WHO EMRO report
Health ministers hold key talks





The World Health Organisation Eastern Mediterranean Regional Committee has called on member states to prioritise the establishment of specialised units and national surveillance systems for noncommunicable diseases, among other key issues. Callan Emery reports from the committee’s 52nd session in Cairo.

Health ministers from across the region gathered in Cairo in September to discuss important health issues affecting the region and adopted a number of resolutions at the World Health Organisation Eastern Mediterranean Regional (WHO EMR) 52nd session in Cairo.

Key issues on the agenda included vector-borne diseases, non-communicable diseases and health promotion. The WHO EMR Committee meeting is one of the most important events on the calendar for ministries of health in the region, enabling them all to meet at one venue, share pertinent health information and foster collaboration.

The WHO EMRO committee is made up of the following countries: Afghanistan, Bahrain, Djibouti, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Pakistan, Palestine, Qatar, Saudi Arabia, Somalia, Sudan, Syria, Tunisia, United Arab Emirates and Yemen. Observers at the 52nd session included Turkey, The Global Fund to Fight AIDS, Tuberculosis and Malaria, League of Arab States, Arabization Center for Medical Science, Arab Board for Medical Specializations, Health Minister’s Council for the Co-operation Council States, Islamic Organisation for Medical Services, General Secretariat for the Arab Red Crescent and Red Cross Organisation, and several other UN bodies and international organisations.

Technical papers were presented and discussions held on a number of topics significant to the region including: a regional strategy for enhancing patient safety; substance use and dependence; vectorborne diseases; noncommunicable diseases; a regional strategy for health promotion; strengthening the health sector response to HIV/AIDS; and an Islamic code of medical and health ethics.

Vector-borne diseases

Dr Abraham Mnzava, representing the WHO’s Roll Back malaria campaign, presented a paper: Vectorborne diseases – addressing a re-emerging public health problem. Vector-borne diseases are transmitted by various species and include diseases such as malaria, leishmaniasis, dengue, Rift Valley fever and Crimean Congo haemorrhagic fever.

He said in recent years the region had witnessed a geographical spread of vector-borne diseases and an increase in their severity and burden. Factors responsible for this problem were climatic and man-made. Climatic factors included conditions such as drought, global warming and floods. Man-made factors included issues such as “inadequate policy environment for vector control”.

He also pointed out that chemicals, used in pesticides for example, killed the natural predators of many of these species. He noted that countries that had decentralised health services and placed emphasis on curative and diagnostic services while shifting vector control resources to other sectors of health, had not only marginalised vector control as an area of work, but also eroded capacity in entomology and vector control. In contrast countries that had retained vector control as a preventative strategy had witnessed a reduction in the burden of some of the diseases and in some cases their complete elimination.

He said the key challenges were to improve management practices, strengthen national capacities for resistance monitoring and to promote investment in the development of new drugs to combat the disease. Dr Mnzava said powerful to tools were available to deal with vector-borne diseases, but what was lacking was a system to implement them.

What is required is an integrated cross-government approach – the so-called Integrated Vector Management which had a WHO policy base. He urged all member states to adopt this management initiative and incorporate it into their national health five-year plans. WHO recommended that ministries of health appoint a qualified and competent national focal person for vector control; allocate a specific budget line for integrated vector management; establish a functional intersectoral mechanism for the collaboration and co-ordination of all sectors in the country “with ultimate authority residing in the Ministry of Health”; and develop national strategies and action plans for carrying our regular needs assessments for vectorborne diseases.

“Political will is needed here,” he remarked. In response to the paper Iran emphasised that improved cross border collaboration was required to prevent illegal trade in goods that could carry vector-borne diseases. The representative for Afghanistan remarked that there were no effective prevention measures for the tick borne Crimean-Congo haemorrhagic fever and added that the country had experienced a number of serious outbreaks over the past 20 to 25 years. He suggested most of these outbreaks were linked to the increased contact with animals during the Eid period when they were brought into the house two to three days before slaughtering. He proposed increasing awareness among hospital staff to recognise the symptoms early.

Mohammad Naseer Khan, the Federal Health Minister of Pakistan, called on the WHO to emphasise the need for clean water supply and sanitation as this was the root cause of many of these diseases. He said the UAE and Saudi Arabia had good systems in place, but the other countries did not. He said Pakistan had recently invested a large sum in water supply and drainage. The representative for Iraq said vector-borne diseases had escalated in the past three years due to the destruction of infrastructure and the lack of medical resources. However, malaria cases had been reduced from 2,000 cases in 2002 to 150 a year through the spraying of homes with insecticides and the use of insecticide-treated bed nets.

