1.5/100,000 post war
(Harrison et al. 2009), down to 0.12/100,000 in 2016 in the USA (Mbaeyi et al.
2018), and to 0.42/100,000 in post-vaccine period in Canada (Ali et al. 2014). The
distribution of serogroups fluctuates over time. Studies suggest that serogroups B
and C are common causes of IMD; however, Y is emerging as a common etiological
cause (Jackson and Wenger 1993; Imrey et al. 1996; Rosenstein et al. 1999). Recent
serogroup distribution in the USA shows the predominance of serogroup Y followed
by B, C, and W (CDC 2008).
There are difficulties in describing the burden of IMD in the Latin American region
due to limited published data. The overall incidence across the region is heterogenous
ranging from 0.1/100,000 population in Mexico up to 2/100,000 population in Brazil,
where serogroups B and C are the most common cause of disease. Recently,
serogroups W and Y IMD are emerging in the region (Al-Tawfiq et al. 2010).
Europe
In the European region, N. meningitidis serogroups B and C are the most frequent
causes of IMD. In 1999, hyperendemic rates of IMD at 1.67/100,000 population led
to the introduction of meningococcal C conjugate vaccines in the UK followed by
several the other countries, that reduced regional IMD to 1/100,000 in 2006. During
the same time, case fatalities ranged between 6% and 8%; however, vaccination
programs have decreased both the incidence of disease and associated fatalities
(Chandra and Ramsay 2007).
Table 1 Reported attack rate (>250/100,000) of meningococcal disease in the African meningitis
belt
Attack ratea
Period (per 100,000) Year Country/Region Dominant serogroup
1971–1980
360 1977 Nigeria, Zaria A
517 1979 Burkina Faso C
1981–1990
593 1986 Niger A
267 1990 Kenya A
1991–2000
608 1992 Burundi A
300 1993 Cameroon NA
465 1995 Niger NA
1605 1996 Burundi NA
984 1997 Gambia A
550 1997 Ghana A
652 1997 Togo NA
2001–2010
10b 2004 AMBc A
6b 2005 AMBc A
13.5b 2006 AMBc A
14.5b 2007 AMBc A
10b 2008 AMBc A
22b 2009 AMBc A
728 2009 Nigeria A
8b 2010 AMBc A
2011–2019
6b 2011 AMBc W
7b 2012 AMBc W
4.5b 2013 AMBc W
1037 2015 Aliero, Nigeria NA
AMB, African meningitis belt; NA, no data available
a
Includes confirmed and suspected cases
b
Rounded to the nearest half
c
Overall incidence rate of confirmed and suspected meningococcal meningitis in the African
meningitis belt for the respected year
Western Pacific
Data to describe the epidemiological scope of meningococcal disease in Western
Pacific region is limited. Epidemics in the past century across China, Hong Kong,
Mongolia, Taiwan, and the Philippines was predominantly caused by serogroup A
(Vyse et al. 2011), with rates of up to 500/100000 in China (Zhang et al. 2008).
Serogroups B and C also occurred with incidence rates of 20/100,000 in South
Vietnam (Oberti et al. 1981). Recent rates of IMD are relatively low across China,
Philippines, South Korea, Singapore, Taiwan (Jafri et al. 2013), and Japan
(Fukusumi et al. 2016). Serogroup A outbreaks have occurred in India more recently
(Nair et al. 2009), with serogroups C, W, and Y emergent in China (Ni et al. 2008),
Singapore (Wilder-Smith et al. 2002), and Taiwan (Chiou et al. 2006), respectively.
Australia is predominantly burdened by N. meningitidis serogroups B and C
(Rouphael and Stephens 2012). IMD incidence was high in the 1990s at a rate of
3/100,000 (Jelfs and Munro 2001), however declined to 1.3/100000 in 2006 due to
serogroup C conjugate vaccinations. Case fatality rates remain stagnant at 7%
(Tapsall and Australian Meningococcal Surveillance Programme 2008). New
Zealand is characterized as a highly endemic country with disease predominantly
caused by serogroup B (O’Hallahan et al. 2005) with incidence rates up to 17.4/
100000 in 2001, subsequently declining to 2.6/100,000 in 2007, in part due to the
use of outer membrane vesicle (OMV) meningococcal serogroup B immunization
(Baker et al. 2001; O’Hallahan et al. 2005).
Eastern Mediterranean Region

Accurate information regarding the epidemiology of meningococcal disease in the
Eastern Mediterranean region is hindered due to limited data and fluctuations in
disease burden across the region. Meningococcal disease in Saudi Arabia is mainly
caused by serogroups A and W, although cases with serogroups B and C persist
(Ceyhan et al. 2012). Disease rates in Saudi Arabia are high during epidemic periods,
mainly influenced by Hajj pilgrimage to Makkah, reaching up to 12.83/100,000.
During non-epidemic periods IMD rates remain low with rates only peaking to 1.65/
100,000 (Jafri et al. 2013). Gulf states such as Bahrain, Kuwait, United Arab
Emirates, and Qatar have relatively low IMD rates occurring at below 2 cases per
100,000 population (Ceyhan et al. 2012).
Mass Gatherings
Mass gatherings (MGs) are defined as either an organized or unplanned gathering of

people for a common purpose at a specific place and time. The number of people
gathering can be as low as a 1000 people, but can reach up to millions, wherein the
influx of participants can stress the host community’s health planning and response
resources (WHO 2008). The location, attendance, and duration of the gathering are
contingent on the type of event. The event may be a one-time gathering (e.g., state
funeral) or of a more frequent pattern (e.g., annual Hajj). It can last from several
hours (e.g., sports events) up to several months (e.g., the Kumbh Mela pilgrimage
and festival in Hinduism lasts ~2.5 months and attracted 60 million people in 2001).
Different MG conditions coincide with variable health monitoring and control
efforts during the event, ranging from an absence of health monitoring to highly
complicated health management and surveillance arrangements. MGs with intense
congestion, shared accommodation, and high-risk personal behaviors magnify com-
municable disease transmission such as IMD and become settings for meningococ-
cal outbreaks (e.g., 2004 EURO football tournament) (Gonçalves et al. 2005; Tully
et al. 2006; Wilder-Smith 2007; Memish et al. 2012). As such, the long periods spent
at Hajj pilgrim sites, in addition to the extreme heat, crowded accommodation, traffic
jams, and the generally advanced age of pilgrims, amplify the rate of N. meningitidis
transmission (Ahmed et al. 2006; Al-Tawfiq and Memish 2014).
Hajj and Umrah
The Hajj is a religious Muslim event that annually gathers millions of pilgrims from
around the world in Makkah, Saudi Arabia. The gathering is a weeklong pilgrimage,
taking place on specific days during the 12th month of the Islamic lunar calendar.
Every able-bodied Muslim must undergo the pilgrimage at least once in his/her
lifetime to enact the journey and rituals performed by the Prophet Mohammed
(PBUH). Pilgrims continue to visit Makkah throughout the year, embarking on a
smaller ritual called the Umrah. International travel renders a high influx of partic-
ipants performing the Umrah, especially during the 3 months preceding the Hajj
(Ahmed et al. 2006).
Hajj pilgrimage is the most notable mass gathering that magnifies meningococcal
transmission and outbreaks. An outbreak in 1987 caused by serogroup A affected
nearly 2000 individuals internationally. Its subsequent introduction to the African
meningitis belt caused major waves of serogroup A epidemics with rates of up to
1000 cases per 100,000 (al-Gahtani et al. 1995; Yezli et al. 2016a). A second
international outbreak caused by serogroup W occurred in 2000–2001, affecting
more than 2400 individuals across Europe, America, and the Middle East (Ahmed
et al. 2006).
Meningococcal Disease at Hajj
Pre-outbreak Era
Prior to the 1980s, health surveillance was limited to describing the nature of IMD
during Hajj due to a lack of accurate and more specific data. It is likely that
meningococcal disease during Hajj was uncommon. Although outbreaks did
occur, these were not routinely documented (al-Gahtani et al. 1995). Since the
1980s, IMD has become a significant public health burden based on the historic
persistence among Hajj pilgrims (Yezli et al. 2016a).
First Outbreak at Hajj in 1987

The significance of the Hajj in influencing local and global IMD epidemiology was
established from multiple outbreaks occurring in Makkah. In 1987, the first reported
Hajj-related international outbreak affected 1841 people, with the majority of cases
coming from Makkah, Medina, and Jeddah (al-Gahtani et al. 1995). N. meningitidis
serogroup A clonal complex III-1 was the etiological cause, believed to have been
introduced into Makkah by Hajjis (pilgrims) from South Asia (Moore et al. 1989);
this corresponded with serogroup A outbreaks in India and Nepal (Cochi et al. 1987)
preceding the Hajj as described in Fig. 1. South Asian Hajjis comprised 10% of the
pilgrim population that year and had the highest attack rates compared to pilgrims
from other nationalities (Moore et al. 1989). The disease later spread to local
populations and international pilgrims (Ahmed et al. 2006). That year, IMD rates
in Saudi Arabia increased to 12.83 cases per 100,000 (Ceyhan et al. 2012).
Returning pilgrims became carriers and transmitted N. meningitidis in their respec-
tive countries, initially through direct contacts (Memish 2002), causing further
outbreaks. The first one of these was detected in neighboring Qatar, with 112
reported serogroup A cases that same year (Ceyhan et al. 2012). Subsequent
introduction of serogroup A III-1 into the African meningitis belt by returning
pilgrims aggravated the regional disease epidemiology. Although N. meningitidis
serogroup A existed in the region since 1915 (Olyhoek et al. 1987), the clonal type
III-1 was only identified after the 1987 Hajj (Moore et al. 1989). Outbreaks later
occurred in 1988 in Sudan and Chad, affecting 7500 and 18,000 people, respectively
(Moore et al. 1989). No associated outbreaks occurred despite the introduction of N.
meningitidis to Egypt, possibly due to a lack of required environmental and social
factors to instigate an epidemic (Moore et al. 1989).
Spread of disease to Europe also occurred. Thirty-four cases of serogroup A
disease were recorded in the UK, the majority of which were in children (Jones and
Sutcliffe 1990). Four direct contacts of returning pilgrims were reported to have
serogroup A IMD in the city of Amiens in France, where three cases were in people
under the age of 18, and one in an adult (Denamur et al. 1987). In the USA, nine
cases of IMD were reported, and 7% of returning pilgrims carried serogroup A
meningococci in their throat (36/550 of inbound passengers) (Moore et al. 1988).
In response to the impeding health threat, the Saudi Arabian authorities mandated
bivalent A/C polysaccharide vaccination for visiting pilgrims and local residents and
compulsory oral ciprofloxacin for visitors from sub-Saharan Africa (Ahmed et al.
2006; Memish et al. 2013); these measures controlled IMD in Saudi Arabia at the
time (al-Gahtani et al. 1995).
Second Outbreak at Hajj in 2000 and 2001

The mandatory bivalent A/C vaccine policy was very effective for more than a
decade until the year 2001 when a new wave of IMD outbreaks occurred during the
Hajj seasons of 2000 and 2001, affecting at least 2400 people globally (Ahmed et al.
2006). Nearly 50% of cases were caused by a newly emerging serogroup W, a strain
with no previous record of causing major epidemics. Serogroup W was first identi-
fied in the 1970s and had been associated with a small Saudi Arabian outbreak in
1996. This was the same strain that caused disease in Mali, Algeria, and Gambia in
the 1990s (Mayer et al. 2002).
A total of 1.7 million Muslims assembled at the Hajj of 2000 (Lingappa et al.
2003). Increased meningococcal rates were observed in Saudi Arabia during Hajj that
year, with 49% and 31% of cases coming from Makkah and Medina, respectively
(Memish et al. 2013). A total of 253 cases (out of 264) were caused by serogroup W,
making it the largest known outbreak caused by this serogroup. Overall, 78 fatalities
were recorded, resulting in a case fatality rate of 28% (Lingappa et al. 2003). Higher
case fatalities (46%) were observed among international pilgrims compared to Saudi
Arabian residents (12%). Among patients admitted to hospital, fatalities peaked as
high as 60% (Lingappa et al. 2003). Moreover, pilgrims who had received bivalent
serogroup A/C vaccines had higher frequencies of serogroup W IMD (Lingappa et al.
2003). By August that year, more than 400 cases of serogroup W disease were
reported across Belgium, the UK, France, the USA, Kuwait, Morocco, Oman,
Indonesia, Singapore, Finland, Denmark, Sweden, Norway, Germany, the Nether-
lands, and Saudi Arabia. All cases were returning pilgrims and close contacts
(Handysides et al. 2000; Lingappa et al. 2003; Ceyhan et al. 2012). Among American
pilgrims administered quadrivalent serogroup A/C/Y/W vaccines, only two cases
were recorded from a return Hajji and a direct contact (Fine et al. 2000).
In 2001, smaller associated outbreaks occurred globally, resulting in 109 cases
and 35 deaths (WHO 2001), with a majority (~50%) of cases caused by serogroup W
(Memish et al. 2003). Intercontinental spread analogous with the 1987 and 2000 Hajj
epidemics was apparent, as serogroup W carriage increased among returning pil-
grims from the USA and Singapore (Wilder-Smith et al. 2002; Dull et al. 2005). The
economic, social, and health burden of the 2000–2001 epidemics led to policy
revisions leading to replacing the mandatory bivalent serogroup A/C vaccination
with quadrivalent serogroup A, C, Y, and W polysaccharide vaccine. Quadrivalent
meningococcal vaccination was made compulsory for all residents over 5 years of
age living near the Hajj sites and to all healthcare/government workers serving at the
Hajj (Memish et al. 2013).
Meningococcal Disease at Umrah

Following the 1987 outbreak, mandatory bivalent serogroup A/C vaccines and oral
ciprofloxacin treatment were administered to local residents and international pil-
grims to control meningococcal disease (Al-Ghamdi and Kabbash 2011). Vaccina-
tion policies eventually restrained outbreaks. However, small Umrah-related
serogroup A and W outbreaks occurred in Makkah and Jeddah in the 1990s,
coinciding with the Ramadan month (al-Gahtani et al. 1995; El Bushra et al.
2000). In 1992, an outbreak in Makkah resulted in 102 serologically confirmed
cases and 80 suspected cases. Fifty-nine percent of confirmed cases, and 24 percent
of suspected cases, were religious visitors. Case fatality rates were as high as 14.7%
for confirmed cases (al-Gahtani et al. 1995). A similar outbreak occurred in Jeddah
that same year, resulting in 41 serologically confirmed cases, of which 32% were
religious visitors, and case fatality rates reached 19.5% (Bushra et al. 1995).
Intercontinental spread was observed with consequent serogroup A outbreaks occur-
ring in Zambia from 1992 to 1994 (Luo et al. 1998). Increased meningococcal
disease rates in Makkah during the 1997 Umrah resulted in an outbreak with 72
cases; 51 were bacteriologically confirmed as being predominantly related to
serogroup A clonal complex III-1. The cases were predominantly Umrah visitors
(70.6%) and non-Saudi residents (25.5%), with a mean age of ~48 years. Case
fatality among patients reached 27.5% and did not differ among residents and
Umrah visitors (Al Salman and El Bushra 1998).
Current Situation at Hajj

The use of quadrivalent (A, C, W, and Y) vaccine uptake has drastically decreased
meningococcal epidemics. No outbreaks have occurred since the mandatory quad-
rivalent vaccine policy was introduced, with only 184 laboratory-confirmed cases of
IMD reported in Saudi Arabia from 2002 to 2011 and disease rates similar between
Hajj and non-Hajj months. Among confirmed cases in Saudi Arabia, only 9% are
Hajj/Umrah pilgrims (Memish et al. 2013). During the period between 1995 and
2011, citizens and residents in the main Hajj pilgrimage destinations had a high
cumulative incidence (Makkah, 9 cases/100,000; Medina, 4.5 cases/100,000)
(Memish et al. 2013) (Fig. 2). Serogroups A and W still cause most cases of IMD;
however, sporadic cases from serogroups B, C, X, Y, and Z still occur (Memish et al.
2013). Mean annual rates of IMD also declined to 2 cases per 100,000 during
epidemic periods. Recent case fatality rates remain low at 11.4% during epidemic
periods, with higher rates among pilgrim visitors (28.9%) compared to Saudi
residents (10.4%) (Memish et al. 2013). However, Hajj attendance is still associated
with increased meningococcal carriage, which raises concerns on the effectiveness
of the vaccine in reducing carriage (Table 2).
The Saudi Arabian Ministry of Health has legislated that anyone arriving at Hajj
zones for Umrah, Hajj, or seasonal work is required to provide a valid certificate of
vaccination with a quadrivalent serogroup A, C, Y, and W meningococcal vaccine
administered no less than 10 days prior to arrival. Local pilgrims are also required to
submit such a certificate in order to obtain their Hajj permit (Al-Tawfiq et al. 2017).
Moreover, the use of quadrivalent conjugate vaccines is recommended over poly-
saccharide equivalents where available and affordable (Ceyhan et al. 2013). The
2000
1800
1600
1400
1200
1000
800
600
400
200
0
20 0
20 1
20 2
20 3
20 4
20 5
20 6
20 7
20 8
20 9
20 0
20 1
20 2
20 3
20 4
15
19 7
19 8
19 9
19 0
19 1
19 2
19 3
19 4
19 5
19 6
19 7
19 8
20 9
0
0
0
0
0
0
0
0
0
0
1
1
1
1
1
8
8
8
9
9
9
9
9
9
9
9
9
9
19
Number of cases in KSA Number of cases in Makkah
Fig. 2 Number of confirmed cases of meningococcal diseases in Saudi Arabia and Makkah from
1987 to 2015 (cases from Makkah were not available for 1987, and cases from Saudi Arabia were
not available from 1989–1994)
Table 2 Studies that reported meningococcal carriage among Hajj/Umrah pilgrims
1300
Year Season Study population Study design Carriage rate Main serogroup Remarks Reference
2001 Hajj Makkah and Jeddah Prospective Pre-Hajj: 7.2% MenW 4.6% of pilgrims were administered antibiotics (Balkhy
residents study Post Hajj: 0.8% et al. 2003)
Overall: 4.7%
2001 Hajj US pilgrims traveling to Prospective Pre-Hajj: 0.8% Non-serogroupable 49% of pilgrims were administered antibiotics (CDC 2001)
and from JFK Airport, study Post Hajj: 2.6%
NY
2001 Umrah Thai pilgrims Cross-sectional Post Hajj: 0% Not Applicable (Phrom-in
2002)
2001 Umrah Singaporean pilgrims Cross-sectional Post Umrah: Non-serogroupable 7% of pilgrims were administered antibiotics (Wilder-
1.30% Smith et al.
2003)
2001 Hajj Singaporean Prospective Pre-Hajj: 0.5% MenW 8.2% of household contacts acquired carriage (Wilder-
pilgrims study Post Hajj: 17% Smith et al.
2002)
2002 Hajj British pilgrims Prospective Pre-Hajj: 8.3% Non-serogroupable 21% of pilgrims were administered antibiotics (El Bashir et
study Post Hajj: 6.3% followed by MenB al. 2004)
2003 Hajj Iranian pilgrims Prospective Pre-Hajj: Group 1: Non-serogroupable Single dose of 500 g oral ciprofloxacin (Alborzi
study 5.2%, group 2: reduced risk of carriage et al. 2008)
8.1%
Post Hajj: Group 1
4.6%, Group 2: 0%
2010 Hajj Turkish pilgrims Prospective Pre-Hajj: 13% MenW 28.2% of household contacts acquired carriage (Ceyhan
study Post Hajj: 27% et al. 2013)
2012 Hajj Iranian pilgrims Prospective Pre-Hajj: 0% Not described 58.5% of pilgrims received quadrivalent (Metanat
study Post Hajj: 1.4% meningococcal A,C,Y, W vaccine et al. 2015)
2014 Hajj International pilgrims Paired-cohort Pre-Hajj: 2.5% Non-serogroupable All pilgrims received quadrivalent (Memish
arriving at Saudi Arabia Post Hajj: 0.15% and MenB meningococcal A,C,Y,W vaccine et al. 2017)
2014 Hajj Australian pilgrims Cross-sectional During Hajj: MenW 78.7% of pilgrims received quadrivalent (Azeem
0.06% meningococcal A,C,Y,W vaccine et al. 2017)
Post Hajj: 0.02%
US, United States; MenB, Neisseria meningitidis serogroup B; MenW, N. meningitidis serogroup W
S. Sebastian et al.
Saudi Arabian authority may opt to administer prophylactic antibiotics to some

travelers (e.g., those from African meningitis belt with dubious vaccination record)
at the points of entry if deemed necessary (Algarni et al. 2016). The Kingdom of
Saudi Arabia has also improved its capacity to accommodate for unpredictable
health threats to pilgrims. Modern facilities (e.g., hospitals, healthcare centers) and
medical specialists are made available to provide healthcare to all Hajj and Umrah
pilgrims free of charge to avert outbreaks and fatalities (Memish 2010). With Saudi
Arabian initiative to increase Hajj and Umrah participation as an integral part of its
2030 vision, further expansion of the region’s preventative measures and health
emergency preparedness and response systems is urgently needed to ensure opti-
mum health and safety of all pilgrims.
In summary, intense crowding, shared accommodation, and compromised
hygiene in mass gatherings such as the Hajj amplify IMD transmission. Interconti-
nental outbreaks of serogroup A N. meningitidis in 1987 and serogroup W in
2000–2001 affected thousands of pilgrims and their direct contacts. Mandatory
bivalent serogroup A/C vaccine implementation following the 1987 outbreak was
ineffective at preventing the 2000–2001 outbreaks, which were, however, subse-
quently controlled through the use of quadrivalent (A, C, Y, and W) vaccines.
Meningococcal Disease at Non-Hajj/Umrah Mass Gathering
IMD outbreaks in non-Hajj/Umrah MGs have been reported in closed and semi-
closed populations such as university hall residents, military establishment recruits,
refugee camps residents, and participants of sports and leisure events (Badahdah
et al. 2018) (Table 3). All common serogroups except for X and Y have been
associated with outbreaks in these settings, with serogroups A and C being the
most frequently reported. The populations most affected are adolescents and young
adults aged 15–24 years, who have the highest rates of N. meningitidis carriage as
sources of disease transmission (Caugant et al. 2007). However, outbreaks in African
refugee camps affected all age groups including children aged 10 years (Haelterman
et al. 1996; Heyman et al. 1998; Santaniello-Newton and Hunter 2000). Military
recruits and university freshmen are categorized as high-risk groups (Nguyen-Van-
Tam et al. 1999; Nelson et al. 2001; Grecki and Bienias 2006; Kushwaha et al. 2010)
as they share some common features with respect to age, live in semi-closed envi-
ronments,and engage in high-risk social activities including patronizing bars and
clubs (Stuart et al. 1988; Edmond et al. 1995; Imrey et al. 1996; Cookson et al. 1998;
Neal et al. 2000; MacLennan et al. 2006), are active and passive smokers (Stuart et al.
1988; Stanwell et al. 1994; Fischer et al. 1997; Cookson et al. 1998; Neal et al. 2000;
MacLennan et al. 2006), and engage in intimate kissing (Tully et al. 2006; MacLen-
nan et al. 2006). These established high-risk behaviors are correlated with other MGs,
including sports and leisure events, including a European football tournament
(Reintjes et al. 2002; Gonçalves et al. 2005), rugby matches (Orr et al. 2001), cruise
ships (Stefanelli et al. 2012), World Scout Jamboree (ECDC 2015), and dance parties
in Brazil (Gorla et al. 2012) and the USA (Finn et al. 2001). Intense congestion and
Table 3 Summary of outbreaks in non-Hajj mass gatherings

Age of
Place of affected Reported
Serogroup Year MG Setting individuals outbreaks Cases Fatalities
MenA 1994, Uganda, Refugee All 3 388 51
2006 Zaire, camps,
India military
barracks
MenB 2007 Spain Sporting 16 years 1 1 0
event
MenC 1991, USA, University 12–59 years 7 47 16
1997, UK, campus
2001, Belgium, residence,
2006, Brazil, sports
2009, Italy, events,
2012 Poland military
barracks,
dance
party,
cruise ship
MenW 2015 Japan World ND 1 8 ND
scout
jamboree
MG, Mass Gathering; MenA, Neisseria meningitidis serogroup A; MenB, N. meningitidis
serogroup B; MenC, N. meningitidis serogroup C; MenW, N. meningitidis serogroup W; UK,
United Kingdom; USA, United States of America; ND, not documented
shared accommodation along with compromised hygiene are also pivotal in IMD
serogroup A, for example, the outbreaks occurring in refugee camps in Uganda
(Santaniello-Newton and Hunter 2000) and Zaire in 1994 (Heyman et al. 1998).
Mass immunization was implemented in serogroup A and C outbreaks in African
refugee camps (Haelterman et al. 1996; Heyman et al. 1998; Santaniello-Newton and
Hunter 2000) and university accommodations in the USA and UK (Imrey et al. 1995,
1996; Gilmore et al. 1999). Chemoprophylaxis treatment was administered to
exposed groups during serogroup C outbreaks in university residence halls (Gilmore
et al. 1999), in military barracks (Grecki and Bienias 2006), and on a cruise ship
(Stefanelli et al. 2012) to control the spread of disease.
Comparing and Contrasting Hajj Versus Non-Hajj Outbreaks
Both Hajj and non-Hajj outbreaks of IMD share common characteristics, particularly
the closed and semi-closed settings, along with congestion and shared accommoda-
tions; however, several distinctions can be made between them. Common serogroups
have been isolated from outbreaks in both MG settings, although serogroup A and C
strains are the most frequent etiological causes in non-Hajj MGs outbreaks compared
to serogroups A and W strains in Hajj-associated epidemics. In comparison to non-
Hajj MGs, outbreaks of IMD at Hajj tend to be large and involve older people. This
may be explained by the fact that younger people frequent non-Hajj MGs more
commonly than at the Hajj where attendants are predominantly older adults. The
high-risk behaviors demonstrated by the youth at these settings increase the risk of
transmission of meningococci and of IMD. However, it is important to recognize the
magnitude of health burden from Hajj-associated epidemics compared to the rela-
tively smaller outbreaks occurring at other MG. Large local and intercontinental
epidemics occurred during and following the Hajj even despite the absence of
classical risk behaviors (smoking is discouraged during Hajj, bar patronage and
drinking are also nonexistent, and intimate relations even between spouses are
avoided as an exercise of abstinence), suggesting that crowding itself is an important
risk factor for transmission of IMD among attendees of any MG.
Conclusion
Meningococcal disease remains a global public health threat, causing worldwide

morbidity and mortality. The complexity of meningococcal epidemiology and lack
of data from certain areas makes it difficult to fully describe the worldwide burden of
disease. Mass gatherings such as the Hajj and Umrah serve as epicenters of disease
transmission and intercontinental spread. Importation of Muslim pilgrims from all
corners of the world to Makkah has drastically affected meningococcal disease
epidemiology in Saudi Arabia. Without prevention, such mass gatherings can
influence global meningococcal epidemiology, introducing invasive N. meningitidis
strains to other regions. Intercontinental outbreaks arising from Makkah have been
documented in 1987 and 2000–2001 predominantly caused by serogroups A and W,
respectively. On the other hand, local Hajj- and Umrah-related outbreaks coinciding
with these international outbreaks were caused by serogroup A.
Subsequent bivalent serogroup A/C vaccines administered to pilgrims after 1987
reduced the burden of disease in succeeding years, yet failed to provide pilgrims
immunity to serogroup W disease, which caused waves of local and global outbreaks
in 2000 and 2001. As a result, quadrivalent serogroup A, C, W, and Y vaccination
became the first line of defense for pilgrims against IMD and is still used to control
local and international Hajj-related outbreaks.
Currently, the Saudi Arabian authorities require quadrivalent serogroup A, C, W,
and Y vaccinations for all local and international pilgrims, as fulfillment for Hajj
permits and visa approvals. Antibiotic chemoprophylaxis is also administered to
international visitors coming from the highly endemic African meningitis belt. Strict
adherence to this policy at all entry points to Saudi Arabia and Makkah in particular,
along with continuing healthcare expansion, is observed in anticipation of the threat
of IMD outbreaks during the Hajj and Umrah.
IMD outbreaks have also been reported in other MGs and crowded settings such
as sporting events, university residences, and refugee camps wherein some social
behaviors (e.g., smoking, intimate relationships, and bar patronage) along with
crowdedness have contributed to these smaller outbreaks, mainly caused by
serogroups A and C. Similar to control efforts at the Hajj and Umrah, vaccinations
and antibiotic treatments were critical in controlling these outbreaks.
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Pre-existing Health Concerns and Their
Management in Ramadan and Mass 53
Gatherings
Maria Kristiansen and Aziz Sheikh
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1312
Notions of Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1312
The Relationship Between Religion and Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1313
Managing Health Concerns in Ramadan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1314
The Fast of Ramadan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1314
The Meaning and Rules of Fasting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1314
Fasting and Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1316
Managing Health Concerns During Mass Gatherings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1318
The Significance of Religious Journeys in Islam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1318
Rituals and Health Risks During Pilgrimage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1319
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1320
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1321
Abstract
Insight into key religious practices and their implications for health is important
for professionals who care for Muslim patients in different sectors of healthcare
systems. In this chapter, we focus on two religious practices of importance for
M. Kristiansen (*)
Center for Healthy Aging and Department of Public Health, University of Copenhagen,
Copenhagen, Denmark
e-mail: makk@sund.ku.dk
A. Sheikh
Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh,
Edinburgh, UK
Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital,
Boston, MA, USA
Centre for Population Health Sciences, The University of Edinburgh, Edinburgh, UK
e-mail: aziz.sheikh@ed.ac.uk

https://doi.org/10.1007/978-3-030-36811-1_53
1312 M. Kristiansen and A. Sheikh
many Muslims around the world: observing the fasting period during the month
of Ramadan and travelling for pilgrimage. We set out with a brief discussion of
the multidimensional notion of health and an overview of how religious practices
may shape the ways in which Muslims perceive and manage health and disease.
This is followed by an outline of the meaning, rules, and practices related to firstly
fasting during Ramadan and secondly travelling to attend the Islamic pilgrimage.
Finally, taking a practice-oriented approach, we tease out practicalities and
recommendations for healthcare professionals caring for Muslims wanting to
observe the fasting period and/or attend mass gathering in the context of the
Islamic pilgrimage.
Keywords
Chronic disease · Ramadan · Fasting · Hajj · Travel · Mass gatherings ·
Healthcare
Introduction
The extent and type of pre-existing health concerns that need to be managed either
during the fasting period in the month of Ramadan and/or when preparing for and
attending mass gatherings differ immensely between individuals, groups, and
contexts. Despite the great diversity in health status across different ethnic and
religious groups in different countries, shaped by complex interplays between
genetics, health behaviors, and exposure to individual and structural adversity
across the life course of the individual (Marmot 2017; Ottersen et al. 2014; Vos
et al. 2013), some practicalities associated with caring for Muslim patients/citizens
wanting to observe the fasting period and/or travel for pilgrimage are relevant to
many healthcare professionals in different healthcare sectors (Gatrad and Sheikh
2008; Sadiq 2008). From a clinical point of view, there is often a need for disease-
specific approaches taking into consideration also the increasing number
of people living with multi-morbidity. For the purpose of this chapter, we will,
however, focus on insights and recommendations that are of relevance to patient-
provider encounters irrespective of the specificities of the underlying disease
and its treatment modalities. Thus, while pre-existing health concerns naturally
vary substantially among Muslims, attempts to tease out ways of managing
health concerns must be based on principles of person-centered care, shared
decision-making, and evidence-based medicine (Barry and Edgman-Levitan 2012;
Rashid 2015).
Notions of Health
While great diversity in health status and associated needs for counselling
and treatment to manage disease exists among the world’s Muslim population,
there are also shared values uniting Muslims based on tenets of faith and the role
53 Pre-existing Health Concerns and Their Management in Ramadan and Mass. . . 1313
of Islam in managing different aspects of life, including illness (Kristiansen and

Sheikh 2012; Padela et al. 2012). Health is a multidimensional concept that covers
the physical, mental, and social well-being of people, thus incorporating complex
and ever-changing aspects related to how we feel and engage with others around us
(World Health Organization 1948). While comprehensive in scope, this notion of
health may meaningfully be expanded to encompass also the capacity to cope with
the changing realities of human life, and some might add that spiritual dimensions
are also for many people part of a healthy life (Huber 2011; Huber et al. 2016).
Correspondingly, within the Islamic tradition, the Arabic concept of al-afiyah
is commonly used to describe a very multidimensional concept of health
that encompasses safety from disease, grief, and troubles, thus emphasizing
the dimensions covered by the WHO’s concept of health and adding spiritual
well-being (Ahmed 2008).
The Relationship Between Religion and Health
Muslims have in common a worldwide religion based on a set of core beliefs, as

outlined in the Qur’an and the Prophetic traditions (Sunnah). However, the meaning
carried by religious identity and the ways that faith shapes health and disease
naturally differ between people and even within the life course of any individual
person. These are informed by personal beliefs and interpretations of the tenets of
faith, but variations are also shaped by a wide range of individual and context-related
factors such as ethnicity, culture, and the behavior and values of people in one’s
social circles (e.g., family and friends) and life experiences. Across the life course
of a person, importance bestowed to faith may vary, and for people living with severe
illness, there may be a particular need for trying to make sense of illness and death
through religious grand narratives (Kristiansen et al. 2014, 2016).
For those Muslims who engage actively with their religious beliefs and practices,
Islam often has a considerable influence on the ways in which they perceive and
manage health and disease (Ahmed 2008; Padela et al. 2012). A large body of
literature based on both Muslim majority and minority contexts around the
world illustrates the importance of faith, often in combination with ethnicity, socio-
economic position, and gender, for health behaviors such as diet or alcohol; health-
seeking behaviors including screening, adherence to treatment plans, and medication
intake; and coping with illness and death, thereby highlighting both shared experi-
ences in how religion shapes health overall and the great diversity caused by
individual, social, and larger societal factors (Bhopal 2013; Ghouri et al. 2006;
Ingleby et al. 2012; Inhorn and Serour 2011; Kristiansen and Sheikh 2017; Laird
et al. 2007; Padela and Curlin 2013; Sheikh and Gatrad 2008). An overview of this
complex field of research is beyond the scope of our chapter; however for healthcare
professionals, a basic understanding of the role of faith for observing/practicing
Muslims may be helpful as it enables a more open dialogue on how to manage health
when either fasting during the month of Ramadan or attending mass gatherings,
more specifically the Islamic pilgrimage to Mecca.
Briefly, among Muslims, religion may be reflected or translated into a wide range
of practices, including the five daily prayers, dietary practices such as fasting during
the month of Ramadan, and an avoidance of substances and practices that are
considered to be forbidden (e.g., drug abuse or extramarital sex). In addition,
Islam encourages Muslims to be physically active, to avoid excessive eating, to
reflect regularly upon and seek to restore mental and spiritual well-being, and to be
constructive members of society (Ahmed 2008; Kristiansen and Sheikh 2017).
These practices have the potential to decrease the risk of adverse health outcomes
through promoting healthy lifestyle choices and fostering mental health. In its
approach to public health, Islam builds upon the principle that public interests
often take precedence over private ones, thus emphasizing the need also to take
measures to promote societal well-being (Rathor et al. 2011).
In the following sections, we will discuss more detailed, practice-oriented
approaches to managing health concerns, firstly in Ramadan and secondly for
those who wish to attend mass gatherings during the Islamic pilgrimage.
Managing Health Concerns in Ramadan
The Fast of Ramadan
Although the practice of fasting is shared across different religious and cultural
groups, the Muslim fasting period during the month of Ramadan is perhaps the most
widely observed fasting practice with implications both for the health status of
patients/citizens and for healthcare provision. Here, we will briefly outline the
meaning of fasting and overall rules taking as a starting point mainstream under-
standings of fasting among Muslims. However, it is important to note, again, the
huge diversity in the understanding and/or approach to religious practices, including
also the fasting period. Therefore, any discussion on fasting should be based on
individualized approaches in a dialogue with patients/citizens and relatives when
relevant.
The Meaning and Rules of Fasting
According to Islam, the month of Ramadan has a special status as it was during this
month that the revelation of the Qur’an began. The month of Ramadan is dedicated
to reaffirming the message brought to mankind through prophets, and it is a month of
reflection, blessing, and moderation for most Muslims (Sadiq 2008). Fasting is a
deeply embodied spiritual experience that can be hard to capture adequately in
words, including when discussing health aspects of the practice with healthcare
professionals. As it is a spiritual exercise shared in communities across the world,
fasting often represents an inward journey reaffirming a consciousness of the
divine based on moderation, willpower, and principles of sincerity. It also cultivates
and strengthens a spirit of social belonging, unity, and equality within Muslim
communities as the ritual is observed in the same manner at the same time
across the world.
The practice of fasting is guided by rules regarding how it is observed, when it
takes place, and who should engage with it. While fasting, Muslims abstain from all
food, drink, and intimate relations in the period from dawn to sunset. Unlike fasts in
many other religious traditions, the Ramadan fast also involves abstinence of water
and smoking. In the period from sunset to dawn, Muslims eat and drink according to
the common regulations regarding what are considered lawful foods and drinks.
However, in the spirit of the Ramadan, overeating is discouraged, and many
Muslims spent the evening and night hours in prayers, often at local mosques, or
in reading from the Qur’an.
Fasting takes place during the ninth month of the Islamic calendar, which is based
on a lunar cycle, and hence the Islamic year is around 9–10 days shorter than the
solar year. This means that the precise dates of the Ramadan vary from year to year
and that for Muslims the Ramadan will fall during all seasons of the year during the
course of a lifetime. With Muslims living across the globe, timings of fasting
differ widely with those living in extreme latitudes experiencing summer fasting
periods that span more than 19 h a day in the summer months and substantially
shorter fasts if Ramadan falls during the winter months. According to some scholars,
it is considered permissible for those Muslims to fast for the length of time of
neighboring regions with more normal cycles of day and night; however this is
still a disputed subject with Muslims following different rulings (Sadiq 2008).
While fasting is one of the five pillars of Islam, underscoring its importance
across time and space, it is obligatory only on those who are considered responsible
and healthy. A number of groups are therefore exempt from fasting (Sadiq 2008).
These include:
• Children under the age of puberty

• People considered unable to comprehend the nature and purpose of fasting,
e.g., due to cognitive disabilities
• Older individuals who are too frail to be able to fast
• Those who are acutely unwell and who will experience an exacerbation of
their health condition if fasting
• People with chronic diseases who may experience detrimental health effects
if fasting
• Travellers with a set minimum limit of approximately 50 miles that may feel
harmed by fasting
• Menstruating women
• Pregnant and nursing women concerned about their own health or that of their
child
While these categories are generally agreed upon, healthcare professionals often
encounter patients falling into one of the mentioned groups who insist on fasting
despite both rulings and recommendations from relatives and, e.g., physicians
(Mir and Sheikh 2010; Mygind et al. 2013; Salti et al. 2004). The spiritual and social
dimensions of fasting may be felt to be more important for the individual Muslim
than discomfort or potential negative health effects caused by the practice. There-
fore, while many groups are exempt from fasting, it is still good practice to discuss
the attitude to fasting and potential strategies for managing health issues even for
those who may clearly be allowed not to fast (Abolaban and Al-Moujahed 2017; Mir
and Sheikh 2010; Mygind et al. 2013).
In general, the overwhelming majority of Muslims fast. In Muslim majority
countries, fasting structures around, e.g., working hours may be adjusted to
accommodate for fasting times and the prayers taking place during evenings and
nights. In countries with Muslim minorities, such as many Western countries, people
may choose to adjust daily life on more individual bases, e.g., by scheduling
vacation to fit the last 10 days of Ramadan that takes on special importance as
days of intense prayers and spiritual reconfirmation of faith and by postponing
outpatient appointments (Sadiq 2008). This raises some demands for organizational
efforts to educate both staff and patients about how to responsibly and adequately
reconcile concerns related to health, health-seeking behaviors, and the practice of
fasting for the benefit of all parties involved (Abolaban and Al-Moujahed 2017;
Sadiq 2008).
Fasting and Health
As outlined above, Muslims may be exempt from fasting if they fall under one of
these categories. For some, this exemption is temporary as their health condition
may be acute or they may be in a temporary situation, e.g., while pregnant,
breastfeeding, or travelling. Once the situation leading to exemption from fasting
has passed, people are required to make up for missed days of fasting. For those who
are in a permanent situation leading to exemption from fasting, fasting may be
substituted by providing food for poor people, most often in countries afflicted by
hunger, war, and poverty (Sadiq 2008). For chronically ill patients and older, frail
patients, this is often the option of choice; however as mentioned, patients may feel
that the emotional, social, and spiritual costs of not fasting are hard to cope with
despite these rather clear rules of exemption (Mygind et al. 2013).
For some citizens/patients, it is harder to determine whether fasting should be
observed or not. This may be the case for those who are not sure if fasting may be
harmful for their health condition or those who do not feel well but are not properly
diagnosed yet. Here, patients are recommended to seek a doctor’s opinion related to
the likely effects of fasting on their health condition, which should then be adhered to
in these cases of uncertainty (Sadiq 2008). However, studies suggest that Muslim
patients may feel that discussing choices and strategies related to fasting, including
effects of fasting on health conditions or adjustment of medication or self-care
regimens, is difficult, thus refraining from raising these concerns in clinical
encounters in primary care, at hospitals, or in pharmacy settings (Mir and Sheikh
2010; Mygind et al. 2013). This may both be due to a perception that non-Muslim
healthcare staff may fail to appreciate the importance of fasting from a religious point
of view and therefore may be inclined to discourage fasting (Mir and Sheikh 2010).
Also, some may feel that the physical dimensions of health, which may deteriorate
in the fasting period, are not of the same importance as the more spiritual and
social dimensions of health and well-being and that the trade-off between feeling
physically unwell and potentially worsening treatment outcomes in the long run is
not worth missing the spiritual dimension of Ramadan. Raising such spiritual,
emotional, and social issues in healthcare encounters may be difficult for patients,
relatives, and healthcare providers (Abolaban and Al-Moujahed 2017; Ali et al.
2016; Amin and Chewning 2014).
Investigating the health effects of fasting has been the subject of a number of
scientific studies, mostly within the field of diabetes but with examples related to
also, e.g., cardiovascular diseases, chronic kidney disease, and Parkinson disease
(Abolaban and Al-Moujahed 2017; Almalki and Alshahrani 2016; Amin and
Chewning 2014; Bragazzi 2014; Chamsi-Pasha et al. 2014; Damier and Al-Hashel
2017; Myers and Dardas 2017; Salti et al. 2004). As changed eating, drinking,
medication, and sleeping patterns during Ramadan may have complex effects on
disease trajectories depending on the type and severity of the underlying disease,
any multi-morbidity the patient may have, general well-being, functional capability,
etc., it is beyond the scope of this chapter to give a detailed overview of specific
health effects and their underlying causal mechanisms. Readers are referred to
scientific literature for more in-depth insight into disease-specific and stratified
approaches to patient education and management related to Ramadan fasting for
patients with diabetes, cardiovascular diseases, respiratory disorders, renal diseases,
or gastrointestinal diseases (Abolaban and Al-Moujahed 2017; Almalki and
Alshahrani 2016; Bragazzi 2014; Car and Sheikh 2004; Ghouri et al. 2012; Hassan
et al. 2014; Myers and Dardas 2017).
Fasting also has implications for medication use. With medication use being a
part of treatment regimens for many diseases, and multi-morbidity leading to
increasingly complex drug interactions at times not adequately attended to by
healthcare professionals across clinical settings, the issue of regulating medication
during fasting period is of key importance for many patients. Any oral intake of
medication – or any other substance – through the mouth nullifies the fast. At times,
dosage times of oral medication can be changed to fit into fasting timings, in
particular during shorter fasting days in winter periods, therefore allowing the patient
to safely combine medication intake with fasting practices. Other options would be
to switch from short-acting to longer-acting agents that may be feasible for patients
with, e.g., respiratory, endocrine, or rheumatic disorders. As stated above, medica-
tion intake and timing considered to be necessary for the patient automatically leads
to a dispensation not to fast, and this should be discussed with patients and relatives
that may have different understandings of the need for medication. Some Muslims
believe that medication may also be taken by other routes than orally without any
consequences for fasting; however the use of specific types of medication routes
during Ramadan is a disputed area. Healthcare professionals may feel a need to seek
out additional, specific counselling from the body of Muslim scholarly literature;
Table 1 Taking care of health while fasting – advice for Muslims

Drink ample amounts of water between sunset and dawn to avoid dehydration
Maintain a well-balanced, healthy diet that is rich in fibers and low in salt and glycemic index
Exercise is encouraged
Adhere to recommended sleep durations appropriate for different age ranges
Take advantage of the changing lifestyle patterns during Ramadan to quit smoking or other
harmful health behaviors
Attend planned necessary healthcare appointments
Table 2 Raising the issue of fasting in clinical encounters – advice for healthcare professionals
Ideally, issues related to fasting during Ramadan should be integrated into health education
programs for patients of Muslim faith
Meanings of Ramadan and intentions to fast should be raised in encounters with Muslim patients,
in particular with patients living with long-term conditions and/or multi-morbidity. Discussions
should take place at appropriate timings, most importantly prior to the month of Ramadan, and in
the patient-provider encounters where disease management is most firmly anchored. This could be
in, e.g., community care settings, pharmacies, primary care settings, in- or outpatient settings, or
the context of patient support associations
Open questions aimed at elucidating meanings of faith in general and Ramadan fasting in
particular should be used, thus adhering to general principles for person-centered, engaging, and
holistic healthcare practice
however often consensus may be hard to find, and shared decision-making based on
the particular patient and his/her overall health situation is advisable (Sadiq 2008).
A list of generic recommendations for Muslim patients prior to the fasting period
is given in Table 1. Table 2 provides advice for healthcare professionals on how
to raise the issue of fasting in clinical encounters with Muslim patients.
Managing Health Concerns During Mass Gatherings
The Significance of Religious Journeys in Islam
While mass gatherings occur in many places and situations, at times raising concerns
for the safety and well-being of attendants, religiously inspired/motivated mass
gatherings are often of particular importance for participants and for healthcare
providers. In Islam, the journey to Mecca, known as the Hajj, is mandatory for
Muslims once in a lifetime provided that the health and financial circumstances of
the person allow for this travel (Gatrad and Sheikh 2008). Significant numbers of
Muslims from all around the world travel to Mecca to perform the Hajj that lasts for
5 days and, as was the case for Ramadan, follows the Islamic lunar calendar, this
varying in exact timings from year to year. Although Hajj is required only once for
each person, many perform the pilgrimage several times as this journey represents
an important spiritual exercise leading to both reaffirmation of faith and a sense
of community with fellow Muslims across different ethnic backgrounds,
socioeconomic position, or geographical origin. A lesser pilgrimage, known as

Umrah, is performed more often and may take place at other times of the year
(Gatrad and Sheikh 2008).
Rituals and Health Risks During Pilgrimage
A number of rituals are carried out while on Hajj, some of which may be strenuous
in particular on those who are not in good health and the frail and elderly (Gatrad
and Sheikh 2008). However, for all Muslims, the pilgrimage is likely to be physi-
cally demanding because of the setting (the hot desert climate of Saudi Arabia),
the large numbers of people present at the same time leading to risks of over-
crowding, the long walking distances, and the limited sanitation facilities – at least
for those not staying in the expensive hotels built in and around Mecca. Long days of
prayer, lack of shade, and lack of access to routine facilities such as healthcare may
also compromise health conditions for some Muslims.
Health problems during pilgrimage differ according to the individual situation,
health status, and functional ability; however some common health concerns are
related to the risks of sunburn, lack of acclimatization to the heat causing heat
exhaustion and heat stroke, injuries, or, although rarely, risks of stampede or fire
accidents caused by the huge numbers of people living in the same area. Outbreaks
of infectious diseases also represent an important health risk, in particular due to the
many people travelling on Hajj from countries with large burdens of communicable
disease and with suboptimal vaccination statuses (Gatrad and Sheikh 2008; Memish
2010; Shafi et al. 2008). Influenza, pneumonia, SARS, and MERS are some diseases
that may spread in the overcrowded context of pilgrimage, despite attempts to
enforce vaccination coverage and timely responses to unexpected symptoms
among pilgrims (Al-Tawfiq et al. 2014; Gatrad et al. 2006; Gatrad and Sheikh
2008; Shafi et al. 2008).
In particular, those with pre-existing health concerns at times coexisting with
frailty and/or older age should take appropriate measures to decrease their risks of
either worsening of their health status or adverse outcomes caused by the risks
mentioned above (Chamsi-Pasha et al. 2014; Memish 2010).
Although Muslims are not required to embark on neither the Hajj nor the Umrah
if their health is poor, often people are determined to travel for the spiritual meanings
of the journey, also among patients who are severely ill and at times in terminal
phases of their illness. Healthcare providers should therefore not assume that
discussing ways of minimizing health risks prior to, under, and after pilgrimage is
not relevant for very ill and/or older patients.
Measures to ensure disease surveillance and raise safety in and around sites
of the pilgrimage, e.g., by structural changes to housing, roads, water and
sanitation, enforcement of rules to lower risk of fires or stampede, and emergency
planning, are the responsibility of the national and local health and safety authorities
in Saudi Arabia (Hines 2000; Shafi et al. 2008). Both authorities and community
groups in Saudi Arabia as well as countries sending pilgrims should collaborate to
Table 3 Managing health concerns during Hajj/Umrah – advice for Muslims and healthcare
providers
Discuss current health status, its prognosis in the foreseeable future, and likely effects of adverse
exposures on health during the pilgrimage
If advisable to travel, ensure appropriate vaccination coverage
Discuss strategies to lower risk of heat exhaustion and sunburn, in particular related to the use of
sun block, minimal sun exposure (e.g., by travelling at night, keeping heads covered at day),
consuming large volumes of fluids, increasing dietary salt intake, and responding to early
symptoms of heat exhaustion and heat stroke (e.g., fatigue, headache, vomiting, delirium)
Ensure medication prescriptions covering the travel period and discuss potential restrictions on or
permissions to take medications into Saudi Arabia
If possible, travelling to Mecca in advance of the Hajj is advisable to ensure acclimatization to the
harsh desert climate
Raise possibility of having an accompanying partner (e.g., spouse, relative, friend) to assist in
particular older or frail pilgrims
Advise related to appropriate footwear able to withstand foot injuries and burns, in particular for
diabetic patients with neuropathy
For women, delaying menstrual bleeding through, e.g., oral contraceptive pills or contraceptive
vaginal rings may be relevant as menstruation is considered a state of ritual impurity that hinders
women in performing the Hajj
Bringing a simple travel pack with common remedies (e.g., analgesia, salt tablets, bandage,
antiseptic cream, and water sterilization)
Being aware of pilgrim health facilities and knowing how to access these
ensure coordinated preventive measures and ensure the availability of both routine
and emergency healthcare services for the millions of people with diverse languages,
cultures, and health needs attending the pilgrimage (Memish 2010; Shafi et al. 2008).
Individual measures to be taken by Muslims to manage pre-existing health
concerns and lower risks of health problems are listed in Table 3. Although recom-
mendations vary according to individual health status and general circumstances,
an important piece of general advice is to conduct a comprehensive medical
checkup and counselling session before the pilgrimage is planned to ensure timely
discussions on whether the patient is fit for the travel and what precautions should
be taken to minimize health risks (Chamsi-Pasha et al. 2014; Gatrad and Sheikh
2008; Memish 2010).
Conclusions
Religious practices related to fasting during the month of Ramadan and travelling
for pilgrimage carry important meanings for many Muslims, but they also have
implications for health and healthcare practices. Although the nature of pre-existing
health conditions to be managed during Ramadan or mass gatherings differs
substantially, a basic understanding of the possible role of faith is important as
this opens up for more open, person-centered care and shared decision-making in
encounters between Muslim patients and healthcare professionals.
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COVID-19 in the Gulf Cooperation Council
Countries: Health Impact and Response 54
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1326
Status of the COVID-19 Pandemic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1327
Public Health Preparedness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1332
Implications for Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1334
Health Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1334
Health Financing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1336
Service Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1340
Human Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1342
Health Responses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1344
Bahrain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1344
Kuwait . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1345
Oman . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1346
Qatar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1347
Saudi Arabia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1348
United Arab Emirates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1349
Possible Additional Health Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1350
Public Health Considerations for Reopening an Economy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1350
Reopening Economies Worldwide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1350
Reopening the GCC Economies: Four Key Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1352
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1354
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1354
Note: All references to dollar and $ are to US dollar unless otherwise noted.
S. El-Saharty (*)
The Middle East and North Africa Department, The World Bank, Washington, DC, USA
e-mail: selsaharty@worldbank.org
A. C. Liu
Public Health Policy Consultant, The World Bank, Washington, DC, USA

https://doi.org/10.1007/978-3-030-36811-1_208
1326 S. El-Saharty and A. C. Liu
Abstract
As of July 31, 2020, cumulative COVID-19 cases reached 668,002 in the six Gulf
Cooperation Council (GCC) countries, with Saudi Arabia having by far the most
(291,468). All six countries are, though, showing a flattening curve, but with
slight recent upticks in Kuwait and the United Arab Emirates. Testing for
COVID-19 in the United Arab Emirates and Bahrain has reached half of their
total populations – some of the world’s highest testing rates. In contrast, on the
most recent Global Health Security Index, for 2019, which covered 195 countries,
the GCC countries scored lower than the average for high-income countries. The
most urgent health challenges are the comingled threats of COVID-19 and
noncommunicable diseases (NCDs), alongside health inequities among low-
waged migrant workers, particularly as the GCC countries have globally high
rates of NCDs and NCD risk factors, notably diabetes, which exacerbate the
impacts of COVID-19 on overall health status: people with NCDs and NCD risk
factors are more likely to become critically ill or die from COVID-19. Although,
in a difficult trade-off, the GCC governments have taken often strict measures to
protect their populations’ health and their economies, they have to face the
scourge of COVID-19 with shrinking fiscal space, largely due to a steep drop
in oil and gas prices in the last few years. Thus, governments should in the
medium term switch their health expenditures to focus on disease prevention,
health promotion, and primary care, away from the current emphasis on higher-
cost secondary and tertiary care services. In the more immediate future, to reopen
their economies, they need to ensure that their health workers are well protected
and their health facilities are safe, among other measures.
Keywords
Gulf Cooperation Council · Health systems · COVID-19 · Public health
preparedness · Noncommunicable diseases · Health financing · Service delivery ·
Pandemic responses · Recover and rebuild
Introduction
In late 2019, a novel coronavirus (SARS-CoV-2), which causes the disease COVID-
19, started to spread from Wuhan, capital of China’s Hubei province. The World
Health Organization (WHO) declared the coronavirus outbreak a public health
emergency of international concern on January 30, 2020, and a pandemic on
March 11. Since then, COVID-19 has touched 188 countries and regions with
17.30 million confirmed cases and 673,279 deaths as of July 31, 2020 (Roser et al.
2020).
To prevent the spread of infection, many governments implemented transmission
control measures starting with “detect, test, isolate and contact trace,” followed by
more severe measures such as lockdowns and travel bans to “flatten the curve.” In
54 COVID-19 in the Gulf Cooperation Council Countries: Health Impact and. . . 1327
parallel, governments have taken unprecedented monetary, fiscal, and structural

measures to mitigate the resulting adverse economic and social impacts.
The objective of this study is to review the status of the COVID-19 pandemic in
the Gulf Cooperation Council (GCC) countries, these six countries’ public health
preparedness, wider impacts on their health systems (including care givers), health
measures taken by the six countries, and the public health considerations for
reopening their economies.
Status of the COVID-19 Pandemic
The first case in the GCC countries was detected in the United Arab Emirates on
January 27, 2020, and most other GCC countries started to detect cases in late
February. Bahrain was the first to record 100 confirmed cases on a cumulative basis,
on March 10, 2020; other GCC countries quickly followed. By March 26, Oman
reached 100 cases – the last GCC country to do so. From late April to July, the GCC-
wide number of cases has grown hugely. As of July 31, 2020, cumulative COVID-19
cases reached 668,002 in the GCC, more than half of them in Saudi Arabia (291,468)
and Qatar (113,646). The infected population counts for at least 1% of the entire
population in the GCC, which is likely to be underestimated due to still-limited
testing. The number of confirmed COVID-19 cases relative to population size in the
GCC countries is among the highest in the world. In Fig. 1, cumulative cases per
million people reached 38,340 in Qatar and 23,951 in Bahrain as of July 31, the
highest and second highest in the world. Kuwait and Oman have the fifth and sixth
Fig. 1 Cumulative confirmed COVID-19 cases per million people. (Data source: Our World in
Data (Roser et al. 2020))
highest cumulative cases per million people in the world, after San Marino and Chile
(Roser et al. 2020). The transmission of SARS-CoV-2 remains at high levels in the
region as of July 31, 2020.
The cumulative numbers of deaths caused by COVID-19 increased rapidly in most
GCC countries (except UAE) from the end of April to the end of July. Cumulative
deaths per million people in Kuwait have risen 17 times from April 30 to July 31, from 6
deaths per million to 104 deaths per million. During this three-month period, the growth
rate of cumulative deaths in Kuwait is significantly higher than that of the other GCC
countries (see the differences in the steepness of the curves in Fig. 2). Cumulative
deaths per million people in Bahrain, Oman, and Saudi Arabia increased about 8 times
from April 30 to July 31 and are close to the global level of 86 deaths per million as of
July 31. UAE is the only GCC country that shows a clear sign of bending the curve of
cumulative deaths from COVID-19 in the past 3 months.
Using data of confirmed cases and deaths shown in Figs. 1 and 2, we can calculate
case fatality rate (CFR) from COVID-19 in the region (see in Fig. 3). CFR in the
GCC has remained significantly low. As of July 31, GCC-wide CFR is 0.6%
(compared to 3.9% globally), which suggests 6 confirmed deaths out of every
1,000 confirmed cases. However, CFR should be cautiously examined to avoid
misleading policymaking and public opinions. CFRs often change over time and
vary widely between countries, from 0.2% in Germany to 7.7% in Italy (Roser et al.
2020). But it is not necessarily an accurate comparison of the true likelihood that
someone will die from COVID-19. CFR is the number of confirmed deaths divided
by the number of confirmed cases. It depends on the number of cases tested positive,
which can overestimate or underestimate the actual mortality risks between countries
due to different testing policies and capacities. Data shown in Figs. 1, 2, and 3 jointly
Fig. 2 Cumulative confirmed COVID-19 deaths per million people. (Data source: Our World in
Data (Roser et al. 2020)). Note: The number of confirmed deaths may not be an accurate count of
the true number of deaths from COVID-19 due to limited testing and data collection challenges
Fig. 3 Case fatality rate of the ongoing COVID-19 pandemic. (Data source: Our World in Data
(Roser et al. 2020))
suggest that relatively lower CFRs in the GCC are primarily driven by larger
denominators – more confirmed cases. From May to July, GCC-wide numbers of
deaths from COVID-19 are not low in absolute terms, but low relative to the
numbers of confirmed cases. Therefore, even though the CFRs are low in the
GCC, it does not mean the risks of dying from COVID-19 are low for all people
in the GCC, especially not for the high-risk groups (the elderly and those with
underlying medical conditions).
To further examine regional cases and trends, the cumulative numbers will be
broken into daily numbers and analyzed together with the number of cases and the
number of tests. It is important to examine tests and cases together to understand the
spread of the virus. In fact, no country knows definitively the number of people infected
with COVID-19. All we know is the infection status of those who have been tested.
GCC countries have shown different trends of daily numbers of new confirmed
cases per million people (Fig. 4). UAE has maintained the flattest curve in the region,
followed by Saudi Arabia. Qatar has followed the steepest bell curve with the peak of
655 cases per million people at 7-day rolling average on June 4, the highest daily
number in the world between April and July. Bahrain and Oman followed upward
trends with several small spikes from April to July and exceeded Qatar to report the
highest daily new cases per million people in mid-July, then rapidly declined in the
end of July. The rapid decline of new cases in Oman happened simultaneously with a
major nationwide lockdown scheduled from July 25 to August 8, after the country
gradually lifted containment restrictions since late May (IMF 2020a). Kuwait
entered a resurgence of new cases from mid-June to the end of July, shortly after
the nation’s five-phase reopening began on May 31 (IMF 2020a). Even though GCC
countries (except Kuwait) were exhibiting downward trends in late July, numbers of
daily new cases per million people were still higher than the other Arab countries.
Fig. 4 Daily new confirmed COVID-19 cases per million people (rolling 7-day average). (Data
source: Our World in Data (Roser et al. 2020))
Fig. 5 Daily new COVID-19 tests per 1,000 people (rolling 7-day average). Data source: Our
World in Data (Roser et al. 2020)
The GCC has performed a large scale of testing relative to the size of the
population and the testing capacities have grown significantly, especially in the
United Arab Emirates and Bahrain who were among the front-runners of mass
testing in the GCC and the world (Fig. 5). From June 1 to July 31, Bahrain and
UAE run between 330 and 610 daily tests per 100,000 people at 7-day rolling
Fig. 6 The share of daily COVID-19 tests that are positive (rolling 7-day average). (Data source:
Our World in Data (Roser et al. 2020)). Note: Test-positive rate is the number of confirmed cases
divided by the number of tests (%). Tests may refer to the number of tests performed, or the number
of people tested, depending on which is reported by the particular country
average, ranking them second and third highest globally after Luxembourg (based on
countries with available data). Other GCC countries ran fewer tests than UAE and
Bahrain, ranging between 50 and 180 daily tests per 100,000 people at 7-day rolling
average, but similar to other high-income countries. According to the available
testing data from the two Arab countries outside the GCC, the numbers of daily
tests performed are lower than the GCC level. During the same period, Morocco ran
27–57 daily tests per 100,000 people and Tunisia performed 4–8 daily tests per
100,000 people at 7-day rolling average (Roser et al. 2020).
The daily rates of positive tests have substantially declined since the latest peaks
from June to July (except for Oman), which suggests that the GCC countries are
adequately testing in order to monitor and control the spread of the virus (Fig. 6).
According to the World Health Organization’s (2020a) guidance, less than 5% of
positive rates for at least the last 2 weeks is one indicator that shows the epidemic is
under control in a country. The United Arab Emirates has remained below a 2.5%
positive rate of tests. Bahrain and Saudi Arabia have lowered their positive rates of
tests to less than 5%. In contrast, Kuwait still has a relatively high positive rate of
18.1% at 7-day rolling average as of July 31. Qatar has brought down its positive rate
of tests from a peak of 39.5% to 7.2% at 7-day rolling average. Oman has a different
testing policy that targets people with symptoms, and as positive rates of such
targeted tests are often higher than those of randomized tests, we do not compare
the positive rates in Oman with those in other GCC countries.
Even when a country reports a low share of samples positive for COVID-19, it
does not necessarily mean the epidemic is under control. The rate of positive tests is
the number of confirmed cases divided by the number of tests; growing numbers of
tests can naturally bring down the rate of positive tests. In addition to the less than
5% positive rate, WHO (2020a) lists a series of criteria to evaluate if the epidemic is
controlled, including (1) at least 50% decline in the observed incidence of confirmed
and probable cases over a three-week period since the latest peak and continuous
decline, (2) decline in the number of deaths for at least 3 weeks, and (3) other criteria
(e.g. at least 80% of cases are from contact lists, decline in hospitalization and ICU
admissions, and decline in age-stratified excess mortality due to pneumonia), which
cannot be covered due to limited data. But based on the first three indicators shown
in Figs. 1, 2, 3, 4, 5 and 6, the GCC region has not yet controlled the pandemic as of
July 31, 2020 (although UAE has a relatively good epidemiological outlook on
COVID-19).
A common concern in the GCC is that migrant workers may be disproportion-
ately affected by the virus due to their health and living conditions. According to
available data, most GCC countries have open testing policies for both nationals and
foreigners, including migrant workers; the virus has been hitting individuals,
irrespective to nationality, whenever it gets a chance. Kuwait is a case in point.
Kuwait Ministry of Health (MOH) released detailed data among population groups
and residential areas from May 30 to July 15. From May 30 to June 5, confirmed
daily new cases among non-Kuwaitis were more than that among Kuwaitis. On June
6, the numbers were exactly the same between Kuwaitis and non-Kuwaitis. From
June 7 to July 15 (except June 21), there were more daily new cases among Kuwaitis
than among non-Kuwaitis. On July 15, MOH reported 703 new cases (from 4041
new tests), among which 434 were Kuwaitis and 269 were non-Kuwaitis (Kuwait
MOH 2020). However, through the entire period with detailed data, the hotspot areas
where majority of new cases were confirmed remained the same, which are Al
Farwaniya, Al Ahmadi, and Al Jahra areas. On July 15, Al Ahmadi area recorded
216 new cases, 4 times as high as the least hit area (capital area with 51 new cases).
In other words, where someone lives may be associated with higher risks of infection
rather than which country is someone from. The bottom line is that nationals and
foreigners, including migrant workers, were in the pandemic together; the whole
society should fight against the virus by adopting collectively public health behav-
iors based on science.
Public Health Preparedness
Strong and resilient public health systems are key for facing pandemic threats.
The Global Health Security Index (GHSI) is a comprehensive assessment and
benchmarking of health security and related capabilities across the 195 countries that
make up the state parties to the WHO International Health Regulations 2005. The
GHSI has indicators for six categories: prevention, detection and reporting, rapid
response, health system, compliance with international norms, and risk environment,
as well as an overall score.
The average overall GHSI score globally in 2019, the latest year with data
available, was 40.2 out of a possible 100 (Cameron et al. 2019). The index shows
that collectively international preparedness for epidemics and pandemics remains
very weak: 116 high- and middle-income countries did not score above 50, including
all the GCC countries (Table 1). In comparison, the GCC countries scored from a
low 39.4 in Bahrain to a high 49.3 in Saudi Arabia, which is lower than the average
score of 51.9 reported in high-income countries.
Interestingly, however, the GHSI score and ranking do not necessarily translate
into action on the ground. The GCC countries’ performance in addressing the crisis
has been better than what the GHSI would suggest. The USA, for example, which
ranked first with a score of 83.5, was slow in taking early actions and ended up with
the highest number of cases worldwide, despite its reported level of preparedness.
GHSI evaluates countries’ health security and preparedness by two categories:
• Country preparedness capacity: Level 5 means that the country has a high
capacity of preventing, detecting, and responding to a public health emergency.
Level 1 is the lowest rating.
• Response category: Level 5 corresponds to higher risk, i.e., the country has shown
community transmission; Level 4 refers to localized transmission; Level 3 imported
cases; Level 2 to a risk of imported cases; and Level 1 for all other countries.
The United Arab Emirates had the highest preparedness capacity, level 5, while
the other GCC countries were at level 4. On the response category, all the GCC
countries had level 4, similar to most European and Middle East countries.
According to the GHSI, all countries in the region except Saudi Arabia face gaps
in infection control practices and availability of equipment, as well as health capacity
in clinics, hospitals, and community care centers, which further reduce structural
quality of care and the readiness of health facilities to deliver both COVID-19 and
non-COVID-19 services.
Given the interrelationship of public health readiness, rapid response, and the
severity of the pandemic, the WHO has developed more specific measures to assess
the capacity of countries in response to COVID-19, in line with the global strategic
preparedness and response plan (see for example, WHO COVID-19 Preparedness
and Response Progress Report, 1 February to 30 June 2020).
Table 1 Global Health Security Index and Rank of the GCC countries
GHSI Rank
Bahrain 39.4 88
Kuwait 46.1 59
Oman 43.1 73
Qatar 41.2 82
Saudi Arabia 49.3 47
United Arab Emirates 46.7 56
Data source: Cameron et al. (2019)
Implications for Health
The COVID-19 pandemic poses unprecedented threats to the overall health status of
the region. If managed inadequately, it may eradicate the hard-won gains in health
outcomes made in recent decades. The health impacts on COVID-19 patients range
from mild disease, moderate disease, severe disease, critically illness with organ
failure, and, of course, death. While patients with mild or moderate symptoms
usually recover from the disease under supportive care, patients with severe disease
have a substantial risk of prolonged critical illness and death (Gandhi et al. 2020;
Berlin et al. 2020). Beyond the direct impact, the “once-in-a-century” pandemic
(Gates 2020) challenges health systems’ crisis response capacities and hits hard on
the weakest joints of a health system and the most vulnerable populations of a
society.
In the GCC countries, the most pressing health challenges are the intertwined
threats of COVID-19 and noncommunicable diseases (NCDs) and health inequity
among low-waged expatriate workers. Further, the GCC faces the plunge in oil
prices and the associated economic depression, with both negative supply shocks
and negative demand shocks caused by the COVID-19 pandemic (Arezki et al.
2020). The health and economic dual crises shrink GCC governments’ capacities on
health financing and exhaust health resources. The following section discusses
further the wider impacts of COVID-19 on GCC health systems through four lenses:
health status, health financing, service delivery, and human resources.
Health Status
Before the COVID-19 pandemic, the GCC countries faced escalating prevalence of
NCDs and NCD risk factors (▶ Chap. 34, “Tackling Noncommunicable Diseases in
the Arab Region”). NCDs are the leading burden of disease in the region, responsible
for 74.3% of all deaths in 2017 (WHO 2017). NCDs also account for over 80% of
years lived with disability in 2017 (GBDCN 2018). In particular, NCDs are account-
able to 88 years out of every 100 years lived with disability in Saudi Arabia, among
the highest rates worldwide (▶ Chap. 34, “Tackling Noncommunicable Diseases in
the Arab Region”). Cardiovascular diseases, cancers, diabetes, and chronic respira-
tory diseases are the four most prevalent NCDs in the GCC countries. In particular,
the prevalence rates of diabetes in the region are among the highest in the world, led
by Kuwait (22% of adults) and Saudi Arabia (18.3% of adults) in 2019 (IDF 2019).
On average in the GCC countries, there is at least one person with diabetes among
every 10 people (▶ Chap. 34, “Tackling Noncommunicable Diseases in the Arab
Region”). Moreover, the region, led by Kuwait, has some of the highest prevalences
of NCD risk factors in the world. In Kuwait in 2016, 73% of women and 60% of men
were physically inactive; 44% of women and 33% of men were obese; and 40% of
men smoked tobacco (WHO 2018).
The widespread NCDs and NCD risk factors exacerbate the adverse impacts of
COVID-19 on overall health status outcomes. People with NCDs and risk factors are
more likely to become critically ill or die from COVID-19. A report from Italy
indicates that 96.2% of patients who died in hospital from COVID-19 had
comorbidities, primarily NCDs (Istituto Superiore di Sanità 2020). A study in
Kuwait using hospital medical records suggests similar comorbidities among 60
patients who died from COVID-19 in intensive care units (ICUs) between February
and April 2020. The most prevalent NCDs among these patients were hypertension
(46.7%), diabetes (40%), cardiovascular disease (21.7%), and asthma (20.3%)
(Alshukry et al. 2020). An association between COVID-19 severity and NCDs has
been reported in Spain, China, and the USA (Kluge et al. 2020). A study in Kuwait
using logistic regression models estimates the odds of being admitted to ICU from
COVID-19 are 5.49–9.38 times as high as among patients with diabetes compared to
patients without diabetes (Al-Sabah et al. 2020).
NCD risk factors such as obesity and smoking are also COVID-19 risk factors for
hospital admissions. According to an empirical study in Kuwait, the odds of ICU
admittance from COVID-19 are 3.95–5.18 as high as among patients with morbid
obesity (BMI 40 kg/m2) compared to patients with normal weight (BMI of 18.5–
24.9 kg/m2) (Al-Sabah et al. 2020). A cohort study using hospital data in Kuwait
finds that smoking is correlated with mortality and ICU admission (Almazeedi et al.
2020). The exact biological mechanism through which NCDs and NCD risk factors
contribute to COVID-19 severity is still unproven, but the empirical evidence
worldwide suggests that high prevalence of NCDs and NCD risk factors may
contribute to the high case fatality rate from COVID-19.
On the flip side, the COVID-19 containment measures can disrupt NCD preven-
tion and delay NCD management, leading to long-term adverse impacts on the
overall health status outcomes. Precautionary measures including lockdowns and
stay-at-home restrictions are important tools to flatten the infection curve, but they
come with a cost: they may restrict people’s access to health services and exacerbate
NCD risk factors, such as physical inactivity, obesity, unhealthy eating, and
increased smoking related to stress and anxiety from lockdown. In a survey study
in the United Arab Emirates, 71% of interviewees reported anxiety; among them,
smokers were 43.5% more likely to report higher anxiety than nonsmokers (Saddik
et al. 2020). Further, patients with NCDs may cancel or postpone their routine
medical appointments and tests for fear of being infected by COVID-19 in hospital
settings, which can worsen their underlying health conditions. According to WHO’s
global survey on NCD service delivery in May 2020, 122 countries reported
disruption of NCD services, especially rehabilitation services, hypertension man-
agement, and diabetes and diabetic complication management (WHO 2020).
Another concern is the dire situation for millions of low-wage foreign workers
(Hubbard 2020). Migrant workers are the majority of the workforce in the GCC, but
they receive fewer benefits for health care coverage and less job security than local
citizens. The economic contraction caused by the COVID-19 pandemic is likely to
worsen their health conditions and livelihoods. Strategies to facilitate infection
prevention and control are needed for people with unsuitable housing and people
who live in overcrowded settings, where physical distancing is difficult or impossi-
ble to achieve (Gandhi et al. 2020). The GCC countries have come to depend on such
low-wage workers, but many of those have lost their jobs. Foreign labor makes up
half or more of the population in many GCC countries and accounts for high
proportions of COVID-19 infections. Unemployment and hardship can also lead to
demoralization, depression, and other psychological traumas. Within the first 4
months of the COVID-19 pandemic, 40 suicides and 15 failed attempts were
reported in Kuwait. The majority of the cases were foreign workers who had
experienced psychological and economic misery after their employers stopped
paying them (Al Sherbini 2020). The pandemic raised the urgent needs to expand
universal health and social protection coverage among migrant informal workers.
Health Financing
Shrinking fiscal space – particularly long-term fiscal sustainability – alongside rising

