DISEASES

Major diseases in the Middle East since 1800.

Endemic and epidemic diseases spread in the modern Middle East and North Africa in the wake of expanding European political and economic power. Political and medical responses to diseases changed over time according to the interests of the imperial and local powers and influenced the allocation of resources to research and policies governing medical intervention. Plague, syphilis, malaria, schistosomiasis, and cholera led to the establishment of new forms of government control and modern medical and public health infrastructures.

Plague epidemics decimated the Middle East and North Africa from the sixth through the nineteenth centuries. In Egypt, famine usually followed plague outbreaks because without intense maintenance normally undertaken by the fellahin (peasantry), the irrigation canals became overgrown with reeds and silted up. Plague and famine were largely responsible for a population decline from perhaps 8 million in 1347 at the onset of plague to 3 million in 1805 when Muhammad Ali became viceroy. Bedouin, however, were able to outrun the disease by fleeing into the desert and their numbers remained constant at about several hundred thousand. Outbreaks continued to decimate urban and rural populations in the Middle East until the nineteenth century when Ottoman and Egyptian authorities took steps to introduce quarantines and other public health controls. In then underpopulated Egypt, when Muhammad Ali, the Ottoman viceroy, learned in 1812 that plague had broken out in Istanbul, he promptly imposed strict quarantine on Ottoman ships. The plague did not arrive. When plague again broke out in the eastern Mediterranean Muhammad Ali established a quarantine station at the port city of Damietta. The time the travelers evaded the quarantine and plague broke out in other port cities. Muhammad Ali imposed a cordon sanitaire around Alexandria and ordered his police and troops to imprison plague victims and burn their possessions. Battling widespread resistance, the authorities rounded up poor families and imprisoned them in quarantine stations on the edge of town, shot heads of households who refused to report sick members, and isolated the wealthy in their homes. Families went to great lengths to bury their dead in secret to evade the draconian measures and plague soon spread up the Nile. About a seventh of the Egyptian population and many European residents of Egypt perished. In a secondary outbreak in 1841 Muhammad Ali stiffened the quarantines and soldiers had orders to shoot to kill villagers who attempted to evade them. Fallahin were rounded up, men and women separated and forced to bathe under the supervision of male and female medical personnel, and given clean clothing. Egypt was plague free for three generations.

Between 1894 and 1898 Drs. Shibasaburo Kitasato, Alexander Yersin, and Paul Lewis Simond discovered the plague bacillus and the role of the rat flea in transmitting the disease. Quarantines, rat control, and antibiotics now control plague in most regions of the Middle East and North Africa, but it remains a threat in remote regions of Algeria, Egypt, Iran, Iraq, Libya, Morocco, Tunisia, and Turkey.

Muhammad Ali was equally concerned with syphilis, which also afflicted his troops and impaired the efficacy of his army. Muhammad Ali recruited Antoine-Barthelme Clot (Bey) to organize a Western-style teaching hospital, which opened in 1827. In an attempt to control the disease, he had Clot Bey organize a school to train women medical practitioners (hakimat). The hakimat vaccinated people against smallpox, reported on and treated the prostitute population for syphilis, registered midwives, and performed postmortem exams.

The British occupied Egypt in 1882 and proceeded to further develop Egyptian agriculture. British engineers completed a dam at Aswan in 1902 and in subsequent years raised it and built and expanded a series of barrages to better control the Nile river flow. The Nile Delta was converted from basin to perennial irrigation enabling fellahin to produce three crops a year but at the same time allowing schistosomiasis (bilharzia), hookworm, and other waterborne diseases to spread to formerly uninfected areas.

