Severe challenges at the nexus of health, environmental resilience, and social and economic equity
Need for funding and training of public health practitioners
SEATTLE (7 August 2017) – Suicide, homicide, and sexual assault are increasing much faster in the Eastern Mediterranean Region than any other region in the world, according to a new scientific study. These violent acts, as well as conflicts, accounted for more than 200,000 deaths in the region in 2015.
“Intractable and endemic violence is creating a lost generation of children and young adults,” said Dr. Ali Mokdad, the study’s lead author and the Director for Middle Eastern Initiatives at the Institute for Health Metrics and Evaluation (IHME) at the University of Washington. “The future of the Middle East is grim unless we can find a way to bring stability to the region.”
In addition to violence in the region, there has been a sharp increase in non-communicable diseases and mental health conditions such as depression, anxiety, bipolar disorder, and schizophrenia. Depression and anxiety disorders were the most common mental conditions, according to the study, published today in the International Journal of Public Health. Both affect women more than men.
“With globalization and urbanization of most societies, women may be exposed to numerous stressors, which have repercussions on the entire household, and children in particular,” said Dr. Raghid Charara, of American University of Beirut and one of the study’s more than 500 collaborators.
Mental disorders contributed to nearly 11 million years lived in less than ideal health, also known as years lived with disability, or YLDs. The problem is exacerbated by the lack of both mental health practitioners and funding for services.
Throughout the region, the ratio of practitioners to 100,000 people was about seven on average and was as low as 0.5 psychiatrists per 100,000 people in countries such as Libya, Sudan, and Yemen. By comparison, among European nations the ratio ranges from nine per 100,000 to more than 40.
“There must be a comprehensive plan to build on existing expertise and projects addressing health challenges that exist at the nexus of human health, environmental resilience, and social and economic equity,” Dr. Mokdad said.
In 2015, nearly 30,000 people in the region committed suicide and another 35,000 died from interpersonal violence, representing increases of 100% and 152%, respectively, over the past 25 years. In other parts of the world during the same period, the number of deaths from suicide increased 19% and interpersonal violence by 12%.
The study found that hanging and poisoning are the most common methods of suicide in the Eastern Mediterranean Region. The authors note that statistics on suicide likely are underestimated due to cultural and religious barriers, social stigma, and legal punishments that discourage victims, families, and governments from disclosing such information.
The 15 papers and three editorials that constitute the study are based on the most recent estimates from the annual Global Burden of Diseases, Injuries, and Risk Factors study (GBD), a systematic, scientific effort to quantify the magnitude of health loss from all major diseases, injuries, and risk factors by age, sex, and population. With more than 2,300 collaborators in 132 countries and 3 non-sovereign locations, GBD examines 300-plus diseases and injuries.
This is the first GBD study to examine trends of HIV/AIDS-related mortality comprehensively in the region between 1990 and 2015. There was a 10-fold increase in HIV/AIDS mortality rates, with most of the cases occurring in three nations – Djibouti, Somalia, and Sudan.
“In this region, individuals infected with HIV are dying faster than the rest of the world,” said Dr. Charbel El Bcheraoui, an Assistant Professor at IHME. “This is a sign that that that that HIV patients are not receiving proper treatment in an era where HIV can be well controlled with the appropriate treatment regimens.”
In addition, this study was the first ever to report on transportation-related deaths and injuries in the region between 1990 and 2015. In 2015, these incidents comprised the eighth leading cause of death in the region overall, but were ranked second in Qatar, Oman, and the United Arab Emirates (UAE). The percentage of total deaths in Qatar was the highest at 20%, followed by Oman (16%) and UAE (14%), whereas the lowest rates were in Pakistan (1.9%), Lebanon (1.8%), and Somalia (1.5%). Death rates from this cause in the region have not fallen as quickly as they have globally, and, in fact, three countries – Libya, Pakistan, and Egypt – had increases in death rates.
“Transportation-related injuries and deaths are just as much a public health issue as HIV or diabetes,” said Dr. Mokdad. “And like HIV and diabetes, prevention measures, combined with education and treatment, are vital to mitigating this problem.”
Other highlights of the report include:
- Ischemic heart disease was the leading cause of death in the region followed by cerebrovascular disease. Changes in total deaths ranged from a reduction of 65% for diarrheal diseases to an increase of nearly 140% for diabetes and tracheal, bronchus, and lung cancer.
