30 June 2020
A look at Arab regional responses to COVID-19
Published online 19 June 2020
The unique context of the Middle East and North Africa provides challenges and opportunities in the battle against COVID-19, explains US-based infectious disease epidemiologist, Amira Roess1 .
The Middle East and North Africa (MENA) was slow to respond to the COVID-19 pandemic. Whereas the authoritarian nature of some of the region’s governments turned the initially slow response into a rapidly enforced quarantine, a trend of misinformation in other countries could lead to an avoidable loss of life.
There are several examples of good COVID-19 public health responses in countries like Saudi Arabia, other Arab Gulf countries, and Jordan, which have been able to successfully implement organized quarantine measures with high compliance. In some Gulf Cooperation Council (GCC) states, curfews are enforced, with reports of arrests and penalties imposed on people who violate them. Initial surges in cases reported in many GCC states were attributed to a robust public health response that involves testing and contact tracing.
Morocco and Algeria have reported several outbreaks recently. Both appear to be making decisions about reopening, based on data from their public health monitoring and testing programmes.
However, some countries in the region have been releasing data that often conflict with other internal reports and are epidemiologically unlikely. In Egypt and Iran, for example, this has resulted in a hampered response, escalating distrust of official numbers, and COVID-19 mortality and morbidity that could have been prevented.
Throughout North Africa, enforcement of movement restrictions and curfews continues to have challenges and low compliance, including in Egypt and particularly during the month of Ramadan, when families and friends often gather to eat.
The situation is most alarming in areas with conflict. Very little information is available from Yemen, Libya, Syria and Sudan, as many years of war and turmoil have decimated their healthcare systems, including their surveillance systems, which are critical for monitoring cases and implementing outbreak investigations and control. Consequently, these countries have very little data to report, since they are unable to test or track. These countries and the refugee camps and informal settlements housing millions of refugees and vulnerable populations throughout the region are at the highest risk of disastrous outcomes should the COVID-19 virus take hold.
How MERS-CoV prepared the region for COVID-19
Nevertheless, several lessons from a different coronavirus, MERS-CoV (Middle East respiratory syndrome-coronavirus), have arguably helped some countries in the region modify their healthcare systems and respond to COVID-19 accordingly.
MERS-CoV emerged in 2012 with the first case reported in Saudi Arabia and outbreaks still reported throughout 2019. By the end of November 2019, MERS-CoV had resulted in 2,494 confirmed cases and 858 deaths, primarily in the Arabian Gulf states, with a reported case fatality rate of 34%2. The industries around camel production and trade were significantly impacted by this virus along with religious tourism. Reporting to the international community seemed sparse, but improved as time wore on, as did international cooperation.
MERS-CoV provided a very recent reminder that the MENA region, like the majority of the world, is not prepared for a pandemic. The majority of MERS cases were in the Arabian Gulf. Despite the higher income status of the affected Gulf countries, hospitals were not prepared to deal with that virus. In fact, the majority of MERS-CoV outbreaks were in hospitals or tied to healthcare facilities3.
In an effort to handle MERS-CoV, affected countries worked on strengthening their healthcare systems. For example, Saudi Arabia’s Ministry of Health invested in improving infection control at multiple levels in their healthcare system, from dialysis centres up through tertiary care hospitals. Saudi Arabia also emphasized training healthcare workers in infection control, as well as in identifying suspected MERS cases. The current pandemic is testing whether these improved protocols will make a difference in the countries previously hit by MERS-CoV.
Public health response must include all
Migrant workers in some countries in the MENA region are particularly vulnerable, with limited access to what is often poor-quality healthcare4-6. They often live in cramped quarters, posing a significant risk of COVID-19 infection. Coupled with this is the underlying stress that migrants often experience due to their work conditions and life circumstances, being away from home and unsure about their future prospects, which further increases the risk of severe illness due to pathogens. In the Arab world, thousands of migrant workers were sent back to South Asian and other countries after reports of a large percentage of COVID-19 cases in migrant worker communities6,7. Many of the receiving countries, which are often low income and are already facing social and economic crises due to COVID-198, were unable to facilitate adequate self-quarantine and follow-up measures, further increasing the risk of COVID-19 outbreaks.
Internally displaced populations and refugees are another large vulnerable group dispersed throughout much of the Middle East, and often overlooked by governments and are thus unable to access healthcare. Many of these populations lack access to adequate nutrition, water, or sanitation, rendering them high-risk for adverse health conditions, which in turn increases their risk of death from COVID-19. Further, just as in the case of migrant workers, chronic stress places these groups at even greater risk of severe COVID-19 outcomes. Movement restrictions are placing additional barriers to access to income and resources, posing a significant threat to the mental and physical health of refugees.
Jordan hosts a large refugee population and is working to keep the virus out of populations, something Jordan is working very hard to achieve.
Refugees and internally displaced persons in other parts of the region remain even more vulnerable, particularly those in Yemen and Syria. Should the virus be introduced into these countries, the humanitarian crises that already exist will devastate affected populations.
Almost all countries in the region did manage to close down houses of worship and schools, and reduce the operating hours of retailers and markets. The response, while not smooth, has highlighted how seriously many states in the region are taking the pandemic. It remains to be seen whether the region can respond by improving infrastructure and health equity, along with regional cooperation, or if this pandemic will lead to widespread political and economic unrest and further weaken healthcare systems in many of the region’s states.
- Amira Roess is a professor of global health and epidemiology at George Mason University, US. She is an epidemiologist with expertise in infectious disease epidemiology, multi-disciplinary and multi-species field research, and evaluating interventions to reduce the transmission and impact of infectious diseases. Roess currently oversees several longitudinal studies to understand the emergence and transmission of zoonotic infectious diseases globally. She also studies mHealth (especially apps) technology integration and evaluations to reduce the impact of infectious disease outbreaks, promote healthcare and reduce health disparities. Her current studies are in the US, Bangladesh, Egypt and Ethiopia.
- World Health Organization. Middle East respiratory syndrome coronavirus (MERS-CoV). MERS Monthly Summary. November 2019.
- World Health Organization. Middle East Respiratory syndrome coronavirus (MERS-CoV). March 2019.
- Batniji, R. et al. Governance and health in the Arab world. The Lancet 383(9914), 343–55 (2014).
- Kumar, R. & Jamil, R. Labor, health, and marginalization: A culture-centered analysis of the challenges of male Bangladeshi migrant workers in the Middle East. Qualitative Health Research https://doi.org/10.1177/1049732320922180 (2020).
- Liu, L. et al. Determinants of healthcare utilisation by migrant workers in the State of Qatar. Health Policy https://doi.org/10.1016/j.healthpol.2020.04.011 (2020).
- Migrant workers in cramped Gulf dorms fear infection. The Economist. April 23, 2020.
- Kiley S, Salem M. Coronavirus leaves the Gulf's migrant workers in limbo, with no income and no easy way out. CNN. May 9, 2020.