In 1913 a Rockefeller Foundation survey of Egypt found that about 60 percent of the population was infected with hookworm, bilharzia, nonfalciparum malaria, and other parasitic diseases. World War I and the Great Depression exacerbated the disease load in Egypt and many suffered from typhus, typhoid fever, and plague. In 1936 the now independent Egyptian authorities upgraded the Department of Public Health to the Ministry of Health but funding remained limited. In 1940 a leading medical researcher estimated that 75 percent of the Egyptian people had bilharzia, 50 percent ancylostomiasis, 50 percent other parasitic diseases, 90 percent trachoma, 25 percent malaria, 7 percent pellagra, and nearly all had severe childhood diseases. Life expectancy was thirty-one years for men and thirty-six years for women.

In 1942 a severe malaria epidemic broke out in Egypt. Malaria, caused by the Plasmodium falciparum parasite, is transmitted to human beings by the anopheles mosquito. The mosquitoes can breed in standing water in irrigation channels, rainfall pools, streams, marshes, and oases, and malaria has been reported in all regions of the Middle East and North Africa, including oases in the Arabian Peninsula and the Sahara. In 1942 nationalist Egyptians insisted that British military aircraft had imported malaria from Sudan, where malaria was endemic. Others connected the disease with the expansion of irrigation. Subsequent research suggested that the mosquito vector might have traveled downriver by boat. Because hundreds of thousands of British troops were in Egypt the British asked the Rockefeller Foundation to launch a malaria control project. Working closely with the Egyptian Ministry of Health the foundation eradicated the disease.

In 1950 and 1951 malaria appeared in Jidda and Mecca, with the increased pilgrim traffic apparently facilitating the spread of the anopheles mosquito. The World Health Organization, the Rockefeller Foundation, and other assistance programs in coordination with national ministries of health, utilized DDT and other pesticides to eradicate the disease almost completely. In recent years, however, newly resistant strains of malaria have reappeared in the Arabian Peninsula, Egypt, Lebanon, Libya, Morocco, and southern Sudan, where it is the leading killer.

Schistosomiasis is endemic in the Nile Valley of Egypt and Sudan and in irrigated regions of Iraq. Schistosomes (blood flukes or parasitic worms) grow in freshwater snails which, when adult, leave the snail and survive in the water for forty-eight hours. The schistosomes may enter the skin of persons wading, washing, or swimming in contaminated water or through the lining of the mouth or intestinal tract of persons who drink contaminated water. The schistosomes grow inside the blood vessels of the body and produces eggs. The eggs travel to the bladder or intestine and are excreted. The infected person must urinate into water infected with freshwater snails for the lifecycle of the schistosomes to be continued. The body's reaction to the parasite's eggs may cause rash, fever, cough, muscle aches, or general debilitation and can damage the liver, intestines, lungs, and bladder. The opening of the Aswan High Dam in 1970 increased land under irrigation by more than 30 percent but also spread schistosomiasis into new regions. A study done in al-Ayaysha, a village on open water in the Nile Delta, found that children swimming in the Nile acquired the disease through repeated contact with contaminated water. They were treated with chemotherapy (Praziquantel), educated about the disease, taught appropriate sanitation procedures, and retested annually. Rein-fection rates dropped markedly, but similar intervention throughout the infected region is prohibitively expensive.

Six pandemics of cholera spread between 1817 and 1923 with increased trade, travel, and troop movements from south Asia where the disease is endemic. Cholera is transmitted by contaminated water or food and causes massive diarrhea, dehydration, anuria, acidosis and shock. The fact that the disease was new led Muslim physicians to consult European medical sources. Ottoman physicians began translating medical works from European languages in the early nineteenth century. In 1819 the Ottoman physician Sanizade Atallah studied medicine in the Muslim medical school and then in Padua. He wrote a medical book based on a Viennese source and added sections from other European works. In 1831 Mustafa Behcet, head of the medical college in Istanbul, published a treatise on cholera based on an Austrian source, which Ottoman authorities distributed free throughout the empire. Ottoman authorities established a quarantine service in about 1832 and had religious leaders publish treatises showing that quarantines were not contrary to Islamic law.

