Comment
At one peer review meeting held during the preparation of the Lancet Series on Health in the Arab World: a View from Within, Karima Khalil gave me a copy of her beautiful book, Messages from Tahrir: Signs from Egypt’s Revolution (American University in Cairo Press, 2011). She inscribed on the inside “These voices from Tahrir”, and powerful voices they were too. They were voices that seemed to herald an era of extraordinary events across the region. Here are some of the messages she captured in photographs of Egyptians during the first few months of 2011: “We are all Egyptians...wake up”; “America should support the people not the tyrant”; “Enough humiliation”; “Stay steadfast for freedom”; “Do not let your revolution be stolen from you.” 3 years later, the sense of hope that this, and other, Arab uprisings gave birth to has been tempered by an understanding that achieving liberty, equality, and democracy will take considerably longer than perhaps was initially thought. The most appalling example of public protest evolving into bitter civil conflict is Syria. The consequences for the region continue to be deeply disturbing. First, the human cost—hundreds of thousands of families displaced and living as refugees in Jordan, Lebanon, Turkey, and Iraq. With over 2 million refugees and over 4 million internally displaced Syrians, the UN last month launched the largest humanitarian appeal in its history. Second, the geopolitical threat—as tensions between nations rise as a result of the Syrian conflict, and as conflicts between different groups within the Arab world escalate, the potential for further confrontations elsewhere remains high. And third, the economic burden—political instability will create adverse economic conditions for sustainable growth in the region, with important impacts on prospects for poverty reduction and increased investments into the health sector. In Syria, the health system is already effectively destroyed. The risk of damage to neighbouring health systems is real. These political events make it all the more important to examine the conditions for advancing health and wellbeing in the region. This Series describes the state of health of Arab and non-Arab peoples living in the Arab world by estimating the burden of diseases, injuries, and risk factors they face.1 But then the Series departs from the usual format of our country studies. When the authors met to plan their work, they did not www.thelancet.com Vol 383 January 25, 2014
want to use the conventional approach of a health systems analysis, a report of the challenges either from infectious diseases or to maternal and child health, and a call to action. Instead, they wished to describe the region by emphasising, in particular, the major political determinants of health. A previous comprehensive analysis of health in the Arab world had already been published,2 so there was considerable scope to, and advantage from, this different approach. With that objective in mind the Series begins with governance.3 It is followed by studies of noncommunicable diseases,4 universal health coverage,5 the changing geographies of war,6 and finally the issue of survival—ecological sustainability in the Arab world.7 These papers are complemented by a Viewpoint on recent political changes across the Arab world and their meaning for health,8 two essays on research networks9 and state formation,10 and four Comments looking at issues ranging from health equity to tobacco control.11–14 Visiting the Arab world today introduces you to unparalleled diversity. The steel and glass efficiency of monumental architectural constructions in Qatar, the quieter but no less intensely successful tourist industry in Oman, the inspiring resilience of the occupied Palestinian territory, the culturally vibrant international urban hubs of Cairo and Beirut, and the endemic and seemingly ineradicable violence of Iraq. This diversity is symbolic of a region in transition—ageing populations, deepening within and between country inequalities, increasing participation of the private sector in health-care delivery, residually weak public sectors, and the resurgence of infectious threats. In my notes taken over the past 2 years preparing for this Series, I wrote three personal hopes: first, to overcome the invisibility and even erasure of the Arab world in global health (and medical journals); second, to identify and emphasise Arab leadership in the Arab region; and third, to elevate the Arab voice in (global) health. One Series alone cannot deliver all of these goals. But I hope it can make a small and irreversible contribution to their ultimate achievement.