health demands confront health financing systems in the GCC countries. In the six
countries, health financing systems rely predominantly on general government
revenues from natural gas and oil, whose prices plummeted by 42.5% with the
onset of the pandemic (World Bank 2020a). Stricken economies have led to an
abrupt tightening of financial conditions. Before the pandemic, GCC oil exporters,
especially Saudi Arabia and Kuwait, made optimistic oil price assumptions while
maintaining partial fiscal adjustments to balance the budget in coming years (IMF
2019a, 2020). These hopes have been shaken by the sharp fall of oil prices in 2020
and a narrowing window of opportunity to reduce dependence on hydrocarbons and
to boost savings.
Although the United Arab Emirates and Qatar have more diversified economies
and considerable financial buffers to weather external shocks, their roles as trade and
financial hubs could make them vulnerable to global financial market volatility and
trade disruptions (IMF 2018, 2019b). World Bank (2020a) forecasts that all GCC
countries will see economic activity contract in 2020. The GCC countries therefore
need to focus on adjusting public spending to a weaker medium-term outlook for oil
prices. To make it through the current crisis and to better prepare for the next one, it
is critical to increase the efficiency of public spending, link health expenditures with
health outcomes, create financial incentives for better performance, focus on lower-
cost preventive care rather than hospital care, and improve equity through expanding
health coverage to the most vulnerable groups. To avert health financing challenges,
we must transform health spending into growth-enhancing investment in human
capital.
In the past two decades, GCC countries have shown two discrete health financing
trends: a rise in health spending per capita in absolute, inflation-adjusted terms and a
decline in the share of out-of-pocket spending (OOPS) on health services as a share
of total spending on health. Together, these trends are defined as the “health
financing transition” (Fan and Savedoff 2014), as countries move toward financing
universal health coverage (UHC). According to the latest updated Global Health
Expenditures Data, average GCC health expenditures per capita increased from $497
to $1,182 between 2000 and 2016 (WHO 2020c). Qatar and Kuwait led the spending
2,500
2,000
1,500
1,000
500
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Bahrain Kuwait Oman Qatar Saudi Arabia United Arab Emirates
Fig. 7 Current health expenditures (per capita in current US$), 2000–2017. (Data source: World
Health Organization (2020c))
growth by tripling their health expenditures per capita in 2000–2017, while the other
GCC countries doubled them (Fig. 7). However, regional health spending started to
drop from 2014, around the same time that oil prices fell by 60% (Yazbeck et al.
2017). Cost escalation may continue to be driven by the greater health demands of
COVID-19 and NCDs, although the willingness and capacity of spending may
decline during economic downturns.
A major crisis like COVID-19 places a disproportionate burden on poorer and
disadvantaged populations. When catastrophic health spending occurs, either due to
sudden illness or chronic diseases, most poor households have to reduce their basic
expenditures to cover health care costs. GCC governments have, however, made vast
investments in UHC and brought down the share of household OOPS on health
spending in 2000–2017 (Fig. 8). OOPS as a percentage of current health expendi-
tures has been declining in the GCC and remains relatively low compared to that in
other Arab countries. Bahrain is the outlier: its OOPS share increased in 2000–2017,
from 25.8% to 30.4% (Fig. 8). Although GCC residents have some risk protection,
the pandemic is likely to increase OOPS, widen income inequality, and hurt low-
waged workers and small-business owners the most.
Tightening fiscal space has direct adverse impacts on government health expen-
ditures in the GCC. Government has been the main source of health care funding in
the region for decades. Government health expenditures accounted for 76% of
current health expenditures in the region in 2016, and 73.7% on average from
2000 to 2017 (authors’ calculations from data sourced by WHO 2020b). GCC
governments contribute a larger share of health expenditures than the average
35.00
30.00
25.00
20.00
15.00
10.00
5.00
0.00
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Bahrain Kuwait Oman Qatar Saudi Arabia United Arab Emirates
Fig. 8 Household out-of-pocket payment as a share of current health expenditures (%), 2000–
2017. (Data source: World Health Organization (2020c))
high-income country in the world. Oman and Kuwait had the highest shares of
government contributions in 2000–2017 (83.7% and 82.4% on average over the
period). Notably, Oman’s government financed nearly 90% of its health expenditures
from 2014 to 2016. Qatar has the fastest growth of government contributions as a
share of current health expenditures, increasing 27.2% from 2000 to 2014, then
declining 6% from 2015 to 2017. UAE government contributions fluctuated over
time, with a sharp decline by 20 percent from 2001 to 2004, then slowly bounced
back to 72% of current health expenditures in 2017. Bahrain and Saudi Arabia
showed relatively stagnant shares of government contributions to health expendi-
tures, the lowest in the GCC, but still above 60%. In other words, if government
budgets are cut due to revenue losses, the existing alternative sources for health
financing are limited in the region (Fig. 9).
Faced with a weaker outlook for the economy and public finances – especially as
alternative sources for health financing are limited in the region if governments cut
their budgets due to revenue losses – the challenge becomes more urgent to increase
the efficiency of government health spending. GCC health systems have ample room
to boost spending efficiency and ensure that the government gets value for money
from its spending.
Strengthening public procurement and accountability is essential to improve
spending efficiency. In the GCC, hospital construction costs are much higher than
international benchmarks. The average cost per bed is estimated at $1.3 million,
which is significantly higher than the international best practice of around $1 million
per bed (Kuwait Life Sciences 2018). The key weakness in procurement is mostly in
bid preparation and tendering, bid evaluation and awarding, and timeliness of
payments (IMF 2019a). Second, wage bill reform should be an essential component
of fiscal adjustment. In the GCC, a large proportion of public spending goes on
100.00
90.00
80.00
70.00
60.00
50.00
40.00
30.00
20.00
10.00
0.00
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Bahrain Kuwait Oman Qatar Saudi Arabia UAE
Fig. 9 Government health expenditures as a share of current health expenditures (%), 2000–2017.
(Data source: World Health Organization (2020c))
public sector wages. In Kuwait for instance, one-third of the government budget is
allocated to pay public wages and benefits (IMF 2020b). Public sector wages are
twice as high as equivalent private sector wages in Kuwait and Bahrain, and 1.5
times as high in Qatar and Saudi Arabia (IMF 2020c). One common practice
worldwide is to shift from line- item budgeting to performance-based finance and
create financial incentives for public sector employees to improve their performance
and quality of services. Third, government health expenditures should focus on
disease prevention, health promotion, and primary care, rather than higher-cost
secondary and tertiary care services, but in most GCC health systems, an excessively
large portion of health spending covers the latter (Raad 2015).
A crisis can also be an opportunity. China is an example of a country that reaped
valuable lessons from the SARS outbreak in 2003. When SARS first happened in the
end of 2002 to early 2003 in Guangzhou, China, neither the government nor the
people were prepared for such a major public health crisis caused by an unknown
virus, following by weeks of panic, chaos, and mismanagement. Learnt from the
hard lessons of SARS, the Chinese government has undergone a series of health
financing reforms on UHC, public funding for primary care, and public emergency
preparedness and response (World Bank and WHO 2019). While its initial reaction
to the COVID-19 outbreak was slow, China’s health investments enabled it to deploy
coordinated public health emergency responses nationwide and minimize the pan-
demic’s impact in a relatively short time. The lessons learnt from SARS 2003 are that
investing in public health emergency preparedness and response must be incorpo-
rated into long-term strategic plans, and the funding must continue even after the
current pandemic is controlled. Pandemic events do not happen often, but once
pandemic hits a totally unprepared system, the whole system collapses. It is hoped
that the COVID-19 pandemic will similarly represent a catalyst for GCC countries to
undertake strategic investments in their health care systems to enable nimble and
effective national responses.
For the GCC, the health sector should play a bigger role in reforms to develop the
nonoil economy in the post-COVID-19 era. The pandemic is likely to shift the global
supply chain from China-dependent to multiple regional centers (Baldwin and di
Mauro 2020), which provide opportunities for the GCC to invest in local production
of essential medicines. The United Arab Emirates is already leading the effort in
vaccine research and development, testing capacity, and medical supplies
production.
But the health sector in general remains a small share of the GCC economy
compared with that in other high-income countries. Current health expenditures in
the GCC were a low and rather stagnant share of GDP in 2000–2017, ranging from
1.6% of Qatar’s GDP in 2008 to 6% of Saudi Arabia’s GDP in 2015 (WHO 2020c).
The regional average of current health expenditures was equivalent to 4.2% of GDP
in 2016, only little over half of the global average for high-income countries (7.8%)
(authors’ calculations based on global health expenditure data). But the GCC
countries have the financial capacity to transform the COVID-19 crisis into a
development opportunity, “if we can learn from our lived experience and make the
bold decision, once and for all, to invest in the infrastructure and the workforce
needed to secure the population’s health” (MacKenzie 2020).
Service Delivery
In the past several decades, the GCC countries have made vast investments in health
service infrastructure and significant improvements in health outcomes. However,
the centralized health service model with a dominant public sector presence does not
present the incentive structures for better service performance (Raad 2015). Now is
the moment to strengthen core public health functions, provide essential medical
services with an integrated care approach, and boost innovative applications of
digital health technologies. Yet the challenges are huge.
First, health service delivery in the GCC faces tremendous challenges to adapt to
the continuing surge from COVID-19 cases. Most of the health system capacity in
the region is facility-based and there is a lack of surge capacity and flexibility.
Countries are undertaking investments to buy ventilators and other COVID-19-
specific equipment and facilities, imposing a constraint on physical resources asso-
ciated with non-COVID-19 services. Hospital resources per capita declined in 2000–
2017 in the GCC, especially in the United Arab Emirates, as indicated by hospital
bed density (Fig. 10). The regional average of hospital bed density was 16.9 beds per
10,000 population in 2017 versus 130.5 in Japan, 80.0 in Germany, 43.1 in China,
and 24.9 in Singapore (WHO 2020d). GCC countries have adopted national plans
and strategies to expand their service capacity since 2016. In 2018, the GCC
35.0
30.0
25.0
20.0
15.0
10.0
5.0
0.0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Fig. 10 Hospital beds per 10,000 population, 2000–2017. (Data source: World Health Organiza-
tion (2020d))
countries have planned the development of 26 hospital “mega projects,” with an

estimated total investment cost of $23.5 billion and an expected increase of 18,123
beds (Kuwait Life Sciences 2018). In addition to the shortage of hospital capacity,
most GCC countries have limited primary health care capacity, which reduces their
ability to manage non-COVID-19 services as well. So, similar if not more invest-
ments are needed to increase the primary health care capacity.
Second, access to routine health care services has been disrupted and most
elective surgeries postponed. One report in late March estimated that some 50% of
the regular care in the GCC is on hold; 400,000 doctors, nurses, dentists, allied
health, and other care professionals were not able to practice medicine, and about
eight million patient contacts were cancelled every week (Gupta Strategists 2020).
Beyond the direct impact, the COVID-19 crisis has the potential to overwhelm
existing health systems, undermining both emergency and nonemergency special-
ties. Health workers’ capacities and mental well-being could also become stretched.
Under usual circumstances, many patients already need the relevant expertise,
ventilators or oxygen, and hospital beds, and a further escalation of cases could
edge such patients out of care. Moreover, postponing primary care visits and elective
surgeries may lead to health complications and, in the longer term, worsening health
outcomes.
Similarly, the inflexibility of service provision and a facility-centered model to
case management both present significant risks in coping with the disease burden
imposed by COVID-19. Given the predominantly chronic burden of disease in the
region, patients have to continue going to health facilities or pharmacies to refill their
prescriptions or receive routine care and physicals, many of which could be avoided
with a shift toward telemedicine or more flexible health service delivery, which are
currently limited in the region. Telemedicine is already common in the GCC
countries for NCD case management, but home-based mobile medical units are not.
Third, service delivery challenges are particularly acute for the most vulnerable
groups, such as migrant workers, disabled people, and the elderly. There are
significant inequities in care-seeking in the region, with women and the elderly
facing higher odds of COVID-19, as well as a more significant impact from the
disruption of existing health care services due to COVID-19. For these vulnerable
populations, most GCC governments are failing to address the social determinants of
health, such as access to food, shelter, and income.
Last, health service delivery in the region is undergoing a structural shift to meet
rising demand for digital health, home health care, and long-term care. Digital health
refers to the routine and innovative use of digital technologies to address health needs,
including eHealth, mobile health (mHealth), telemedicine, and the emerging use of
advanced computing sciences in big data, genomics, and artificial intelligence (WHO
2019). Some GCC governments are investing in digital health, as seen, for example,
in the United Arab Emirates Ministry of Health and Prevention’s Innovation Strategy
2019–2021, which emphasizes information capital and technology as two of the five
main strategic indexes (UAE 2019); the Ministry has invested $11.5 billion in digital
health start-ups (Arab Health 2018). The Saudi Arabia National Transformation
Program Delivery Plan 2018–2020 also refers to eHealth as the key enabler of the
healthcare transformation (Kingdom of Saudi Arabia 2018). Digital health is not an
end in itself, but a powerful tool to transform GCC health systems from the traditional
facility-based model to a performance-driven, patient-centered care model.
The pandemic is certainly a hugely disruptive shock to service delivery but is also
a driving force of change. It calls out our societies and governments on what is the
most important in health care and shreds light on how we should move forward.
On the one hand, we are reminded of the utmost importance of core public health
functions of governments and communities; on the other hand, we are forced to
adapt to a new normal that requires bold innovations and digital transformation
towards new care models. For too long, our health systems had been spending too
much on medical treatments but too little on prevention and well-being. The fact that
a strong immune system is a person’s best protector against a novel virus reinforces
the urgency to transform health service delivery and incentive structures toward
disease prevention and population health management.
Human Resources
Human resources suffer from even greater challenges than physical resources, with
unequal and inflexible capacity and distribution. The GCC countries have relatively
low densities of health workers (below the WHO recommended threshold of 45
doctors, nurses, and midwives per 10,000 population) and other challenges include
the skills mix, underemployment, inequality in geographic distribution, and poor
work environments. Health workers are at particular risk, as many lack access to
control measures to protect against infection, which introduces risks to continuity of
care. These are exacerbated by the lack of task-shifting and inflexible work arrange-
ments, as well as a lack of community health workers, which together constitute an
onerous challenge to mitigate the increased demand on the health system in the time
of COVID-19. The COVID-19 containment measures, such as travel and transport
40
35
30
25
20
15
10
0
1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 2020
Fig. 11 Medical doctors per 10,000 population, 2000–2018. (Data source: World Health Organi-
zation (2020d))
restrictions, hit the expatriate medical workforce – the majority of health providers in
the GCC countries – disproportionally hard. In addition, healthcare infrastructure
building programs (the so-called hospital “mega projects”) that started across the
GCC in recent years will require a further surge of labor supply, with estima-
tions of needing additional 21,933 doctors, 48,908 nurses, 6065 pharmacists, and
26,736 allied health professionals or more to staff these new hospitals (Kuwait Life
Sciences 2018).
The GCC region, despite its high GDP per capita, has had a similar doctor density
on average to the global average of 20.7 since the 1990s (WHO 2020d). The regional
average was 20.1 doctors per 10,000 population in 2014 (the latest year with
reported data in all GCC countries) and 24.1 since the 1990s. A majority of the
GCC countries reported trend growth in physician density in 2000–2018 (Fig. 11) –
Saudi Arabia especially, from 7.2 to 26.1. In recent years, doctor densities seem to be
converging (Bahrain aside).
Staff densities for nurses and midwives vary more widely than doctor densities
across GCC countries. The number of nurses and midwives per 10,000 population in
Kuwait has been roughly three times that in Bahrain in recent years (Fig. 12). Many
GCC countries, except Bahrain, have shown significant increases in nursing staff in
2000–2018, particularly Saudi Arabia, from 17.7 to 54.8 per 10,000 population. Yet,
nurse and midwife density in the region is still much lower than in high-income
countries on average – 47.6 in 2014 (the latest year with reported data for all GCC
countries) versus, for example, most European Union countries, with over 100 such
staff per 10,000 population.
Furthermore, COVID-19 shock recalls professionalism and good management,
which are unfortunately missing in many places in the region. Health system resilience
is more about software than hardware. To bounce back from this shock and better
prepare for the next, health systems in the GCC not only need to be adequately sourced
80
70
60
50
40
30
20
10
0
1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 2020
Fig. 12 Nurses and midwives per 10,000 population, 2000–2018. (Data source: World Health
Organization (2020d))
with health workers and facilities, but also provide with sound planning processes,
management and leadership capacities, productive cultures, and healthy team power
dynamics among system actors (Gilson et al. 2017). GCC governments need to create
an enabling environment for human capital formation that integrates health, education,
jobs, and social protection in strategic planning and implementation (El-Saharty et al.
2020). They also require health facilities to improve performance management and to
create organizational motivation for quality service.
Health Responses
The GCC countries undertook public health measures based on their experience in
combating MERS-CoV in 2012, and on other measures, such as suspending passen-
ger flights into and out of the country; imposing lockdowns; introducing curfews;
curtailing religious and sports activities; asking many office-based workers to work
from home; and closing movie theatres, gyms, public swimming pools, public
beaches, and theme parks.
The following lists of country actions are not exhaustive, but aim to give an idea
of the GCC countries’ health measures in the critical first-half year of the COVID-19
pandemic.
Bahrain
Bahrain’s COVID-19 strategy focuses on “trace, test, and treat.” After confirming
the first COVID-19 case of a traveler from Iran on February 21, the government
closed all theaters, gyms, public swimming pools, and theme parks on March 18;
ordered the release of hundreds of prisoners on March 21; and designated the
Bahrain International Exhibition and Convention Center as the main testing center
for COVID-19 on March 23. On March 24, Bahrain’s central Bank instructed foreign
exchange companies to sterilize local and overseas currencies, and all nonessential
commercial enterprises were ordered closed from March 26. On March 30, the
Ministry of Health (MOH), with the Ministry of Interior, set up sample collection
stations across Bahrain where teams collected samples through mobile screening
units. On March 31, Bahrain’s Information and eGovernment Authority released the
BeAware Bahrain application on App Store and Google Play. The application uses
GPS location data to alert users about nearby active cases of COVID-19 or locations
visited by positive cases of the disease.
On April 6, the authority began distributing electronic waterproof wrist bands
with location tracking to monitor individuals under home quarantine. On April 7,
Bahrain suspended the fees levied on the delivery of health services to foreign
patients at public health centers. On April 8, the government advised people to
wear face masks in public. April 9 saw the Ministry of Health launch a COVID-19
drive-through testing center at the Bahrain International Exhibition and Convention
center, as well as suspending the BD7 medical consultation fee.
On April 10, Bahrain converted the third floor of the Bahrain Defense Force
Hospital parking area into a large intensive care unit capable of accommodating 130
beds equipped with respiratory and reanimation equipment. The authorities extended
closure of nonessential businesses from April 23 through May 7, including movie
theaters, sports centers, gyms, and salons. Restaurants were restricted to food
delivery and takeaway only. Grocery stores, medical facilities, banks, and other
essential businesses could stay open. On April 28, the authorities developed a
comprehensive contact tracing plan to flag active cases and contacts amongst
expatriate workers, while clarifying whether residences are owned by an employer
or are self-provided shared accommodation.
The authorities announced the reopening of shops and industrial enterprises
starting from May 7, while restaurants remain closed to in-house diners. Cinemas,
sports facilities, and salons stayed closed. The public mandate on wearing face
masks and practicing physical distancing remained in force. On May 13, the
National Taskforce for Combating the Coronavirus highlighted the COVID-19
measures including a new feature of the BeAware application that allows citizens
and residents to schedule their end-of-isolation swab. A number of 3,519 of the total
8,404 swabs have been scheduled via the application, while 4,885 have been
scheduled over the phone. In addition, the capacity at isolation canters have been
expanded to reach 4,257 beds and 5,489 beds at quarantine centers, of which 3,330
and 515 beds are occupied, respectively.
Kuwait
Kuwait’s COVID-19 measures emphasize social control alongside public health

interventions. During the National Day holiday week in late February, Kuwait
recorded the first case of COVID-19, imported from Iran, causing the authorities to
cancel national holiday parades and large gatherings. The MOH began detailing
coronavirus cases on its website (and on television) on February 24. On April 6, a
curfew was introduced, from 5 in the evening to 6 in the morning. Work was
suspended across all ministries and government institutions initially for April 12–
26 and then with an extension to May 31. All private health clinics and laboratories
were also closed.
On April 14, it was announced that medical requests for nationals and those
exempt from fees could be made through the MOH. The MOH announced a partial
curfew, including international waters, beach houses, farms, and residential areas;
this banned walking on beaches, walking inside residential areas, and boat rides. All
nonemergency government offices would be closed at least through April 23, unless
otherwise notified. All public transportation, including taxi services, was suspended,
and all mosques, public parks, beaches, and public spaces were closed until further
notice.
The authorities implemented a total lockdown nationwide, starting at 4 pm on
May 10 until May 30. All outdoor activities were forbidden, except walking inside
residential areas between 4:30 pm and 6:30 pm. All home delivery services were
discontinued, except for cooperative societies, food outlets, and pharmacies. Resi-
dents can request special permit to go out for medical emergency. Each household is
allowed to make one online appointment for grocery shopping per week.
Between May 10 and May 14, the authorities closed some cooperative societies
and supermarkets after employees tested positive for COVID-19. On May 17, the
Health Ministry launched drive-through coronavirus testing site. The Public Author-
ity for Civil Information was also set to randomly select 180 people a day for testing.
Oman
Following the confirmation of the first two cases of COVID-19 returning from Iran,
the government introduced airport screening from travelers arriving from endemic
countries and established surveillance and isolation of symptomatic arrivals. On
March 3, all retail outlets, including shopping malls and supermarkets, were
instructed to install sanitizers. On March 17, a ban was imposed on entry of all
non-Omanis, except GCC nationals, into the country. All mosques were ordered
closed, except for the call to prayer (Athaan), as were all areas of worship for non-
Muslims. Similarly, all gatherings, activities, and conferences were suspended in the
sultanate. The same day, the government imposed a lockdown on Doha Industrial
Area, home to many migrant workers. On March 18, treatment services provided for
routine nonemergency cases were temporarily suspended. On March 19, the MOH
launched the Tarassud App on Apple store as an interactive COVID-19 map, and on
March 22, the Supreme Committee directed government agencies to reduce the
number of employees in the government sector to no more than 30% of the total
number of employees, with the rest of the employees to work from home (as
determined by the authority in which the employee works).
On March 21, the Supreme Committee on coronavirus set out six decisions,
starting March 15 for 30 days, with prohibitions on tourist visas, sports activities,
non-class student activities, and entry of cruise ships, while limiting attendance at
court sessions to those involved in the cases only. On March 25, the committee
decided to activate the “Medical Response and Public Health” sector and the
“Shelter and Relief” sector.
Several hospitals such as Al Nahda Hospital announced the suspension of all
outpatient appointments and surgical appointments starting from April 1.
On April 6, it was announced that some hospitals such as Al Masarra hospital had
recently initiated community psychological support for anyone needing it. On April
8, the entire capital was placed under lockdown for April 10–22. On April 9, the
MOH announced that all COVID-19 tests and treatment would be free for all. On
April 14, the MOH started using plasma from recovered COVID-19 patients to treat
critically ill patients in the Royal Hospital.
On April 28, the government allowed some commercial businesses to open,
including car servicing, repair, and rental agencies, currency exchanges, outlets
selling electrical and electronic appliances, printing houses, and quarries.
Qatar
On February 24, precautionary measures were taken as recommended by WHO to

prepare for COVID-19, including preparing residential buildings for quarantine. On
February 25, the Ministry of Public health (MOPH) gave advice to avoid traveling
unnecessarily to countries with COVID-19 cases. On February 27, the first case of
COVID-19 was confirmed (IMF 2020c). On March 10, the MOPH banned shisha
and hookah in cafes and restaurants, and on March 12 precautionary measures were
announced to avoid social gatherings. On March 23, the MOPH publicly sought
volunteers to support Qatar’s response to the COVID-19 outbreak, while launching a
volunteer campaign “For Qatar”. On March 28, the MOPH activated remote access
channels to health care services, and on March 29 nonemergency health services at
private health facilities, including dental clinics, dermatology centers, laser clinics,
and plastic surgeries were suspended.
In early April, Hazm Mebaireek General Hospital was designated as the national
treatment facility, and two primary health care centers were selected for screening,
testing, and putting COVID-19 patients into quarantine. On April 9, the MOPH
intensified health control campaigns on food establishments as a precautionary mea-
sure. On April 13, the government sought to improve outreach to non-Arabic speakers,
and issued guidelines for employers and employees in several languages. On April 16,
the health sector launched a remote COVID-19 and diabetes outreach program. All
workers have access to free testing and health care, regardless of their status.
On April 22, Qatar Computing Research Institute partnered with the MOPH and
Hamad Medical Corporation launched an online self-assessment application to
educate users on the symptoms of COVID-19 and to advise when to seek medical
help. On May 5, the authorities fully opened Doha Industrial Area following
widespread testing. Strict entry and exit regulations have been put in place, managed
by the use of a mobile application by employees and employers entering or exiting
the area.
Saudi Arabia
On March 2, the first case of COVID-19 was confirmed. On-ground transportation (and
flights) between cities and districts were halted from mid-March (except for logistics,
delivery, and medical services). In a further tightening of restrictions originally launched
in late February at the Great Mosque in Mecca and the Prophet’s Mosque in Medina, the
government on March 20 suspended entry and praying for the general public at the two
mosques. Announcements were also made that all prayers were to be conducted at
home. The MOH tested for COVID-19 in densely populated areas. In addition, the
government used the buildings of some 3,600 currently vacant public schools to
accommodate low-wage foreign workers from densely populated areas. The MOH
also established an eHealth strategy that includes the use of telemedicine. On March
29, private and public sector employees were barred from going to their workplaces.
On March 30, the King instructed that all COVID-19 patients should be treated
for free. In addition, the MOH mandated that health insurance cards be extended
automatically for at least 6 months. The government initiated a “Home Medicine
Program” to deliver required medications to patients with chronic diseases.
On April 2, Saudi Arabia put the holy cities of Makkah and Medina under 24-
hour curfew. On April 5, King Abdullah Medical City, Makkah, activated the virtual
clinics initiative at outpatient clinics, which allows direct contact between doctor and
patients. On April 18, specialized medical teams visited high-risk areas for mass
testing and active COVID-19 screening. On April 26, the government allowed
businesses to reopen and eases bans on movement to lessen economic toll of the
coronavirus containment measures.
On May 3, the Saudi authorities isolated the industrial area of the eastern city of
Dammam until further notice, though freight shipments will continue. On May 9, the
Ministry of Interior decided to lift the precautionary measures announced on March
27 in the districts of Al-Shuraibat, Banidhafar, Qurban, Al-Jumuah, part of Al-Iskan,
and Bani Khadrah in Madinah, starting from Saturday 9 May 2020. Residents are
granted free movement from 9 am until 5 pm, while maintaining health precaution-
ary measures. On May 12, the authorities announced a 24-h curfew in the gover-
norate of Beesh, Jizan, until further notice. Measures from May 14 to May 22
include: (1) continue to allow commercial and economic activities that were
excluded according to the royal order issued on April 25, 2020, while implementing
the adopted precautionary measures; (2) continue to allow the movement freely
during the day for 8 h, starting from 9 A.M and ending at 5 P.M, in all cities and
regions, except for Makkah city; (3) continue the 24-h curfew in Makkah city; and
(4) continue to prevent entry and exit from the areas, cities, and neighborhoods for
which isolation decisions were issued. A nationwide 24-h curfew was announced for
May 23 to 27.
The first case in the United Arab Emirates was confirmed on 29 January – a 73-year-
old Chinese woman who had come to the country on vacation with her family from
Wuhan, China. The United Arab Emirates was ranked as the world’s 10th best for the
treatment of coronavirus in mid-April, according to the Deep Knowledge Group, and
the first among Arab nations. The government launched one of the most ambitious
testing programs globally, with accessible, free testing and treatment. The United
Arab Emirates has tested more than one in ten of the population, around 1.3 million
people, by mid-May.
The Ministry of Health and Prevention stated on March 7 that over 620 school
buildings and 6,000 buses had been sterilized. Dubai started an 11-day sterilization
campaign on March 22. The country also continued to ramp up testing services,
launching a home-testing service for people with disabilities as well as drive-through
centers. Since March 21, the authorities started to close public and private beaches,
parks, swimming pools, movie theatres, shopping malls, commercial centers, and
restaurant dine-in services. On April 1, the National Emergency Crisis and Disasters
Management Authority launched “Weqaya,” a website to raise public health awareness
on the coronavirus. Dubai police have utilized artificial intelligence solutions to
demarcate vehicles that have movement permits or belong to people working within
vital sectors, from vehicles of individuals in breach of the lockdown enforced on April
5. Hospitals across the United Arab Emirates have adopted telemedicine services. In
addition, the Telecommunications Regulatory Authority has launched 18 initiatives to
support distant learning and the safety of citizens, residents, and visitors.
On April 12, the Dubai Health Authority began using blood plasma from recov-
ered COVID-19 patients to treat critical COVID-19 cases. On April 15, Dubai’s
COVID-19 command and control center announced full genome sequencing of the
COVID-19 virus. The authorities launched a “Don’t Worry” campaign to promote
mental health.
The authorities focus on reopening public and private sectors alongside mass
testing in May. On May 9, Abu Dhabi Police launches mobile coronavirus screening
center. On May 10, the United Arab Emirates government enacted eight basic
preventive requirements related to the reopening of commercial centers, malls, and
shops around the country, most notably not allowing children under the age of 12
and adults over the age of 60 to enter the mentioned public areas. On May 12, Dubai
Supreme Committee of Crisis and Disaster Management approved protocols for
easing restrictions on movement in the emirate, effective May 12. The protocols
allow (1) the opening of public parks with strict enforcement of specific preventive
measures; (2) operations of trams and maritime transport including the Dubai Ferry,
water taxis, and car sharing services; and (3) sports and recreational activities in open
spaces for up to five people. On May 13, the Dubai Health Authority announced the
launch of three clinics to collect convalescent plasma from recovered COVID-19
patients. Abu Dhabi Emergency Crisis and Disasters Committee for COVID-19
inaugurated the Al Razeen Field Hospital, which was constructed within 9 days
and have a capacity of 250 beds (including 50 ICU beds).
Possible Additional Health Measures
The disruptions caused by the COVID-19 pandemic will have a long-term impact if
governments do not taken action to mitigate the impact of the crisis on vulnerable
people. While GCC countries have announced some measures in this area, success-
ful implementation will be crucial, and monitoring efforts will have to be ramped up.
Monitoring efforts have been hindered in the past by low capacity and confidenti-
ality. This crisis may be the opportunity to address those shortcomings.
At first instance, all GCC governments should continue to invest in strengthening
their health systems. This is critical to break the chains of transmission and to
diagnose and treat cases while maintaining essential services. It is equally important
to protect the health of frontline health workers, and to anticipate and address the
mental health needs of the health workforce. Finally, continuing to assess and
mitigate potential financial barriers to accessing care related to COVID-19 and
also other essential health services, including for the foreign population, is critical.
Public Health Considerations for Reopening an Economy
The GCC countries have entered different phases of reopening as of July 31, 2020,
even though the COVID-19 pandemic has not yet been under control region wide.
Even countries achieving containment in other parts of the world experienced
setbacks and have responded with rapid reescalation of control measures. Mean-
while, no economy can survive from long-term lockdown restrictions. That means
all countries need to move toward reopening and recovery while continuing control
for transmission and preparing for resurgence.
Reopening Economies Worldwide
As there is a trade-off between the need to curb the pandemic and to reopen the
economy, policymakers across the globe are contemplating the question of when to
start reopening the economy, in which sectors, and how quickly. Many reports and
articles have attempted to answer this question, mainly for high-income countries.
The American Enterprise Institute, working with Johns Hopkins University,
proposed a four-phase stepwise approach, depending on the ability to aggregate
and analyze data in real time (American Enterprise Institute 2020). Phase I: Slow the
spread. This is the current phase in which community transmission is occurring and
most activities are shut down. These measures will need to be in place until
transmission has measurably slowed and when health infrastructure can be scaled
up to safely manage the outbreak and care for the sick. Phase II: Gradual reopening.
This phase can be launched when the health system is able to safely diagnose, treat,
and isolate COVID-19 cases and their contacts. However, some physical distancing
measures and limitations on gatherings will still need to be in place to prevent
transmission from accelerating again. Phase III: Establish immune protection and
lift physical distancing. Here, physical distancing restrictions and other Phase II
measures can be lifted when safe and effective tools for mitigating the risk of
COVID-19 are available, including broad surveillance, therapeutics that can rescue
patients with significant disease or prevent serious illness in those most at risk, or a
safe and effective vaccine. Phase IV: Rebuild readiness for the next pandemic. This
phase will require investment into research and development initiatives, expansion
of the public health and health care infrastructure and workforce, and clear gover-
nance structures to execute strong preparedness plans.
Vital Strategies (2020), an international public health consultancy, proposed an
“adaptive approach” consisting of four stages: preparedness, containment, mitiga-
tion, suppression, and recovery. Containment entails preventing the spread of disease
in early stages of transmission (sporadic and clusters of cases) through measures
such as early detection and isolation of cases, and contact tracing and quarantine.
Mitigation entails minimizing epidemic impact from local and widespread transmis-
sion, delaying the outbreak peak, and reducing the peak number of cases to reduce
strain on the health care system, which is achieved largely through public health
social measures and specific treatments, when available. Suppression entails reduc-
ing and maintaining low levels of disease transmission through intermittent loosen-
ing and tightening of public health social measures, detection and isolation of cases,
and contact tracing and quarantine.
These two strategies offer a public health approach, based on slowing transmis-
sion and lifting public health capacity, in which countries progressively relax
measures as new cases slow and public health capacity increases.
Other reports have combined the public health considerations with economic
considerations. For example, McKinsey proposed a matrix that determines the extent
of the health care system’s ability to handle virus transmission along two dimensions
(Latkovic, Pollack, and VanLare 2020). First is the virus spread, which entails the
number of new daily infections, virus transmission rate, and new daily cases requiring
hospitalization and treatment in an intensive care unit. Second is public health readi-
ness, which requires medical capacity to manage critical cases, adequate medical
resources, ability to rapidly test, and effectiveness in tracking and isolation. In addition,
the approach analyzed the prioritization of reopening economic sectors based on two
dimensions: risk of virus transmission in these sectors and their economic relevance.
Brookings offers a variant of this view, emphasizing virus-proofing public nodes,
especially airports and rail stations, with a focus on telework and protecting leading
industry clusters and “Main Street.” (Florida and Pedigo 2020)
The international consultancy Castalia presents a risk-cost framework that weighs
the epidemic risks of lifting measures with the economic costs of maintaining them
(James and Gawith 2020). For New Zealand, it suggests lifting domestic travel
restrictions as soon as possible (and international ones much later); easing compul-
sory shutdowns when the reproductive rate is low enough; and keeping restrictions
on large gatherings in place. It also proposes keeping in place intensified private and
public hygiene, as well as heightened surveillance, for a longer period.
An advisory paper based on the UK context by Lyons and Ormerod (2020)
suggests a similar risk-calibrated approach based on “traffic lights,” where red
entails limited openings and high individual vigilance; orange expanded openings
and continued individual caution; and green going back to (the new) normal.
This fast-growing literature suggests considerable agreement about the key steps
toward reopening, particularly the importance of seeing declining rates of infection,
strengthened public health responses, and increasingly granular data about epidemic
transmission dynamic and intervention impact to inform which sectors of the
economy can be gradually reopened.
Reopening the GCC Economies: Four Key Considerations
Based on current knowledge, the World Bank (2020b) summarizes some key
considerations for easing lockdowns. For the GCC countries, the following are the
four key public health considerations for reopening the economy.
Epidemic force. The greater the epidemic force, the more urgent, large scale, and
long lasting the required lockdowns, and the greater the likelihood and size of
subsequent rebounds when measures are relaxed. The overall epidemic force is
primarily about contagiousness, called the reproduction rate, and is about 2–2.5 –
double that of influenza. It is important to drive this rate below one before the
epidemic slows enough to reopen safely. Other drivers of epidemic force are
“superspreading” events, such as religious gatherings and festivals, and more per-
manently, aged homes and hospitals. A key element of epidemic force is community
transmission, where the virus spreads locally without imported infection chains.
Epidemic force also influences the likelihood and size of further epidemic waves,
because unless the reproduction rate is driven below one before measures are
relaxed, rapid, large rebounds are likely and even subsequent epidemic waves are
still likely, though they may be slower and smaller.
In the GCC countries, the large expatriate population and international travel hubs
in some countries were enhancing the epidemic force as most of the new cases were
imported or traced to imported cases before local transmission began. This risk was
mitigated by the capacity to implement targeted measures such as protecting the
borders to control imported infections, quarantining suspected cases, and cancel-
ations of major public gatherings to limit community transmission. These measures
can lay the ground for reopening internally.
Population health. The larger the pool of the elderly, the comorbid, and health
workers, and the higher the number of these groups infected, the less a country may
contemplate reopening. Coronavirus fatality can be as high as 10% among tested
cases, when those infected are elderly, comorbid (including those with lung, heart, or
liver disease or with diabetes, as well as the obese, hypertensive, immunocompro-
mised, and smokers), or health workers (who may be exposed to repeated high viral
doses). Air pollution, housing density, and malnutrition may also exacerbate disease
progression. In contrast, case fatality can be below 0.5% in healthy young commu-
nities with good health services.
In the GCC countries, prevalence of NCDs such as diabetes and their risk factors
such as obesity among nationals will be a serious challenge, which may be offset by
the large, relatively young expatriate population, although the living conditions of
low-wage foreign workers is often accelerating cluster transmission but less critical
cases. The GCC countries have done far less about the teeming environments in
which millions of low-wage foreign workers live and work (Economist 2020).
Public health and health services capacity. Countries with high and tested public
health capacity experience fewer infections because they managed to prevent
imported infections from becoming community transmission and can reopen earlier –
Germany, for example. If countries do not possess these core pandemic capabilities,
they must utilize the time bought by lockdowns to rapidly strengthen these functions,
as they will be required for reopening. The core public health skills are the ability to
protect and screen effectively at borders; test, isolate, and treat positives; trace
contacts; quarantine the exposed; and minimize unlinked cases (those without
identifiable contact chains). For example, Bahrain flattened the curve through its
strong public health measures. In addition, a country needs well-protected health
workers and safe health facilities before it can consider reopening its economy.
Adequate hospital and critical care beds also increase a country’s confidence in its
ability to reopen.
Health service capacity, particularly at hospitals, is of paramount importance. The
first imperative is effective personal protective equipment for all health workers so as
to avoid multiple consequences: their becoming infected, hospitals superspreading
infection concentrators, health workers rapidly becoming overwhelmed by repeated,
intensive viral doses and then sickening and dying quickly – in turn overwhelming
health systems and causing higher mortality among patients. Other necessities for
safely reopening the economies include effective isolation wards and enough critical
care places, equipment, and supplies, including oxygen concentrators and ventila-
tors, and critical care teams.
Health services in the GCC countries have effectively managed the case load as
reflected by the low case fatality rate, which remains below 1% among those tested
positive. Yet, as cases are set to increase in some GCC countries, governments will
want to pay more attention to ensuring the readiness of their health services to
manage critical cases.
Scientific and technological innovations. These have been quite impressive and
offer the hope of a relatively rapid pathway to reopening. Their impact generally
increases among four broad categories: digital mobility and public health tracking
tools; testing; treatment; and vaccines. The first and second are the most relevant for
the GCC countries, and the last would indeed be transformative.
There are two types of test that can help governments shorten and soften
economically costly suppression measures while still containing the COVID-19
pandemic. The first – a PCR assay – identifies people currently infected by testing
for the presence of live virus in the subject, which can help contain the disease
because it facilitates the identification of infected persons. The second – an antibody
test – identifies those rendered immune after being infected by searching for
COVID-19-specific antibodies, which can help us assess the extent of immunity
in the general population or subgroups, to fine-tune social isolation (de Walque
et al. 2020).
The fruits of digital mobility and public health tracking tools are already being
harvested. COVID-19 is the most digitally tracked pandemic in history, with lock-
downs accompanied by almost instant digital mobility and distancing measures fed
into mathematical models that are updated and recalibrated daily. Several other
digital mobility dashboards complement these reports. It has never been possible
to monitor social interventions more precisely or rapidly. Yet the ability to capitalize
on these data requires national decision-making capacity and coordination across
many different government branches, far beyond the health sector.
Conclusion
“[T]he best economic response was a strong health response,” as the prime minister
of New Zealand Jacinda Arden (2020) points out. The COVID-19 pandemic has
brought to the fore to policymakers all over the world the value of a well-developed
health care system and good governance that is prepared to promptly tackle the
challenges of a pandemic. “Whether countries or regions have successfully elimi-
nated the virus, suppressed transmission to a low level, or are still in the midst of a
major outbreak; now is the time to do it all, invest in the basics of public health and
we can save both lives and livelihoods” (Ghebreyesus 2020).
Responding to the pandemic, the GCC countries have taken multiple and often
strict measures to protect their populations’ health and their economies, often being
compelled to make an unavoidable trade-off. As of July 31, 2020, these measures
appear to be paying off. A GCC country’s decision to reopen its economy need to
closely consider public health considerations to avoid a resurgence in infections and
any further erosion of its human capital. Such a decision need to also consider the
wider context of steps taken by other GCC countries – and beyond.
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Part VII
Environmental Causes of Disease
Air Pollution and Health Outcomes in the
Eastern Mediterranean Region: Knowledge 55
and Research Gaps and Need
Yousef Saleh Khader
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1362
Health Effects of Air Pollution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1363
Sources of Air Pollutants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1366
The Effect of Air Pollution on Health in the EMR Countries: The Strength of the Evidence . . . 1367
The Effect of Air Pollution on Health in the EMR: Knowledge Gaps . . . . . . . . . . . . . . . . . . . . . . . . 1368
Air Pollution and Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1386
Air Pollution and Cardiovascular Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1392
Air Pollution and Pregnancy Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1393
Carbon Monoxide Poisoning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1393
Disease Biomarkers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1394
Neurological Disorders and Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1394
Sleep Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1394
The Adaptation Plans for Air Pollution in the EMR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1395
The Effect of Air Pollution on Health in the EMR: Research Gaps and Needs . . . . . . . . . . . . . . 1397
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1399
Abstract
Although air pollution is recognized as an emerging public health problem in the
EMR countries, it is difficult to construct evidence on the effect of air pollution on
health in the EMR countries for several reasons, in part because the impact of air
pollution on health is not recognized as a priority area by health researchers,
health professionals, and policy makers in the EMR countries. Although the
burden of diseases from air pollution is expected to be high in the EMR, a limited
number of studies in a few areas of the EMR countries have assessed the
Y. S. Khader (*)
Department of Community Medicine, Public Health and Family Medicine, Faculty of Medicine,
Global Health Development (GHD)/The Eastern Mediterranean Public Health Network
(EMPHNET), Amman, Jordan
e-mail: yskhader@just.edu.jo

https://doi.org/10.1007/978-3-030-36811-1_56
1362 Y. S. Khader
association between various air pollution exposures and health outcomes. For the
majority of reviewed studies, limitations do exist – even in well-conducted ones.
The limitations and shortcomings arise from inappropriate study designs, poor
assessment of exposure and outcomes, questionable sources of data, lack of
standardized methods, poor adjustment of confounders, limited geographical
area studies, small sample sizes, poor statistical modeling, and not testing for
possible interactions between exposures.
Tobacco smoking increases the risk of some types of cancers. Nitrogen dioxide
increases the risk of lung and breast cancer incidence. Outdoor and indoor
pollution, using fuel for heating, and living near an electric generator are associ-
ated with an increased risk of lung cancer. Air pollution is associated with
cardiovascular morbidity, especially in high-risk groups. Moreover, exposure to
poor ambient air quality and particulate matter increases blood pressure in
schoolchildren. The few studies in the EMR that have examined the effect of
air pollution on pregnancy outcomes show that prenatal secondhand smoke,
carbon monoxide, and exposure to wood fuel smoke have harmful effects on
the weight of newborn babies and increase the risk of spontaneous abortion. Other
ambient air pollutants have no significant association with the mean birth weight
and do not affect preterm birth.
In conclusion, it is difficult to gauge the evidence on the effects of air pollution
on health in the EMR countries based on the limited number of published material
and the poor qualities of many of the studies. Policy makers should use the best
available evidence to make recommendations. Standardized reliable assessments
on national levels for various air pollutants in different countries should be
implemented and made publicly available for research purposes. Advancing
and utilizing epidemiological designs is of key importance. Best epidemiological
designs should be used to yield information on rare chronic health outcomes. In
addition, well-designed case-control studies should be used to study the health
effects of airborne toxins and pollutants. Accurate exposure levels, detailed
outcome assessments, and incorporating appropriate confounders should be con-
sidered in future studies, which should also consider exposures to pollutants that
are emitted together, or as individual pollutants, to better understand the mech-
anisms of the health outcomes of environmental pollutants.
Keywords
Air pollution · Health outcomes · Research gaps · Epidemiology
Introduction
Air pollution, both indoors and outdoors, is a major environmental health problem
affecting people in both developed and developing countries. Although there are
many air pollutants, among the most important ones are particle pollution including
particulate matter (PM), ground-level ozone (O3), carbon monoxide (CO), sulfur
oxides (SOx), nitrogen oxides (NOx), and lead (Pb) (which are found in ambient air
55 Air Pollution and Health Outcomes in the Eastern Mediterranean Region. . . 1363
and also known as “criteria pollutants”), environmental tobacco smoke, formalde-

hyde and polycyclic organic matter, and also indoor pollutants (Bruce et al. 2002;
Senevirathne 2003).
Exposure to air pollutants leads to a variety of health effects depending on the
type of pollutants, quantity, duration, and frequency of exposure to pollutants, and
the toxicity profiles of the pollutants. These exposures are associated with a broad
range of acute and chronic health effects varying from subclinical effects to prema-
ture mortality (American Thoracic Society 2000). Although air pollutants are cate-
gorized in a number of different ways, most air pollutants generally do not occur in
isolation but in complex mixtures that create the potential for synergistic effects
among them (HEI 2004). The composition of air pollutants and their associated
toxicity vary in different settings. Age, cultural practices, lifestyle, and socioeco-
nomic status can influence the effects of exposure to air pollutants (HEI 2004). The
effects of air pollutants and the severity of health outcomes in a given population will
depend on the sensitivities of individuals in that population (American Thoracic
Society 2000). Groups that are more sensitive to air pollutants include unborn and
young children, elderly people, and those with a history of cardiorespiratory diseases
(WHO 2004). Hence, the demographic profile of a given population is also
important.
The Eastern Mediterranean Region (EMR) has 21 countries including Afghani-
stan, Bahrain, Djibouti, Egypt, Iran (Islamic Republic of Iran), Iraq, Jordan, Kuwait,
Lebanon, Libyan Arab Jamahiriya, Morocco, Oman, Pakistan, Qatar, Saudi Arabia,
Somalia, Sudan, Syrian Arab Republic, Tunisia, UAE, and Yemen. The proper
understanding of which air pollutants are of major concern in the EMR and under-
standing of their associated health outcomes are crucial for developing policies and
nationwide interventions. Unfortunately, there are very limited studies that properly
address those issues in the EMR, with most of research focused on the effects of
ambient air pollution. This chapter aims to summarize knowledge on the impact of
air pollution on health outcomes in the region and identify some knowledge and
research gaps.
Health Effects of Air Pollution
Exposure to outdoor air pollution has been linked to health effects in many meta-
analysis and systematic reviews (Zhang et al. 2018; Li et al. 2017; Raaschou-Nielsen
et al. 2017; Zhao et al. 2017; DeVries et al. 2017; Chen et al. 2016; Hamra et al.
2015; Filippini et al. 2015; Eze et al. 2015; Stieb et al. 2012; Forbes et al. 2009).
Table 1 presents the findings of main meta-analyses studies that studied the link
between air pollution and multiple health outcomes. Short-term exposures may
exacerbate pre-existing respiratory disease (especially asthma and chronic obstruc-
tive pulmonary disease) and pre-existing cardiovascular disease (including ischemia,
arrhythmias, and cardiac failure), with increased hospitalization and emergency
department visits. Long-term exposure to air pollution is associated with increased
mortality, increased incidence of lung cancer and pneumonia, and development of
atherosclerosis. Air pollutants exert their effect on the respiratory system through
1364
Table 1 The findings of main meta-analyses studies that studied the link between air pollution and multiple health outcomes
Authors Exposure Outcome Main findings Conclusions
Zhang et Nitric dioxides Chronic The overall relative risk (RR) of COPD risk related to a 10 μg/m3 Consistent evidence of the potential
al. (2018) (NO2) obstructive increase in NO2 exposure increased by 2.0%. The pooled effect on positive association between NO2 and
pulmonary prevalence was 17% with an increase of 10 μg/m3 in NO2 COPD risk
disease (COPD) concentration, 1.3% on hospital admissions, and 2.6% on mortality
Li et al. Particulate Daily total Significant association between PM2.5 and mortality. A 10 μg/m3 PM2.5 is associated with increased
(2017) matter (PM2.5) mortality increase in 2-day moving average PM2.5 concentrations on total mortality risk
morality corresponded to a 0.17% (95% confidence interval
(CI): 0.10, 0.23) in national level
Raaschou- PM10, PM2.5, Kidney Higher hazards ratios (HRs) in association with higher PM Exposure to outdoor PM at the residence
Nielsen et PMcoars, NO2, parenchyma concentration, e.g., HR ¼ 1.57 (95% confidence interval (CI): may be associated with higher risk for
al. (2017) nitric oxides cancer 0.81–3.01) per 5 μg/m3 PM2.5 kidney parenchyma cancer
(NOx)
Zhao et al. PM10, PM2.5, Out-of-hospital PM10, PM2.5, NO2, and O3 were found to be significantly Associations between short-term
(2017) sulfur dioxide cardiac arrest associated with increase in OHCA risk. The acute exposure to exposure to PM2.5, PM10, and O3 and a
(SO2), NO2, (OHCA) SO2 and CO was not associated with the incidence of OHCA. high risk of OHCA, with the strongest
carbon Population attributable fractions for PM10, PM2.5, and O3 were association being observed for PM2.5
monoxide 2.1%, 3.9%, and 1.6%, respectively
(CO), and
ozone (O3)
DeVries et Short-term COPD-related An increase in PM2.5 of 10 ug/m3 was associated with a 2.5% (95% Ambient outdoor concentrations of
al. (2017) exposures of emergency CI: 1.6–3.4%) increased risk of COPD-related ED and HA, an PM2.5, NO2, and SO2 were significantly
PM2.5,NO2, department increase of 10 ug/m3 in NO2 was associated with a 4.2% (2.5– and positively associated with both
SO2 (ED) visits, 6.0%) increase, and an increase of 10 ug/m3 in SO2 was associated COPD-related morbidity and mortality
hospital with a 2.1% (0.7–3.5%) increase
admissions
(HA), and
mortality
Y. S. Khader
55
Chen et al. Prenatal Preterm birth Pooled ORs for exposure to NO2, PM10, CO, PM2.5, and NO Exposures to PM10, CO, and PM2.5
(2016) outdoor air during the entire pregnancy were 0.960 (95% CI: 0.935–0.985), during the entire pregnancy, to NO2
pollution 1.068 (95% CI: 1.035–1.103), 1.122 (95% CI: 1.078–1.168), during the first trimester, or to NO2 and
1.110 (95% CI: 1.043–1.181), and 0.994 (95% CI: 0.973–1.016) SO2 during the third trimester were
associated with preterm births
Hamra et NOx Lung cancer The meta-estimate for the change in lung cancer associated with Consistent evidence of a relationship
al. (2015) a 10 μg/m3 increase in exposure to NO2 was 4% (95% CI: 1%, between NO2, as a proxy for traffic-
8%). The meta-estimate for change in lung cancer associated sourced air pollution exposure, with lung
with a 10 μg/m3 increase in NOx was similar and slightly more cancer
precise, 3% (95% CI: 1%, 5%)
Filippini Outdoor air Childhood Results for NO2 exposure and benzene showed an OR of 1.21 A link between ambient exposure to
et al. pollution leukemia (95% CI 0.97–1.52) and 1.64 (95% CI 0.91–2.95), respectively traffic pollution and childhood leukemia
(2015) risk, particularly due to benzene
Eze et al. Air pollution Diabetes Increased risk of T2DM by 8–10% per 10 μg/m3 increase in Positive association of air pollution and
(2015) mellitus exposure [PM2.5, 1.10 (95% CI: 1.02, 1.18); NO2, 1.08 (95% CI: T2DM risk
(T2DM) 1.00, 1.17)]. Associations were stronger in females
Stieb et al. Ambient air Birth weight Pooled estimates of decrease in birth weight ranged from 11.4 g There is a large evidence base which is
(2012) pollution and preterm (95% confidence interval 6.9–29.7) per 1 ppm CO to 28.1 g indicative of associations between CO,
birth (11.5–44.8) per 20 ppb NO2, and pooled odds ratios for low NO2, PM, and pregnancy outcome
birth weight ranged from 1.05 (0.99–1.12) per 10 μg/m3 PM2.5
to 1.10 (1.05–1.15) per 20 μg/m3 PM10 based on entire
pregnancy exposure
Forbes et Particulate Cardiovascular The combined estimates suggested that an increase of 1 μg/m3 in Evidence of the size of the association
al. (2009) matter disease concentration of particulate matter less than 10 microns in between particulate air pollution and the
diameter was associated with an increase of 2.9% (95% CI prevalence of cardiovascular disease but
0.6% to 6.5%) in prevalence of cardiovascular disease in men no evidence for an association with
and an increase of 1.6% (95% CI 2.1% to 5.5%) in women gaseous pollutants
Air Pollution and Health Outcomes in the Eastern Mediterranean Region. . .
1365
1366 Y. S. Khader
pulmonary inflammation, airway obstruction, and increased susceptibility to infec-

tion and sensitivity to allergens. Cardiovascular effects associated with short-term
exposure include changes in heart rate variability, blood pressure, vascular tone, and
blood coagulability, while long-term exposure might accelerate the progression of
atherosclerosis. Many of these effects are mediated through proinflammatory path-
ways and the generation of reactive oxygen species.
Sources of Air Pollutants
One of the main air pollutants is PM. Although the biological mechanism of action is
not yet fully understood, the association between PM and health is generally
regarded as causal (World Health Organization 2000), and a nonthreshold concen-
tration-response relationship with, for example, mortality and hospital admission has
been observed in several settings. Cohort studies conducted in the USA found
increase in total and cardiorespiratory mortality in populations of cities with higher
long-term mean PM10 concentrations (Dockery et al. 1993; Abbey et al. 1999).
Short-term studies have demonstrated effects occurring shortly after elevated con-
centration days: hospital admission (Anderson et al. 1998; Schwartz 1994), inci-
dence of new cases of bronchitis, and occurrence of respiratory symptoms and
asthma exacerbation (Braun-Fahrlander et al. 1997) for adults and children.
The main sources of air pollutants are the combustion of fossil fuels for trans-
portation, home heating and cooling, and industry. Particulate matter is classified
according to size. Size is important, as smaller particles with diameters of less than
2.5 μm (PM2.5) penetrate deeper into the lungs, reaching and affecting the alveoli,
while larger particles with diameters from 2.5 to 10 μm (PM10) are filtered out at
higher levels in the airways. The smallest particles, ultrafine particles with diameters
of less than 0.1 μm, can cross the alveolar membrane into the bloodstream. The
chemical properties of particles are complex, varying according to their sources, and
also play a part in the effects on health.
Air pollution sources and resulting health risks in the region can differ signifi-
cantly from those in developed countries, in part due to the use of diesel fuel and
high-sulfur content coal, as well as the widespread practice of biomass burning.
Before 2010, the Middle East had the highest pollutant levels in the world caused by
rapid economic growth. Currently, the pollution level in the Middle East varies
widely with some of the major cities in Iran, Saudi Arabia, and Bahrain being the
worst affected. Other than the frequent sandstorms which affect some parts of the
continent, industrial emissions and vehicle emissions have contributed to the poor air
quality (World Atlas).
This region faces considerable air quality challenges especially from natural
sources. The World Health Organization estimates that air pollution is responsible
for approximately 133,000 premature deaths annually, with natural sources of air
pollution, mainly windblown desert dust, being the most important cause of prema-
ture deaths estimated at more than 60,000 (World Health Organisation). Although
natural sources of air pollution, such as windblown dust, are the most important
sources of air pollutants in the region, several anthropogenic emission sources also
play a major role in driving air quality. Industrial emissions are the most important
anthropogenic source of air pollution which results from the high number of
petroleum refineries and fossil fuel powered power plants in the subregion (Middle
East and North Africa – UN Environment Document Repository).
Vehicular emissions are also an important driver of air pollution in the subregion.
The lack of vehicle emission standards and fuel quality are some of the reasons cited
for the high emission rate from this sector. Low investment in public transport also
contributes to emissions as the preferred mode of transport is usually private
vehicles. Emissions from fuels used to meet household energy demand contribute
to air pollutants emissions. Open burning of waste is another major source of air
pollution in the subregion, with at least 15 out of the 17 countries still practicing
open burning of agricultural and/or municipal waste. None of the countries in the
subregion have effectively managed to reduce open waste burning of both agricul-
tural and municipal waste.
The Arab region was among the worst performers in air quality, according to the
World Health Organization (EcoMENA). Recorded levels of air pollution often
exceeded 5 to 10 times the World Health Organization limits, and several Arab
cities are among the 20 most polluted cities in the world. Excessive emissions
include carbon monoxide that results from the transport sector, oxides of sulfur,
and oxides of nitrogen, leading to the formation of acid rain, ozone, and volatile
organic compounds.
One of the major emission sources in major cities of the Gulf Cooperation
Council region is the transportation. In an estimation from the emitted PM10, it is
around 63% (including road traffic, seaport, and airport emission). The second major
source is the emission of the industry with 15%, after that the non-road emissions
and power plants around 10%. Traffic is responsible almost for the half (43%) of the
transportation’s PM10 (Merétei et al. 2017).
The Effect of Air Pollution on Health in the EMR Countries: The

Strength of the Evidence
Although air pollution is recognized as an emerging public health threat in the EMR
countries, it is difficult to gather evidence on the effect of air pollution on health in
the EMR countries for several reasons:
• The impact of air pollution on health is not recognized as a priority by health

researchers, health professionals, and policy makers in the EMR countries. The
main reason for this may be that air pollution coexists with other important public
health problems, such as communicable diseases, vector-borne diseases, malnu-
trition, and poor sanitation, which are given higher priority in circumstances
where economic resources are limited.
• Although the burden of diseases from air pollution is expected to be high in the
EMR, a limited number of studies in selected areas in the EMR countries have
1368 Y. S. Khader
assessed the association between various air pollutants and health outcomes.
These studies do not sufficiently represent the different geographic locations
and population characteristics of the various countries. In addition, it is difficult
to compare the results of different studies in the region due to differences in study
designs and the potential covariates that were not controlled for.
• Limitations exist in all studies (even well-conducted ones), arising from inappro-
priate study designs, poor assessment of exposure and outcomes, questionable
sources of data, lack of standardized methods, poor adjustment of confounders,
limited geographical areas studied, small sample sizes, poor statistical modeling,
and not testing for possible interactions between exposures.
• Knowledge of air pollution and health is based on limited information primarily
due to weak technical capacity, particularly in the area of modeling air pollutants
and the lack of relevant data.
• There is a lack of international research collaborations and partnerships and not
much multidisciplinary research to address public health challenges and risks
associated with air pollution.
The Effect of Air Pollution on Health in the EMR: Knowledge Gaps
Tables 2, 3, 4, 5, 6, 7, 8, and 9 show the characteristics and main findings of

some studies (Al-Rawas et al. 2009; El-Ghitany and Abd El-Salam 2012; Abdul
Wahab and Mostafa 2007; Shiva et al. 2003; Al-Mousawi et al. 2004; Yeatts et al.
2012; Maziak et al. 2005; Fahim and El-Prince 2013; Awadalla et al. 2012;
Ghozikali et al. 2015; Hamadeh and Al-Roomi 2014; Waked et al. 2012;
Mohammad et al. 2014; Qorbani et al. 2014; Masjedi et al. 2003; Akhtar et al.
2007; Zeidan et al. 2014; Merghani and Saeed 2013; Hammad et al. 2010;
Mansourian et al. 2010; Houssaini et al. 2007; Abu Sham’a et al. 2010; Meo et al.
2013; Kobrossi et al. 2002; Thalib and Al-Taiar 2012; Al-Taiar and Thalib 2014;
Qasem et al. 2008; Li et al. 2010; Leski et al. 2011; Hasnain et al. 2012; Gholampour
et al. 2014; Luqman et al. 2014; Elshabrawy et al. 2014; Mahboub et al. 2014; Sasco
et al. 2002a; Aoun et al. 2013a; Chen et al. 2015; Simoni et al. 2015; Abusalah et al.
2012; Araban et al. 2012; Janghorbani and Piraei 2010; Khader et al. 2011; Moridi et
al. 2014; Siddiqui et al. 2008; Wadi and Al-Sharbatti 2011; Wahabi et al. 2013a;
Wahabi et al. 2013b; Edraki and Rambod 2011; Wheatley and Sadhra 2010; Al-
Ahmadi and Al-Zahrani 2013; Aoun et al. 2013b; Zheng et al. 2012; Sasco et al.
2002b; Feng et al. 2009; Bener et al. 2009; Dehghani et al. 2014; Fatmi et al. 2014;
Hosseinpoor et al. 2005; Khanjani and Bahrampour 2013; Nabavi et al. 2012;
Poursafa et al. 2014; Qorbani et al. 2012; Sughis et al. 2012; Nazari et al. 2010;
Dianat and Nazari 2011; Sheikhazadi et al. 2010; Emami-Razavi et al. 2014; Al
Kaabi et al. 2011; Battah et al. 2009; El Sayed and Tamim 2014; El-Hodhod et al.
2011; Hosseinpanah et al. 2010; Kelishadi et al. 2014; Merghani et al. 2012; Abdel
Rasoul et al. 2012; Heydarpour et al. 2014; Talaat et al. 2014; Nahidi et al. 2013;
Vigeh et al. 2011; Abou-Khadra 2013; Kheirandish-Gozal et al. 2014) in the EMR
that have examined the impact of air pollution on different health outcomes
55
Table 2 The characteristics and main findings of studies in the EMR that have examined the impact of air pollution on respiratory health outcomes
Year of Country/ Study
Study outcome Authors publication region Study design Population/sample years Exposure
Asthma in children Al-Rawas et 2009 Oman A retrospective cohort 10 years old – Arabian incense
al. (2009) study schoolchildren (bakhour)
Arabian incense burning is a common trigger of wheezing among asthmatic children in Oman. However, it is not associated with the prevalence asthma.
Bakhour use more than twice a week was three times more likely to affect child breathing compared to no bakhour use (adjusted odds ratio (OR) 3.01; 95%
confidence interval (CI) 2.23–4.08), and this effect was 2.55 times higher in asthmatics (adjusted OR 2.55; 95% CI 1.97–3.31) compared to non-asthmatics
Childhood asthma El-Ghitany 2012 Egypt Interventional study A total of 160 Jan Physical and chemical
improvement and Abd El- asthmatic children 2010– environmental control
Salam aged 5–12 years Jan measures for house
(2012) 2011 dust mites
The group for which physical control measures were used showed significant improvement in all outcome measures, including the control of asthma symptoms
in asthmatic children sensitized to house dust mites allergen
Asthma Abdul 2007 Qatar Case-control study of Asthmatic and healthy Sept– Incense
Wahab and asthmatic (cases) and children Nov
Mostafa non-asthmatic 2005
(2007) children (control)
Exposure to Arabian incense was more common among asthmatic children than non-asthmatic children
Respiratory Shiva et al. 2003 Tehran, Clinic-based survey 6–60 months children Jan– Secondhand smoke
complaints; asthma (2003) Iran Dec
2001
Indoor second secondhand smoking was significantly associated with common respiratory illnesses among children. Of the children whose fathers smoked
freely in the same room, 7.1% had a history of hospitalization owing to a respiratory illness as opposed to 1.7% in children not living with a smoker (odds
ratio ¼ 4.4; 95% CI ¼ 1.4–14.2). There was a significant difference in incidence of the illnesses between children whose fathers smoked freely in the same
room and children not living with a smoker a [upper respiratory tract infection (OR 4.5; 95% CI 1.5–12.7; p ¼ 0.004), otitis media (OR 1.9; 95% CI 1.02–3.7;
p ¼ 0.04), asthma (OR 4.2; 95% CI 1.5–10.7; p ¼ 0.005)]
Sensitization and Al-Mousawi 2004 Kuwait Case-control study Asthmatic children Indoor allergens
asthma et al. (2004) (9–16 years) and
healthy controls
1369
(continued)
1370
Table 2 (continued)
Pet ownership markedly increased the risk of sensitization to pets. Despite low allergen exposure, the pattern of childhood asthma in Kuwait follows that
described in Western communities (strong association with sensitization). Sensitization to Alternaria was the strongest independent associate of the asthma
Asthma, respiratory, Yeatts et al. 2012 United A population-based 628 households Oct Indoor sources of
and neurologic (2012) Arab cross-sectional study including 1590 family 2009– combustion (tobacco
symptoms Emirates members June smoking, gas stoves,
(UAE) 2010 incense); sulfur
dioxide (SO2),
nitrogen dioxide
(NO2), hydrogen
sulfide (H2S),
formaldehyde
(HCHO), carbon
monoxide (CO),
particulate matter
(PM2.5), PM2.5–10,
and PM10
There are potential health risks from pollutants commonly found in indoor environments in the UAE. Participants in households with quantified SO2, NO2, and
H2S (i.e., with measured concentrations above the limit of quantification) were twice as likely to report doctor-diagnosed asthma. Participants in homes with
quantified SO2 were more likely to report wheezing symptoms [ever wheezing, prevalence odds ratio [POR] 1.79 [95% confidence interval (CI) 1.05, 3.05];
speech-limiting wheeze, POR 3.53 (95% CI: 1.06, 11.74)]. NO2 and H2S were similarly associated with wheezing symptoms. Quantified HCHO was
associated with neurologic symptoms (difficulty concentrating POR 1.47; 95% CI: 1.02, 2.13). Daily burning incense was associated with increased headaches
(POR 1.87; 95% CI: 1.09, 3.21), difficulty concentrating (POR 3.08; 95% CI: 1.70, 5.58), and forgetfulness (POR 2.68; 95% CI: 1.47, 4.89)
Self-reported Maziak et al. 2005 Syria Population-based Adults aged 18– 2004 Environmental
symptoms/diagnosis (2005) (Aleppo) survey 65 years in Aleppo tobacco smoke (ETS)
of asthma, bronchitis,
hay fever, and
spirometry assessment
Y. S. Khader
55
There was a significant dose-response pattern in the relationship of ETS score with symptoms of asthma, hay fever, and bronchitis, but not with diagnoses of
these outcomes. The magnitude of the effect was in the range of twofold increases in the frequency of symptoms reported in the high exposure group compared
to the low exposure group. Severity of specific respiratory problems, as indicated by frequency of symptoms and healthcare utilization for respiratory
problems, was not associated with ETS exposure. Exposure to ETS was associated with impaired lung function, indicative of airflow limitation, among women
only
Pulmonary function, Fahim and 2012 Egypt A comparative study 21 women exposed to 2011 Passive smoking
bronchial hyper- El-Prince ETS compared to 34
responsiveness (2013) nonexposed women
A higher prevalence of dyspnea and wheezing was found among exposed compared to nonexposed. Pulmonary measurements showed significantly lower
forced vital capacity (FVC), forced expiratory volume (FEV1)/FVC, and FEF75 values among exposed compared to nonexposed and a significantly higher
prevalence of borderline bronchial hyper-responsiveness
Idiopathic pulmonary Awadalla et 2012 Egypt Multicenter hospital- 201 patients with Jan Occupational agents
fibrosis (IPF) al. (2012) (Cairo, based case-control confirmed IPF (cases) 2010– and environmental
Tanta, and study and 205 age-, sex- and Jan exposures
Mansoura) residence-matched 2011
controls
Farming, raising birds, and wood working are important risk factors for the development of IPF. Compared with the controls, the risk of IPF in male workers
was observed to increase significantly in chemical and petrochemical industries and carpentry and wood working (OR ¼ 2.56, 95% CI: 1.02–7.01) and with
occupational exposures to wood dust and wood preservatives. Among female workers, a significant increase was observed in farming (OR ¼ 3.34, 95% CI:
1.17–10.12), raising birds, and occupational exposures to animal feeds, products, and dusts and pesticides. The environmental exposures to birds and cats were
significantly associated with elevated risk of IPF development in both sexes
Chronic obstructive Ghozikali et 2014 Iran, Cross-sectional study 2009 Ozone (O3), nitric
pulmonary diseases al. (2015) Tabriz dioxide (NO2), and
(COPD) sulfur dioxide (SO2)
Significant positive associations between the levels of all air pollutants and hospital admissions for COPD. For every 10 μg/m3 increase in O3, NO2, and SO2
concentrations, the risk of COPD increased to about 0.58%, 0.38%, and 0.44%, respectively. About 3% (95% CI 1.2–4.8%) of COPD were attributed to O3
concentrations over 10 μg/m3. Also, 0.9% (95% CI 0.1–2.2%) and 0.4% (95% CI 0–1.1%) of COPD were attributed to NO2 and SO2 concentrations over
10 μg/m3, respectively
Respiratory, allergic, Hamadeh 2014 Bahrain A retrospective cross- Medical records of 2007 SO2
dermatological, and and Al- sectional study people who attended
the health centers
1371
(continued)
Table 2 (continued)
1372

gastrointestinal Roomi
diseases (2014)
Visit rates for all four diseases had peaks, in spring and in autumn, with the lowest rates in the summer season when the average temperatures were highest and
average humidity was lower. Respiratory-related visits were highest when the air concentrations of SO2 were highest
Chronic obstructive Waked et al. 2012 Lebanon A cross-sectional Lebanese residents Oct Secondhand smoking;
pulmonary disease (2012) study aged 40 years and 2009– and gas, wood, and
(COPD) and chronic above Sept diesel fuel products
bronchitis 2010
Exposure to fuel (gas, wood, diesel) products and secondhand smoking was associated with increased risk of COPD and chronic bronchitis. Individuals
heating their houses by gas or wood had a considerable higher prevalence of chronic bronchitis (18.1% and 17.2%), compared to those heating houses
electrically (8.4%). Heating home by gas (OR ¼ 1.90) and higher number of smokers at work (OR ¼ 1.11 for every additional smoker) were associated with
increased odds of chronic bronchitis
Chronic obstructive Mohammad 2013 Syria Extraction of data on 788 randomly selected 2009 Environmental
pulmonary disease et al. (2014) from the Global females seen during tobacco smoke (ETS)
(COPD) Alliance Against 1 week in the fiscal
Chronic Respiratory year 2009–2010 in 22
Diseases survey primary care centers
in six different regions
of Syria
EST was associated with COPD in women. The adjusted OR for COPD in females exposed to ETS was 3.2 (95% CI 1.1–9.2). The adjusted OR was 2.1 (95%
CI 1.4–3.3) for FEV1 percent predicted <80% [considered abnormal] and 1.8 (95% CI 1.0–3.3) for FEV1/FVC < 70% after bronchodilators [significant
airway obstruction]
Anthracosis Qorbani et 2014 Iran Hospital-based case 83 anthracotic cases Sept Biomass fuel (wood,
al. (2014) control and 155 controls 2009– peat, animal dung and
Dec agricultural crop
2010 residues) smoke
Indoor smoke exposure due to the traditional baking was associated with anthracosis (OR, 4.30; 95% CI, 1.31 to 14.10). Women were significantly more
susceptible to anthracosis than men are when exposed to smoke exposure
Y. S. Khader
55
Asthma and COPD Masjedi et al. 2003 Iran A cross-sectional Attendances of the Sept CO, SO2, NO2, O3,
(2003) study emergency 1997– THC, PM10
departments for acute Feb
respiratory conditions 1998
Although a variation in the daily mean levels of pollutants was noticeable, they remained within the range of the World Health Organization (WHO) standards
on the majority of days. A significant association, although weak, has been demonstrated between outdoor NO2 and SO2 and asthma admissions
Chronic bronchitis Akhtar et al. 2007 Three Cross-sectional study 1426 female from Sept Biomass fuel cooking
(2007) villages in “test villages” and 2003–
rural 1131 female from June
Peshawar, “control villages” 2004
Pakistan
Biomass fuel exposure is strongly associated with chronic bronchitis in women who are involved in cooking in rural Peshawar. A strong association was found
between bronchitis and the use of wood (OR, 2.38; 95% CI, 2.12 to 3.01), dung cake (OR, 2.01; 95% CI, 1.72 to 2.42), rice straws (OR, 3.32; 95% CI, 1.11 to
9.88), and Kai grass (OR, 1.96; 95% CI, 1.75 to 2.45)
CO and respiratory Zeidan et al. 2014 Lebanon A cross-sectional Young workers in Passive smoking
symptoms in young (2014) study restaurants serving (waterpipe and
adults waterpipes. cigarette smoking)
University students
who sit frequently in
the university
cafeteria where
cigarette smoking is
allowed and
university students
spending time in
places where smoking
is not allowed
Young non-smoker subjects demonstrated more chronic cough and elevated carbon monoxide levels when exposed to SHS, while the effect of waterpipe was
even more evident. Exposure to cigarette smoke in university (adjusted odds ratio (ORa) ¼ 6.06) and occupational exposure to waterpipe smoke (ORa ¼ 7.08)
were predictors of chronic cough. Living near a heavy traffic road (ORa ¼ 9.49) or near a local power generator (ORa ¼ 7.54) appeared responsible for chronic
sputum production. Moreover, predictors of chronic allergies were being male (ORa ¼ 7.81), living near a local power generator (ORa ¼ 5.52), and having a
family history of chronic respiratory diseases (ORa ¼ 17.01)
1373
(continued)
Table 2 (continued)
1374

