PUBLIC HEALTH IN THE MIDDLE EAST Reconnaissance of Issues and Developments

PREAMBLE: Over the past 15 years, PacificSci principals have had the opportunity to be involved in aspects of public health development in countries grouped within the Eastern Mediterranean Regional Office of the World Health Organization (WHO/EMRO), specifically Kuwait, Pakistan and the United Arab Emirates (UAE). This has been by virtue of both full time geographically-based work (1998-2003), as well as short term consultancies and collegial links.

These countries and their neighbours in the region face many common and similar challenges in terms of social and economic development, status of women, environmental control and regulation, a highly mobile migrant workforce and other demands of competing in a globalized economy.

Over the past decade especially, the region as a whole has also been dealing with social and political unrest, much of this of an extreme nature, largely resulting from a lack of good governance combined with negative geopolitical dynamics that have given scant regard to the wellbeing of the general populace.

Good public governance, referring to how public institutions function responsively, transparently, and with accountability, is a key mechanism through which the values of development are secured for people. These values include equality of treatment, freedom to choose, opportunities to participate in the process, and not least of all - justice. Such governance recognizes the integrity, rights, and needs of everyone within the state, and is essential to reducing poverty and stimulating growth.[1]

Good governance also embodies the value of “healthy public policy”, characterized by explicit concern for health and equity in all areas of policy and by accountability for health impact. The main aim of health public policy is to create a supportive environment to enable people to lead healthy lives. Such a policy makes health choices possible or easier for citizens. It makes social and physical environments health-enhancing. In the pursuit of healthy public policy, government sectors concerned with agriculture, trade, education, industry, and communications need to take into account health as an essential factor when formulating policy. Healthy public policy benefits populations, communities and individuals.[2]

This brief Reconnaissance consists of two sections: first, the published perspectives of the World Bank and WHO/EMRO, and secondly, our own observations of the emergence of two important networks: public health associations, and membership of national public health institutes in a new global organization.
Note: Minor edits were made to this posting on May 17 and 18, 2012.

PUBLIC HEALTH IN THE MIDDLE EAST
– Regional Perspectives
A DECADE AGO, the World Bank supported a regional conference in Beirut which led to a major report entitled Public Health in the Middle East and North Africa – meeting the challenges of the twenty-first century.[3]

Based on discussion elaborated in chapters of this report, six priorities emerged: 1. Leadership and Political Will 2. A New View of Public Health 3. Data and Surveillance 4. Partnerships and Collaboration 5. Emerging Health Problems 6. Public Health “Best Buys”

The report stated that “the status of public health practitioners is a significant problem. One of the main challenges facing public health in the... region is the recruitment and retention of appropriate skills and expertise, in terms of both quality and quantity.”

The persistence of an outmoded view of public health therefore is part of the challenge in this region, and could be the greatest obstacle to change: a view of public health as an adjunct to the health care system, rather than as a strategic force for a healthy population.

The challenge therefore is to envision what public health throughout the region could become within a reasonable period, say 15-20 years, then determine how to take it there. Insightful leadership with political support can lead this change.

It is on this particular issue regarding outmoded concepts of public health that the following selected extracts from the 2002 World Bank summary of priority issue #2 (above) justify consideration (bullets added and sequence adjusted for emphasis) and are highly applicable to the region:

A New View of Public Health:
• Countries should undertake assessments of their public health functions and capacity in the near future…. steps should be taken to build capacity and broaden the scope of public health beyond the activities of physicians….
• Public health infrastructure should not be an adjunct to curative health systems. Rather it should be part and parcel of a comprehensive health system that blurs the boundaries between curative and public health services.
• There must be greater multisectoral commitment to healthy public policies; this can be accomplished by developing objectives and targets for healthy populations and lifestyles, including the necessary laws and regulations.
• Developing community based health promotion programs can be an effective way to increase the health literacy of communities.

Now moving to a more recent review by World Bank regional specialists [4], disease-surveillance systems as reviewed by the WHO Regional Office WHO/EMRO) were considered mostly inadequate, with insufficient commitment, lack of practical guidelines, overwhelming reporting requirements, lack of transparency, shortage of human resources, and poor analysis of data. It is stated that: “this deficit in the capability to assess and monitor population health will have to be addressed if effective plans for public health capacity building are to be put in place”.

Equally critical, the World Bank reviewers considered that, while many public-health services are well-established, management functions such as inter-sectoral policymaking, public information and education, and quality assurance, are underdeveloped.

Further, when compared with other world regions, the limited interaction between governments and civil society is considered likely to reduce the social dividend by not meeting rising expectations in the population.

The review argued that higher health sector spending will not translate into effective results if investments are not well managed or directed towards cost-effective solutions, and concludes that new institutional capacities and governance structures are needed.