- Progress on child survival remains uneven, and total deaths for children under the age of 5 decreased at a slower rate than globally, with about 80% of under-5 deaths occurring in six countries: Afghanistan, Pakistan, Somalia, South Sudan, Sudan, and Yemen. Three countries – Sudan, Afghanistan, and Pakistan – are among the 10 countries with the highest child mortality in the world.
- The top five causes of under-5 mortality were: neonatal preterm birth complications, neonatal encephalopathy, lower respiratory tract infections (LRI), congenital defects, and diarrheal diseases.
- Communicable diseases and the health consequences of natural disasters reduced substantially between 1990 and 2015. However, these gains have been offset by the health effects of war, mental health disorders and self-harm.
- Among adolescents, tobacco use and high body mass index were common health risks; many countries had high rates of adolescent pregnancy and unmet need for contraception.
- Poor diet is the leading cause of disability-adjusted life years (DALYs) in the region. People in many countries are suffering from malnutrition and at the same time from poor diet that is leading to disease. In addition, tobacco smoking and high blood pressure are among the top causes of DALYs.
- The region also has wide variation in per capita gross national product (GNP), ranging from a high of $134,420 in Qatar to a low of $2,000 in Afghanistan.
- The proportion of the population living below the national poverty line, according to World Bank data, is more than 20% in seven EMR countries: Afghanistan (36%), Egypt (22%), Iraq (23%), Pakistan (22%), Palestine (22%), Sudan (47%), and Yemen (35%). In five of these countries, approximately one-third of the population is also food-insecure: Afghanistan (34%), Iraq (30%), Pakistan (30%), Sudan (33%), and Yemen (36%).
- Several countries in the region face significant environmental challenges due to lack of water, rising temperatures, and sand storms. The paper calls for renewed efforts to address problems associated with ambient air pollution.
“In recent years, many of the health gains for some countries have slowed and several health conditions that were under control are re-emerging, said Dr. Mokdad. “This study clearly indicates that the future health of the region is in danger.”
The Eastern Mediterranean Region is home to more than 600 million people, representing a diverse group of 22 countries: Afghanistan, Arab Republic of Egypt, Bahrain, Djibouti, Iraq, Islamic Republic of Iran, Jordan, Kingdom of Saudi Arabia (KSA), Kuwait, Lebanon, Libya, Morocco, Oman, Pakistan, Palestine, Qatar, Republic of Yemen, Somalia, Sudan, Syrian Arab Republic (Syria), Tunisia, and the United Arab Emirates (UAE).
The complete set of papers and data visualizations are available at www.healthdata.org.
Top 10 Findings on the Eastern Mediterranean Region
- War and violence were the leading causes of deaths in 2015 in Syria, Yemen, Iraq, Afghanistan, and Libya.
- Deaths by suicide in 2015 totaled 28,695, as compared to 14,335 in 1990, in increase of 100%.
- The prevalence of obesity increased by 37% since 1980, and today one in five adults are obese in EMR countries; Qatar and Kuwait have the highest prevalence among adults and children.
- Mental disorders contributed to nearly 11 million years lived in less than ideal health, also known as years lived with disability, or YLDs.
- Heart and related cardiovascular diseases were the top causes of death in the region in 2005 and again in 2015, accounting for one-third of all deaths.
- Deaths resulting from HIV/AIDS in the EMR have continued to increase even with the availability of antiretroviral treatment in 2015; the highest rate of 46 per 100,000 population was in Djibouti.
- Cancer was responsible for approximately one tenth of all deaths in 2015; breast cancer, lung cancer, and stomach cancer were the most common types of cancer.
- Eighty percent of deaths among children under age 5 occurring in six countries: Afghanistan, Pakistan, Somalia, South Sudan, Sudan, and Yemen. Three countries – Sudan, Afghanistan, and Pakistan – are among the 10 countries with the highest child mortality in the world.
- At more than 190,000 deaths, lower respiratory infections comprised the third leading cause of mortality in 2015, with Somalia, Djibouti, and Afghanistan having the highest rates.
- In 2005, diarrhea ranked fifth in the top 10 causes of premature death; in 2015, it ranked ninth, the largest drop among those top 10 causes.
Established in 2007, the Institute for Health Metrics and Evaluation (IHME) is an independent research center within UW Medicine at the University of Washington in Seattle. IHME provides rigorous and comparable measurement of the world’s most important health problems and evaluates strategies to address them. IHME makes this information available so that policymakers, donors, practitioners, researchers, and local and global decision-makers have the evidence they need to make informed decisions about how to allocate resources to improve population health. For more information, visit www.healthdata.org.