Lung function Merghani 2013 Sudan A cross-sectional Male school children – Secondhand smoke
and Saeed study aged 9–14 years
(2013)
Regular secondhand smoke exposure at home causes significant reduction in FVC and FEV1 by about 7–8% in school pupils in Khartoum
Respiratory Hammad et 2010 Pakistan A cross-sectional Married women in a Jan– Passive smoking
symptoms and clinical al. (2010) study rural community in July
correlates Islamabad 2009
Passive smoking was associated with respiratory symptoms among married women in this study. The two major respiratory symptoms that were found to be
associated with passive smoking were sinusitis (adjusted OR (95% CI) 2.2 (1.3–3.5)) and cough (adjusted OR (95% CI) 2.4 (1.2–4.8)). Wood used as fuel for
cooking purposes also contributed to one of the symptoms such as headache ( p ¼ 0.007)
Hospitalization for Mansourian 2010 Iran Hospital admission 120 pediatric patients Mar PM10, NO2, SO2, and
respiratory diseases et al. (2010) data for respiratory 2005– CO
Mar
2006
PM10 and SO2 concentrations had statistically significant positive association with number of respiratory admissions of children
Acute respiratory and Meo et al. 2013 Saudi Descriptive study Volunteers from Mar Sandstorm
general health (2013) Arabia schools, colleges, and 2011–
complaints university hospitals, June
who had single 2012
outside exposure to
sandstorm
Exposure to sandstorm causes cough, runny nose, wheeze, acute asthmatic attack, eye irritation/redness, headache, body ache, sleep, and psychological
disturbances
Respiratory Kobrossi 2002 Lebanon Households survey Children (5–15 years Nov Cement industry
complaints et al. (Abu old) in Northern 1999– emissions and
Sham’a et al. Lebanon Feb fertilizer factory
2010) 2000 emissions
Y. S. Khader
55
Children living close to cement and fertilization industries are at higher risk of developing respiratory problems such as cough, phlegm, congestion, chest cold,
and wheezing. Living within 0–3 km of industries, as compared to living farther away (4–7 km), was associated with a statistically significant increase in the
risk for cough with colds (adjusted odds ratio (OR) ¼ 3.40), phlegm with colds (OR ¼ 2.14), yearly episodes of cough and phlegm (OR ¼ 4.63), yearly chest
colds (OR ¼ 4.12), and wheezing (OR ¼ 2.23). When compared to living in the non-industrialized district, children living within 0–3 km of industries showed
a significantly higher risk for yearly chest colds (OR ¼ 2.30). A higher risk of respiratory problems was reported among children living close to cement than
fertilizer industries
Respiratory diseases, Houssaini 2007 Morocco A 4-year cross- Schoolchildren 2000– SO2
asthma, and infectious et al. (Meo sectional survey 2004
diseases et al. 2013)
Respiratory diseases, asthma, and infectious diseases were significantly more prevalent in more polluted areas. Strongly polluted zone (OR 3.62, 95% CI 1.71–
7.81) was recognized as high-risk factor for asthma
Lung function and Abu Sham’a 2010 Palestine Cross-sectional study Farmers aged 22– – Pesticide and dust
respiratory symptoms et al. 77 years
(Kobrossi
et al. 2002)
No clear association between exposure to pesticides or dust and lung function or between such exposures and respiratory symptoms
Asthma and all Thalib and 2012 Kuwait A population-based Daily emergency – Dust storm
respiratory diseases Al-Taiar retrospective time- asthma admissions
(2012) series study and admissions due to
respiratory causes in
public hospitals in
Kuwait
Dust storms have a significant impact on respiratory and asthma admissions. During the 5-year study period, 569 (33.6%) days had dust storm events, and they
were significantly associated with an increased risk of same-day asthma and respiratory admission (adjusted relative risk of 1.07 (95% CI: 1.02–1.12) and 1.06
(95% CI: 1.04–1.08)), respectively, and particularly among children
Mortality due to Al-Taiar and 2014 Kuwait A population-based Dust storms
respiratory, Thalib retrospective

cardiovascular, and all (2014) ecological time-series
causes study
There was no significant association between dust storm events and same-day respiratory mortality (RR ¼ 0.96; 95% CI 0.88–1.04), cardiovascular mortality
(RR ¼ 0.98; 95% CI 0.96–1.012), or all-cause mortality (RR ¼ 0.99; 95% CI 0.97–1.00)
1375
(continued)
1376
Table 2 (continued)
Asthma Qasem et al. 2008 Kuwait Ecological study Jan Aerial fungal spores
(2008) 2003–
Dec
2003
Meteorological factors, aeroallergen concentrations, and asthma-related visits are interrelated
Burden of disease Li et al. 2010 UAE Spatial-statistical 2007 Particulate matter
(premature deaths) (2010) methods (PM) and ozone in
ambient air
Approximately 545 (95% CI: 132–1224) excess deaths in the UAE in the year 2007 are attributable to PM in ambient air. These excess deaths represent
approximately 7% (95% CI: 2–17%) of the total deaths that year. A total of 62 premature deaths (95% CI: 17–127) were attributed to ground-level O3 for the
year 2007
Human pathogens in Leski et al. 2011 Iraq and Dust
dusts (2011) Kuwait
The results indicated the presence of potential human pathogens, including Mycobacterium, Brucella, Coxiella burnetii, Clostridium perfringens, and Bacillus.
The presence of Coxiella burnetii, a highly infectious potential biowarfare agent, was confirmed and detected in additional samples by use of a more sensitive
technique, indicating a high prevalence of this organism in the analyzed samples
Level of IgE in blood. Hasnain et 2012 Pakistan 2010 Airborne fungal flora
al. (2012)
Cladosporium spp. (44.8%), Alternaria spp. (15.5%), Periconia spp. (6.1%), Curvularia spp. (2.1%), Stemphylium spp. (1.3%), and Aspergillus/Penicillium
type (1%) were major components constituting more than 70% of the airborne fungal flora. Cladosporium, Curvularia, and Stemphylium displayed a clear
seasonal trend, while there were no clear seasonal trends for other fungal spore types
Mortality Gholampour 2014 Iran Ecological study Tabriz city Sept PM
et al. (2014) 2012–
June
2013
Y. S. Khader
55
Total mortalities associated with PM10 and PM2.5 concentrations were 327, 363, and 360, respectively
Lung cancer Luqman et 2014 Pakistan Case-control study 400 cases and 800 – Pesticide exposure
al. (2014) controls and exposure to diesel
exhaust
Strong associations were observed for pesticide exposure (OR ¼ 5.1, 95%CI ¼ 3.1–8.3) and exposure to diesel exhaust (OR ¼ 3.1, 95% CI ¼ 2.1–4.5). Other
associated factors observed were welding fumes (OR ¼ 2.5, 95% CI ¼ 1.0–6.5), wood dust (OR ¼ 1.9, 95% CI ¼ 1.2–3.1), and asbestos exposure (OR ¼ 1.5,
95% CI ¼ 0.5–4.4). Strongest dose-response relationships were observed for pesticide exposure (R2 ¼ 50.9) and exposure to diesel exhaust (R2 ¼ 51.8).
Pesticide exposure and diesel exhaust are main lung cancer determinants in Pakistan
Allergic diseases Elshabrawy 2014 Saudi A cross-sectional – Agricultural
et al. (2014) Arabia survey pollutants
The highly exposed subjects to pollution are at high risk of developing an allergy
Allergic rhinitis Mahboub et 2014 UAE A cross-sectional, Seven emirates – (Dust, grass/pollens)
al. (2014) population-based and proximity to
observational study animals
Thirty-seven (44%) patients were poly-sensitized. Symptoms were aggravated by dust (59%), grass/pollens (44%), and proximity to animals (21%). Winter
was the peak season (37%), followed by spring (30%), autumn (18%), and summer (15%). Grass/pollen allergies were clustered in the winter, spring, and
summer ( p 0.001). Dust was nonseasonal ( p 0.121), and animal allergy was worse in the winter ( p ¼ 0.024) and spring ( p ¼ 0.044). Spring symptoms
were less common in people living in the inner city ( p ¼ 0.003)
Lung cancer Sasco et al. 2002 Morocco Hospital-based case- 118 incident lung Jan Secondhand smoking,
(2002a) control study cancer cases and 235 1996– domestic exposures
controls Jan (cooking practices,
1998 use of coal and
candles, ventilation)
(continued)
1377
1378
Table 2 (continued)
Exposure to passive smoking (OR ¼ 1.36 (95% CI: 0.71–2.62)), cooking/heating with coal (OR ¼ 0.74 (95% CI: 0.17–3.14)), lighting with candles
(OR ¼ 1.44 (95% CI: 0.42–5.01)), and poor ventilation of kitchen (OR ¼ 1.22 (95% CI: 0.57–2.58)) were not significant contributors to lung cancer in the
multivariate analysis
Lung cancer Aoun et al. 2013 Lebanon A pilot case-control Patients in a tertiary Smoking and air
(2013a) study healthcare center pollution
Outdoor and indoor pollution factors were potential risk factors of lung cancer. Using fuel for heating (ORa ¼ 9.12) for females and living near an electricity
generator (ORa ¼ 13.26) are the main risk factors for lung cancer
Acute respiratory Al-Wahaibi 2015 Liwa and Retrospective cross- 27,688 population Jan Industrial zone (SO2,
diseases and asthma and Ariana Sohar sectional study aged 20 2006– NOx, VOC,
(Chen et al. provinces; Jan aluminum
2015) Oman 2011 compounds, fluoride
compounds, heavy
metals)
Living within 10 km from the industrial zone was associated with a greater risk ratio for acute respiratory diseases (RR, 2.02; 95% CI, 1.88–2.17) and asthma
(RR, 3.61; 95% CI, 2.96–4.41), compared to a control exposure zone. Greater exposure effects were observed among ages 50 years and lower SES groups
Respiratory Amarloeil et 2015 Ilam, Iran Survey Population of 172,000 Aug– Dust storms
spirometry al. (Simoni et people. Sample of 250 Sept
al. 2015) participants who were 2013
18 years old
Mean values of respiratory capacities measured in all participants were less than predicted mean values by the European Community for Coal and Steel
Reference (ECCS). 21.6% of the population suffered from obstructive lesions. This value among males (24.1%) was more than females (19.6%)
Y. S. Khader
55
Table 3 The characteristics and main findings of studies in the EMR that have examined the impact of air pollution on adverse pregnancy outcomes
Country/
Study outcome Authors Year region Study design Population/sample Study year Exposure
Low birth Abusalah et 2012 Gaza strip Comparative study Residents of Gaza Strip at May–June Secondhand smoking (SHS),
weight (LBW), al. (2012) least 1 year before delivery 2007 and July– wood fuel smoke
mean birth who delivered a live Aug 2007
weight (MBW) singleton infant
Prenatal exposure to SHS and wood fuel smoke is independently associated with LBW. Prenatal exposure to SHS indoors is related to a reduction in MBW of infants by
237 g (95% CI: 415, 58) for pregnant women exposed to 1–20 cigarettes per day and by 391 g (95% CI: 642, 140) for exposure to more than 20 cigarettes per
day. Exposure to wood fuel smoke exhibits a reduction of infants’ adjusted mean birth weight by 186 g (95% CI: 354, 19)
LBW Araban et al. 2012 Tehran, Cohort study on 225 Births of women aged 18– June–Oct 2007 Ozone (O3), nitric dioxide
(2012) Iran births in 6 teaching 35 years (singleton live (NO2), sulfur dioxide (SO2),
hospitals term births) carbon monoxide (CO),
particulate matter (PM10)
CO exposure was a significant risk factor for LBW during the whole pregnancy (OR, 2.08; 95% CI, 1.7, 4.6) and in the second trimester (OR, 3.96; 95% CI, 1.83, 12.5).
None of the other pollutants was significantly associated with LBW
Preterm birth Janghorbani 2013 Isfahan, Cohort study on 4758 Births of women aged 18– Jan 2010–June CO, O3, NO2, SO2, PM10
(PTB), LBW and Piraei Iran births in a main 35 years carrying a 2012
(2010) hospital singleton fetus
The pollutant standard index (PSI) during the entire pregnancy was significantly associated with PTB (OR, 1.26; 95% CI, 1.20, 1.33). No association was found between
PSI and PTB/LBW in exposure during the entire pregnancy period; the first, second, and third trimesters; last 4, 6, and 8 weeks; 1 week before birth; and at birth. There
was no indication for an adverse effect of air pollution on LBW from these analyses
PTB, LBW, Khader et al. 2011 Northern A cross-sectional Women attended for Apr–Sept 2007 SHS
MBW (2011) Jordan study on 8490 births delivery
in 4 main
governmental
hospitals
Exposure to SHS during pregnancy was significantly associated with increased odds of LBW (OR, 1.56; 95% CI, 1.31, 1.89) and PTB (OR, 1.61; 95% CI, 1.30, 1.99). The
MBW (SD) in Kg for children of exposed women (3.06 (0.56)) was significantly lower than that for children of nonexposed women (3.2 (0.53))
Spontaneous Moridi et al. 2014 Tehran, Retrospective case- Women with singleton June 2010–Feb CO, O3, NO2, SO2, PM10
abortion (2014) Iran control study pregnancy 2011
(continued)
1379
1380
Table 3 (continued)
Country/
Study outcome Authors Year region Study design Population/sample Study year Exposure
Among all the five pollutants, exposure to ambient CO throughout the pregnancy showed the strongest effect on spontaneous abortion (OR, 1.95; 95% CI, 1.49–2.54 for
each 1 ppm increase in CO levels). Exposure to NO2, PM10, and O3 showed weak, but statistically significant, effect on spontaneous abortion (OR, 1.00; 95% CI, 1.00–
1.01 for each 1 μg/m3 increase in PM10; OR, 1.03; 95% CI, 1.01–1.05 for each 1 ppb increase in NO2; and OR, 1.09; 95% CI, 1.05–1.13 for each 1 ppb increase in O3).
No association was found between SO2 and spontaneous abortion
LBW, MBW Siddiqui et 2008 Rehri Cohort study on 634 Women delivered a 2004–2005 Wood fuel smoke
anthropometrics al. (2008) Goth, women singleton live birth
Pakistan
Infants born to wood users averaged 82 g lighter than infants born to natural gas users. The adjusted OR for LBW associated with wood use was 1.86 (95% CI: 1.11,
3.14). No significant association between the exposure to wood fuel smoke and infant’s anthropometrics
MBW Wadi and 2011 Baghdad, Retrospective cohort Births of healthy mothers Feb–Aug 2004 SHS
Al-Sharbatti Iraq study who had a singleton
(2011) pregnancy
The MBW of exposed newborns was significantly lower by 198 g than nonexposed newborns. In exposed newborns, a significant inverse relationship was noticed
between MBW and the number of cigarettes smoked by household members (r ¼ 0.27)
LBW, MBW, Wahabi et al. 2013 Riyadh, Retrospective cohort Women with singleton Oct 2011– SHS and maternal body mass
anthropometrics (2013a) Saudi study on 3231 women pregnancy Sept 2012 index (BMI)
Arabia in a teaching hospital
Exposure to SHS was associated with reduced MBW and anthropometric measurements of the newborn and increased rate of LBW infants, irrespective of maternal BMI
LBW, MBW, Wahabi et al. 2013 Riyadh, Retrospective cohort Women with singleton July 2011–June SHS
anthropometrics (2013b) Saudi study on 3426 women pregnancy 2012
Arabia in a teaching hospital
After adjustment for confounding factors, the MBW of infants of mothers exposed to SHS remained significantly lower by 35 g (95% CI: 2–68 g) compared to infants of
unexposed mothers. Crown-heel length of infants born for women who were exposed to SHS were significantly shorter by 0.261 cm (95% CI: 0.058–0.464 cm) than
infants of nonexposed women. The difference in mean head circumference and the frequency of LBW between infants of exposed mothers and unexposed mothers did
not reach statistical significance
Y. S. Khader
55
Table 4 The characteristics and main findings of studies in the EMR that have examined the impact of air pollution on cancer
Country/ Study
Study outcome Authors Year region Study design Population/sample year Exposure
Childhood cancer Edraki 2011 Iran A hospital-based case- 98 children newly Dec Parental smoking
and control study diagnosed with cancer 2007–
Rambod before the age of 14 years Nov
(2011) and 100 age- and sex- 2008
matched controls
Maternal smoking (prior to and during pregnancy and after the birth) and the numbers of maternal cigarettes smoked were not associated with an increased risk
of childhood cancer. However, maternal exposure to passive smoke during pregnancy increased the risk of cancer childhood (OR ¼ 3.6, 95% CI: 1.3–5.0).
Father’s smoking prior to (OR ¼ 1.8, 95% CI: 1.4–6.0) and during pregnancy (OR ¼ 3.0, 95% CI 1.4–5.0) was significantly associated with an increased risk
of cancer, and this increased with heavy smoking. There were no relationship between an enhanced risk of childhood cancer and father’s smoking after the
child’s birth
Carcinogenic risk Wheatley 2010 United Modeling risk assessment Clinical waste
and Arab incineration (CWI) and
Sadhra Emirates road traffic emissions
(2010) (UAE)
Emissions associated with operation of the CWI present a negligible contribution to overall cancer risk from polycyclic aromatic hydrocarbons (PAHs) and
other carcinogens
Cancer incidence Al- 2013 Saudi National cancer registry Cancer registry; 45,532 Jan Atmospheric NO2
Ahmadi Arabia data were correlated cancer cases 1998
and Al- nitrogen dioxide (NO2) to Dec
Zahrani atmospheric level 2004
(2013)
High coefficients of determination were observed between NO2 concentration and lung and breast cancer incidences, followed by prostate, bladder, cervical,
and ovarian cancers

Lung cancer Aoun et 2013 Lebanon A pilot case-control study Patients were recruited in a Smoking and air pollution
al. tertiary healthcare center
(2013b)
(continued)
1381
1382
Table 4 (continued)
Country/ Study
Outdoor and indoor pollution factors were potential risk factors of lung cancer. Using fuel for heating (ORa ¼ 9.12) for females and living near an electricity
generator (ORa ¼ 13.26) are the main risk factors for lung cancer
Urothelial Zheng et 2012 Egypt A case-control study Bladder cancer cases and July Environmental tobacco
carcinoma (UC) al. (2012) non-cancer controls 2006– smoke (ETS)
and squamous cell Aug
carcinoma (SCC) 2010
Exposure to environmental tobacco smoke increases the risk of both SCC and UC. Among male, ETS exposure at home and outside the home was significantly
associated with UC (OR ¼ 2.5, 95% CI ¼ 1.2 to 5.1), but not with SCC (OR ¼ 0.9, 95% CI ¼ 0.3 to 2.5). Among women, ETS exposure both at home and
outside the home was not significantly associated with UC (OR ¼ 1.8, 95% CI ¼ 0.8 to 3.8) and borderline significantly associated with SCC (OR ¼ 2.1, 95%
CI ¼ 1.0 to 4.4)
Lung cancer Sasco et 2002 Morocco Hospital-based case- 118 lung cancer cases and Jan Secondhand smoking,
al. control study 235 controls 1996– domestic exposures
(2002b) Jan (cooking practices, use of
1998 coal and candles,
ventilation)
Exposure to passive smoking (OR ¼ 1.36 (95% CI: 0.71–2.62)), cooking/heating with coal (OR ¼ 0.74 (95% CI: 0.17–3.14)), lighting with candles
(OR ¼ 1.44 (95% CI: 0.42–5.01)), and poor ventilation of kitchen (OR ¼ 1.22 (95% CI: 0.57–2.58)) were not significant contributors to lung cancer in the
multivariate analysis
Nasopharyngeal Feng et al. 2009 Algeria, Multicenter case control 2009 Cannabis, tobacco, and
carcinoma (NPC) (2009) Morocco, domestic fumes
and
Tunisia
Cigarette smoking and snuff (tobacco powder with additives) intake were significantly associated with differentiated NPC but not with undifferentiated
carcinoma (UCNT), which is the major histological type of NPC in these populations. Domestic cooking fumes intake by using kanoun (compact charcoal
oven) during childhood increased NPC risk, whereas exposure during adulthood had less effect. Neither alcohol nor shisha (waterpipe) was associated with
risk
Y. S. Khader
55
Table 5 The characteristics and main findings of studies in the EMR that have examined the impact of air pollution on cardiovascular diseases
Country/
Study outcome Authors Year region Study design Population Study year Exposure
Cardiovascular Bener et al. 2009 Qatar Retrospective time-series All hospital ischemic 2002–2006 Mean daily concentration
disease (2009) study heart disease and of ozone (O3), nitric
cardiovascular illness dioxide (NO2), sulfur
data dioxide (SO2), carbon
monoxide (CO),
particulate matter (PM10)
Increasing air pollutant levels and patients admitted for cardiovascular diseases followed the same trend
Cardiopulmonary Dehghani et 2014 Shiraz, Iran Cross-sectional study Deaths from Mar 2011– Pollutant standards index
mortality al. (2014) cardiovascular disease Jan 2012 (PSI) for SO2, CO, PM10,
registered in a local and NO2
health department
There was no significant correlation between deaths due to cardiovascular diseases and SO2, CO, PM10, and NO2 emissions
Acute coronary Fatmi et al. 2014 Mirpurkhas, A matched case-control 1. Women Aug 2010– Solid fuel used for cooking
syndromes (2014) Pakistan study on 73 matched pairs. 2. Living within the Feb 2012
Cases: acute coronary catchment area of a
syndromes. Controls: public sector tertiary
patients with no acute care hospital
coronary syndromes
Current use of solid fuel was strongly associated with acute coronary syndromes (OR, 4.8; 95% CI, 1.5, 14.8), and risk was lowest in women who had last used solid fuel
>15 years earlier. The population attributable fraction for acute coronary syndromes in relation to current use of solid fuel was 49.0% (95% CI: 41.3%, 57.4%)
Angina pectoris Hosseinpoor 2005 Tehran, Iran Retrospective time-series All hospital admissions Mar 1996– Mean daily concentration
et al. (2005) study from angina pectoris Mar 2001 of SO2, NO2, CO, O3, and
PM10
CO was the only air pollutant that had a significant association with 1-day lag angina hospital admissions, so that a rise in its level of 1 mg/m3 was associated with an
increment of 0.9% in the expected number of hospital admissions due to angina pectoris (RR for 1 mg/m3, 1.00934; 95% CI, 1.00359, 1.01512)
Cardiovascular Khanjani and 2013 Kerman, Ecological time-series Deaths from 2004–2008 Mean daily concentration
mortality Bahrampour Iran study for a period of 4 years cardiovascular disease of SO2, NO, NO2, NOX,
(2013) registered in a local CO, O3, and PM10
health department
1383
(continued)
1384
Table 5 (continued)
Country/
Study outcome Authors Year region Study design Population Study year Exposure
No significant correlation was found between cardiovascular disease and the air pollutants
Cerebral stroke Nabavi et al. 2012 Tehran, Iran Ecological time-series All hospital admissions 2004 An air quality index (AQI)
(2012) study for a period of 1 year from cerebral stroke for SO2, CO, PM10, and
in 8 hospitals NOX
Air pollution had a direct association with the incidence of stroke, and this association differed among different subgroups of patients
Blood pressure Poursafa et 2014 Iran National cross-sectional Students aged 10– 2009–2010 AQI
and al. (2014) survey 18 years, from 27
cardiometabolic provinces
risk factors
Exposure to air pollutants in the pediatric age has an adverse cardiometabolic risk. There is a significant positive correlation between AQI and cardiometabolic risk
factors including systolic blood pressure, fasting blood glucose, total cholesterol, LDL cholesterol, and triglycerides, as well as significant negative correlations with
HDL cholesterol
Acute coronary Qorbani et 2012 Tehran, Iran Case-crossover study on Patients with a first Apr–Sept Mean daily concentration
syndromes al. (2012) 250 acute coronary episode of acute 2007 of CO and PM10
syndrome patients coronary syndrome
admitted to a local
health center
The risk of acute coronary syndrome was significantly associated with elevated concentrations of CO the day before the event (OR, 1.18; 95% CI, 1.03, 1.35) but not
significantly with PM10. Women were more susceptible than men to CO levels
Blood pressure Sughis et al. 2012 Lahore, Cross-sectional study on Children between 8 and Jan–Apr Mean daily concentration
(2012) Pakistan 166 children living near a 12 years living in close 2009 of PM (PM1, PM2.5, and
school in high polluted area proximity (within PM10)
or another school in a low ~3 km) of their school
polluted area
Systolic and diastolic blood pressure was significantly higher in children living in the high pollution area than in the low pollution area
Y. S. Khader
Table 6 Characteristics and main findings of nine studies in the EMR that have examined the
carbon monoxide (CO)
Study Country/ Population/ Study
outcome Authors Year region Study design sample year Exposure
Carbon Nazari et al. 2010 Iran A The records of 2003– CO
monoxide (2010) retrospective the main 2008
poisoning survey provider of
(COP) emergency
incidence medical
and death transportation
and from death
certificate
reports of the
legal medicine
organization
CO poisoning has a high prevalence in this geographic region, with elderly adults being at the
greatest risk, especially during the winter season
COP Dianat and 2011 Iran A descriptive All Mar CO
incidence Nazari retrospective unintentional 2007–
and death (2011) study (CO) poisoning Mar
in Northwest 2009
Iran
The ratio of unintentional CO-related poisoning cases in relation to all poisonings was 17.6%.
Nonfatal CO poisoning was higher in females and adults aged 25–44 year olds, whereas the death
rate was highest for those over 64 years. Domestic gas appliances were involved in 98% of
nonfatal incidents and in all fatal poisonings, with gas water heaters (59.2%) and free-standing
heaters (25.3%) being the most common causes of CO exposure
COP Sheikhazadi 2010 Iran A A population of Jan CO
deaths et al. (2010) retrospective 11.1 million. 2002–
survey The data Dec
included 666 2006
deaths due to
CO poisoning
Middle-age people, young adults, and elderly people were at the greatest risk for unintentional CO
poisoning, and rates were highest in the winter months. Death from suicidal CO poisoning was
very rare in this study; on the other hand, unintentional CO poisoning deaths are increasing in
Tehran. The overall rate of unintentional poisonings over the 5-year period was 7.5 per 100,000,
with an annual rate of 1.5 per 100,000. Over the 5-year period, increasing rates of death from CO
poisoning were found annually to be approximately 20%
COP Yari et al. 2012 Iran A cross- 143 cases of CO July CO
incidence (Emami- sectional poisoning 2006–
Razavi et al. study referred to the Mar
2014) only center for 2008
the reference of
poisoning cases
CO poisoning is a serious public health problem in west of Iran (Kermanshah). The number of CO
poisoning cases was highest in the colder seasons of the year, whereas the majority of the
poisoning cases could be prevented. One-hundred forty-two cases (99.3%) were accidental, and
only 1 case (0.7%) was suicidal. Mortality rate was (21.7%, n ¼ 31). The highest mortality was
found in the age groups of 20–30 years and below 10 years. The greatest frequency happened in
(continued)
1386 Y. S. Khader
Table 6 (continued)
autumn and winter. Gas water heaters (35%), room heaters (32%), stoves (24%), and other items
(9%) were the principal sources of the individuals’ exposure to CO
COP Al Kaabi et 2011 UAE A case series Cases of CO 2007– CO
incidence al. (2011) poisoning 2009
Foreign nationals compromised 80% of the cases, and the incidence was 3.1 cases per 100,000
residents per year. Burning charcoal in poorly ventilated residences was the predominant source of
the carbon monoxide poisoning. Almost all cases (98%) were admitted during the winter months,
most in the early morning hours. Carboxyhemoglobin (COHb) was significantly increased in
cases with loss of consciousness and depressed consciousness. There were no reported fatalities
COP Battah et al. 2009 Jordan Postmortem 107 COP deaths 2000– CO
deaths (2009) forensic 2004
pathology
reports for all
autopsies
examined at a
national
center
Autopsied cases, where the cause of death was attributed to toxic substances, accounted for 3.2%
(n ¼ 184). The COP fatalities constituted for most deaths due to poisoning (58.1%, n ¼ 107).
These COP fatalities accounted for 1.8% of all causes of deaths over the 5 years and corresponded
to 3.56 deaths per million persons per year. All COP fatalities were accidental during the night,
and the majority occurred during the period between December and March, which are the coldest
months of the year, and they peaked during January. Kerosene heaters, gas heaters, and gas water
heater accounted for about 72% of sources of COP
COP El Sayed 2014 Beirut, A CO poisoning Jan CO
incidence and Tamim Lebanon retrospective patients 2009–
(2014) chart review Jan
of all patients 2013
CO poisoning in Beirut, Lebanon is mainly due to charcoal burning grills used indoors and to fire-
related smoke. Most of the cases presented during winter months (56%). Young females were
more likely (58.3%) to present with CO poisoning secondary to using grills burning charcoal
indoors, while males were more likely (90%) to present with CO poisoning from fire-related
smoke
including respiratory health outcomes, adverse pregnancy outcomes, cancer, cardio-

vascular diseases, preclinical biomarkers, neurological disorders, hearing loss, cog-
nitive abilities, prenatal health, and sleep disorders (Table 10).
Air Pollution and Cancer
There is an overarching need to understand the effects of air pollution on cancer and
which particular air pollutants contribute to the incidence of particular types of
cancers. Unfortunately, there are very few studies that address cancer incidence
and air pollution in EMR countries. These studies report that environmental tobacco
55
Table 7 Characteristics and main findings of studies in the EMR that have examined the impact of air pollution on preclinical biomarkers
Country/ Study
Lipid profile; apoptosis El-Hodhod et 2011 Cairo, Cross-sectional Clinically healthy – Secondhand smoke
in peripheral blood al. (2011) Egypt study on 40 school-age children
lymphocytes children
Lipid profile showed significantly higher values of serum cholesterol, triglycerides (TG), and low-density lipoprotein (LDL) and lower values of high-density
lipoprotein (HDL) among passive-smoking children compared to nonexposed ones. The deranged lipid profile was related to the smoking intensity. In
addition, early apoptotic lymphocytes were significantly higher among children exposed to cigarette smokers compared to nonexposed ones
Vitamin D storage Hosseinpanah 2010 East Tehran Cross-sectional Outpatient Sept Ultraviolet B light as a
et al. (2010) and study on 200 housewives, aged 2007 surrogate of air pollution
Ghazvin women between 20 and
City, Iran 55 years
Median serum 25-hydroxy vitamin D (25(OH)D) was significantly higher in Ghazvin (low polluted area) women. The prevalence of vitamin D deficiency and
insufficiency were higher in Tehranians (high polluted area) compared to those who were living in Ghazvin (low polluted area)
Serum c-reactive protein Kelishadi et 2014 Isfahan, Iran Cross-sectional Prepubescent boys 2011 Secondhand smoke and mean
(CRP) al. (2014) study on 100 in Isfahan daily concentrations of
children particulate matter (PM10)
PM10 concentration had a significant independent association with biomarkers of endothelial dysfunction and inflammation in healthy children. Increased
PM10 was associated with an increase in CRP concentration in children not exposed to passive smoking. Regardless of passive smoking, PM10 concentration
has a significant independent association with serum CRP
CRP, interleukin 4 (IL4), Merghani et 2012 Khartoum, A comparative School pupil, aged 2009 Secondhand smoke
and tumor necrosis al. (2012) Sudan study (69 9–14 years
factor alpha (TNF-α) exposed, 66
nonexposed)
Passive smoking causes significant rise in plasma TNF-α and IL4 with a dose-dependent effect among school pupils
1387
1388
Table 8 Characteristics and main findings of studies in the EMR that have examined the impact of air pollution on neurological disorders, hearing loss, and
cognitive abilities
Country/ Population/ Study
Study outcome Authors Year region Study design sample year Exposure
Intelligence Abdel 2012 Menoufiya, Cross-sectional Primary – Lead
quotient (IQ) and Rasoul et al. Egypt study school
hearing loss (2012) children
Exposure to lead would deteriorate IQ, school performance, and hearing level of school children. The mean value of environmental lead in urban schools air
was significantly higher than that in rural areas. Blood lead level had a significant negative correlation with IQ; it was positively correlated with the hearing
threshold. With increasing blood lead level, the school performance of children decreased significantly
Multiple sclerosis Heydarpour 2014 Tehran, Iran Time series for a 2003– Mean daily concentrations of nitric
et al. (2014) period of 9 years on 2013 dioxide (NO2), sulfur dioxide (SO2),
2188 cases particulate matter (PM10)
A significant difference in exposure to air pollutants was observed in multiple sclerosis cases compared with controls
Sensorineural Talaat et al. 2014 Kuwait Cross-sectional 5–11 years Jan Secondhand smoke
hearing loss (2014) study old 2010–
children Nov
2012
Passive smoking in childhood correlates with sensorineural hearing loss, and it is an important risk factor for development of minimal hearing loss
Y. S. Khader
Table 9 The characteristics and main findings of two studies in the EMR that have examined the
impact of air pollution on prenatal health
Preeclampsia Nahidi 2014 Tehran, Case-control Iranian Sept Mean daily
et al. Iran study: 65 women; 2010– concentrations
(2013) with and 130 singleton Mar of ozone (O3),
without pregnancy; 2011 nitric dioxide
preeclampsia gestational (NO2), sulfur
age > 20 week dioxide (SO2),
carbon
monoxide
(CO),
particulate
matter (PM10)
There was no statistically significant relationship between exposure to air pollutants including
CO, particulate matter, SO2, NO2, and O3, and preeclampsia. The combined effect was also not
significant
Gestational Vigeh 2011 Tehran, Cross- Women aged Apr Mean daily
hypertension et al. Iran sectional 15–40 years 2007– concentration
(2011) study on residing within Mar of CO
2707 women two miles of air 2008
pollution
monitoring
stations during
pregnancy
Living in the relatively high-level versus low-level CO polluted areas was significantly associated
with pregnancy hypertension
Table 10 Characteristics and main findings of studies in the EMR that have examined the impact
of air pollution on sleep disorders
Study Country/ Study Population/ Study
outcome Authors Year region design sample year Exposure
Sleep Abou- 2013 Egypt Cross- School Dec Mean daily
disorders Khadra sectional children 2010 concentrations
(2013) study aged 6– of particulate
13 years matter (PM10)
Air pollution exposure has a negative impact on children’s sleep with significant association
between exposure to PM10 and sleep disturbances. There were statistically significant associations
between PM10 exposure and initiating and maintaining sleep and sleep hyperhidrosis
Habitual Kheirandish- 2014 Tehran, Cross- 6- to 12- – Ambient air
snoring Gozal et al. Iran sectional year-old pollution
(2014) study children
Partition of habitual snoring rates according to neighborhood air quality characteristics revealed
significantly higher habitual snoring frequencies among children residing in neighborhoods with
greatest pollution
1390 Y. S. Khader
smoke increases the risk of urothelial carcinoma, squamous cell carcinoma, naso-
pharyngeal carcinoma, but not undifferentiated carcinoma, nor childhood cancer.
Nitrogen dioxide increases the risk of lung and breast cancer incidence. Cooking
with coal did not increase lung cancer incidence, but did increase nasopharyngeal
carcinoma risk if the exposure occurred during childhood. Lung cancer risk is
increased by outdoor and indoor pollution, using fuel for heating (in females) and
living near an electricity generator.
The high levels of multicomponent air pollution in large cities of the EMR
countries provide a unique opportunity as a natural laboratory for studying this
relationship. To study the pathologic role of air pollution, large longitudinal studies
with extensive and accurate measurements of outdoor air pollution, as well as
controls for potential confounding factors, are urgently needed. Improving the
measurement of exposure to air pollution at the individual level will be a common
challenge in all studies focused on this link. Biomarkers for exposure, such as DNA
adducts and molecular alterations (e.g., loss of heterozygosity, gene mutations, and
aberrant gene promoter methylation), will be useful for understanding the mecha-
nisms of the air pollution-cancer association and for facilitating early detection and
treatment of high-risk groups.
Given the ubiquity of combustion-source ambient air pollution exposure, the
contribution of this exposure across a population may be of public health impor-
tance. Direct epidemiologic observations of exposed populations could provide
better information for evaluating the magnitude of outdoor air pollution-related
cancer, but the expected relative effects of air pollution are likely to be weak in
many settings, and new studies that could better guide policies for protection of
public health will face considerable challenges. In general, large-scale epidemiologic
studies of air pollution and cancer will be needed if we are to obtain sufficiently
informative data, but it is not obvious that such studies are feasible. Assessing their
feasibility is important to evaluate objectively. Large numbers of cases will be
necessary to better measure the small relatively significant effects that have been
reported so far; other factors to measure include the joint effects of air pollution and
other factors such as occupational hazards and smoking. A better understanding of
the effects of mixtures of ambient pollutants (i.e., potential synergism between PM
and gaseous or vapor-phase pollutants such as ozone) is clearly needed.
Current development of biologic markers of exposure to and the molecular effects
of PAHs represents one approach for improving epidemiologic methods. Markers of
genetic susceptibility are also needed. In addition, and of equal importance, methods
for the retrospective estimation of long-term exposure to air pollutants should be
developed and tested so that large case-control and retrospective cohort studies can
be conducted.
Future studies should develop methods and collect data that can be used to
quantify exposure measurement errors and compute adjusted effect estimates.
Some specific areas for future research should include:
• Identification of the specific pollutants and pollution sources associated with

increased occurrence of cancer. Studies in single locales where levels of
pollutants are correlated with disease rates will generally be unable to estimate the
contributions of specific pollutants or sources. Ideally, longitudinal observation of
large populations over decades would be required to determine the possible role
of long-term exposure to air pollution in the pathogenesis of cancer. If the current
high level of interest in the effects of long-term exposure to particulate air
pollution on chronic disease incidence and mortality results in either new cohort
studies or the retrofitting of existing cohorts with air pollution data, such longi-
tudinal observations may be possible.
• Measurements of the interaction of ambient air pollution with other known or
suspected causes of cancer, i.e., cigarette smoking, occupation, and diet. The
effects of air pollution on cancer rates (including lung cancer) may depend,
perhaps critically, on other factors, such as cigarette smoking, genetic predispo-
sition, diet, occupational exposures, and social class. Although the combined
effects of ambient air pollution and smoking have not been well characterized, the
combined effects of smoking with air pollution merit particular consideration
because of the strength of smoking as a cause of lung cancer and the continued
high, and in some cases growing, prevalence of smoking in the region.
• Studies on the contribution of ambient air pollution to lung cancer occurrence in
countries currently undergoing rapid urbanization. Current knowledge about
ambient air pollution and cancer is based largely on the experience of populations
of Western industrialized nations. However, industrial and infrastructure devel-
opment in poorer countries has led to increases in urban air pollution that may
contribute to increased occurrence of cancer. These studies will present even
greater challenges than those in the industrialized West. In addition to the generic
problem of estimating long-term exposure to air pollution, the ambient air
pollution mixture in urban centers in the EMR countries is changing, due in
part to the increases in automobile traffic. Characterizing these changes as they
occur over time, including choosing and measuring indicator pollutants for
different pollution sources, requires careful planning.
• The topics of potential high-priority opportunities for research in the near term could
be conducted in the context of intervention studies to determine whether different
types of solid fuels are associated with different types of cancer. Studies should also
determine whether some populations are more susceptible than others and then
identify routes of exposure that must be accounted for to accurately quantify dose.
• Estimated effects of household solid fuel combustion on cancers other than lung
cancer. Many carcinogens are present in both tobacco smoke and smoke from
solid fuel combustion products, which suggests that other cancers associated with
tobacco smoking may also be associated with exposure to indoor air pollution.
• Determine whether genetic susceptibility modifies associations between indoor
air pollution and cancer. Incorporating genetic analyses into intervention studies
may improve risk assessment by clarifying whether the dose-response relation-
ship between indoor air pollution and cancer differs for genetically susceptible
subgroups. Toxicological and genetic studies may also identify or confirm chem-
ical constituents or complex mixtures responsible for mediating the effects of
indoor air pollution on cancer.
1392 Y. S. Khader
Air Pollution and Cardiovascular Disease
The effect of air pollution on cardiovascular disease has been studied in few EMR
countries, with most of the studies coming from Iran. Air pollution has a significant
association with cardiovascular morbidity, especially in high-risk groups. This
finding is not in line with findings in other parts of the world. It has been concluded
that 27% of deaths due to heart diseases are attributable to air pollution. Moreover,
exposure to poor ambient air quality and particulate matter increases blood pressure
in schoolchildren, and carbon monoxide and indoor biomass fuel combustion
increases the incidence of acute coronary syndrome among exposed women. In
addition, exposure to carbon monoxide increases hospital admissions for angina
pectoris; and exposure to air pollutants including nitrogen oxides, carbon monoxide,
and sulfur dioxide increases the risk of cerebral stroke in high-risk groups.
Investigations on the interaction between pre-existing traditional cardiovascular
risk factors (e.g., diabetes, hypertension) and air pollution are lacking. This should
be taken into consideration along with the effects of potential of air pollutants that
exacerbate or worsen the effects of these risk factors. Determining the extent to
which treatment of traditional cardiovascular risk factors, especially in patients with
known cardiovascular disease, could modify the risks associated with air pollution
exposure should be investigated. The dose-response relationship between different
air pollutants and their mixtures and cardiovascular diseases should be studied as a
function of susceptibility (e.g., age, pre-existing disease). Another need is to enhance
research on the complex synergistic effect of temperature, weather variability, long-
term air pollution, and environmental exposures such as criteria air pollutants on
various cardiovascular disease outcomes. There is a need to identify and quantify the
co-benefits of cardiovascular health caused by reducing our reliance on fossil fuel-
based energy and the changing emission scenarios.
There is a need to better define susceptible individuals or vulnerable populations
and document the time course and specific cardiovascular health benefits induced by
reductions in air pollution exposure.
Additional large studies specifically considering ischemic and hemorrhagic
stroke are needed. Few studies have evaluated whether the association between
PM and stroke varies according to PM composition or source. Studies to identify
PM components or sources most relevant to stroke mortality and morbidity are
needed.
Given the heavy reliance of prior studies on administrative data, outcome mis-
classification due to the use of International Classification of Diseases codes is
prevalent in current studies particularly for stroke subtypes. More epidemiologic
studies based on registry data or using medical record review for outcome ascer-
tainment should be carried out to replicate current results.
Studies are needed to evaluate the association between stroke recurrence and
particulate matter. Given the inconsistent results for an association between PM and
hospital admission for total cerebrovascular diseases, additional large studies are
needed to replicate the current results for PM10. More studies, particularly large
studies that simultaneously leverage statistical correction of exposure or outcome
errors, case ascertainment via physician diagnosis, and accurate exposure data for
PM components or PM2.5–10, are warranted to further elucidate the association
between short-term change in ambient particulates and stroke.
Air Pollution and Pregnancy Outcomes
In the EMR, the relationship between air pollution and prenatal health has only been
studied in Iran. Studies on the effect of secondhand smoke exposure and indoor
biomass fuel burning in Arab countries are almost lacking. In addition, the relation-
ship between gestational diabetes mellitus and hyperglycemia and air pollution is yet
to be studied. The few studies in the EMR that have examined the effect of air
pollution on pregnancy outcomes showed that prenatal secondhand smoke and
exposure to wood fuel smoke have a significant negative effect on the weight of
the newborn baby and increase the odds of low birth weight by 2–3 times. Second-
hand smoking also has a significant association with preterm birth. Carbon monox-
ide has significant effect on the weight of the newborn and the risk of spontaneous
abortion. Other ambient air pollutants have no significant association with the mean
birth weight and controversial association with preterm birth.
More studies with appropriate sample sizes and methodologies are needed for
studies in the EMR countries. Future research on the effect of air pollution during
pregnancy and on pregnancy outcomes such as sudden infant death syndrome and
perinatal mortality and morbidity are needed.
Linking clinical data with air quality data can become the basis for surveillance
systems to track occurrence of environmental exposures to health risks. Potential
health outcomes that can be monitored at the community level include hospital visits
due to asthma, lead poisoning of children through inhalation or ingestion, emergency
room visits due to heat stress, etc. Such linkages of information including birth
outcomes data, identification of underserved areas, or monitoring of patient out-
comes and quality of care are just a few examples of information that can guide and
formulate policy and action. Systematic reporting of birth records at the population
level will yield important insights into specific risks and outcomes. The use of
electronic health records offers great potential in linking healthcare providers and
institutions to environmental and public health researchers for understanding disease
trends or documenting the impact of health interventions.
Carbon Monoxide Poisoning
It is imperative to understand the prevalence of carbon monoxide poisoning in the

EM countries. Proper understanding of the sociodemographic populations to target,
seasonal changes, and the key factors for designing an influential prevention for
carbon monoxide poisoning is essential for developing necessary interventions.
Well-designed studies should be carried out in each country of the EMR to under-
stand the burden of carbon monoxide poisoning. Once the burden and the important
1394 Y. S. Khader
demographic risk factors are appropriately determined, an awareness campaign

should be organized to assess the knowledge gaps in carbon monoxide poisoning
causes, symptoms, and prevention. A national level education program to increase
awareness of carbon monoxides emission sources and installing carbon monoxide
detectors should be undertaken, and their use encouraged specifically in peak
seasons for susceptibility to carbon monoxide poisoning is highly recommended.
Furthermore, studies should focus on the causes and mechanism of carbon monoxide
poisoning to reinforce stronger public health interventions.
Disease Biomarkers
There are only a few studies on the effects of secondhand smoke, air pollution, and
particulate matter on disease biomarkers. Air pollution is associated with biomarkers
of inflammation, endothelial dysfunction, and vitamin D deficiency. A study by
Oliveira et al. (Zhang et al. 2018) reviewed the effect of air pollution on disease
biomarkers. More than 230 biomarkers were reported to be affected by air pollution
worldwide. This shows the significant gap in research in the EMR, where only six
biomarkers have been investigated in only three countries. More research is needed
to cover a wider range of biomarkers and terrestrial regions. In addition, studies are
needed to investigate the effects of other air pollutants such as gaseous pollutants and
indoor biomass burning.
Neurological Disorders and Mental Health
Although there is emerging evidence on the effects of air pollution on neurological

disorders and mental health, this effect is poorly studied in the EMR. In addition to
the very low number of studies in the EMR, they were poorly designed and failed
to control for important confounders (e.g., the potential effect of prenatal habits or
noise on hearing loss and academic performance). Therefore, comprehensive and
methodologically sound research is needed on a wide range of neurological
problems that affect the central and peripheral nervous systems, vision, smell,
hearing, and taste. In addition, the adverse effects of the complex mixtures of
polluted air components are poorly understood. Also, susceptible groups need to
be identified in order to direct future protection and adaptation measures toward
them.
Sleep Disorders
The evidence on the effects of air pollution on sleep disorders from the EMR is
inadequate due to the low number of studies and inappropriate measurement tools.
More studies that use clinical and laboratory measurements in the assessment
of sleep disorders are needed. Also data on the effect of main pollutants are lacking
(e.g., gaseous air pollutants and indoor biomass fuel combustion). Studies also need
to consider the synergistic effect of a mixture of pollutants and the climatic changes
on sleep disorders. In addition, it is important to identify groups at risk of sleep
disorders. The mechanisms on which different air pollutant may affect sleep in
different groups are yet to be investigated.
The Adaptation Plans for Air Pollution in the EMR
Data on mitigation plans for air pollution in the EMR are lacking, especially for
ambient and indoor air pollution. Few studies have investigated the effectiveness of
local interventions to reduce and/or avoid secondhand smoking. Education-based
interventions improve knowledge and attitudes on secondhand smoking. Education
also can improve the response to secondhand smoking, especially among the
vulnerable groups (i.e., women and children). Secondhand smoking educational
interventions are more effective when children become involved. Using more
efficient and smoke-free stoves instead of traditional biomass-fueled stove positively
impact the environment and health of women. The effect of banning diesel-powered
motor vehicles on emergency admission for respiratory complaints by children is not
conclusive and requires further study. Education on the impact on health strategy
should be considered in the mitigation of the effects of air pollution on pregnancy
outcomes.
The lack of a proper air quality monitoring system to track human exposure is a
major limitation in the EMR. This has to be addressed to determine the impact of
programs and to identify future directions. The availability of stringent standards by
itself is of no use if the air quality that citizens are exposed to is unknown; an
evidence-based approach is needed to identify areas for intervention. Therefore,
establishing a modern ambient air quality monitoring network, at least covering large
cities in each country in the EMR, is an early need.
In addition, there are no specific interventions implemented at national level to
reduce indoor air pollutants or to minimize the exposure of vulnerable groups to
indoor air pollutants. There is a lack of reliable indoor air quality data and determi-
nants of indoor air quality, a priority that needs to be addressed when estimating the
burden of disease associated with indoor air pollutants. Practices and other determi-
nants that increase human exposure to air pollutants need to be identified in local
communities. Robust research studies should be designed to generate individual
exposure data, identify and evaluate determinants associated with air pollution
exposures, and quantify the public health effects of such exposures. Public health
impact of outdoor air pollution control activities should be assessed to monitor and
modify such mitigation activities.
Modifying existing regulatory practices based on findings of robust research
studies, strict adherence to regulations at community and household level, and
identifying new mitigation strategies can play a key role in minimizing the impact
of air pollution on health.
1396 Y. S. Khader
Specific research questions need to be addressed to better understand the health

effects of exposure to indoor smoke so that appropriate interventions and policies
can be designed and implemented:
• What factors determine human exposure, and what are the relative contributions
of each of these factors to personal exposure? These factors include energy
technology (stove-fuel combination), housing characteristics (e.g., the size of
the house, its ventilation and the building materials, the arrangement of rooms),
and behavioral factors (e.g., the amount of time spent indoors or near the cooking
area).
• What is the quantitative relationship between exposure to indoor air pollutants
and the incidence of disease (i.e., the exposure-response relationship)?
• Which determinants of human exposure will be influenced, and to what extent, by
implementing intervention strategies?
• How do the interventions on human exposure impact health outcomes, and how
would these impacts persist or change over time?
• What are the broader environmental effects of any intervention, its costs, and the
social and economic institutions and infrastructure required for its success?
• The number of affordable and effective interventions for reducing the risks
associated with exposure to indoor smoke from household energy technology in
the region is currently limited. Possible causes include overlooking the complex-
ities of household energy and exposure in designing new interventions and a lack
of infrastructure to support technologic innovations, marketing and dissemina-
tion, and maintenance. Even less is known about combinations of technologies
that may be used by any household and the factors that motivate the households to
adopt them. For this reason, randomized intervention trials, which focus on the
effectiveness of a limited number of existing interventions under well-controlled
conditions, may not provide the most useful information for large-scale interven-
tions, despite being epidemiologically convincing. Randomized trials will none-
theless continue to play important roles in verifying some of the effects estimated
from nonexperimental or indirect methods. Therefore, a selected number of such
studies must supplement more detailed data collection. Further, to realistically
monitor exposure, health effects, and interventions in a large number of settings at
the population level, indicators for some of the variables of interest will have to be
developed. At the same time, it is important to use an array of indicators when
they consist of more distal factors and to calibrate the indicators and their
interactions locally. The choice of the appropriate indicators itself requires
detailed pilot projects that illustrate the strength of different variables as predic-
tive indicators of exposure and health impacts.
Given the central role of housing, household energy, and day-to-day household
activities in determining exposure to indoor smoke, reliable data are needed on even
quantitative variables (such as exposure) and require an integration of methodology
and concepts from a variety of disciplines (ranging from quantitative environmental
science and engineering, to toxicology and epidemiology, to the social sciences).
Given the fundamental interactions of these variables, integration of tools and

techniques should take place early in the design of studies as well as in data
collection, analysis, and interpretation.
The Effect of Air Pollution on Health in the EMR: Research Gaps

and Needs
For the majority of published studies, limitations exist even well-conducted ones.
The limitations arise from inappropriate study designs, poor assessment of exposure
and outcomes, questionable sources of data, lack of standardized methods, poor
adjustment of confounders, limited geographical area studies, small sample sizes,
poor statistical modeling, and not testing for possible interactions between expo-
sures. Longitudinal studies over extended periods of time that investigate the link
between air pollution and health are missing in the EMR region. The following
illustrate general gaps and limitation in studies that investigated the effect of air
pollution on health in the EMR.
Lack of systematic exposure assessment: In general, exposure needs to be
quantitatively and properly assessed for a valid conclusion about its health effects.
Diseases such as cancer usually take decades to develop, and patterns of air pollution
change over time. Therefore, repeated exposure measures are necessary for validity
assessment. The different articles had different methodologies for exposure assess-
ment which sometimes lead to different conclusions for the same exposure-outcome
relationships. Many studies of the EMR relied on single and/or historic indicators of
exposure that were collected through questionnaires, so affecting precise estimates
of exposure and giving rise to recall bias. Measures of validity and reliability for
given questionnaires were seldom or nonexistent in most included studies. Studies
which measured the different air pollutants rather than surveying the exposure are
rare. Nevertheless, these studies also had other limitations as well.
1. First, repeated measures of the same pollutants were rarely mentioned or incor-
porated. For example, in some studies, more than one station measured different
ambient pollution sources, and the average concentration per unit time was taken.
However, day-to-day variability and reproducibility and robustness of the mea-
sures from one station to the other were not discussed.
2. Measurements of indoor air pollution were made in one room in the house under
the assumption that the exposure is homogenous in the whole household which
might not be the case.
3. Exposure to different air pollutants does not necessary reflect the actual dose that
accumulated in the human body. Assessment of biomarkers of exposure is a key
step in risk assessment in elucidating dose-response and cause-effect relation-
ships; this is lacking in most EMR studies. International meetings for the risk
assessment chapter in the Society of Toxicology emphasized the overarching
need to incorporate biomarkers of exposure in environmental settings. Most
studies relied on self-reported exposures rather than reliable biomarkers.
1398 Y. S. Khader
4. Most of the EMR countries lacked national standards for air pollution monitoring,
limiting the exposure assessment in few areas and then only for a few pollutants.
5. Outdoor pollution studies did not measure the individual exposures, which is a
huge challenge of population studies on air pollution. Not measuring an individ-
ual’s response can lead an ecologic fallacy, where associations at the aggregate
level do not necessarily reflect individual associations. If important synergistic or
antagonistic factors were ignored, the magnitude of the bias might be amplified.
6. Many assessments were done for each of the pollutants separately without
considering co-exposures.
7. Most of the exposure assessments in the studies were related to acute exposures,
with some exposure assessment for over 1 year in few studies.
Improper or poor characterization of health outcome: Some of the EMR

studies relied on self-reported symptoms and signs and not on clinically diagnosed
outcomes which might result in recall and outcome biases. Outcome mis-
classification is a concern for studies with self-reported outcome rather than robust
clinical diagnosis. Even among doctor-diagnosed outcomes, some of these were
carried out in multiple health centers without confirming the validity and consistency
in the diagnosis between the different centers. Furthermore, lack of blinding of
participants, healthcare providers, observers, or interviewer was dominant in most
studies which could have increased observer’s bias.
Limitations in study designs and the association between exposure and
outcome: Most of the studies were based on acute exposure assessments, despite
the fact that a lot of the health outcomes were chronic in nature and can take several
years to develop. Because exposures and outcomes were assessed at a single point in
time in cross-sectional studies, it is not possible to determine whether the exposure
preceded the outcomes or to examine changes over time. Some exposure-outcome
associations were established by built-in models. However, there was no verification
of the model’s assumptions. Few studies had real-time data on different ambient
exposures, which hindered the ability to establish a dose-specific tolerable exposure
limit. Advancing and utilizing epidemiological designs is of key importance. Best
epidemiological designs to yield strong and valuable information for chronic health
outcomes are well-designed prospective cohort studies to ascertain the relevance of
air toxics and pollutants to health outcomes onset and chronicity. Alternatively, acute
health outcomes are best studied with repeated measures studies that evaluate acute
exposure dose-response relationship in the population. Of course, accurate exposure
and outcome assessments, as well as incorporating the appropriate confounders, are
key factors in designing the study. It is advisable to consider exposures to mixtures,
especially ones that are emitted together, as well as individual pollutants to fully
understand the mechanism of the health outcome.
Limitations in confounder selection: Confounders were not always adequately
adjusted for in some studies. One of the major confounders, for example, includes
genetics and family disposition to a certain outcome. While some studies controlled
for some family history, others failed to consider this important aspect. Studies of
secondhand smoking did not control for the effect of exposure to other sources of
air pollution. This also applies on studies on ambient air pollution which did not
control for indoor and outdoor secondhand smoking exposure. Most of the studies
did not model the duration of exposure into their assessment. While most people tend
be indoors, the duration tends to vary by age and occupation. Variation in the amount
spent at home for indoor measurements, and in different indoor places (home vs. work
or school), is an important consideration that was mostly overlooked in many studies.
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Vector-Borne Diseases in Arab Countries
56
Abdulla Salem Bin Ghouth, Ali Mohammad Batarfi,
Adnan Ali Melkat, and Samirah Elrahman
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1406
Vector-Borne Diseases in Arab Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1407
Brief Epidemiological Description of the Most Important Vector-Borne
Diseases in EMRO/WHO Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1407
Malaria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1407
Dengue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1409
Dengue in the WHO Eastern Mediterranean Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1410
Schistosomiasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1410
Leishmaniasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1411
Filariasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1412
Crimean-Congo Hemorrhagic Fever (CCHF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1412
Onchocerciasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1413
Yellow Fever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1414
Plague . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1414
Murine Typhus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1415
Relapsing Fever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1415
Chikungunya . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1416
West Nile Fever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1416
Rift Valley Fever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1416
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1417
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1418
A. S. B. Ghouth (*) · A. M. Batarfi · A. A. Melkat

Hadramout University, Yemen, Yemen
e-mail: abinghouth2007@yahoo.com; ambatarfi@yahoo.com
S. Elrahman
University of Gezira, Wad Medani, Sudan
e-mail: samhamid2002@yahoo.co.uk

https://doi.org/10.1007/978-3-030-36811-1_57
1406 A. S. B. Ghouth et al.
Abstract
Vector as a term is universally applied to hematophagous mosquitoes, and we use
this definition in this chapter to describe epidemiology of vector-borne diseases in
Arab countries.
About 15 vector-borne diseases (VBDs) are common in the Arab countries with
great variations from one country to another. They are malaria, dengue, schistoso-
miasis, leishmaniasis (visceral and cutaneous), lymphatic filariasis, Crimean-
Congo hemorrhagic fever (CCHF), onchocerciasis, yellow fever, plague, murine
typhus, relapsing fever, chikungunya, West Nile virus, and Rift Valley fever.
Understanding the epidemiology of each VBD makes the coordination toward
regional control possible. In this chapter, the authors presented the epidemiolog-
ical distribution of the most common 15 VBDs in Arab countries. The results
show that there are two diseases of complex epidemiology (malaria and schisto-
somiasis), but their distribution was limited in certain countries including Sudan.
A lot of neglected tropical diseases including emerging diseases like dengue and
Crimean-Congo hemorrhagic fever (CCHF) and chikungunya are common.
Leishmaniasis, either visceral or cutaneous, is spread in most of the Arab coun-
tries, while Sudan bears the most burden of the VBDs in the Arab world.
Keywords
Vector-borne diseases · Arab countries · Epidemiology
Introduction
Vectors are living organisms that can transmit infectious diseases between humans or
from animals to humans. Many of these vectors are bloodsucking insects that ingest
disease-producing microorganisms during a blood meal from an infected host
(human or animal) and later inject them into a new host during their next blood
meal. Mosquitoes are the best-known disease vectors. Others include some species
of ticks, flies, sandflies, fleas, bugs, and freshwater snails (WHO 2014) (Table 1).
Many parasites and pathogens responsible for some of the most important diseases
in humans, agriculture, and nature are routinely described as “vector-borne.” However,
different definitions of a vector are used in different fields. For instance, the term is
universally applied to hematophagous mosquitoes (Wilson et al. 2017), and we use
this definition in this chapter to describe epidemiology of vector-borne diseases in
Arab countries.
Vector-borne diseases are illnesses caused by pathogens and parasites in human
populations and account for more than 17% of all infectious diseases (http://www.
emro.who.int/egy/programmes/neglected-tropical-diseases.html). More than one
billion people are infected every year, and more than one million people die from
vector-borne diseases such as malaria, dengue, schistosomiasis, leishmaniasis,
Chagas disease, yellow fever, lymphatic filariasis, and onchocerciasis (WHO 2014).
56 Vector-Borne Diseases in Arab Countries 1407
Table 1 Vectors and the diseases that they can transmit (WHO 2014)
Vector Diseases
Mosquitoes:
Aedes aegypti Dengue, yellow fever, chikungunya, Zika virus
Aedes albopictus Chikungunya, dengue, West Nile virus
Culex Lymphatic filariasis
quinquefasciatus
Anopheles Malaria
Sandflies Leishmaniasis
Triatomine bugs Chagas disease
Ticks Crimean-Congo hemorrhagic fever (CCHF), tick-borne encephalitis,
typhus, Lyme disease
Fleas Plague, murine typhus
One sixth of the illness and disability suffered worldwide is due to vector-borne
diseases, with more than half the world’s population currently estimated to be at risk
of these diseases (World Health Organization 2004).
Vector-Borne Diseases in Arab Countries
About 15 vector-borne diseases are common in the Arab countries with great varia-
tions from one country to another (Table 2).
Brief Epidemiological Description of the Most Important Vector-

Borne Diseases in EMRO/WHO Region
All Arab countries except Algeria and Mauritania are members of the EMRO region
of the WHO so this section will descript the main epidemiological feature of malaria
as a disease and the main epidemiological features in these countries.
Malaria
Malaria is a parasitic disease that triggers fever, chills, and a flu-like illness. Symptoms
usually appear after a period of 7 days or more after infection from a mosquito bite
(WHO 2014).
Malaria is caused by Plasmodium parasites transmitted through the bites of female
Anopheles mosquitoes, which are active mainly between dusk and dawn. Five parasite
species cause malaria in humans, and Plasmodium falciparum and P. vivax are the
most common. P. falciparum is the most dangerous, with the highest rates of compli-
cations and mortality. This deadly form of malaria is a serious public health concern in
most countries in sub-Saharan Africa. Anopheline mosquitoes are the only vectors of
1408
Table 2 Vector-borne diseases in some Arab countries (Al et al. 2017; Gould 2008; Cuomo)
Saudi
Diseases Algeria Bahrain Djibouti Egypt Iraq Jordan Kuwait Lebanon Libya Morocco Mauritania Oman Qatar Arabia Somalia Sudan Syria Tunisia UAE Yemen
Malaria + + + + + + + +
Dengue + + + + + +
West Nile virus + + + + + + + + + + + + + + +
Cutaneous + + + + + + + + + + + + + +
leishmaniasis
Visceral + + + + + + + + + + + + + +
leishmaniasis
Schistosomiasis + + + + + + + + + + +
Onchocerciasis + + +
Bancroftian + + +
filariasis
CCHF (Al et al. + + + + + + + + + + + +
2017)
Tick-borne + + + + +
relapsing fever
Louse-borne + + + +
relapsing fever
Plaque + + + + + + + + + +
Murine typhus + + + + + + + +
Chikungunya + + +
(Gould 2008)
Yellow fever +
(Gould 2008)
A. S. B. Ghouth et al.
Table 3 The main malaria control measures in the most affected countries in 2017 (WHO 2017)
Country Insecticide-treated mosquito nets Indoor residual Chemoprevention

spraying
ITNs/LLINs ITNs/LLINs ITNs/LLINs IRS is DDT is IPTp used Seasonal
are are distributed recommen used to prevent malaria
distributed distributed through mass ded for malaria chemopreve
free of to all age campaigns to by malaria IRS during ntion
charge groups all age groups control pregnancy
program
Algeria
Saudi
Arabia
Mauritania
Sudan
Somalia
Djibouti
Yemen
Actually implemented
Not implemented
the Plasmodium parasites. Each of the 60 known species of Anopheles that can
transmit malaria has its own biological and ecological peculiarities. Disease transmis-
sion is more intense where the mosquito species has a long lifespan and a habit of
biting only humans, for example, An. gambiae (WHO 2014).
Burdens of malaria in Arab countries are in Sudan, Yemen, Somalia, and Dji-
bouti. Saudi Arabia is in the road for malaria elimination, while Oman reported zero
indigenous malaria cases in 2017. Morocco and the United Arab Emirates were
declared malaria-free. The other Arab countries are not risk of malaria as the diseases
is not a common health problem (Table 3).
Dengue
Dengue fever is a severe, flu-like illness. Symptoms include high fever, severe
headaches, muscle and joint pains, nausea, vomiting, swollen glands, or rash.
Dengue itself is rarely fatal, but severe dengue is a potentially fatal complication,
with symptoms including low temperature, severe abdominal pains, rapid breathing,
bleeding gums, and blood in vomit. There are four known serotypes of dengue virus
(DEN 1 to 4). Recovery from infection by one provides lifelong immunity against
that particular serotype. However, subsequent infections by other serotypes increase
the risk of developing severe dengue (WHO 2014).
The Aedes aegypti mosquito is the primary vector of dengue. The virus is
transmitted to humans through the bites of infected female mosquitoes. Once an
infected mosquito has incubated the virus for 4–10 days, it can transmit the virus for
the rest of its life. Infected humans are the main carriers and multipliers of the virus,
serving as a source of the virus for uninfected mosquitoes. Patients who are already
infected with the dengue virus can transmit the infection (for 4–5 days; maximum
12) via Aedes mosquitoes once their first symptoms appear. The Ae. aegypti mos-
quito lives in urban habitats and breeds mostly in man-made containers. This species
is a daytime feeder; its peak biting periods are early in the morning and in the
evening before dusk. Female Ae. aegypti bite multiple people during each feeding
period. Aedes albopictus, a secondary dengue vector in Asia, has spread to North
America and Europe largely due to the international trade in used tires (a breeding
habitat), timber, and other goods such as “lucky bamboo” (a decorative house plant
that is marketed worldwide). This mosquito species can survive in cooler temperate
regions of Europe. Ae. albopictus has a wide geographical distribution, is particu-
larly resilient, and can survive in both rural and urban environments. The mosquito’s
eggs are highly resistant and can remain viable throughout the dry season. It is also a
daytime feeder (WHO 2014).
Dengue in the WHO Eastern Mediterranean Region
Outbreaks of dengue have been documented in the Eastern Mediterranean Region,

possibly as early as 1799 in Egypt (Messina et al. 2015). The frequency of reported
outbreaks continues to increase, with outbreaks, for example, in Sudan (1985, DEN-1
and DEN-2) (25) and in Djibouti (1991, DEN-2) (Amazigo 2006). Recent outbreaks of
suspected dengue have been recorded in Saudi Arabia, Sudan, and Yemen, 2005–2006
(Messina et al. 2015). Yemen is also affected by the increasing frequency and
geographic spread of epidemic dengue, and the number of cases has risen since the
major DEN-3 epidemic that occurred in the western Al-Hudaydah governorate in
2005. In 2008, dengue affected the southern province of Shabwa. Since the first case of
DHF died in Jeddah in 1993, Saudi Arabia has reported three major epidemics: a
DEN-2 epidemic in 1994 with 469 cases of dengue, a DEN-1 epidemic in 2006 with
1269 cases of dengue (WHO 2009). In Somalia infections of DENV-1, DENV-2,
DENV-3, and coinfections of DENV-1/2 and DENV-2/3 serotypes were identified in
the Magdieshou outbreak in 2011 (Kyobe Bosa et al. 2014) (Fig. 1).
Schistosomiasis
Schistosomiasis is a parasitic disease caused by trematodes of the genus Schistosoma.