Andrew McConnell/Panos
Health in the Arab world: a renewed opportunity
Published Online January 20, 2014 http://dx.doi.org/10.1016/ S0140-6736(13)62703-8 See Comment pages 284 and 286 See Perspectives page 299 See Articles page 309 See Series page 343, 356, and 368 See Online/Comment http://dx.doi.org/10.1016/ S0140-6736(13)62381-8 and http://dx.doi.org/10.1016/ S0140-6736(13)62370-3 See Online/Series http://dx.doi.org/10.1016/ S0140-6736(13)62299-0 and http://dx.doi.org/10.1016/ S0140-6736(13)62338-7 See Online/Viewpoint http://dx.doi.org/10.1016/ S0140-6736(13)62567-2 See Online/Essay http://dx.doi.org/10.1016/ S0140-6736(13)62548-9 and http://dx.doi.org/10.1016/ S0140-6736(13)62704-X
Richard Horton The Lancet, London NW1 7BY, UK
283
Comment
I owe special thanks to a large network of Arab scientists who have contributed to this Series. Special thanks go to Huda Zurayk, Rita Giacaman, Samer Jabbour, and Iman Nuwayhid for their persistent and exceptional commitment to this project. Thanks also to IDRC for financial support, and to the Faculty of Health Sciences at the American University of Beirut for hosting our planning and peer review meetings. 1
2 3
4
5
6
Mokdad AH, Jaber S, Abdel Aziz MI, et al. The state of health in the Arab world, 1990–2010: an analysis of the burden of diseases, injuries, and risk factors. Lancet 2014; published online Jan 20. http://dx.doi.org/10.1016/ S0140-6736(13)62189-3. Jabbour S, Giacaman R, Khawaja M, Nuwayhid I. Public health in the Arab world. Cambridge: Cambridge University Press, 2012. Batniji R, Khatib L, Cammett M, et al. Governance and health in the Arab world. Lancet 2014; published online Jan 20. http://dx.doi.org/10.1016/ S0140-6736(13)62185-6. Abdul Rahim HF, Sibai A, Khader Y, et al. Non-communicable diseases in the Arab world. Lancet 2014; published online Jan 20. http://dx.doi.org/ 10.1016/S0140-6736(13)62383-1. Saleh SS, Alameddine MS, Natafgi NM, et al. The path towards universal health coverage in the Arab uprising countries Tunisia, Egypt, Libya, and Yemen. Lancet 2014; published online Jan 20. http://dx.doi.org/10.1016/ S0140-6736(13)62339-9. Dewachi O, Skelton M, Nguyen V-K, et al. Changing therapeutic geographies of the Iraqi and Syrian wars. Lancet 2014; published online Jan 20. http://dx.doi.org/10.1016/S0140-6736(13)62299-0.
7
8
9
10
11
12
13
14
El-Zein A, Jabbour S, Tekce B, et al. Health and ecological sustainability in the Arab world: a matter of survival. Lancet 2014; published online Jan 20. http://dx.doi.org/10.1016/S0140-6736(13)62338-7. Jabbour S. Health and contemporary change in the Arab world. Lancet 2014; published online Jan 20. http://dx.doi.org/10.1016/S01406736(13)62567-2. Giacaman R, Al-Ryami A, Bashour H, et al. Importance of research networks: the Reproductive Health Working Group, Arab world and Turkey. Lancet 2014; published online Jan 20. http://dx.doi.org/10.1016/S01406736(13)62704-X. Tell T. State formation and underdevelopment in the Arab world. Lancet 2014; published online Jan 20. http://dx.doi.org/10.1016/S01406736(13)62548-9. Alwan A. Responding to priority health challenges in the Arab world. Lancet 2014; published online Jan 20. http://dx.doi.org/10.1016/S01406736(13)62572-6. Rashad H. Health equity in the Arab World: the future we want. Lancet 2014; published online Jan 20. http://dx.doi.org/10.1016/S01406736(13)62350-8. Nakkash R, Afifi R, Maziak W. Research and activism for tobacco control in the Arab world. Lancet 2014; published online Jan 20. http://dx.doi. org/10.1016/S0140-6736(13)62381-8. Zurayk H, Giacaman R, Jabbour S. The making of the Lancet Series on health in the Arab world. Lancet 2014; published online Jan 20. http://dx.doi. org/10.1016/S0140-6736(13)62370-3.
