“Before the Kingdom of Saudi Arabia was established in 1932, health care was generally provided by local healers”, explains the website for the Saudi Arabian embassy in the USA. “One of King Abdulaziz's first initiatives for his new state was to establish free health care, not just for citizens, but for the pilgrims who come to the Kingdom to visit the Islamic holy sites”. According to Bloomberg, Saudi Arabia now has the 16th most efficient health-care system in the world, ahead of countries such as Canada, Germany, Sweden, and the USA. Saudi Arabia's development plan for 2010–20 envisages the creation of dozens of new hospitals and hundreds of primary care centres. Money is not a problem for the oil-rich state, but it is heavily reliant on foreigners—only 20% of the country's 34 000 physicians are Saudi nationals. The Government provides roughly 60% of the nation's health care, the rest is made up of the private sector and institutions that cater for state employees. “The establishment of a modern health care and social services system has been one of Saudi Arabia's most stunning successes”, concludes the statement on the embassy's webpage.
So the country should be reasonably equipped to deal with any worsening of the current Middle East Respiratory Syndrome (MERS) outbreak. Saudi Arabia recorded 61 new cases of the disease in the first 20 days of September, bringing the total number of cases in the country since the virus was initially identified in June 2012, to 1246, with 532 deaths. A continuing outbreak in a Riyadh hospital has so far been implicated in at least 62 cases. Saudi Arabia is by some distance the country worst affected by MERS—overall there have been about 1500 cases in 26 countries. WHO has declined to declare a public health emergency, but released a statement on the outbreak on Sept 3, pointing out that the start of Hajj is pending. More than 2 million Muslims from all over the world are expected to arrive in Saudi Arabia. “Many pilgrims will return to countries with weak surveillance and health systems”, noted WHO. “The recent outbreak in the Republic of Korea demonstrated that when the MERS virus appears in a new setting, there is great potential for widespread transmission and severe disruption to the health system and to society”. The statement drew attention to the importance of raising awareness of the disease, but did not recommend any travel restrictions or entry screening.
The Saudi Arabian authorities have made ample preparations for any possible outbreak during this year's Hajj, mobilising staff and establishing clinics. Last year, there were no identified cases of MERS related to the pilgrimage. “The Saudi Command and Control centre is excellent with extensive experience of infectious diseases prevention and control”, University College London's Alimuddin Zumla told The Lancet Respiratory Medicine. He praised the country for banning the sacrifice of camels. “But the outbreak in Seoul, Korea, a couple of months ago, where a traveller imported MERs from Saudi Arabia and it spread to 187 people, with 33 deaths, emphasises that MERS-CoV remains a major threat to global health security and could have epidemic potential with time, even in the absence of virus mutation”, Zumla stressed. Moreover, for the past 18 months or so, the west African Ebola epidemic has overshadowed other global infectious disease threats such as MERS. For Zumla, this “highlights the inadequacies of global surveillance systems to focus concurrently on several emerging and re-emerging infectious diseases simultaneously”.
Respiratory infections are a constant risk during Hajj, especially for those with pre-existing health conditions. The pilgrimage itself is arduous, and the huge concentration of people, many of whom are elderly, from all over the world compounds the problem. Pilgrims commonly return to their home country with so-called Hajj cough. A study coauthored by Ziad Memish, former deputy minister of health, found that 14% of environment samples taken at Jeddah airport during the 2013 Hajj season tested positive for at least one respiratory pathogen.
Saudi Arabia's public health response is coordinated by two dozen committees, including one devoted to preventive medicine. The country's health authorities work alongside regional WHO representatives, and maintain surveillance networks for novel coronaviruses and influenza. The Saudi Arabian ministry of health recommends that all pilgrims are vaccinated against seasonal influenza. The control efforts seem to be effective. The study of mass gatherings medicine is still in its infancy, but a scientific review undertaken for the British Government noted that “new evidence supports the findings that respiratory viruses (including influenza) are transmitted at specialised events such as the Hajj; however specific evidence for pandemic influenza does not suggest widespread transmission occurs”.