Urinary schistosomiasis is a disease caused by Schistosoma haematobium of tropical
and intertropical zones. The disease is endemic in several areas in Africa, Madagascar,
and the Middle East. The route of infection for humans is skin exposure to parasite-
Sudan (No data)
Somalia (1982, 1993, DEN-2)

Djibauti (1991-1992, DEN-2)
DEN-2:
1994: 673 suspected cases, 289 confirmed cases Al-Hudaydah, Mukkala, Shaabwa
1995: 136 suspected cases, 6 confirmed cases (1994, DEN-3, no data);
1996: 57 suspected cases, 2 confirmed cases
Al-Hudaydah, Yemen
(September 2000, DEN-2, 653 suspected cases, 80 deaths (CFR = 12%));
1999: 26 suspected cases, 3 confirmed cases Al-Hudaydah, Yemen
2000: 17 suspected cases, 0 confirmed cases (March 2004, 45 suspected cases, 2 deaths);
2001: 7 suspected cases, 0 confirmed cases Al-Hudaydah, Mukkala
2005: 32 suspected (confirmed) (March 2005, 403 suspected cases, 2 deaths);
Fig. 1 Outbreaks of dengue fever in the WHO Eastern Mediterranean Region, 1994–2005
(WHO 2009)
infested freshwater during routine occupational, recreational, or domestic activities

(Colley et al. 2014).
The parasitic transmission cycle starts when people with urinary schistosomiasis
contaminate freshwater sources with urine that contains parasite eggs. Under specific
environmental conditions, the eggs hatch, and the released miracidia penetrate specific
freshwater snails, the intermediate hosts. Cercariae, the infective form, are released by
the snails and can penetrate the skin of a human host upon exposure to fresh water. In
their human hosts, adult Schistosoma live 3–10 years, but in some cases, they can live
for 40 years. The disease caused by S. haematobium is characterized by chronic
urogenital complications due to the presence of eggs in tissues (Bamgbola 2014). In
endemic areas, the infection in people can remain subclinical for a long period but still
causes progressive damage to the urogenital tract (Eurobian Center for Disease
Control and Prevention).
Leishmaniasis
The leishmaniases are a group of diseases caused by protozoan parasites from >20
Leishmania species that are transmitted to humans by the bite of infected female
phlebotomine sandflies (98 of which are of medical importance). There are four main
forms of the disease: visceral leishmaniasis (VL, also known as kala-azar), post-kala-
azar dermal leishmaniasis (PKDL), cutaneous leishmaniasis (CL), and mucocutaneous
leishmaniasis (MCL). While cutaneous leishmaniasis is the most common form of the
disease, visceral leishmaniasis is the most serious and can be fatal if untreated (WHO).
Leishmaniasis is a major health problem worldwide, with several countries reporting

cases of leishmaniasis resulting in loss of human life or a lifelong stigma because of
bodily scars. The Middle East is endemic for cutaneous leishmaniasis, with countries
like Syria reporting very high incidence of the disease (WHO). Leishmaniasis is
endemic in Iraq, where both forms of the disease, cutaneous and visceral, are found,
while cutaneous leishmaniasis is the most common form of the disease present in Saudi
Arabia and Jordan (Salam et al. 2014). Although other Arab countries reported either
forms of leishmaniasis like Yemen and Morocco, Tunisia but three Arab countries are
within the ten top countries in the global burden of cutaneous leishmaniasis; they are
Algeria, Syria, and Sudan, while 90% of visceral leishmaniasis in the world occurred in
six countries, including Sudan (WHO).
Filariasis
Lymphatic filariasis (LF), also known as elephantiasis, is a major disease of tropical

and subtropical regions worldwide. LF is endemic in 80 countries, and it is estimated
that 120 million people are infected, with one third of them suffering from chronic
manifestation of the disease. One billion more individuals are at risk of acquiring the
infection (Ottesen 2002).
Lymphatic filariasis is a mosquito-borne parasitic disease caused by three nematode
worms of the family Filariidae: Wuchereria bancrofti, Brugia malayi, and B. timori.
Wuchereria bancrofti is responsible for 90% of worldwide infections, with 9% caused
by B. malayi in Southeast and Eastern Asia, whereas 1% results from infection with
B. timori in the Pacific region (Michael and Bundy 1997). The disease is transmitted
by Anopheles, Culex, and to a lesser extent by Aedes and Mansonia mosquito species.
The disease is known to be focally endemic in three Arabic countries: Egypt,
Sudan, and the Republic of Yemen, whereas the LF situation in Djibouti, Oman,
Saudi Arabia, and Somalia is currently uncertain. However, clinical cases have been
reported in Oman, Saudi Arabia, and Somalia (El and Ramzy1 2003) (Fig. 2).
Crimean-Congo Hemorrhagic Fever (CCHF)
Crimean-Congo hemorrhagic fever (CCHF) is a vector-borne viral disease, widely

distributed in different regions of the world. The fever is caused by the CCHF virus
(CCHFV), which belongs to the Nairovirus genus and Bunyaviridae family. The
virus is clustered in seven genotypes, which are Africa-1, Africa-2, Africa-3, Europe-
1, Europe-2, Asia-1, and Asia-2. The virus is highly pathogenic in nature, easily
transmissible, and has a high case fatality rate of 10–40%. The reservoir and vector of
CCHFV are the ticks of the Hyalomma genus. Therefore, the circulation of this virus
depends upon the distribution of the ticks. The virus can be transmitted from tick to
animal, animal to human, and human to human. The major symptoms include
headache, high fever, abdominal pain, myalgia, hypotension, and flushed face.
Fig. 2 Global distribution of lymphatic filariasis; Egypt, Sudan, and Somalia are the most affected
Arabic countries (CDC)
As the disease progresses, severe symptoms start appearing, which include petechiae,
ecchymosis, epistaxis, bleeding gums, and emesis (Aslam et al. 2016).
Historical evidence points to the probable description of CCHF by a physician in
Tajikistan in 1100 AD in a patient with hemorrhagic manifestations (Al-Abri et al.
2017; Hoogstraal 1979; Maltezou and Papa 2011). In recent times, the disease was
first recognized during an outbreak in Crimea in 1944; however, it later became
evident that the causative agent was identical to a virus isolated from a patient in
Congo in 1956, and the name CCHF was adopted (Messina et al. 2015). The disease
is endemic in many regions, such as Africa, Asia, Eastern Europe, and the Middle
East (Messina et al. 2015). The known distribution of CCHFV covers the greatest
geographic range of any tick-borne virus, and there are reports of viral isolation
and/or disease from more than 30 countries across four regions: Africa (Democratic
Republic of Congo, Uganda, Mauritania, Nigeria, South Africa, Senegal, Sudan),
Asia (China, Kazakhstan, Tajikistan, Uzbekistan, Afghanistan, Pakistan, India),
Europe (Russia, Bulgaria, Kosovo, Turkey, Greece, Spain), and the Middle East
(Iraq, Iran, Kuwait, Saudi Arabia, Oman, the United Arab Emirates (UAE)) (World
Health Organization 2013).
Onchocerciasis
Onchocerciasis is caused by worms, Onchocerca volvulus. The adult worms measure

nearly a meter long and live in coiled mating pairs in nodules under the skin.
Reproducing adult females spawn about 2000 immature worms every day. These
tiny juvenile worms migrate throughout the skin and eyes, causing the various
symptoms of the disease. Although they are damaging, these immature worms
cannot mature to adulthood without being transmitted by a blackfly of the genus
Simulium. This fly breeds in rapidly flowing streams and rivers and thus the name
“river blindness.” The most important vector is Simulium damnosum sensu lato,
which has a wide range throughout Africa and the Middle East (Amazigo 2006).
Onchocerciasis used to be endemic in some 30 countries in Africa (including
Sudan) where over 99% of all cases in the world were found (Zouré et al. 2014;
World Health Organization 1995). In Yemen, the disease, locally termed as sowda, is
unique in its clinicopathologic pattern, being of the localized, non-blinding, hyper-
reactive onchocercal skin disease (Abdul-Ghani et al. 2016).
Yellow Fever
Yellow fever (YF) is a viral disease, endemic to tropical regions of Africa and the
Americas. YF principally affects humans and nonhuman primates and is transmitted
via the bite of infected mosquitoes. The agent of YF, yellow fever virus (YFV), can
cause devastating epidemics of potentially fatal, hemorrhagic disease (Gardner and
Ryman 2010). Yellow fever virus is the prototypic member of the genus Flavivirus,
family Flaviviridae, flavus being Latin for yellow. The three genera in this family
contain a large number of major human and veterinary pathogens (Gould and
Solomon 2008), including dengue (DENV), Japanese encephalitis (JEV), and West
Nile (WNV) viruses in the Flavivirus genus (Gardner and Ryman 2010).
Plague
Plague is a zoonotic disease caused by the gram-negative bacterium Yersinia pestis

(Dennis et al.). Humans are extremely susceptible to plague and may be infected either
directly or indirectly. Indirect transmission through the bite of a flea is the most
common route of transmission between plague-infected rodents and humans.
Human infection most frequently occurs when an epizootic develops among syn-
anthropic rats in centers of human population, following contact with infected wild
rodents. Commensally rat fleas, including plague-infected fleas, leave the bodies of
rats killed by plague seeking a blood meal from another host and may bite human
beings. Humans who contract the disease may subsequently become infective to other
people (Tikhomirov 1999).
According to the World Health Organization (WHO) reports published in 2009
(World Health Organization 2009) and 2016 (Bertherat 2016), >95% of the 15,396
cases reported worldwide during 2004–2014 occurred in Africa, especially in the
Democratic Republic of the Congo (DRC, 8,379 cases), Madagascar (5,583 cases),
Uganda (436 cases), and Tanzania (World Health Organization 1983, Abedi et al
2018).
Natural foci of plague are known to exist in broad areas of Africa. These include
areas in the Democratic Republic of the Congo, Kenya, Lesotho, Libya, Madagascar,
Mauritania, Mozambique, Namibia, Senegal, South Africa, Tanzania, Uganda, and

probably Egypt. In Asia, Endemic foci are found in Cambodia, China, India, Indone-
sia, Iran, Mongolia, Myanmar, Nepal, Vietnam, and the southern part of the Arabian
Peninsula, the Yemen-Saudi Arabian border, and in Saudi Arabia (Tikhomirov 1999).
Plague is one of three epidemic diseases still subject to the International Health
Regulations and notifiable to the World Health Organization (1983). Recently,
Madagascar in Africa reported a fatal plague outbreak in August 2017 (WHO/
AFRO).
Murine Typhus
Murine typhus, also called endemic typhus or flea-borne typhus, is a disease caused
by a bacterium “Rickettsia typhi.” Murine typhus is spread to people through contact
with infected fleas. People get sick with murine typhus when infected flea feces are
rubbed into cuts or scrapes in the skin. In most areas of the world, rats are the main
animal host for fleas infected with murine typhus. Murine typhus occurs in tropical
and subtropical climates around the world where rats and their fleas live (Murine
typhus). Currently there have been reports of the presence of Rickettsia typhi in
America in countries like Brazil in 2005, which reports the presence of rickettsial
antibodies to Rickettsia typhi in a rural community as well as other Rickettsia and
Rickettsia rickettsii, causal agent of Rocky Mountain spotted fever (da Costa et al.
2005); a similar study was conducted in Argentina also founding these antibodies in
a healthy population of a community rural (Ripoll et al. 1999). The importance about
these studies is the presence of R. typhi in the population which has already been
infected possibly being misdiagnosed (Peniche Lara et al. 2012). In Arab countries,
murine typhus seems to be frequent in Tunisia (Znazen et al. 2013) and maybe in
Algeria and Egypt (Angelakis et al. 2010).
Relapsing Fever
Relapsing fever is characterized by recurring episodes of fever and nonspecific

symptoms (e.g., headache, myalgia, arthralgia, shaking chills, and abdominal com-
plaints). The illness is caused by infection with Borrelia species that vary their
surface antigens, lending to repeated spirochetemias and stimulation of the immune
system by each new antigen and a febrile response by the patient (Goubau 1984;
Dennis and Hayes 2005). These Borrelia (spirochetes) are transmitted to humans by
exposure to the bite of an infected Ornithodoros tick (TBRF) or contact with the
hemolymph of an infected human body louse (Pediculus humanus) (louse-borne
relapsing fever [LBRF] or epidemic relapsing fever) (Southern and Sanford 1969).
LBRF is caused by infection with Borrelia recurrentis. These spirochetes are
introduced by crushing the louse (e.g., when scratching), which releases the insect’s
infected hemolymph and contaminates abraded or normal skin and mucous mem-
branes (Dworkin et al. 2008). In Arab countries, louse-borne relapsing fever
occurred in Sudan (Ahmed et al. 1980). It remains endemic and seasonally epidemic
in the highlands of Sudan and Somalia and the hilly areas of Yemen (Warrell 2017).
Chikungunya
Chikungunya virus (CHIKV) is an alphavirus whose principal vectors are the Aedes
aegypti and Aedes albopictus mosquitoes. In the Middle East and North Africa
(MENA), the epidemiology of CHIKV remains poorly characterized despite recent
reports of outbreaks and novel transmission in the Arabian Peninsula. Autochthonous
transmission was identified in eight countries in the Arab region (Djibouti, Egypt, Iraq,
Kuwait, Saudi Arabia, Somalia, Sudan, and Yemen). Recently, CHIKVoutbreaks were
reported from Djibouti, Sudan, and Yemen (Humphrey et al. 2017).
Chikungunya virus (CHIKV) is an alphavirus of the Togaviridae family which is
transmitted by Aedes mosquitoes and causes epidemic arthritis or arthralgia together
with fever and rash (Rougeron et al. 2015). Since its discovery in 1952, CHIKV was
responsible for sporadic and infrequent outbreaks. However, since 2005, global
chikungunya outbreaks have occurred, inducing some fatalities and associated with
severe and chronic morbidity. Chikungunya is thus considered as an important
re-emerging public health problem in both tropical and temperate countries, where the
distribution of the Aedes mosquito vectors continues to expand (Rougeron et al. 2015).
West Nile Fever
West Nile virus (WNV) is a neurotropic human pathogen that is the causative agent
of West Nile fever and encephalitis (Colpitts et al. 2012). Others reported on the
occurrence of West Nile virus fever in Tunisia, the United Arab Emirates, Saudi
Arabia, Qatar, Jordan (Malik et al. 2013), and Morocco (Negev et al. 2015). The
virus has also spread to dengue-endemic countries such as Sudan, Yemen, Djibouti,
and Somalia.
Rift Valley Fever
Rift Valley fever (RVF) is a zoonotic disease and humans become infected through
contact with tissues of infected animals or mosquito bites. Infection in humans is
usually associated with mild to moderately severe influenza-like illness, but severe
complications such as retinal damage and blindness, encephalitis, or hemorrhagic
disease occur in about 1% of patients (FAO).
Outbreaks were reported exclusively from sub-Saharan Africa until 1977–1978,
when infections in 18,000 persons and 598 deaths were reported in Egypt (El-Akkad
1978; Meegan 1979). In 1987, after dam construction on the Senegal River caused
flooding in the lower Senegal River area, a major epidemic, which caused
200 human deaths, occurred for the first time in Mauritania (Digoutte and Peters
Fig. 3 Map summarizing the main trade movements of livestock (cattle and small ruminants) in the
region from the Horn of Africa at risk of RFV (FAO)
1989). In 2001, epidemic of RVF in southwestern Saudi Arabia and the neighboring
northwestern regions of Yemen represented the first occurrence of this disease
outside of Africa (Madani et al. 2003). In East Africa, epidemics have been associ-
ated with above average rainfall favouring the breeding of the mosquito vectors of
RVF. This has been the case in late 2006 and early 2007, when El Niño-driven
rainfalls dramatically affected the Horn of Africa, with subsequent flooding and RVF
outbreaks in Kenya, Somalia and Tanzania. In mid-October 2007, Rift Valley fever
cases in humans were detected in the Kosti District, White Nile state of Sudan
(FAO).
There is a relationship between transmission of RV virus and the trade of livestock,
and it is expected that there is a large trade flux of livestock moving from the African
eastern region to the Arabian Peninsula, Saudi Arabia and Yemen in particular. Sudan
and Somalia are the two countries of the Horn of Africa with the biggest volume of
livestock exports (cattle, sheep, and goats) (FAO) (Fig. 3).
Conclusions
A lot of vector-borne diseases are endemic in Arab countries, and there were no
specific policies and strategies to control their spread except the global strategies to
compact malaria. Leishmaniasis is the most VBD spread in most Arab countries.
Dengue is an emerging challenge, while schistosomiasis and Crimean-Congo hem-
orrhagic fever (CCHF) are still endemic in some countries. Most of the VBDs are
endemic is Sudan, while Algeria and Tunisia are the least Arab countries for
endemicity of VBDs.
The limitation of this work is that there were limited studies addressing the epide-
miology of VBDs in Arab countries especially about what is called “neglected tropical
diseases,” and accordingly authors looking for further studies strengthen the national
surveillance activities and regional coordination and partnership toward control and
elimination of VBDs in Arab countries within a global strategy.
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Health Impact of Airborne Fungi
57
Amal Saad-Hussein and Khadiga S. Ibrahim
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1422
Definition of Fungi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1422
Outdoor Fungal Exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1423
Indoor Fungi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1423
Measurement of Fungi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1424
Health Hazards of Exposure to High Concentrations of Fungi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1425
Mycotoxins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1427
Major Groups of Mycotoxins with Health Hazards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1427
Health Effects of Fungal Mycotoxins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1429
Occupational Health Hazards Due to Fungi and Mycotoxins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1430
Protection from the Risk from Fungi and Mycotoxins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1431
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1432
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1432
Abstract
Fungi are ubiquitous microorganisms present in outdoor and indoor environ-
ments. There are relationships between environmental fungal exposures and
human health effects. Exposure to indoor air pollutants might be more hazardous
for inhabitants than exposure to outdoor air pollutants. Known health effects from
fungal exposure include infection, illness from inhalation or ingestion of myco-
toxins, and various hypersensitivity disorders. Exposure to high concentrations of
indoor fungal spores can cause many health problems, such as bronchial asthma,
A. Saad-Hussein (*)
Department of Environmental and Occupational Medicine, Environmental Research Division,
National Research Centre, Cairo, Egypt
e-mail: amel_h@hotmail.com
K. S. Ibrahim
Department of Environmental and Occupational Medicine, National Research Centre,
Cairo, Egypt
e-mail: khadigasalah@yahoo.com

https://doi.org/10.1007/978-3-030-36811-1_59
1422 A. Saad-Hussein and K. S. Ibrahim
in addition the health hazards of exposure to high concentrations of mycotoxins

for long durations.
Mycotoxins are toxins naturally produced as secondary metabolites by some
fungi, such as aflatoxins, ochratoxins, zearalenone, trichothecenes, and
fumonisins. Aflatoxins appear particularly dangerous and capable of causing
disease and death in both humans and animals because of their carcinogenic
properties. Reducing moisture, killing fungi, and removing contaminated mate-
rials can decrease this risk of morbidity.
Keywords
Fungi · Mycotoxins · Health problem
Introduction
Airborne particles are present throughout the environment. Bioaerosols are very
small airborne particles (ranging from 0.001 to 100 μm) that originate from plants,
animals, and microorganisms (Georgakopoulos et al. 2009). These microorganisms
could be pathogenic or nonpathogenic and dead or alive and include viruses,
bacteria, and fungi (Mandal and Brandl 2011). The basic sources for these micro-
organisms in bioaerosols are soil, water, plants, animals, and humans. Regular or
ordinary human activities (e.g., coughing, washing, toilet flushing, talking, walk-
ing, sneezing, and sweeping floors) can generate microorganisms in bioaerosols
(Chen and Hildemann 2009). Bioaerosols play an important role in the dispersal of
microorganisms over long distances (Després et al. 2012; Womack et al. 2015).
Environmental conditions, in the form of temperature and humidity, can influence
the extent of formation and dispersal of microorganism in bioaerosols due to
their controlling effects on the growth of microorganisms (Dedesko et al. 2015).
Microorganisms in bioaerosols are of many different forms and are affected by
climate, ventilation, and the quality of life (Ruzer and Harley 2005). The airborne
microbial quantity and quality vary with the time of day, year, and location
(Lighthart 2000).
Definition of Fungi
A fungus is any member of the group of eukaryotic organisms that includes

microorganisms; some of these are pathogenic (e.g., Aspergillus, Fusarium, etc.),
while others are of value to human and animal development (such as yeasts and
some mushrooms).
Fungi are common in indoor and outdoor environments, but indoor airborne
fungal concentrations are lower in outdoor air. The most common detectable air-
borne fungi, both indoors and outdoors, and in all seasons and regions, are
57 Health Impact of Airborne Fungi 1423
Cladosporium, Penicillium, and Aspergillus. Fungi in bioaerosols are not only

abundant but also affect physical and chemical processes in the atmosphere
(Womack et al. 2015). Fungal concentrations are highest in autumn and summer
and lower in the winter and spring.
Fungal spores often settle on surfaces and will not germinate unless there is
sufficient moisture. When moisture or even high humidity is available, spores can
germinate and form fungal colonies, from which thousands of new spores are
produced. If the new spores settle on wet or damp organic materials, then they too
develop into new fungal colonies and the process continues.
Outdoor Fungal Exposure
Outdoor fungi reach concentrations of fungal spores in outdoor air from 50 spores/
m3 during cold, snowy weather to 50,000 or more spores/m3 of air during warm
moist seasons as mentioned (Barnes et al. 2000; Pashley et al. 2012). Temperature
and dew point are important factors that determine the types of spores found in
outdoor air; for example, ascospores are associated with precipitation, while
Alternaria and Cladosporium are associated with drier conditions (Troutt and
Levetin 2001). Alternaria is the most prevalent fungus in dry, warm climates
(Pulimood et al. 2007; Targonski et al. 1995). Xerophilic spores, such as Alternaria,
Cladosporium, and Epicoccum, tend to peak during low humidity in the afternoon,
while hydrophilic spores such as ascospores and basidiospores (mushrooms, puff-
balls) tend to peak during high humidity conditions.
Cladosporium is the most commonly identified outdoor fungus (Bensch et al.
2012) and is found on dead plants or vegetable matter. Aspergillus can be isolated
from house dust and is also found in compost heaps and dead vegetation. Penicillium
is found in soil, food and grains, and house dust. These fungi grow in water-damaged
buildings, wallpaper, and decaying fabrics.
Indoor Fungi
Outdoor air is the dominant source of indoor fungi; fungi are also sometimes present
as contaminants of building materials and contents. Fungi usually enter buildings
from outdoor air through doors and windows and from air intake for heating,
ventilation, and air conditioning systems. If elevated moisture conditions persist
for a sufficient time in a building, fungal growth and sporulation can occur.
Indoor fungal concentrations are likely to vary depending on building construc-
tion and the indoor temperature and humidity. A large number of microorganisms,
including different types of fungi, often colonize in the filters of air-conditioning
systems and represent a direct source of fungal air pollution. The indoor microor-
ganisms present in bioaerosols can settle on different surfaces and can develop in
layers on the walls, windows, and food remains, under carpets, and on any other
damp surface (Lee 2011).
Measurement of Fungi
Estimation of exposure to fungi in the environment occurs by three phases: sampling

of the air, morphological identification, and interpretation. For identification of
fungi, methods vary from direct microscopy or culture-based volumetric air sam-
pling for measurement of fungal metabolites such as beta-D-glucan or ergosterol.
Fungal diversity can also be evaluated by immunoassays, polymerase chain reaction,
and genomic sequencing (Levetin 2004). Further, many fungal allergens are broadly
cross-reactive (Chou et al. 2011).
For estimation of environmental fungi, aerosol samples are collected for 10 min
using a low flow personal sampling pump pre-calibrated to a flow of 2/1 min and
from surfaces located 1.5–2.5 m above the floor level. Incubation of the fungal
colonies on Sabouraud Dextrose Agar (SDA) media plates for 7 days at 37 C is used
for fungal culturing.
For fungal culture colonies (Fig. 1), colonies are aseptically transferred to differ-
ent Sabouraud Dextrose Agar slant tubes and incubated at 37 C (Fig. 2). Fungal
growth on the plate is then identified morphologically using a microscope.
Fig. 1 Fungal slants. (Saad-

Hussein et al. under review)
Fig. 2 Some photos of fungal culture on Sabouraud Dextrose Agar. (Saad-Hussein et al. under
review)
For additional later confirmation, cultures are stored for future DNA extraction
and PCR identification of fungal species, as well as genomic sequencing is becoming
more widely used (Levetin 2004).
Gas chromatography/mass spectrometry, liquid chromatography/mass spectrom-
etry, the Limulus amebocyte lysate test, and enzyme-linked immunosorbent assay
(ELISA) can be used for detection of fungal cell wall components, microbial volatile
organic compounds, mycotoxins, and allergens and can reveal the nature of fungal
diversity and concentrations within house dust and/or air (Méheust et al. 2014).
Health Hazards of Exposure to High Concentrations of Fungi
Fungal diseases are often caused by fungi that are common in the environment.
Fungi live outdoors in soil and on plants and trees as well as on many indoor surfaces
and on human skin. Most fungi are not dangerous, but over 100 species of fungi
are associated with serious human and animal infections. Indoor fungi cause
adverse health effects (Etzel et al. 1998; Harrison et al. 1992). Candidiasis is a
fungal infection caused by yeasts of the genus Candida. There are over 20 species of
Candida yeasts that can cause infection in humans, the most common of which is
Candida albicans. Candida yeasts normally reside in the intestinal tract and can be
found on mucous membranes and skin without causing infection; however, over-
growth of these organisms can cause symptoms to develop. Symptoms of candidiasis
vary depending on the area of the body that is infected.
Exposure to fungi can cause several types of human health problems, mainly
respiratory irritations, infections, and allergies (Johanning et al. 1996). Diseases are
frequently associated with exposure to large amounts of fungal spores in the air
(Mendell et al. 2011). Infectious diseases caused by inhalation of different fungi
depend not only on the number of spores inhaled but also on the site of deposition in
the respiratory system, which is directly related to the aerodynamic diameter of
fungal spore. Bioaerosol containing fungi smaller than 5 μm are called respirable
particulate and are able to penetrate into the alveoli and lead to allergic alveolitis and
other serious illnesses (Pastuszka et al. 2000).
Aspergillosis is an infection caused by Aspergillus, a common fungus that lives
indoors and outdoors. Most people breathe in Aspergillus spores every day without
getting sick. However, people with weakened immune systems or lung diseases are
at a higher risk of developing health problems due to Aspergillus, such as allergic
reactions, lung infections, and infections in other organs. Occupational exposure to
high concentrations of environmental fungi is related to the prevalence of pulmonary
abnormalities in exposed workers in industrial areas. Workers in the ceramic ind-
ustry are at risk of developing respiratory problems and ventilatory function
abnormalities not only due to their exposure to dusty environment but also due to
their exposure to airborne fungi, which is not influenced by the duration of exposure
(Saad et al. 2006). The authors detected increases in the indoor concentrations of
fungal spores of Penicillium, Aspergillus fumigatus, and Aspergillus niger. Increased
Fig. 3 Sputum cultures (Saad et al. 2006)
levels of fungal spores are related to the elevation of these fungi in sputum cultures
(Fig. 3) and the skin sensitivity through skin prick test (Saad et al. 2006).
Invasive fungal infections are receiving more interest, largely because of the
increasing size of the population at risk. Fungal infections are a major health problem
for immunocompromised persons, patients treated with corticosteroids or receiving
chemotherapy.
Fungal eye infections are extremely rare but can be very serious. The most
common way for someone to develop a fungal eye infection is as a result of an
eye injury, particularly if the injury was caused by plant material such as a stick or a
thorn. Inflammation or infection of the cornea (the clear, front layer of the eye) is
known as keratitis, and inflammation or infection in the interior of the eye is called
endophthalmitis. Many different types of fungi can cause eye infections. Moreover,
climate warming should not be neglected as a potential risk factor for the increase in
fungal health problems. Fungal keratitis, a fungal infection of the human
cornea, increased from 1995 to 2007 and is likely to continue to increase until
2030 (Saad-Hussein et al. 2011).
Fungal nail infections are common infections of the fingernails or toenails that
can cause the nail to become discolored, thick, and more likely to crack and break.
Infections are more common in toenails than fingernails. The technical name for a
fungal nail infection is “onychomycosis.” Moreover, ringworm is a common skin
infection that is caused by a fungus. It can cause a circular rash (shaped like a ring)
that is usually red and itchy. The fungi that cause this infection can live on skin,
surfaces, and on household items such as clothing, towels, and bedding.
Mucormycosis (zygomycosis) is a serious but rare fungal infection caused by a
group of fungi called mucormycetes. These fungi are present in the environment and
mainly affect people with weakened immune systems. It most commonly affects the
sinuses or the lungs after inhaling fungal spores from the air or the skin after the
fungus enters the skin through a cut, scrape, burn, or other type of skin trauma.
Toxigenic fungi are fungi producing toxigenic mycotoxins and can cause addi-
tional adverse health effects (Johanning et al. 1996). Indoor fungi are a source of the
mycotoxins in buildings, and people living or working in these areas have increased
chances of suffering adverse health effects. Some indoor mycotoxins are produced
by Alternaria, Aspergillus (multiple forms), Penicillium, and Stachybotrys (Nielsen

2003). Stachybotrys chartarum contains a higher number of mycotoxins than other
types and grows in the indoor environment and is associated with allergies and
respiratory inflammation (Mendell et al. 2011). An infestation of this fungus is
common in buildings containing gypsum board, as well as on ceiling tiles, and
recently Stachybotrys chartarum was recognized as the fungus causing problems.
Therefore, it is essential to stress on the importance of good ventilation and moisture
control in residential homes and community buildings.
Mycotoxins
Mycotoxins are toxins naturally produced by certain types of fungi as secondary

metabolites (Richard 2007). The fungi that produce mycotoxins grow on foods such
as cereals, dried fruits, nuts, and spices. These fungi can occur either before harvest
or after harvest, during storage, or on/in the food itself under warm and humid
environmental conditions. Mycotoxins are produced mainly by different species of
fungi, including Aspergillus, Penicillium, Fusarium, Trichoderma, and cellulolytic
Stachybotrys chartarum (Kuhn and Ghannoum 2003). Mycotoxin production
in vitro depends on several factors including genetic predisposition of the mold to
produce mycotoxins, substrate, humidity, and the presence of fungicides or other
competitive microbial species (Kosalec et al. 2009).
Most mycotoxins are chemically stable and overcome food processing. Several
mycotoxins have been identified, but the most commonly observed mycotoxins
capable of causing disease and death in both humans and other animals are afla-
toxins, ochratoxin A, patulin, fumonisins, and zearalenone (Bennett and Klich
2003). Mycotoxins appear in the foodstuffs as a result of mold infection of crops
both before and after harvest. Exposure to mycotoxins occurs either directly
(by eating infected food) or indirectly (from animals that are fed on contaminated
feed, in particular milk and milk products).
Major Groups of Mycotoxins with Health Hazards
Aflatoxins (AFs) are among the most poisonous mycotoxins and are produced by
some molds such as Aspergillus flavus and Aspergillus parasiticus (Martins et al.
2001), as well as Penicillium, Aspergillus fumigatus, and Aspergillus niger. The term
aflatoxin refers to four different types of mycotoxins (B1, B2, G1, and G2) produced
(Yin et al. 2008). The crops that are frequently affected by Aspergillus spp. include
cereals (corn, sorghum, wheat, and rice), oilseeds (soybean, peanut, sunflower, and
cotton seeds), spices (chili peppers, black pepper, coriander, turmeric, and ginger),
and tree nuts (pistachio, almond, walnut, coconut, and Brazil nut). These toxins can
also be detected in the milk of animals that are fed contaminated feed, in the form of
aflatoxin M1, a metabolite of aflatoxin B1.
Aflatoxin B1 (AFB1) is a potent carcinogen and has several adverse health

effects. It’s the most hepatocarcinogenic compound, causing various cancers of the
liver and other body organs in humans and animals (Hamid et al. 2013). AFs mainly
enter the body through contaminated diets. Occupational exposure to AFs occurs by
inhalation of dust generated during the handling and processing of contaminated
crops (National Toxicology Program 2011; Saad-Hussein et al. 2016a, b).
Large doses of AFs lead to acute poisoning (aflatoxicosis), a life-threatening
condition, but chronic exposure to low doses of AFs can lead to liver damage.
AFs are genotoxic, meaning they can damage DNA and cause cancer in animals.
AFs are also considered as carcinogens to human based on the National Toxicology
Program (2011). Of the 550,000–600,000 new hepatocellular carcinoma (HCC)
cases worldwide each year, about 25,200–155,000 can be attributed to aflatoxins
exposure (Liu and Wu 2010).
Estimation of exposure to varying dietary AFs can be substituted by a more
precise evaluation of total AFs exposure in body fluids (such as milk, urine and
blood) by measuring AF metabolites (Hall and Wild 1994) such as aflatoxin M1
(AFM1) (Cheng et al. 1997; Romero et al. 2010; Saad-Hussein et al. 2012).
AFM1 is the major metabolite of AFB1 detected in the biological fluids
of exposed individuals (Groopman et al. 1992a, b; Wang et al. 2001). Urinary
levels of AFM1 in Chinese adults correlate with the intake of AFB1 in the diet
(Zhu et al. 1987).
Ochratoxin is a mycotoxin that is produced by Penicillium and Aspergillus
species in three secondary metabolite forms, A, B, and C. Ochratoxin B (OTB) is
a non-chlorinated form of ochratoxin A (OTA), while ochratoxin C (OTC) is an ethyl
ester form of ochratoxin A (Bayman and Baker 2006). Contamination of cereals and
cereal products, coffee beans, dry vine fruits, wine and grape juice, spices, and
liquorice occurs in parts of the world. OTA forms during crop storage.
Ingestion is the main source of exposure to OTA. Nephrotoxicity is common
with OTA poisoning (Mateo et al. 2007; Bui-Klimke and Wu 2015). OTA is a
putative human carcinogen according to the International Agency for Research on
Cancer (IARC 1993). A frequent site for OTA-induced cancer is the urinary tract
(Mateo et al. 2007; Bui-Klimke and Wu 2015). While the evidence for OTA as a
human carcinogen is still limited due to the high number of confounding factors,
OTA is a renal carcinogen in several animal species (Hagelberg et al. 1989; Duarte
et al. 2011).
OTA can also affect fetal development and the immune system (Bondy and
Pestka 2000). OTA exposure reduces mitochondrial function and can lead to apo-
ptosis in neurons (Zhang et al. 2009). Other adverse effects of OTA include
increased lipid peroxidation and inhibition of mitochondrial respiration due to the
inhibition of macromolecular synthesis (Kuiper-Goodman and Scott 1989;
Marquardt and Frohlich 1992). Genotoxicity assays with high specificity suggest
that OTA is directly genotoxic (Haighton et al. 2012).
Citrinin is a mycotoxin produced by several species of the genera Aspergillus,
Penicillium, and Monascus. Citrinin occurs mainly in stored grain (Föllmann
et al. 2014) such as wheat, rice, corn, barley, oats, rye, and food colored with
Monascus pigment. Citrinin is associated with yellowed rice disease in Japan and
is a nephrotoxin in all animal species tested (Bennett and Klich 2003). Citrinin
can also act synergistically with OTA to depress RNA synthesis in murine
kidneys (Čulig et al. 2017).
Patulin is a mycotoxin produced by molds such as Aspergillus, Penicillium, and
Paecilomyces fungal species. Patulin can occur in grains, moldy fruits, and other
foods. Major human dietary sources of patulin are apples and apple juice made from
affected fruit (Moss 2008). The acute symptoms in animals include liver, spleen, and
kidney damage (Pal et al. 2017). Patulin increases the activities of serum alanine
transaminase (ALT) and aspartate transaminase (AST) in mice and also causes lipid
peroxidation as measured by thiobarbituric acid reactive substances (Song et al.
2014). Patulin alters the intestinal barrier function (Mahfoud et al. 2002) and
damages the immune system in animals (Moss 2008). However, patulin is consid-
ered to be genotoxic, although its carcinogenic potential effect is unknown.
Fusarium is produced by over 50 species of Fusarium and has a history of
infecting cereals such as wheat and maize (Schaafsma and Hooker 2007). The most
toxicologically important fusarium mycotoxins are trichothecenes (including
deoxynivalenol (DON) and T-2 toxin (T-2), zearalenone (ZEN), and fumonisin B1
(FB1). Fusarium can be acutely toxic to humans, causing rapid irritation to the skin
or intestinal mucosa and lead to diarrhea. Fusarium is related to esophageal cancer in
humans (Antonissen et al. 2014).
Chronic exposure to fusarium causes liver and kidney toxicity in animals
(Antonissen et al. 2014). Exposure of pigs to high concentrations of DON causes
abdominal distress, malaise, diarrhea, emesis, and even shock or death, while in
horses fumonisins can cause equine leukoencephalomalacia (ELEM) of the brain
(Devreese et al. 2013). Reported chronic effects of trichothecenes exposure
in animals include suppression of the immune system. The effects of zearalenone
are estrogenic and can cause infertility at high intake levels, particularly in pigs.
Health Effects of Fungal Mycotoxins
The negative health effects of mycotoxins depend on the concentration, the duration
of exposure, and individual sensitivities. The concentrations experienced in a
normal home, office, or school are often too low to trigger a health response in
occupants. The effects of some food-borne mycotoxins are acute, with symptoms
of severe illness appearing quickly after consumption of food products
contaminated with mycotoxins. Other mycotoxins occurring in food have been
linked to long-term effects on health, including the induction of cancers and immune
deficiency. Exposure to fungi and mycotoxins can affect several organs in the
body with several adverse health effects. The nervous system may be affected
directly or through immune cell activation, thus contributing to neurodevelopmental
disorders such as autism spectrum disorder (Ratnaseelan et al. 2018).
Occupational Health Hazards Due to Fungi and Mycotoxins
Organic dusts, such as cotton dust, grain dust, and wood dust, are commonly
contaminated with fungi, and their mycotoxins could precipitate in development of
numerous symptoms and diseases. But little is known about blood and tissue
concentrations after inhalation of mycotoxins and about the human health effects
due to this route of exposure (Nielsen 2003), although it is known that mycotoxins
occur in bioaerosols and dust at workplaces (Eduard et al. 2012). This could be partly
because methods for mycotoxin detection are not sensitive enough for the small dust
collections obtained by personal sampling, which is needed for inhalation exposure
measurements.
The health risk from ingesting mycotoxin-contaminated agricultural products is
widely known and to a certain extent controlled. Most publications deal with
the hazards due to the toxic effects of ingested mycotoxins (Hussein and Brasel 2001;
Bennett and Klich 2003). But few studies discuss the effect of inhalation of air contam-
inated with fungus and mycotoxins. Occupational pulmonary mycotoxicoses have been
reported as a result of inhaled fungal toxins through organic dust (Perry et al. 1998).
Saad-Hussein et al. (2016b) detected high concentrations of Aspergiluus in the
workplaces that can lead to elevation of the serum levels of AFB1 in the exposed
workers. Chronic occupational exposure to Aspergillus flavus in flour mill and
bakery workplaces increases serum levels of AFB1 and liver enzymes in workers
inhaling flour dust during the different processes, and these elevations increased with
greater levels of environmental concentrations of Aspergillus flavus (Saad-Hussein
et al. 2016). Exposure to fungi in textile workers causes significant elevations of
tumor biomarkers related to the elevated urinary levels of AFM1, especially in
allergic textile workers regardless of the duration of exposure, as confirmed by
allergic response to skin prick test to the fungus (Saad-Hussein et al. 2013a).
Wheat handlers exposed to high concentrations of Aspergillus flavus have a high
levels of serum AFB1 and the tumor biomarker alpha-l-fucosidase, suggesting that
they are at high risk of developing HCC (Saad-Hussein et al. (2014a).
The role of GST polymorphism in detection of gene susceptibility to the health
hazards of occupational exposure to high concentration of toxigenic fungi, such as
Aspergillus and Penicillium, has been examined in several studies.
Occupational exposure to organic dust increases AFB1/Alb and liver enzymes of
exposed workers, and GST gene polymorphism plays an important role in suscep-
tibility to hepatic parenchyma cell injury, except in workers with GSTT1 and
GSTM1 null genotype. Gene susceptibility seemed to have a minor role compared
to the role of environmental exposures. Workers with GSTT1 have a lower ability to
detoxify AFB1 (Saad-Hussein et al. 2013b, 2016).
One reason for this may be due to the relationship between the oxidative stress
produced by the elevation of AFB1 and the scavenger effect of the antioxidant
glutathione reductase. Exposure of wheat milling workers to AFB1 increases MDA
levels (marker of oxidative stress). Since GST has a crucial role in the detoxification
of AFB1, polymorphisms in GST influences the levels of plasma Zn and vitamin C
(Saad-Hussein et al. 2014b). Glutathione pathway is reported to play a vital role in
Arachnoid acid(2)
Cox-2 (5)
DNA/protein synthesis
Cytokines (1,2, 5)
Fenton reaction (3) Inflammatory response
iNOS (5)
NO (1)
NOX-2 (1)
Bcl-2/Bax (1-5)
Cytochrome C (1,3,4)
Cytocrome P450 (3,4)
AFB1 (1) Casp-3 (1-5)
FB (2) ROS Mitochondria
OTA (3)
PAT (4)
ZEA (5)
Nrf2 (1,3) Ca2+ level (3)
CAT (1,3,4, 5) Hsp 25/70 (2)
Apoptosis
GPx (1,2, 3, 5) MAPKs (2, 4)
SOD (1-5) p53 (1, 4, 5)
GSH
Lipid peroxidation
MDA
Fig. 4 Summary of the intracellular lesions associated with oxidative stress induced by the
mycotoxins. AFB1, aflatoxin B1 (1); FB1, fumonisin B1 (2); OTA = ochratoxin A (3);
PAT = patulin (4); ZEA = zearalenone (5). SOD = Superoxide dismutase; CAT = catalase;
GPx = glutathione peroxidase; Nrf2 = nuclear factor erythroid 2; NO = nitric oxide; GSH = glu-
tathione; MDA = malondialdehyde; Casp-3 = caspase protein; Hsp = heat shock proteins;
MAPKs = mitogen-activated protein kinases; COX-2 = cyclooxygenase-2; iNOS = nitric oxide
synthase; Nox2 = NADPH oxidase 2. The numbers in brackets indicate the mycotoxins involved in
each process. For example, AFB1 (1) causes changes in intracellular antioxidant mechanisms such
as Nrf2, SOD, GPx, and CAT expression. OTA (3) can cause damage due to oxidative stress through
the generation of hydroxyl radicals and decrease the expression of the intracellular antioxidant
enzymes (GPx, CAT, and SOD) promoting an increase in MDA levels. The toxic effect of PAT (4) is
associated with ROS generation and activation of p53 protein and the cleaved caspase 3, and the
decrease in SOD and CAT activations. (da Silva et al. 2018)
the detoxification of AFB1 (Farombi and Nwaokeafor 2005). The role of oxidative
stress due to exposure to high concentrations of mycotoxins is shown in Fig. 4.
Protection from the Risk from Fungi and Mycotoxins
It is important to note that fungi that produce mycotoxins can grow on a variety of
different crops and foodstuff and can penetrate deep into food and not just grow on
the surface. These fungi usually do not grow well in dried and stored foods, as they
need humidity and warmness. Proper drying of stored foods and maintenance of a
dry state, along with appropriate storage, are effective measures to limit the
growth of these fungi and the production of their mycotoxins. Some mycotoxins
are harmful to other microorganisms such as other fungi or even bacteria,

e.g., penicillin is one example (Keller et al. 2005), although further studies on this
aspect are needed.
Recommendations to minimize the health risk from exposure to mycotoxins:
• Discard any foodstuff that looks moldy, discolored, or shriveled, and inspect
whole grains (corn, sorghum, wheat, and rice), dried figs, and nuts (peanuts,
pistachio, almond, walnut, coconut, Brazil nuts, and hazelnuts), to decrease
ingestion of foods contaminated with aflatoxins.
• Avoid ingestion of damaged grains (either before or during drying and stored
grains), as damaged grain is more prone to invasion of fungi and therefore
production of mycotoxins.
• Buy grains and nuts that are as fresh as possible.
• Make sure that foods are stored properly (dry and not too warm) and kept free of
insects.
• Not to keep foods for extended periods of time before being used.
• Provide good indoor ventilation and minimizing accumulation of fine dust.
Conclusion
• Fungi are ubiquitous microorganisms that are present in outdoor and indoor
environments. All fungi are capable of producing toxins (mycotoxins). Fungi
exposure can indeed cause adverse health effects, including infections, hypersen-
sitivity disorders, and toxic/irritant effects. There are a variety of symptoms
resulting from indoor mold exposure, including fatigue, nausea, cognitive dys-
function, and immune dysfunction, as well as putative syndromes such as “toxic
mold syndrome” and “mold-induced immune dysregulation.” In addition, chron-
ically high dietary levels of aflatoxins have been implicated in the development
of hepatocellular carcinoma.
• Reduced indoor exposure using a variety of interventions primarily aimed at
reducing moisture, killing fungi, and removing contaminated materials has been
shown to decrease this risk of morbidity.
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Water Quality and Its Impact on Health
Care in the Arab World 58
Mohamed F. Hamoda
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1438
Water Quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1439
Water and Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1440
Water Supply and Sanitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1443
Drinking Water Quality Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1446
Aesthetic/Acceptability Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1446
Microbial Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1447
Chemical Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1447
Radiological Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1447
Water Pollution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1448
Wastewater Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1450
Water Reuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1451
Reuse Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1456
Health Impact . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1457
Environmental, Social, and Economic Concerns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1458
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1459
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1460
Abstract
Water is vital to sustain all forms of life, but if contaminated, it can be a source of
spreading various diseases; thus the water quality should be good to be safe for
use as to protect public health. Contaminated water may contain disease-causing
organisms such as bacteria, protozoa, viruses, and helminths as well as some toxic
chemicals. Known pathogens for which water is a transmission route continue to
increase as new or previously unrecognized pathogens continue to be discovered.
M. F. Hamoda (*)
Environmental Engineering, Department of Civil Engineering, Kuwait University, Safat, Kuwait
e-mail: mfhamoda@gmail.com

https://doi.org/10.1007/978-3-030-36811-1_61
1438 M. F. Hamoda
Childhood diarrhea is still the second-leading cause of childhood mortality. This

chapter presents water supply and sanitation issues and the health impacts of
contaminated water with focus on drinking water quality aspects in the Arab
countries. Adequate sanitation reduces or prevents human fecal pollution of the
environment, thereby reducing or eliminating transmission of waterborne dis-
eases from the source and compliments the efforts to safeguard public health and
improve health care. The sources of water pollution and the methods of water and
wastewater treatment are discussed with emphasis on current practices in the
Arab region. Since most Arab countries suffer from water scarcity, water reuse
has a great potential in significantly increasing available water resources and
maintaining a clean environment, as long as health impacts of reuse of treated
wastewater are taken into consideration. Finally, supply of safe drinking water
and adequate sanitation is essential for improving health care in the Arab coun-
tries where most people live in rural areas.
Keywords
Drinking water quality · Health care · Sanitation · Water reuse · Water pollution ·
Wastewater treatment
Introduction
Water is essential for all forms of life in the environment. However, water can be
contaminated and can be a cause of spreading various diseases; thus the quality of
water should be good to be safe for use. Clean water is needed in homes, commu-
nities, businesses, industries, and nature. It is used for drinking, bathing, cooking,
swimming, fishing, and boating. It is also used in agriculture, industry, and in almost
all activities in life. Safe, clean water leads to better health. However, there is no
guarantee that clean water, relied on so heavily, will always be available.
The supply of clean water on earth is finite, and water quality is being threatened
by water pollution. Water quality degradation may be caused by natural processes
(e.g., erosion and sedimentation) or anthropogenic sources (e.g., municipal and
industrial discharges and agricultural runoff) which threaten its quality. It is becom-
ing a serious problem today, in spite of endless efforts to control it. To act effectively
in preventing disease and promoting health, it is important to know not only how
much disease is caused by factors related to water, sanitation, and hygiene but also
how effectively changes in their management can improve health. Therefore, water
supply must be adequate, safe, and accessible to all. In addition, every effort should
be made to achieve proper sanitation. Improving access to safe drinking water and
sanitation can result in tangible benefits to health care.
The Arab region is ranked as the most water scarce in the world. While 5% of the
world’s population resides in the 22 Arab countries, the region has less than 1% of
the world’s available freshwater supply. These startling statistics demonstrate that
water scarcity is a major threat to the region. Therefore, water resources management
receives much attention in the Arab region and includes water supply, wastewater
58 Water Quality and Its Impact on Health Care in the Arab World 1439
treatment, and water reuse. Estimates that, for Arab sustainable development, water
supply and wastewater treatment capacity will have to more than double over the
next 10 years in order to accommodate the region’s population and economic growth
(ESCWA 2015). Population and economic growth remains more dynamic among the
six Arab countries of the Gulf Cooperation Council (GCC), which include Bahrain,
Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates, as compared to
the rest of the Arab nations. Meanwhile, since most of the people in Arab countries
live in rural areas, more attention is currently focused on development in rural areas.
This chapter introduces the practical concepts in water and health, water quality,
water pollution and control, drinking water standards, sanitation, wastewater treat-
ment, and water reuse as related to health care in the Arab countries.
Water Quality
All the waters of the world are connected by the hydrologic cycle. The rivers and
streams are connected to the lakes, ponds, and wetlands. The surface water is
connected to the groundwater. The rivers are connected to the bays and estuaries,
which are ultimately connected to the seas and oceans. These connections are
extremely important to water quality; they all allow materials entering the water at
any point in the hydrologic cycle to move from one water body to the next. Although
water takes on many different forms as it moves continuously through the hydrologic
cycle, the world’s supply of water is finite. With the different forms of water in
nature, all have unique water quality characteristics. While it is relatively easy to
express the quantity of water, it is very difficult to express its quality because a large
number of variables determine the water quality. Although water has the simple
formula H2O, it is a complex chemical solution. “Pure” water essentially is nonex-
istent in the natural environment. Natural water, whether in the atmosphere, on the
ground surface, or under the ground, always contains dissolved minerals and gases
as a result of its interaction with the atmosphere, minerals in rocks, organic matter,
and living organisms.
By definition, water quality refers to the chemical, physical, biological (bacteri-
ological), and radiological characteristics of water. In particular, water quality
describes the condition of the water, usually with respect to its suitability for a
specific purpose such as drinking or swimming. Factors affecting water quality
include pollutants that can be released into the environment as gases, liquids,
dissolved substances, or particulates and can enter aquatic ecosystems by atmo-
spheric deposition, soil erosion, seepage, runoff, or direct discharge of wastewaters.
Examples of physical water quality parameters are temperature, salinity, total
dissolved solids (TDS), color, odor, and turbidity. Examples of chemical water
quality are heavy metals, pH, dissolved oxygen (DO), biochemical oxygen demand
(BOD), chemical oxygen demand (COD), nitrogen, and phosphorus. Examples of
biological water quality parameters are pathogens and indicator microorganism
(fecal coliforms, E. coli). Generally concentrations of physical and chemical param-
eters are in milligrams/liter (mg/L) except for some parameters such as pH. There are
standard methods used for determination of water quality parameters (APHA 2012).
1440 M. F. Hamoda
Countries of the Arab region get their water supply mainly from rivers, ground-
water, or seawater. Such waters have different qualities and should be treated to
remove impurities and obtain treated waters to satisfy drinking water quality stan-
dards. Different treatment methods are used, but by far the most costly processes are
those used in desalination of seawater. Disinfection is of unquestionable importance
in the supply of safe drinking water. The destruction of pathogenic microorganisms
is essential, and, in the Arab countries, it involves the use of reactive chemical agents
such as chlorine. Disinfection is an effective barrier to many pathogens (especially
bacteria) during drinking water treatment and is used for surface waters and for
groundwater subject to fecal contamination. Residual disinfection is used to provide
a partial safeguard against low-level contamination and growth within the water
distribution system.
Water and Health
The human body is approximately 70% water, and all functions of the body depend
on the fluid to transport vital nutrients to the various organs. An adult needs 2–3 l of
water daily which could be obtained by drinking water or through food. Drinking
water helps maintain the balance of body fluids. The functions of these bodily fluids
include digestion, absorption, circulation, creation of saliva, transportation of nutri-
ents, and maintenance of body temperature. The health effects of drinking contam-
inated water are a subject of immense complexities due to the variety and
concentrations of the contaminants encountered in the water that we drink. Such
contaminants could of microbial or chemical nature.
Several microbes could be found in water and could be broadly classified as
bacteria, viruses, protozoa, and helminths. On the other hand, numerous water-
related diseases could affect humans. Table 1 presents a classification of the groups
of water-related diseases in the Arab countries. Tiny worms and bacteria live in water
naturally and lead to microbial contamination of water. Most of the bacteria are
harmless, but some of them can cause devastating disease in humans, and since they
can’t be seen, they can’t be avoided. Most of these waterborne diseases are not found
in cities of some Arab countries (e.g., GCC countries) because of the sophisticated
water systems that filter and chlorinate water for different uses to eliminate all
disease-causing organisms (i.e., pathogens), but these diseases are common in
rural areas of a number of Arab countries. On the other hand, typhoid fever, cholera,
and many other diseases are still common in some Arab countries such as Yemen.
Diarrhea is the most important public health problem directly related to water and
sanitation in rural areas of the Arab countries. Diarrhea is caused by a variety of
microorganisms including viruses, bacteria, and protozoans. It causes a person to
lose both water and electrolytes, which leads to dehydration and, in some cases, to
death. The simple act of washing hands with soap and water can cut diarrheal disease
by one-third. Next to providing adequate sanitation facilities, it is the key to
preventing waterborne diseases. Meanwhile, infection of humans through water is
not limited to drinking since other routes are also possible. Figure 1 shows
Table 1 Groups of water-related diseases in the Arab countries

Group Diseases
Waterborne diseases (diseases transmitted by water) Cholera; typhoid
Bacillary dysentery
Infectious hepatitis
Giardiasis
Water-washed diseases (caused by lack of water) Scabies
Skin sepsis and ulcers
Yaws; leprosy
Lice and typhus; trachoma
Dysenteries; ascariasis
Parathyroid
Water-based diseases Schistosomiasis
Dracunculiasis
Bilharziasis
Filariasis
Threadworm
Water-related insect vector diseases Yellow fever
Dengue fever
Bancroftian filariasis
Malaria
Onchocerciasis
Fig. 1 Transmission pathways for water-related pathogens (WHO 2017a)

1442 M. F. Hamoda
transmission pathways for water-related pathogens. By far, most of the diseases are
transmitted through drinking water. Therefore, all natural waters should receive
adequate treatment, including disinfection before being provided to consumers
through a water supply system or as bottled water.
The relationship between water and health is not limited to pathogen since several
chemicals, heavy metals (Chaudhury et al. 2016) and radioactive materials could
reach water and cause diseases to humans. For instance, different levels of nitrates,
calcium, magnesium, and fluorides have detrimental effects on human health.
Fluoride concentration in drinking water, in particular, can affect the teeth. More-
over, sensitive biological-chemical functions can be easily altered by minute
amounts of just the right chemical to cause a disastrous chemical reaction in the
body. One example is bisphenol A (BPA), a hormone mimicker and endocrine
disruptor which can lead to feminization of males. BPA is found in consumer
products such as plastic bottles, nonstick cooking surfaces, and can liners.
Arsenic is a naturally occurring poison that can find its way easily into drinking
water through many pathways. Only 60 ppm (parts per million) is enough to poison a
grown person. Consumption of low levels of arsenic for a long period of time can
cause skin pigmentation and cancer of the skin, bladder, kidney, and liver. Therefore,
drinking water guidelines regulate arsenic at 10 ppb (parts per billion).
Certain serious illnesses result from inhalation of water droplets (aerosols) in
which the causative organisms have multiplied because of warm temperatures and
the presence of nutrients. These include legionellosis and Legionnaires’ disease,
caused by Legionella spp. and those caused by the amoebae Naegleria fowleri
(primary amoebic meningoencephalitis [PAM]) and Acanthamoeba spp. (amoebic
meningitis, pulmonary infections). Schistosomiasis (bilharziasis) is a major parasitic
disease in rural areas of Egypt and Sudan that is transmitted when the larval stage
(cercariae), which is released by infected aquatic snails, penetrates the skin. It is
primarily spread by contact with water. Availability of safe drinking water contrib-
utes to disease prevention by reducing the need for contact with contaminated water
sources – for example, when collecting water to carry to the home or when using
water for bathing or laundry as practiced in rural areas of some Arab countries.
It is likely that there are other pathogens that are also transmitted by water. This is
because the number of known pathogens for which water is a transmission route
continues to increase as new or previously unrecognized pathogens continue to be
discovered. Moreover, most of the human pathogens listed in Table 1, such as those
causing outbreaks of cholera or guinea worm disease, are common during the wars
as occurred in Iraq, Syria, and Yemen.
The greatest risk from water is only one vehicle of transmission. Contamination
of food, hands, utensils, and clothing can also play a role, particularly when domestic
sanitation and hygiene are poor. Improvements in the quality and availability of
water, in disposal of excreta, and in general hygiene are all important in reducing
fecal-oral disease transmission. Drinking-water safety due to microbes in water is
associated with consumption of drinking-water that is contaminated with human and
animal excreta, although other sources and routes of exposure may also be signifi-
cant. For pathogens transmitted by the fecal–oral route, drinking may not be related
only to fecal contamination. Some organisms grow in piped water distribution

systems (e.g., Legionella), whereas others occur in source waters (guinea worm
Dracunculus medinensis) and may cause outbreaks and individual cases. Some other
microbes (e.g., toxic cyanobacteria) require specific management approaches.
Water Supply and Sanitation
Almost one-tenth of the global disease burden could be prevented by improving

water supply, sanitation, hygiene, and management of water resources (Prüss-Üstün
et al. 2008). This is true knowing that a number of infectious diseases are caused by
pathogenic bacteria, viruses, protozoa, and helminths which are most common and
widespread health risk associated with drinking water, especially in developing
countries such as the Arab nations.
From hygienic standpoint, supply of clean water should go hand in hand with
provision of proper sanitation. Globally, about two million people die each year
from water-, sanitation-, and hygiene-related causes, mostly under the age of 5
(Trevett 2003). Childhood diarrhea is still the second-leading cause of childhood
mortality. Infants and young children are especially susceptible to diseases because
their immune systems are experiencing everything for the first time (WHO-UNICEF
2014). Even in developed countries, many mothers boil water before giving it to
their children – just to be doubly safe. In poor countries, the fuel for the fire can be so
expensive that mothers can’t afford to boil water and cook food. Meanwhile, Trevett
et al. (2004) mention a wide number of critical points in the capture, transport,
storage, distribution, and use of water during which contamination could be intro-
duced – for example, hands, containers, ladles, filter cloths, dust, insects, and
animals are potential sources of contamination that could lead to the presence of
bacteria or other pathogenic organisms in the water. In order to reduce the impacts of
these sources of pollution, better management of the water supply is necessary,
incorporating good practices from the source of supply to the consumer. In addition,
extreme hydrometeorological changes caused by climate change may affect water
quality, especially surface water, by altering physical and chemical variables includ-
ing pH, alkalinity, and temperature (Moreira and Bondelind 2017).
Sanitation reduces or prevents human fecal pollution of the environment, thereby
reducing or eliminating transmission of diseases from that source (although other
sources, such as animal excreta, may remain important). Effective sanitation isolates
excreta and/or inactivates the pathogens within feces. High-tech solutions are not
necessarily the best: some simple latrines can be very effective, while untreated
sewage distributes pathogens in the environment and can be the source of disease.
Interventions that work in rural areas of the Arab countries may be very different
from those in urban areas.
There has been increasing recent interest in “total sanitation” – i.e., achieving a
level of overall sanitation in a community that will significantly reduce disease. The
importance of sanitation extends to aspects of privacy, dignity, and school atten-
dance. Improved drinking water concerns access and use of water as well as
1444 M. F. Hamoda
monitoring its quality (safety). In the Arab countries, rural water sources have the
highest levels of fecal contamination but are the least monitored.
Access to safe and good-quality drinking water is a human right. Moreover, the
United Nations Millennium Development Goal 7, is to ensure environmental
sustainability; Target 10, is to reduce by half the proportion of people without
sustainable access to safe drinking water and basic sanitation; Indicator 30, Pro-
portion of the population with sustainable access to an improved water source; and
Indicator 31, Proportion of the population with access to improved sanitation.
Everyone has the right to water in sufficient quantity to meet their needs because
it is essential for human development, health, and well-being. In 2015, the Millen-
nium Development Goals target of 88% of the population having access to
improved sources of drinking water was achieved (WHO 2017a). However, approx-
imately 663 million people around the world still lack basic access to safe drinking
water (Fanucchi 2017). Water supply per person should be continuous and suffi-
cient for personal and domestic use but must also be free of microorganisms,
chemical substances, and radiological hazards which pose a threat to human health.
The lack of drinkable water, inadequate management of water resources, presence
of pathogenic organisms, and lack of sanitation and hygiene eventually increase the
presence of diseases that can affect human health. Contamination of drinking water
is caused by natural or anthropogenic factors, which can be present between the
source and the distribution point, therefore increasing the possibility of transmitting
diseases.
Urgent action is needed to improve water, sanitation, and hygiene as well as
health-care waste management and environmental cleaning in health-care facilities.
The WHO/UNICEF (2019) Joint Monitoring Programme reported in 2019 found
that one in four health-care facilities globally lacked basic water services and one in
eight had no sanitation service. In addition, many health-care facilities lacked basic
facilities for hand hygiene and safe segregation and disposal of health-care waste.
This is particularly important in rural health-care facilities in Arab countries of North
Africa.
An understanding of progress in achieving access to water sanitation in the Arab
region is thus needed to put into perspective the deliberations on a new set of water-
related goals and targets in a post-2015 development agenda. According to the
WHO/UNICEF Joint Monitoring Programme (JMP) for Water Supply and Sanita-
tion, out of a total Arab population estimated at 364 million people in 2012,
approximately 15% (nearly 55 million people) still do not have access to an
improved drinking water source, and 18% (nearly 66 million people) do not have
access to an improved sanitation facility. While this is an improvement on figures for
the year 2000, the categories that define what constitutes an “improved water supply
source” and an “improved sanitation facility” fall short of considering the level and
quality of water and sanitation services actually accessed by people on a daily basis.
This is largely because the categorization developed by the JMP was initially
conceived to monitor public health improvements and to reduce the risk of unim-
proved water sources and sanitation facilities spreading disease. While important
issues to consider, the ability to access clean, reliable, and affordable drinking water
and sanitation services under conditions of freshwater scarcity is also of priority

concern for health care in the Arab countries.
Furthermore, the country-level figures often referenced from the JMP report mask
significant differences between rural and urban areas, as well as subregional progress
and achievements. For instance, in the Arab region (Cherfane et al. 2015), 69%
(nearly 38 million) of the 55 million people without access to drinking water are
located in rural areas, with 60% (33 million) residing in the region’s least developed
countries (LDCs). Similarly, more than 73% (48 million) of the 66 million people
without access to improved sanitation are located in rural areas, with 71% (47
million) residing in the LDCs.
Securing adequate water supply and proper sanitation is particularly important for
the Arab region, the world’s most water-insecure region and hosting 14 of the
world’s 20 most water-stressed countries. The average person has access to only
about 12% the renewable water levels of an average global citizen. Meanwhile, more
than half of all water originates from outside the region itself, making the Arab
region the most dependent on external sources. Water insecurity has also grown due
to the escalation of conflicts in Libya, Syria, Iraq, and Yemen. In Syria, for example,
70% of the Syrian population is without regular access to safe drinking water
because of water cuts and destruction of basic infrastructure. In spite of that, great
differences exist between the Arab countries regarding percentage of people served
by water supply and sanitation (Fig. 2). In this respect, while people in the GCC
countries are almost totally served, only 20% of people in other countries such as
Yemen have water supply and sanitation services. Moreover, the percentages shown
in Fig. 2 are based on overall population which include both those who live in cities
and urban areas and those residing in rural areas. Generally, people living in rural
and remote areas have considerably less access to adequate water supply and
sanitation. Moreover economic hardship and wars in some Arab countries contrib-
uted to deficiency in water supply and sanitation.
Fig. 2 Percentage population

served by water supply and
sanitation in the Arab
countries
1446 M. F. Hamoda
Drinking Water Quality Guidelines
The purpose of having drinking water quality guidelines and regulations is to ensure
that all human beings within a country have access to safe drinking water. In
developing countries (WHO 2017a), it is estimated that over 80% of disease is
caused by contaminated drinking water and as a consequence, over 30% of work
productivity is lost. Today, in almost all cities of the Arab countries, it is a standard
practice to provide people with safe drinking water, as a basic human right and a
cost-effective measure of reducing disease (i.e., preventative medicine), but this is
not necessarily the case in rural areas because of lack of funds.
The World Health Organization sets up some guidelines for drinking water
quality which are the international reference point for standards setting and drinking
water safety. The international guidelines drawn up by the WHO are those agreed to
in Geneva (1993). Updates were published by the WHO in 2014, with the latest
addendum in 2017 (WHO 2014, 2017a). Safe drinking water, as defined by the
guidelines, does not represent any significant risk to health over a lifetime of
consumption, including different sensitivities that may occur between life stages.
The approach followed in these guidelines is intended to lead to national standards
and regulations that can be readily implemented and enforced and are protective of
public health. On the other hand, the US Environmental Protection Agency (EPA
2018) has recently published the drinking water standards to update those published
in the year 2012 to incorporate “Drinking Water Specific Risk Level Concentration”
for cancer. All these important parameters aim at providing potable and palatable
drinking water to reduce waterborne diseases and foster healthy living. Meanwhile,
all Arab countries adopt the WHO water quality guidelines (WHO 2011), but the
GCC countries adopt amended WHO standards incorporating some of the USEPA.
Safe drinking water is required for all usual domestic purposes, including drinking,
food preparation, and personal hygiene. The guidelines are applicable to packaged
water and ice intended for human consumption. However, water of higher quality may
be required for some special purposes, such as renal dialysis and cleaning of contact
lenses, or for certain purposes in food production and pharmaceutical use. The guide-
lines may not be suitable for the protection of aquatic life or for some industries.
The following are the aesthetic, microbial, chemical, and radiological aspects of
drinking water quality focused in the guidelines.
Aesthetic/Acceptability Aspects
Water should be free of tastes and odors that would be objectionable to the majority of
consumers. In assessing the quality of drinking water, consumers rely principally upon
their senses. Microbial, chemical, and physical constituents of water may affect the
appearance, odor, or taste of the water, and the consumer will evaluate the quality and
acceptability of the water on the basis of these criteria. Although these constituents may
have no direct health effects, water that is highly turbid and is highly colored or has an
objectionable taste or odor may be regarded by consumers as unsafe and rejected. In
extreme cases, consumers may avoid aesthetically unacceptable but otherwise safe
drinking water in favor of more pleasant but potentially unsafe sources. It is therefore
wise to be aware of consumer perceptions and to take into account both health-related
guideline values and aesthetic criteria when assessing drinking water supplies and
developing regulations and standards. Changes in the normal appearance, taste, or odor
of a drinking water supply may signal changes in the quality of the raw water source or
deficiencies in the treatment process and should be corrected.
Microbial Aspects
Securing the microbial safety of drinking water supplies is based on the use of
multiple barriers, from source to consumer, as to prevent the contamination of
drinking water or to reduce contamination to levels not injurious to health. The
preferred strategy is a management approach that places the primary emphasis on
preventing or reducing the entry of pathogens into water sources and reducing
reliance on treatment processes for removal of pathogens.
In general terms, the greatest microbial risks are associated with ingestion of water
that is contaminated with feces from humans or animals (including birds). Feces can
be a source of pathogenic bacteria, viruses, protozoa, and helminths. Fecally derived
pathogens are the principal concerns in setting health-based targets for microbial
safety (Edberg et al. 2000). Microbial water quality often varies rapidly and over a
wide range (Kostyla et al. 2015). Short-term peaks in pathogen concentration may
increase disease risks considerably and may trigger outbreaks of waterborne disease.
Furthermore, by the time microbial contamination is detected, many people may have
been exposed. For these reasons, reliance cannot be placed solely on end-product
testing, even when frequent, to determine the microbial safety of drinking water.
Chemical Aspects
The health concerns associated with chemical constituents of drinking water differ
from those associated with microbial contamination and arise primarily from the
ability of chemical constituents to cause adverse health effects after prolonged
periods of exposure. There are few chemical constituents of water that can lead to
health problems resulting from a single exposure, except through massive accidental
contamination of a drinking water supply. Moreover, experience shows that in many,
but not all, such incidents, the water becomes undrinkable owing to unacceptable
taste, odor, and appearance.
Radiological Aspects
The health risks associated with the presence of naturally occurring radionuclides in
drinking water are taken into consideration, although the contribution of drinking
1448 M. F. Hamoda
water to total exposure to radionuclides is very small under normal circumstances.

