Obstacles to health in the Arab world.

Editor—Health indicators in the Arab world show stark differences between individual countries. But aggregate figures provide only a narrow perspective. They do not show variation according to socioeconomic group, sex, education, or political affiliation. The scarcity of databases available to collect such detailed data reflects the fact that inadequate political support exists for rigorous intersectoral research of relevance for health in the region. National development agendas and public policies are focused on economic development. Funding for health tends largely to be directed at providing curative medical services designed to emulate Western health systems. Patriarchal and religious principles embedded in the state structures of many Arab countries—such as Lebanon, Egypt, and Saudi Arabia—are a further obstacle to unpicking and taking action to tackle poor health and health inequity in the region. The conservative values of the Arab world render public debates about religion, politics, and sexuality unacceptable and place social stigma around drug users, commercial sex workers, and mentally ill people. As a result, health data on such groups are limited and unreliable, which presents an obstacle for the development of appropriate services. Although national cultural, social, and economic structures are to blame for patchy and inequitable public health services, particularly in Egypt, Morocco, and Lebanon, regional and global forces influence health provision too. The Arab-Israeli conflict, the wars in Iraq, the Gulf, Lebanon, Yemen, and Sudan have brought about hunger, epidemics, displacement, and death. These wars have been tacitly bolstered by multinational corporations, which have sold billions of dollars worth of weapons to Arab countries in conflict. Governments’ expenditures on defence in some Arab countries are greater than their expenditure on health. International political action (and inaction), notably in Iraq and Lebanon, has played a part too. Similarly, global decisions have led to fluctuations of funding for the United Nations Relief and Works Agency (UNRWA), the leading health and social service provider to Palestinian refugees. Multilateral and bilateral aid has also influenced public policy making in many economies of the Arab world, owing to demands for reform and reduced public sector spending. These have had a disproportionate effect on low income groups. Although several Arab countries have banned tobacco advertisements, tobacco companies continue to reach Arab homes through satellite television stations, another global feature. Tobacco related mortality is expected to reach 0.5 million deaths in the Arab world by 2020. Further investigation of the ways that powerful regional and global agents effect health in the Arab world and beyond is crucial for a clearer perspective on obstacles to health. Only then will the possibility of advocacy for lasting health see the light.