Responding to priority health challenges in the Arab world Published Online January 20, 2014 http://dx.doi.org/10.1016/ S0140-6736(13)62572-6 See Comment pages 283 and 286
Lynsey Addario/VII/Corbis
© 2014. World Health Organization. Published by Elsevier Ltd/Inc/BV. All rights reserved.
284
The Arab world today faces major challenges to health development, which are captured by papers in this Series. After my election as WHO Regional Director for the Eastern Mediterranean in January, 2012, my first task was to work closely with WHO member states to agree on an agenda to address these challenges. A series of high-level consultations was held with countries and experts, after a process of objective analysis of the health situation in the countries of the region. It is a region of great diversity. Although many countries, both Arab and non-Arab,
have made great gains and have built extensive modern networks of health infrastructure with wide deployment of medical technologies, these gains have not been shared across and within countries. Many of the challenges cut across the health sector and are shared by all countries. In October, 2012, health ministers of the region agreed on five key priority areas—highly relevant to all countries—and on strategic directions for public health action to tackle them.1,2 The priority areas were aligned with the five categories for priority setting that were endorsed by all WHO Member States during the World Health Assembly in May, 2012. Although these directions were intended to guide the work of WHO, their focus and nature make them applicable for a much broader range of stakeholders and partners. One of the five priorities is strengthening of health systems. Accelerating progress towards universal health coverage by reforming health systems is top priority for WHO in the region. The aim is to ensure access for all people to quality health services without risk of financial hardship. This is a difficult challenge considering the current low levels of prepayment schemes and high out-of-pocket health expenditures in many countries. With support from WHO, and working closely with the World Bank and other partners, countries are beginning to develop a vision, www.thelancet.com Vol 383 January 25, 2014
At one peer review meeting held during the preparation of the Lancet Series on Health in the Arab World: a View from Within, Karima Khalil gave me a copy of her beautiful book, Messages from Tahrir: Signs from Egypt’s Revolution (American University in Cairo Press, 2011). She inscribed on the inside “These voices from Tahrir”, and powerful voices they were too. They were voices that seemed to herald an era of extraordinary events across the region. Here are some of the messages she captured in photographs of Egyptians during the first few months of 2011: “We are all Egyptians...wake up”; “America should support the people not the tyrant”; “Enough humiliation”; “Stay steadfast for freedom”; “Do not let your revolution be stolen from you.” 3 years later, the sense of hope that this, and other, Arab uprisings gave birth to has been tempered by an understanding that achieving liberty, equality, and democracy will take considerably longer than perhaps was initially thought. The most appalling example of public protest evolving into bitter civil conflict is Syria. The consequences for the region continue to be deeply disturbing. First, the human cost—hundreds of thousands of families displaced and living as refugees in Jordan, Lebanon, Turkey, and Iraq. With over 2 million refugees and over 4 million internally displaced Syrians, the UN last month launched the largest humanitarian appeal in its history. Second, the geopolitical threat—as tensions between nations rise as a result of the Syrian conflict, and as conflicts between different groups within the Arab world escalate, the potential for further confrontations elsewhere remains high. And third, the economic burden—political instability will create adverse economic conditions for sustainable growth in the region, with important impacts on prospects for poverty reduction and increased investments into the health sector. In Syria, the health system is already effectively destroyed. The risk of damage to neighbouring health systems is real. These political events make it all the more important to examine the conditions for advancing health and wellbeing in the region. This Series describes the state of health of Arab and non-Arab peoples living in the Arab world by estimating the burden of diseases, injuries, and risk factors they face.1 But then the Series departs from the usual format of our country studies. When the authors met to plan their work, they did not www.thelancet.com Vol 383 January 25, 2014