Formal guideline values are not set for individual radionuclides in drinking water.
Rather, the approach used is based on screening drinking water for gross alpha and
gross beta radiation activity. Although finding levels of activity above screening
values does not indicate any immediate risk to health, it should trigger further
investigation to determine the radionuclides responsible and the possible risks,
taking local circumstances into account. The guidance levels for radionuclides
recommended in the drinking water quality guidelines do not apply to drinking
water supplies contaminated during emergencies arising from accidental releases of
radioactive substances to the environment.
The latest amended World Health Organization guidelines (WHO 22017a are
intended to support the development and implementation of risk management
strategies that will ensure the safety of drinking water supplies through the control
of hazardous constituents of water. These strategies may include national or regional
standards developed from the scientific basis provided in the guidelines. The guide-
lines describe reasonable minimum requirements of safe practice to protect the
health of consumers and derive numerical “guideline values” for constituents of
water or indicators of water quality. When defining mandatory limits, it is preferable
to consider the guidelines in the context of local or national environmental, social,
economic, and cultural conditions. The guidelines should also be part of an overall
health protection strategy that includes sanitation and other strategies, such as
managing food contamination. This strategy would also normally be incorporated
into a legislative and regulatory framework that adapts the guidelines to address local
requirements and circumstances.
The nature and form of drinking water standards may vary among countries and
regions. There is no single approach that is universally applicable. It is essential in
the development and implementation of standards that the current or planned
legislation relating to water, health, and local government is taken into account
and that the capacity of regulators in the country is assessed. Approaches that may
work in one country or region will not necessarily transfer to other countries or
regions (Lee et al. 2017). It is essential that each country review its needs and
capacities in developing a regulatory framework.
Almost all the 22 Arab countries adopt the WHO drinking water guidelines or
developed a modified version of the WHO drinking water standards considering
some water quality parameters, such as the GCC countries, and implemented those
guidelines to a certain extent.
Water Pollution
Water pollution is the contamination of water bodies such as rivers, lakes, seas,
oceans, and groundwater aquifers, usually as a result of human activities. It occurs
when harmful substances, often chemicals or microorganisms, contaminate a body
of water, degrading water quality and rendering it dangerous to human health and the
environment. Chemicals and other substances discharged into water bodies from
farms, towns, and factories readily dissolve into water and mix with it or become
suspended or floating on water, causing water pollution. When contamination
originates from a single source, it is called point source pollution. Examples include
wastewater discharged legally or illegally by a manufacturer, oil refinery, or waste-
water treatment facility, as well as contamination from leaking septic systems,
chemical and oil spills, and illegal dumping. Nonpoint source pollution is contam-
ination derived from diffuse sources such as farms, agricultural land drainage, or
storm (rain) water runoff or debris blown into waterways from land. Pollution is the
largest environmental cause of disease and death in the world today, responsible for
an estimated nine million premature deaths in 2015. Almost 92% of all pollution-
related mortality is seen in low-income and middle-income countries (Das and
Horton 2018).
Discharge of untreated wastewaters or partially treated effluents from sewage
treatment facilities in the Arab countries, as well as runoff from farms and urban
areas, contributes harmful waterborne pathogens from human and animal waste to
waterways. This constitutes a major cause of illness from contaminated drinking
water drawn from polluted water bodies in rural areas. Due to the difficulty to
diagnose pathogens, indicator organisms are used instead. Indicator microorganisms
such as total coliform, fecal coliform, fecal streptococci, and E. coli are used to
indicate the possibility of sewage pollution in the water. The higher the coliform
bacteria concentration, the higher the possibility of having pathogens in water.
On the other hand, chemicals and heavy metals from industrial and municipal
wastewater are toxic to aquatic life – most often reducing an organism’s life span and
ability to reproduce – and make their way up the food chain as predator eats prey.
Moreover, a wide range of chemical pollutants, from heavy metals such as arsenic
and mercury to pesticides and nitrate fertilizers, are getting into water supplies. Once
they are ingested, these toxins can raise many health issues, from cancer to hormone
disruption to altered brain function. Children and pregnant women are particularly at
risk. The problem with polluted water bodies is that humans depend on such waters
for drinking water supply, fishing, and irrigation.
Dissolved oxygen is an important water quality parameter as it gives a good idea
about how healthy the water is. High DO concentrations (10 mg/L) are usually
associated with clean water, while low DO concentrations (4 mg/L or less) are
associated with polluted water. Dissolved oxygen in water is usually reduced due
to organic pollution or due to thermal discharges from industries. Very low dissolved
oxygen in water has adverse effects on most flora and fauna including fish and might
lead to extinction of some species. Fish and other aquatic organisms need oxygen to
live. However, oxygen can be present in the water but at too low a concentration to
sustain aquatic life. Water pollution contributes oxygen-demanding organic matter
(e.g., sewage, industrial wastes, soils from streambank and lakeshore erosion, and
from agricultural runoff) or nutrients that stimulate growth of organic matter and
cause a decrease in average DO concentrations. Oxygen production and oxygen
consumption could be balanced through self-purification processes in running water
streams, but a low DO concentration of less than 4 mg/L may become more of a
problem causing septicity and fish kills. When water pollution causes algal blooms
1450 M. F. Hamoda
in a lake or marine environment due to presence of nitrogen and phosphorous

“eutrophication,” the proliferation of newly introduced nutrients stimulates plant
and algae growth, which in turn reduces oxygen levels in the water, as reported in
lakes of Egypt and Sudan.
Wastewater Treatment
The degree of wastewater treatment is usually based on the planned uses of the
treated effluent such as reuse for different purposes or discharge into water courses
(e.g., rivers, seas, oceans) or disposal on land and is dictated by standards set by
regulatory agencies in each case. The treatment of wastewater is brought in stages
(primary, secondary, tertiary, quaternary) by a sequential combination of physical,
biological, and chemical processes to remove suspended solids, organic materials
(BOD, COD), nutrients (nitrogen and phosphorus), trace metals, and pathogens from
wastewater. Figure 3 summarizes the wastewater treatment stages, treatment opera-
tions/processes, and water reuse options for the treated effluent produced in each
stage (Hamoda 2013).
The primary treatment removes mostly suspended materials and domestic waste-
water pollutants by about 30%, while secondary treatment removes primarily
organic materials and achieves about 85–90% of pollutants from domestic waste-
water. Tertiary treatment removes mostly nutrients and residual solids escaping
Increasing Levels of Treatment;

Increasing Acceptable Levels of Human Exposure
Primary
Treatment: Secondary treatment: Tertiary Treatment: Quaternary Treatment:
Sedimentation Biological Oxidation, Chemical Coagulation, Membrane Processes,
Disinfection Filtration, Disinfection Disinfection
• No uses • Surface irrigation of • Landscape and golf • Direct potable reuse
Recommended orchards and course irrigation • Groundwater
at this level vineyards • Toilet flushing recharge of potable
• Non-food crop • Vehicle washing aquifer
irrigation • Food crop irrigation • Surface water
• Restricted landscape • Unrestricted reservoir
impoundments recreational augmentation**
• Groundwater recharge impoundment
of non potable • Indirect potable
aquifer** reuse**
• Wetlands, wildlife
habitat, stream
augmentation**
• Industrial cooling
processes**
*Suggested uses are based on Guidelines for Water Reuse, developed by U.S.PA (2004).
**Recommended level of treatment is site-specific.
Fig. 3 Wastewater treatment levels, treatment processes, and water reuse options (Hamoda 2013)
secondary treatment as well as trace elements and pathogens. It achieves from 90%
to 95% of pollutants and produces water suitable for reuse in irrigation. The
quaternary (membrane-based) treatment removes residual pollutants as well as
salts and pathogens with removal efficiencies up to 99.9% and produces effluents
satisfying water quality requirements for reuse in all purposes including drinking
water. Effluent disinfection by chlorination, ozonation, or ultraviolet (UV) radiation
is highly efficient in removing enteric pathogens. Table 2 displays the removal
efficiencies of specific water treatment processes such as filtration, membrane-
based, and chlorination in removing various enteric pathogen groups. Selection of
appropriate sequence depends on the characteristics of the raw wastewater, required
effluent quality, and cost of treatment. The primary and secondary treatments of
municipal wastewater are required by most regulatory authorities worldwide to
protect the environment. The tertiary and quaternary treatments (also known as
advanced or reclamation stages) are commonly required for water reuse to safeguard
the public health.
In many Arab countries, primary and secondary treatment of domestic wastewa-
ters are considered sufficient levels to combat water pollution and production of
effluents for reuse in irrigation of restricted agricultural lands. However in the GCC
countries, treatment of domestic wastewaters up to the tertiary level is required by
regulatory agencies, while quaternary treatment is practiced in some cases (e.g.,
Kuwait and Saudi Arabia) to satisfy the water quality criteria for reuse. Table 4
presents water quality of quaternary-treated wastewater effluent produced from
Sulaibiya advanced wastewater treatment plant in Kuwait. This plant, with a capac-
ity of 425,000 m3/d, was commissioned in March 2005 as the largest membrane-
based municipal wastewater treatment and reclamation plant worldwide and the first
infrastructure of its size to be executed as BOT (build-operate-and-transfer) facility
(Hamoda et al. 2015a). The plant uses ultrafiltration and reverse osmosis membrane
processes to remove residual organics, solids, most colloids, trace elements, salts,
bacteria, and viruses from the secondary (activated sludge)-treated effluent. This
plant consistently produces effluent with a potable water quality (Table 3) which is
currently used in irrigation and groundwater recharge.
Water Reuse
The scarcity of freshwater in most countries in the Arab region is an increasingly

acute problem, particularly as populations continue to grow and place higher
demands on water resources. Fourteen of the 22 Arab countries are in water deficit,
with less than 500 m3 of renewable fresh water supply per capita per year according
to the World Bank report (2006). Meanwhile, the latest collection of simulation
results reviewed by the Intergovernmental Panel on Climate Change show a strong
consensus that precipitation will decrease substantially in Arab countries (IPCC
2007), thus decreasing the water resources in these countries. In this context, the
development of nonconventional resources such as desalinated water and reclaimed
wastewater is increasingly relevant.
1452 M. F. Hamoda
Table 2 Removal of enteric pathogens by water treatment processes

Enteric
Process pathogen group Average removal efficiency
Filtration
Granular Bacteria 85%
High-rate
Filtration Viruses 80%
Protozoa 70%
Slow sand Bacteria 50%
Filtration
Viruses 20%
Protozoa 50%
Precoat Bacteria 30–50%
Filtration,
Including
Diatomaceous Viruses 90%
Earth and
Perlite
Protozoa 99.9%
Membrane Bacteria 99.9–99.99%, providing
Filtration – Adequate pretreatment and
Microfiltration Membrane integrity conserved
Viruses <90%
Protozoa 99.9–99.99%, providing
Adequate pretreatment and
Membrane integrity conserved
Membrane Bacteria Complete removal, providing
Filtration – Adequate pretreatment and
Ultrafiltration, Membrane integrity conserved
Nanofiltration, Viruses Complete removal with nanofilters, with reverse osmosis
and reverse Protozoa and at lower pore sizes of ultrafilters, providing adequate
osmosis pretreatment and membrane integrity conserved
Complete removal, providing adequate pretreatment and
membrane integrity conserved
Disinfection
Chlorine Bacteria Ct99: 0.08 mgmin/liter at 1–2 C,
pH 7; 3.3 mgmin/liter at 1–2 C,
pH 8.5
Viruses Ct99: 12 mgmin/liter at 0–5 C;
8 mgmin/liter at 10 C; both at
pH 7–7.5
Protozoa Giardia
Ct99: 230 mgmin/liter at 0.5 C;
100 mgmin/liter at 10 C;
41 mgmin/liter at 25 C; all at pH
7–7.5
Cryptosporidium not killed
Table 3 Treated effluent quality from Sulaibiya advanced wastewater treatment plant in Kuwait
(Hamoda 2013)
Kuwait
maximum Average effluent
No. Pollutant Symbol Unit limit quality from Sulaibiya
1 pH pH – 6.5–8.5 7.3
2 Biological oxygen BOD Mg/L 20 1
demand
3 Chemical oxygen COD Mg/L 100 5
demand
4 Fats, oil, and grease FOG Mg/L 5 0.015
6 Total suspended solids TSS Mg/L 15 0.024
7 Total dissolved solids TDS Mg/L 1500 39
8 Phosphate PO4 Mg/L 30 0.08
9 Ammonia NH3-N Mg/L 15 0.025
10 Nitrate NO3 Mg/L 35 0.73
11 Total recoverable phenol C6H5OH Mg/L 1 Nil
12 Fluorides F Mg/L 25 1.2
13 Sulfides H2S Mg/L 0.1 1.3E–4
14 Chlorine Cl2 Mg/L 0.5–1.0 0
15 Dissolved oxygen DO Mg/L >2 4
16 Hydrocarbons HC Mg/L 5 Nil
17 Aluminum Al Mg/L 5 Nil
18 Arsenic As Mg/L 0.1 Nil
19 Barium Ba Mg/L 2 Nil
20 Baron B Mg/L 2 Nil
21 Cadmium Cd Mg/L 0.01 Nil
22 Chromium Cr Mg/L 0.15 Nil
23 Nickel Ni Mg/L 0.2 Nil
24 Mercury Hg Mg/L 0.002 Nil
25 Cobalt Co Mg/L 0.2 Nil
26 Iron Fe Mg/L 5 Nil
27 Copper Cu Mg/L 0.2 Nil
28 Manganese Mn Mg/L 0.2 Nil
29 Zinc Zn Mg/L 2.0 Nil
30 Lead Ld Mg/L 0.5 Nil
31 Most probable number – MPN/ 400 1
of total coliform 100 ml
32 Most probable number – MPN/ 20 0
of fecal coliform 100 ml
33 Egg parasites – – <1 Nil
34 Worm parasites – – Nil Nil
In the Arab region, agriculture is by far the biggest consumer of water, and, as
water stress increases, it will cause higher need for treated wastewater reuse in
irrigation (ACWUA 2010). Farmers in some Arab countries, such as Jordan, depend
on wastewater or wastewater-receiving water bodies to irrigate their crops, since they
1454 M. F. Hamoda
Table 4 Wastewater reuse guidelines in some Arab countries. (Adapted from Choukr-Allah 2011)
Country/ E. coli or fecal coli/ Nematode Othera Crops eaten uncooked
organization 100 ml eggs/l parameters are allowed
WHO 10,000,000,000 <111 No Yes
Jordan 100 <=1 Yes No
100
Morocco 1000 Absence Yes Yes
Palestine 1000 <1 Yes No
Syria 1000 <1 Yes No
Tunisia – <1 Yes No
Kuwait 20 <1 Yes No
Oman 200 <1 Yes Yes
Saudi Arabia 2.2 <1 Yes No
Egypt 200 <1 Yes No
Bahrain 20 <1 Yes No
a
Other parameters such as BOD, COD, TSS, nitrates, and phosphates may be specified for specific
reuse
do not have other alternative water sources. However, in some Arab countries, water
reuse is not limited to agriculture, and treated wastewater is used for landscaping,
industrial water, cooling water, or groundwater recharge such as the GCC countries.
There are important technical developments for wastewater treatment applica-
tions to meet improved legal regulations in Arab region (Fig. 4) where wastewater
technology exists to produce effluents of different quality to satisfy five possible
levels (types). Achievement of better quality for treated wastewater is a key factor for
sustainable use of this source. At this point, source control of pollutants is necessary
to protect water bodies. Some Arab countries have their own water reuse regulations.
The concerns of reusing reclaimed wastewater are not limited to “the relevant
treatment infrastructure and applied treatment technology” but extend to “other
key parameters such as the quality of the influents as well as the subsequent reuse
options.”
There are some social and health concerns associated with water reuse. From
social standpoint, all Arab countries do not allow use of treated wastewater effluents
for potable water supply. Meanwhile, according to Fatta et al. (2005), concerns for
human health and the environment are the most important constraints in the reuse of
treated wastewater. It is frequently the case that wastewater treatment plants in Arab
counties do not operate satisfactorily, and, in most cases, treated wastewater dis-
charges exceed the legal and/or hygienically acceptable maxima. This is attributed to
the lack of adequately trained staff with the technical skills to operate these plants, as
well as the lack of an adequate budget for plant maintenance and operation.
Water reuse technologies are emerging as a vital solution to the Arab region
(Hamoda et al. 2015b). With proper treatment, seawater and wastewater can be
reused for beneficial purposes such as drinking water, agricultural, and landscape
irrigation and industrial processes, enabling communities and countries to stretch
limited freshwater supplies. Advancing wastewater technologies have empowered
Fig. 4 Wastewater infrastructure development from collection to reuse (World Bank 2009)
Arab countries to set their sights on dramatically increased reuse targets. The key to
the success of a wastewater reuse program is tertiary filtration, capable of consis-
tently producing a high-quality effluent while enhancing the disinfection process –
both chlorination and UV – and improving water quality. Good tertiary filters offer
the benefit of lowering total suspended solids, turbidity, and biochemical oxygen
demand to meet the required discharge permits. From the standpoint of cost and
technical efficiency, biological treatment has proven to be an excellent tertiary
treatment technology for reuse applications (Hamoda et al. 2004).
More than 40% of wastewater is reused in many GCC countries, and many of
these countries are aiming for 100% reuse of treated sewage effluent within the next
few years. Total reuse is estimated at 2.17 km3 per year in the Arab region (Abdel-
Dayem and Choukr-Allah 2011). Egypt, Jordan, Syria, the United Arab Emirates,
1456 M. F. Hamoda
and Saudi Arabia are the largest users, accounting for 75% of the Arab region in
terms of the total domestic water reuse. Meanwhile, a single Arab country, Jordan, is,
by far, the largest in water reuse since almost 90% of its treated wastewater is reused
mainly in agriculture.
Reuse Options
Reuse options are manifold and strongly depend on a country’s economic structure.
Agriculture plays a major role for reuse in Jordan, Egypt, and Yemen, while the
United Arab Emirates, Tunisia, and Morocco focus on green space irrigation in
urban centers and tourist facilities. Groundwater recharge is another option for
wastewater reuse and is particularly considered in countries where seawater intrusion
into freshwater aquifers is threatening the already scarce water resources. Recycling
for industrial and domestic reuse is another option. Recently, several municipalities
facing water shortages consider high-tech wastewater treatment system in modern
large housing complexes and high-rise buildings to reuse the reclaimed water “in-
house” for cooling purposes or toilet flushing. One promising variation of this
approach is gray water recycling. Water from showers and sinks is collected sepa-
rately and treated in state-of-the-art gray water treatment systems with a disinfection
unit. Such systems allow a cost-efficient and safe reuse of high-quality service water
close to the point of generation. This technology is particularly on the rise in Jordan.
Quality parameters are set in most of the Arab countries; however only few have the
capacity and means to meet these standards. Though certain quality control for
irrigation water is in place, hardly any corrective measures are available in case of
unacceptable pollution or misuse. Jordan can be considered as the most advanced
country with regard to quality control and safety schemes for reuse, as it has
implemented a safety control system for agricultural produce grown on a mix of
treated wastewater and freshwater. However, this scheme is currently limited to the
Jordan Valley and requires further national upscaling. Other countries like Egypt or
Tunisia have set very strict reuse standards, limiting reuse to forestry, green spaces,
and industrial crops. As many urban centers in Arab countries are located along
coastal lines, a lot of wastewater is “lost” as outfall to the sea (Choukr-Allah 2011,
2019). Particularly Morocco (60%), Lebanon (80%), and Sudan (5%) are
discharging the major amount of treated or untreated wastewater into the sea.
In Morocco and Lebanon, most of the treated or untreated wastewater is
discharged into the sea. Both countries increased efforts in the construction and
rehabilitation of WWTPs with the aim to reduce environmental pollution and protect
the seashores. Reuse is not considered in all new projects. Yemen is the least
advanced country with regard to wastewater reuse and safety control as it has a
predominantly rural setting, limited sewer connection, deteriorated WWTPs which
do not meet national quality requirement, and reuse patterns which are completely
uncontrolled as farmers illegally abstract water either directly from the plants or
downstream from the effluent discharge point. The United Arab Emirates (Dubai and
Abu Dhabi) are hardly comparable with other countries in the region due to their
Table 5 Water quality guidelines for water reuse in restricted irrigation in some Arab countries
Parameter Unit Saudi Arabia Tunisia Jordan
pH 6–8.4 6.5–8.5 6–9
BOD5 mg/L 10 30 30
COD mg/L 50 90 100
DO mg/L >2
TSS mg/l 40 30 50
NO3-N mg/l 10 30
E. coli CFU/100 ml 100 100
smaller-scale, predominantly urban setting, and fast-growing character. However,

while Abu Dhabi has a strategy for its wastewater treatment and reuse, Dubai is still
struggling with one overloaded WWTP and illegal dumping.
Health Impact
Irrigation with inadequately treated wastewater poses serious public health risks, as
wastewater is a major source of excreted pathogens – bacteria, viruses, protozoa, and
helminths that cause gastrointestinal infections in human beings. Inappropriate
wastewater use poses direct and indirect risks to human health caused by the
consumption of polluted crops and fish. Farmers in direct contact with wastewater
and contaminated soil are also at risk. Reuse of unsuitable wastewater in agriculture
may also lead to livestock infections.
There is a more strict restriction for reuse of treated wastewater for edible foods.
Regulations include conventional water parameters, such as pH, BOD, turbidity,
fecal coliform, and residual chlorine (Tables 4, 5, and 6). Wastewater reuse has
numerous benefits, such as utilizing nutrients that reduce the need for using chemical
fertilizers and reducing the need for freshwater sources. However, there is generally
a social defense of people, who do not want to consume food irrigated with
wastewater, even if it was treated. So as not to face an objection, farmers generally
do not state that they use wastewater for irrigation. Nutrient ingredients of waste-
water also encourage them for prolonged use.
In most of the Arab countries, this practice is not being controlled properly and
has serious challenges, such as uncontrolled industrial discharges to sewer system,
insufficient water quality monitoring, and lack of awareness for environmental
protection. Untreated industrial discharges to sewer system increase pollutant load
of municipal wastewater. Long-term application of untreated or insufficiently treated
wastewater causes soil deterioration and pollution of agricultural products.
Neglecting microbial quality of wastewater arise serious risks. Use of untreated
wastewater for edible crops threats human health, but reuse of treated effluents in
restricted irrigation in the Arab countries was so far not associated with reported
disease outbreaks.
1458 M. F. Hamoda
Table 6 Effluent water quality criteria as compared to potable water quality criteria (Hamoda et al.
2015a)
WHO
Actual Max Kuwait standards for un-
Kuwait effluent from allowable bottled potable water
Parameter Unit Standards Sulaibiya limits (max.)
pH – 6–9 7.3 6.5–8.5 6.5–8.5
TDS mg/l >100 39 1200 1000
TSS mg/l >1 0.024
VSS mg/l >1 0.019
BOD mg/l >1 0.23
Ammonia mg/l >1 0.03 35 1.5
nitrogen as
N
Nitrate mg/l >1 0.7 10
nitrogen as
N
Total mg/l 2 0.08
phosphate
Sulfide mg/l >0.1 1.3E–04 0.1 0.05
Fats, oil, mg/l >0.05 0.015 0.01
and grease
Total mg/l >2 0.34
organic
carbon
Hardness mg/l >10 500 500
as CaCO3
Color TCU >1 Clear 15
Total MPN/ >2.2 1 Free
coliform 100 ml
The spread of water reuse across countries is surprisingly uneven and slow. To
date, few countries in the region have achieved the implementation of substantial
reuse. Among these, the Gulf Cooperation Council (GCC) countries are the highest
in implementing successful water reuse policies.
Environmental, Social, and Economic Concerns
In environmental safety terms, unregulated irrigation with wastewater may lead to

problems such as deterioration in soil structure (soil clogging due to high content of
suspended solids in treated wastewater), which results in poor infiltration, soil
salinization, and phytotoxicity. In Jordan, salt levels in the soil tended to increase
in some areas that have been irrigated with treated wastewater, which was attributed
to the salinity of wastewater as well as on-farm management. Higher salinity implies
that a certain number of less resistant crops cannot be irrigated by wastewater. In
Saudi Arabia, Al-Jassim et al. (2015) raised concerns that the use of reclaimed
wastewater for the irrigation of crops may result in the continuous exposure of the
agricultural environment to antibiotics, antibiotic-resistant bacteria, and antibiotic-
resistant genes.
In almost all Arab countries, a major quality concern for wastewater reuse is the
high pollution load of industrial wastewater. It is mixed with domestic wastewater in
some Arab countries such as Egypt putting an additional burden on the already
stretched capacities of existing WWTPs. Furthermore, many WWTPs cannot elim-
inate persistent chemical compounds or heavy metals. Besides organic pollutants,
the high salt content of industrial effluents jeopardizes and efficient reuse as many
plants are sensitive to excessive salt concentrations in irrigation water.
The consideration of regulatory, economic, technological, and social factors
seems essential to successfully accomplish a reclaimed water reuse project (USEPA
2004, WHO 2006). Success in water reuse projects requires that the degree of human
contact is minimal, protection of public health and environment is clear, promotion
of water conservation is a clear benefit of the reuse, cost of treatment and distribution
technologies and systems is reasonable, awareness of water supply problems in the
community is high, and the role of reclaimed water in overall water supply is well
defined. Good communication and awareness campaign demonstrating the benefits
of plant nutrients present in treated wastewater in increasing crop yield, while
assuring the health issues of recycling. Although some water users and farmers
realize these issues, others require assistance to set up water user associations for a
better and more efficient distribution and use of treated wastewater.
In the Arab countries, people are socially against potable water reuse for many
reasons including religious concerns, while landscape and agriculture irrigation are
mostly acceptable as non-potable water reuse. Tertiary filtration is required to
remove residual suspended from secondary-treated wastewater effluents that may
adversely affect the cultivated soils. Also, disinfection is required to remove path-
ogens. On one hand, this constitutes additional cost that farmers may share, but, on
the other hand, more plant nutrients are removed in spite of the need for such
nutrients to save on fertilizers. Moreover, there are some concerns on the adverse
effects on plants from residual chlorine in chlorinated wastewater effluents. Such
issues cause some concerns to the end users of the treated wastewater effluents.
Therefore, public awareness from key stakeholders is essential for the reuse of
reclaimed water.
Conclusion
Adequate water supply and sanitation reduces or prevents human fecal pollution of
the environment, thereby reducing or eliminating transmission of waterborne dis-
eases from the source, and compliments the efforts to safeguard public health and
improve health care. There are different sources of water pollution in the Arab
countries. Water and wastewater treatment is receiving considerable attention in
most Arab countries in spite of financial constrains in some countries. Since most
1460 M. F. Hamoda
Arab countries suffer from water scarcity, water reuse has a great potential in
significantly increasing available water resources and maintaining a clean environ-
ment, as long as health impacts of reuse of treated wastewater are taken into
consideration. Finally, supply of safe drinking water and adequate sanitation is
essential for improving health care in the Arab countries where most people live in
rural areas.
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Water, Sanitation, and Hygiene Within
Healthcare Facilities in Jordan 59
Yousef Saleh Khader
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1464
WSH in Healthcare Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1465
Drinking-Water Sources in Jordan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1466
The Structure of the Jordanian Water-Quality Surveillance and Monitoring System
and National Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1467
Sanitation, Drinking-Water, and Hygiene Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1468
Health System in Jordan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1469
Water, Sanitation, and Hygiene (WSH) Within Healthcare Facilities in Jordan . . . . . . . . . . . . . . 1469
WSH Services Coverage in the Healthcare Facility Inspection System . . . . . . . . . . . . . . . . . . . . . . 1470
Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1471
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1472
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1473
Abstract
There is limited knowledge on the status of water, sanitation, and hygiene (WSH)
in healthcare facilities in Jordan. The World Health Organization (WHO) 2015
report underlined the importance of adequate WSH in healthcare facilities in
preventing infections and spread of disease and protecting staff and patients’
health, dignity, and privacy. It is clear that extensive work is still needed to
examine the availability of WSH services in healthcare facilities in the Eastern
Mediterranean Region (EMR). Therefore, the primary objective of this chapter is
to describe WSH conditions in healthcare facilities in Jordan. The majority of
healthcare facilities have a safe (100%) and functional water source all of the time
Y. S. Khader (*)

https://doi.org/10.1007/978-3-030-36811-1_142
1464 Y. S. Khader
(84.2% for hospitals and 90.9% for health centers) to provide enough water for
the needs of the facility. Overall, 96.5% of all drinking water facilities are
functional, and all hospitals had improved and gender-separated toilets in inpa-
tient settings, and 84.2% had the same in outpatient settings. Of all health centers,
54.5% had improved and gender-separated toilets and 81.8% had toilets with
convenient handwashing facilities. For the majority of hospitals, all or most of the
toilets were clean at the time of inspection. All toilets used by patients were clean
in five (45.5%) health centers and for staff in seven (63.6%) health centers.
Healthcare waste segregation at the point of generation is practiced in all hospi-
tals. All hospitals have sufficient containers for healthcare waste, separate collec-
tion of hazardous and non-hazardous healthcare wastes, and separate storage area
for hazardous and non-hazardous healthcare waste. WSH services policies should
be integrated with existing national policies on environmental health in health
facilities. Policies for effective governance and management of WSH services
and standards at national, regional, district, and health-setting levels are needed.
Keywords
Water · Sanitation · Hygiene · Healthcare facilities
Introduction
Inadequate drinking water, sanitation, and hygiene in healthcare facilities impact the
health, particularly in low- and middle-income countries. There is limited knowledge
on the status of WSH in such settings. The World Health Organization (WHO) 2015
report (World Health Organization 2015) underlined the importance of adequate
water, sanitation, and hygiene (WSH) in healthcare facilities in preventing infections
and spread of disease and protecting staff and patients’ health, dignity, and privacy.
Healthcare-associated infections are prevalent, with about 15% of patients esti-
mated to develop one or more infections during a hospital stay (Allegranzi et al.
2011). The risks associated with sepsis are 34 times greater in low-resource settings
(Oza et al. 2015). In the Middle East, it is difficult to gather reliable global
information on healthcare-associated infections because most countries lack surveil-
lance systems for healthcare-associated infections. The low quality and limited data
from low- and middle-income countries show that healthcare-associated infections
are more frequent in resource-limited settings than in developed countries. At any
given time, the prevalence of healthcare-associated infection varies between 5.7%
and 19.1% in low- and middle-income countries (WHO). The average prevalence is
significantly higher in high-quality studies than in low-quality studies (15.5% vs
8.5%, respectively) (WHO). Results clearly indicate that healthcare-associated
infections are significant. An 18-month prevalence survey in a hospital in the United
Arab Emirates gave a nosocomial infection (hospital-acquired infection) rate of
4.7% (McCormack and Barnes 1983). A 1-day point prevalence survey in the
King Fahad National Guard Hospital in Riyadh, Saudi Arabia, of 562 patients
59 Water, Sanitation, and Hygiene Within Healthcare Facilities in Jordan 1465
revealed a rate of 8% (Balkhy et al. 2006a). Prevalence of nosocomial infection in

Iranian hospitals was reported to be between 1.3% and 10% (Askarian et al. 2012;
Balkhy et al. 2006b; Hashemi et al. 2013).
Several factors can cause healthcare-associated infections, such as inadequate
environmental hygienic conditions and waste disposal, poor infrastructure, insuffi-
cient equipment, poor knowledge and application of basic infection control mea-
sures, lack of standard infection control procedures, and absence of local and
national guidelines and policies. Lack of access to water and sanitation in healthcare
facilities may be associated with poor health outcomes especially in pregnant women
and newborns (Velleman et al. 2014), and although this aspect of healthcare waste is
not included in the definition of WSH, it is a critical component of infection
prevention and control.
It is clear that extensive work is still needed to examine the availability of WSH
services in healthcare facilities in the EMR. Therefore, the primary objective of this
chapter is to assess WSH conditions in healthcare facilities in Jordan.
WSH in Healthcare Facilities
A proposed target of universal basic coverage of WSH in healthcare facilities by

2030 has been recommended for inclusion in the post-2015 UN Sustainable Devel-
opment Goals, Global Health Initiatives such as “Every Woman Every Child,” and
the integrated “Global Action Plan against Pneumonia and Diarrhea.” The quality of
care during childbirth highlights the importance of basic, universal WSH services in
healthcare facilities (WHO 2014).
According to the 2014 UN-Water Global Analysis and Assessment of Sanitation
and Drinking-Water (GLAAS) findings, only one quarter of countries have policies
on WSH in healthcare facilities that are implemented with funding and regular
review (WHO/UNICEF 2014).
In general, there is a lack of publicly available data on WSH in healthcare
facilities. The three most common healthcare facility surveys with water and sani-
tation indicators are the Service Availability and Readiness Assessment (SARA), the
Service Delivery Indicator (SDI) survey, and the Service Provision Assessment
(SPA). However, the definitions of the water and sanitation indicators vary between
these assessments, making it difficult to compare data from different sources, and
often fall short of the WHO minimum and do not cover important aspects of WSH.
Furthermore, most of the data do not account for reliability, quantity, or safety of
supplies or functionality of sanitation services.
Ideally a more comprehensive definition would be used that consider quality,
quantity, and functionality of WSH services. Targets for basic coverage of WSH in
healthcare facilities are also lacking. Over half (52%) of the countries (n = 94) in
GLAAS do not have targets for hygiene in facilities, and over a third of countries do
not have targets for sanitation (35%) or water (44%). These figures indicate that
policy development and planning is inadequate for WSH in healthcare facilities.
1466 Y. S. Khader
The World Health Organization (WHO) 2015 report reviewed information from
18 national and subnational sources on the availability of WSH services in
healthcare facilities. The review covered information on 90 healthcare facilities
from 54 low- and middle-income countries, mostly from Africa and the Americas.
The report indicated that 38% of healthcare facilities did not have an acceptable
water source, 19% did not have adequate sanitation, and 35% did not have water and
soap for handwashing. Provision of water was lowest in the African region, with
42% of all healthcare facilities lacking an acceptable water source on-site or nearby.
In comparison, provision of sanitation is lowest in the Americas, with 43% of
healthcare facilities lacking such services.
Data from the Eastern Mediterranean Region (EMR) are very limited. Only four
countries in the EMR (Afghanistan, Egypt, Morocco, and Sudan) reported on the
availability of WSH in healthcare facilities. Water coverage was more frequently
measured and reported than sanitation coverage or hygiene coverage. A subnational
Integrated Management of Childhood Illness (IMCI) survey demonstrated 96% and
91% water coverage in Morocco and Sudan, respectively. A Service Provision
Assessment (SPA) national survey conducted in Egypt showed water coverage of
88%, while a subnational UNICEF survey conducted in Afghanistan reported an
alarming low water coverage of 56%. Data on sanitation and hygiene coverage were
only available from Afghanistan and Egypt. Hygiene coverage was moderate in both
countries (72% and 71%, respectively), still far less than the required 100% cover-
age. Sanitation coverage was reported as 91% in the UNICEF survey that was
conducted nationally in Afghanistan and 78% in the SPA national survey that was
conducted in Egypt.
The Patient Safety Friendly Hospital Initiative (PSFHI) is a WHO initiative aimed
at assisting institutions in countries to launch a comprehensive patient safety pro-
gram (Siddiqi et al. 2012). The objective of the PSFHI is to enhance patient safety by
developing harmonized standards to which hospitals adhere and by encouraging the
participation of hospital managers, clinicians, and patients to collaborate in this
effort. Ministries of health of seven countries – Egypt, Jordan, Morocco, Pakistan,
Sudan, Tunisia, and Yemen – were requested to nominate one hospital as a pilot site
for the PSFHI (Siddiqi et al. 2012). These hospitals ranged from large teaching to
medium-sized public sector hospitals with the number of hospital beds varying from
162 to 1041. In the domain of safe environment, several hospitals displayed deficient
performance. While many hospitals had a waste management system in place and
demonstrated adherence to some regulations and procedures related to biological and
hazardous waste disposal, none met the physical and infrastructural standards that
ensured patient safety.
Drinking-Water Sources in Jordan
Jordan is water-scarce country. Drinking-water comes mainly from groundwater

sources (80%), with the remainder coming from surface water (Properzi 2010). In
reality, the demand is higher and most people buy water from tanker trucks. The
main problems with the drinking-water supply include shortage of water, intermit-
tent water supply, the deteriorating quality of water sources, the increasing demand
on the water supply system, and water leakage throughout the distribution network
(Properzi 2010).
The Structure of the Jordanian Water-Quality Surveillance and

Monitoring System and National Standards
The two major actors in the structure of the Jordanian surveillance and monitoring
system for drinking-water quality are the Water Authority of Jordan and the Ministry
of Health. The former is responsible for managing water, from extraction to distri-
bution, while the latter is the monitoring agency responsible for public health. Both
agencies carry out routine tests of drinking-water quality at their laboratories (Pro-
perzi 2010).
The main laws regulating the Jordanian system (Properzi 2010) for monitoring
drinking-water quality are:
• Water Authority Law number 18, promulgated in 1988 and amended in 2001,
which defines the role of the Water Authority of Jordan
• Public Health Law number 54, promulgated in 1988 and amended in 2002, which
defines the role of the Ministry of Health
• Law number 12, passed in 1995, which created the Ministry of Environment
The current Jordanian standard for drinking-water quality is number 286/2001,

issued by the Jordan Institute of Standardization and Metrology. The Jordanian
national standards for drinking-water quality allow the maximum permitted limit
to be used as the standard when the allowed limit is exceeded and an alternative
water supply is not available.
The main references for the Jordanian standards include:
• Standard methods for the examination of water and wastewater, 20th edition.
Washington, DC, American Public Health Association, 1998.
• Guidance manual for compliance with filtration and disinfection. Requirements
for public water systems using surface water sources. Washington, DC, US
Environmental Protection Agency Office of Drinking Water, Criteria and Stan-
dards Division, 1990.
• Guidelines for drinking-water quality, Vol. 2. Health criteria and other
supporting information, 2nd ed. Geneva, World Health Organization, 1996.
According to the World Health Organization/United Nations Children’s Fund

(WHO/UNICEF) pilot project (2004–2005) (WHO/UNICEF Joint Monitoring Pro-
gramme for Water Supply and Sanitation 2004), the validity of routine national
monitoring data in Jordan is confirmed, which showed that drinking-water quality is
generally high in the distribution network (Properzi 2010). Compliance with WHO
1468 Y. S. Khader
guideline values and national standards for bacteria is 99.9%, and overall compli-
ance is 97.8% (this figure includes data for chemical contaminants). Although
household samples show that some contamination occurs between the network
pipes and household taps, the chlorination level usually ensures the safety of water
at the time of consumption.
Sanitation, Drinking-Water, and Hygiene Status
In spite of the water scarcity challenge in the country and the limited available
financial resources, Jordan has made major achievements in providing almost
universal access for drinking-water and improved sanitation. Political instability in
the region, which results in continuous refugee influxes to Jordan, has impacted
water and sanitation sector. High numbers of refugees have created added burdens
on the water and sanitation services in the country and have impacted services
provided in schools and health centers (WHO 2014).
In terms of governance, several ministries and institutions share the responsibil-
ities for sanitation and drinking-water services. The Ministry of Health leads local
hygiene promotion initiatives and has a number of responsibilities related to sanita-
tion and water. However, there is no national policy for health awareness and
hygiene with stated targets and necessary investments. The Ministry of Water and
Irrigation is the lead institution in policies and strategy formulations and develop-
ment of investment plans and financing of projects in the country. The Water
Authority of Jordan and Public Utilities are responsible of water and wastewater
service provision. Surveillance is currently performed by a service provider (Water
Authority of Jordan) and also performed directly by an independent regulator
(Ministry of Health).
Clearly defined performance indicators for monitoring performance of utilities
exist. Jordanians enjoy equal and nondiscriminatory access to water and sanitation
services. Water is subsidized for low-income populations. However, no tracking
system exists for different population groups, mainly because services are tracked
against service areas and population centers (WHO 2014).
There is a human resource strategy for delivering drinking-water and sanitation
services (including hygiene promotion). Capacity is being developed to meet current
and future needs.
Jordan has developed mechanisms to allocate, spend, and track financial flows
for the Water and Sanitation Sector. At the beginning of every fiscal year, the
Budget Law for the Government is prepared with estimated committed funding for
WSH. At the end of the fiscal year, a new report is prepared that includes
expenditures.
The Government Program for 2013–2016 includes coverage targets for water and
sanitation, projects that need to be implemented, and the investments needed.
Investments for new infrastructure projects are major, and there is a continuous
need for securing funds for such projects from external funding sources. The
government cannot cover such investments from its financial sources.
Health System in Jordan
Jordan’s health system is a complex amalgam of three major sectors: public, private,
and donors (Ministry of Health). The public sector consists of two major public
programs that finance as well as deliver care: the Ministry of Health (MOH) and
Royal Medical Services (RMS). Other smaller public programs include several
university-based programs, such as Jordan University Hospital (JUH) in Amman
and King Abdullah Hospital (KAH) in Irbid. The extensive private sector includes
60 hospitals and many private clinics. Over 1.6 million Palestinian refugees in
Jordan get access to primary care through the United Nations Relief Works Agency
(UNRWA). Each of the healthcare sub-sectors has its own financing and delivery
system.
Water, Sanitation, and Hygiene (WSH) Within Healthcare Facilities

in Jordan
In a recent study funded by CEHA-WHO, a sample of 20 hospitals (15 public and 5

private) and 11 health centers from Jordan were assessed. All healthcare facilities
(100%) had a safe water source, and the majority had a functional water source at all
times (84.2% for hospitals and 90.9% for health centers) to provide enough water for
the needs of the facility. Water was sufficient and available at all times for drinking,
food preparation, personal hygiene, medical activities, cleaning, and laundry in
94.7% of hospitals and 81.8% of health centers.
Overall, all hospitals had improved toilets in inpatient settings and were gender-
separated (1 per 20 users), and 84.2% had the same in outpatient settings (at least five
toilets; one for male staff, one for female staff, one for male patients, for female
patients, and one for patients with special needs). Of all health centers, 54.5% had
improved and gender-separated toilets (at least five toilets; one for male staff, one for
female staff, one for male patients, for female patients, and one for patients with
special needs), and 81.8% had toilets with convenient handwashing facilities. For the
majority of hospitals, all or most of the toilets were clean at the time of inspection.
All toilets used by patients were clean in five (45.5%) health centers and for staff in
seven (63.6%) health centers. Overall, 84.2% of hospitals had sufficient and func-
tioning handwashing basins with soap and water, and 79.0% of hospitals had
sufficient showers.
Wastewater is disposed using the public sewage in 16 (84.2%) hospitals, on-site
treatment plant in one hospital, and septic tanks in two hospitals (10.2%). Healthcare
waste segregation at the point of generation is practiced in all hospitals. All hospitals
have sufficient containers for healthcare waste, separate collection of hazardous and
non-hazardous healthcare wastes, and separate storage areas for storage of hazardous
and non-hazardous healthcare waste. Two hospitals did not have sufficient trolleys
for internal collection of hazardous healthcare waste. Healthcare waste segregation
at the point of generation was practiced in all health centers. All health centers had
separate collections of hazardous and non-hazardous healthcare wastes and separate
1470 Y. S. Khader
storage areas for hazardous and non-hazardous healthcare waste. One health center
did not have sufficient containers for healthcare waste and did not have sufficient
trolleys for internal collection of hazardous healthcare waste.
All health centers had a policy for the safe management of healthcare waste, a
body in charge of healthcare waste management, and adequate training programs on
healthcare waste. Healthcare waste on-site treatment facilities was correctly operated
and maintained in all health centers.
WSH Services Coverage in the Healthcare Facility Inspection

System
The existing healthcare facility inspection system in Jordan includes WSH compo-
nents such as water and healthcare waste. It also includes sanitation for hospitals
with wastewater treatment units only. However, the annual report of the Ministry of
Health does not include data on essential WSH services. The representative of MOH
in Jordan reported that there is a national policy on WSH in healthcare facilities in
Jordan. However, there is an inadequate mechanism to coordinate WSH between
healthcare facilities and other relevant stakeholders at the local level. Other than the
technical guidelines for drinking water quality, national standards on WSH in
healthcare facilities are lacking. There is an appropriate national body that is engaged
in monitoring compliance with WSH in healthcare facility standards, and officials
are trained on the national standards on drinking water quality, but this is for water
quality only.
Public hospitals in Jordan have public health divisions which are responsible for
environmental health services, namely, food safety, vector control, water quality,
housekeeping, and medical waste management. Large private hospitals have health,
safety, and environment divisions, which are responsible for environmental health
services within the healthcare facilities. The WSH indicators that are reported
routinely by the health facility inspection system include the following:
1. Bacteriological quality of drinking water (free residual chlorine and presence/

absence of total coliform)
2. Availability of final treatment and disposal of medical wastes
Water samples are collected routinely (according to the frequency mentioned in

the relevant standards) from HCFs by health inspectors and analyzed in the water
laboratories of the MOH to ensure that the water quality complies with the relevant
Jordanian standards. Water storage tanks are inspected to ensure that they are clean
and tightly covered. Sanitary inspections are carried out from source to storage to
assess any potential risks of contamination within the HCF. Information on the
quantities of water consumed (available water) is available in each HCF.
Only two hospitals have wastewater treatment plants; these are inspected rou-
tinely. Samples from the final effluent are collected according to the frequency set by
the relevant standard and analyzed at the Environmental Health Department at MOH
laboratories to ensure the quality is in compliance with the required criteria based on
the final reuse of the treated effluent. Where hospitals are located in areas not served
with public sewage networks, health inspectors request receipts that confirm that the
wastewater (sewage) is transported via suction tankers to the nearest municipal
wastewater treatment plants.
There is a well-established mechanism for monitoring healthcare waste man-
agement and reporting the quantities of treated healthcare waste. Monitoring
(inspection/assessment) of HCFs is performed by medical waste inspectors to
ensure adherence to the Medical Waste Management Instructions No. 1 of 2001.
There are 20 inspectors from the 12 Health Directorates who routinely (4 times/
year) assess healthcare waste management in hospitals using a specially
designed checklist. These assessment checklists are analyzed by the EHD/
MOH for further actions. Health inspectors also assess healthcare waste man-
agement at the 677 healthcare centers of the MOH annually; these assessments
are sent to the Environmental Health Department at the MOH for analysis and
further action.
There are no reports of datasets as such on environmental health in HCFs.
Datasets on healthcare waste quantities are available, as are datasets on HCFs’
water quality and datasets on treated wastewater quality from the two hospitals (all
included in monthly and annual reports).
Recommendations
Strengthening National Policies and Standards

• Integrate WSH services policies with the existing national policies on environ-
mental health in health facilities. Create policies for effective governance and
management of WSH services and standards at national, regional, district, and
health-setting levels.
• Establish national standards and targets for the older healthcare facilities to
increase access and improve services. A 100% coverage for WSH in healthcare
facilities should be set as a target.
• Develop strategies that identify adequate funding, human resources, and institu-
tional arrangements to ensure that standards are implemented.
• Develop effective mechanisms to ensure the compliance of health facilities with
national standards. WSH indicators should be used as criteria for accreditation of
health facilities or certifying the health facilities.
• Build political will, mobilize resources, support actions, and raise awareness on
environmental health in healthcare facilities among key stakeholders and sustain a
healthy healthcare environment.
WSH Monitoring System

• Develop and implement a monitoring system for WSH services or at least support
inclusion of WSH services in routine monitoring of healthcare services.
1472 Y. S. Khader
• Ensure that human resources, financial support, and capacity building can guar-
antee sustainability of ongoing assessments and improve the ability to regularly
identify deficiencies.
• Ensure that national bodies exist for implementing monitoring standards and
overseeing compliance with national standards.
Training
• Training should equip individuals to operate and maintain essential services as
well as to enable staff and patients to use WSH services properly. This might be
achieved by developing joint training packages for healthcare staff that combine
WSH services with infection prevention and control. There should be regularly
trained individuals for ensuring that water and sanitation facilities are properly
operated and maintained and that essential services such as safe disposal of
healthcare waste are available. Training should be delivered to those operating
WAH infrastructure, staff, and patients.
• Develop training supporting tools such as appropriate reminders (e.g., posters),
refresher courses, and incentives.
Improving and Managing WSH Services

• Ensure correct design and construction of buildings and sanitary infrastructure
and maintain services.
• Improve WSH services in healthcare facilities by undertaking immediate, inex-
pensive measures to improve WSH conditions.
• Healthcare facilities need to encourage patients and carers to adopt appropriate
behaviors and to comply with procedures for use and care of water and sanitation
facilities and observe appropriate hygiene measures. They should also maintain
water and sanitation facilities.
Research
• Operational research is important for informing effective implementation and
further understanding the links between WSH services in healthcare facilities
and health outcomes.
Conclusion
The majority of healthcare facilities in Jordan have a safe and functional water to
provide enough water for the needs of the facility. Overall, the majority of health
facilities has improved and has gender-separated toilets in inpatients and outpatient
settings. Healthcare waste segregation at the point of generation is practiced in all
hospitals. All hospitals have sufficient containers for healthcare waste, separate
collection of hazardous and nonhazardous healthcare wastes, and separate storage
area for storage of hazardous and nonhazardous healthcare waste.
References
Allegranzi B, Bagheri Nejad S, Combescure C, Graafmans W, Attar H, Donaldson L, Pittet D
(2011) Burden of endemic health-care-associated infection in developing countries: systematic
review and meta-analysis. Lancet 377(9761):228–241
Askarian M, Yadollahi M, Assadian O (2012) Point prevalence and risk factors of hospital acquired
infections in a cluster of university affiliated hospitals in Shiraz, Iran. J Infect Public Health 5
(2):169–176
Balkhy HH, Cunningham G, Chew FK et al (2006a) Hospital and community acquired infections: a
point prevalence and risk factors survey in a tertiary care center in Saudi Arabia. Int J Infect Dis
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Hospital and community-acquired infections: a point prevalence and risk factors survey in a
tertiary care center in Saudi Arabia. Int J Infect Dis 10(4):326–333
Hashemi SH, Esna-Ashari F, Tavakoli S, Mamani M (2013) The prevalence of antibiotic resistance
of Enterobacteriaceae strains isolated in community- and hospital-acquired infections in teach-
ing hospitals of Hamadan, west of Iran. J Res Health Sci 13(1):75–80
McCormack JG, Barnes M (1983) Nosocomial infections in a developing Middle East Hospital.
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Ministry of Health/Jordan. http://www.moh.gov.jo
Oza S, Lawn JE, Hogan DR, Mathers C, Cousens SN (2015) Neonatal cause-of-death estimates for
the early and late neonatal periods for 194 countries: 2000–2013. Bull World Health Organ
93:19–28
Properzi F (2010) Rapid assessment of drinking water quality in the Hashemite Kingdome of
Jordan. Country report of the pilot project implementation in 2004–2005. WHO, Geneva, p 3
Siddiqi S, Elasady R, Khorshid I, Fortune T, Leotsakos A, Letaief M, Qsoos S, Aman R, Mandhari
A, Sahel A, El-Tehewy M, Abdellatif A (2012) Patient safety friendly hospital initiative: from
evidence to action in seven developing country hospitals. Int J Qual Health Care 24(2):144–151
Velleman Y, Mason E, Graham W, Benova L, Chopra M, Campbell OMR et al (2014) From joint
thinking to joint action: a call to action on improving water, sanitation, and hygiene for maternal
and newborn health. PLoS Med 11(12):e1001771. Healthcare associated infections
WHO. Health care-associated infections. Fact sheet. http://www.who.int/gpsc/country_work/gpsc_
ccisc_fact_sheet_en.pdf. Accessed Aug 2012
WHO (2014) UN-water global analysis and assessment of sanitation and drinking-water (GLAAS)
2014 report. Investing in water and sanitation: increasing access, reducing in inequalities. World
WHO/UNICEF (2014) WASH post-2015: proposed targets and indicators for drinking-water,
sanitation and hygiene. World Health Organization, Geneva. http://www.wssinfo.org/
fileadmin/user_upload/resources/post-2015-WASH-targets-factsheet-12pp.pdf. Accessed 9 Feb
2015
WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation (2004) Meeting the
MDG drinking water and sanitation target: a mid-term assessment of progress. http://www.
unicef.org/wash/files/who_unicef_watsan_midterm_rev.pdf
World Health Organization (2015) Water, sanitation and hygiene in health care facilities: status in
low- and middle-income countries and way forward. http://apps.who.int/iris/bitstream/10665/
154588/1/9789241508476_eng.pdf
Part VIII
Health Systems and Health Management
Health Policy and Systems Research in
the Arab World: Concepts, Evolution, 60
Challenges, and Application Necessity
for COVID-19 Pandemic and Beyond
Mohammed AlKhaldi, Khaled Al-Surimi, and Hamza Meghari
Contents
Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1479
HPSR Development and the Interconnected Concepts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1480
Conceptual Framework of HPSR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1480
Development, Goals, and Importance of HPSR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1482
HPSR Versus Other Types of Health Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1486
HPSR in the Arab World . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1486
Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1486
M. AlKhaldi (*)
Council on Health Research for Development, COHRED, Genéve, Switzerland
Department of Public Health, Unit of Health Systems and Policies, Swiss Tropical and Public
Health Institute (Swiss TPH), Basel, Switzerland
e-mail: moh.alkhaldi@swisstph.ch
K. Al-Surimi
College of Public Health and Health Informatics, King Saud bin Abdulaziz University for Health
Sciences (KSAU-HS), College of Public Health and Health Informatics, Riyadh, Saudi Arabia
Healthcare Management Consultant, Saudi Commission for Health Specialties, Riyadh, Saudi
Arabia
King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
School of Public Health, Faculty of Medicine, Imperial College, London, UK
e-mail: surimik@ksau-hs.edu.sa
H. Meghari
Research Committee Advisor, Women Deliver Organization, New York, NY, USA
Global Health and Development, Institute for Global Health, University College London UCL,
London, UK
e-mail: h.meghari.17@ucl.ac.uk

https://doi.org/10.1007/978-3-030-36811-1_62
The Capacity of HPSR in the Arab World . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1488

Challenges of HPSR in the Arab World . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1489
HPSR in the Arab World: A Case Study from Palestine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1491
Importance of HPSR in Response to the Coronavirus Disease (COVID-19) Pandemic . . . . . 1492
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1496
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1497
Abstract
This chapter discusses the Health Policy and Systems Research (HPSR) in Arab
countries in the context of the Eastern Mediterranean Region. It highlights the
conceptual framework of HPSR and its relevance, the development of HPSR and
its current situation and challenges, opportunities, and applications. The chapter
consists of five main sections: (1) background and introduction to HPSR, (2) the
phases of HPSR development, concept, and its relevance and interconnectedness
with other health research fields, its goals, and importance, (3) the landscape of
HPSR in the Arab world describing the current status of HPSR, exploring
capacity, and identifying challenges, (4) examples and experiences from Arab
countries, and (5) the importance of HPSR and the response to coronavirus
disease 19 (COVID-19). The chapter concludes by proposing strategies on how
to strengthen HPSR in the Arab world.
Keywords
Health research · Health policy and systems research · Arab world · COVID-19
Abbreviations List and Description

EMR East Mediterranean Region is composed of 22 member states of the
World Health Organization and is populated by nearly 679 million
people (WHO and EMRO 2020).
HPR Health policy research applies political science methods to understand-
ing, at meso- and macrolevels, government behavior in relation to health
(WHO and AHPSR 2007).
HRS Health research system is a social system defined as “the people, insti-
tutions, and activities whose primary purpose in relation to research is to
generate high-quality knowledge that can be used to promote, restore,
and/or maintain the health status of populations; it should include the
mechanisms adopted to encourage the utilization of research” (Pang et
al. 2003). In other words, the health research system is essentially a
governing system regulating all health research fields.
HSR Health system research produces social sciences, economics, and anthro-
pological investigations typically on macrolevel questions concerned
with the health policy and health systems as a whole (Remme et al.
2010; Bennett et al. 2018).
HSS Health system strengthening is an approach to solving problems from a
wider dynamic system through a deeper understanding of linkages,
60 Health Policy and Systems Research in the Arab World: Concepts, Evolution,. . . 1479
relationships, interactions, and behaviors in all elements of the health

system (Adam and de Savigny 2012).
HST Health system thinking offers a practical explanation for complex health
issues and helps to understand what works, how, and under what cir-
cumstances (Adam and de Savigny 2012).
SDG Sustainable development goals were adopted by the international com-
munity represented by the United Nations in 2016 to address health,
environmental, economic, political, and social issues by 2030 (Bennett
et al. 2020).
Background
It is important to start by introducing the conceptual and theoretical aspects of Health

Policy and Systems Research (HPSR) as an essential entry point for a better
understanding of HPSR concepts in relation to other interconnected health research
concepts and disciplines. The field of HPSR has evolved over the past 20 years
(World Health Organization, Alliance for HPSR 2017). This recent growth empha-
sizes the growing global interest in promoting health policy and systems research to
strengthen health system performance and health outcomes in the context of increas-
ing global health challenges, public health threats, and diseases burdens, calling for
increased investment in HPSR (WHO, Alliance for HPSR 2007 and Alliance for
HPSR 2016).
This global interest in HPSR was initiated by the WHO as a strategic direction
that aims to harness implementation sciences, operations research, and knowledge
transfer and translation processes in health decision-making and policy formulation
for improving health systems equity and efficiency (Gonzalez Block and Mills 2003;
Ijsselmuiden and Jacobs 2005; Pang et al. 2003; WHO 2012; Alliance for HPSR
2016). Therefore, HPSR emerged as a result of a global effort to reinforce the rise of
the health system thinking approach and evidence-informed policy and decision-
making (De Savigny et al. 2009 and Peters 2014). There is also a pressing need to
link global health, sustainable development goals (SDGs), and research evidence to
achieve health system-wide sustainable development goals (Gonzalez Block and
Mills 2003; Ijsselmuiden and Jacobs 2005; WHO, Alliance of HPSR 2007, Bennett
et al. 2020).
This chapter provides an overview of HPSR from two perspectives: first, con-
ceptualization (which relates to the definition of HPSR and its relevance with other
notions, its goals and importance, conceptual framework, and phases of develop-
ment), and second, a focus on HPSR in the Arab world and developing countries
(describing the current status of HPSR, identifying gaps, challenges and opportu-
nities, showing examples from Arab countries, proposing strategies and practical
solutions to strengthening HPSR in the Arab world, and ending with HPSR case
study from one of the Arab countries). Thus, it is important to initially mention that
the HPSR has a close link and interconnection with concepts such as health system
thinking, health systems strengthening, health research system, health policy
research, and health systems research. For the purpose of this chapter, we will
combine the HPR and HSR to form HPSR. Presenting a conceptual background
on these concepts provides a holistic understanding of best practices and serves to
guide health policy-makers, health practitioners, and health researchers to better
appreciate the interrelationships between these concepts, at operational levels, and
also to recognize the interrelational and differential aspects.
HPSR Development and the Interconnected Concepts
Conceptual Framework of HPSR
It is useful to begin by defining the “system” concept as a group of elements

operating in organic harmony to achieve a common goal (Arrasmith 2015). Linking
this system with health leads to a health system, a set of organizations, people, and
actions whose primary intent is to promote, restore, or maintain health. The aims are
to improve health and health equity in ways that are responsive, financially fair, and
make the best or most efficient use of available resources (WHO 2000; De Savigny
et al. 2009). A global consensus has been shaped by a focus on a primary question of
strengthening health systems amid a lack of a conceptual framework and formula to
apply improvement interventions, as well as by expanding investments in health and
healthcare. To tackle this complexity, the combined principles of health system
thinking and health system strengthening form an important approach that is rou-
tinely used in the literature of health system science.
Health system thinking (HST) is a way of thinking, but health system strength-
ening is an approach to solving problems from a wider dynamic system through a
deeper understanding of linkages, relationships, interactions, and behaviors in all
elements of the health system (Adam and de Savigny 2012). It is generally accepted
that health systems have at least six building blocks as described by WHO (service
delivery, health workforce, information, medical technologies, financing, and gov-
ernance/leadership) that are followed horizontally by four intermediate processes
(outcomes, access, coverage, quality, and safety, eventually) designed to achieve the
overall goals of the health system: equity, responsiveness, social and financial
protection, and improved efficiency (De Savigny et al. 2009).
The notion of HST under the slogan “no health without research” (Pang and Terry
2011) caused the global health community to appreciate the importance of health
research and knowledge transfer and translation by paying more attention to HPSR.
Research is not only about enabling health systems by offering evidence to policy-
makers about system dynamics and performance, health determinants, and defining
the best use of technological advancement in improving health, but can also be a
catalyst in the development process of other sectors (Pang et al. 2003; Council on
Health Research for Development 2000). As a sequence, the concept of health
research systems was introduced by the WHO and applied regionally and nationally
(WHO, Regional Office for the Eastern Mediterranean 2008; Hanney and González-
Block 2016) as among the requirements for HPSR.
The health research system (HSR), as a social system, is defined as “the people,
institutions, and activities whose primary purpose in relation to research is to
generate high-quality knowledge that can be used to promote, restore, and/or
maintain the health status of populations; it should include the mechanisms adopted
to encourage the utilization of research” (Pang et al. 2003). This system, which
should be structurally and functionally interconnected with health systems (Fathalla
2004; Decoster et al. 2011), regulates all research operations aiming at advancing
scientific knowledge to improve health and equity (Chanda-Kapata et al. 2012).
Thus, the health research system and health system are the main elements of HPSR
since evidence from HPSR supports the policy-making in health system perfor-
mance and health outcomes. Furthermore, health research systems and HPSR share a
common goal and play pivotal and complementary roles in strengthening the health
systems operations and policies by producing the required knowledge. The health
research system serves as a vehicle that drives all HPSR activities or programs within
a well-organized and governing structure. This regulatory and operational structure,
the health research system, supports the HPSR in producing this knowledge on the
health system’s six building blocks.
HPSR has the potential to provide evidence to improve decision-making,
strengthen health systems and improve health outcomes, and achieve health-related
development; however, there are many misunderstandings on what HPSR is and how
it can make this difference (WHO, Alliance for HPSR 2007; Ghaffar et al. 2013).
Therefore, a better understanding of HPSR will guide its applications. HPSR has
undergone several definitions; however, the adopted and refined definition for HPSR is
“It is both multi-disciplinary and inter-disciplinary in nature field seeks primarily to
produce new knowledge to understand and improve how societies organize them-
selves in achieving collective goals, including how they plan, manage and finance
activities to improve health, as well as the roles, perspectives, and interests of different
actors in this effort. HPSR focuses on policies, organizations, and programs from a
system-wide perspective, but not on clinical or basic research” (WHO n.d.; Tancred
et al. 2016; Bennett et al. 2008; WHO, Alliance HPSR 2007). This definition is
reinforced by the delineation that HPSR is a system-oriented field addressing all of
the six building blocks required to create a comprehensive picture of how health
systems respond and adapt to health policies, and how these policies can shape and be
shaped by health systems and the broader determinants of health (Remme et al. 2010).
Further deliberations to develop a more specific and clearer definition of HPSR
are crucial amid the recognition that the current definition causes confusion between
the terms of health policy research (HPR) and health system research (HSR). While
HPR originated from the application of political science methods to understanding,
at meso- and macrolevels, government behavior (WHO, AHPSR 2007), HSR pro-
duces social sciences, economics, and anthropological investigations typically on
macrolevel questions concerned with the health policy and health systems as a whole
(Remme et al. 2010; Bennett et al. 2018). Additionally, health system research refers
to low- and middle-income countries, including Arab world countries, largely
because the clinical and services health research fields are relatively contemporary
(Hyder et al. 2014).
In summary, these definitions are designed to be knowledge-oriented and share

common health targets with some differences in the conceptual and operational frame-
works, actors, influence levels in the health system, and utilization and application of
knowledge output. Nonetheless, it is essential to emphasize that the notion of a health
research system is essentially a governing system regulating all health research fields.
The field of HPSR, which overlaps with services research in their fields of
interest, has two domains: health policy research analysis and health system
research. Both terms are integrated areas generating evidence on health system and
health policy interactions (Ghaffar et al. 2016). As a summary point, HPSR is a
combination of health policy research and health system research, where the imple-
mentation of its activities requires health research systems to regulate and manage
these activities that seek to strengthen the health system pillars. HPSR can be driven
by applied approaches such as health system thinking and health system strength-
ening for analyzing, understanding, and strengthening the health systems in low- and
middle-income countries from a sector-wide perspective, including the Arab coun-
tries. This reinforces the importance of HPSR and the need to apply it through
appropriate mechanisms in developing countries, including the Arab world.
This chapter proposes this overall conceptual framework to help all health
stakeholders (health officials, academics, managers, practitioners, partners, and
medical students) to better understand the interconnectedness of these concepts at
the micro (individual), meso (institutional), and macro (national) levels, and so
enabling all health stakeholders to apply these concepts in decision-making.
Development, Goals, and Importance of HPSR
The field of HPSR has evolved rapidly over the past 20 years, as manifested in the
growing international endeavors, levels of funding, and the number of publications
(Bennett et al. 2018). HPSR has brought impressive changes to an evolving land-
scape, which will continue to grow in complexity due to various challenges such as
demographic transition, environmental and political changes, disease emergence,
diversity of stakeholders, and the nature of health systems complexities. However,
HPSR reduces the consequences of these critical challenges, most notably the
evolving universal health coverage and sustainable development goals paradigms,
through a close and synergized link with the concepts related to the health system
such as health system strengthening, health system thinking, and the other main
building blocks.
There was already substantial interest in health services research in the developed
world by the 1970s, when discussions in the World Health Assembly drew attention
to the importance of HPSR. In 1972, an emphasis for greater investment in this field
proposed studies on (1) the economics of health, (2) manpower resources and
development, (3) community participation, and (4) the selection, specification and
standardization of the procedures and techniques used by skilled personnel (AHPSR
2004; Bennett et al. 2018). Building on this, a perspective of moving from disease or
service-specific ways of viewing health services in low- and middle-income
countries to a more integrated and systems-focused approach was developed and

adopted, as now embodied both in universal health coverage and in the sustainable
development goals (Ghaffar et al. 2016).
Later, in 1996, the WHO published the volume Health Policy and Systems
Development and created an agenda for research which laid the foundation for the
establishment of the Alliance for HPSR in 1999. From the start of the Alliance in
1999, it was considered important to include the letter “P” to signal the close link
between research and policy (emphasizing that informs policy), and the importance
of doing research not just for policy but also on policy (Alliance for HPSR 2004;
Bennett et al. 2018). The Alliance has become a respected leader in the field of
HPSR, demonstrating a key role in strengthening HPSR to make health systems in
low- and middle-income countries more resilient and more functional. This has
resulted in regular consultation and guidance services, and annual global meetings
to achieve progress in HPSR. This evolution (Figs. 1 and 2) shows the historical
milestones and knowledge production on HPSR (Ghaffar et al. 2016; Bennett et al.
2018; WHO, Alliance for HPSR 2017).
Fig. 1 Publications on health policy and systems research and those related to health policy.
(Source: Ghaffaret et al. 2015)
1484
Fig. 2 Key publications and events promoting health policy and systems research (HPSR). (Source: Bennett et al. 2018 and references therein)
M. AlKhaldi et al.
The strength of HPSR lies in its novelty, inclusiveness, and utility. HPSR is a
knowledge-based field used by the global health community where it aims to achieve
global health goals such as universal health coverage, quality and safety, health
equity, and the efficiency of the health systems (Bennett et al. 2008; Ghaffar et al.
2013; WHO n.d.). It comprises various disciplines, including economics, sociology,
public health, and political science. In addition, HPSR has assessment and evalua-
tion tools that can be used in investigating health systems and health interventions.
These approaches have quantitative, qualitative, or mixed methods; however, there is
a need to advance these methods to provide an improved operational framework for
better HPSR application and utilization. Inter-, trans-, and multidisciplinarity con-
cepts and blended analytical approaches strengthen and promote HPSR.
HPSR investigates the interactions, impacts, and interconnections between poli-
cies and health systems to better understand the system from social, public health,
economic, and political perspectives. Building on this perspective, there are three
consecutive central levels of HPSR goals: 1) generating new and solid knowledge to
understand and improve societies organization and policy implementation (Tancred
et al. 2016; WHO, Alliance for HPSR 2007), 2) providing influencing and informing
approaches and tools for health policy-makers serving to lead and adapt to changes
in the health sector (Peters 2018), and 3) applying this knowledge using HPSR tools
and methods, such as knowledge transfer and translation and policy briefs to
improve health system performance (quality, efficiency, and/or equity) with the
goal of achieving improved health status and health equity (Ghaffar et al. 2016).
HPSR is of great importance in developing countries, including the Arab, in
generating evidence-based solutions to address health challenges (Sheikh et al.
2011). Furthermore, improving HPSR capacity in developing countries occurs at
various levels to impact policy change and practice: at the macrolevel where health
policies are made, the mesolevel where policies at the institutional level are designed
and implemented, and the microlevel to educate individual behaviors (Shroff et al.
2017).
More importantly, health policies, which represent the core focus of HPSR, are
the driving force of health system improvement. However, research to address the
policy process and decision-making in all stages of policy formulation remains
neglected and should be increased, especially in developing countries, including
the Arab world so as to improve health system performance and health outcomes
(Ghaffar et al. 2016). It is important to bridge the gap between knowledge production
and its application in health decision-making and policies in developing countries,
including the Arab world. This organizational and implementation process is driven
by HPSR, even though this field remains underdeveloped in these countries (Parvin
et al. n.d.; Koon et al. 2013).
To summarize, understanding the interrelationship between the concepts of
“Health System Thinking,” “Health System Strengthening,” “Health Policy
Research,” “Health System Research,” and “Health Research System” should be
conceptually aligned with HPSR so as to identify the context, purposes, and uses of
HPSR. All of these concepts, especially HPSR, share a common goal of strength-
ening and enabling health system performance and health outcomes. HPSR has to be
well interlinked with the national health system and national development system
which embraces four functional levels: individual, institutional, national, and inter-
national. In this structure, HPSR requires perspectives from economics, sociology,
anthropology, political science, business, medicine, and public health.
HPSR Versus Other Types of Health Research
The need for HPSR is growing in light of increased belief in evidence-based

decision-making. The use of HPSR outputs is becoming an essential advocacy tool
to inform and advise researchers, policymakers, and health stakeholders by 1)
identifying priority health issues; 2) providing a broad choice of evidence-based
policy options; 3) informing the process and dialogue of developing national health
policies, strategies, and plans; and 4) setting the stages for implementation processes,
and monitoring and evaluating the outcomes of selected policies, strategies, and plan
(Lavis et al. 2002; Campbell et al. 2009). Although the production of HPSR research
is necessary, production alone is not sufficient to strengthen health systems and
improve health status. This field is devoted specifically to assessing and using new
methods and approaches, areas not covered by other health research fields. In other
words, in addition to producing research, there should be also a capacity among
policy-makers to use evidence routinely in policymaking, developing evidence-based
strategic planning, and making operational decisions from a system-wide approach.
While HPSR and other health research such as social science research in
healthcare are undermined and under-funded, biomedical and clinical research is
dominating health research. Existing funding bias toward biomedical and clinical
research has created an imbalance in HPSR capacity development (Cairney and
Oliver 2017). This dominance and bias can reduce the potential impact of health
system thinking and evidence-based decision-making approaches in improving
health systems. This requires continuing promotion and appreciation of HPSR and
engagement of health practitioners and policy-makers and related stakeholders in
HPSR. The uniqueness of HPSR, compared to other types of research, lies in the
distinction of its audience, unconventional approaches, and a mixture of disciplines
and sectors that together interact to form a holistic approach to health systems.
HPSR in the Arab World
Overview
There is a global interest in HPSR, including the Arab countries. One of the aims of
HPSR is to bridge the gap between research producers (researchers) and research
consumers (policymakers) and promote the evidence-informed decision-making
approach when developing national health policies, strategies, and plans.
The use of HPSR in Arab countries is evolving, with limited published literature
on HPSR in the Arab world (El-Jardali et al. 2010, 2011). Analysis of print media
conducted in 2007 covering 44 low middle-income countries, including many Arab

countries, revealed that the WHO Regional Office for the Eastern Mediterranean
counties are among the lowest producers in terms of using evidence for
policymaking and practice improvement or discussing policy priorities in the health
sector (Cheung et al. 2011; El-Jardali et al. 2011). Likewise, the WHO Regional
Office for the Eastern Mediterranean countries reports that many Arab countries
were among the lowest producers of systematic reviews (Law et al. 2011).
Systematic reviews are considered among the best sources of HPSR evidence-to-
policy decision-making. The annual production of HPSR articles in some Arab
countries for 2000–2008 is shown in Fig. 3; Jordan, Egypt, Lebanon, Sudan, and
Tunisia show progressive increases in producing health system research literature
compared with other counties such as Yemen, Palestine, Libya, and Syria (Ibrahim
2015; Fadlallah 2015).
The average number of health-related research publications in the WHO Regional
Office for the Eastern Mediterranean, including Arab countries, is well below the
world average for the same groups (Mediterranean 2008; El-Jardali et al. 2011).
Some factors for the poor production and use of health research evidence in the
health policymaking in Arab counties include the following:
1. The low value given to research evidence in general.

2. Difficulty in accessing available research evidence.
3. The complexity of the policymaking environment and processes in the region.
60
50
Bahrain
40
Number of Articles
Egypt
Jordan
Lebanon
Libya
30
Morocco
Oman
Palestine
20 Sudan
Syria
Tunisia
Yemen
10
0
2000 2001 2002 2003 2004 2005 2006 2007 2008
Year of Production
Fig. 3 HPSR in eastern Mediterranean countries: A stocktaking of production and gaps

(2000–2008). (Source: Adapted from El-Jardali et al. (2011))
4. The inadequacy of budget allocated to HPSR research.

5. Lack of a user-friendly format of research evidence packaging to be used by
policymakers (Ghannem 2011; Kennedy et al. 2008; Hyder et al. 2007, 2011;
El-Jardali et al. 2012a, b).
Although publications in health research are increasing, these reports are mostly
published locally in nonindexed journals and/or in grey literature, making them
inaccessible or unsearchable to other researchers and also to policymakers (Deleu
et al. 2001). Thus, there are clear structural and technical barriers related to produc-
ing and using the HPSR in the Arab countries; as long as no mechanisms are in place
to hold decision-makers accountable for their decisions, HPSR will not be used to
produce evidence-based public health policies to improve the performance of health
systems in the region.
The Capacity of HPSR in the Arab World
Strengthening HPSR in the Arab countries has become a priority aimed at encour-
aging collaborations and partnerships with the aim of revitalizing HPSR and health
research in the region (Horton 2019), although there are many challenges. Monitor-
ing and evaluating the capacity to generate HPSR research are difficult in the region
due to shortages in expertise, tools, stakeholder participation, and contextual differ-
ences (Bates et al. 2015).
These challenges include a poor research capacity, shortages of investment and
funding, and a lack of political support and sustainability (El Achi et al. 2019). Other
challenges include a lack of security, collapse of infrastructure, and the need to
cultivate trust among stakeholders involved in HPSR (El Achi et al. 2019). There are
many calls initiated by the WHO to address these weaknesses by building research
capacity to support HPSR productivity, communicate its outputs with policy-makers,
and support health research in general. Strengthening HPSR and health research
helps improve health systems (Sheikh et al. 2011; Oxman et al. 2009). Many
international partners implemented different capacity-building projects in the region,
and although progress has occurred, commitment and sustainability remain impor-
tant gaps.
The WHO produced resolutions that embrace HPSR, proposed translating mech-
anisms such as knowledge transfer and translation and evidence-informed-policy,
and allocated resources for building this capacity. These WHO initiatives also apply
to the Arab world and should be implemented at the national, institutional, and
individual levels. This chapter classifies the HPSR challenges into five areas: 1) a
lack of HPSR recognition and application in decision-making; 2) the fragmentation
and lack of governance and a single agreed definition of the field of HPSR; 3) the
dominance of biomedical, applied, and clinical research; 4) poor demand for HPSR
from policymakers; and 5) weaknesses in institutional and individual capacities. All
these five challenges are common among most of the Arab countries, and they are
interlinked with various weaknesses such as political will, governance, awareness,
resources, and institutional capacity and individual competencies to undertake high-

quality and useful HPSR.
Challenges of HPSR in the Arab World
Poor Recognition of HPSR in Policy and Decision-Making

HPSR in developing countries, including the Arab countries, requires adoption and
application. HPSR is recognized in some Arab countries such as Lebanon and the
United Arab Emirates, while it is neglected in countries such as Iraq, Libya, Yemen,
and Syria. The weakness of HPSR in Arab countries can be attributed to structural
challenges such as the inadequacy of stewardship to build research institutions,
fragmented policies and uncoordinated efforts, lack of prioritization exercises, and
inadequate political support (AlKhaldi et al. 2018a). HPSR requires a health research
system as a prerequisite to establishing regulatory frameworks to drive HPSR
activities, but this system does not exist in many countries in the region, leading to
stakeholder disengagement and fragmented research that is rarely aligned with the
actual needs. Anecdotal evidence indicates that the scope and scale of HPSR requires
more efforts from governments and institutions alike (Gonzalez Block and Mills
2003).
With many challenges facing HPSR in the Arab countries, among them is the low
and disparity in funding which still the main issue (Bennett et al. 2011). However,
this significant challenge in HPSR in developing countries and Arab world countries
may not always due to the unavailability of fund, but rather inadequacy resources
invested in research, especially HPSR, and lack of institutional capacity, including
academic\research institutions (El-Jardali et al. 2015).
HSR Conceptualization Issue

The Alliance for HPSR recognizes HPSR as a mean for strengthening health systems
as it acknowledges the inveterate connections and dynamics among health system
building blocks (Alliance for HPSR 2004). This recognition can be incorporated
within the WHO’s “health system” building blocks that cover six health system
areas: leadership and governance, health systems financing, human resources for
health, service delivery, medical products and technology, and information and
evidence (El-Jardali et al. 2015; WHO 2007). However, the ongoing terminological
confusion and overlap between “health system research” versus “health services and
clinical research” require clarification. Although the alignment between the two
concepts is getting clearer over time, greater efforts are still needed to clarify HPSR.
On the one hand, there is an improved understanding of the concept of HPSR in
health research in general, but on the other hand, there is no consensus on the
conceptualization of health system research. Health system stakeholders’ under-
standing, on the concepts of health research systems and evidence-informed
policymaking, is poor due to lack of orientation and practices of using research
evidence (AlKhaldi et al. 2018). Understanding these concepts and practices related
to the supply side (researchers) and the demand side (policymakers) is not well
integrated in Arab countries. There are different gaps in research structure, capacity
and resources, and individual incompetency behind the weak integration. There is an
urgent need in the region for creating opportunities, including policy/knowledge
think tanks or excellence centers, to improve understanding of HPSR concepts and
facilitate the communication between the researchers as a producer of evidence and
policymakers as implementers of evidence.
The Dominance of Biomedical and Clinical Research Model

It is clear that there is an imbalance between disease perspective and health and
systems perspectives and bias toward disease perspective which is still the predom-
inant model in both developed and developing countries. This perception has
resulted in patient and clinical services-oriented health systems instead of people
and health/wellness oriented systems, which hinders the progress of health research
fields such as HPSR, policy and management research, and social science research in
healthcare (Cairney and Oliver, 2017). In the complex health systems of today,
concepts of “health information systems,” “health costs, health financing systems,”
“quality and safety,” and “the wasteful of resources including misuse of drugs”
cannot be researched from a diseases perspective, but rather from a system approach.
Therefore, fair and unbiased investment and development in all health research
models can achieve the common goal of improving public health.
Lack of Demand for HPSR and Poor Research Prioritization and

Intersectoral Coordination
It was not until the late 1990s and early 2000s that the term HPSR emerged in the
literature of health research, and knowledge transfer and translation were then
widely used in implementing research findings in policy-making. The fields of
knowledge transfer and translation and evidence-informed policy-making are still
growing, especially in developing countries including Arab counties, although these
are not well conceptualized and often inappropriately performed (AlKhaldi et al.
2019). Although HPSR evidence was used by international agencies who support
health sector reforms in most of the developing countries, little attention was paid to
capacity building in these countries. In addition, exercises of research prioritizations
to reflect national health goals and health system needs should be regularly and
systematically approached. The current exercises remain a problematic issue and
need improvement. A study from Palestine reports that exercises in research priority-
setting appear to be evolving despite the lack of consensus and the low levels of
knowledge and experience, and not to mention that intersectoral coordination does
not exist as supposed to be supporting the HPSR requirements (AlKhaldi et al.
2018).
Lack of Institutional and Individual Capacity Building

The biased focus on biomedical and clinical training of human resources for health
(although it is important) is one of the reasons for the limited health system research
in the Arab region. Moreover, as far as the HPSR is concerned, most efforts over the
last 2 decades focused on developing the skills and career development of
individuals, and ignored institutional capacity. The development of HPSR requires a

critical mass of high-quality collaborative HPSR researchers with different expertise
related to the health system. This collaborative research capacity building needs to
be supported by academic institutions with enabling environments (Ghaffar et al.
2016). The potential impact of HPSR depends on bridging the gap between health
system researchers, policy-makers, and policy brokers. This requires not just pro-
viding research facilities such as libraries, databases, and research incentives, but
also creating enabling environments and matching the evidence with the appropriate
decision-makers (Gilson et al. 2011). Despite the availability of competent person-
nel, providing financial resources and facilities remain a central challenge. In
general, health research financing is limited, unsustainable, and flows from external
and individual sources. Public and private funds are limited with resources mis-
allocation and donor conditionality. Other common concerns are a lack of gover-
nance, coordination, health research system resources, infrastructure, capacity,
resource allocation, systematic and reliable data, and an evidence-informed culture
(AlKhaldi et al. 2019).
HPSR in the Arab World: A Case Study from Palestine
The health research system is crucial for developing and enabling health systems,
particularly in developing countries. The WHO recognizes the role of national health
research systems in addressing health needs by analyzing this system in order to
strengthen it. This case study is the first analysis on HPSR and health research
system in strengthening health research (including HPSR) in Palestine (AlKhaldi
2018).
Four key pillars of the system in Palestine were investigated: 1) assessing the
health research system concept and its importance, 2) evaluating their satisfaction
with overall system performance and political attention to health research, 3) exam-
ining the stewardship, governance, policy, and priorities, as a central pillar of this
system, and 4) analyzing stakeholder roles and research capacity. Based on these
four axes of analysis, key gaps and avenues for strengthening the health research
system in Palestine were identified. Three sectors were targeted: relevant govern-
ment institutions, schools of public health, and major local and international health
agencies. A qualitative analytic approach was used where data was collected through
52 in-depth interviews and 6 focus group discussions with 104 policymakers,
academics, directors, and experts.
This case study indicates that understanding of health research system concepts
by Palestinian health experts is inadequate and is not sufficiently conceptualized for
application. The health research system in Palestine is underperforming and lacks
political support and engagement. Stewardship functions are problematic, meaning
that a system for health research in Palestine is still not embodied and lacks structural
and regulatory framework with limited efforts in health research. In addition, there
are weaknesses in ethical review and limited experience in research. Involvement of
society, private, local, and the international sectors in supporting health research is
insufficient, and significant deficits in health research system capacity continue. This
is mainly due to limited and unsustainable funding of research in Palestine which
leads to low-quality research and poor-knowledge transfer. Other gaps identified
include: lack of health system culture, systems values, and principles; structure;
policy; resources; defined roles; connection and network; evidence-informed con-
cepts; and political awareness (AlKhaldi et al. 2018). These identified gaps in
Palestine likely also exist in most of the Arab world.
HPSR and research prioritization in Palestine reveal that although HPSR is of
interest to experts and policymakers, it remains a major challenge to implement as
shown in the first and prefinal ranking highlighted in green in Table 1, suggesting
that health research priority-setting in Palestine is growing. However, this does not
necessarily provide the national health research priorities that Palestine lacks. Some
studies suggest that no previous priority-setting exercises was implemented in HPSR
in the WHO Regional Office for the Eastern Mediterranean, with only three coun-
tries in the region setting national health research priorities (AlKhaldi et al. 2018,
2019). There are several gaps in prioritization, determined mostly by political
powers and influenced by social, political, and environmental groups to meet
specific interests. A deficiency in knowledge and expertise occurs where prioritiza-
tion exercises are not practiced systematically in an integrated national perspective.
Further, the issues of stakeholder compliance to the outputs of these exercises, and
the scarcity of resources, are problematic.
A comparison of the three health research priority-setting exercises implemented
in Palestine is shown in Table 1, and ranked according to frequency. The most
important priorities to be addressed by the health research system are the areas of
health system research such as health governance, financing, workforce, capacity,
policy, and healthcare coverage and access. Other health research priorities are
noncommunicable and communicable diseases, nutritional conditions, disability,
and environmental concerns; these are the major causes of death and are the most
affected by the escalation of instability and crises in the region. Medical diagnosis
and genetic and molecular diseases received lower research priorities. Research
policy, including specific subjects such as interdisciplinary sciences, excellence
centers, evidence-based medicine, medical education, ethical and jurisprudence,
research capacity, accessing grants, publishing papers, and data sharing and analysis,
does not receive priority. In general, although HPSR is a research priority of the state
and nonstate health system stakeholders in Palestine, there is a need to also prioritize
other areas of policy research.
Importance of HPSR in Response to the Coronavirus Disease

