WHO-EMRO
The way forward

Health ministers from across the region gather each year for the WHO Eastern Mediterranean Regional Committee meeting to determine the way forward for public health in the region. Callan Emery attended the talks in Cairo and provides an overview of the key issues.

The World Health Organisation Eastern Mediterranean Regional (WHO EMR) Committee’s annual conference is of vital importance to this vast region as ministers of health from the EMR gather to discuss pertinent public health concerns and challenges, issue recommendations and adopt resolutions to improve and secure the health of the people of the EMR.

I have been attending this conference for the past several years and am always struck by this remarkable demonstration of the ability of people to come together and make crucial decisions that will be enacted at the highest levels of government and affect the lives of millions of people.

It is a great manifestation of international cohesiveness, cooperation and the power of human organisation. It provides great hope in our ability to address threats that, in some cases, have the potential to devastate humanity.

This is particularly fitting in the arena of public health, where multisectoral and cross-border cooperation are essential to combat hazards such as health emergencies or the rapid spread of infectious disease which are not confined by political boundaries or economic status.

The EMR comprises 22 countries extending from Morocco in the west to Afghanistan and Pakistan in the east.

Each year the WHO EMR committee meeting is hosted by one of the regional Member States following the United Nations World Health Assembly. The 2007 meeting – the 54th meeting of the WHO EMR committee – was held in October at the EMR headquarters in Cairo. Dr Margaret Chan, the director-general of WHO, Dr Hussein Gezairy, the regional director of WHO EMRO, ministers of health of EMR Member States, as well as observers from UNICEF, UNHCR, the Arab League and many other international and regional organisations attended.

The EMR was praised for its work in particular fields of public health, such as health development through poverty alleviation and polio eradication, and criticised for its lack of progress in others, such as HIV/AIDS surveillance.

Importantly, critical public health issues such as noncommunicable diseases; neonatal mortality; HIV/AIDS; polio eradication; the tobacco-free initiative; tropical diseases; the emerging threat of haemorrhagic diseases and, among others; food marketing to children, were discussed and the way forward charted.

In his opening address Dr Gezairy said the region faced health challenges continually from all quarters, both man-made and natural disasters.

He highlighted the situation in Somalia’s Darfur region and the Iraqi refugee crisis in Syria “which is becoming acute”. “Public health is increasingly challenged by urbanisation, overpopulation, pollution resulting from increased demand from energy and transportation.

These are not just environmental issues, indeed they are also health issues. And if they are health issues they are also economic issues,” he said.

Poverty alleviation

Addressing the committee, Dr Chan, praised the EMR’s initiatives for meeting basic developmental needs through poverty alleviation.

“We all know the problem,” she said. “Globalisation creates wealth, and this is good. But globalisation has no rules that guarantee fair distribution of this wealth. “I believe that, in matters of health, the world is out of balance as never before.

Life expectancy can differ by as much as 40 years between the richest and the poorest countries,” Dr Chan said. “As we all know, this world will not become a fair place for human development all by itself. I believe there is no sector better placed than health to insist on greater equity and social justice.

“The argument is easily expressed. No one should be denied access to life-saving or health-promoting interventions for unfair reasons, including those with economic or social causes.

“For health, inequalities really are a matter of life and death.” Dr Chan referred to this region’s initiative for meeting basic development needs saying it is “a poverty alleviation strategy closely aligned with the values, principles, and approaches of primary health care”.

“Since 1988, experiences in this region have shown how community-based initiatives, supported by a multi-sectoral approach, can tackle the fundamental determinants of health on multiple fronts.

“Women are often the key to improving a population’s health, and this is especially true in the Eastern Mediterranean region. Projects that empower women and provide basic needs are transforming poor communities.” Dr Chan said she had seen this first-hand in Afghanistan and Pakistan.

“Abundant evidence shows that health policies that promote equitable access to services, and equitable health outcomes, bring economic and social benefits. “Health is a foundation for prosperity and pro-poor health policies contribute to stability,” she emphasised.