© 2015 Ammar Awad/Reuters/Corbis
© 2015 Muhammad Hamed/Reuters/Corbis
And while Ebola distracted international attention away from MERS, the emergence of MERS seems to have forced Saudi Arabia to postpone implementation of its ambitious plans to eliminate tuberculosis (elimination is defined as less than one case per 1 million population). Incidence of the disease in the country hovers at around 13–14 cases per 100 000 population, which approximates to 4000 cases per year. Roughly half the infected population are Saudi nationals, the remainder are migrant workers. Many migrants have come from countries with high tuberculosis burdens; overcrowded housing conditions within Saudi Arabia and their poor nutritional status leaves them vulnerable to reactivation of latent tuberculosis. Saudi Arabia offers treatment to nationals and foreign workers, but fear of deportation can disincentivise individuals from seeking care, particularly if they are in the country illegally. Private companies, for example, may decline to renew contracts for workers diagnosed with tuberculosis. “What is possibly worrying is the large numbers of pilgrims who visit Saudi Arabia from high multidrug-resistant tuberculosis countries like India, Pakistan, South Africa, and since tuberculosis is a chronic drawn-out disease the impact would only surface years after infection during the Hajj/Umrah ceremonies”, adds Zumla.
In 2012, Memish arranged a formal assessment of the Saudi Arabian tuberculosis programme. “There were some weak areas—lack of standardisation of laboratory procedures, and a disconnect between the national programme and what was happening in specific districts of the country”, recalls WHO's Mario Raviglione. “But there was an unprecedented commitment to really go for elimination, and this is a country that has the resources and the system, which just needs to be optimised, to achieve this goal”. The advent of MERS was a setback. “MERS must have limited certain activities to deal with tuberculosis in the way that was foreseen at the time of the review”, Raviglione concluded.
In the long-term, however, it is non-communicable diseases that are likely to pose the greatest threat to the health of the Saudi Arabian people. Around one-quarter of the population are affected by asthma. It is impossible to say whether the rising prevalence over the past few decades is attributable to changing lifestyles or increasing awareness of the condition.
Saudi Arabia signed up to the Framework Convention on Tobacco Control in 2005, but despite establishing some eye-catching antismoking initiatives, much remains to be done. The holy cities of Mecca and Medina are both smoke-free. It is forbidden to sell tobacco within the limits of either city, smoking is banned in the areas surrounding the Holy Mosques, and neither city permits shisha (water-pipe) cafes to operate. According to WHO, Saudi Arabia has adopted a “faith-based strategy to address the country's tobacco control challenge”. Several religious authorities have issued edicts (fatwas) recommending Muslims foreswear tobacco. “The fatwas and opinions of religious leaders and scholars provided important support, motivation and justification for the tobacco control actions adopted”, commented WHO in a case study exploring the tobacco policies of Mecca and Medina.
Nevertheless, smoking in Saudi Arabia is on the rise. “Tobacco consumption is increasing, especially among the younger generation”, Ritesh Menezes (University of Dammam, Dammam, Saudi Arabia) told The Lancet Respiratory Medicine. “The upward trend reflects the need for a change in the attitude of the people”. About 27% of men and 3% of women smoke. This disparity is the result of the stigma associated with women smoking cigarettes. But shisha use is not so heavily stigmatised. “Generally, it is considered OK for men to smoke, and shisha is considered OK for women”, explains Menezes. He believes that Saudi Arabia's tobacco epidemic is largely driven by rising disposable incomes and a growing population of young people. Mobile clinics and antismoking centres are proving effective, but the country does not conduct lengthy mass media campaigns, nor does it tax cigarettes beyond the 22% import duty.
“The country's unique position in the Islamic world of being the land where the two holy cities Mecca and Medina exist provide an opportunity for spreading smoke-free and wider tobacco control messages far and wide”, noted the WHO case study. Menezes stresses the importance of political leadership. The late King Fahd was key to the establishment of the smoke-free cities, and in addition to his efforts with tuberculosis, Memish was a pioneer in the field of mass gatherings medicine. If the antismoking lobby were able to secure an equally energetic and well-placed advocate, there is no reason why Saudi Arabia could not become a world leader in tobacco control.