(COVID-19) Pandemic
The COVID-19 pandemic has rapidly transformed global health systems and their
responses to the crisis. The pandemic proved that HPSR is imperative to an evi-
dence-based response. With no data and evidence about the virus and the appropriate
public health action to manage it, health research has become the primary goal. State
Table 1 Comparison of three NHRPs based on the scientific council of research (SCR) manual, Palestinian National Insitute of Public Health (PNIPH), and
60
workshop and perceptions from study experts

National setting
exercises SRC manual on HRPs PNIPH workshop on HRPs HRPs identified by study experts
Areas (2014) (2017) Government Academia NGOs
Health care system Health financing, HIS, Access, coverage, Cost of referral Governance, resources Financing and policy,
workforce capacities, workforce, PHC, health abroad allocation, health accesses, workforce,
education and medical financing, and HIS economic, and care care quality, and
accreditation, coordination, quality efficiency
and management system
Mother-child Healthcare and protocols Maternal, PNC, FP, Child MCH MCH and youth
health evaluation, school health, women’s health, behaviour
nutrition, anemia, child vaccination, nutrition
obesity, FP, early detection
of genetic disease
Noncommunicable Causes and risk factors, Preventive care, tobacco NCDs, cancer NCDs NCDs, cancer, and
diseases assessing prevention- control, healthy lifestyle, social determinants
promotion, diagnosis and cancer, CVDs, stroke, HTN,
management, health care DM, and determinants
quality, and providers
performance
Nutrition Anaemia, providers roles, Anemia, vitamin deficiency, Nutrition, Nutrition, thalassemia
association with NCDs, food and obesity anemia
toxicity and pesticides, and
obesity
Mental health Causes, addiction, suicide, Psychosis, stress-related Mental illnesses Mental illnesses,
prisoners, wounded and disability disability
wars victims, and care
Health Policy and Systems Research in the Arab World: Concepts, Evolution,. . .
quality
(continued)
1493
1494
Table 1 (continued)
National setting
exercises SRC manual on HRPs PNIPH workshop on HRPs HRPs identified by study experts
Areas (2014) (2017) Government Academia NGOs
Environmental Water, air and soil, and Water quality, waterborne Water and Water and
health diseases, wars remnants, diseases, toxins, safety, environmental environmental health
industrial effects, and traffic safety, and buildings health, RTA
medical waste management
Infectious diseases Risk factors and causes, Meningitis, leishmaniosis, Infectious diseases, Infectious diseases
assessing of prevention- and foodborne diseases NTDs
promotion programs and
protocols, and surveillance
Research policy Interdisciplinarity in basic, HR capacity, accessing Medical education
clinical and community grants, publishing papers,
sciences, excellence centers, data sharing, and analysis
evidence-based medicine,
medical education, and
ethical and jurisprudence
Others Dental care, the Mortality Osteoporosis, inherited Socio-economic and
advancement of medical causes, diseases, molecular political determinants
diagnostic methods, genetics antibiotic biology, and medical
and molecular biology, resistance diagnoses
pharmaceuticals and natural
plants use, and medications
financing and supplying
M. AlKhaldi et al.
and nonstate stakeholders, including universities and international organizations,

rushed to support COVID-19 research. Many are working on understanding the
epidemiological characteristics of the virus, investigating the appropriate policies,
researching possible effects of available drugs, and developing vaccines. While
others have been looking into the impact on the health system and its components
to achieve the best preparedness and response (AHPSR n.d.). Like never before, the
increase in demand for evidence, particularly from policy and decision-makers, is
encouraging and offers an opportunity for health research systems to demonstrate its
ability to impact decision-making (AHPSR 2020). In addition, there has been
unprecedented research collaboration at all levels, from governments and health
organizations to researchers and individuals. This partnership is key in what the
world has achieved in terms of containing the virus so far (Turner and El-Jardali
2020).
On the other hand, the COVID-19 pandemic exposed the weaknesses of health
research systems, from slow research production and conflicting evidence to poor
research translation into policies and practices. The delay in research production
is primarily attributed to rigorous and avoidable bureaucratic publication stan-
dards, which slow the knowledge translation process and subsequently put people
at risk. Furthermore, the conflicting and sometimes confusing evidence that is
circulating on research platforms and social media overwhelmed policy-makers
(Turner and El-Jardali 2020). This necessitates new strategies such as curated
systematic reviews that present robust and comprehensive evidence Health Sys-
tems Global (HSG), Thematic Working Group (TWG) (2018). Such strategies
could speed knowledge translation and increase evidence uptake by policy-
makers (Alliance for HPSR n.d.). Having said this, the WHO Alliance for
HPSR outlined some strategies to reliably speed up health policy and system
evidence synthesis including: i) parallelization of tasks which means that multiple
reviewers simultaneously complete review steps, ii) narrowing the scope by
limiting the number of target populations, interventions, and endpoints, iii)
using review shortcuts by reducing or omitting one or more systematic review
steps, and iv) automating review steps in which new technologies are used to fast-
track the standard systematic review steps, e.g., data abstraction (Langlois et al.
2019 and Alliance for HPSR n.d.).
The COVID-19 pandemic has changed the landscape of HPSR globally, but more
noticeably in developing countries, including Arab countries (OECD 2020). The real
challenge, however, is to maintain and develop this desire to evidence to strengthen
health systems. The quickly evolving nature of the COVID-19 pandemic requires
fast HPSR evidence synthesis to support health systems’ response and practices in
low and middle-income countries. The WHO Alliance for HPSR has established
rapid evidence synthesis platforms and centers for HPSR, including systematic
review centers (WHO 2020). One such center is hosted by the American University
of Beirut in Lebanon (the Center for Systematic Reviews on Health Policy and
Systems Research (SPARK)). SPARK is a leading resource center for producing
high-quality evidence synthesis products on health policy and systems priorities in
the Eastern Mediterranean Region.
While varying attention is given to HPSR in the Arab world in the shadow of
COVID-19, many challenges hinder its application. Here, we would like to shed the
light on one particular challenge. A number of Arab countries have experienced
conflicts which significantly damaged their health systems (OECD 2020). For
example, the Israeli occupation of Palestine severely disrupted the government of
Palestine’s response. The systematic harmful actions of the Israelis in East Jerusalem
to close COVID-19 testing centers established by the Government of Palestine and
restricting the movement of health staff, medical equipment, and testing kits between
the Palestinian territories are all designed to prevent the translation of evidence-
informed policies adopted in East Jerusalem. Although the health systems response
in Palestine to COVID-19 outperformed other countries in the region, the ongoing
Israeli occupation (Politics) and intra-Palestinian divide (Policies) severely impact
the already handicapped health system in terms of its governance, resources, and
capacity (AlKhaldi et al. 2020).
The COVID-19 pandemic presents valuable insights on the weaknesses and
strengths of HPSR. We are reminded of the need to invest in HPSR as a means of
strengthening health systems. By looking at the evidence-based response to COVID-
19 in the Arab countries, we can appreciate the potential of health research systems
in general and HPSR in particular. There is an opportunity, but also a challenge, to
convert this desire to research and evidence into a standard practice by health
systems, funders, and most important state and nonstate actors in the Arabic
countries.
Conclusion
The HPSR is still a growing discipline, and implementation of HPSR as research and
science is still in its infancy period of development and insufficient in the Arab
world. It is important to understand HPSR in relation to the health system, health
system thinking, health system strengthening, health system research, health policy
research, and health research system. The purpose is to provide evidence to inform
health policy development and to hold the decision-makers accountable for their
policies. In the Arab world, HPSR requires acceptance as a discipline that can guide
policymakers. Thus, there is a need to empower stakeholders, researchers, and
professionals on HPSR subjects, by providing a supportive environment for
strengthening HPSR. In spite of the scarcity in the region, HPSR funding in the
Arab world is conditional and often funded by external donors and further sustain-
able investment is a priority. The COVID-19 pandemic highlights the important role
of HPSR in an evidence-based response not only to the COVID-19 pandemic but
also to other public health issues and threats.
We identified several challenges related to HPSR in Arab world countries that
need to be addressed. An important challenge is the gap and the inability of health
researchers and policy-makers to use the health system thinking approach for
developing, implementing, and evaluating health policy options and health system
improvement interventions. Insufficient awareness and lack of practices in the HPSR
field are the main reasons behind this gap. Therefore, there is an urgent need to
initiate serious efforts to strengthen HPSR in the Arab region. The following are key
issues that need to be addressed to develop and strengthen HPSR in the Arab world:
1. Conceptually: improving public image of research evidence in general and

HPSR in particular, with a focus on improving the knowledge of health system
professionals, academic staff, and students in health schools.
2. Institutionally: building institutional research capacity and resources related to
HPSR across departments, institutions, and sectors. Create an excellence center or
think-tank unit for HPSR, structurally embedded in the ministry of health
hierarchy.
3. Evidence: improve access to best available literature evidence on HPSR and
knowledge databases related to HPSR.
4. Capacity Building: increase training and education programs on HPSR and
interconnected approaches in the curriculum of health faculties and colleges.
5. Resources: provide adequate budgets and incentives for HPSR research by
proposing fixed and multilateral funding models adopted by governments and
international partners.
6. Barriers: Improve communication between the HPSR researchers and policy-
makers in the region at the macro-, meso-, and microlevels.
7. Networking: Increase opportunities for networking by local and international
scientists in the HPSR field to allow for greater sharing of knowledge, expertise,
and research.
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Pharmaceutical Sector in Palestine
An Introduction
61
Dima M. Qato, Jenny S. Guadamuz, Bashayer Al-Shehri,
Reem Al-Sultan, and Rania Shahin
Contents
Background and Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1505
Demographics and Health Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1507
The Provision and Availability of Health Care and Pharmacies . . . . . . . . . . . . . . . . . . . . . . . . . . . 1507
Health Care Financing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1509
The Pharmaceutical Sector in Palestine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1510
Pharmaceutical Regulations in Palestine, Including Sanctions and Border Controls . . . . . . . . . 1512
Marketing Authorization and Registration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1512
Manufacturing Licensing, Quality Control, and Counterfeit and Substandard
Medicines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1513
Restrictions in the Importation and Exportation of Pharmaceuticals . . . . . . . . . . . . . . . . . . . . . . 1514
Pharmacovigilance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1515
Medicines Supply System in Palestine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1515
Shortages of Essential Medicines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1515
Medicines Financing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1516
National Health Insurance and MOH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1516
UNRWA, NGOs, and Private Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1517
D. M. Qato (*)
Program on Medicines and Public Health, School of Pharmacy, University of Southern California,
e-mail: dimaqato@uic.edu
J. S. Guadamuz
Department of Pharmacy Systems, Outcomes and Policy, University of Illinois College of
Pharmacy, Chicago, IL, USA
Institute of Minority Health Research, University of Illinois at Chicago, Chicago, IL, USA
B. Al-Shehri · R. Al-Sultan
Department of Pharmacy Practice, University of Illinois College of Pharmacy, Chicago, IL, USA
R. Shahin
Ministry of Health, Nablus, Palestine

https://doi.org/10.1007/978-3-030-36811-1_64
1504 D. M. Qato et al.
High Medicine Costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1517

Pricing Regulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1517
Medicines Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1519
Essential Medicines List and Rational Use of Medicines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1519
Pharmacists and Their Role . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1520
Conclusions: Summary and Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1521
Implications and Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1521
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1521
Abstract
Policies aimed at strengthening the delivery of safe, effective, and affordable
medicines in Palestine have improved over the last decade. The capacity of both
the public and private pharmaceutical sector in Palestine, particularly in the West
Bank, has improved. However, several areas warrant increased attention both
from policy and public health officials. These include the high cost of essential
medicines, the lack of pharmacovigilance and safety regulations, and a monitor-
ing and evaluation system to ensure prescribing practices and the use of medi-
cines in the population to promote public health. Moreover, future policy and
health delivery reforms should incorporate the government, the private sector,
NGOs, and UNRWA, especially concerning the areas of payment and reimburse-
ment systems, medicine supply chain, and the cost of medicines. This is important
considering the largest payer of health care are households and that the vast
majority of the population utilize services from the private sector, including local
pharmacies.
Keywords
Medicines in Palestine · Medicines access · Pharmaceuticals in Palestine ·
Medicines expenditures · Pharmaceutical regulations
ADE Adverse drug events
API Active pharmaceutical ingredients
CAM Complementary and alternative medicine
CDS Central drug store
DDCR Drug Control and Registration Department
Directorate General Directorate of Pharmacy
EML Essential medicines list
EU European Union
GDP Gross domestic product
GHI Government Health insurance
GMP Good manufacturing practices
IMOH Israel’s Ministry of Health
MOH Palestinian Ministry of Health
61 Pharmaceutical Sector in Palestine 1505
MOSA Ministry of Social Affairs

NGO Nongovernmental organizations
PCBS Palestinian Central Bureau of Statistics
PHIC Palestinian Health Information Center
PMMS Palestinian Military Medical Services
PNA Palestinian National Authority
UNRWA United Nations Relief and Works Agency
USAID United States Agency for International Development
USD United States dollar $
WB World Bank
Background and Introduction
Medicines are necessary in the treatment and prevention of acute and chronic illness
for which the pharmaceutical sector is responsible for ensuring policies are
implemented that promote their access and use. Palestine, which is comprised of
the West Bank and Gaza, is a state under occupation. Thus, the population is
persistently exposed to violence and political conflict and is undergoing an epide-
miologic transition with both infectious and chronic conditions prevalent for which
the pharmaceutical sector must address. To assure that Palestinians have appropriate
access to medicines, one must understand the political background, the health
system, and the pharmaceutical regulations that impact the pharmaceutical sector.
In this chapter, we discuss pharmaceutical situation in Palestine with a focus on
pharmaceutical policies and regulations.
Palestine, also known as the occupied Palestinian territories of the West Bank and
the Gaza Strip (Fig. 1) (Giacaman et al. 2009), has been occupied by Israel since
1948 (Sweileh et al. 2016). In 1993, negotiations between Israel and the Palestine
Liberation Organization led to the Declaration of Principles on Interim Self-Gover-
nance Arrangements, or the Oslo Accords, which aimed to provide a framework for
transition to Palestinian self-governance while negotiating a final peace treaty
(Giacaman et al. 2009). No such treaty has been completed.
The Oslo Accords divided the West Bank into three zones, with some areas under
the control of the transitional Palestinian National Authority (PNA) (Giacaman et al.
2009). The PNA has civilian and security authority over Zone A, which includes
most of the urban areas in the West Bank but only 3% of the land (Giacaman et al.
2009). The PNA has civilian authority and shared security authority with Israel over
Zone B, which includes an additional 27% of land in the West Bank. The remaining
70% of the West Bank is completely controlled by Israel and contains agricultural
land, natural reserves, Israeli settlements, and military areas (Giacaman et al. 2009).
The PNA does not have control over borders including the movement of people or
goods (Giacaman et al. 2009). Israel has placed progressively stricter restrictions on
movement of Palestinian goods and labor across the borders between the West Bank
Fig. 1 Governorates in Palestine, figure reprinted as originally appeared in “Health status and
health services in the occupied Palestinian territory” (Giacaman et al. 2009)
and Gaza and within the West Bank (Giacaman et al. 2009). West Bank communities
are further separated by settlements, military zones, controlled roads, and a barrier
wall between East Jerusalem and the rest of the West Bank (De Ville de Goyet
et al. 2015; Daher 2015). Hamas gained de facto control of Gaza in 2007 (Giacaman
et al. 2009) and Israel responded by blockading the area for the last 12 years.
In part due to restrictions of movement and periodic military violence, the
Palestinian economy has contracted 4.2% between 2001–2005 and 2006–2010 and
declined a further 1.5% in 2011–2015 (World Bank 2016; Giacaman et al. 2009;
World Health Organization 2013). As of 2014, the gross domestic product (GDP) is
USD 12.7 billion, or USD 2,966 per capita (World Bank 2016). (For comparison,
Israel’s GDP per capita was USD 37,206 in 2014 (World Bank 2015).) In 2014, the
unemployment rate reached 26.2% (World Bank 2016). However, the labor force
participation rate is under 50% (Palestinian Central Bureau of Statistics 2016a).
Unemployment is known to be much higher in Gaza compared to the West Bank
(World Health Organization 2013; Palestinian Central Bureau of Statistics 2016a).
Nearly 40% of people in Gaza live in poverty versus 17.8% of West Bank residents
(Palestinian Central Bureau of Statistics 2016a).
Demographics and Health Indicators
Nearly 5 million people live in Palestine, 60% reside in the West Bank (Palestinian
Central Bureau of Statistics 2016a). Palestine is in the middle of the demographic and
epidemiological transition (Mataria et al. 2009; Palestinian Central Bureau of Statistics
2016a). As such, the population is still relatively young and both infectious and chronic
diseases are common. In 2017, children under 14 years of age accounted for 36.6% of
the total population and only 5.1% of the population was 60 years of age or older;
however, the middle- and older-aged populations are growing in size (World Health
Organization 2013; Palestinian Central Bureau of Statistics 2016a). In 2011, the crude
birth rate and death was 32.7 and 3.9 per 1,000 people, respectively (Palestinian Central
Bureau of Statistics 2016a; Sweileh et al. 2016). The birth and death rates are declining
in Palestine (Sweileh et al. 2016; Palestinian Central Bureau of Statistics 2016a). Life
expectancy is 72.1 for men and 75.2 for women, the life expectancy of men and women
is lower in the Gaza Strip than the West Bank (Palestinian Central Bureau of Statistics
2016a). Noncommunicable diseases are the leading cause of morbidity and mortality in
Palestine, but infectious diseases and maternal and child health are still significant
burdens (Table 1) (Sweileh et al. 2016; Giacaman et al. 2009; World Health Organiza-
tion 2013; Palestinian Health Information Center (PHIC) 2011, 2014).
The Provision and Availability of Health Care and Pharmacies
Most health care in Palestine is provided by (1) the Ministry of Health (MOH), (2)
the United Nations Relief and Works Agency (UNRWA), (3) nongovernmental
organizations (NGOs), (4) Palestinian Military Medical Services (PMMS), and (5)
Table 1 Top ten leading causes of death, adapted from “Health Annual Report Palestine 2014”
(Palestinian Health Information Center (PHIC) 2014)
Cause of death % of deaths
Cardiovascular disease 29.5
Cancer 14.2
Cerebrovascular disease 11.3
Diabetes 8.9
Respiratory system disease 5.4
Perinatal conditions 5.2
Accidents 5.0
Renal failure 3.9
Infectious disease 3.3
Senility 3.1
the private sector (Mataria et al. 2009). These varied actors result in a fragmented
system within and between the West Bank and Gaza.
The MOH was established in 1994, after the Oslo Accords, and inherited a health
system that was fragmented and neglected (Mataria et al. 2009). Due to the physical
and political separation between the West Bank and Gaza, two ministries emerged
(Mataria et al. 2009). The MOH provides care for all individuals enrolled in the
Government Health Insurance (GHI) scheme – 57% and 62% of the population in
the West Bank and the Gaza Strip, respectively (United States Agency for Interna-
tional Development and International Chamber of Commerce Palestine 2013).
UNRWA was established in 1949 to provide services to the approximately
700,000 Palestinians expelled from their homes in 1948 (Giacaman et al. 2009;
Comité nacional UNRWA España 2013) – UNRWA provides free health care,
including medicines, to Palestinians in refugee camps (Giacaman et al. 2009).
There are approximately 1,000 private pharmacies and 600 MOH health centers
with a pharmacy (World Bank 2009). There are 604 primary health centers in the
West Bank and 163 in Gaza – the MOH (68%), NGOs (20%), and UNRWA (9%)
operate most of the centers (Palestinian Health Information Center (PHIC) 2014).
Eighty hospitals serve Palestine as of 2014–2015 in the West Bank and 30 in Gaza.
In 2014, a similar number of hospital beds were available in the West Bank and
Gaza (13.1 per 10,000 people) (Palestinian Health Information Center (PHIC) 2014).
During the 2014 Israel–Gaza conflict, more than half of the health facilities in Gaza
were damaged or destroyed and 23 health care workers were killed (De Ville de
Goyet et al. 2015; Daher 2015) – exacerbating the inequities in resources between
the West Bank and the Gaza Strip.
In terms of human resources, there are only 2.2 physicians per 1,000 people in
Palestine (Table 2), significantly lower than neighbors, including as Israel (3.6) and
Jordan (3.4). A quarter of all health service personnel in Palestine are employed by
MOH. From 2010 to 2014, the number of personnel employed by MOH increased by
12% in the West Bank but declined steeply in the Gaza Strip (21%) (Table 3)
(Palestinian Health Information Center (PHIC) 2014). Therefore, efforts should
Table 2 Number of health service personnel in Palestine in 2014 (Palestinian Health Information
Center (PHIC) 2014)
No. No. per 1,000 people
Physicians 9,783 2.15
Pharmacists 5,795 1.27
Nurses 10,556 2.32
Midwives 941 0.21
Dentists 3,005 0.66
Table 3 Number of MOH health service personnel in the Palestine by region in 2010 and 2014
(Palestinian Health Information Center (PHIC) 2014)
2014 versus 2010
2010 2014 Gross change Growth rate
West Bank Total 3,357 3,776 419 12%
General physician 653 622 31 5%
Specialist physicians 310 345 35 11%
Dentist 47 60 13 28%
Pharmacist 172 198 26 15%
Nurse 1,975 2,275 300 15%
Midwife 200 276 76 38%
Gaza Strip Total 4,320 3,425 895 21%
General physician 1,567 1,173 394 25%
Dentist 238 216 22 9%
Nurse 1,597 1,295 302 19%
Midwife 84 71 13 15%
Palestine Total 7,677 7,201 476 6%
General physician 2,220 1,795 425 19%
Dentist 285 276 9 3%
Nurse 3,572 3,570 2 0%
Midwife 284 347 63 22%
consider focusing on expanding health services, including in the pharmaceutical

sector, especially in Gaza.
Health Care Financing
Total health expenditures in Palestine were USD 305.8 per capita. Most health
expenditures were sourced from households (i.e., out-of-pocket) (40.8%) and the
government (36.9%) in 2014 (Table 4). While total health expenditures and health
Table 4 Funding sources as a percentage of health expenditure in Palestine in 2013–2014, adapted

from “Statistical Report, Palestinian Health Accounts 2014” (Palestinian Central Bureau of Statis-
tics 2016b)
% of health expenditure
Funding source 2013 2014
Government/MOH 43.3 36.9
Private insurance 2.2 3.1
Households 37.7 40.8
Nonprofit institutions 15.8 18.3
International aid 1.0 0.9
Total expenditure (USD millions) 1,347.4 1,391.4
expenditures per capita increased, GDP spent on health expenditure declined from
13.7% in 2010 to 11.0% in 2014 (Palestinian Central Bureau of Statistics 2016b).
Household expenditure is growing as a portion of total health expenditure (Pales-
tinian Central Bureau of Statistics 2016b).
Health care and medicines are financed through taxes, health insurance, co-payments,
out-of-pocket payments, international donors, and in-kind donations (Mataria et al.
2009; Palestinian Central Bureau of Statistics 2011). The economic downturn, increas-
ing health expenditures, and sanctions have led to funding gaps for the MOH’s health
budget. For example, in 2006, Israel withheld Palestinian tax revenues for 11 months in
protest of Hamas winning a majority in the PNA – tax revenues account for 75% of the
PNA budget (Giacaman et al. 2009). International donors also exacerbate instability –
they often fail to fulfill their commitments and demand spending that may not be based
on the health needs of the country (Giacaman et al. 2009; Mataria et al. 2009; De Ville de
Goyet et al. 2015). International aid has fallen significantly between 2009 and 2014 (De
Ville de Goyet et al. 2015). As of 2014, international aid accounts for less than 1% of
health services provided in Palestine (excluding UNRWA and other nonprofits) (Pales-
tinian Central Bureau of Statistics 2016b).
The Pharmaceutical Sector in Palestine
The Palestinian pharmaceutical market is valued at least USD 150 million (Pales-
tinian Ministry of Health 2011) with a disproportionate share donated in-kind (World
Bank 2009). Generics account for half of the pharmaceutical market value (Pales-
tinian Ministry of Health 2011). In Palestine, approximately 2,800 pharmaceutical
products are registered as drug products for human consumption (Palestinian Health
Information Center (PHIC) 2014).
In terms of manufacturing, the pharmaceutical industry employs approximately
1,200 people and is one of the most productive industries in Palestine (Almi et al.
2012). Between 2002 and 2009, manufacturers in Palestine invested over USD 50
million to update facilities and many qualify for good manufacturing practices
(GMP) certification (United States Agency for International Development and
Palestinian Federation of Industries 2009). Four Palestinian manufactures are GMP

compliant and two have European Union (EU) GMP certifications (Table 5) (Pales-
tinian Ministry of Health 2011; Almi et al. 2012).
Manufacturers in Palestine have the ability to formulate medicines from active
pharmaceutical ingredients (API) and repackage medicines in their finished dosage
forms (Table 6) (Palestinian Ministry of Health 2011). As a result, all medicines
produced in Palestine are generics, either branded or unbranded (World Health
Organization 2000; United States Agency for International Development and Pales-
tinian Federation of Industries 2009) – mostly anti-infective, musculoskeletal, and
alimentary agents (United States Agency for International Development and Pales-
tinian Federation of Industries 2009; Palestinian Health Information Center (PHIC)
2014).
Table 5 Palestinian pharmaceutical manufacturers (Palestinian Ministry of Health 2011; General

Directorate of Pharmacy and Ministry of Health 2016; Salah 2015)
Compliant
Year EU-
Company established Location GMP GMP
Birzeit Palestine Pharmaceutical Company 1973 Birzeit, ✓ ✕
(BPC) West Bank
Jerusalem Pharmaceutical Company (JePharm) 1967 Al-Bireh, ✓ ✕
West Bank
Beit Jala Pharmaceuticals (Jordan Chemical 1969 Beit Jala, ✓ ✓
Laboratory) West Bank
Gama Chemical Company 1973 Beitunia, ✕ ✕
West Bank
Dar Al Shifa Pharmaceuticals (Pharmacare) 1985 Beitunia, ✓ ✓
West Bank
SAMA Pharmaceuticals Manufacturing Co. Nablus,
LTD West Bank
Middle East Pharmaceutical and Cosmetics 1993 Beit ✕ ✕
Laboratories Company LTD (MEGAPHARM) Hanoun,
Gaza Strip
SAMCO Gaza Strip
Arab-German Pharmaceuticals & Cosmetics 2013 Gaza Strip
Company
Table 6 Palestine pharmaceutical manufacturing capabilities, adapted from “Pharmaceutical

Country Profile – Palestinian National Authority” (Palestinian Ministry of Health 2011)
Manufacturing capabilities
Research and development activities to develop new active substances (e.g., new molecular ✕
entities)
Production of active pharmaceutical ingredients (APIs) ✕
Production of formulations from APIs ✓
Repackaging of finished dosage forms ✓
Table 7 Reasons for medicines testing

For quality monitoring in the public sector ✓
For quality monitoring in the private sector ✓
When there are complaints or problem reports ✓
For product registration ✓
For public procurement prequalification ✓
For public program products prior to acceptance and/or distribution ✓
Ninety percent of drugs manufactured in Palestine are sold locally (United States
Agency for International Development and Palestinian Federation of Industries
2009). Approximately, half of the Palestinian pharmaceutical market (55% in
terms of quantity and 50% in terms of revenue) is supplied by local manufactures
(United States Agency for International Development and Palestinian Federation of
Industries 2009). The second half of the Palestinian pharmaceutical market consists
of imports; 15% from the Israel alone (Almi et al. 2012).
In Palestine, quality control testing is performed in Central Public Health Labo-
ratory, which is not a functional part of Medicines Regulatory Authority. The
existing laboratory facilities have not been accepted by WHO Prequalification
Program. Table 7 summarizes the reasons for drug testing:
Over a 2-year period, 2900 samples were tested, and 4% of the samples failed to
pass the quality standards. Additionally, post-marketing surveillance testing is not
performed by the government inspectors (Palestinian national Authority 2011).
Pharmaceutical Regulations in Palestine, Including Sanctions and

Border Controls
The General Directorate of Pharmacy (referred to as the “Directorate” henceforth)

holds regulatory authority over pharmaceuticals in Palestine and is housed within the
MOH in Ramallah (Palestinian Ministry of Health 2011). Funding for the Director-
ate is not provided through the regular government budgets; it does not retain the
revenue from regulatory activities (e.g., licensing fees), instead the Ministry of
Finance receives these funds (Palestinian Ministry of Health 2011). The Directorate
receives technical assistance from the WHO and the World Bank (Palestinian
Ministry of Health 2011; World Bank 2009). Israel’s Ministry of Health (IMOH)
regulates import and exports of raw and finished pharmaceuticals products in
Palestine, because PA does not control over borders between countries (United
States Agency for International Development and International Chamber of Com-
merce Palestine 2013; Almi et al. 2012).
Marketing Authorization and Registration
All pharmaceutical products sold in Palestine require market authorization (Drug

Control and Registration Department 2007). The Drug Control and Registration
Department (DDCR) within the Directorate processes all applications. The objec-
tives of the market authorization process are to assure “acceptable standards of
quality, safety and efficacy” (Drug Control and Registration Department 2007).
Product registration is valid for 5 years (Drug Control and Registration Department
2007). The DDCR does not utilize a computerized system to manage or store
documents from registrations (Palestinian Ministry of Health 2011).
Marketing authorization applications must include information about the compo-
sition, development (e.g., clinical studies), pharmacodynamics and pharmacokinet-
ics, packaging, and finished product specifications (Drug Control and Registration
Department 2007). Generic product applications must include bioequivalence stud-
ies if they are from local manufactures and countries which are “considered not
highly regulated” (Drug Control and Registration Department 2007). The applicant
must also submit a sample of the medicine, and innovator drug in the case of generic
medicines, which is tested to meet quality standards and specifications reported in
the application.
Legal provisions for granting patents to pharmaceutical manufactures does not
exist in Palestine (Palestinian Ministry of Health 2011). Therefore, Palestinian
manufactures can legally produce products that are patent protected in other coun-
tries (United States Agency for International Development and International Cham-
ber of Commerce Palestine 2013). In the past, Israel has stopped production lines
and financially penalized Palestinian companies who manufacture medicines that are
patent protected in Israel, in response to demands of multinational pharmaceutical
companies (United States Agency for International Development and International
Chamber of Commerce Palestine 2013).
Manufacturing Licensing, Quality Control, and Counterfeit and

Substandard Medicines
Both local and imported drug manufactures must be licensed and comply with the
GMP adopted in 1992 from the WHO (Palestinian Ministry of Health 2011).
Importers, wholesalers, and distributors must be licensed but are not required to
comply with good distribution practices (Palestinian Ministry of Health 2011). There
are 83 wholesalers and importers in Palestine (World Bank 2009).
Laboratories to test the quality of medicines exist in Palestine but they are not part
of the Directorate (Palestinian Ministry of Health 2011). The adequacy of the staff
and equipment at outsourced laboratories is questionable – there have been several
cases in which university laboratories in Palestine report that seized medicines meet
quality control standards but in reality, the medicines are either fake or expired (Bake
2012). In 2014, the MOH reported that 8.2% samples tested failed to meet quality
standards (Palestinian Health Information Center (PHIC) 2014). Test results are not
publicly available making it impossible to know which medicines or patients were
affected (Palestinian Ministry of Health 2011). There are no legal provisions to allow
quality control testing of medicines imported through authorized ports (Palestinian
Ministry of Health 2011).
The Directorate disseminates counterfeit drug warnings from the WHO on its
website and requests that providers report any counterfeit drugs encountered
(General Directorate of Pharmacy and Ministry of Health 2016; Palestinian Min-
istry of Health 2011). However, no publicly available information reports the
extent of counterfeit drugs in Palestine. It is known that counterfeit drugs are
produced and distributed in Palestine (Park 2010; Bake 2012). For example,
counterfeit Gleevec (imatinib) was found in a raid of a Palestinian distributor
which supplies the MOH and 15 people served by a public hospital in Hebron
died of leukemia (Bake 2012).
Restrictions in the Importation and Exportation of Pharmaceuticals
Palestinian manufactures are required to receive an importation license from the

Israeli Ministry of Health (IMOH) for each shipment of raw products (including all
APIs) from abroad (Almi et al. 2012). Securing licenses for each shipment is
expensive and often causes delays in productions (up to several weeks) (Almi
et al. 2012). Importing raw products into Gaza is even more expensive and compli-
cated. It requires docking the goods in Israel to undergo security screenings and
charged import duties (Almi et al. 2012). Afterwards, Israeli trucks deliver the
products to the Gaza Strip border before undergoing additional screenings and
transfers to Palestinian trucks (Almi et al. 2012).
In addition to Palestinian market authorization, all pharmaceuticals imported in
Palestine must be registered with the IMOH and are held to Israeli standards
(Schoenbaum et al. 2005; Palestinian Ministry of Health 2011). Most companies
registered in Israel are from Western countries thus Palestine is deprived of
cheaper generics from China, India, and Eastern Europe (Almi et al. 2012).
Smaller foreign companies are also unable to enter the Palestinian market due to
the expenses of registration in Israel and transportation from Israel to Palestine
(Almi et al. 2012).
Due to the Paris Protocol (joint customs envelope) within the Oslo Accords,
Palestine and Israel do not directly tax each other for most goods (Almi et al. 2012).
Therefore, Israeli medicines enter the Palestinian market without customs, import
taxes, or extraneous logistical burdens (e.g., shipment disturbances) (Almi et al.
2012). Israeli manufacturers are not required to label their medicines in Arabic;
however, user guides are required to be printed in English, Hebrew, and Arabic
according to IMOH regulations (Almi et al. 2012).
Palestine does not export any pharmaceuticals to neighboring counties (with the
exception of Jordan) because these counties refuse to send their delegations to Israel
(Almi et al. 2012; Sweileh et al. 2016). Palestine cannot export to Israel due to
“security concerns”; Israeli inspectors for product registration refuse to enter Pales-
tine because their safety cannot be assured (Almi et al. 2012; Sweileh et al. 2016).
As a result of these trade restrictions, Palestinian pharmaceutical products are often
more expensive than products from other developing nations, further hampering any
export potential (Almi et al. 2012; Sweileh et al. 2016).
Pharmacovigilance
There is no legal mandate to provide pharmacovigilance activities by the Pharmacy

Directorate or pharmaceutical Companies (Palestinian Ministry of Health 2011). No
national pharmacovigilance agency exists (Palestinian Ministry of Health 2011). No
system is in place to report adverse drug events (ADEs) to the Directorate (Pales-
tinian Ministry of Health 2011). National data on ADEs is not collected (Palestinian
Ministry of Health 2011). The Directorate does not have a national committee to
provide technical assistance for ADEs (Palestinian Ministry of Health 2011). An
official standardized form to report ADEs was developed by the Directorate; how-
ever, its utility is questionable given that no agency is responsible for collecting or
analyzing this information (Palestinian Ministry of Health 2011).
Medicines Supply System in Palestine
Medicines in Palestine are procured by a variety of health care operators. The private
sector purchases medicines directly from local manufactures or distributors (World
Health Organization 2000). UNRWA procures medicines through an international
tendering process and distributes them to two main drug stores – one in Jerusalem
and another in the Gaza Strip (World Health Organization 2000). NGOs usually use
medicines donated in-kind (World Health Organization 2000). When necessary,
NGOs purchase medicines from local manufactures or distributors (World Health
Organization 2000).
The MOH in Ramallah, West Bank, procures medicines for the West Bank and the
Gaza Strip through a tendering procedure which includes quality and price consider-
ations (World Health Organization 2011; Palestinian Ministry of Health 2011). Med-
icines purchased through this procedure are randomly tested for quality and these
results are made public (Palestinian Ministry of Health 2011). Due to preferential
policies toward the local industry, 40% of medicines procured by the MOH come from
local manufactures (World Health Organization 2011, Palestinian Ministry of Health
2011). However, HIV, tuberculosis, oncology, epilepsy, and psychiatric medicines are
always procured abroad (World Health Organization 2011). The MOH has a Central
Drug Store (CDS) at the national level and an additional CDS in the Gaza Strip (World
Health Organization 2011; Palestinian Ministry of Health 2011). Both CDSs distribute
to local warehouses and health facilities (World Health Organization 2011; Palestinian
Ministry of Health 2011). Items that are not available at either CDS can be purchased
directly by health facilities with authorization from the General Directorate of Phar-
macy (World Health Organization 2000).
Shortages of Essential Medicines
Since 2000, drug shortages of at least 10% of essential medicines (as per essential
medicines lists (EML) in the West Bank and Gaza) are reported by the MOH in
Ramallah and the Gaza Strip (World Health Organization 2012). Shortages have
been more desperate in Gaza due to ongoing armed conflict with Israel and the
destruction of health infrastructure (e.g., in 2011 an MOH drug warehouse was
bombed) (World Health Organization 2011). During the last 10 years, at least 20% of
essential medicines were at zero stock (i.e., less than 1 month supply is available at
the CDS) in Gaza (Daher 2015). As of January 2018, the Gaza CDS reported that on
40% of medicines were at zero stock (Hass 2018). This had led to staff in the MOH
to resort to reusing medical disposables and prescribing second- or third-line med-
icines (Health Cluster 2014). Patients with financial means are able to buy medicines
from the private sector, which is usually better stocked, therefore, access to medi-
cines depends on the wealth of the individual (Health Cluster 2014).
The MOH in Ramallah cites that budgetary restrictions are the main reason for the
medicines shortages at the central level (World Health Organization 2011, 2012).
The political rift between Fatah and Hamas may further disturb logistics between the
West Bank and Gaza (World Health Organization 2011).
In-kind donations to Gaza helped bridge the gap in medicine procurement.
Unfortunately, less than 10% of medicines donated in-kind were donated to the
MOH in Ramallah, and were instead donated to UNRWA or NGOs (World Health
Organization 2011). Twenty-two percent of medicines donated during 2008–2009
were expired or inappropriate and an additional 20% resulted in a surplus over
pharmaceutical needs in Gaza (World Health Organization 2011).
Medicines Financing
Public expenditure on pharmaceuticals was USD 54.1 million in 2010 (Palestinian

Health Information Center (PHIC) 2011). Private expenditure on pharmaceuticals in
2009 were estimated at USD 100 million (Palestinian Ministry of Health 2011). The
World Bank estimates that per capita pharmaceutical expenditure is between USD 35
and USD 40 per year (World Bank 2009). Seventeen percent of expenditure is spent
on antibiotics and another 16% are spent on chronic conditions (World Bank 2009).
Medicines expenditure account for 50% of household and 20% of MOH health
spending (World Health Organization 2011; World Bank 2009).
No recent studies have examined the impact of medicines expenditures on
households and their well-being. However, it is known that over 12% of Palestinian
households fall into poverty due to health spending and that households with lower
income spend a larger portion of health spending on medicines (World Bank 2009;
Mataria et al. 2010).
National Health Insurance and MOH
In 1994, the newly established PNA created the Government Health Insurance (GHI)
under the administration of the MOH (World Bank 2009). The GHI is funded by
premiums and co-payments; however, the health services and goods delivered cost
far more than GHI premiums and co-payments (World Bank 2009). While the
creation of the GHI was intended to be the first step towards universal health
insurance coverage, this model has not proven sustainable in its current form
(World Bank 2009).
Six categories of beneficiaries are covered under the GHI: (1) government
workers, (2) Palestinians who work in Israel, (3) individuals and households, (4)
businesses and employer groups, (5) hardship cases/individuals and families on
social assistance, and (6) unemployed individuals (World Bank 2009). The first
two categories are mandated to purchase insurance, and the last category is exempt
from premiums and co-payments (World Bank 2009). All categories have the option
to extend their coverage to dependents and extended family for an additional
payment (Table 8) (World Bank 2009). As of 2007, 30% of individuals insured by
GHI are covered under the unemployed category (World Bank 2009).
UNRWA, NGOs, and Private Insurance
NGOs generally finance medicines through internal and international donations,

both monetary and in-kind, and deliver medicines at reduced costs or free of charge
(World Health Organization 2000). Similarly, UNRWA receives international dona-
tion for its operations and provides medicines free of charge (World Health Organi-
zation 2000). Private insurance policies, which cover less than 3% of the population,
generally provide medicines coverage but they are not required to provide coverage
of medicines on the EML (World Health Organization 2006; Palestinian Ministry of
Health 2011).
High Medicine Costs
Medicines in Palestinian are more expensive than in other Arab countries with
similar economic development and some branded products are more expensive
than in Israel (World Bank 2009). A World Bank survey in 2007 found that MOH
procurement prices are on average 6.9 times more expensive international reference
prices (World Bank 2009). Generic medicines purchased for sale in the private sector
are 9.7 times more expensive than international reference prices (World Bank 2009).
Most patients in the public sector do not receive medicines free of charge in Palestine
(Palestinian Ministry of Health 2011). Patients under 3 years of age must pay NIS 1
and patients over 3 years of age must pay NIS 3 (USD 0.79), regardless of their
ability to pay (Palestinian Ministry of Health 2011). Individuals with tuberculosis,
sexually transmitted diseases, HIV/AIDS, and childhood vaccines are delivered at no
cost to all Palestinians (Palestinian Ministry of Health 2011).
Pricing Regulations
The political instability and trade barriers discussed in earlier sections of this chapter
have resulted in high medicine prices in Palestine. Additionally, Palestine does not
Table 8 GHI premiums and collection system, adapted from “Reforming Prudently Under Pres-
sure: Health Financing Reform and the Rationalization of Public Health Sector Expenditures”
(World Bank 2009)
Beneficiary
category Compulsory Monthly premium Collection
Government/ ✓ 5% of basic salary, minimum Deducted from salary and
Public sector NIS 50 (USD 12.9), transferred to GHI/MOH
maximum NIS 100 (USD
25.8)
For pensioners: 5% of
payment, no minimum,
maximum NIS 100
Workers in ✓ NIS 93 (USD 24.0) collected Israeli authorities should
Israel by Israeli authorities, NIS 75 deduct NIS 93 (USD 24.0) per
(USD 19.1) provided to month and transfer NIS 75
MOH in Palestine (USD 19.1) to Palestine every
month
Most individuals have not paid
since 2000
Individuals ✕ NIS 80 (USD 20.6) per Paid to one of the health
and family directorates in the West Bank
households NIS 50 (USD 12.9) for any or to post offices in Gaza on a
individual monthly, half yearly, or yearly
NIS 20 (USD 5.2) for any basis
student
NIS 80 (USD 20.6) for any
member of any professional
union
NIS 50 (USD 12.9) for any
member of a workers’ union
Businesses ✕ 5% of basic salary, minimum Payments made collectively
and NIS 50 (USD 12.9), through employer on a
employer maximum NIS 100 (USD monthly or yearly basis
groups 25.8)
Hardship ✕ No cost to family. Ministry of MOSA identifies “hardship
cases Social Affairs (MOSA) pays cases” per household income.
NIS 45 per family The Ministry of Finance
transfers the allocated portion
of MOSA’s budget to MOH
Registered ✕ Exempt Must be registered as
as unemployed with the Ministry
unemployed of Labor
All ✕ NIS 5 (USD 1.3) per Collected via corresponding
categories additional dependent category
Israeli new shekel (NIS)
benefit from differential pricing policies applied by multinational companies

according to the country’s economic development (referred to as “pricing discrim-
ination”) (World Bank 2009). Instead, Palestine is considered to be the same
economic zone as Israel, a country 12 times as wealthy as measured by GDP per

capita (World Bank 2009, 2015, 2016).
The PNA and MOH have also failed to regulate pricing adequately. In the public
sector, local manufacturers have preferential treatment, thus prices offered by these
firms are on average 15% higher than international bidders (World Bank 2009).
Because of reasons that may be outside of Palestinian control, the number of
international bidders for MOH tenders are usually low; for 10% of tenders, there
are no international bidders (World Bank 2009).
Prices of medicines purchased by private retailers for resale are not regulated,
instead prices are stipulated by distributers or manufacturers (World Bank 2009).
Due to limited competition, Palestinian manufacturers sell at relatively high prices
(World Bank 2009). Medicines produced in Palestine are known to sell for up to 50%
below local private sales price abroad (World Bank 2009).
Markup caps are in place to regulate private retail prices (Palestinian Ministry of
Health 2011). On average, locally manufactured drugs have a 25% markup and
imported products have a 10–15% market up in private pharmacies (Qadah et al.
2011). Generic medicines may be substituted at the point of dispensing in public
sector facilities but not in private facilities (Palestinian Ministry of Health 2011).
Medicines Use
While population-level prevalence of medicines use is unknown, information from

household surveys and expenditure data indicate that medicines are commonly used
in Palestine. Medicines commonly stored in Palestinian households include analge-
sics, nasal preparations, antibiotics, and cardiovascular medicine (Sweileh et al.
2010). However, this is not indicative of use and cannot be used to determine the
number of individuals using these therapeutic classes (Sweileh et al. 2010).
Even though selling prescription medicines without a prescription is prohibited,
in practice, pharmacies are not regulated and sales of prescription medicines without
a prescription are common (Palestinian Ministry of Health 2011; Jaradat and Sweileh
2003). Antibiotics and injectables are often sold over-the-counter. Antibiotics,
analgesics, and drugs to alleviate flu/cold symptoms are the most commonly used
self-prescribed medicines (Al-Ramahi 2012). Self-prescribing may result in poor
management of conditions, inappropriate use of dangerous medicines, and, at the
population-level, antibiotic resistance. Use of alternative medicines is also common,
resulting in high risk for interactions with prescription or over-the-counter medicines
(Ali-Shtayeh et al. 2012, 2016; Al-Ramahi et al. 2015).
Essential Medicines List and Rational Use of Medicines
To improve the rational use of medicines and contain costs, the MOH in Ramallah
introduced an essential drug list in 2000; this list was last updated in 2013 (State of
Palestine Ministry of Health 2013a). A second EML was developed by the MOH in
Gaza (World Health Organization 2012). Currently, there are 517 medicines
included in the West Bank EML and 480 medicines included in the Gaza EML
(World Health Organization 2012; State of Palestine Ministry of Health 2013a). The
EML for the West Bank is relatively comprehensive and includes medicines for
infectious diseases, chronic conditions, and a variety of mental health and psychiat-
ric conditions (State of Palestine Ministry of Health 2013a).
The Committee of Therapeutics and Pharmacology in the MOH in Ramallah –
considers “evidence based-medicine, the epidemiological situation in the country,
and the principle of cost-effectiveness” when selecting medicines for inclusion in the
EML; however, the process used to make these determinations is not available
(World Health Organization 2011; Palestinian Ministry of Health 2011). Publicly
available documents do not outline the process for the EML created by the MOH in
Gaza.
The introduction of EMLs improved rational use of medicines in Palestine. After
the initial introduction (1997–1999 vs 2000–2003) researchers observed that
the average number of medicines prescribed per clinic visit decreased, the percent-
age of medicines prescribed that were antibiotics and injections decreased, and the
percentage of medicines included in the EML being prescribed increased (Younis
et al. 2009).
Given the positive effect of EMLs, it is surprising that the MOH has not
made it official policy to align the standard treatment guidelines with the EML
or to coordinate with the local industry to assure essential medicines can be
locally produced (Palestinian Ministry of Health 2011). The most updated
guidelines only make suggestions for 11 conditions/treatments – notably, dia-
betes and hypertension were excluded (State of Palestine Ministry of Health
2013b). Local industry can only produce 160 medicines on the EML (World
Bank 2009).
Pharmacists and Their Role
Pharmacists are required to be licensed by the Palestinian Pharmaceutical Associa-

tion to practice (Palestinian Ministry of Health 2011). However, graduates of
Palestinian universities are not required to sit in an exam, and there are no continuing
education requirements and no published code of ethics for pharmacist (Palestinian
Ministry of Health 2011; Sweileh et al. 2016).
Palestine has a relatively high density of pharmacists per 10,000 people, twice
as many as the 5 pharmacists per 10,000 recommended by the WHO (Qadah
et al. 2011). Most patients surveyed about their perception of community phar-
macies indicated that they would like to receive additional preventive health
services from their pharmacists (Khdour and Hallak 2012). Eleven percent of
pharmacists in Nablus were unemployed and 34% worked in community phar-
macies (Qadah et al. 2011). Pharmacists may be underutilized as clinicians
considering patient desires and the ongoing shortage of other health care
providers.
Conclusions: Summary and Implications
While Palestine has made strides in improving and expanding its ability to manu-
facturer generic medicines, these efforts may be undercut by instability in its supply
chain due to international pressures, such as sanctions and border controls. These
international pressures also hamper the ability to import necessary medicines that
cannot be produced domestically. Continual shortages of essential medicines (espe-
cially the Gaza Strip) threaten the health of the population in terms of acute
conditions and management of increasingly common chronic diseases.
Domestic and international pressures have resulted in high medicines costs.
While the MOH provides care for a large portion of the population, the government
schemes do not appropriately protect from the financial burden of medicines,
because they are often unavailable through government channels meaning that
patients must purchase medicines through private pharmacies. Out-of-pocket
health costs are increasing in Palestine – contributing to an inequitable health
system.
Implications and Recommendations
In terms of domestic policy, the MOH should align their EML with their treatment
guidelines – this would improve medicine prescribing via rational drug use. To
improve the availability and stable supply of medicines, the MOH should continue to
encourage the domestic pharmaceutical production, especially production of essen-
tial medicines. While often under-discussed in the context of developing countries,
policy makers need to address the lack of pharmacovigilance, quality and safety
regulations, and a monitoring and evaluation systems to ensure prescribing practices –
addressing these issues would improve the quality, efficacy, and safety of the
medicines used in Palestine.
Future policy and health delivery reforms should incorporate the government, the
private sector, NGOs, and UNRWA, especially concerning the areas of payment and
reimbursement systems, medicine supply chain, and the cost of medicines. This is
important considering the largest financer of health care are households and that the
vast majority of the population utilize services from the private sector, including
local pharmacies.
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Patient-Centered Care in the Middle East
62
Hana Hasan Webair
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1526
Why Patient-Centered Care? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1526
Defining Patient-Centered Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1526
Principles of Patient-Centered Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1527
Patient-Centered Care in the Middle East . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1528
The History of Patient-Centered Care in the Middle East . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1529
Principles of Patient-Centered Care in the Middle East . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1531
Barriers to Patient-Centered Care in the Middle East . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1534
Conceptual Framework of Patient-Centered Care in the Middle East . . . . . . . . . . . . . . . . . . . . . 1536
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1538
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1539
Abstract
Patient-centered care (PCC) is care that is responding to patients’ preferences,
values, and needs. The concept was developed in the late 1960s. In 2001, the
National Academy of Medicine announced PCC as one of the six main goals of
healthcare. PCC is culture-sensitive. Although there is a large amount of literature
in Western countries in this regard, much less work has been done in the Middle
East. This chapter discusses the history of PCC in the Middle East, the concept of
PCC, and barriers against its application and finally draws a conceptual frame-
work for PCC in the Middle East.
Keywords
Patient-centered care · Middle East
H. H. Webair (*)
Hadhramout University, College of Medicine, Mukalla, Yemen
e-mail: hhwebair@gmail.com

https://doi.org/10.1007/978-3-030-36811-1_66
1526 H. H. Webair
Introduction
Why Patient-Centered Care?
People generally prefer to make their own decisions themselves. What if the decision
is about their own health, the most precious thing they have? Therefore, human
nature necessitates that the patient is central to the healthcare journey. Patients
should be empowered adequately for this role. Despite the widespread emphasis
on patient-centered care (PCC) in healthcare, some professionals and organizations
still struggle to involve their patients and to learn from their experiences (Groene
et al. 2009; Moore et al. 2017).
In its 2001 Crossing the Quality Chasm report, the National Academy of Med-
icine (NAM) concluded that incorporating PCC as one of its six healthcare aims was
ethically the right thing to do since it provided better clinical outcomes for patients
and was unavoidable given the quantity of medical information now available to
patients on the Internet. The WHO reported that people-centered healthcare has a
positive impact on patient safety, adherence to care plans, treatment and health
outcomes, satisfaction with care, and quality of life, as well as provider satisfaction
(World Health Organization 2007). Studies have also shown that PCC is associated
with the following positive outcomes:
1. Better recovery from discomfort and concerns (Oates et al. 2000; Rathert et al.
2013)
2. Better emotional health (Oates et al. 2000; Rathert et al. 2013)
3. Fewer diagnostic tests and referrals (Oates et al. 2000)
4. Fewer emergency department admissions for older patients (Jackson et al. 2013)
5. Better care processes, especially preventative services (Jackson et al. 2013)
6. More self-management and adherence (Robinson et al. 2008; Rathert et al. 2013)
7. Modest improvement in staff experience (Jackson et al. 2013)
There is insufficient evidence to comment on direct clinical benefits and on the

impact of any economic outcomes (Oates et al. 2000; Jackson et al. 2013; Rathert
et al. 2013). However, the impact of PCC on clinical outcomes is expected to be
indirect (Epstein and Street 2011), for example, through improving adherence and
self-management which is known to improve clinical outcomes especially in case of
chronic diseases.
Defining Patient-Centered Care
Patient-centered care – along with similar terms like person-centered, consumer-

centered, personalized, and individualized care – encompasses qualities of compas-
sion, empathy, and responsiveness to the needs, values, and expressed preferences of
the individual patient (Institute of Medicine 2001). Michael and Enid Balint coined
the term “patient-centered medicine” in 1969. They emphasized that patients should
62 Patient-Centered Care in the Middle East 1527
be understood as unique human beings; their illness is an incident or part of them that
is better understood within the context of the whole patient (Balint 1969).
Patient-centeredness or patient-centered care (PCC) has been studied for several
decades. Numerous definitions have emerged since 1969; unfortunately, there is no
universal definition of PCC (International Alliance of Patients’ Organizations 2006),
though research has shown that a reliable definition must incorporate the patient’s
perspective (Peschel and Peschel 1994). Among the most useful definitions of PCC
are those adopted by the National Academy of Medicine (NAM), the International
Alliance of Patients’ Organizations (IAPO), the Institute for Patient and Family-
Centered Care (PFCC), and the World Health Organization (WHO).
In 2001, the NAM identified PCC as one of the six main goals of healthcare
(Institute of Medicine 2001). It defined PCC as “care that is respectful of and
responsive to individual patient preferences, needs and values, and ensuring that
patient’s values guide all clinical decisions.” The other five goals of healthcare
highlighted by the NAM are safe, effective, timely, efficient, and equitable care.
However, some medical professionals argued that it might be impractical to make
decisions based on patients’ preferences, which are not always appropriate (Berwick
2009). Thus, the IAPO created a definition in 2006 that limited patient input based
on appropriateness and cost-effectiveness: “The essence of patient-centered
healthcare is that the healthcare system is designed and delivered to address the
healthcare needs and preferences of patients so that healthcare is appropriate and
cost-effective” (International Alliance of Patients’ Organizations 2006).
The WHO in 2007 suggested a more comprehensive approach, extending the
definition of PCC to include all people involved in the healthcare system – from
patients, families, and community members to healthcare providers. This approach
reaches people outside of the clinical setting, before they become patients, helping
them to promote their own health and prevent diseases. The WHO calls this a
people-centered approach (World Health Organization 2007).
In summary, the PFCC in 2012 adopted a broader definition of PCC by incorpo-
rating the concept of family centeredness. PCC is not sufficient to adequately
describe the PFCC’s innovative approach to healthcare. The PFCC promotes “an
innovative approach to the planning, delivery, and evaluation of health care that is
grounded in mutually beneficial partnerships among health care providers, patients,
and families. Patient- and family-centered care applies to patients of all ages, and it
may be practiced in any health care setting” (Johnson and Abraham 2012).
Principles of Patient-Centered Care
Most of these dimensions are based largely on the Picker Institute’s eight principles
of PCC. In 1986, research was conducted by the Harvard School of Medicine, on
behalf of the Picker Institute and the Commonwealth Fund, using a wide range of
focus groups and a literature review. The research identified seven dimensions of
PCC. In 1987, the dimensions were named the Picker Principles of Patient-Centered
Care, and the eighth principle – access to care – was added (Picker Institute).
1528 H. H. Webair
The development of these principles was traced and documented by Peschel and
Peschel (1994) in the book Through the Patient’s Eyes: Understanding and Promot-
ing Patient-Centered Care. The principles are:
1. Respect for patients’ values, preferences, and expressed needs

2. Coordination and integration of care
3. Information, communication, and education
4. Physical comfort
5. Emotional support and alleviation of fear and anxiety
6. Involvement of family and friends
7. Transition and continuity
8. Access to care (Peschel and Peschel 1994)
The IAPO, PFCC, and other organizations adopted similar principles with more
emphasis on patient empowerment and participation in the healthcare system (Inter-
national Alliance of Patients’ Organizations 2006; Bechtel and Ness 2010; Johnson
and Abraham 2012). The IAPO set five principles: respect, choice and empower-
ment, patient involvement in health policy, access and support, and information
(International Alliance of Patients’ Organizations 2006). The National Partnership
for Women & Families added comprehensive care and coordination and identified
four principles, whole-person care, coordination and communication, patient support
and empowerment, and ready access (Bechtel and Ness 2010), while the PFCC
defined four core principles including respect and dignity, information sharing,
participation, and collaboration (Johnson and Abraham 2012).
These principles are considered the general dimensions of PCC, though patient
perspectives may differ according to care setting, culture, and illness. Numerous
studies have been conducted to explore patients’ needs and their expectations in
defined settings, as in cancer care, fertility care, and primary care. These areas are
beyond the scope of this chapter.
Patient-Centered Care in the Middle East
The Middle East encompasses the countries around the southern and eastern sides of
the Mediterranean Sea, from North Africa to the Arabian Peninsula. Though the
specific area of the Middle East is defined differently by different sources, the United
Nations identifies 14 countries in the Middle East: Bahrain, Egypt, Iraq, Jordan,
Kuwait, Lebanon, Libya, Oman, Qatar, Saudi Arabia, the Syrian Arab Republic, the
United Arab Emirates, Yemen, and Palestine (World Tourism Organization
(UNWTO) 2018). The WHO has a slightly different list which includes Afghanistan,
Djibouti, Tunisia, Iran, Morocco, Pakistan, Somalia, and Sudan (World Health
Organization 2018). All of these countries share some cultural and religious features;
they have been heavily influenced by Islam, Judaism, and Christianity, as well as
numerous other belief systems. Arabic is the most widely spoken language in the
region.
During the Islamic Golden Age, which extended from the eighth to the thirteenth
century, most Middle Eastern countries were caliphates, led by an Islamic steward
called a caliph, and subject to the rules and regulations of Islamic law. Even after the
decline of the caliphates and during the Ottoman conquest of the Middle East, Islam
remained the main religion in the region. Thus, the history of medicine in the Middle
East cannot be discussed without considering the history of Islamic medicine
(Shanks and Al-Kalai 1984; Majeed 2005).
The History of Patient-Centered Care in the Middle East
The Medieval Period

PCC refers to patient care provided in the context of a healthcare system. Therefore,
the history of PCC began with the origin of healthcare systems, specifically hospi-
tals. Although medicine originated with early humans, the establishment of well-
structured hospitals was an outstanding contribution of Islamic medicine; the earliest
Islamic hospital was built in Baghdad in 805, and hospitals flourished in the region
throughout the Abbasid caliphate (750–1258). The relationship between Islamic
hospitals and the centers for the poor and sick (found in Christian monasteries as
early as the Middle Ages) has not been fully explained. However, the medieval
Islamic hospital was a structured institution, operated within a well-developed
system and with a wider range of functions than the monastic relief centers.
Medieval Islamic hospitals were called bimaristan or maristan, and most were
located in the Middle East (U.S. National Library of Medicine; Nagamia 2003).
Treating the ill – whether male or female, civilian or military, adult or child, rich or
poor, Muslim or non-Muslim – is a moral imperative of Islam. Islam also prohibits
destruction and stresses the importance of learning, cleanliness and personal
hygiene, respect for authority, autonomy, and tolerance for other religions. These
principles were largely reflected in medieval Islamic hospitals, which were clean
institutions located in large urban structures. They provided all services free of
charge, and upon discharge, patients received sums of money to support themselves
until they could return to work (U.S. National Library of Medicine; Syed 2002;
Majeed 2005). Islamic hospitals were financed from the revenues of waqf (endow-
ments) and were also part of the state budget. Wealthy men, especially rulers,
donated property – which included shops, mills, caravansaries, or even entire
villages – as endowments whose revenue was used to build and maintain hospitals
(U.S. National Library of Medicine).
Given the importance of moral values in Islam, ethics were recognized as an
essential requirement for Islamic physicians. Only qualified doctors were allowed to
practice medicine, and in 931, Caliph Al-Muqtadir ordered all physicians to take an
examination in order to qualify for a license to practice medicine. The licensing
examination became compulsory from that time on. Furthermore, the Hippocratic
Oath, a code of medical ethics, became mandatory for all medical practitioners (Syed
2002). Throughout most of the medieval period, a portion of medical textbooks also
focused on medical ethics (Amine and Elkadi 1981).
1530 H. H. Webair
One of the main achievements of the Islamic Golden Age was the ninth-century
book Ethics of a Physician, written by the Arab physician Ishaq bin Ali al-Rohawi. It
discussed topics related to medical ethics, including the faith and loyalty of physi-
cians, problems of responsibility, ethical dilemmas in patient-physician relation-
ships, issues that physicians must avoid, topics related to visitors, medical aspects
of people’s moral values, and harmful habits. All these topics fall within our modern
definitions of PCC; thus, PCC is clearly not a new concept in the Middle East (Al-
Ghazal 2004). Unsurprisingly, Ethics of a Physician was translated into English in
the 1960s (Al-Ruhāwī and Levey 1967).
The high level of healthcare in Middle Eastern countries during the medieval
period resulted from high-quality hospitals and the careful preparation of physicians,
especially in terms of ethics and licensing, and providing financial assistance and
comprehensive care to patients, regardless of age, gender, or religion. Middle
Eastern countries were leaders in healthcare and shared their knowledge of medical
science with the Western world. Although the concept of PCC had not yet been
defined, it was already being partially practiced in the Islamic world by the tenth
century.
The Contemporary Middle East

After the medieval period, the flow of scientific and technological knowledge from
the Middle East to the West slowed gradually and then reversed (Bulliet 2004). This
was reflected in the level of healthcare in Middle Eastern countries. The WHO report
published in 2000 revealed that only 8 out of the 22 countries in the Middle East
were ranked among the top 50 in overall health system performance (WHO 2000). In
2018, Bloomberg Health Care Efficiency ranked 6 of these countries among the top
50 based on 2015 data (Miller and Lu 2018). Generally speaking, the level of
healthcare in the Middle East is not the best today when compared to other regions
in the world. Although some countries in the region ranked among the best in the
healthcare system, the majority are still behind. In many of these countries, there is
little financial support for healthcare from governments; patients may have to
contend with high out-of-pocket expenses, inequitable access to care, inconsistent
and poor quality of care, long wait times, and high absenteeism rates among pro-
viders (Yazbeck et al. 2017). Moreover, the health systems suffer from inadequate
documentation, lack of well-designed, updated population databases, and very low
biomedical publication rates (Mathers et al. 2005; Maziak 2005). All these issues
work against PCC and lead to extreme variations in PCC within the region.
In reality, there is great variation in the quality of healthcare in the region. At one
end of the spectrum are oil- and gas-rich countries that offer good healthcare services
to the majority of their local population; at the other end are poor countries that are
unable to provide even the basic minimum required healthcare services to their
people (Qidwai et al. 2012). Despite these variations, Qidwai et al. (2013) found that
the majority of physicians in select Middle Eastern countries prefer a PCC approach,
while half of the patients in these countries prefer a mixed approach of PCC and
physician-centered care. Unemployment and low educational level are associated
with patients’ preference for physician-centered care (Qidwai et al. 2013).
Promisingly, there are many possible applications for PCC in the region. Psychi-
atrists in the Middle East have followed a patient- and family-centered approach for
several decades – before the introduction of the term PCC (El-Islam 2017) – in
addition to the culture and religion of the Middle East which are conducive to PCC.
Strong religious beliefs, a strong family network, and social support for patients
among families, friends, and the community all favor the application of PCC in the
region (El-Islam 2017).
Principles of Patient-Centered Care in the Middle East
Very few publications about PCC have been produced in Middle Eastern countries
compared to countries in other regions. Moreover, all of the definitions shared in the
introduction of this chapter – and most of those in the existing literature – are based
on the experience of patients from outside the Middle East. A study to define PCC in
terms of fertility care in the Middle East was presented by Webair et al. (2017). They
were, however, unable to develop a comprehensive definition of PCC from the
perspective of infertile Arab patients, though such a definition had already been
developed from the perspective of European patients, with a validated questionnaire
to measure patient centeredness in fertility care (Webair et al. 2017). Current
literature search has also failed to find such a definition from the Middle Eastern
perspective. The time has come now to comprehensively define PCC from the
perspective of patients in the Middle East in order to improve the quality of
healthcare in the region. This chapter will discuss only some of the principles of
PCC from the perspective of Middle Eastern patients.
Communication
Communication is a central principle of PCC. Communication skills are key to
understanding patients’ needs, values, and preferences. However, communication is
culture-sensitive, and it is one of the common barriers to PCC in the Middle East.
What is considered good communication in the Western world may be perceived
negatively in the Middle East; thus, the definition of communication in the context of
PCC could be different from a country to country.
A study on the definition of good communication surveyed medical students from
three different countries: the United Kingdom, India, and Egypt (Mole et al. 2016).
Although there were commonalities in their views on good communication, there
were also many differences. All of the students shared the view that good commu-
nication is extremely important for patients and involves trust and compassion on the
part of medical professionals. The students also identified a feeling of disempower-
ment among medical professionals when working with highly educated patients.
Patients’ increasing power was, to some extent, perceived negatively by the students.
The Egyptian students emphasized the importance of considering care for both
the family and the patient (family centrism) as part of positive communication; they
viewed patient-centrism, without a focus on the patient’s family, as inappropriate. In
contrast, the British students preferred patient-centrism.
1532 H. H. Webair
The Egyptian respondents also felt that care tailored to the patient’s gender was a
good communication approach, while the British respondents valued gender blind-
ness, considering gender largely irrelevant to patient care and communication. In the
same vein, the British respondents thought that communication should remain
professional and detached, rather than emotive and familiar. Appropriate physical
touch was also considered positive by Egyptian students but perceived negatively by
the British students.
This study on good communication indicates that there is no universal definition
for good communication for medical professionals; communication is impacted by
culture and religion. Briefly then, in the Middle East, good communication is marked
by trust and compassion, caring for the patient and family together (family centrism),
following a gender-specific approach, and touching the patient with empathy and
affection when appropriate.
Information
Another important area of PCC that differs across cultures is the disclosure of
information to patients (Silbermann et al. 2013). Silbermann et al. (2013) found
that the majority of Middle Eastern medical professionals preferred not to disclose a
serious diagnosis or prognosis to a patient; this runs counter to the universal
approach in the USA, where both patients and medical practitioners place a high
value on individual autonomy. American doctors fully disclose all medical informa-
tion to patients, even if their prognosis is poor. Likewise, the fear and stigma
associated with some diseases in the Middle East, which often lead patients to
wait to visit the doctor until a disease has advanced, can affect disclosure of
information and communication between patients and medical professionals
(Silbermann et al. 2013).
Dignity
Dignity is understood differently in different parts of the world. There are significant
differences between Russian and Arab caregivers in Israeli nursing homes (Bentwich
et al. 2017). Arab caregivers prioritized the concept of dignity, regardless of the
norms of the institutional setting (Bentwich et al. 2017). The Arab caregivers
supported their patients’ dignity by referring to them by name, avoiding insulting
or disparaging them, treating them affectionately, giving them as much help as
possible, dedicating time to them, respecting their families, and avoiding silencing
them. They also preferred to treat only patients of their same gender. The collective
approach of multi-person households, which respects their different preferences, is
common in Middle Eastern societies. This approach creates a supportive environ-
ment for both family members and the community. Such an environment leads to
care that emphasizes the dignity and worth of the patient.
Cultural Competence
Many of the elements of PCC, like communication preferences, differ across cultures
and even between patients of the same culture. Cultural competence means learning
relevant attitudes, values, beliefs, and behaviors of different cultural groups (Epner
and Baile 2012). It helps care providers to anticipate some issues, but it is also
extremely important that they not make assumptions about a patient’s preferences
and needs based solely on his or her culture. Cultural competence when applied with
PCC is expected to help overcome cultural challenges and meet patient satisfaction
(Epner and Baile 2012). The key principles of patient-centered cultural competence
were summarized by Epner and Baile (2012). Eight of these principles are listed
below, based on the literature about PCC in the Middle East.
1. A skillful consultation is a golden tool. It provides a medical professional with

information about the patient’s needs, values, and expectations. In order to
encourage the patient to speak openly from the beginning, the medical profes-
sional should encourage the patient to explain the purpose of the visit. He or she
should then explore the patient’s ideas, concerns, and expectations and therefore
discover the purpose for the visit. This exploration will also alert the medical
professional as to how much the patient wants to know and what information the
medical professional should disclose. The medical professional should take a full
medical history of the patient in order to reach a diagnosis and/or promote health
and prevent diseases. Social history also helps to establish the doctor-patient
relationship.
2. Family is an extension of the patient (Epner and Baile 2012). Most people have a
profound love for and loyalty to their family. Asking a patient about his or her
family, especially family members living with the patient, opens a window into
his or her life and has diagnostic and therapeutic value (Epner and Baile 2012).
The family could be a contributing factor to the patient’s illness, as in cases of
domestic violence, but it could also be a tool for healing. Families can support
patients and help them adhere to their management plan. Watching how the
patient interacts with family members could also give the medical professional
clues about whether the patient prefers to disclose information related to the
illness in front of some or all family members.
3. Words can harm or heal (Bedell et al. 2004). How the medical professional
responds to the emotions of the patient and his or her family builds trust and
rapport (Epner and Baile 2012). It is important to provide information in a
way that the patient and family members can easily understand, avoiding
medical jargon, and breaking bad news appropriately to lessen their painful
effect.
4. Physical touch is a powerful tool that can be destructive or healing (Epner and
Baile 2012). A medical professional should avoid greeting patients of the oppo-
site gender by extending a hand unless the patient extends his or her hand first.
A simple smile and nod indicate sufficient respect. It is essential for a medical
professional to act with propriety when touching a patient during a physical exam
(Epner and Baile 2012).
5. Nonverbal signals are powerful (Epner and Baile 2012). People convey as much
or more information through nonverbal cues as through words (Epner and Baile
2012). A medical professional must use these cues effectively especially while
exploring the patient’s preferences and agenda.
1534 H. H. Webair
6. Spirituality is extremely important (Epner and Baile 2012). Faith and religion
often strengthen a patient during times of illness and weakness. The medical
professional must treat the patient’s faith respectfully. Offering prayers to a
religious patient could have a healing effect (Epner and Baile 2012). Medical
professionals must remember that a patient may refuse some procedures or
treatments because of his or her religious beliefs or may need to consult with a
religious scholar before making a decision. The medical professional must give
the patient the time to make a decision and avoid pressing the patient to accept
treatment that is prohibited by his or her religion. The medical professional can
best help the patient by explaining all available care options.
7. The patient and his or her family are the center of the healthcare process (Epner
and Baile 2012). The care provider should permit the patient and his or her family
to control the consultation as much as possible, focusing on their agenda and
priorities when reasonable (Epner and Baile 2012).
8. Familiarity and empathy should not interfere with professionalism. Patients
usually prefer to be dealt with in an emotive, familiar way by their care providers,
especially when they are vulnerable. This treatment will make a patient more
open and could have a healing effect in stressful healthcare situations. However, it
should not interfere with the medical professional’s goal to help the patients
conquer their illness and improve their health.
Barriers to Patient-Centered Care in the Middle East
There are still significant challenges for PCC in terms of implementation, even in
developed countries (Ekman et al. 2011; Mezzich et al. 2011). Studies undertaken in
Bahrain, Egypt, Iran, Iraq, Jordan, Pakistan, and Saudi Arabia have found barriers to
PCC at multiple levels within Middle Eastern healthcare systems – among healthcare
institutions, providers, and patients (Anoosheh et al. 2009; Farahani et al. 2011;
Qidwai et al. 2013, 2015; Esmaeili et al. 2014). Some of the barriers to PCC in the
Middle East are summarized in Table 1; most are related to communication and team
coordination.
Fortunately the literature on PCC available in the Middle East offers possible
corrective measures that healthcare institutions can implement to overcome seven
identified barriers: lack of a definition of PCC, time constraints, financial constraints,
cultural beliefs, communication, dysfunctional healthcare systems, and patient
behavior (Qidwai et al. 2012, 2015; McMillan et al. 2013; Elkhammas and Mahmud
2014; Esmaeili et al. 2014). First, in order to address the lack of a comprehensive
definition and holistic view of PCC, institutions should survey patients and their
family members, as well as healthcare professionals, to develop a country- or region-
specific definition of PCC that encourages patient autonomy while respecting their
patients’ unique cultural and religious perspectives. Institutions should also use PCC
as a quality indicator. Second, by reducing the number of patients that each
Table 1 Barriers to patient-centered care in the Middle East from the perspective of physicians,
nurses, and clients
Physicians Nurses Clients
1. Patients desire to 1. Having contagious diseases 1. Time constraints
allow doctors to decide
for them
2. Cultural reasons 2. Heavy nursing workload 2. Doctors feeling of being
superior
3. Increased cost 3. Hard nursing tasks 3. Lack of doctors training
4. Religious reasons 4. Lack of welfare facilities for 4. Having contagious diseases
nurses
5. Clients’ misunderstanding 5. Sex differences between
manifested by repeated question- nurses and patients
asking
6. Lack of collegiality between 6. Lack of empathy
physicians and nurses
7. Cultural reasons 7. Lack of respect for patient
privacy and confidentiality
8. Lack of team coordination 8. Use of medical jargon or
giving unclear or inaccurate
messages
9. Lack of organizational support 9. Differing languages between
patients and healthcare
providers
healthcare provider sees in a given time period, institutions can help to alleviate
providers’ time constraints. Third, by accepting the increased costs of improving the
quality of patient care and by making health insurance available for all patients on
appropriate terms, institutions can address financial constraints. Fourth, healthcare
systems and providers can both respect and embrace patients’ cultural beliefs by
educating community leaders about PCC and its benefits and by increasing patients’
capacity to engage with healthcare professionals. Fifth, medical professionals can
overcome communication barriers by consciously avoiding the use of medical
jargon when communicating with patients and showing empathy. Healthcare insti-
tutions can also apply information and communication technologies to improve
communication between health facilities and patients. Sixth, to address the barriers
caused by dysfunctional healthcare systems in many parts of the Middle East, the
highest authority can implement family practice, ensure adequate healthcare cover-
age for the population, conduct research to develop and test primary care models to
positively change healthcare delivery, and encourage patient and community partic-
ipation in the healthcare system. Finally, and perhaps most importantly, in order to
address patient behavior – as well as time constraints, financial constraints, cultural
beliefs, and communication barriers – healthcare institutions should improve patient
education about PCC and provide training for healthcare professionals to enhance
their consultation and communication skills.
1536 H. H. Webair
Conceptual Framework of Patient-Centered Care in the Middle East
Levels of the Healthcare System

