FEATURE
A tidal wave of cancer crashing on the Middle East INTERNATIONAL INNOVATION
As the world’s second leading killer, cancer is a disease that has touched the lives of nearly everyone across the planet. International Innovation’s Rosemary Peters takes a look at how cancer is affecting the Arab world, with a focus on the Middle East and the Gulf countries
CANCER POSES A major and ever present threat to public health. It is already the second leading cause of death worldwide, and the number of cancer victims is growing.
THE GLOBAL BURDEN OF CANCER Dr Ali Mokdad is a major contributor to the Global Burden of Disease (GBD) enterprise, a collaboration of more than 1,500 researchers in more than 120 countries worldwide. The GBD collaboration produced the Global Burden of Cancer 2013 in Journal of the American Medical Association. At the Institute for Health Metrics and Evaluation website, you also can use an interactive tool that enables users to explore and compare the world’s health levels and trends from 1990 to 2013. This comprehensive tool allows users to drill into specific country details so they can watch how disease patterns have changed over time and see which causes of death and disability are having more impact and which are waning.
Incidence rates have increased in most countries since 1990, and the International Agency for Research Explore the tool for yourself at: http://vizhub.healthdata.org/gbd-compare on Cancer (IARC)’s latest World Cancer Report notes that in 2012 the world was flooded with 14 million new cases and 8.2 million cancer-related deaths. why the current is changing with such force, one needs to look back 40 years and understand why cancer incidence It was a grim announcement made even more depressing as in the Middle East and the Gulf countries was so low to the report went on to predict that the number of new cases begin with. is likely to rise to 22 million by the end of 2030. Moreover, the report underscores, the grip of death is tightening “If you go back to the 1970s, especially in the Gulf countries, around the neck of the world’s most poverty stricken at a diets were good, physical activity was high and smoking was disproportionately high rate – by 2025 almost 80 per cent of non-existent,” Mokdad notes. These factors are important the increase in the number of all cancer deaths will occur in because healthy diets and appropriate levels of physical less developed regions. activity are key to the fight against many forms of cancer, as they both contribute to obesity, which is increasingly being The Middle East and the surrounding region is one place labelled as a major cancer risk factor. where a tidal wave of cancer is due to crash down with devastating consequences. Cancer incidence in the Middle Around this time, many countries in the Middle East and the East is prime to increase more compared to the rest of the Gulf countries were also starting down a path to providing globe; it is expected to double by the middle of 2020. public healthcare to its citizens. Now, Oman, Pakistan, Saudi Arabia, Qatar, Syria and Turkey all have universal This cancer surge is sure to be a shock to the region, healthcare programmes. which, historically, has had the lowest cancer incidence rates in the world and, until the turn of the decade, had Mokdad also attributes the region’s culture as a driving force actually been experiencing a tremendous improvement in its behind why its citizens made such impressive strides in citizens’ health. their health between 1990 and 2010 – especially considering the political and social instability in the region at the time. “This fact is amazing given how heavily the odds have been “These people are resilient. They have a strong community, stacked against them,” says Dr Ali Mokdad, Director of and their sense of community is very powerful – it is a tribal Middle Eastern Initiatives and Professor of Global Health system,” he says. at the Institute for Health Metrics and Evaluation at the University of Washington. “In spite of some extremely poor This tribal system has driven Middle Eastern history. medical systems and wars, mortality was declining, life Stretching from the northernmost tip of Iraq down to the expectancies were increasing and infectious diseases were Arabian Peninsula and all the way across to Morocco, for being controlled.” millennia the tribes inhabiting this area and the values they hold most dear have shaped what is and is not culturally CANCER INCIDENCE IN THE MIDDLE EAST IS RISING accepted. “Consumption of alcohol is very low, so you don’t There are many reasons behind the region’s turning tide in see cancers that are associated with alcohol,” expands cancer cases. But according to Mokdad, to truly understand Mokdad. “Also, since historically it has not been culturally
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acceptable to smoke, this has kept the lung cancer rates low in this population.” However, the creeping spread of the Western lifestyle and diet, obesity, an increase in smoking, a high prevalence of hepatitis C infection, and industrial and agricultural pollution look set to take hold in the region in the coming decades. These factors have all been linked to the increasing rate of cancer incidence in the Middle East and these issues have been compounded in the wake of the Arab uprisings that originated in Tunisia in December 2010 and quickly took hold in Egypt, Libya, Syria, Yemen, Bahrain, Saudi Arabia and Jordan. SMOKING IN LEBANON: CAN YOU LEND ME A CIGARETTE? One place in the Middle East where smoking has developed a strong foothold is Lebanon. Between 1990 and 2012, rates of smoking in Lebanon increased by nearly 500 per cent. In fact, a study in the Economist pointed out that in 2012, the average Lebanese person smoked 2,379 cigarettes. According to Mokdad, there are many reasons that explain why smoking has become part of Lebanese culture. One has to do with a shift in the Lebanese population. “Lebanon is becoming more affluent, Westernised and educated, and there are more foreigners there. Moreover, women can openly smoke a cigarette, whereas that would be a big ‘no’ in Saudi Arabia,” he points out. A second reason comes down to advertising. Currently, tobacco companies do not have to contend with any bans on direct forms of advertising. While Lebanon has implemented
the seven bans on forms of indirect advertising that the World Health Organization (WHO) suggests in its best practices for tobacco control policy, there is only a 60 per cent compliance rate. “Tobacco companies pushed a lot of advertisements,” notes Mokdad. “Like the Marlboro Man advertisements in the US, tobacco companies did the same in Lebanon. They showed all of these handsome actors smoking.” Moreover, the main seller of tobacco in Lebanon is the Régie – a state run monopoly in charge of regulating the tobacco market. Of the approximately dozen government-owned tobacco companies worldwide, six of them are in Arab countries – a fact that concerns Mokdad. “On the one hand these countries are saying they want to prevent smoking, but on the other, they own the tobacco companies and they are selling it to the people.” Another issue that Lebanon is contending with concerns tobacco policy. There are very few laws in place to prevent people from smoking. In fact, last year Lebanon’s Interior Minister Mohammad Machnouk announced that Law 174 – which banned people from smoking indoors – was going to be relaxed. Moreover, the country hits very few of WHO’s best practices for tobacco control policy. For example, WHO suggests that 75 per cent of the retail price comes from an excise tax – in Lebanon, it is only 33 per cent. THE DOWNSIDE TO CULTURE Although Middle Eastern culture has helped keep certain types of cancer at bay, it has also contributed to higher numbers of others. “Cancer screening is very low in Saudi Arabia even though it is free. In fact, it is very low in many of the Arab countries,” Mokdad shares.