want to use the conventional approach of a health systems analysis, a report of the challenges either from infectious diseases or to maternal and child health, and a call to action. Instead, they wished to describe the region by emphasising, in particular, the major political determinants of health. A previous comprehensive analysis of health in the Arab world had already been published,2 so there was considerable scope to, and advantage from, this different approach. With that objective in mind the Series begins with governance.3 It is followed by studies of noncommunicable diseases,4 universal health coverage,5 the changing geographies of war,6 and finally the issue of survival—ecological sustainability in the Arab world.7 These papers are complemented by a Viewpoint on recent political changes across the Arab world and their meaning for health,8 two essays on research networks9 and state formation,10 and four Comments looking at issues ranging from health equity to tobacco control.11–14 Visiting the Arab world today introduces you to unparalleled diversity. The steel and glass efficiency of monumental architectural constructions in Qatar, the quieter but no less intensely successful tourist industry in Oman, the inspiring resilience of the occupied Palestinian territory, the culturally vibrant international urban hubs of Cairo and Beirut, and the endemic and seemingly ineradicable violence of Iraq. This diversity is symbolic of a region in transition—ageing populations, deepening within and between country inequalities, increasing participation of the private sector in health-care delivery, residually weak public sectors, and the resurgence of infectious threats. In my notes taken over the past 2 years preparing for this Series, I wrote three personal hopes: first, to overcome the invisibility and even erasure of the Arab world in global health (and medical journals); second, to identify and emphasise Arab leadership in the Arab region; and third, to elevate the Arab voice in (global) health. One Series alone cannot deliver all of these goals. But I hope it can make a small and irreversible contribution to their ultimate achievement.
Andrew McConnell/Panos
Health in the Arab world: a renewed opportunity
Published Online January 20, 2014 http://dx.doi.org/10.1016/ S0140-6736(13)62703-8 See Comment pages 284 and 286 See Perspectives page 299 See Articles page 309 See Series page 343, 356, and 368 See Online/Comment http://dx.doi.org/10.1016/ S0140-6736(13)62381-8 and http://dx.doi.org/10.1016/ S0140-6736(13)62370-3 See Online/Series http://dx.doi.org/10.1016/ S0140-6736(13)62299-0 and http://dx.doi.org/10.1016/ S0140-6736(13)62338-7 See Online/Viewpoint http://dx.doi.org/10.1016/ S0140-6736(13)62567-2 See Online/Essay http://dx.doi.org/10.1016/ S0140-6736(13)62548-9 and http://dx.doi.org/10.1016/ S0140-6736(13)62704-X
Richard Horton The Lancet, London NW1 7BY, UK
283
Comment
I owe special thanks to a large network of Arab scientists who have contributed to this Series. Special thanks go to Huda Zurayk, Rita Giacaman, Samer Jabbour, and Iman Nuwayhid for their persistent and exceptional commitment to this project. Thanks also to IDRC for financial support, and to the Faculty of Health Sciences at the American University of Beirut for hosting our planning and peer review meetings. 1
2 3
4
5
6
Mokdad AH, Jaber S, Abdel Aziz MI, et al. The state of health in the Arab world, 1990–2010: an analysis of the burden of diseases, injuries, and risk factors. Lancet 2014; published online Jan 20. http://dx.doi.org/10.1016/ S0140-6736(13)62189-3. Jabbour S, Giacaman R, Khawaja M, Nuwayhid I. Public health in the Arab world. Cambridge: Cambridge University Press, 2012. Batniji R, Khatib L, Cammett M, et al. Governance and health in the Arab world. Lancet 2014; published online Jan 20. http://dx.doi.org/10.1016/ S0140-6736(13)62185-6. Abdul Rahim HF, Sibai A, Khader Y, et al. Non-communicable diseases in the Arab world. Lancet 2014; published online Jan 20. http://dx.doi.org/ 10.1016/S0140-6736(13)62383-1. Saleh SS, Alameddine MS, Natafgi NM, et al. The path towards universal health coverage in the Arab uprising countries Tunisia, Egypt, Libya, and Yemen. Lancet 2014; published online Jan 20. http://dx.doi.org/10.1016/ S0140-6736(13)62339-9. Dewachi O, Skelton M, Nguyen V-K, et al. Changing therapeutic geographies of the Iraqi and Syrian wars. Lancet 2014; published online Jan 20. http://dx.doi.org/10.1016/S0140-6736(13)62299-0.