New Public Health Networks
In some countries, there are organized public health professional and lay networks. These are generally found in larger countries, although with varying levels of vitality e.g., national public health associations exist in Egypt, Ethiopia, Iran, Lebanon, Pakistan, Sudan and Yemen. At the other extreme, the Gulf states so far generally lack this type of non-governmental support for public health; these entities typically have much smaller national populations (with the exception of Saudi Arabia with 27.4 million people, of whom some 19 million are nationals).  Such associations have the opportunity to affiliate with a long-standing and reputable international body: the World Federation of Public Health Associations (WFPHA).[5]

Note: The six Arab states bordering the Arabian Gulf: Saudi Arabia, UAE, Qatar, Kuwait, Bahrain and Oman form the Gulf Cooperation Council (GCC). Although Iraq is an Arab state and shares a small border with the Gulf, it is generally not included within this grouping.

Interestingly, national public health institutes are also reaching out among themselves, by affiliating with a recently formed International Association of National Public Health Institutes (IANPHI).[6] Among EMRO countries, these include Afghanistan, Iran, Jordan, Morocco, Pakistan and Saudi Arabia. Turkey and Israel are also members of IANPHI, but not included within the WHO-EMRO group of countries (they are considered within WHO-EURO).

In other words, these governmental public health agencies are starting to link up within an international network. According to their website, IANPHI spearheads improvements in national public health systems through a peer-assistance evaluation, grant support and efforts focused on NPHI advocacy, collaboration, and sustainability. It provides direct funding to governments in low-resource countries to build and strengthen national public health capacity through development of NPHIs. It does this through grants to support NPHI to NPHI evaluations, longer term capacity building initiatives, and seed grants to assist particular research agendas.

All this may make it attractive for other Middle Eastern countries to consider both supporting the development of public health associations and also joining this global intergovernmental agency network, particularly those who need to build capacity... and (when it comes down to it) who doesn't? 

Developing a national public health association, especially, is a  way of strengthening the role of civil society in a domain that can only be in the best interests of the population.

Envoi –Springtime for Public Health in the Middle East?
Prerequisites for health and social development everywhere are peace and justice; nutritious food and clean water; education and decent housing; a useful role in society and an adequate income; conservation of resources and the protection of the ecosystem. These increasingly appear to be the aspirations of Middle Eastern peoples, and indeed throughout the greater Eastern Mediterranean Region.

The vision of healthy public policy is the achievement of these fundamental conditions for healthy living. The achievement of global health rests on recognizing and accepting interdependence both within and between countries. Commitment to global public health will depend on securing the means of international cooperation, especially to act on issues that cross national boundaries.[6]

While the road ahead will have its challenges, and will require new forms of leadership, the international networking that is starting to emerge in the Middle East may well be a forerunner of an “Arab Spring for public health”. If so, this can only be to the ultimate benefit of all who live in the region.

References
1. World Bank. Better Governance for Development in the Middle East and North Africa: Enhancing Inclusiveness and Accountability. 2011. http://web.worldbank.org/WBSITE/EXTERNAL/COUNTRIES/MENAEXT/EXTMNAREGTOPGOVERNANCE/0,,contentMDK:20261216~pagePK:34004173~piPK:34003707~theSitePK:497024,00.html Accessed May 14, 2012.
2. Report on the Adelaide Conference. Healthy Public Policy. 2nd International Conference on Health Promotion April 5-9, 1988 Adelaide South Australia. http://www.who.int/healthpromotion/conferences/previous/adelide/en/index1.html Accessed May 14, 2012.
3. Pierre-Lousie AM, Akala FA, Karam HS. Public health in the Middle East and North Africa: meeting the challenges of the twenty-first century. World Bank Institute. WBI Learning Resources Series. The World Bank 2004.
4. Akala FA, El-Saharty S. [The aWorld Bank, Middle East and North Africa Region, Human Development Sector, Washington, DC] Public-health challenges in the Middle East and North Africa. The Lancet (2006) 367: 961-4.
5. World Federation of Public Health Associations. http://www.wfpha.org/  Accessed May 16, 2012.
6. Public Health Institutes of the World (IANPHI). http://www.ianphi.org/  Accessed May 13, 2012.

INTERNATIONAL & GLOBAL DEVELOPMENT - YEAR IN REVIEW 2007

LATE BREAKER: For a thought-provoking critical analysis of what the Bhutto assassination on December 27 means for Pakistan and the "war on terror", see the new addition in our sidebar.

PREAMBLE: This issue also completes our first full year of blogging. Drawing from topics covered during the year, we offer below: overviews views on three major issues for humankind, followed by paraphrases from our monthly themes in 2007.