WHERE THERE’S SMOKE, THERE’S CIGARETTES While rates of smoking in lebanon are the highest amid Middle Eastern countries, according to Dr Ali Mokdad’s study, Jordan is following suit, and a few other countries are also showing increased tobacco consumption. “Our studies in Saudi Arabia and the Gulf countries are telling us that the rates are also increasing in the Gulf countries for things like lung cancer and other cancers associated with smoking,” Mokdad states. “If Saudi Arabia takes the path of Lebanon in terms of smoking, it will be a disaster.”
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According to Mokdad, approximately three
MIDDLE EASTERN COUNTRIES – there are various definitions of the countries that are included in the Middle East, but most people agree that the region includes 17 countries: Bahrain, Cyprus, Egypt, Iran, Iraq, Israel, Jordan, Kuwait, Lebanon, Oman, Palestinian territories, Qatar, Saudi Arabia, Syria, Turkey, United Arab Emirates and Yemen GULF COUNTRIES – The Arab states of the Persian Gulf are the seven Arab states which border the Persian Gulf: Kuwait, Bahrain, Iraq, Oman, Qatar, Saudi Arabia and the United Arab Emirates.
out of every four people in the region do not go for a regular screening, despite the fact that it would cost more for them to take a taxi to their doctor than it would to pay for the visit. “They only go to a doctor when they are sick. That is where the culture can cause harm. Many of them believe everything is in God’s hands and they believe that if they are going to get better, it will just happen.”
Algeria’s cancer crisis is the perfect example of this cultural mindset in action. Between 2008 and 2013, the number of people suffering from cancer increased by 50 per cent in the country. However, only 30 per cent of cancers are diagnosed in the early stages of the disease; physicians find the rest after it is too late to operate, if they find them at all. Another issue is the fact that it is still unacceptable in the Gulf countries for a woman to have a male doctor perform her mammogram. “Women having to be treated by women in these countries may prevent a woman from doing a pap smear or a mammogram,” says Mokdad. “We have seen in Saudi Arabia that mammogram rates are very low even though it is free for everyone.” The number of women who have pap smears is even lower. “Unless a woman is married, a pap smear is not conducted on her, because women are supposed to stay virgins until they are married,” he shares. “You cannot do massive pap smear screening for cancer.” INVESTING IN TECHNOLOGY Tackling rise in cancer incidence in the Middle East requires a myriad of solutions, but there is one that Mokdad would like to see happen sooner rather than later: an investment in health information systems. These types of systems would give countries a better feel for the magnitude of the problem they are dealing with, an especially important benefit as many countries in this region have not held a census in
decades. “For example, in Lebanon, a census hasn’t taken place since 1932,” says Mokdad. “They don’t know how many people they are actually dealing with.” Better health information systems would also help solve another major problem facing the region – the fact that its cancer registries are missing a large number of cancer cases. This is a problem for several reasons, including a tendency for people to go abroad for medical treatments (thus enabling them to maintain their privacy) or to receive treatment by visiting medics who are able to provide the best treatment at the lowest cost. Crucially, a more robust information system could help capture cases that are currently lost. In general, Mokdad maintains it is important for the Middle East and surrounding regions to start looking at solutions to the problems it faces now. “When you look at the cancer rates in the Middle East compared to everywhere else in the world, they still have lower cancer rates than many other countries. Part of it lies in genetics and part of it is that historically risk factors for cancer have been very low in the region,” he notes. However, this will change, especially if diets continue to decline while smoking spikes. “People are smoking more, exercising less and eating more. Obesity and diabetes are increasing. We are seeing this in every country in the world. Our studies are telling us that the rates of cancer are increasing, and they will continue rising unless these trends are reversed,” he concludes.
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