A conceptual framework for PCC should be based on the healthcare system. This
chapter adapts the four-level model of the healthcare system developed by Ferlie and
Shortell, with some modifications (Ferlie and Shortell 2001; Reid et al. 2005). The
healthcare system is divided into four interactive levels:
1. The client level refers to an individual patient (and his or her family) who is
seeking medical help for either preventative or therapeutic purposes.
2. The healthcare team level refers to healthcare providers – including physicians,
nurses, technicians, and all other professionals involved in the patient’s care.
Caregivers from the community and patient advocates should also be included at
this level.
3. The organizational level refers to hospitals, clinics, and other healthcare facili-
ties within which the patient receives healthcare services. The institutions at the
organizational level provide the required support for healthcare teams through
infrastructure and complementary resources. Patient and community representa-
tion is encouraged at this level.
4. The environment level refers to the environment outside the healthcare organi-
zation, within which the patient, healthcare team, and organization are embedded.
It provides political and economic regulatory services (e.g., finances, payment
regimes, and markets). It includes all possible environmental support sources,
including people surrounding the patient, community leaders, and local and
international bodies.
Concept of PCC
Unfortunately, there is no existing definition of PCC in the Middle East. Most
definitions in the literature are based on studies that focus on patients outside the
Middle East. Because the cultural and religious background of the Middle East is
reflected in the healthcare preferences of its population, these factors must be kept in
mind when drawing the framework for PCC in the region. In order to enhance PCC
in the Middle East, healthcare authorities must engage community representatives in
planning, implementing, and evaluating the healthcare system at the organizational
and environmental levels. These representatives should communicate the prefer-
ences of patients and their families and help institutions determine how to design a
healthcare system that is responsive to their needs. Community representatives can
also play a significant role in the evaluation and modification of the healthcare
system to ensure that it is working with the community hand in hand, to achieve
PCC.
There are two factors that are essential to a Middle Eastern-specific definition of
PCC: family and religion. PCC begins with the patient and his or her family. In the
Middle East, the patient cannot be separated from his or her family (Lovering 2012).
Moreover, because most Middle Eastern patients are religious, their religion will also
heavily impact on their care. Some religions have written forms like holy or sacred
books, which clarify the religion’s principles and guide its followers (Bonney 2004).
Many adherents believe that they must follow all of the rules given in these books. It
is impractical to argue with a patient about a treatment that runs counter to the rules
of his or her religion. Instead, the care provider should discuss alternative options
with the patient when available.
Another important point to be considered is the degree of physician participation.
About half of the respondents in a survey of Middle Eastern patients indicated that they
preferred a mixed model of care, with both PCC and physician-centered care rather than
just PCC (Qidwai et al. 2013). Middle Eastern patients feel more satisfied when their
physicians actively participate in their care; some still believe that physicians are next
to God. Mixing both PCC and physician-centered care models empowers the patient
with the particulars about their condition and the treatment options, helping – but not
guiding – the patient to express his or her preferences, needs, and expectations (Lewis
and Pignone 2009). There must be a two-way flow of information and queries between
the patient, his or her family, the healthcare team, possibly the organization, and maybe
even the environment. It is not fruitful for a medical professional to use a consultation
as a lesson or to adopt a one-way flow of information (from the provider to the patient
only). Instead, the consultation must be interactive, including all levels of the healthcare
system as needed. A mixed model of care means sharing treatment decisions rather than
leaving it to the patient to decide alone about what he or she wants.
Examples of Applying a Middle Eastern PCC Conceptual Framework

The following clinical situations help to illustrate how to apply a Middle Eastern
PCC Conceptual Framework. For some clinical scenarios, there is only one clearly
superior decision, and patient preferences play little or no role. For example, acute
appendicitis must be treated with emergency surgery. Still, it is of paramount
importance to fully inform the patients and their families so that they understand
that surgery really is the only option. For many other clinical scenarios, however,
more than one treatment option exists, and there are different combinations of
possible therapeutic effects and side effects. Decisions about therapy for the induc-
tion of labor in post term pregnancy or for the treatment of irritable bowel syndrome
are good examples. In such cases, patient and family involvement in decision-
making adds substantial value. The process of sharing decision-making should
take place at the level of healthcare providers; it can also be extended to include
discussions with healthcare organizations, or possibly the environment, arranged
through the care provider to achieve the highest possible quality of care. An example
is when a care provider encounters a child with frequent asthma attacks despite
proper medical management. It is helpful to search for triggers that might be the
cause behind that. Common triggers can be found in the school environment,
especially if the attacks occur more frequently during school days. In such a case,
the care provider communicating with the school to both diagnose possible causes
and put corrective measures in place to help the child is extremely helpful. In this
way, the maximum healthcare benefit is expected to be achieved for both the patient
and the health system using the available resources, with the least cost, shortest time,
and maximum satisfaction. Figure 1 illustrates the conceptual drawing.
1538 H. H. Webair
Fig. 1 Conceptual drawing of patient-centered care in the Middle East
Conclusion
PCC in the Middle East still lags behind healthcare provided elsewhere in the world.
There is no comprehensive Middle East–specific definition of PCC that takes the
cultural and religious values of the region into account. However, the literature does
define some PCC principles from the perspective of Middle Easterners. In the
Middle East, good communication is marked by trust and compassion, caring for
the patient and family together (family centrism), maintaining patient dignity,
following a gender-specific care approach, and touching the patient only when
appropriate. Good communication is emotive and familiar. Many healthcare pro-
viders in the Middle East believe that the disclosure of serious diagnoses and
prognoses to the patient is unacceptable. However, healthcare providers should not
make assumptions about the patient’s preferences based on culture alone. They must
ask the patient what he or she prefers to know and involve his or her family in the
decision-making based on patient’s preference. Applying cultural competence and
PCC together is helpful in this regard. Fear and stigma associated with diseases are
also common in the Middle East, and medical professionals should consider these
factors and deal with them appropriately when communicating with their patients.
There is a need for PCC in the Middle East, but many barriers still exist. These
barriers include the lack of a comprehensive definition and holistic view of PCC,
time and financial constraints, cultural beliefs, patient behavior, lack of appropriate
communication, and the existing dysfunctional healthcare system in the Middle East.
Nonetheless, Middle Eastern culture and religious adherence could be used to
positively enhance PCC in the region. During the medieval period, religious values
and culture were used to improve the quality of healthcare and patient satisfaction.
The suggested conceptual framework of PCC includes the four levels of healthcare
systems: client, care team, organization, and environment. It focuses on engaging the
patient and his or her family and community as members of the healthcare system,
facilitating informed decision-making, and encouraging the patient and healthcare
provider to share decision-making, across all levels of the healthcare system.
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Spirituality and Spiritual Care in the Arab
World 63
Mysoon Khalil Abu-El-Noor and Nasser Ibrahim Abu-El-Noor
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1544
Spirituality and Spiritual Care Concepts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1545
Concept of Spirituality and Its Relation to Religion and Health . . . . . . . . . . . . . . . . . . . . . . . . . . 1545
Spirituality Aspect of Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1546
Spiritual Care for Patients with Chronic Diseases in Clinical Practice . . . . . . . . . . . . . . . . . . . . . . . 1547
Health Workforce and Spirituality Care as a Discipline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1548
Islamic View of Spirituality and Spiritual Care in Health and Wellness . . . . . . . . . . . . . . . . . . . . . . 1548
Perception of Muslims Toward Health and Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1550
Spiritual Care Practices in Muslim Arab Communities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1551
Research in Spiritual Care and Health in the Arab Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1552
Adequacy of Spiritual Care in Arab Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1553
Barriers to Spiritual Care in the Health-Care Systems of Arab Countries . . . . . . . . . . . . . . . . 1561
Improving Spiritual Care in Arab Health-Care Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1563
Educational and Training Preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1564
Organizational Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1564
Policy Innovations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1564
Miscellaneous Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1565
Future Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1565
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1565
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1566
Abstract
Recent advancements in medical technology and pharmacological treatments
have increased life spans and also the number of people living with chronic
diseases. The growing number of people with chronic diseases will need frequent
hospitalizations, subjecting them to stress, anxiety, and depression. Providing
spiritual care to these patients benefits their health and improves their quality of
M. K. Abu-El-Noor · N. I. Abu-El-Noor (*)

Faculty of Nursing, Islamic University of Gaza, Gaza, Palestine
e-mail: Naselnoor@iugaza.edu.ps

https://doi.org/10.1007/978-3-030-36811-1_68
1544 M. K. Abu-El-Noor and N. I. Abu-El-Noor
life. Despite these benefits, health-care professionals, including health-care pro-

viders in the Arab countries, tend to provide inadequate spiritual care to their
patents as they tend to focus on the physical needs of their patients.
Spirituality and spiritual care are deeply rooted in Arab countries as they are
part of the Islamic practice which prevails in the area. The authors of this chapter
explain the interwoven relationship between religion and spirituality and how a
Muslim’s beliefs affect healthy behaviors. Based on their religious beliefs, Mus-
lims use the Quran, prayer, Dua’a, and Ruqya as a means for spiritual care.
Research over the last decade suggests several barriers that impede spiritual
care in the Arab countries and other parts of the world. Examples of these barriers
include inadequate staff, lack of time, lack of training on provision of spiritual
care, the ambiguity of spirituality, and the absence of spiritual care in the job
descriptions for health-care professionals.
More attention has been paid recently to spirituality in health care, and the
relationship between spirituality and illness is at the center of a growing body of
literature in Western countries. As a result, many hospitals in the West have
started to offer spiritual care to their patients and assigned clergy within the
health-care team. Unfortunately, there is a dearth of literature on this topic in
Arab countries, but there is recent emergence of literature in some Arab countries,
particularly from Jordan, Saudi Arabia, and Palestine. To improve the level of
spiritual care provided in Arab countries, new policies should be adopted. In this
chapter, the authors propose several recommendations to improve the assessment
and provision of spiritual care within Arab health-care systems. Examples include
increasing the number of staff, providing training to staff on assessing and
providing spiritual care, and adopting new polices to ensure spiritual care to
Arab patients.
Keywords
Spirituality · Spiritual care · Arab world · Chronic diseases · Islam
Abbreviations
CARF Commission on Accreditation of Rehabilitation Facilities
JCAHO Joint Commission on Accreditation of Healthcare Organizations
PBUH Peace be upon him
Introduction
The rapid advancements in medical technology and the pharmaceutical industry

have greatly benefited the treatment of many seriously ill patients and prolonged
their lives. As a result, the number of people living with chronic diseases continues
to increase. Patients diagnosed with chronic diseases will need frequent hospitaliza-
tions, subjecting them to stress, anxiety, and depression. This leads to increased
utilization of health-care services and frequent and prolonged hospital stays
63 Spirituality and Spiritual Care in the Arab World 1545
(Sullivan et al. 2004), leading to an increase in health expenses per patient and total
cost. Experiencing pain and discomfort, dealing with strangers and unknown care-
givers, invasion of privacy, uncertainty, and dependence on others during hospital-
ization are potential reasons for spiritual pain (Noguchi et al. 2006). Thus,
management of both physical and spiritual stress should be the primary treatment
goal. Spirituality was described as a core human component that can alleviate
suffering, facilitate recovery, and optimize coping mechanisms and adjustment to
chronic diseases (Albaugh 2003).
Inhabitants of the Arab countries are more vulnerable than other groups elsewhere
because of frequent wars, poverty, high rates of unemployment, and political con-
flicts that prevail in the area. Such factors create more stress and suffering. With the
increasing number of stressors and limited resources in most of the Arab countries, it
becomes necessary to introduce spiritual care for patients, in addition to existing
traditional medicine. This includes offering spiritual care for patients. Health-care
providers can offer a holistic approach by providing emotional and spiritual care to
their clients. In order to provide holistic care, it is important for health-care providers
to include the physical, psychological, sociocultural, and spiritual dimensions in
their care (Timby 2009). The World Health Organization (WHO) definition of health
since 1948, as well as several other definitions, clearly includes a spiritual aspect of
health (WHO 2006). According to this model, a holistic approach of taking care of
the physical, mental, and spiritual components of health should be considered when
caring for patients (Anandarajah 2008).
Spiritual well-being is associated with less depression in patients diagnosed with
terminal illnesses. According to Westlake and Dracup (2001), spirituality affects
functioning, quality of life, and the general health status of patients diagnosed with
chronic diseases, since spirituality plays a vital role in coping with their illness. On
the other hand, low-levels of spiritual well-being may be associated with spiritual
pain which manifests as symptoms of physical (e.g., intractable pain), psychological
(e.g., anxiety, depression, hopelessness), religious (e.g., the crisis of faith), or social
(e.g., disintegration of human relationships) manifestations.
Despite the importance of including emotional and spiritual needs in patient care,
health-care providers mostly focus on meeting the physical, social, and psycholog-
ical needs of their clients and rarely recognize their spiritual needs (Bar-Sela et al.
2016). Understanding the spiritual needs of the patients will minimize the use of both
inpatient and outpatient medical services. Therefore, an economic analysis of health-
care system may require establishing new policies that mandate spiritual care.
Spirituality and Spiritual Care Concepts
Concept of Spirituality and Its Relation to Religion and Health
The word “spirit” in Greek culture contrasts body and material realities. In Western
cultures, a spiritual person is one who is indifferent to material gain or worldly
concerns. In Hebrew, spirit is opposed to death, destruction, and negative aspects of
the law, such as obligation, fear, and punishment. Spirit is understood to be within
the body, providing a life force, acting through it, and motivating action” (Golberg
1998).
Spirituality is an abstract, subjective, and complicated term, whose definition
varies between individuals, philosophies, and cultures, and which has abstract
components associated with many subjective meanings (Noble and Jones 2010).
These characteristics lead many authors to argue that there is no agreement on the
definition of spirituality as a concept (Narayanasamy 2006). One of the definitions of
spirituality is “the individual’s sense of peace, purpose, connection to others, and
beliefs about the meaning of life” which may be expressed through religion or other
means. In addition, spirituality consists of different dimensions that include mean-
ing, control, identity, and relationships (National Cancer Institute 2015).
There are debates on whether spirituality differs from religion (Chaturvedi 2007).
Although spirituality promotes developing a relationship with a Higher Power such
as God (Burkhardt and Nagai-Jacobson 2002), some believe that spirituality is
broader than religion (Stoll and Stoll 1989). Congruently, Narayanasamy (2004)
argued that along with prayer to God, spirituality also encompasses meaning,
purpose, and connections with others.
According to Rumbold (2003), spirituality is personal and unique and can also
encompass religion for some, but not other, individuals. Moreover, Rassool (2000)
added that “Spiritual care is important for all people, not only those who express a
religious belief, as spirituality is a fundamental need that goes beyond religious
affiliation.”
For Muslims, spirituality arises from religion and guides their practices and
thoughts when contemplating God (Allah, in Islam). Muslim patients usually
boost their spiritual religious practices by reading the Quran (holy book of Islam)
and praying at times of illness (Omari et al. 2013).
Spirituality Aspect of Health Care
Despite the disagreement about its definition, there is consensus about the impor-
tance of spirituality in health care (Larson et al. 2002; Levin et al. 2005; Mako et al.
2006; McSherry and Ross 2002; O’Connor et al. 2007). There is sometimes a non-
distinction between spirituality and the emotional and psychological well-being
(Halm et al. 2000). Medicine and spirituality were intertwined historically, where
healers were also the priests or the religious leaders; priests used to take care of both
the body and the spiritual needs of ill persons (Greenberg 2003).
Spiritual needs refer to factors that assist the individual with establishing or
maintaining a dynamic, personal relationship with God (Shelly and Fish 1988). In
addition, Forbis (1988) identified spiritual needs as giving and receiving love,
realizing hope, and finding meaning in life, illness and death. Spiritual care was
defined by Lovering (2008) as “actions to meet the spiritual needs of the patient and
family,” while Lunn (2004) defined it as “meeting people where they are
and assisting them in connecting or reconnecting to things, practices, ideas, and
principles that are at their core of their being-the breath of their life, making a
connection between yourself and that person.”
Health care should include a component of spiritual care intervention provided by
nurses to meet the patient’s spiritual needs (Royal College of Nursing 2011). This
also applies to other health-care professionals. In the context of nursing care for
Muslim Arab patients, Lovering (2012) reported that spiritual care is a key compo-
nent of professional nursing, according to the Crescent of Care nursing model.
Spiritual Care for Patients with Chronic Diseases in Clinical

Practice
There has been an agreement over the last few years on the need for spiritual care
within health-care systems, especially in chronic diseases and palliative care. The
role of spirituality in coping with chronic illnesses is gaining interest within health-
care domains, and spiritual care is now an essential component of palliative care and
in the care of terminally ill patients (Hills et al. 2005).
A routine spiritual assessment as an essential component of holistic health care
has been emphasized by policy, research, and practical guidelines for health-care
professionals (Murray et al. 2004). As a result, the Joint Commission on Accred-
itation of Healthcare Organizations (JCAHO) states that patients’ “psychosocial,
spiritual and cultural values affect how they respond to their care” (Joint Com-
mission Resources 2003), so establishing spirituality and emotional well-being as
essential aspects of patient care. In practice, ignoring the spiritual needs acknowl-
edges an inability to appreciate the holistic view of the human being (Gray et al.
1994).
There is increasing interest in the holistic view of health care and consequently in
the understanding that emotional and spiritual needs are inextricable from physical
and psychological needs (Mueller et al. 2001). Clinical studies report that providing
spiritual care decreases anxiety, depression, and psychological distress (Tuck et al.,
2001; Thoresen and Harris 2002); reduces the risk of early mortality; reduces pain
and the need for pain medication, stress levels, and demand on health-care providers;
and improves patients’ satisfaction (Larson et al. 2002). This decreases the frequency
of hospitalization and shortening of hospital stays. Moreover, spirituality promotes
inner harmony and equilibrium (McSherry 1983).
There is little disagreement in the health-care policy arena about including
spiritual care in the treatment process (Handzo and Koenig 2004). The JACHO
and the Commission on Accreditation of Rehabilitation Facilities (CARF) requires
that health-care providers assess and meet patients’ spiritual beliefs, practices, and
needs (Clark et al. 2003). Many countries such as Great Britain, Norway, Malta,
Israel, and the United States of America (Bentur et al. 2010) implemented policies
that mandates health-care providers to provide spiritual care to their clients; as a
result, many hospitals in these countries now offer spiritual care to their clients, at
least when requested (Clark et al. 2003).
Health Workforce and Spirituality Care as a Discipline
While providing spiritual care is considered an essential aspect of health care, there
is no agreement about who should offer spiritual care within the health-care system.
Although several hospitals in Western countries assign chaplains and pastoral teams
to address the emotional and spiritual needs of the patients, nurses, physicians, and
other health caregivers also play equally important roles (Clark et al. 2003). Thus,
health workers need academic preparation and clinical training to enable them to
offer spiritual care.
Furthermore, the proximity of nurses to their patients places them in a unique
position for fulfilling the spiritual needs of their patients. Ross (2006) claims that
nursing intervention to resolve spiritual needs have a positive effect on patients’
health and quality of life. As stated by McSherry and Ross (2002): “There is a
general assumption that nurses have the skills, knowledge and expertise to undertake
a spiritual assessment,” and Highfield and Cason (1983) argued that the physical
presence of nurses can be considered as a form of spiritual care. Any inadequacy in
nursing practices in providing spiritual assessment and care can call into question the
basis of their practice (Highfield and Cason 1983). Spiritual care is a vital component
of nursing care, and other health-care providers should also embrace the principles of
the spiritual well-being of their patients. There are some recent discussions
suggesting that proposals that every member of the health-care team either working
in inpatient or outpatient facilities, in acute or chronic settings, or in public or private
health-care facilities should have some level of competence and comfort in assessing
and meeting the spiritual needs of their patients. Recent discussions propose that
every member of the health-care team, regardless of the setting (e.g., inpatient or
outpatient facilities, acute or chronic settings, public or private health-care facilities),
should have some level of competence and comfort in assessing and meeting the
spiritual needs of their patients.
Reviewing the literature of spiritual care in health-care systems shows that while
America is leading the way in exploring the concept of spirituality and establishing
its importance in holistic care, the British are also making great efforts in this aspect
of patient wellness (Oldnall 1996). Many or most hospitals in Western countries
offer spiritual care by chaplains, at least when requested (Clark et al. 2003).
However, spiritual care is mostly offered on a limited basis or even neglected in
the Arab world; there is often no formal spiritual care provided at hospitals or other
health-care facilities. Some Arab countries, such as Jordan, Egypt, Iraq, Morocco,
and Saudi Arabia, have recently initiated programs to increase spirituality and
spiritual care as a part of palliative care (Fadhil et al. 2017).
Islamic View of Spirituality and Spiritual Care in Health and

Wellness
Religious belief systems and spiritual well-being are positively associated with
physical and mental health as well as the quality of life (Koenig 2009). The healthy
practice of one’s faith usually correlates with positive mental and physical health
(Powell et al. 2003), both of which are associated with the prevention of illness
across divergent religious communities (Koenig 2009). Since the majority of the
Arab world (consisting of 22 countries) is Muslim, this chapter will focus on
spirituality, and spiritual care will be defined and measured within the Islamic
religious boundaries.
Islam means “complete submission and obedience to Allah” and, therefore,
instructs every aspect in a Muslim’s life. It deals with all aspects of life whether
physical, social, economic, or health. Islamic law aims to achieve five goals for
human beings: protecting the religion, protecting self, protecting one’s possessions,
protecting one’s mind, and protecting one’s offspring. The religious values of Islam
that guide Muslim lives originate from the interpretation of the Quran (the holy book
of Islam), Sunnah ‫[ ﺍﻝﺱﻥﺓ‬The sayings, deeds, or approvals and acts of the Prophet
Mohammad, peace be upon him (PBUH)], and Shar’ia ‫( ﺍﻝﺵﺭﻱﻉﺓ‬The Islamic law)
(Nabolsi and Carson 2011). In Islam, spiritual care consists of more than just
religious care; it provides a framework for health-care professionals to connect
with patients and deliver person-centered, holistic care (Jafari et al. 2014b).
Islam, like most other religions, takes care of the physical and spiritual compo-
nents of the individual. In Islam, the human being is a “united body and spirit”
(Isgandarova 2005). Well-being in the Islamic view emphasizes the wholeness of the
person, integrating a balance between the spirit (rouh ‫)ﺭﻭﺡ‬, body (badan ‫)ﺏﺩﻥ‬, and
emotions (naphs ‫)ﻥﻑﺱ‬. This Islamic view influences the beliefs and practices of
Muslims that integrate emotional, physical, and spiritual aspects of the self (Nabolsi
and Carson 2011). Although the soul has its own maladies (e.g., forgetting the
presence of the Divine, selfishness, and so on) and the body has its disabilities,
both are combined in one entity in the form of spirituality (Isgandarova 2005).
Islamic teachings and practice have enabled the production of a holistic framework
in meeting the physical, spiritual, psychosocial, and environmental needs of indi-
viduals and communities (Rassool 2000). There is no distinction between spirituality
and religion within the Islamic context; Muslims live in a manner in which their
religious beliefs pervade all of their actions and across all facets of life, including
their work, daily activities, health, etc. (Jafari et al. 2014b). There is no opportunity
to separate spirituality from religion, because for Muslims, spirit arises from religion
and guides their practices and thoughts to approach Allah (Omari et al. 2013).
Muslim patients usually increase their spiritual and religious practices such as
reading the Quran and praying, especially during times of hardship such as sickness.
Moreover, spirituality is inseparable from religion and offers salvation
(Isgandarova 2005). In Islam, the concept of religion is embedded in the umbrella
of spirituality (Rassool 2000). Based on the Quran and guidance from the Prophet
Mohammed (PBUH), spirituality in Islam is built on “unity” or “Tawheed ‫”ﺕﻭﺡﻱﺩ‬,
which means believing that there is no God except Allah. Muslims recognize the
Divine, and they inquire about “meaning, purpose, and happiness” in both lives
(worldly life and the one after death) (Isgandarova 2005). These are important
differences between Western and the Islamic views of spirituality.
According to Rahman (1980), spiritual discipline “which educates and trains the
inner self of man” is at the core of the Islamic system. It also frees man from the
slavery of the “self,” purges his soul from the lust of a materialistic life, and instills a
passion of love for Allah. It is through this process of patience, perseverance, and
gratitude that opens the door for spiritual and physical well-being.
As Islam takes care of the soul and the body (Isgandarova 2005), it also empha-
sizes individual health and well-being. Isgandarova (2005) argued that spirituality in
Islam implies a healthy relationship between the body and the spirit. The Quran is
not a medical textbook, but does provide guidelines for health and treatment.
According to El-Kadi (1993), the Holy Quran has a clear and positive influence on
health, either through healing from illnesses or health promotion and disease pre-
vention. The health-related components of the Quran are achieved through three
approaches: the legal approach, the guiding approach, and the direct healing
approach (El-Kadi 1993). As Muslims strive to obey Allah, they seek His guidance
in life including those related to health issues. Prophet Mohammed (PBUH) taught
the Muslims that “your body has rights over you,” which means that the Muslim is
responsible to protect his/her body through maintaining his/her health. The Prophet
also said “Ask Allah for forgiveness and well-being.” Medicine, prayers, fasting, and
Ruqya ‫( ﺭﻕﻱﺓ‬spelling or reciting Quran on the sick for the purpose of treatment) are
all methods for remedy in Islam. Many Muslim patients rely heavily on Islamic legal
tradition and religious scriptures for healing and guidance when making difficult
decisions, including whether to continue aggressive treatment, participate in family
planning, or receive or donate organs (Sheikh 2007; Abu-El-Noor and Abu-El-Noor
2014b). Also, many Muslim patients rely on Allah’s will and use prayers and
supplications to seek help from Allah during hardship time and times of illness.
Moreover, Nabolsi and Carson (2011) report that faith of Muslim patients plays a
central role in making choices between healthy and unhealthy or in accepting or
rejecting their responsibility in promoting future health and well-being. However,
Muslims must seek treatment from illnesses through medical means and protect the
sanctity of life and wellness as these are both gifts granted to them. Muslims are
custodians of their bodies and are obligated to keep them as healthy as possible.
Muslims believe that physicians are tools for healing and that actual healing and
health outcomes are determined by Allah, unto whom the body and soul ultimately
belongs. Such a belief system allows Muslims to live in spiritual peace (Abu-El-
Noor and Abu-El-Noor 2014b).
Maintaining health is advocated in Islam, either through the Quran or Sunnah.
Therefore, taking care of hygiene, diet, avoiding accidents such as fire and poison-
ing, and even isolating people with infectious diseases are all emphasized in Islam. A
healthy diet relates to the interconnectedness of physical and spiritual health as
“healthy eating not only satisfies hunger but also has an effect on how well we
worship” (Stacy 2008). “O ye people! Eat of what is lawful and good on earth, and
do not follow the footsteps of Satan. Verily he is to you an avowed enemy” (Quran
2:168).
Perception of Muslims Toward Health and Illness
Muslim patients consider illness as atonement, rather than punishment, for their sins,
and death as part of a journey to meet God (Athar 1998). Illnesses can attack both
people who are considered highly religious and adhere to Allah’s orders, as well as
those who do not believe in Allah at all. Experiencing disease is a normal part of
natural life. “And certainly, We shall test you with something of fear, hunger, loss of
wealth, lives and fruits, but give glad tidings to the patient ones” (Holy Quran,
2:155). Thus, Muslims who recognize this will not question Allah’s love and mercy,
or question why they were inflicted with illness, or the purpose of life. Muslims
believe that they were created with the sole purpose of worshipping Allah. The
perception by Muslim patients about health and illness causes them to accept illness
and death with patience, meditation, and prayers. Muslims accept that illness,
suffering, and dying as natural parts of life and tests from Allah (Rassool 2000).
According to Al-Jibaly (1998), an unwell Muslim should keep in mind that his
sickness is a test from Allah which carries tidings of forgiveness and mercy for him.
Thus, Muslims are encouraged not to complain of such suffering, to accept their
illness with patience and satisfaction, and to ask Allah to reduce this distress.
Muslims use faith and prayer for healing and to cope with illness (Koenig 1998).
Through prayer, meditation, and relying on Allah’s will, many Muslims seek support
and help from Allah during suffering and illness (Errihani et al. 2008).
Muslims always should obey Allah and thank Him for everything happens to
them, whether perceived as bad or good. “The reality is that Allah is just, therefore,
whatever situation a believer finds himself in, he/she knows there is goodness and
wisdom embedded in it” (Stacy 2008). Consequently, seeking treatment for illness is
not considered as a sign of conflict with confidence on Allah for a cure. Prophet
Muhammad said (in a close translation of the meaning): “Seek treatment, because
Allah did not create a sickness but has created a treatment for it; except for old age”
(Rassool 2000).
Terminally ill patients experience fear of death and loneliness which may end
with spiritual crisis (Asadi-Lari et al. 2008). Approaching death may stimulate
several questions regarding the presence of God, the power of God, love by God,
the purpose of life, and why this happens (Pembroke 2008). Anxiety, depression,
despair, and hopelessness may affect terminally ill patients (Asadi-Lari et al. 2008).
It may be argued that Muslim patients receiving proper and adequate spiritual care
may be able to overcome such crisis or even not go through it. Reminding Muslim
patients suffering from chronic diseases with the purpose of life (worshipping
Allah), value of patience, nature of death as a passage between the two segments
of a continuous life (Asadi-Lari et al. 2008), and that this disease is a chance for
forgiveness, all of these can minimize the stressors which they face. Providing
spiritual care to Muslim patients produces positive outcomes in terms of promoting
health status and minimizing the symptoms of disease (Mardiyono et al. 2011).
Moreover, Saffari et al. (2013) found that spiritual interventions and religiosity are
associated with the quality of life and health status among Muslim patients.
Spiritual Care Practices in Muslim Arab Communities
The practice of regular prayer is the most fundamental practice in Islam. Dua’a ‫ﺩﻉﺍﺀ‬
is considered a type of prayer. Muslims become habituated to using Dua’a in several
events and situations. However, Burn (2001) claimed that Muslims “forget the
healing power of prayers in healing.” She claimed that several studies in the modern
medicine supported the powerful healing of prayer itself and in augmenting the
effect of other medicines. Allah says (in the meaning of) “And your Lord says: Pray
unto me: and I will hear your prayer” (Quran, 40:60). The prayer of a patient can be
considered as Dua’a or also as Ruqya. The healer puts the right hand on the site of
pain or health problem and begins to read some verses from Quran. The origin of
these prayers came from the Prophet’s (PBUH) time. In the Hadith of Bukhari,
A’isha [wife of prophet Mohammad, (PBUH)] reported, “When any person among
us fell ill, Allah’s Messenger (PBUH) used to rub him with his right hand and then
say: O Lord of the people, grant him health, heal him, for Thou art a Greet Healer.
There is no healer, but with Thy healing Power one is healed and illness is removed”
(Al Bukhari). The most frequently used chapter of Quran for healing is the first
chapter of the Holy Quran, known with the name “Al-Fatihah ‫( ”ﺍﻝﻑﺍﺕﺡﺓ‬Burn,
2001), and it is the recommended prayer for the person who does not know the
specific supplication for a particular illness. The Prophet (PBUH) allowed the
treatment of a poisonous sting with Ruqya, and Allah’s apostle said that you are
entitled to take wages for doing a Ruqya with Allah’s Book, thus granting Ruqya a
professional status.
Burns (2001) suggested that with the death of hundreds of people in American
hospitals as a result of the medication side effects, “one should not rule out prayer as
at least a supplemental healer.” Herbert Benson, director of the Mind/Body Medical
Institute, (cited by Cromie, 1997), said “Anecdotal information about the healing
power of faith has existed for centuries. We’ll try to put that information on a
scientific basis by measuring the possible effects of intercessory prayer. If we can
show that prayer helps people who don’t even believe in God; that would be
revolutionary!” Congruently, Byrd (1988) concluded from his experiment with
393 cardiac patients that prayers promote healing. “Many physicians and patients
all over the world believe in the spiritual dimension in healing, such as the power of
prayer as an adjunct or a complementary medicine to modern or conventional
medicine” (Syed 2009). He expanded that “Muslim prayer consists of contact prayer
(Salat ‫)ﺹﻝﺍﺓ‬, (Dhikr ‫ )ﺫﻙﺭ‬or remembrance of Allah and recitation of the Quran.
These elicit the physiologic relaxation response.” Muslim congregational prayers act
as a buffer against the adverse effects of stress and anger, perhaps via psychoneur-
oimmunologic pathways. It is considered that congregational prayers can lead to
better health (Syed 2009). Based on the explanations above, Islamic view of illness,
treatment, and spirituality can be depicted in Fig. 1, which will be explained later in
this chapter.
Research in Spiritual Care and Health in the Arab Countries
The Arab Nation consists of 22 countries (Algeria, Bahrain, Comoros, Djibouti,

Egypt, Iraq, Jordan, Kuwait, Lebanon, Libya, Mauritania, Morocco, Oman, Pales-
tine, Qatar, Saudi Arabia, Somalia, Sudan, Syria, Tunisia, United Arab Emirates,
Social Physical
dimension dimension
Human
Being
Emotional
Cognitive
dimension
dimension
Spiritual
dimension
Spiritual well-
Spiritual crisis
being
Spiritual Beliefs and Needs
Qura'n Sunnah Prayers Ruqya
Medication
Diet Level
Health Assigned meanings to health Follow up of
Beliefs activities
Activities Compliance
Fig. 1 Model of spiritual care in Islam
Yemen) with about 423 million inhabitants. In spite of much research in Western
countries about spirituality and spiritual care, there is a paucity of studies related to
this topic in the Arab world. This has changed recently as there is an increasing
number of studies emerging from Middle Eastern countries focusing on spiritual care
and spirituality in health-care settings of their Muslim populations (Jafari et al.
2014a). The authors searched Google Scholar for articles related to spiritual care
using the search terms “spiritual care” and the name of each of the 22 Arab countries;
this resulted in 18 studies which are summarized in Table 1. Half of these studies
were conducted in Jordan, 5 in Palestine, 3 in Saudi Arabia, and 1 was conducted in
14 different countries. The majority of the studies (15 of 18) were quantitative
studies, while the remaining three were qualitative. Most of the studies were
descriptive and none were interventional.
Adequacy of Spiritual Care in Arab Countries
In spite of the deep and ancient roots of spiritual care in Islam (the main religion in
the area), providing spiritual care to patients by health-care providers in Arab
countries was described as insufficient in several studies. For example, Bar-Sela
et al. (2016) conducted a study to measure provision of spiritual care in the Middle
East, with 770 respondents (40% physicians, 60% nurses) from 14 Middle Eastern
countries. The results indicated that 44% of the participants provided spiritual care
less often than they think they should have. But when caring for patients with
incurable diseases, respondents offered some form of spiritual care to 47% of their
1554
Table 1 Studies on spirituality and spiritual care in the Arab world

Author (year),
country Aim Study design Sample and data collection Main findings
Al Ghaferi et To explore whether the Qualitative design Men in addiction treatment Addiction was associated with a range of health (physical
al. (2017) biopsychosocial spiritual with semi- (n = 25) in a center in and psychological), social and spiritual factors. Unpleasant
Jordan model of addiction was structured, face-to- Amman, Jordan. physical withdrawal effects, psychological symptoms,
relevant to an addicted face interviews Themes were mapped onto such as anxiety and suicide attempts, were experienced.
treatment population in the biopsychosocial- There was breakdown in marital and family relations, loss
Jordan spiritual model of addiction of employment, involvement in crime and neglect of
religious practices, resulting in social isolation
Al-Natour et To investigate the Descriptive The Arabic version of the A positive linear relationship was found between
al. (2017) relationship between correlational Functional Assessment of spirituality and quality of life. The highest score of
Jordan spirituality and quality of Chronic Illness Therapy- correlation was seen between spirituality and the functional
life Spiritual Well-Being domain of the FACIT-SWB
(FACIT-SWB) was used to
collect data from Jordanian
women with breast cancer
(n = 150)
Musa (2017) To explore the frequency of Descriptive A sample of Jordanian Results revealed that Jordanian Muslim nurses provided
Jordan providing aspects of correlational Muslim Arab nurses who religious aspects of spiritual care intervention to their
spiritual care intervention work in private and public Muslim patients infrequently and that their own spiritual
and its association with hospitals (n = 355) was well-being was positively associated with the frequency of
nurses’ own spiritual well- recruited provision of spiritual care interventions. The study
being concluded that most frequently provided spiritual care
interventions were existential (not overtly religious) were
commonly used, more traditional, and did not require direct
nurse involvement. Moreover, the findings revealed that
spiritual well-being was important to those nurses, which
has implications for improving the provision of spiritual
care intervention
M. K. Abu-El-Noor and N. I. Abu-El-Noor
63
Melhem et al. To describe nurses’ A cross-sectional, The Spiritual Care-Giving The participating nurses had a high level of spirituality and
(2016) Jordan perceptions of spirituality descriptive design Scale was used. A spiritual care perception. Significant differences were
and spiritual care in Jordan convenience sample of 408 found between male and female nurses’ perceptions of
and to investigate the Jordanian registered nurses spirituality and spiritual care; previous attendance of
relationship between their participated in the study courses on spiritual care also made a significant difference
perceptions and their to perceptions of participants
demographic variables
Musa (2016) To explore differences in A cross-sectional, SWBS was used in a The findings revealed that the scale consists of two factors
Jordan factor structure of the descriptive convenience sample of 553 for the Jordanian Arab group, representing the “Religious
Spiritual Well-Being Scale Jordanian Arab and 183 Well-Being” and the “Existential Well-Being” subscales,
(SWBS) among Jordanian Malaysian Malay Muslim and consists of three factors for the Malaysian group,
Arab and Malaysian university students from representing the “Affiliation/Meaning and Purpose,”
Muslim participants and to governmental universities “Positive Existential Well-Being/God Caring and Love,”
examine its validity and in northern Jordan and Alienation/Despair” subscales. The SWBS scale was
reliability psychometrically sound with evidence of acceptable to
good validity and reliability in both groups of participants
Musa and To assess the psychometric Cross-sectional The Arabic version of The findings broadly supported the factor structure of the
Pevalin (2014) properties of the Arabic SWBS was used. SWBS in other Arab samples in that the scale consists of
Spirituality and Spiritual Care in the Arab World
Jordan version of the Spiritual A convenience sample of three factors, representing positive existential well-being,
Well-Being Scale (SWBS) 340 Arab Christians was affiliation, and alienation subscales. Therefore, the Arabic
in Arab Christians recruited from the adult version of the SWBS can be used as an instrument to
community population of measure levels of spiritual well-being in Arab Christian
northern Jordan populations
Lazenby et al. To determine the Descriptive Arabic-speaking cancer The FACIT-SWB indicates that it is a psychometrically
(2013) Jordan psychometric properties of correlational patients (n = 205) who sound instrument for detailed assessment of the spiritual
the Arabic FACIT-SWB were in treatment at the well-being of Arabic-speaking cancer patients
and explore associations King Hussein Cancer
between its three factors Center, Jordan
(peace, meaning, and faith)
and health-related quality
of life (HRQoL)
(continued)
1555
1556
Table 1 (continued)
Author (year),
Lazenby and To determine whether Descriptive A sample of Arabic- Physical well-being was negatively correlated with the
Khatib (2012) spiritual well-being is correlational speaking cancer patients FACIT-SWB for men, divorced, and stage IV disease.
Jordan correlated with health- was recruited (n = 159). Social well-being was positively correlated with the
related quality of life and Physical, social, functional,FACIT-SWB for ages 18–34 and 35–49 years; both sexes;
whether participants’ age, and emotional domains of married, never married, and divorced; breast, bone/
sex, marital status, site of health-related quality of life
sarcoma, and gastrointestinal cancers; and stages II–IV.
cancer, and stage of disease were measured using the Emotional well-being was negatively correlated with the
are related to spiritual well- FACT-G, and spiritual FACIT-SWB for ages 35–49; males; never married; and
being well-being was measured stages III and IV. Functional well-being was positively
using the FACIT-SWB correlated with the FACIT-SWB for ages 35–49 and
50–64; both sexes; married or never married; and stages II
and III. Age and cancer site showed a positive relationship
with spiritual well-being
Musa and To develop and validate an Cross-sectional The article reports on two The SWBS used in the main study had a two-factor
Pevalin (2012) Arabic language version of studies. The first study was structure consistent with previous studies. Descriptive data
Jordan the Spiritual Well-Being a pilot study at a major for a range of demographic variables are presented. Issues
Scale (SWBS) government university in of inadequate translation and lack of variation in responses
Jordan (N = 75, students). for some items are identified and the results discussed in
The second and main study light of dominant Islamic theological frameworks
was conducted in 5 large
regional hospitals in Jordan
(N = 63, patients). The
SWBS was translated from
English to Arabic and
reviewed by an expert
panel for language,
cultural, and spiritual
consistency
63
Abu-El-Noor To assess if spiritual care is A cross-sectional, 279 cardiac patients filled a Results revealed that there is a severe shortage of providing
(2016a) provided to the hospitalized descriptive questionnaire that assesses spiritual care to cardiac patients and the majority of them
Palestine cardiac patients who live in provision of spiritual care preferred that nurses provide spiritual care to them
Gaza Strip and who should
provide this care
Abu-El-Noor To examine how Qualitative with Thirteen nurses who work Findings identified the following themes: meaning of
(2016b) Palestinian nurses working interpretive in ICUs in the Gaza Strip spirituality and spiritual care (it was difficult for nurses to
Palestine in intensive care units descriptive using semi-structured define both terms); identifying spiritual needs
(ICUs) understand approach interviews (communication with patients and family members, the
spirituality and the health status and/or diagnosis of patients, close observation
provision of spiritual care at of the environment, and direct expression of feelings were
the end of life identified as means of recognizing spiritual needs of
patients); and taking actions to meet spiritual needs (nurses
become more aware about and more responsive to spiritual
needs of their clients when treatment becomes futile)
Abu-El-Noor To explore barriers and Qualitative, Semi-structured interview Participants identified several barriers for providing
and Abu-El- solutions for providing descriptive with 12 health-care spiritual care to cardiac patients including inadequate
Noor (2016) spiritual care to providers (doctors and preparation of staff, ambiguity of spirituality, lack of time,
Palestine hospitalized cardiac nurses) who work in shortage of staff, policy barriers, and personal barriers.
patients living in Gaza Strip different coronary care Participants suggested several strategies to overcome these
units in the Gaza Strip, barriers which include policy innovation, organizational
Palestine actions, educational and training preparation, and other
miscellaneous interventions
Abu-El-Noor To explore spiritual well- A cross-sectional, Spiritual Well-Being Scale High scores of SWBS were reported. Scores for the total
and Radwan being of Arab, Muslim descriptive (SWBS) was used in a SWBS was 101.16 while 58.91 for Religious Well-Being
(2015) prostate cancer survivors sample of 117 Muslim subscale and 42.25 for Existential Well-Being subscale.
Palestine living in Gaza Strip, Arab patients from the Scores were not affected by demographic characteristics of
Palestine Gaza Strip participants
(continued)
1557
Table 1 (continued)
1558
Author (year),
Abu-El-Noor To assess the perception of A cross-sectional, The Arabic version of Results revealed that both assessing spiritual needs
and Abu-El- hospitalized cardiac descriptive Spiritual Well-Being Scale (69.69%) and providing spiritual care (76.97%) were very
Noor (2014a) patients in coronary care was used in a sample of 275 important to cardiac patients with rating spiritual care
Palestine units (CCUs) in the Gaza cardiac patients who were intervention as more important than spiritual assessment
Strip about the importance admitted to the CCUs of the
of assessing and providing Gaza Strip, Palestine
spiritual care to them
Cruz et al. To investigate the A descriptive, Spiritual Care-Giving Scale The mean value on the SCGS-A was 3.84. Spiritual
(2017a) Saudi perception of baccalaureate cross-sectional Arabic version (SCGS-A) perspective received the highest mean (4.14) followed by
Arabia nursing students toward design was used in a convenience attribute for spiritual care (3.96), spiritual care attitude
spirituality and spiritual sample of 338 (3.81), defining spiritual care (3.71), and spiritual care
care baccalaureate nursing values (3.57). Gender, academic level, and learning
students in two spiritual care from classroom or clinical discussions
government-run showed a statistically significant effect on the five factors
universities in Saudi Arabia of SCGS-A
Cruz et al. To explore the influence of Descriptive, Religiosity was measured Older patients were found to reveal higher levels of
(2017b) Saudi religiosity and spiritual correlational using the Muslim Religious religiosity, whereas the younger ones expressed a lesser
Arabia coping on health-related design Index; spiritual coping usage degree of religious and nonreligious coping. Unemployed
quality of life (HRQoL) of was measured using the patients reported greater involvement in Religious
Saudi patients receiving Arabic version of the Spiritual Practices (RP) and more frequently used religious coping
hemodialysis Coping Strategies scale; and than those employed who showed lower intrinsic
health-related quality of life religiosity and nonreligious coping usage than the
was measured using the unemployed. The respondents reported the greatest
Arabic version of Ferrans and satisfaction scores on their psychological/ spiritual
Powers Quality of Life Index- dimension and the least scores on the social and economic
Dialysis Version-III. A dimension. Therefore, the factors that could influence the
sample of patients receiving HRQoL of the respondents were identified as involvement
hemodialysis (n = 168) was in RP, intrinsic religious beliefs, religious coping usage and
recruited age
63
Cruz et al. To assess the validity and Descriptive A sample of patients The SCS-A showed an acceptable internal consistency and
(2016) Saudi reliability of the Spiritual correlational undergoing hemodialysis strong stability reliability over time. The exploratory factor
Arabia Coping Strategies Scale (n = 60) was recruited. analysis produced two factors (nonreligious and religious
Arabic version (SCS-A) Internal consistency coping). Satisfactory construct validity was established by
reliability, stability, the convergent and divergent validity and known-groups
reliability, factor analysis, method
and construct validity tests
were performed
Bar-Sela et al. To assess level of spiritual Cross-sectional, The Religion and 80% of respondents think that staff should provide patients
(2016) care provision in the descriptive Spirituality in Cancer Care with spiritual care at least occasionally, but 44% provide
Multiple Middle East by nurses and Study questionnaire was spiritual care less often than they think they should.
countries (14) doctors used. Participants were Respondents offered some form of spiritual care to 47% of
physicians and nurses their patients diagnosed with incurable diseases
caring for advanced cancer
patients in 14 countries
from the Middle East
(n = 770)
1559
clients. The results of another study conducted in Jordan revealed that Jordanian
Muslim nurses provided spiritual care intervention to their Muslim patients infre-
quently. The most frequent religious spiritual care interventions provided by
Jordanian Muslim nurses were providing a suitable place for religious practice
and facilitating access to religious/spiritual resources. The direct involvement of
nurses in providing spiritual care by offering to pray, reading from the Quran, or
meditating with patients was among the least frequent spiritual interventions.
Ironically, the spiritual intervention of referring to a religious leader or Imam had
the lowest frequency. On the other hand, Jordanian nurses provide more existential
aspects of spiritual care. The author described the spiritual interventions provided
by nurses as traditional, commonly used, generally passive, representing funda-
mental nursing care values, not requiring direct nurse involvement, and helping
patients in their personal spiritual development in an independent way (Musa
2017).
Similar results were reported in Palestine. The results of a study by Abu-El-Noor
(2016a) revealed a severe shortage of spiritual care provided to patients admitted to
coronary care units in the Gaza Strip (Palestine) and that the majority of patients
preferred that nurses provide spiritual care to them rather than by other health-care
professionals in the health-care team. Moreover, spiritual care offered by nurses
working in the intensive care units increases at the end of life or when nurses felt that
the treatment of their patients was futile (Abu-El-Noor 2016b).
While many studies reveal a general lack of spiritual care in some Arab countries,
a study from Palestine revealed that assessing the spiritual needs and providing
spiritual care were important to cardiac patients (Abu-El-Noor and Abu-El-Noor
2014a). Similarly, Jordanian cardiac patients reported considering their spiritual
needs as the most important nurse caring item in a study conducted by Omari
et al. (2013).
Although the health-care systems in several Western countries are now paying
more attention to assessing and meeting spiritual needs of patients, and several
hospitals have assigned chaplains and pastoral teams as part of the health-care
team to take care of clients’ spiritual needs (Clark et al. 2003), this structure is not
established in most Arab countries. For example, the majority of health-care facil-
ities and institutions in Jordan do not have pastoral services, and hospitals don’t
assign a clergyman (Imam) to provide spiritual care for patients (Musa 2017).
Similarly, Abu-El-Noor and Abu-El-Noor (2016) reported that the health-care sys-
tem in the Gaza Strip, Palestine, does not include an Imam as a part of the health-care
team. They further added that some spiritual care is provided by community
religious leaders who voluntarily visit the hospitals sporadically and provide some
level of spiritual care to hospitalized patients, including strengthening their faith and
their relationship with Allah and teaching them how to perform obligatory prayers
according to their health conditions. In Iraq, in some cases, the religious leader’s role
is confined to the family of terminal patients in terms of life after death to alleviate
the suffering of the family; in the same context, some patients seek the care of
spiritual and religious healers and some people visit holy places to seeking cure
(Ghali 2017).
Barriers to Spiritual Care in the Health-Care Systems of Arab

Countries
There are several barriers which impede provision of spiritual care in Arab nations.
According to Abu-El-Noor and Abu-El-Noor (2016) and Musa (2017), these barriers
include: ambiguity of the concept of spirituality, shortage of staff, inadequate time,
lack of educational and training preparation, absence of spiritual care from the job
descriptions, and some personal barriers. However, other factors such as incongru-
ences between spirituality, religious and cultural aspects of patients, and those of the
health-care providers can occur particularly in the Arab Gulf area, where the vast
majority of nurses are not Arabs or Muslims, as they are from the Philippines,
countries from South Asia, Europe, and America.
Inadequate Preparation
Receiving inadequate education and training (either formal or nonformal) on pro-
viding spiritual care is the most common barrier reported. Moreover, the personal
interests of some teachers usually drive discussions of this aspect of care as spiritual
care is usually not a part of the curriculum. The subject of providing spiritual care is
not common in education programs and seminars. In fact, some health-care pro-
viders (particularly physicians) rarely, if ever, learn about spirituality and spiritual
care in their educational programs. This barrier is not exclusive to Arab countries, as
other studies also indicate that health-care providers receive no or inadequate
education and training on spiritual care (Balboni et al. 2014; Chan 2010; Feudtner
et al. 2003; McSherry and Jamieson 2011; Rushton 2014; Van Leeuwen et al. 2006).
Moreover, it is likely that the absence/inadequately addressing spirituality in health
education curricula could lead to poor and improper provision of spiritual care (Van
Leeuwen et al. 2006; Ross 2006).
Ambiguity of Spirituality
The vague nature of spirituality is another major barrier to provision of spiritual care
in Arab and non-Arab health-care systems. In general, there is no agreement on the
definition of “spirituality” (Rushton 2014; Lemmer 2005; Abu-El-Noor and Abu-El-
Noor 2016). However, the majority of Muslim Arab health-care providers usually
connect the term of spirituality with religion and belief in Allah. This is not strange
as the majority of Arabs are Muslim. A major aspect of the Islamic doctrine is to
believe in Allah and to believe in destiny. The interwoven concept of religion and
spirituality is also dominant in the Western literature as spirituality is used in many
cases as a synonymous term of religion (McSherry and Jamieson 2011; Stranahan
2001).
Shortage of Staff and Lack of Time

Shortage of staff in health-care facilities is well documented (Chan 2010; Feudtner
et al. 2003). Staff shortage is common in most of the Arab health-care systems and is
a significant challenge for provision of spiritual care. Such shortage of staff will limit
the time available to assess and meet the patient’s spiritual needs.
In agreement with studies from Western countries (Chan 2010; Balboni et al.
2014; Rushton 2014; Van Leeuwen et al. 2006; Lemmer 2005; Keall et al. 2014;
Kuuppelomäki 2001; Williams 2008), a lack of time is a barrier to providing
spiritual care, as health-care providers are usually busy meeting the physical
needs of their clients. This is more evident in units/wards where patients are
critically ill or terminally ill, and they are more dependent on nurses. On the
other hand, the limited time spent by physicians with their patients is usually
limited to assessing their physical (medical) needs (Murray et al. 2003). Williams
(2008) added that such time constraints affect the quality of care, where health-care
providers will not be “attentive to deeper dimensions of patients’ concerns”
including their spiritual needs.
Language and Cultural Barriers

Due to shortages of health-care professionals in many Arab countries, especially in
the Gulf area, there is common employment of nurses, doctors, and other health-
care professionals qualified from the Philippines, countries from South Asia (such
as India, Bangladesh, Indonesia, etc.), Europe, and America. For example, foreign-
trained nurses form 91.75% (in Qatar) and about 40% (in Bahrain) of the total
nurses in these two countries (Shukri 2005). Most of these professionals have
different cultural backgrounds, are often not Muslim, and don’t speak the Arabic
language. All of these factors can impede their ability to provide spiritual care to
their patients.
Policy Barriers
Policies within Arab health-care systems form another barrier to spiritual care, as
evidenced by a lack of clear guidance on the provision of spiritual care in job
descriptions. In fact, there is a claim that health policy makers are not aware of the
importance of providing spiritual care to hospitalized patients, and this causes them
to not advocate or promote spiritual care in health-care settings. This results in staff
who are not expected to offer such services offering spiritual care. This is different
from most developed countries, where there are clear policies on the responsibilities
of health-care providers, especially doctors and nurses, related to providing spiritual
care (Clark et al. 2003). Besides mandates by individual countries, other interna-
tional organizations also mandate health-care providers to meet spiritual needs of
patients. For example, the International Council of Nurses identifies provision of
spiritual care as a duty of nurses (International Council of Nursing 2012).
Personal Barriers
Personal traits can sometimes be a barrier for providing spiritual care. For example,
health-care providers may lack the concept of spirituality and religiosity and so be
less inclined to offer it. Another factor is an inability to communicate sensitive
concepts. Lacking spirituality makes it challenging for both Arabs and non-Arabs to
provide spiritual care (Ross 2006; Williams 2008; Chung et al. 2007).
Improving Spiritual Care in Arab Health-Care Systems
According to the WHO, health is defined as “a state of complete physical, mental and
social well-being and not merely the absence of disease or infirmity” (World Health
Organization 1946). A holistic approach posits that the human being is an integration
of interrelated biopsychosocial, cognitive, and spiritual components. Thus, any
changes, whether positive or negative, in any component will influence other aspects
of health (Timby 2009).
The authors conceptualize provision of spiritual care to Muslim patients
based on a holistic approach for health (Fig. 1), which shows that humans are
in a continuum between spiritual well-being and spiritual crisis. Spiritual beliefs
are considered the umbrella for spiritual peoples and are derived from the Quran
and Sunnah as well as practicing prayer and Ruqya; these practices can directly
affect the health of Muslims and influence their level of compliance with
treatment, especially, when diagnosed with chronic diseases. As previously
discussed, Muslims are required to seek and comply with treatment ordered by
Prophet Mohammed (PBUH). They are ordered by to abandon any substance,
diet, or behavior that can (or has the potential to) harm or deteriorate their health.
“There should be neither harming (darar ‫ )ﺽﺭﺭ‬nor reciprocating harm (dirar
‫ ”)ﺽﺭﺍﺭ‬said Prophet Mohammed (PBUH). Belief and practicing this guidance
increase compliance with treatment and therefore enhance health and decreases
suffering and pain.
The goal of health-care providers is to optimize the individual’s health by
assessing and meeting his/her health needs, including spiritual needs derived from
their spiritual beliefs. Assessing and meeting spiritual needs of patients can play a
key role in maintaining health and the quality of their lives. According to the model
shown in Fig. 1, health providers assess how patients express their hopes and wishes.
This can help in modifying the health behaviors of Muslim patients and conse-
quently improve their health status and the quality of their lives. Health-care pro-
viders should focus on well-being, quality of life, meanings, inner awareness, and
self-actualizations as health indicators. An application of this model will enable
health-care providers, patients, and their families to experience “multidimensional
healing” (Halm et al. 2000).
Meeting the spiritual needs of patients can help them modify their health behav-
iors. Accordingly, their health can improve; they will suffer less, seek fewer health
services, and attain an improved quality of life. On the other hand, neglecting
spiritual needs or failing to meet these needs can result in a lower quality of life,
more pain and suffering, seeking more health services, and consuming more health
resources.
Strategies and methods in the Arabic and Western literature to improve provision
of spiritual care within health-care systems can be categorized into (1) educational
and training preparation, (2) organizational actions, (3) policy innovations, and (4)
miscellaneous interventions.
Educational and Training Preparation
Since inadequate educational preparation was the foremost barrier impeding spiritual
care, it is a logical starting point. All academic health-related curricula, including
those in medicine, nursing, physiotherapy, should include spirituality either as a
separate course or at least be a component that is integrated with other courses.
Spiritual care should be a component of in-service education and seminars at the
workplace. Including spiritual care in the health education curricula will equip future
health-care providers with the knowledge and skills that will help them in assessing
the spiritual needs of their patients (McSherry and Jamieson 2011; Keall et al. 2014;
Williams 2008). Health-care providers, especially nurses, can be trained on provid-
ing spiritual care while providing physical care and other nursing interventions to
their patients.
Organizational Actions
Besides the actions to be taken by academic health institutions, the Arab health
organizations must also play a greater role by embracing some interventions. These
interventions include increasing the staff numbers and including providing in-ser-
vice education and training for health-care providers on assessing the spiritual needs
and providing spiritual care to all patients, particularly terminally ill patients.
Recruiting more Muslim Arab health-care providers is important in the Arab
Gulf, as Muslim Arab health-care providers are likely to share the same religion and
culture as their patients and are more likely to assess the spiritual needs and provide
and evaluate the spiritual care for Muslim Arab patients. Providing Arab health-care
personnel removes language barriers.
Health organizations should provide electronic and written materials such as
books, journals, and videos related to spiritual care. This will help health-care
professionals to provide better spiritual care to their clients. Arabic health-care
organizations also can offer some spiritual care through the use of media such as
TV and headphones connected to radio stations or electronic devices playing record-
ings of the Quran, in the belief that this could help patients grow their spirituality, as
reported in several studies (Murray et al. 2003; Abu-El-Noor and Abu-El-Noor
2016; Kurtz et al. 2016).
Policy Innovations
Since health policy makers may have inadequate knowledge about spirituality in
health, enlightening them about the importance of spiritual care would be an
important process. Policy makers need to know of the impact of providing spiritual
care on patient outcomes. Such enlightenment could lead to adoption of new policies
that embed spiritual care in Arab health-care systems. But adopting a policy also
requires follow-up measures to monitor the effectives of implementation of such
policies, both from the perspectives of the patient and health-care provider.
Providing spiritual care should be included in the job descriptions of all health-care
team members, with clear expectations that health-care providers will be expected to
provide it. In addition, health policy makers should establish the position of the
“Imam” as a new health team member and who is charged with offering spiritual care
for Muslim patients. The presence of a clergyman or a chaplain in the health-care
team is well recognized in the literature (Chan 2010; Feudtner et al. 2003; Clark et al.
2003; Pronk 2005).
The call for involving health policy makers and regularity bodies in setting clear
policies and regulations pertaining to the provision of spiritual care is not a unique
requirement for Arab health-care policy makers only. Others have emphasized the
importance of tracking the provision of spiritual care to patients to ensure its efficacy
(McSherry and Jamieson 2011; Clark et al. 2003).
Miscellaneous Interventions
Other recommendations that can improve spiritual care within the Arab health-care
systems include educating the public about the importance of spiritual care for
patients and its effect on their health and well-being. Arabic Ministries of Informa-
tion are called to adopt strategies to enlighten their citizens on the significance of
spirituality in health care through the use of media and social media using dedicated
websites, social media platforms on spirituality in health care, etc. The Ministry of
Religious Affairs can provide guidance on the topic for use in obligatory Friday
sermons delivered in all mosques.
Future Research
Arab researchers also can play a vital role to highlight the importance of spirituality
and spiritual care as an essential aspect in health care. Research is needed in the
perception and experiences of patients, health-care providers and educators, policy
makers, as well as students enrolled in medical and nursing schools on spirituality, its
importance, and the barriers to implementation. Scholarly research on the outcomes
of providing spiritual care to different patient groups (terminally ill, chronic diseases,
etc.) is needed, using (a) ethical guidance and (b) evidence-based approaches. Issues
to be discussed include the impact on health costs, resource limitations, time needed
to provide spiritual care, etc. A structured approach created with the guidance of
physicians, nurses, religious experts, and hospital administrators should be created
and used in the region.
Conclusions
Although providing spiritual care to patients has its deep routes within the Islamic
culture, health-care providers in Arab hospitals provide inadequate spiritual care to
their patients. The literature identifies several barriers to the provision of spiritual
care, including lack of time, inadequate staff at the hospitals, ambiguity of spiritu-
ality, and the absence of spiritual care in the job descriptions of health-care providers.
In spite of the paucity of studies from Arab countries, some research (mainly from
Jordan, Saudi Arabia, and Palestine) assessed health-care providers about spiritual
care and the needs of patients with chronic diseases. It is hoped that such studies, and
our recommendations, will encourage health policy makers and other stakeholders of
health-care systems in Arab countries to improve the provision of spiritual care to
their patients.
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Access to Health Using Cell Phones by
War Refugees 64
Soha El-Halabi, Salla Atkins, Lana Al-Soufi, Tarik Derrough,
Lucie Laflamme, and Ziad El-Khatib
Contents
Refugees’ Needs and Healthcare Service Provision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1573
Utilization of Mobile Health (mHealth) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1577
Distribution of Refugees in EMR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1579
Use of mHealth for Maternal and Child Services in the EMR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1580
Courtesy of World Health Organization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1582
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1583
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1584
Abstract
The world is experiencing the largest ever humanitarian crisis since World War II,
with the largest number of the world’s refugees being hosted in the Eastern
Mediterranean Region (EMR). Many of these refugees are females of reproductive
S. El-Halabi
Skoun, Lebanese Addiction Center, Beirut, Lebanon
Department of Learning, Informatics, Management and Ethics, Karolinska Institutet,
Stockholm, Sweden
S. Atkins
Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
L. Al-Soufi
T. Derrough
Vaccine Preventable Diseases, European Centre for Disease Prevention and Control (ECDC),
Stockholm, Sweden

https://doi.org/10.1007/978-3-030-36811-1_73
1572 S. El-Halabi et al.
age. Refugees require special healthcare services that host countries are not always
able to provide. Mobile health (mHealth) technologies may serve as an added value
to reduce the gap in this population. mHealth is the support of medical and public
health practice by mobile devices including mobile phones, patient monitoring
devices, personal digital assistants, or other wireless devices. These technologies
can facilitate access to unavailable services. In low- and middle-income countries,
mHealth interventions have improved treatment adherence and appointment com-
pliance. Despite promising results and the presence of cell phone networks such as
second, third, and fourth generation (2G, 3G, or 4G) and global positioning system
(GPS), mHealth technologies are still not being implemented.
This chapter provides a holistic picture of refugee settlement in EMR by
identifying the distribution of refugees, asylum seekers, and stateless people and
mapping the published evidence on the use of mHealth interventions by refugees for
improving maternal and child health in EMR. The use of combined methods pro-
vides more insight on the well-being of refugees in the EMR. A literature review to
map the distribution of refugees per country within the EMR and scoping review
methods for identifying published evidence on mHealth interventions on maternal
and child health used among refugee populations in EMR were applied. The
findings reveal the presence of only three interventions on maternal and child health
in EMR. Only one study demonstrated that short message system (SMS) was an
effective reminder system to improve compliance with immunization appointments
and a source of motivation to show up on their appointments. This chapter highlights
the potential of SMS-based mHealth technologies and the general lack of evidence
on effective mHealth technologies in EMR. It serves as the first step in this process
of expanding mHealth to EMR and identifying priorities for further study.
Keywords
mHealth · Refugees · Maternal and child health · Eastern Mediterranean Region
L. Laflamme
Institute for Social and Health Sciences South Africa, University of South Africa, Johannesburg,
South Africa
South African Medical Research Council, University of South Africa’s Violence, Injury and Peace
Research, Johannesburg, South Africa
Z. El-Khatib (*)
Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
World Health Programme, Université du Québec en Abitibi-Témiscamingue (UQAT),
Rouyn-Noranda, QC, Canada
e-mail: ziad.khatib@gmail.com
64 Access to Health Using Cell Phones by War Refugees 1573
Refugees’ Needs and Healthcare Service Provision
Over 65.5 million refugees were displaced due to persecutions, conflicts, violence, or
other human rights violations in 2016. Of these, 22.5 million persons had to flee their
countries (UNHCR 2016a). Various conflicts and wars make women and children
among the most vulnerable (Otten 2017). Although the demographics of refugees
vary, a large proportion of them are females of reproductive age (Table 1). The EMR
countries (countries within this region include Afghanistan, Bahrain, Djibouti,
Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Pakistan,
Palestine, Qatar, Saudi Arabia, Somalia, Sudan, Syria, Tunisia, United Arab Emir-
ates, and Yemen) the largest number of the world’s refugees (UNHCR 2017a).
Refugees need different types of healthcare services, including care for mental
health, noncommunicable diseases (NCDs), chronic obstructive pulmonary dis-
ease (COPD), diabetes, hypertension, and cardiovascular diseases (World Health
Organization 2015). In addition to these chronic diseases, refugees in the EMR
also need reproductive, maternal, and child healthcare services (World Health
Organization 2015). Currently, there are low rates of antenatal care use and also
high rates of caesarean sections (World Health Organization 2015). Further, due to
lack of safe water, there is an increase in infections in children. The postponement
of immunization campaigns means that there is an increased risk of disease
outbreaks.
At the same time, the need for healthcare services is increased in hosting
communities because of the increased numbers of refugees, resulting in a high
physician-to-patient ratio. The countries of conflict have a shortage of surgeons,
anesthesiologists, laboratory professionals, female reproductive health profes-
sionals, and mental health experts (World Health Organization 2015). This increased
demand has increased healthcare costs and created service challenges such as delays
in diagnosis and treatment and postponement of immunization campaigns (World
Health Organization 2015). Given these challenges, many refugees face problems in
accessing healthcare services in EMR.
Access to healthcare is further hampered by language differences on several
levels of the healthcare system that is not only restricted to doctor-patient interac-
tions but extends to the entire patient journey from making an appointment to filling
a prescription. Differences in cultural beliefs also influence refugee healthcare
choices, as refugees have different conceptions of prevention services, expectations
of care, and stigma pertaining to their health conditions compared to their host
communities (Morris et al. 2009). More general health system barriers also contrib-
ute to access problems, such as availability of transportation and appointments,
difficulty in scheduling appointments, and waiting times (Morris et al. 2009).
Because of the lack of timely care, services are often provided when problems are
more serious, which places even more pressure on the health system and has serious
consequences for public health in the EMR.
Given the health system challenges affecting refugee access to services for these
conditions, innovations are needed to improve access to healthcare and to address
the health of refugees in EMR.
Table 1 Demographics of registered refugees, asylum seekers, and stateless persons in countries within the EMR
1574
0–4 Years 5–11 Years 12–17 Years 18–59 Years 60+ Years
M F M F M F M F M F
Refugees, 262,281 239,795 237,597 242,089 207,582 188,178 434,083 434,462 53,156 45,006
asylum seekers, and stateless (22%) (21%) (20%) (21) (17%) (16%) (36%) (38%) (4%) (4%)
persons in Afghanistan
Refugees, 54 55 165 176 290 273 219 216 29 30
asylum seekers, and stateless (7%) (7%) (22%) (23%) (38%) (36%) (29%) (29%) (4%) (4%)
persons in UAE
Refugees, 26 17 26 30 14 (1%) 14 126 112 12 5
asylum seekers, and stateless (13%) (10%) (13%) (17%) (8%) (62%) (63%) (6%) (3%)
persons in Bahrain
Refugees, 1749 1720 2635 2565 1805 1650 6604 6322 412 400
persons in Djibouti
Refugees, 17,277 16,022 21,932 24,169 22,747 16,392 70,419 66,276 3947 4156
persons in Egypt
Refugees, 1945 1828 (13%) 2516 2516 2933 2762 6391 6403 876 602
asylum seekers, and stateless (13%) (17%) (18%) (20%) (20%) (43%) (45%) (6%) (4%)
persons in Iran
Refugees, 20,772 19,896 22,572 21,441 15,253 13,492 85,342 68,793 4226 4652
persons in Iraq
Refugees, 53,844 50,847 79,278 74,806 48,922 46,393 163,035 173,119 13,002 17,566
persons in Jordan
Refugees, asylum seekers, 45 32 150 87 122 139 488 457 44 65
and stateless persons in (5%) (4%) (18%) (11%) (14%) (18%) (57%) (59%) (5%) (8%)
Kuwait
S. El-Halabi et al.
64
Refugees, 91,985 87,881 125,298 119,602 69,769 67,101 192,848 248,564 12,553 15,702
persons in Lebanon
Refugees, 755 737 3064 2904 2063 1856 15,650 9826 1029 663
persons in Libya
Refugees, 388 384 450 432 519 329 2757 1351 64 59
persons in Morocco
Refugees, 43 31 46 69 43 45 188 183 14 21
persons in Oman
Refugees, 193,584 165,688 292,999 260,958 196,595 164,671 573,163 519,356 63,541 46,931
persons in Pakistan
Refugees, 13 16 25 22 9 19 95 93 17 10
persons in Qatar
Refugees, 5 7 14 10 17 16 67 49 – –
Access to Health Using Cell Phones by War Refugees
asylum seekers, and stateless (5%) (8%) (13%) (12%) (16%) (19%) (64%) (57%)
persons in Saudi Arabia
Refugees, asylum seekers, 15,320 14,837 26,900 26,334 19,824 19,910 46,732 56,510 5676 5685
and stateless persons in Sudan (14%) (12%) (24%) (21%) (17%) (16%) (41%) (46%) (5%) (5%)
260,108 199,298(26%) 236,043 192,069 115,219 83,579 229,954 256,317 24,305 26,286
(30%) (27%) (25%) (13%) (11%) (27%) (34%) (3%) (3%)
(continued)
1575
1576
Table 1 (continued)
0–4 Years 5–11 Years 12–17 Years 18–59 Years 60+ Years
M F M F M F M F M F
Refugees, asylum seekers,
and stateless persons in
Somalia
Refugees, asylum seekers, 2124 2088 3192 3151 2246 2272 6925 8179 1155 917
and stateless persons in Syria (14%) (13%) (20%) (19%) (14%) (14%) (44%) (49%) (7%) (6%)
Refugees, 20 15 45 19 35 14 255 151 6 8
persons in Tunisia
Refugees, 120,315 125,186 427,717 429,161 307,157 273,913 716,408 765,651 62,705 49,741
persons in Yemen
Data source: (UNHCR 2016d)
M, males; F, females
S. El-Halabi et al.
Utilization of Mobile Health (mHealth)
Given the challenges in the current provision of healthcare to refugees, mobile health
(mHealth) interventions may serve as a practical tool to enhance healthcare service
provision in the EMR. Mobile health (mHealth) is the support of medical and public
health practice by mobile devices including mobile phones, patient monitoring
devices, personal digital assistants, or other wireless devices (World Health
Organization 2011).
This includes the use of one or more utility provided by mobile phones, e.g., short
messaging service (SMS), voice messages, more complex functions such as specific
applications (apps), and/or Bluetooth technology. The cellular networks may include
second, third, and fourth generation (2G, 3G, or 4G) and global positioning system
(GPS) (World Health Organization 2011). mHealth interventions facilitate access to
unavailable services (Opoku et al. 2017) and have improved treatment adherence
and appointment compliance in low- and middle-income countries (Hall et al. 2014).
In addition to this, mHealth is used in resource-limited settings to improve the
quality of pregnancy care (both pre and post) and to enhance healthcare utilization
(Sondaal et al. 2016). The use of mHealth interventions, particularly those delivered
using SMS, increases utilization of healthcare, including pre- and postnatal
healthcare services, skilled birth attendance, and vaccination (Nurmatov et al.
2014). Some mHealth interventions have also positively impacted the rates of
exclusive breastfeeding for 3 or 4 months compared to those without mHealth
interventions (Nurmatov et al. 2014). In the same study, the rates of initiating
breastfeeding within 1 h after birth were also higher in the groups given a SMS/cell
phone prenatal intervention than in groups not given the SMS/cell phone interven-
tion (Nurmatov et al. 2014). Beyond health effects, mHealth is also an important data
collection tool that can also assist in the development of support networks by health
workers (Rajput et al. 2012). While these results on using mHealth are promising,
there is little evidence of mHealth implementation within the EMR due to several
barriers challenging the adoption of this technology (Aranda-Jan et al. 2014).The use
of mHealth in EMR could be of great value to refugees in most countries given the
challenges they face (Wallis et al. 2017) . In addition, most refugees live in areas
connected to mobile phone networks, with access to second-generation (2G) and
third-generation (3G) wireless technologies (Fig. 1).
Despite high cellular network coverage (including 2G and 3G technologies), with
48% of WHO Member States reporting using mobile devices in emergency and
disaster situations, these technologies are not used in emergency and disaster
situations in Africa or the EMR (World Health Organization 2011). This may be
caused by several countries not adopting mHealth due to the increasing pressure to
perform under various challenges within the healthcare system, including shortage
of human resources and limited budgets (World Health Organization 2011).
The need for services by end-line users is an important factor to mHealth adoption
among them, especially when faced with other barriers to access including travel
time, waiting time, and travel costs (Opoku et al. 2017). As cell phone coverage is
high and the need for solutions is urgent, mHealth could be used in EMR refugee
100
percentage of refugees in EMR with internet
90
80
70
60
coverage(%)
50
40
30
20
10
0
At least 3G
At least 2G
At least 3G
At least 2G
At least 3G
At least 2G
At least 2G
At least 3G
At least 2G
At least 3G
At least 2G
At least 3G
At least 3G
At least 2G
At least 3G
At least 2G
At least 3G
At least 2G
At least 2G
At least 3G
At least 2G
At least 3G
At least 2G
At least 3G
Algeria Djibouti Egypt Iraq Iran Jordan Kuwait Lebanon Morocco Syria Somalia Yemen
Fig. 1 Percentage of refugees in EMR living with Internet coverage. (This figure excludes refugees
living with no geo-location data.) (Data Source: UNHCR 2016)
contexts. In order to start implementing mHealth, however, it is important to collate

the evidence of the current use of mHealth approaches in these contexts and also to
know the number of refugees settled in the area. Currently, the distribution of
refugees in EMR hosting countries is based on different estimates from various
reports and mHealth-related interventions. Information related to mother and child
health that has been obtained and evaluated in a humanitarian setting is not available.
In this chapter, we set out to achieve two aims: (1) to identify the distribution of
refugees, asylum seekers, and stateless people in the EMR by reviewing reports
of various organizations to obtain a holistic picture of refugee settlement and (2) to
map the published evidence on the use of mHealth interventions by refugees for
improving maternal and child health in EMR in order to identify gaps and priorities
for further study through using scoping review methods.
We used a combined mixed-method approach: (1) we conducted a literature
review to map the distribution of refugees per country, within the EMR, and their
distribution based on gender and age group; and (2) we used scoping review
methods for identifying published evidence on mHealth interventions on maternal
and child health used among refugee populations in EMR. These combined methods
gave greater insight on the situation of refugees, asylum seekers, and stateless
persons in the EMR.
We used the following definitions of each group:
1. Refugees are people who have been forced to flee their country because of
persecution, war, or violence. They are defined and protected by international
law and cannot be expelled or returned to situations where their life and freedom
are at risk (UNHCR 2017a).
Table 2 Distribution of refugees, asylum seekers, and stateless persons in the EMR (total
number = N)
Refugees Asylum seekers Stateless persons
Country N N N
Afghanistan 239,477a 92a –
Bahrain – – –
Djibouti 63,684 2,641 –
Egypt 120,154 38,171 22
Iran 979,410 42
Iraq 239,639 7,420 50,000
Jordan 2,839,437 24,935 –
Kuwait 741 900 93,000
Lebanon 1,240,000 12,139 473,671
Libya 9,305 27,479 –
Morocco 30,622 1,910 –
Oman 51,000 190 –
Pakistan 1,561,162 6,442 –
Palestine 2,051,096b – –
Qatar 120 118 1,200
Saudi Arabia 39,880 32 70,000
Somalia 48,161 12,635 –
(not specified)
Sudan 1,688 12,581 –
Syria 549,729a 5,251 160,000
Tunisia 665 90 –
UAE 663 421 –
Yemen 170,870 1,340 –
a
Average
b
Palestinian nationals who were defined as refugees according to UNHCR (2016b, c, 2017b, c, d),
UNICEF (2017), and UNRWA (2015)
2. Asylum seekers are individuals who have sought international protection and
whose claims for refugee status have not yet been determined (UNHCR 2017a).
3. Stateless persons are persons who do not have a nationality of any country and
have been denied the enjoyment of fundamental human, social, and political
rights such as access to education and healthcare and freedom of movement
(UNHCR 2015).
Distribution of Refugees in EMR
The EMR carries the largest burden of displaced populations globally with the flow
and influx to it being larger than other countries. In fact, more than half of the world’s
refugees are hosted by countries in the EMR (Table 2) (UNHCR 2016a).
Table 3 Summary of the included studies