THREE LEADING ISSUES FROM 2007: Flowers or Fertilizer?
1. GLOBAL STEWARDSHIP: In our view, the lead issue here is Climate Change (May, October), which is already displacing some of the world’s vulnerable populations, and ultimately threatening life on this planet. This is followed closely by global food security (February) and displacement by rich countries of grain for use as automotive fuel, thereby creating pressure on its use in food in developing countries, and even the price of food in developed ones, impacting on access and affordability. Flowers: to the European Community for its global leadership on climate. Fertilizer: To Canada’s Conservative government which has set the world’s worst example of procrastination on climate.

Note: At the recently concluded UN Climate Summit in Bali, Canada received a “Fossil Award” for its dismal performance on addressing climate change, while the tactics adopted by our Conservative government to undermine the developing global consensus on the need for binding targets now were described by numerous observers as "hypocritical" and “deceitful”.

2. INTERNATIONAL DEVELOPMENT: Viewed broadly, we consider the leading issue here to be Maternal & Child Health (April, November). The determinants include gender inequality, global poverty, and insufficient policy and program development at all levels. Even in developed western countries this is an issue: taking our own country Canada as an example, the “new” Conservative government’s reneged on the Kelowna Accord to improve conditions for aboriginals, and failed to ensure an adequate child care platform (March, April). Further, with the exception of the Nordic nations, official development assistance from wealthy developed countries is still far less than targets agreed decades ago. Flowers: Norway, whose 4.7 million people already contribute almost $4 billion a year to aid developing countries ($850 for each Norwegan man, woman and child). Fertilizer: The powerful G7 nations for allocating proportionally less Gross National Income (GNI) for international development: 0.30%, compared with .50% for non-G7 nations.

3. HUMAN RIGHTS ABUSES: Still topping the list continues to be the War in Iraq (January, August). Primary responsibility is shared between the Bush and Blair regimes (not equally) for promoting false rumours of weapons of mass destruction, unsupported by UN inspections led by Hans Blix. While insurgents share responsibility for the mayhem and catastrophe, the end results include over half a million Iraqis killed (a genocide?), massive numbers of refugees, and the undermining of Geneva Conventions that were born out of the worst excesses of World War 2. Flowers: Pastor Martin Niemoller (1892-1984). Fertilizer: George Bush (most dangerous US President in history).

Historical Notes:
1) For a revealing 2003 interview of Hans Blix, visit: http://www.truthout.org/docs_03/041203A.shtml
2) For an October 2006 update on JHU estimates of Iraqi deaths: http://www.jhsph.edu/publichealthnews/press_releases/2006/burnham_iraq_2006.html

2007 AS WE RECORDED IT:
 January: PEACE, SECURITY, HEALTH & HUMAN RIGHTS: In our first issue of 2007, we took note of the incoming UN Secretary General Ban Ki-moon, acknowledging the immense contribution of former Secretary-General Kofi Annan, focused on war and peace in the Middle East, and completed the transfer of reports and commentaries from our News & Reports site (as announced in our December 2006 posting).

 February: GLOBAL FOOD SECURITY – A MATTER OF SURVIVAL: In 1996, the World Food Summit set a target to halve the number of undernourished people by 2015. However, in 2007, it appears unlikely that this target will be met. This issue focused on the conflict between grain for fuel or for food, the stalled Doha round, and food security.

 March: COLONIZED MINORITIES IN DEVELOPED COUNTRIES: Colonized racial, cultural or religious minorities exist throughout the world, within powerful societies eg., Tibet in China, Japan's Ainu, India's Dalits, Amerindian enclaves in the Caribbean, tribal minorities in Africa, Boznian Muslims, the Kurds of Iraq, others in all continents and among the Pacific islands. The issues apply to several economically advanced western countries where it is sometimes said that one may find “3rd world conditions in 1st world settings”. Because these countries claim leadership for human rights, they also must live up to these principles.

 April: EARLY CHILD DEVELOPMENT – POLICY SHIFTS, GLOBAL VIEWPOINTS, AND THE EVIDENCE BASE: This issue focused on Canadian policy shifts of global interest. Sadly, Canada’s reputation for enlightened social policy is being undermined by a neo-conservative ideology. Over a million Canadian children live in poverty and cannot access child care. In support of child-friendly interventions, we included evidence reviewed by the US-based RAND Corporation showing that childhood intervention programs yield benefits in behavior, educational progression and attainment, delinquency and crime, and labor market success, among other domains.

 May: CLIMATE CHANGE, KYOTO ACCORD, EUROPE RESPONDS & CANADA REMAINS CHALLENGED: The European Community (EU) takes Climate Change seriously, and is making progress towards its Kyoto targets. On April 26, 2007, Canada’s Conservative government released its first “climate-change plan”. Despite Canada leading the world in reducing ozone destroying chlorofluoro-carbons (Montreal Protocol 1987), signing the Kyoto Protocol (1997), and hosting its ratification (2005), this plan is incapable of meeting Canada’s Kyoto targets. Ranked 27th of 29 by the OECD on Greenhouse Gas (GHG) emissions, Canada remains among the most environmentally delinquent industrialized countries.