Addressing this issue, Dr Gezairy, said: “The region has two decades of experience of addressing health development through poverty reduction. The basic developmentneeds approach and other community-based initiatives have shown exceptional results in the social health and economic arenas.”

Non-communicable diseases

Discussing the issue of noncommunicable disease Dr Gezairy noted that the matter should be high on all agendas. Reciting key points from his WHO EMRO report for 2006, he said that non- communicable diseases are rising significantly in the region.

“Currently 52% of the region’s disease burden is due to non-communicable disease and this is expected to rise to 60% by 2020.”

He pointed out that regional guidelines on hypertension, diabetes, dyslipidaemia and breast cancer have been published. And reiterated that ministers of health at the 53rd session of the WHO EMRO committee meeting in Isfahan, Iran in 2006, had endorsed a new global goal to reduce by 2% per year non-communicable chronic disease death rates through national programmes supported by EMRO.

He said some of the challenges included the long process of integration of non-communicable disease into primary healthcare, and stressed that strong political commitment was needed to implement the process, allocate resources and train nationals to put into action the regional guidelines.

In particular, blindness was a major public health problem with more than 20 million people visually impaired in the region, which has a severe economic impact. This was especially disastrous as over 80% of blindness is avoidable.

Neonatal mortality

Dr Chan emphasised the need for an integrated, multi-sectoral approach to healthcare. She pointed out that of all the Millennium Development Goals (to be achieved by 2015) the health goals are the least likely to be met.

“Within countries, the underlying causes of ill health increasingly lie outside the direct responsibility of the health sector. This demands that multiple sectors work together, giving priority to health concerns,” she said.

“Globally, the goals set for reducing maternal and child mortality pose the greatest challenge. This should come as no great surprise, given the many determinants of these deaths in multiple sectors.

“Almost 99% of these deaths occur in low and middleincome countries. To reduce these deaths, broad social determinants must be addressed. Dr Chan stressed the need for a wellfunctioning health system, which is able to reach the poor.

“The vast majority of deaths in young children can be attributed to just four diseases, amplified by malnutrition. Again, this opens the opportunity for an integrated approach. “Most chronic diseases are caused by a limited number of shared risk factors linked to human behaviours.

This opens opportunities for comprehensive preventive policies,” Dr Chan said. She said regional rates of exclusive breastfeeding were unacceptably low.

“More than 40% of pregnant women are anaemic. Only around half of deliveries benefit from a skilled birth attendant.” Dr Chan pointed out that although the region has made great strides in improving female literacy.

Similar improvements are needed for female health literacy. “Women need better nutrition, skilled attendants at birth, and access to emergency clinical care for themselves and their infants.

“But they also need better information about the numerous things that can be done, in households and communities, to protect themselves and their babies.” The Committee adopted a resolution on neonatal mortality which, among several key points, called on member states to:

● Further reduce underfive mortality, as required by Millennium Development Goal no. 4, it is essential to reduce neonatal mortality, which represents 40% of deaths among children under five years;

● Ensure universal coverage of the existing cost-effective interventions at both health system and community levels;

● Improve the quality of health care for mothers during pregnancy and for mothers and newborns at childbirth, including by ensuring availability of skilled health personnel;

● Support and implement community-based interventions, especially in countries with weak health systems and inadequate human resources;

● Improve the quality of vital registration and other relevant information and auditing systems in order to provide reliable data on maternal, neonatal and child health indicators and to monitor progress.

HIV/AIDS

Dr Gezairy noted that although access to treatment and care of HIV/AIDS has expanded, only a small proportion of those in need are receiving life-saving antiretroviral therapy (ART).

The main obstacles to universal access include the persisting fear and stigma associated with HIV, overburdened health systems, inefficiency in spending increasing funds available for HIV programmes and high cost of HIV treatment, in particular second-line ART.

