Pooling the Middle East's medical resources, physicians compare notes

Has peace finally settled on the Middle East, allowing people from Iran, Lebanon, Egypt, and Israel to sit together and discuss differences in healthcare among them and the governmental, social, economic, and/or environmental policies?

No, but such a meeting occurred last February in Washington, DC. The Arab doctors spoke to the Israelis and Americans very warmly and frankly. No one from Syria attended, but the event occurred before the defeat and exile to Russia of its ruthless, murderous dictator, Bashar Assad (an ophthalmologist by profession).

Together, the physicians wrote an article that has just been published in the Journal of Allergy and Clinical Immunology Global entitled “Health disparities in the Middle East: Representative analysis of the region” about the experience and what they learned.

The authors were Prof. Amal Assa’ad, formerly of Ain Shams University, Cairo, who today is associate director of the Division of Allergy and Immunology at the University of Cincinnati in Ohio;

Prof. Alon Hershko, head of the internal medicine department at Hadassah-University Medical Center in Jerusalem; Associate Prof. of Medicine, Carla Irani at St. Joseph University and a practicing clinician at Hôtel-Dieu de France in Beirut; Dr. Mahboobeh Mahdavinia of the internal medicine and pediatrics departments at the University of Texas, who earned her MD at Tehran University School of Medicine Sciences; Dr. David Khan of the department of internal medicine at the University of Texas Southwestern Medical Center in Dallas; and Dr. Jonathan Bernstein of the Division of Rheumatology, Allergy and Immunology at the University of Cincinnati College of Medicine.

All of the authors are members of the American Academy of Allergy, Asthma & Immunology (AAAAI), the leading membership organization of more than 7,100 allergists/immunologists who treat allergies, asthma, and immune-deficiency disorders.

Healthcare disparities refer to differences in health and healthcare between groups that are closely associated with governmental, social, economic, and/or environmental policies.

To address this gap in knowledge, a forum to address health disparities in different regions of the world was developed as an AAAAI presidential initiative (under Dr. Bernstein) in partnership with the World Allergy Organization to better understand political and socioeconomic issues within different countries and how they affect their healthcare systems.

The first region selected was the Middle East.

“Although we were not able to include all countries in this region, it is apparent that the healthcare systems for those that participated are heterogeneous as a result of socioeconomic, educational, and governmental infrastructures,” they wrote.

“However, all regions noted health disparities that appeared to be linked to social determinants of health. Unfortunately, conflict in this region has had an additional adverse effect on these healthcare systems, making solutions even more challenging.

“Recognition of the problems that loom large for allergy/immunology, in particular, can provide an opportunity for international collaboration that focuses on providing patient and physician education and identifying strategies to improve access to specialized healthcare.”

Intersectional healthcare

IN THE US, disparities have been linked to socioeconomic status, race/ethnicity, age, gender/sex, disability status, and sexual orientation, which affects not only the recipient of healthcare but also the entire population by resulting in unnecessary costs.

Addressing health disparities is increasingly important as our population becomes more diverse. People of color are expected to account for over half of the US population in 2050, and a significant percentage of the population will be composed of immigrants from different regions of the world with diverse cultural and religious preferences that influence their utilization of healthcare.

As a global society, nations must not only understand the increasing complexities of their own healthcare systems but also those in other regions of the world without universal access to healthcare.

The participants wanted to better understand political and socioeconomic issues within different countries and how they affect their healthcare systems. They also wanted to create an opportunity to advance research and education in allergy/immunology among countries in the region that can begin to find solutions to healthcare disparities.

The first region to be selected was the troubled Middle East.

Representatives from the four Middle Eastern countries elaborated on the educational level, viability of the allergy/immunology specialty in each country, healthcare costs, mortality rates of common conditions including asthma, and features of their current healthcare system (such as socialized or insurance-based).

They also discussed access to basic and specialty healthcare and to basic and advanced therapeutics, as well as unique cultural differences and beliefs that affect the delivery of traditional healthcare to subpopulations within each country.

Hershko told The Jerusalem Post that at the recent annual conference of the Israel association, he was asked by his colleagues how the war affected their specialty and treatment of patients. He noted that allergy clinics were opened at hotels in Eilat and the Dead Sea for Israelis who had to be evacuated from their homes in the South and the North.

The conflict also affected clinical trials in which researchers abroad usually cooperate. “They weren’t willing to work with us due to war, anti-Israel sentiment, or other reasons. Foreign physicians who were studying here went home, and fewer patients came for diagnosis and treatment, as is common in crises like the pandemic.