 June: OFFICIAL DEVELOPMENT ASSISTANCE & GLOBAL HEALTH TRENDS: This issue reviews the vexing issue of development assistance from wealthy developed countries such as Canada, references a report on global social and economic trends, then selects reports from a discipline essential to understanding global health trends: Health Situation Analysis. Selected examples included Africa, the State of the World Children, and Projections of Mortality and Burden of Disease to 2030.

 July: CELEBRATING THE AFRICAN MEDICAL AND RESEARCH FOUNDATION: In 1957, three surgeons in Kenya had a vision that could revolutionize health care in Africa. They launched a Flying Doctor Service (FDS). Over the next 5 decades, men set foot on the moon, satellites explored our solar system, the universe was probed with powerful orbital telescopes, robots explored the surface of Mars, and shuttles began servicing an international space station. In the meantime, with poverty and ill-health still pervading the planet, FDS became Africa’s largest indigenous health organization: the African Medical and Research Foundation.

 August: FIRST THEY CAME... VIGNETTES IN THE DISMANTLING OF DEMOCRATIC MYTHS: In this issue we offered a selection of extracts from reputable sources that focus on the disastrous trajectory of the current US administration in undermining the beliefs that underpin western democracies. We dedicate the issue to Pastor Martin Niemoller (1892–1984), whose famous poem “First they came…” about the inactivity of German intellectuals during the Nazi rise to power and the subsequent purging of their chosen targets, group by group, most devastatingly to German Jews.

 September: THIRD WORLD AID TO FIRST WORLD COUNTRIES: This issue featured the "brain drain" from sub-Saharan Africa, citing a report from Juan Ramos of ProCOR (website listed in sidebar). Practical responses re examined: striving for better compensation for indigenous health professionals, attention to policies that determine recruitment and retention of health professions in low income countries, fixing the ethics of western firms that raid poor countries to meet the service demands of rich ones, and finding ways to compensate third world "donor" countries for their loss of human resources. Through official inaction, "first world" countries benefit from a massive subsidy from the "third world", equal to the direct and indirect costs of their investment in this health human resource, and the opportunity costs entailed by its loss.

 October: IS CLIMATE CHANGE AN ACT OF AGRESSION?: In this issue we abstracted an article carried by The Economist (on-line Sept 24th, 2007) that reported on Ugandan President, Yoweri Museveni's declaration that climate change is an act of aggression by the rich world against the world’s poor. We also noted a statement from the Church World Service (CWS): "The issue... is how climate change frames development and justice", said Rajyashri Waghray, CWS director, education & advocacy.

For stark contrast we noted Canada’s uncertain posture, quoting from a Globe and Mail Editorial (September 26): “Prime Minister Stephen Harper’s progress from a climate-change skeptic to an environmental convert has been a perplexing odyssey. After a half-hearted attempt to tackle greenhouse-gas emissions late last year, his Conservative government hurriedly introduced new regulations and incentives, which made a good start in fostering reductions. Earlier…(in September), in Australia, he even announced his personal commitment to ‘careful environmental stewardship’. That seemed heartfelt. Now it is fair to question the sincerity of that conversion. On… (Sept 24), at a UN climate change conference aimed at saving the Kyoto Protocol, Mr Harper announced that Canada had asked to join a rival climate-change pact, the Asia-Pacific Partnership. The six members of that pact include nations that have refused to ratify the protocol, such as the United States, and others among the world’s worst polluters, such as India and China. Together they account for nearly half of all greenhouse gas emissions”.

 November: MATERNAL MORTALITY: WHAT DO SOUTH ASIA, THE UNITED STATES, AND AFRICA SHARE?: Maternal Mortality represents the largest rich-poor disparity tracked by the World Health Organization. On the heels of a study released by the United Nations (UN), the Women Deliver Global Conference in London, 18-20 October, assessed high levels of maternal mortality round the world. Little progress has been made in reducing maternal deaths in many countries. Areas of major focus were South Asia, parts of Africa, and even the United States, as it lags the developed world in its maternal health performance. The conference was supported by non-governmental, intergovernmental and development agencies as well as private sector and philanthropic entities aiming to create the political will to improve the health of pregnant mothers and their children, and to strengthen health systems around the world to prevent the deaths during pregnancy or childbirth of "one woman every minute of every day ".

“The eradication of poverty and hunger… cannot be achieved if questions of population and reproductive health are not addressed”. Kofi Annan

HOLIDAY GREETINGS: We extend to readers our best wishes for the holiday season and the New Year. We hope you found our selections during 2007 thought provoking and factually informative, and that you will continue to monitor this report.