7
8
9
10
11
12
13
14
El-Zein A, Jabbour S, Tekce B, et al. Health and ecological sustainability in the Arab world: a matter of survival. Lancet 2014; published online Jan 20. http://dx.doi.org/10.1016/S0140-6736(13)62338-7. Jabbour S. Health and contemporary change in the Arab world. Lancet 2014; published online Jan 20. http://dx.doi.org/10.1016/S01406736(13)62567-2. Giacaman R, Al-Ryami A, Bashour H, et al. Importance of research networks: the Reproductive Health Working Group, Arab world and Turkey. Lancet 2014; published online Jan 20. http://dx.doi.org/10.1016/S01406736(13)62704-X. Tell T. State formation and underdevelopment in the Arab world. Lancet 2014; published online Jan 20. http://dx.doi.org/10.1016/S01406736(13)62548-9. Alwan A. Responding to priority health challenges in the Arab world. Lancet 2014; published online Jan 20. http://dx.doi.org/10.1016/S01406736(13)62572-6. Rashad H. Health equity in the Arab World: the future we want. Lancet 2014; published online Jan 20. http://dx.doi.org/10.1016/S01406736(13)62350-8. Nakkash R, Afifi R, Maziak W. Research and activism for tobacco control in the Arab world. Lancet 2014; published online Jan 20. http://dx.doi. org/10.1016/S0140-6736(13)62381-8. Zurayk H, Giacaman R, Jabbour S. The making of the Lancet Series on health in the Arab world. Lancet 2014; published online Jan 20. http://dx.doi. org/10.1016/S0140-6736(13)62370-3.
Responding to priority health challenges in the Arab world Published Online January 20, 2014 http://dx.doi.org/10.1016/ S0140-6736(13)62572-6 See Comment pages 283 and 286
Lynsey Addario/VII/Corbis
© 2014. World Health Organization. Published by Elsevier Ltd/Inc/BV. All rights reserved.
284
The Arab world today faces major challenges to health development, which are captured by papers in this Series. After my election as WHO Regional Director for the Eastern Mediterranean in January, 2012, my first task was to work closely with WHO member states to agree on an agenda to address these challenges. A series of high-level consultations was held with countries and experts, after a process of objective analysis of the health situation in the countries of the region. It is a region of great diversity. Although many countries, both Arab and non-Arab,
have made great gains and have built extensive modern networks of health infrastructure with wide deployment of medical technologies, these gains have not been shared across and within countries. Many of the challenges cut across the health sector and are shared by all countries. In October, 2012, health ministers of the region agreed on five key priority areas—highly relevant to all countries—and on strategic directions for public health action to tackle them.1,2 The priority areas were aligned with the five categories for priority setting that were endorsed by all WHO Member States during the World Health Assembly in May, 2012. Although these directions were intended to guide the work of WHO, their focus and nature make them applicable for a much broader range of stakeholders and partners. One of the five priorities is strengthening of health systems. Accelerating progress towards universal health coverage by reforming health systems is top priority for WHO in the region. The aim is to ensure access for all people to quality health services without risk of financial hardship. This is a difficult challenge considering the current low levels of prepayment schemes and high out-of-pocket health expenditures in many countries. With support from WHO, and working closely with the World Bank and other partners, countries are beginning to develop a vision, www.thelancet.com Vol 383 January 25, 2014