“We were treated very badly, especially by the European allergy specialists, who were very neutral and didn’t even mention Hamas terrorism and their murderous attack on Israel. But a shining exception was American Jews, who established an organization called Allergy for Israel, headed by Jonathan Bernstein. It sent letters of support, and some even came here.”

One of the hostages released in last year’s prisoner exchange was a 12-year-old boy who was dangerously allergic to peanuts. He was fed rice and peanuts by the terrorists, and no Epipen to counter the allergic reaction was available. Fortunately, Hershko recalled, he had been treated for the allergy for several years at Shamir Medical Center, so his reactions were not major.

“In ordinary times, we provide expensive but free treatment in Israel to Gaza[n] children with severe allergies and immune conditions. These are frequent among Arabs who inbreed (marry first cousins). Jews and Arabs work together in our hospitals, and fundamentally, the conflict didn’t enter the hospital doors,” he continued.

Hershko said: “We sat on the podium: a doctor from Lebanon who lives in Beirut, doctors from Egypt and Iran, who now live in the US, and I, who live in Jerusalem. It was agreed in advance that we would all refrain from political statements and would deal solely with medical and health matters.

“The reactions in the audience were wonderful, and we became an attraction of the conference. After the joint panel, we shook hands. We all agreed that we would write a joint article together, the likes of which have never been written, on the challenges of medicine and health in our countries.”

He added that their article proved that “despite the political and military tension in the Middle East, it was possible to reach a dialogue. It is not known whether we’ll be able to promote cooperation, but it is definitely worth fighting for.”

THE MAIN conclusion was that despite the differences between the health systems of the four countries, there are also similarities in terms of the causes of health disparities related to social factors, as well as the addition of many complexities due to the conflicts in the Mediterranean region.

There is a heavy burden on public health resources in Egypt, where 95% of its 113 million residents live in great density in a narrow strip of 1,540 people per square kilometer.

The age distribution of the population is pyramid-like: 32.5% are children, 62.5% of its citizens are of working age, and only five percent are adults. Greater health resources are allocated to young Egyptians at the expense of adults and the elderly.

Investment in health is only four percent of Egypt’s GDP (about $150 per capita). The country imports most of its medicines, and there is often a shortage of essential medicines, even in the largest cities.

Almost a third of the population is poor, and they can get free health services only in public clinics and government hospitals. In Egypt, there is also a gap between the health status of city residents and rural residents and between Upper Egypt and Lower Egypt.

The child mortality rate under the age of five is 42 deaths per 1,000 births in rural Upper Egypt – compared to an average of 20 deaths per 1,000 births in an urban environment. Despite having 30 medical schools with 70,000 students, the country has a severe shortage of doctors, with only 10 doctors per 10,000 residents (compared to a global average of 32 doctors per 10,000 people).

The average life expectancy in Egypt is relatively low at less than 73 years. Many diseases are caused by air pollution and urbanization from polluting factories located in densely populated areas that contribute to the spread of diseases.

In the small country of Lebanon, more than half of its population is poor. Its private and unregulated health system forces many residents to pay for medical care out of pocket or through private insurance companies. A severe economic crisis, especially since 2019, has deepened poverty, reaching 44% of the population.

80% of medicines there are imported and many of them are expensive and inaccessible. Allergy and clinical immunology physicians are trained in the US or Europe due to the lack of a residency program in the country.

Air pollution in Lebanon is very high and aggravates respiratory diseases and allergies. Many people suffer from allergies – almost four percent of schoolchildren have food allergies, 8.3% of the population have asthma, 45.2% have allergic rhinitis, and 12.8% have eczema.

Iran’s population is about 89 million, with about 24% of them under the age of 14. The geographical topography is diverse and includes dry deserts, mountainous areas, and areas near the shores of the Caspian Sea and the Persian Gulf.

The climate is diverse – from deserts to cold climates in the north. There are significant gaps in health services and chronic diseases between rural areas and cities.

Unfortunately, war has had an additional impact on these healthcare systems, making solutions even more challenging.

However, recognition of the problems that loom specifically related to allergy/immunology can provide the opportunity for international collaboration that focuses on educating patients and physicians and identifying strategies to improve access to specialized healthcare.

Although allergy/immunology diseases are seldom fatal, they have a great impact on day-to-day quality of life and productivity.

Discussing health disparities in different regions is an opportunity to collaborate as we all try to find common solutions for improving patient care,” the study authors concluded.