He said the marshes area remained a problem and that they needed to take advice from WHO EMR partners. The representative for Syria noted that the country had eradicated most of these diseases with the help of the WHO, although leishmaniasis remained a major challenge. The representative for Yemen said malaria, dengue, Rift Valley fever and leishmaniasis to a lesser degree were the main vector-borne diseases afflicting the country. He thanked Saudi Arabia and Oman for their assistance in eradication programmes and added that a malaria eradication programme set up in 2001 had made good progress. He said in Socotra, for example, a 70% malaria incidence had been reduced to less than 3%.

Professor Dr Mohamed Awad Tag El Din, the Minister of Health and Population for Egypt, said most of the recommendations had been implemented in Egypt. He called for an exchange of expertise and suggested the WHO EMR Office draw up a new map of the different vectors and their insecticide-resistance and called for a new list of useful products to combat vector-borne diseases. Dr Hussein Gezairy, regional director WHO EMR, pointed out that integrated vector management was a cost-effective project as it did not allow wastage or duplication of effort. Regarding entomology, he said: “We do not provide adequate training in this discipline to produce graduates to deal with the issue of vector-borne diseases.”

In response, member states, in the resolutions, called on the regional director to establish a regional master certificate course in entomology funded by allocations from countries’ regular budgets and other resources.

Non-communicable diseases

Dr Oussama Khatib, the regional adviser for noncommunicable diseases (NCDs) presented a technical paper: Non-communicable diseases – challenges and strategic directions. He said NCDs such as cardiovascular disease, diabetes, cancer, renal, genetic and respiratory diseases were rising significantly in the EMR.

“Currently the region’s disease burden attributable to NCDs is 47%. This is expected to increase to 60% by 2020,” Dr Khatib warned. “Most of these diseases are a result of lifestyle behaviour as well as social and economic status. “The modifiable risk factors of smoking, unhealthy diet, physical inactivity, expressed as diabetes, obesity and high lipids, are the root causes of the global non-communicable disease epidemic.’ He estimated that these risk factors were responsible for up to 75% of these diseases in the region. Dr Khatib said: “In the EMR there are a number of barriers that hamper the process of prevention and care, including: lack of reliable national epidemiological information; lack of appropriate and culturally orientated national NCD strategies; and a shortage of trained human resources and financial resources.”

He recommended member states: develop and implement a national integrated prevention and control programme; set national strategies that raise community awareness; encourage policy makers and health authorities to develop community-based programmes; ensure appropriate management of highrisk patients; and integrate in a comprehensive way the prevention and care of NCD in a primary health setting. Responding to the paper Dr Gezairy said management of these diseases was costly and difficult. He noted the inappropriate way drug companies promoted drugs for NCDs.

“Doctors should use a scientific approach and not a commercial approach when it came to choosing medicines,” he said. He said member states should prioritise NCDs at the ministries of health. “We can treat all these disease by changing lifestyle behaviour. This will significantly reduce the burden of morbidity, Dr Gezairy said. However, this was not that simple Dr Nada Abbas Haffadh, the Minister of Health for Bahrain pointed out. “It’s a problem of lifestyle, yet the more we speak of this problem, frankly speaking, the more we feel our failure,” she said.

“We face many challenges, such as free commercial activity and free enterprise. We cannot control restaurants and satellite TV,” she said, referring to a Saudi Arabian initiative to ban fast food advertising and a suggestion from Oman to use satellite TV channels to promote lifestyle awareness. “I do not think these activities will bare any fruit. “People are aware [of these risk factors], but they don’t change their behaviour. We have to be more innovative to change the pattern of behaviour,” Dr Haffadh remarked. “We should steer clear of routine answers. There is a need for a different way of thinking.”

The representative of Jordan said the burden of known cases of NCDs in the country cost JOD350 million (about US$493 million). If the total was taken into account Jordan’s Ministry of Health estimated it would cost in the region of JOD650 million a year. The representative noted that Jordan had a national strategy to promote good nutrition, physical exercise and anti-smoking. Early detection centres for breast cancer were being developed and physicians were being trained to staff four diabetes centres. Dr Faizullah Kakar, the deputy minister of Public Health, Afghanistan, emphasised the need to use the channel of mosques to promote healthy lifestyle education and community awareness.