An estimated total of 75,000 people living with HIV/AIDS in need of ART are living in the EMR. Of these, more than two thirds live in Sudan. In 2006, access to HIV/AIDS treatment and care services expanded steadily in almost all countries except in Afghanistan, Yemen and Iraq, where ART services were not available.

However, the shortfall in access to lifesaving ART is still considerable: as of December 2006 fewer than 5% of the estimated number of people living with HIV in need were receiving ART.

By the end of 2005, the estimated number people living with HIV in the EMR reached 620,000 and an estimated 100,000 new HIV infections occurred in 2006. Despite efforts to increase access to ART in the region, an estimated 47,000 adults and children died as a result of HIV infection.

However, the WHO points out that due to the weak surveillance systems in most countries of the region, margins of these estimates remain wide.

More than half (55.6%) of the reported AIDS cases in the region to date are adults aged between 25 and 39 years; 8.1% are youth aged between 15 and 24 years and 1.8% are children below 5 years of age. 30% of the cumulative total reported AIDS cases are female. Sudan, Djibouti and parts of Somalia are experiencing generalised epidemics (HIV prevalence >1% in the general population).

Concentrated epidemics (HIV prevalence >5% in atrisk groups) among injecting drug users are established in the Islamic Republic of Iran, Libyan Arab Jamahiriya and Pakistan. In the remaining countries of the region, available data suggest that the HIV/AIDS epidemic has remained at low level (<1% HIV prevalence in the general population and <5% in at-risk groups).

However, the lack of reliable information on the extent to which HIV has entered the most at-risk populations prevents early detection of concentrated epidemics among such groups.

Dr Gezairy called upon Member States to increase the availability of voluntary and confidential HIV testing and to expand access to HIV/AIDS treatment and care services through systematic integration into existing healthcare delivery.

Polio eradication

Dr Chan said during her address: “This region is home to two of only four countries where polio remains endemic.” Dr Chan said that security concerns in some areas jeopardise the success of global health initiatives, such as polio eradication.

“As I speak, Somalia has now been free of transmission for more than six months. This is a milestone.

This region is now the first to have stopped all the outbreaks that followed international spread of the virus from 2003–2006. “This demonstrates the tremendous commitment of Member States, under the regional director’s leadership.

“In this region, the biggest remaining challenge is to reach children in the rugged and restive area along the Pakistani-Afghan border where the virus remains endemic.

She noted that in September 2007, the Taliban Shura announced the full participation of Talibancontrolled areas in polio immunization campaigns, enabling the September polio campaign access to almost 100,000 children who had been missed for more than two years.

According to the progress report, the key challenges facing the polio eradication programme include securing necessary resources both from national funds and external resources, maintaining interest and commitment of national authorities and the public and reaching children living in securitycompromised areas with the necessary vaccine.

Food marketing

Resolution WHA60.32 of the World Health Assembly calls for the promotion of initiatives “aimed at implementing the global strategy with the purpose of increasing availability of healthy food, and promoting healthy diets and healthy eating habits, and to promote responsible marketing including the development of a set of recommendations on marketing of foods and non-alcoholic beverages to children”.

In response to this resolution, a technical paper discussed at the WHO EMRO meeting aimed to “alert policy makers to the growing influence of commercial media and marketing on the dietary behaviour and health of children and adolescents in the region” and calls for comprehensive preventive educational and regulatory responses.

The resolution was adopted due to the rising incidence non-communicable disease and injury, which represent more than half of the total disease burden of the EMR and is often attributed to the rising trend in overweight and obesity among adults and young people.

The technical paper notes that “commercial media have proliferated in recent years, with heavy promotion of television entertainment programmes targeted at young people and heavily sponsored by the food and beverage industry.

In the absence of clear regulations and appropriate legislation and enforcement, urgent preventive measures are needed to protect and promote the health of children and young people.” Dr Chan said there is an urgent need for “strong protective measures at the highest policy level”.

 Date of upload: 22nd Jan 2008