Target
Study Study Intervention type population/
ID Author design and media used sample Outcome
1 Schermerhorn Mixed SMS to parent’s 100 urban Reminders:
methods: mobile phone refugee children defaulter
cohort/ and 13 parents tracing
interview Immunization
2 HaBaby app N/A Mobile phone Transitionary No outcome
app education and stationary
based on women
trimester. Free, refugees.
easy to use, Specifically, in
multilingual, Syria, Iraq,
after download Lebanon,
no need of Greece,
connection Germany,
France, UK,
Sweden, Turkey,
and Hungary
3 VaccinePass N/A Mobile phone For Syrian No outcome
app for parents to refugees staying
keep track of in camps like
their children’s Turkey
vaccinations.
Data is only
stored locally on
the phone
Use of mHealth for Maternal and Child Services in the EMR
In addition to distribution of refugees in EMR, we identified three studies on use of

mHealth for maternal and child services relevant to EMR (Table 3).
The refugee populations in the reviewed articles included urban refugee children
and parents (study 1); transitioning and stationary women refugees in Syria, Iraq,
Lebanon, and other countries (study 2); and Syrian refugees staying in Turkish
camps (study 3).
Of the three included studies, one study was conducted using mixed methods
including a cohort study with interview (study 1). The study was less than a year in
duration. This intervention sent an SMS to parents via mobile phones to remind them
of their children’s immunization process. The aim was to initiate contact with
immunization defaulters to improve their attendance. Study 2 was a description
of an application. The application used was “HaBaby,” a free and multilingual
educational mobile application for prenatal and postnatal care among refugee
women. The application could be used without an Internet connection and needed
to be downloaded on the smartphone. The application allows women to access
information regarding trimester details and symptoms as well as medications and

free support options within the country of residence. HaBaby also includes an
anonymous message board and an option to live chat with a healthcare professional
(Maternova n.d.). Study 3 was a prospective cohort study aimed of mobile phone
application use as a reminder for parents to keep track of their children’s vaccina-
tions. The study also reported on the use of mHealth to schedule appointments for
vaccination.
The application of mHealth in the EMR has not been evaluated in two of the
studies we found (Crimi n.d.; Empower Hacks 2017; Maternova n.d.). However,
where evaluated, it showed that an SMS reminder message increased the attendance
for child immunization after a missed appointment (Schermerhorn 2015), where
77% of patients returned to care within a median of 16 days prior to the SMS
reminder and were vaccinated a median of 1.5 days after the reminder was received
by the caregiver (study 1). Positive responses were also seen regarding the utility of
SMS reminders by the defaulters who did not show up on the scheduled appointment
for their children’s immunization. The system also provided a good platform to
improve patient’s perception in the healthcare system, therefore improving health-
seeking behavior.
The refugee mothers in study 1 appreciated the provision of a Maternal-Child
Health handbook, but it was utilized irregularly. Participants also reported missing
immunization appointments simply because they forgot. However, the study results
show that SMS messaging was an excellent reminder system to improve compliance
with immunization appointments; participants reported that the text message served
not only as reminder but had also motivated them to show up on their appointments
(Schermerhorn 2015).
The world is currently experiencing the largest humanitarian crisis since World
War II (UNHCR 2016a). Our results identified a high number of refugees settled in
the EMR area, but only three studies on the use of mHealth for maternal and child
health in these areas. Given that women and children are the most vulnerable group
of refugees, and low rates of antenatal care identified (World Health Organization
2015), a finding which is of great concern. The presence of mHealth is essential,
given its role in enhancing access to medical information and improving
patient outcomes in resource-limited settings (Wright et al. 2015). The application
of mHealth in such settings significantly improves case management as well as
positively impacts health knowledge, attitudes, and practices (Higgs et al. 2014).
Thus, in the absence of a structured healthcare system, mHealth is a means to fill
the gaps.
This minimal engagement of mHealth could be due to barriers to implementation,
such as conflicting health systems priorities, policies, cost-effectiveness, and knowl-
edge (Fig. 2). Countries within the EMR report that the main barrier to mHealth
implementation is due to conflicting health systems priorities, that funding is gener-
ally allocated to other programs ahead of mHealth, or a lack of general interest or
understanding of the field. Most of the new applications can be more effective when
implemented under an umbrella of eHealth strategy (World Health Organization
2011), although some elements of eHealth can be implemented separately. The lack
100%
Global
80% Eastern
Mediterranean
Percent of countries
60%
40%
20%
0%
Priorities Policy Cost effectiveness Knowledge
Barriers
Fig. 2 Top four barriers to mHealth implementation in EMR
of ministerial guidance and an absence of financial support from governments

contribute to the failure of mHealth projects (Aranda-Jan et al. 2014). Another
important barrier is not recognizing mHealth as an approach to health-related issues
by the country or regional eHealth policy. In addition, the lack of knowledge and
cost-effectiveness of mHealth applications and initiatives can also block the imple-
mentation in the EMR (Aranda-Jan et al. 2014) (Fig. 2).
Courtesy of World Health Organization
ID: 267714 Permission authorization for WHO copyrighted material

Another reason for the lack of implementation of mHealth for mother and child
health could be the technical challenges in starting such an intervention. Technical
challenges in the initial programming and rollout/uptake of the application as well as
frequent crashes in its initial versions can decrease its [application] utility by
interested providers, despite technical repairs (Doocy et al. 2017).
Cost and cost-effectiveness are significant barriers to the implementation of
mHealth; the initial outlay and implementation costs can be high, such as in the
Central African Republic. For this indicator, research is already available. For
example, a 15-week pilot project conducted by the Ministry of Health at the Central
African Republic and Médecins Sans Frontières, to test a disease surveillance app in
21 health facilities, shows that the total cost of the pilot project was US$41,300$.
El-Khatib et al. estimated a cost of US$18,000 for communication fees to maintain
the app in the 21 facilities (El-Khatib et al. 2018). Despite the initially high outlay
costs, mHealth can be used in health campaigns for a lower cost and broader reach,
as in Bangladesh (World Health Organization 2011).
There are other examples of the potential cost-effectiveness (lower cost and
broader reach) of mHealth. For example, in Bangladesh, nationwide SMS health
campaigns are conducted at no cost for both the mobile telephone users and the
Ministry. This leaves the Ministry with the cost of the bulk SMS service for its health
staff members only, and mobile operators are paid less than one cent of a
Bangladeshi Taka (BDT) per SMS message. Subscribers pay for the campaign at a
discounted rate. This means that operational costs are minimal at the Ministry level,
since staff members do the work as part of their duties. The long-term sustainability
of this project is ensured by the Ministry’s budget and political support (World
Health Organization 2011). In a sub-Saharan setting such as in Rwanda, blood
testing machines based on mobile phone technology were combined with cloud-
based medical records. These were shown to cost less compared to other alternatives.
In particular, the mobile blood testing devices cost US$1,000 – compared to
US$19,000 for benchtop machines (Hall et al. 2014). In another African setting in
Malawi, St Gabriel’s Hospital piloted a scheme aiming to overcome the barriers of
poor doctor-patient ratio and distance to hospitals through interventions done by
community health workers. Seventy-five community health workers generally
volunteering from villages were given mobile phones and trained to use them for
patient adherence reporting, appointment reminders, and communication with phy-
sicians regarding tuberculosis. The piloted scheme resulted in a total saving of US$
2,750, mainly due to reduced fuel costs providing a chance to effectively double
tuberculosis treatment due to an increase in time available to community health
workers (Hall et al. 2014).
These examples of cost-effectiveness should be taken into account when promot-
ing and planning mHealth services in the EMR. Important in this regard is also
improving knowledge of these alternatives, to support prioritization and policy
alternatives for using mHealth. These are areas where further research is needed.
Conclusion
The EMR hosts a large number of refugees with limited access to healthcare
services. We identified only three implementations of mHealth approaches for
maternal and child health in the region, despite its potential benefits for healthcare
access. As a first step in this direction, mHealth interventions based on SMS
messaging show promising results in terms of improving compliance to healthcare
services. This may be worth exploring for future policy-oriented work, especially
when addressing access to healthcare services. On a broader level, adopting mHealth
requires changes within healthcare systems to support feasibility and facilitate
adoption of mHealth interventions. This process requires coordination and support
from governments, funders, and industries. We need to address the barriers identi-
fied: knowledge of the systems and cost-effectiveness, priority setting, and policies.
Evidence is already available on the cost-effectiveness, policies, and knowledge
of mHealth from other settings, and further evidence is needed within the EMR.
Well-conducted studies and evaluations can provide evidence of mHealth interven-
tions that can support national and regional policies and prioritization of discussions.
Acknowledgments ZEK is funded by Grand Challenges Canada, which is funded by the

Government of Canada and is dedicated to supporting Bold Ideas with Big Impact (GCC grant
ID: R-ST-POC-1807-12490), and the Karolinska Institutet foundations and funds – Karolinska
Institutet research foundation grants. The views and opinions expressed herein are the authors’ own
and do not necessarily state or reflect those of European Centre for Disease Prevention and Control
(ECDC). ECDC is not responsible for the data and information collation and analysis and cannot be
held liable for conclusions or opinions drawn.
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The Potential of Telemedicine in the Rural
Eastern Mediterranean Region for 65
Noncommunicable Diseases: Case Study
from Jordan
Soha El-Halabi, Salla Atkins, Yousef Saleh Khader, Adel Taweel,

Aiman Alrawabdeh, and Ziad El-Khatib
Contents
Telemedicine: The Pros and Cons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1589
Overview of the Disease Burden in the Eastern Mediterranean Region . . . . . . . . . . . . . . . . . . 1590
Overview on the Access to Internet Technology in EMR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1592
Telemedicine Utilization in EMR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1593
Telemedicine Technology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1594
The Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1594
Evaluation of the Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1594
S. El-Halabi
Skoun, Lebanese Addiction Center, Beirut, Lebanon
Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm,
Sweden
S. Atkins
Y. S. Khader
A. Taweel
Department of Computer Science, Birzeit University, Birzeit, Palestine
Department of Informatics, King’s College London, London, UK
A. Alrawabdeh
American Healthcare Technology Solutions, Jordan Healthcare Initiative – Cisco Systems, Amman,
Jordan

https://doi.org/10.1007/978-3-030-36811-1_74
Potential of Teleconsultations in EMR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1595

General Characteristics of the Patients Included in the Three Studies . . . . . . . . . . . . . . . . . . . . 1595
Impact of Teleconsultations on Changes in Diagnosis and Treatment Plan . . . . . . . . . . . . . . . 1596
Effect of Teleconsultations on Patient’s Quality of Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1597
Future of Telemedicine in EMR: Conclusion and Recommendations . . . . . . . . . . . . . . . . . . . . . . . . 1599
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1600
Abstract
Telemedicine is the integration of technological advancements within health-care
systems, where distance is a critical factor, to respond to the health needs of
communities. In the Eastern Mediterranean Region (EMR), the prevalence of
noncommunicable diseases (NCDs) has increased in the last decade with cardio-
vascular diseases and kidney diseases ranking within the first top ten mortality
ranks in the region. This rise in NCD prevalence is accompanied with an increase
to the access of Internet technology, making the incorporation of telemedicine an
asset in terms of increasing access to health care, especially for people in remote
areas. In Jordan, the Ministry of Health has been a pioneer in the EMR in
integrating telemedicine to improve access to health-care services, especially in
rural areas. The Jordan initiative resulted in three telemedicine interventions,
where they have focused on the experience of patients and access to tele-
cardiology, teledermatology, and telenephrology services in two hospitals in the
north and south of Jordan. The aim of this chapter is to draw together lessons
learnt from these three interventions. The studies aimed to assess the impact of
live interactive telemedicine consultations in cardiology, dermatology, and
nephrology for diagnosis and management of the diseases and to assess the
presence of an association with improvement in patients’ quality of life and
savings in cost and time. Results indicate that telemedicine services were suc-
cessful in establishing diagnosis (71.1%, 43.2%, and 62.5% in disease categories,
respectively) and treatment plans (77.3%, 67%, and 62.5% in disease categories,
respectively) among patients or changing previously established diagnosis
(17.1%, 19.3%, and 12.5%) and treatment plans (16%, 9.1%, and 31.2%) due
to telecardiology, teledermatology, and telenephrology consultations, respec-
tively. This impact not only improved the patients’ quality of life but also
decreased cost through reducing travel and waiting times to and from clinics.
However, there are certain barriers for the implementation of telemedicine within
the health-care system. Overcoming these barriers may lead to a promising future
in this region. Also, for telemedicine to be implemented within the health-care
Z. El-Khatib (*)
Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
World Health Programme, Université du Québec en Abitibi-Témiscamingue (UQAT), Rouyn-
Noranda, QC, Canada
e-mail: ziad.khatib@gmail.com
65 The Potential of Telemedicine in the Rural Eastern Mediterranean. . . 1589
system, certain efforts need to be put into practice on the policy level. These
include including telemedicine on national agendas, developing a legal frame-
work, and allocating a comprehensive budget for it. Moreover, there is a need for
training on the benefits of telemedicine on the community level and building
capacity in implementing it.
Keywords
Telemedicine · Noncommunicable diseases · Eastern Mediterranean Region ·
Access to care
Telemedicine: The Pros and Cons
Telemedicine is “the delivery of health care services, where distance is a critical

factor, by all health care professionals using information and communication tech-
nologies for the exchange of valid information for diagnosis, treatment and preven-
tion of disease and injuries, research and evaluation, and for the continuing
education of health care providers, all in the interests of advancing the health of
individuals and their communities” (World Health Organization 2010). Telemedi-
cine is a constantly evolving science as it depends on the incorporation of techno-
logical advancements to respond and adapt to the health needs and contexts of
communities (World Health Organization 2010). Telemedicine can be an asset in
improving access to health care, especially for people living in remote areas, nursing
home residents, and prisons (Abdul Rahim et al. 2014; Parmar et al. 2015).
Telemedicine technology has a number of applications for both non-
communicable diseases (NCDs) and infectious diseases, but also in different phases
of the treatment cycle, from diagnosis to follow-up (Alajmi et al. 2013; Bashshur
et al. 2014; Bloomfield et al. 2014). Some examples of the utility of telemedicine in
bringing expertise closer to low-resource areas include enhancing social security and
quality of medical services, through linking a child health hospital in Tunisia with
another in France, when other hospitals related to neurology, teleradiology, and
telepathology were linked to Romania, Italy, Bulgaria, Australia, and Greece
(Alsadan et al. 2015). Other examples of the ways telemedicine has improved
services include monitoring type 1 diabetes patients’ sugar levels and administering
insulin without injections (Ramsey 2017); screening and delivery of health-care
services to people with diabetes in underserved rural areas in India (Mohan et al.
2012); diagnosis of ear infections among children using mobile phones; and online
patient consultations (Wootton and Bonnardot 2015). Telemedicine can also
decrease patient costs. For example, at the Chinese University of Hong Kong, the
cost for telepsychiatry for nursing home geriatric patients was 13.2% lower in
comparison to in-person visits when the setup and maintenance costs were shared
by various departments of the university (Hyler and Gangure 2003).
Though telemedicine technologies have advantages, several challenges need to
be overcome before their full potential can be realized. These challenges are
common among different sectors of information technology, one which is Health

Information Technology (HIT) given the interrelation between telemedicine and
HIT, whereby the delivery of medical and educational services or consumer health
information (telemedicine components) depends on electronic records, management
information systems, and network management (Alsadan et al. 2015). A systematic
review on Health Information Technology (HIT) highlights challenges related to
lack of financial resources, bureaucracy and poor management in the hospitals, low
information technology (IT) competency of the staff, lack of qualified staff, and lack
of hospital administrators who value HIT (Alajlani and Clarke 2013). Challenges
also include limited infrastructure, parallel reporting, and lack of coordination. Other
challenges to implementation are the lack of supervision and feedback to lower
levels of health-care programs and acceptance of telemedicine, particularly doctor
and patient resistance in cases where patients are concerned and uncomfortable with
being connected to doctors from different backgrounds (Alajlani and Clarke 2013).
Because of the number of benefits of and challenges to telemedicine, a framework
of factors that may influence the adoption of telemedicine technologies was devel-
oped. The framework categorizes influences to adoption such as privacy, culture,
attitude toward telemedicine, benefit, cost, technical support, top management
support, connectivity, IT capability, compatibility, data warehouse concept, policy,
and upper-level leadership (Fig. 1) (Abd Ghani and Jaber 2015).
The Eastern Mediterranean Region (EMR) includes the following countries:
Afghanistan, Bahrain, Djibouti, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Libya,
Morocco, Oman, Pakistan, Palestine, Qatar, Saudi Arabia, Somalia, Sudan, Syria,
Tunisia, United Arab Emirates, and Yemen (World Health Organization 2017). In
this region, telemedicine has potential to increase access to health-care services,
especially where the patient to doctor ratio is high, and to reduce treatment costs
(Alajmi et al. 2013). With its adaptability to different disease categories and phases
of treatment and with the increase in internet users in this region, telemedicine could
be beneficial in EMR in the field of NCDs.
In this chapter, after providing an overview of the burden of NCDs and on the
access to Internet technology in EMR, we discuss the evaluation of three telemed-
icine studies that focused on the experience of patients and access to cardiology
(called Study 1 hereafter) (Khader et al. 2014), nephrology (called by Study 2
hereafter) (AlAzab and Khader 2016), and dermatology (called by Study 3 in the
text) (Al Quran et al. 2015) services in Jordan.
Overview of the Disease Burden in the Eastern Mediterranean

Region
Countries in EMR have witnessed an increase in the mortality rate due to NCDs
(Fig. 2) (Global Burden of Disease 2015).
In 2008, NCDs accounted for the death of more than 1.2 million people in EMR
(Abdul Rahim et al. 2014). This accounts for nearly 60% of all deaths in this region,
with more than 34% of deaths among individuals younger than 60 years (Abdul
Rahim et al. 2014).
Privacy
Culture
Attitude toward
telemedicine
Benefit
Cost
Technical support
Adoption of telemedicine
Top management
support
Connectivity
IT capability
Compatibility
Data warehouse
concept
Policy
Upper level
leadership
Source: Abd Ghani, M. K. & Jaber, M. M. Willingness to Adopt Telemedicine
in Major Iraqi Hospitals: A Pilot Study. Int. J. Telemed. Appl. 2015, (2015).
Fig. 1 Factors influencing the willingness to adopt telemedicine. (Source: Abd Ghani and Jaber
2015)
Cardiovascular diseases (CVDs) and kidney diseases are within the ten leading
causes of mortality in EMR (Abdul Rahim et al. 2014). Specifically, ischemic heart
disease contributed to 14.3% of deaths in 2010. On the other hand, skin disease
causes a huge burden in the region and it is one of the leading causes of nonfatal
burden expressed as years lost due to disability in 2010 (Hay et al. 2013).
This increase in the prevalence of NCDs in the EMR is accompanied by a series of
challenges in terms of diagnosing and managing patients for these diseases, especially
in remote areas (Abdul Rahim et al. 2014). Trained primary care physicians are
reportedly more efficient in diagnosing dermatological conditions, but 60% of patients
400
Median mortality rate per 100,000
350
300
for NCDs in EMR
250
200
150
100
50
0
1995 2005 2015
Source: Global Burden of Disease, 2015
Fig. 2 Median mortality rate, per 100,000, for NCDs in the Eastern Mediterranean Region during
years 1995, 2005, and 2015. (Source: Global Burden of Disease 2015)
in the region of the Middle East with dermatological diseases were treated by non-
dermatologists (Al-Hoqail et al. 2002). Transportation presents another challenge to
accessing health care from remote areas in the EMR, both in terms of cost and ease of
boarding public buses (Kronfol 2012). Car ownership is limited to the more econom-
ically advantaged groups (Kronfol 2012; Syed et al. 2013). As the high cost of health-
care services also contributes to access problems (Alsadan et al. 2015), it is clear that
there is an economic gradient to health-care access particularly from remote areas.
The governance and organizational structures in the public health sector in some
EMR countries have remained unchanged despite the nature of public health and
health care changing in the past few decades (Saleh et al. 2014). Given the present
challenges, innovative ways are needed to connect doctors to medical resources and
to deliver health-care services.
Overview on the Access to Internet Technology in EMR
Internet technology is evolving globally and connecting patients to health-care ser-

vices. In EMR, the average rate of individuals using the Internet (includes all individ-
uals who have used the Internet within the past 3 months) (World Bank 2016) has
increased from 25% in 2010 up to 44% in 2015 (World Bank 2016). The country with
the lowest Internet coverage in the EMR is Somalia (1.8% of the population) and the
highest Bahrain (93.5% of the population). In Jordan, the number of Internet users as
percentage of the population is 53.4%. Internet usage in the EMR is increasing rapidly:
in Bahrain by over fourfold from 20% in 2005 to 93.5% within 10 years, in the West
Bank and Gaza by almost threefold from 16% in 2005 to 57% in 2015, and in Jordan
by fourfold from 12% in 2005 to 53% in 2010, shown in Fig. 3 (World Bank 2016).
The increase in NCDs and access of Internet technology raises the potential use of
telemedicine for NCDs in EMR. In Jordan, in particular, this has resulted in
Fig. 3 Access of Internet technology in EMR (as percentage of population). (Source: World Bank
2016)
telemedicine interventions. The next section presents results of the evaluation of

three telemedicine studies in Jordan.
Telemedicine Utilization in EMR
Three studies were conducted in Jordan that focused on live interactive consultations
via the Internet. Study 1 focused on telecardiology (Khader et al. 2014), Study 2
focused on telenephrology (AlAzab and Khader 2016), and Study 3 focused on
teledermatology (Al Quran et al. 2015). The aim of the three studies was to assess the
impact of live interactive – teledermatology, telecardiology, and telenephrology –
consultations on the diagnosis and management of the diseases related to cardiology,
nephrology, and dermatology according to the providers’ perception. The studies
also aimed to assess if there was any association with improvement in patients’
quality of life and cost and time-savings according to patients’ perceptions.
The three studies were conducted at two hospitals in the north and south of Jordan.
The teleclinics were launched in 2011 at Mafraq Governmental Hospital, north
of Jordan, and in 2012 at Queen Rania Hospital, south of Jordan. The three studies
evaluated the process and outcomes of teleconsultations that took place in those
teleclinics between September 2013 and January 2014. The studies included
patients who were attending or referred to the teleclinics for suspected disease or
follow-up, in both hospitals, during the study period. The intervention evaluation
was done through pre- and posttests focusing on the evaluation of telecardiology,
teledermatology, and telenephrology and their impact. Evaluation forms were filled
by physicians or nurses who were trained on data collection methods in both
hospitals before and after the consultation session. The quality of life question-
naires were filled again 8 weeks post-consultation via phone interviews. Phone
interviews were conducted according to protocols previously determined by the
investigator.
Telemedicine Technology
The teleclinics in the three studies were equipped with Cisco Health Presence
Technology solution, which consisted of Cisco Technologies including audio,
video, security, networking solutions, and applications platform. Cisco technology
is considered a leader in the field of telemedicine solutions, especially when it comes
to improving access to care, in rural areas (Sidhu 2015). The technologies were
integrated with AMD medical equipment including general exam camera, electronic
stethoscope, vital signs monitor, ENT scope, ophthalmology scope, and dermatology
scope. The Cisco audio-video technologies consisted of the Cisco TelePresence
System (CTS500) offering two resolution settings (720p or 1080p) and four quality
settings (lite, good, better, or best). To ensure connectivity between the main data
center and all teleclinics, a National Broadband Network (NBN) of 10 MB dedicated
line and a Secure Government Network (SGN) via NBN which depends on the Fiber
Optic technology were used.
The Settings
The location of the hospitals is in a rural area Mafraq (North) and Ma’an (South) of
Jordan (Map 1), where the estimated number of residents is 551,500 and 144,500
residents, respectively.
Evaluation of the Studies
The tools used in the three studies’ evaluations included questionnaires filled by
trained nurses or physicians. The questionnaires evaluated patient quality of life,
their perception of travel time and cost, and consultation requests and record forms
that evaluated the physician’s perception on diagnosis and treatment plan after
consultations through teleclinics (Table 1).
In all the three studies, all questionnaires and forms used were chosen based on a
literature review of relevant studies. The questionnaires were also piloted among ten
patients and revised as necessary. English questionnaires were translated into Arabic
using forward-backward translation method and later adapted to the Arabic
language.
Map 1 The location of the studies
Potential of Teleconsultations in EMR
In the three studies conducted, the benefits of telemedicine were demonstrated

through improved treatment and diagnosis plans, improved quality of life, and
patient cost saving on travel and reduced waiting times. Details on the characteristics
of patients who participated, the impact of telemedicine technologies on treatment
and diagnosis plans, costs and travel time, according to their perceptions, are
presented below.
General Characteristics of the Patients Included in the Three Studies
Overall, a total of 228 patients participated in the three studies, with an equivalent
duration of 4 months. The patients included in the studies were both males and
Table 1 Tools used in the three studies

Measured
Study Tool used outcomes References
Cardiology SF-8 Health Surveya Quality of Ware et al.
life (2001)
Minnesota Living with Heart Failure Quality of Rector and
Questionnaire (LIhFE) life Cohn (1992)
Nephrology SF-8 Health Survey Quality of Ware et al.
life (2001)
Kidney Disease Quality of Life Survey Quality of Hays et al.
(KDQOL) life (1994)
Dermatology SF-8 Health Survey Quality of Ware et al.
(pilot 3) life (2001)
Dermatology Life Quality Index (DLQI) Quality of Basra et al.
life (2008)
a
A health survey of eight questions that determines a person’s quality of life
Table 2 General characteristics of the patients’ population in the three studies

Characteristics Cardiology Nephrology Dermatology
Age (years) N = 76 N = 64 N = 88
<45: 23 (30.3%) 50: 21 (32.9%) <20: 37 (42.0%)
45–54: 32 (42.1%) >50: 43 (67.2%) 20–50: 45 (51.1%)
55: 21 (27.6%) 50: 6 (6.8%)
Sex
Females 35 (46.1%) 30 (46.9%) 31 (35.2%)
Males 41 (53.9%) 34 (53.1%) 57 (64.8%)
Hospital
MGHa 68 (89.5%) 56 (87.5%) 9 (10.2%)
QRHb 8 (10.5%) 8 (12.5%) 79 (89.8%)
Source of patients
Inpatient clinic 9 (11.8%) 4 (6.3%) –
Outpatient 62 (81.6%) 52 (81.3%) 15 (17%)
Outside clinic 5 (6.6%) 8 (12.5%) 73 (83%)
Duration of the study (months) 4 4 4
a
Mafraq Governmental Hospital
b
Queen Rania Hospital
females with an age range between 16 and 93 years old. The sources of patients’
referral were inpatient/outpatient hospital clinics as well as clinics outside the
hospital (Table 2).
Impact of Teleconsultations on Changes in Diagnosis and Treatment

Plan
For all patients, the main reason to receive telecardiology, teledermatology, and
telenephrology consultations was to establish a diagnosis or treatment plan (Table 3).
Table 3 The perception of the referring provider on the impact of teleconsultations on changes in
diagnosis and treatment plan
Cardiology, N Dermatology, N Nephrology, N
Perception of provider (%) (%) (%)
Diagnosis
Established as part of the 54 (71.1%) 38 (43.2%) 40 (62.5%)
teleconsultation
Remained the same as the initial plan 9 (11.8%) 33 (37.5%) 16 (25%)
Changed as a result of the 13 (17.1%) 17 (19.3%) 8 (12.5%)
teleconsultation
Treatment plan
Established as part of the 58 (77.3%) 59 (67%) 40 (62.5%)
teleconsultation
Remained the same as the initial plan 5 (6.7%) 21 (23.9%) 4 (6.2%)
Changed as a result of the 12 (16%) 8 (9.1%) 20 (31.2%)
teleconsultation
The referring providers thought that the final diagnosis was established in 71.1%
of patients who received telecardiology consultations, and 43.2% and 62.5% of
patients who received teledermatology and telenephrology consultations, respec-
tively. Teleconsultations were also thought to change the diagnosis from that
assigned by the referring provider in 17.1%, 19.3%, and 12.5% of patients who
received telecardiology, teledermatology, and telenephrology consultations, respec-
tively. In some cases, the diagnosis remained the same as that of the referring
provider; 11.8%, 37.5%, and 25% of patients who received telecardiology, tele-
dermatology, and telenephrology consultations, respectively.
Also, a treatment plan was established for 77.3%, 67%, and 62.5% of patients
who received telecardiology, teledermatology, and telenephrology consultations,
respectively. In other cases, the treatment plan was changed as a result of tele-
consultations; 16%, 9.1%, and 31.2% of patients who received telecardiology,
teledermatology, and telenephrology consultations, respectively. In 6.7% of patients
who received telecardiology consultations, 9.1% of patient who received tele-
dermatology consultations, and 31.2% of patients who received telenephrology
consultations, the treatment plan remained the same as the initial plan.
Effect of Teleconsultations on Patient’s Quality of Life
After 2 months of consultations via the teleclinics, the patients’ quality of life
improved resulting better health, based on assessments using the SF8 tool and
other tools relevant to each study (Table 4). The mean SF8 score increased signif-
icantly in the three studies: from 40.7 to 62.4 for telecardiology consultations, from
33.1 to 45.0 for telenephrology consultations, and from 20.6 to 100.0 for tele-
dermatology consultations. All SF8 domains (general health, physical functioning,
bodily pain, physical role, vitality, social functioning, mental health, and emotional
role) have improved significantly after 2 months of telecardiology and
Table 4 The effect of teleconsultations on patient’s quality of life

Tool number Cardiology Nephrology Dermatology
SF-8 results – Mean changes in scorea,b 21.7 11.9 26.2
General health 31.6 20.9 7.3
Physical functioning 17.5 12.0 28.9
Bodily pain 15.3 16.3 22.1
Role-physical 19.6 16.5 23.5
Vitality 17.0 8.3 18.1
Social functioning 40.8 5.4 48.4
Mental health 4.5 5.4 18.8
Role-emotional 36.7 6.3 43.2
For the Minnesota Living with Heart Failure Questionnaire (LIhFE) was used for Cardiology
(Changes in score mean): 12.8 (6.4, 19.3); For the Kidney Disease Quality of Life survey
(KDQOL) results) – Changes in score: Burden of Kidney disease subscale (0.6); Symptoms and
Problems subscale (29); Effects of Kidney Disease on Daily Life subscale (25.4); For the Derma-
tology Life Quality Index (DLQI) – Changes means score (95% CI): Symptoms and feeling (1.1
(1.7, 0.5)); Daily activities (1.2 (1.7, 0.6)); Leisure (0.6 (1.0, 0.1)); Work and school
(0.1 (0.2, 0.4)); Personal relationships (0.6 (0.9, 0.3)); Treatment (0.2 (0.3, 0.0))

After minus () Before ) so the score was calculated through subtracting pre from post (post
minus pre)

Before minus () After ) pre minus post
teledermatology consultations, where the highest improvements were seen in social

functioning and role-emotional domains of SF8; as for telenephrology consultations,
only the “general health,” “bodily pain,” and “role-physical” have improved signif-
icantly after 2 months of consultations.
Moreover, after 2 months of teleconsultations, the baseline mean LIhFE (a self-
assessment of how heart failure affects a person’s quality of life) score decreased
significantly from 47.8 to 34.9. As for Dermatology Life Quality Index (DLQI)
scores, there was a decrease from 9.4, at baseline, to 5.9, with a mean change of 3.5
indicating that the disease had much lower effect on patient’s life compared to the
baseline. The telenephrology consultations resulted in significant increases in the
scores of “Symptoms and Problems” subscale and “Effects of Kidney Disease on
Daily Life” subscale. This implies that patients were less bothered by some symp-
toms caused by kidney diseases. However, there was no significant improvement in
the “Burden of Kidney Disease” subscale.
As shown in Table 5, 96.1% and 95.5% of patients reported that their visits to
telecardiology and teledermatology clinics respectively required less travel time
compared to visiting a specialist clinic in a referral hospital in Amman. Half of the
patients (50%) were managed locally in telecardiology clinics which meant that
patients avoided travel to specialist clinics in the referral hospital.
Patients, who attended telenephrology clinics, also thought that the visits required
less travel time compared to visiting the specialist clinic at the referral hospital. In
addition, most patients said that their waiting time and costs of health care were
reduced during teleclinic visits when compared to specialists’ clinics at the referral
hospital.
Table 5 Patients’ perception of the visit to the teleclinic in terms of travel time, waiting time, and
cost as compared to visiting the specialist in the referral hospital
Cardiology, Dermatology, Nephrology,
Patients’ perceptions N (%) N (%) N (%)
Travel time
Same travel time required 0 2 (2.3%) –
More travel time required 3 (3.9%) 2 (2.3%) –
Less travel time required 73 (96.1%) 84 (95.5%) –
Waiting time in the clinic
Same waiting time 1 (1.3%) 4 (4.5%) –
Increased waiting time 0 11 (12.5%) –
Reduced waiting time 75 (98.7%) 73 (83%) 62 (96.9%)
Self-reported cost comparing telemedicine
to regular visits to a specialist
Same cost 0 0 –
Greater cost 0 4 (4.5%) –
Lower cost 76 (100%) 84 (95.5%) 63 (98.4%)
Recommendations for
telemedicine in EMR
Community level Governmental level
Training on the Allocate a

Capacity Develop a legal
importance of comprehensive
building for HR framework
telemedicine budget
Fig. 4 Recommendations for the implementation of telemedicine in EMR
Future of Telemedicine in EMR: Conclusion and

Recommendations
This chapter described the EMR NCD burden of disease, along with challenges of
health-care systems and related this to the potential of telemedicine in addressing
some of these challenges. Published reports on telemedicine in the EMR region were
only found for Jordan, which may not be fully representative of EMR. However,
Jordan may be considered as an example of an EMR country given the similarity of
the burden of disease of NCDs, demography, and limitation in access to health-care
services in rural areas for other EMR countries. Given the rise in NCD prevalence in
some countries in the EMR region and the challenges faced in meeting health-care
resource needs, governments are under greater demand to consider using innovative
solutions to deliver their health-care service beyond traditional, but more expensive,
mechanisms. The above three studies indicate that telemedicine was acceptable to
both service providers and users. For service providers, the teleconsultations were
successful in establishing diagnosis and treatment plans for some patients or chang-
ing previously established diagnoses or plans. This impact not only improved
patients’ quality of life but also decreased cost through reducing travel and waiting
times to and from clinics.
As evidenced by these studies, telemedicine is a window of opportunity for
health-care systems to improve the quality of health-care delivery services. This
improvement, using telemedicine, is increasingly becoming more possible in EMR
countries as access to information technologies has increased dramatically in the last
decade.
However, for telemedicine to have a promising future in this region, it is impor-
tant that telemedicine is included in national agendas and further invest in this field
through scaling up pilot studies, if found, or plan and implement new studies. In
order to implement successful telemedicine services, governments also need to
ensure that health systems are able to deliver services. We recommend that health
ministries develop a legal framework for these technologies and allocate a compre-
hensive budget. Moreover, human resource capacity to implement these interven-
tions needs to be developed and training needs to be conducted among end users to
help the adoption of these interventions (Fig. 4).
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Healthcare Ethics
From Medical Paternalism to Patient Autonomy
66
Abdullah Saeed Hattab
Contents
Historical Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1604
Ethics and Morality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1604
Medical Ethics as a Special Field of Ethics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1605
Historical Evolution of Medical Ethics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1605
The Contribution of the Arabic and Islamic Civilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1606
The Doctor Patient Relationship . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1606
Medical Paternalism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1608
Patient Autonomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1610
Concept of Autonomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1610
Informed Consent: Concept and Elements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1610
Ethical and Legal Foundations of the Informed Consent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1611
Elements of the Informed Consent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1612
Critiques of Patient Autonomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1613
Relational Autonomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1613
Cultural Relativity of Patient Autonomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1614
Patient Autonomy: An Islamic Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1615
Sanctity of Human Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1616
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1617
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1618
Abstract
This chapter discusses the concepts of medical paternalism and patient autonomy
and their implications for the doctor patient relationship, medical practice, and
healthcare. For more than 25 centuries, paternalism was the dominant model of
the doctor-patient relationship, where the doctor uses his skills and knowledge to
serve the best interests of the patient as a moral obligation. This is in compliance
with the classical ethical principles of the Hippocratic Oath: beneficence, non-
maleficence, truth-telling, confidentiality, and fidelity to the patient. The pater-
nalistic approach assumes that patients and doctors have the same goals, that
A. S. Hattab (*)
Public Health, University of Aden, Aden, Yemen

https://doi.org/10.1007/978-3-030-36811-1_77
1604 A. S. Hattab
physicians can accurately judge patient preferences, and that only the physician
had the expertise necessary to determine what should be done. All theories of
autonomy agree on two essential conditions: the first is liberty, specifying the
independence from controlling influences; and the second is agency, referring to
the capacity for intentional action. Used in clinical ethics, autonomy functions
primarily to examine decision-making in healthcare and serves to identify actions
that are protected by the rules of informed consent, informed refusal, truth telling,
and confidentiality. An important difference between autonomy and paternalism
is the weight given to patient values. Autonomy considers patient values as
decisive. Modern paternalism considers these values as only one factor among
others weighed by the physician in making a decision. Moral values are culturally
relative. Autonomy must be balanced with other morally important concepts in
the doctor-patient relationship, including loyalty, integrity, solidarity, and
compassion.
Keywords
Ethics · Morality · Healthcare · Doctor patient relationship · Medical
paternalism · Patient autonomy
Historical Background
The main goal of this chapter is to discuss the concepts of medical paternalism and
patient autonomy and their implications for the doctor patient relationship, medical
practice, and healthcare.
Ethics and Morality
Ethics is derived from the Greek word ethos means the manner and habits of man or
of animals. There are many definitions for ethics, but generally all of them coincide
with the meaning of the ethos. For example, some define Ethics as the Philosophy of
Morality; others define it as “the science dealing with Morality, its origin and
development, the rules and norms of conduct of people, their duties towards society
and towards each other.”
The term Morality emerged of the Latin words Mores that originally had the same
meaning as the Greek word Ethos: habits, customs, or traditional behavioral. In the
course of the historical development, different meanings for Ethics and Morality
appeared. The word Morality is used to characterize the behavioral patterns or moral
duties imposed by the society that support its stability and survival, as well as the
relationship between its members.
Morality is a system of opinions, representations, norms, and evaluations about
the regulation of the conduct of individuals. Accordingly, morality identifies and
establishes the demands of society that reflect the prevalent social values that should
66 Healthcare Ethics 1605
be respected and followed by everyone in his daily life. Those demands are the
obligations or the duties that individuals should fulfill with respect to others, their
families, colleagues, and society as a whole. This concept is consistent with the
philosophy of the eminent scholar Edmund Pellegrino who asserted that “the
moment we introduce the words right with respect to an action and good with
respect to an end we introduce morality.” Pellegrino defines Morality as “any system
of strongly held beliefs and values against which behavior is judged.” Behavior in
accord with such values is considered to be moral, behavior contrary to them is
immoral (Pellegrino 1978).
Medical Ethics as a Special Field of Ethics
Medical Ethics is the branch of Ethics that is concerned with the Philosophy and
theory underlying the principles and norms of the right professional conduct in
medical practice. Medical Ethics implies the obligations of the physician towards
the healthy and sick person, obligations towards colleagues and other health pro-
fessionals, as well as obligations towards society. Medicine presupposes certain
fundamental values such as the preservation of life and relief of suffering. These
values distinguish Medicine from other professions and imply some special respon-
sibilities, particularly for the physician and other members of the health profession.
According to the Hippocratic Oath, the most important obligations of the physi-
cian towards the patient are fidelity to the patient’s interest, truth telling, and
confidentiality of patient information. In a physician-patient relationship, where
there are emotional and physical intimacies, patients often entrust their bodies and
sometimes even their lives to the physician, and therefore trust must exist. Medical
Ethics provides the basis for this trust. To assure patients that their interests are the
most important, to promise to keep their confidence, and to deal honestly with them
are fundamental values of Medicine to which physicians must adhere.
Historical Evolution of Medical Ethics
The history of Medical Ethics is closely linked to the history of Medicine and medical
practice, as explained in the following paragraphs. At each stage of its evolution,
Medicine has been concerned with the alleviation of suffering, preserving health and
combating disease in accordance with the degree of development of man’s knowl-
edge about the nature of disease, its etiology, and contributing factors.
Interest in establishing rules and norms that guide and govern the conduct of
doctors is very well documented in the Code of Hammurabi, 2000 BC, under which
the Babylonian surgeon was rewarded – or indeed punished – for his efforts,
depending on their outcome and social status of the patient.
The Hippocratic Oath is the most ancient well-known Code of Medical Ethics.
It embodies the moral ideal of the professional excellence of the Greek Medicine that
explains its impact and following extension around the world (Kleisiaris et al. 2014).
1606 A. S. Hattab
The Hippocratic Oath is one of the earliest attempts aimed for binding doctors to a
certain code of conduct and establishing the foundations of the basic ethics of
medical practice. It involves the notion of doing no harm, of prescribing no deadly
substance, of not provoking abortion, of not abusing the professional relationship to
achieve sexual ends and of maintaining secrecy, as well as doctor’s devotion to his
teachers.
Hippocrates of Cos lived at the beginning of the Golden Century of the Greek
culture (5th century BC) is the best representative of the medical school which took
his name. The Corpus Hippocraticum is a collection of books that were written by
different authors of this medical school, and that the tradition had been attributed to
Hippocrates. Hippocratic Oath is one of the most important books of that collection
(Dobken 2018). The Hippocratic Oath established two main moral principles of the
medical practice: Beneficence: to do all in the best interest of the patient, and
Nonmaleficence: to abstain from doing any harm to the patient.
The Contribution of the Arabic and Islamic Civilization
The contribution of the Arabic and Islamic Civilization to medical science and
practice is well recognized and documented in the literature of the history of
Medicine. Rhazes (Al-Razi), Ishaq ibn Ali Al-Ruhawi, Avicena (Ibn-Sinna), and
Abulkassim Azzahrawi are only few examples of the long list of prominent scholars,
physicians, and philosophers internationally recognized as the pioneers and leaders
of Medicine and medical education for more than eight centuries covering the period
from the ninth to sixteenth centuries. Many prominent scholars of this period have
significantly contributed to medical ethics, among them were al-Ruhawi and al-Razi;
both have written the earliest and most thorough books on medical ethics. Al-
Ruhawi’s most famous work is Adab al-Tabib (“Practical Ethics of the Physician”
or “Practical Medical Deontology”). Al-Ruhawi considered physicians as “guard-
ians of souls and bodies.” The work was based on Hippocrates and Galen and
consisted of 20 chapters on various topics related to medical ethics. Al-Razi has
also written a very comprehensive book on medical ethics called Akhlaq al-Tabib
(Medical Ethics) (Chamsi-Pasha and Albar 2013).
Since the eighties of the twentieth century, the Islamic organization of Medical
Sciences (IOMS) played a leading role in addressing the ethical issues in medical
practice from an Islamic perspective. In this line, the IOMS has organized several
regional and international conferences and issued numerous documents among
which the Islamic Code of Medical Ethics (IOMS 1981) and the Islamic Interna-
tional Charter of Health and Medical Ethics (IOMS 2005).
The Doctor Patient Relationship
The Doctor-patient relationship is the central focus of interest for Medical Ethics.
This issue has great importance, because it is inherent in every aspect of the
professional practice in Medicine and Public Health. The relationship between

patients and doctors in the clinical realm has historically been framed in terms of
benevolent paternalism. It entails that the doctor uses his skills and knowledge to
serve the best interest of the patient as a moral obligation. This comes in compliance
with the classical ethical principles of the Hippocratic Oath: beneficence, non-
maleficence, truth-telling, confidentiality, and fidelity to the patient.
This paternalistic approach assumed that patients and providers had the same
goals, that providers could accurately judge patient preferences, that only the
physician had the expertise necessary to determine what should be done, and that
it was appropriate to spare patients the worry of decision-making or even “to deceive
them in order to engender faith, reassurance and hope” (Deber 1994). Until about
1960, most codes of medical ethics relied heavily on the Hippocratic tradition,
framing the obligations of physicians solely in terms of promoting the welfare of
the patient, while remaining silent about patients’ rights (Truog Robert 2012).
During the second half of the twentieth century, the medical technologies have
reached high invasive power in the body and privacy of the persons and the
medical services became more and more expensive. On the other side, patients
began to demand more participation in the process of decision-making about
their health, the options of treatments in case of disease, and the public policy in
the allocation of medical resources. This situation emerged as a part of a wider
societal transformations have seen tectonic societal shifts that have resulted in
increasing empowerment of individuals against the authority of government and
institutions, creating a surge of rights-based movements, with patients’ rights
emerging as a societal demand alongside women’s rights, minority groups’
rights, consumers’ rights, and others. This dramatic shift appeared to move the
locus of authority in decision making from the physician to the patient (Truog
Robert 2012).
The extraordinary progress in medical sciences and technology has great influ-
ence on organizing, financing and delivery of healthcare and on health policy as a
whole. The ways in which health policy, ethics, and human values interrelate were
described by the American physician and philosopher, Edmund Pellegrino:
The health policy of a nation or a community is its strategy for controlling and optimizing the
social use of its medical knowledge and resources. Human values are the guides and
justification that people use for choosing the goals, priorities and means that make up that
strategy. Ethics acts as the bridge between health policy and values. It examines the moral
validity of the choices to be made and seeks to resolve conflicts between values that
inevitably occur in making those choices. Ethics, therefore, orders human choices in
accordance with normative principles.
Over the last few decades the discourse regarding the physician patient relation-
ship has focused on two extremes: autonomy and paternalism. Emanuel and
Emanuel (1992) intensively discussed this issue and proposed four models of the
physician patient interaction, emphasizing the different understandings of the goals
of the physician patient interaction, the physician obligations, the role of patient
values, and the conception of the patient autonomy.
1608 A. S. Hattab
In the following sections of this chapter, we are going to discuss the concepts of
paternalism and autonomy and their implications in the context of doctor patient
relationship, medical practice, and healthcare.
Medical Paternalism
Medical paternalism was the dominant model of the doctor patient relationship for
more than twenty-five centuries. It entails that the doctor uses his skills and knowl-
edge to serve the best interest of the patient as a moral obligation.
Pellegrino asserts that, “medicine is at heart a moral enterprise. All its efforts
converge ultimately on decisions and actions which are presumed to be good for
some person in need of help and healing. This fact has been acknowledged explicitly
for two millennia in the professional moral codes of Eastern and Western medicine”
(Pellegrino 1978). While benevolent in intention, these codes enjoin the physician to
do what he deems best for the patient, but no mention is made of the patient’s
participation in that determination. The physician is assumed to be the patient’s
moral agent, and no notice is taken of the possibility of a conflict between the
physician’s and the patient’s value systems. Such a paternalistic construing of the
physician-patient relation is increasingly untenable and even immoral (Pellegrino
1978).
Gerald Dworkin defined paternalism as “the interference with a person’s liberty of
action, justified by reasons referring exclusively to the welfare, good, happiness,
needs, interest, or values of the person being coerced” (Dworkin 1971). Medical
paternalism is defined similarly as interference by the physician with the patient’s
freedom of action, justified on the grounds of the patient’s best interests.
Paternalism cares for an individual’s interest in place of autonomy, either by force
or by necessity. For example, children and persons with physical and/or intellectual
disability could not exercise their full autonomy to protect their interests or to be
involved in decision making process with respect to diagnostic and therapeutic
interventions; under such conditions, paternalism would be necessary and appro-
priate approach to manage the situation. Another example is the management of
some communicable diseases, for example, tuberculosis, HIV, and other communi-
cable diseases that require notification to the health authorities to enforce the
appropriate preventive and therapeutics measures not only for the patient but also
for the contacts, environment, and community at large.
The vulnerability to which patients are subjected because of illness has been clearly
illustrated in the words of Pellegrino who asserts that “the fact of illness wounds the
humanity of the person who is ill and deprives him of some of the freedoms most
fundamental to being human: freedom to move about as one wishes, freedom to make
one’s own decisions, freedom from the power of others, and freedom to construct one’s own
self-image.” (Pellegrino 1978)
Komrad argued that paternalism is not necessarily coercive behavior; there is

another side to it that connotes the concern, care, and self-sacrifice of the
paternalistic agent. Nor does the notion of coercion fully characterize paternalism,
which may manipulate thought and information as well as action.
Some of the early codes of the medical profession seemed to promulgate absolute
paternalism as an appropriate professional etiquette. The priest-like status of doctors
historically encouraged paternalism to which patients readily acquiesced (Deber 1994).
Hannah W (2013) defined paternalism, as the act of overriding an autonomous
person’s decision-making ability out of duty for beneficence. Oftentimes, paternal-
ism is used in instances in which the individual in question is viewed to have
questionable ability to make decisions regarding their life. Those in support of
paternalism use the justification that experts have the greatest capability of making
the proper decision in their field of expertise; thus, doctors should be permitted to
override an individual’s decision in order to benefit that individual’s overall health.
Through the consequentialist perspective, it is the doctor’s duty to treat a patient
because it is morally right to cause good; therefore, by not proceeding with the
necessary treatment, the doctor is not doing what is right. Oftentimes associated with
consequentialism is the core tenant of utilitarianism which emphasizes doing what
benefits the most people and will create the most good overall (Hannah 2013).
Komrad (1983) noted that many philosophers identify a category of persons who
are legitimate candidates for paternalism: people who “do not culture reason” (Kant),
the immature (Mill), the inherently “nonautonomous” (Beauchamp and Childress),
etc. This suggests that there are some human conditions in which people are not
capable of enjoying a full measure of autonomy and that paternalism should protect
their interests where autonomy is wanting. According to this interpretation, Komrad
suggested that capability should be a determinant of “degree of autonomy.” Individ-
uals with impaired capacities suffer diminished autonomy. Paternalism is actually a
response to this incapacity and not a negation of rights. Surely the human condition
is protean and people occasionally experience diminished or imperfect autonomy,
often only temporarily. Autonomy is neither permanent nor immutable, but is a
dynamic state liable to perturbation (Komrad 1983).
Siegler asserts that constant feedback between patient and doctor should enable
the balance of paternalism and autonomy to be continuously updated and fine-tuned.
This spirit of kinetic reciprocity whereby paternalism is molded to the situation is
central to concept of “the physician-patient accommodation, which is not a perma-
nent, stable and unchanging relationship between physician and patient; it is a
dynamic model and is always in flux” (Siegler 1972).
Komrad debates that Paternalism is not always incompatible with the principle of
autonomy and, in fact, paternalism may be instituted to restore it (as in the doctor
patient relationship), or to establish it (as in paternalism towards children). The
restitution of diminished autonomy is the only rationalization of medical paternalism
that does not profane autonomy. The admonition that a physician should “respect the
patient’s autonomy” does not explicitly acknowledge that a patient presents in a
condition of incomplete autonomy. Rather, one might more appropriately ask instead
that the doctor respect the patient’s potential for autonomy. Komrad proclaims that
the maximization of autonomy within the bounds of the patient’s potential seems to
be a legitimate goal of the therapeutic encounter (Komrad 1983).
1610 A. S. Hattab
Patient Autonomy
Concept of Autonomy
Beauchamp and Childress define autonomy as a form of personal liberty of action

where the individual determines his or her own course of action in accordance with a
plan chosen by himself or herself. Respect for autonomy or respect for persons is one
of the main principles of biomedical ethics or research ethics, respectively. This
principle historically has its roots in the liberal moral and political tradition of the
Enlightenment in Western Europe. Accordingly, the ethical justification of actions or
practices strongly depends on the free decisions of individuals, that is, an action or
practice can only be ethically justified when undertaken without any coercive
influence or undue inducement and entered by free and informed agreement
(Azétsop and Rennie 2010).
The Belmont Report (1979) states that “Respect for persons incorporates at least
two ethical convictions: (Azétsop and Rennie 2010) individuals should be treated as
autonomous agents, and (Baylis et al. 2008) persons with diminished autonomy are
entitled to protection.” An autonomous person is an individual who could express
and debate his aims/targets and strive to their realization. To respect autonomy is to
give consideration to persons’ deliberated opinions and choices while abstaining
from impeding their actions, unless they are clearly harmful to others. Lack of
respect for an autonomous agent could be manifested in denying that person’s
considered judgments, rejecting an individual the freedom to act on those deliberated
judgments, or not disclosing information necessary to make free independent deci-
sion-making.
The legal focus on autonomy in Western healthcare evolved as a result of the
perceived and somewhat actual threat of paternalistic choices on patients’ lives
(Elliott 2001). A historical view of the patient-physician relationship as summed
that it was the role of the physician acting in the best interests of the patient, to
direct care and to make decisions about treatment. The primary moral principle to
be pursued was beneficence, and the patient’s role was to comply with the
physician’s orders. The adoption of the concept of respecting patients as autono-
mous agents contributed a new qualitative dimension to the informed consent.
Now, it is not just a legal doctrine, but also “a moral right of patients that generates
moral obligations for physicians.” Whereas it was implicit under the paternalism of
the beneficence model that knowledge of what was in the patient’s best interests
was solely the province of physicians, now came a presumption under the auton-
omy model that “competent individuals are better judges of their own good than are
others” (Will 2011).
Informed Consent: Concept and Elements
Respect for persons requires that subjects, to the degree that they are capable, be
given the opportunity to choose what shall or shall not happen to them. This
opportunity is provided when adequate standards for informed consent are satisfied
(The Belmont Report 1979).
The informed consent as an ethical and legal requirement first appeared in the
Nuremberg Code promulgated by the World Medical Association (WMA) in 1947 as
a consequence of the trial of physicians (the Doctors’ Trial) who had conducted
atrocious experiments on un-consenting prisoners and detainees during the Second
World War. The Code, designed to protect the integrity of the research subject, set
out conditions for the ethical conduct of research involving human subjects. The first
point of the code emphasizes that “The voluntary consent of the human subject is
absolutely essential.”
In clinical practice, the evolution of the informed consent was linked to lawsuits
and malpractice. At the beginning it was used as a tool for protecting physicians
against patients’ claims and litigations rather than as an ethical and moral require-
ment for patient’s involvement in decision-making process regarding his health
problem. The scientific technological development in medical sciences and practice
significantly influenced medical and healthcare organization and practice. As a
result, the decision-making process in clinical practice get more complex, and the
simple consent to a diagnostic or therapeutic procedure – that has been in use for
decades – would not be adequate. Hence, a new qualitatively different concept, the
informed consent, emerged. This concept was first articulated in the court’s verdict in
the case of Salgo v Leland Stanford Jr University Board of Trustees (1957) stating
that: “the physician owes the patient a duty to inform him or her of any facts which
are necessary to form the basis of an intelligent consent.” This concept was further
elaborated in the well-known case of Canterbury v Spence in 1972 in which the court
resolution stated that “true consent to what happens to one’s self is the informed
exercise of a choice, and that entails an opportunity to evaluate knowledgeably the
options available,” which can only be accomplished when a patient is able to look to
the physician “for enlightenment with which to reach an intelligent decision” (Will
2011).
Ethical and Legal Foundations of the Informed Consent
The legal foundation for adopting the doctrine of informed consent is two fold:
(Azétsop and Rennie 2010) to establish and promote patient autonomy and (Baylis et
al. 2008) to promote informed, rational decisions. The consent process should be the
foundation of the fiduciary relationship between a patient and a physician. Physi-
cians must recognize that informed medical choice is an educational process and has
the potential to affect the patient-physician partnership to their mutual benefit. This
educational process should inform the patient enough to allow for an informed
decision. Information disclosure will not necessarily lead to an ideal patient-physi-
cian partnership, but it should promote patient autonomy in the decision-making
process and achieve a foundation for an ethical and trusting relationship between a
physician and patient. When physicians and patients take medical informed consent
seriously, the patient-physician relationship becomes a true partnership with shared
1612 A. S. Hattab
decision-making authority and responsibility for outcomes. It is fundamental to the

patient-physician relationship that each partner understands and accepts the degree
of autonomy the patient desires in the decision-making process (Paterick et al. 2008).
Elements of the Informed Consent
Three main elements have been identified for the informed consent: competency,
disclosure, and voluntariness.
Competency
To give valid informed consent, the patient should have legal capacity to give
consent. Capacity means the ability to process information received and to commu-
nicate a meaningful response. An element of capacity is that the person making the
decision is an adult and has not been judged incompetent or is not otherwise
prohibited by law from exercising that decision-making capacity. Decision-making
capacity means the ability to understand the significant benefits, risks, and alterna-
tive to proposed healthcare and to make and communicate a healthcare decision
(Paterick et al. 2008).
Disclosure
The patient should be provided with adequate information that lead to acquiring
sufficient knowledge and comprehension of the nature of the proposed intervention,
expected benefits, and possible risks to enable him/her to make an adequate under-
standing and enlightened decision. Another standard, currently popular in malprac-
tice law, requires the practitioner to reveal the information that reasonable persons
would wish to know in order to make a decision regarding their care. The magnitude
of the risks and their frequency should receive special emphasis. Also considered are
alternative treatments and their benefits, risks, and measured utility; the likely results
of no treatment; and the probability of a good outcome with the proposed strategy.
This information must be presented in language the patient can understand. Special
provision may need to be made when comprehension is severely limited – for
example, by conditions of immaturity or mental disability. Each class of subjects
that one might consider as incompetent (e.g., infants and young children, mentally
disable patients, the terminally ill, and the comatose) should be considered on its
own terms. Respect for persons also require seeking the permission of other parties
in order to protect the subjects from harm. Such persons are thus respected both by
acknowledging their own wishes and by the use of third parties to protect them from
harm (The Belmont Report 1979).
Voluntariness
The patient should be so situated as to be able to exercise free power of choice,
without the intervention of any element of force, fraud, deceit, duress, over-reaching,
or other ulterior form of constraint or coercion. Coercion occurs when an overt threat
of harm is intentionally presented by one person to another in order to obtain
compliance. Undue influence, by contrast, occurs through an offer of an excessive,
unwarranted, inappropriate, or improper reward or other overture in order to obtain

compliance. Also, inducements that would ordinarily be acceptable may become
undue influences if the subject is especially vulnerable (The Belmont Report 1979).
Critiques of Patient Autonomy
The concept of Autonomy in the West and particularly in the USA is mainly charac-
terized by an individualistic perspective. The over emphasis on individual indepen-
dence, self-rule, and self-determination in the notion of personal autonomy stressing
the freedom from interference by others – lead to underestimating the importance of
inter-dependence and interconnection with the social and natural environment as
determinants of health and disease.
For the advocates of autonomy rights for patients, the physician’s obligations to
the patient of disclosure, seeking consent, confidentiality, and privacy are established
by the principle of respect for autonomy. Informed consent acts as the process by
which an autonomous individual accepts or denies proposed intervention (diagnos-
tic, therapeutic intervention or participation in research). This individualistic per-
spective of autonomy is mainly concerned with the right to decision-making rather
than what the decision is (Kelly et al. 2017).
The dominance of patient autonomy as a leading principle of bioethics is strongly
associated with the growing tendency of commoditization of medicine in many part
of the world, particularly in industrially developed countries. For the more, the
medical practices are justified by reference to patient’s choice, the more that patient
will be viewed as client and healthcare professional perceived as service providers.
Once medicine is understood as commoditized product like any other, those who
cannot afford services are merely unfortunate consumers. Hence, a strong emphasis
on autonomy would enhance a culture in which disease prevention and health
promotion are no longer at the center of clinical practice and biomedical research
(Azétsop and Rennie 2010).
There is increasing evidence that the emergence and the dominance of patient
autonomy have been an outcome of profound social and economic transformations
as well as the transformations in health policy and health organization; all of which
challenged the beneficence model that has dominated the practice of medicine for
centuries. This change is sustained by waning trust in the traditional patient-physi-
cian relationship. With the control of medicine by the forces of the market, patients
have become consumers of a market commodity called medical care. As a result of
this change, the clinical relationship between the patient and physician begins to be
seen as a contract and not as a covenant of care as it has been for centuries (Azétsop
and Rennie 2010).
Relational Autonomy
Over the past few decades, the individualistic notion of autonomy as the self-rule of
independent, self-determining, and rational individuals has been subjected to
1614 A. S. Hattab
increasing contests, particularly by scholars advocating a more relational form of

autonomy. Individualistic autonomy has been criticized for ignoring values such as
mutual responsibility, cooperation, and care towards others – values seen as playing
a crucial role in important areas of decision-making such as healthcare and research.
Individualistic autonomy disregards the fact that people are rarely, if ever, fully
independent individuals. Instead, they are relational beings whose identities and
interests are shaped by their connections to others. As a response to these challenges,
a new conception of autonomy, relational autonomy emerged (Kelly et al. 2017).
Relational autonomy can be viewed as a conception of autonomy that places the
individual in a socially embedded network of others. Relationships (with family,
community, and society), responsibility, care, and interdependence are key attributes
of relational autonomy. People develop their sense of self and form capacities and
life plans through the relationships they establish on a daily and long-term basis.
Relational autonomy asserts, therefore, that social environment and relationships are
crucial for developing autonomy and encourages us to act in ways guided by ethics
of trust and care (Baylis et al. 2008; 1:196–209).
Cultural Relativity of Patient Autonomy
Culture has been defined as a set of shared attitudes, values, beliefs, language, rituals,
and practices that distinguish a particular social group; this entails a set of guidelines
that people inherit as members of a particular community that guide them how to view
the world and how to behave in relation to other people (Helman 2007). In the context
of healthcare, cultural heritage influences the perceptual framework of illness, well-
ness, and accepted treatment modalities (Berger 1998; Gilbar and Miola 2015).
Orr et al. (1995) noted that recently, a body of growing literature has addressed
cultural diversity and ethical issues associated with healthcare, research ethics,
disclosure of medical information, informed consent, family role, limitations of
treatment, and critical care.
Elliott (2001) argued that the elements of informed consent in Western healthcare
may pose potential challenges in cross-cultural healthcare encounters. Full, truthful
disclose may be at variance with cultural beliefs about hope, wellness, and thriving
of persons; autonomous decision making may contradict family-centered values and
the social meaning of competency; and un-coerced choices may counter cultural
norms of obedience to the wishes of spouse or family members.
The fact that autonomous decision-making usually demands full information does
not mean that disclosure is universally respectful of patients. Deep respect for
individuals is demonstrated not by faithful observance of what practitioners believe
is best for the person but by consideration of what the patient requests and his or her
perceptions of care (Gostin 1996; Katims 1995).
Studies reported from the Middle East (Mobeireek et al. 2008) and South Asia
(Chaturvedi et al. 2009) indicated patients’ reluctance to receive bad news; hence,
relatives act as the recipients of the information, especially when the diagnosis and
prognosis are poor.
This perspective is consistent with a growing body of national and cross-

national literature suggesting that moral values are culturally relative, that family
and community decision making should be considered more seriously, and that
autonomy must be balanced with other morally important concepts in the provider-
patient relationship, including loyalty, integrity, solidarity, and compassion (Gostin
1995).
In some non-Western societies, the family has a dominant role in decision-
making. The East Asian bioethical approach provides the family rather than the
individual patient the authority in medical decision making. This derives from the
significance Confucianism attaches to the family and the belief that one’s life is
inseparable from those of their family. Care and harmonious dependence are com-
mon and influential features in the decision-making process in many East Asian
families (Fan 1997).
Whereas in the Western societies the individual patient in general has the final
say, in Middle-Eastern, North-African, and South-Asian societies, the family is more
likely to be hierarchical and male member(s) have a dominant role in decision-
making, often more than the patient (Moghadam 2004). Thus, when treatment
decisions have to be made, the spouse, male parent, or eldest son will have the
decision-making authority with an input from the patient and other relatives (Jafarey
and Farooqui 2005).
Numerous studies reported that religion and religious beliefs play a significant
role in the perception of health, disease, and health-seeking behavior as well as
decision-making process. Moazam from Pakistan explained that religion has an
influence on people’s decision-making. In Islam, the family is perceived as a
source of strength and protection (Moazam 2000). This view is also shared
Hinduism and Sikhism where decision-making is generally based on a strong
sense of moral responsibility to one’s family, so making decisions about illness
is a collective duty carried out by the family unit as a whole (Coward and Sidhu
2000).
Patient Autonomy: An Islamic Perspective
In Islam, the bioethics principles and practice are founded on the Shari’ah
(Islamic law), which has two main sources: the Holy Qur’an and the Sunnah
(the sayings and traditions) of Prophet Muhammed (peace be upon him), in
addition to the Ijtihad (deductive reasoning). Therefore, to address any problem,
the discussion should be based on guidance and directions of the Holy Qur’an and
the Sunnah (Kassim et al. 2014).
The basic principles of bioethics in the international declarations and guidelines:
patient autonomy, beneficence, nonmal

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Ismail Laher

With 388 Figures and 346 Tables

ISBN 978-3-030-36810-4 ISBN 978-3-030-36811-1 (eBook)

cannot be underestimated, with consanguineous marriages ranging from 20% to

BC, Canada Ismail Laher

Lawrenz B, Coughlan C, Melado L, Fatemi HM (2019) Ethnical and sociocultural

Part I Women’s Health in the Middle Eastern Countries . . . . . . . . . 1

11 Violence Against Women in the Arab World: Eyes Shut

Part II Health Needs of the Displaced and Refugee Population . . . 315

Part III Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411

23 Burden of Cancer in the Arab World . . . . . . . . . . . . . . . . . . . . . . 495

Part IV Social Determinants of Health ...................... 575

36 Social Determinants of Health in Fragile and Conﬂict Zones

Part V Obesity and Systems Biology . . . . . . . . . . . . . . . . . . . . . . . . 891

38 Health Promotion for Preventing Obesity in the Arab

Part VI Mass Gatherings and Infectious Diseases . . . . . . . . . . . . . . 1181

46 Health Issues of Mass Gatherings in the Middle East . . . . . . . . . 1183

47 The Rise of Antimicrobial Resistance in Mass Gatherings . . . . . . 1199

Part VII Environmental Causes of Disease ................... 1359

55 Air Pollution and Health Outcomes in the Eastern

59 Water, Sanitation, and Hygiene Within Healthcare Facilities in

Part VIII Health Systems and Health Management . . . . . . . . . . . . 1475

60 Health Policy and Systems Research in the Arab World:

72 Patients’ Rights, as Part of Human Rights, in the

76 The Health of Arab Israelis: A Population in Transition . . . . . . . 1813

84 Literature on Sleep Disorders in Arab Countries . . . . . . . . . . . . . 2021

Part IX Selected Health Conditions . . . . . . . . . . . . . . . . . . . . . . . . . 2147

87 Geriatric Medicine in the Arab World . . . . . . . . . . . . . . . . . . . . . 2149

Part X Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2417

Part XI Childhood Diseases ............................... 2519

103 Asthma Among Children in the Arab World . . . . . . . . . . . . . . . . 2521

110 Chronic Childhood Illness in the Arab World . . . . . . . . . . . . . . . 2653

111 Cleft and Craniofacial Plastic and Reconstructive Surgery . . . . . 2673

112 Sudden Unexpected Infant Death . . . . . . . . . . . . . . . . . . . . . . . . . 2681

113 Perinatal and Neonatal Mortality in Jordan . . . . . . . . . . . . . . . . . 2695

Part XII Smoking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2717

114 Cessation of Waterpipe Smoking . . . . . . . . . . . . . . . . . . . . . . . . . 2719

115 Smoking Dokha Tobacco Through a Midwakh Pipe:

Part XIII Cardiovascular and Pulmonary . . . . . . . . . . . . . . . . . . . . . 2755

116 Cardiovascular Risk Factors in Adolescents . . . . . . . . . . . . . . . . . 2757

117 Chronic Respiratory Diseases in the Arab World . . . . . . . . . . . . . 2767

118 Management of Chronic Obstructive Pulmonary Disease . . . . . . 2807

119 Asthma Among Arab Nations: An Overview . . . . . . . . . . . . . . . . 2827

120 Coronary Artery Disease in the Arab World . . . . . . . . . . . . . . . . 2855

121 Oral Anticoagulant Therapy in the Arab World . . . . . . . . . . . . . 2871

Part XIV Musculoskeletal and Dermatology . . . . . . . . . . . . . . . . . . 2897

122 Musculoskeletal Disorders Among Healthcare Workers:

Part XV Central Nervous System . . . . . . . . . . . . . . . . . . . . . . . . . . . 2939

123 Mental Health Services in the Sultanate of Oman . . . . . . . . . . . . 2941

Part XVI Infectious Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2991

134 Women with HIV Living in the MENA Region . . . . . . . . . . . . . . 3157

Part XVII Future Directions ............................... 3203

136 Academic Medicine and the Development of Future Leaders

Part XVIII Ethics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3259

138 The Lures of the Scalpel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3261

147 Deconstructing the Challenges of Doing Research in Conﬂict

Part XIX Dental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3413

149 Trigeminal Neuralgia in the Arab World Together with an

Ismail Laher graduated from the University of London

Section: Central Nervous System

Section: Health Systems and Health Management

Section: Childhood Diseases

Section: Childhood Diseases