In the early nineteenth century European physicians were no better at treating cholera and other diseases than were traditionally trained Muslim physicians. Westernizing Muslim rulers had deducted from the demonstrably superior European weaponry and other scientific and technological advances that European medicine ought to be superior as well. In addition, European physicians were useful for political purposes and by the mid-nineteenth century had largely displaced their Muslim counterparts.

Cholera again spread in 1883, 1896, and 1902. In each of the epidemics, pilgrims returning from Mecca apparently carried the disease with them. In 1883 while working in Cairo, Robert Koch discovered the causative agent, vibrio cholerae. Following the cholera epidemics and outbreaks of plague from 1898 to 1905 the British authorities upgraded the al-Tawr quarantine station, which the Egyptian government had established in 1855 and used for the first time in 1862.The discovery of the cholera vibrio and the means of transmission led to improved public health and quarantine procedures in Mecca and throughout the region, which nearly ended the pandemics. The last major epidemic occurred in Egypt in 1947. The outbreak occurred near a British base where troops returning from India were quartered and Egyptians accused the British of having introduced the disease, creating a major and unresolved political controversy. Cholera is treated effectively with oral rehydration solutions to replace lost fluid and rarely is seen in epidemic form. In recent years the al-Tawr cholera vibrio has appeared in sporadic outbreaks.

Tuberculosis was widespread throughout the region but since the 1950s WHO and UNICEF helped ministries of health to vaccinate their populations and the rate of infection dropped significantly. The Egyptian Organization for Human Rights (EOHR) and the Human Rights Center for the Assistance of Prisoners (HRCAP) recently has reported that severe overcrowding, poor ventilation and sanitation, and inadequate nutrition in Egyptian prisons has led to the rapid spread of tuberculosis and other diseases among the prison population.

Eye diseases leading to impaired vision and blindness are common throughout the Middle East and North Africa. Trachoma, the most serious of them, is caused by the bacterium Chlamydia trachomatis. The Chlamydia bacterium infects the conjunctiva and inflammation may result in scarring and even blindness. The disease is spread through secretions from the infected eye spread directly or through common use of towels or bed clothing. Trachoma is prevalent in hot, dry climates with poor sanitary conditions and water shortages. The disease can be treated with tetracycline, but surgery is often necessary to repair damage to the eye. Improved public health and personal hygiene has reduced the incidence of trachoma, but it remains a threat in many parts of the Middle East and North Africa.

Pellagra, caused by inadequate niacin in the diet, is often seen in impoverished regions where corn is a staple and intake of varied plant and animal foods limited. Pellagra causes a distinctive reddish rash and lesions on the neck and is easily prevented by dietary supplements or vitamins. Other debilitating conditions resulting from nutritional deficiencies, such as anemia, are widespread and result directly from poverty.

Hepatitis A, a viral infection of the liver transmitted by the fecal oral route, is endemic throughout the region but can be avoided by consuming only well-cooked food and potable water. Hepatitis B, a viral infection of the liver, is transmitted primarily through behaviors that result in the exchange of blood or body fluids containing blood. Vaccinations are available for Hepatitis A and B. Hepatitis C, also a viral infection of the liver, is endemic in many regions. Recent research suggests that efforts to prevent schistosomiasis may have contributed to its spread. Improperly sterilized needles often were used to administer medications for schistosomiasis and apparently transmitted Hepatitis C, which is now a major health problem.

Changes in lifestyle resulting in part from urbanization, increased smoking, a high-fat diet, lack of exercise, and increased obesity have resulted in exceptionally high rates of diabetes. Diabetes is a major public health challenge in Egypt and much of the Eastern Mediterranean region.

AIDS/HIV infection rates in the Middle East and North Africa are relatively low compared with Asia, Europe, and sub-Saharan Africa, but the incidence is rising rapidly and deaths from AIDS have increased since the early 1990s. The disease is most often spread through heterosexual intercourse and to a lesser extent through the transfer of blood and other bodily fluids from an infected person to an uninfected person. Early intervention is crucial because the disease spreads widely once a threshold is reached. Safe sex education, public information programs, greater use of condoms, convenient voluntary testing services, and treatment of sexually transmitted diseases can avert much suffering and crippling medical expenses. Yet the vast majority of infected persons live in the developing world where poverty, malnutrition, and limited education complicate preventive efforts. In addition, some Muslim authorities believe that safe sex education encourages or implies promiscuity and view the disease as a punishment for immoral behavior. In an effort to encourage preventive action, the World Bank, WHO/EMRO and UNAIDS, recently prepared a report titled "Overview of the HIV/AIDS Situation in the Middle East and North Africa and Eastern Mediterranean Region." The report encourages governments to establish national plans for prevention and management of the disease. The government of Morocco is one of the first to prepare a National AIDS action plan and has received funds from the Global Fund to Fight AIDS, TB and Malaria to launch its program. Islamic reformers are advancing the concept of darar (the sin of harming others) to argue that men and women are each other's protectors and that spouses are obliged to protect their partners and in turn are entitled to self-protection from exposure to the disease. Recognizing the limits of law enforcement programs, Indonesia and Iran have introduced needle exchange programs to curtail transmission of HIV and hepatitis. Lebanese and other women in the region have argued that women's status must be raised through education, training, and economic independence to enable women to avoid contracting and transmitting the disease by gaining control over their sex lives.

In recent years, the most serious recurrence of disease was in Iraq where the eight-year war with Iran, the 1991 Gulf War, the twelve years of sanctions, and the 2003 U.S. and British occupation resulted in deteriorating conditions, especially for children and the elderly. During the 1990s about 5,000 children died every month from acute diarrheal diseases caused by bacteria, viruses, helminths, or protozoa. In most regions of the world, oral rehydration solution, a mixture of water, glucose, sodium, potassium, and electrolytes, greatly reduced infant mortality rates. The solution, distributed throughout the region by ministries of health, the World Health Organization, the United Nations Children's Fund (UNICEF), and nongovernmental organizations, helps children retain vital fluids and nutrients leading to full recovery. In Iraq, however, potable water and oral rehydration therapy were unobtainable and one in eight children died before his or her fifth birthday. Cholera, easily treated with oral rehydration, also appeared in parts of Iraq and chronic diseases went untreated. The percentage of underweight children increased by over 400 percent, and one in four children under age five was chronically malnourished. After the war UNICEF shipped thousands of tons of emergency medical and water supplies for the prevention and cure of waterborne diseases and high-protein food to fight malnutrition, but unstable conditions greatly impeded distribution.

In the Occupied Territories of Palestine nearly 10 percent of Palestinian children suffer from acute and 13 percent from chronic malnutrition. Malnutrition impairs physical and mental development and when combined with the trauma that Palestinian children have suffered from being exposed to gunfire, tank and helicopter attacks, tear gas, and house demolitions, will have serious long-term consequences. The Israeli reoccupation of Palestinian territories undermined the Palestinian health system and economy; severe overcrowding, poor sanitary conditions, shortage of health facilities, and political unrest have resulted in a massive public health crisis.

Despite setbacks, most regions of the Middle East and North Africa have in recent years experienced substantially decreased infant mortality and increased life expectancy. The current life expectancy now exceeds 65 years of age and is increasing. Noncommunicable diseases are more prevalent than communicable diseases and public health policy makers must adapt their priorities and strategies to the new disease patterns.

See also Medicine and Public Health.

Bibliography

Barlow, Robin, and Brown, Joseph W., eds. Reproductive Health and Infectious Disease in the Middle East. Brookfield, VT: Ashgate Publishing, 1998.

Fahmy, Khaled. "Women, Medicine, and Power in Nineteenth-Century Egypt." In Remaking Women: Feminism and Modernity in the Middle East, edited by Lila AbuLughod. Princeton, NJ: Princeton University Press, 1998.

Gallagher, Nancy. Egypt's Other Wars: Epidemics and the Politics of Public Health. Syracuse, NY: Syracuse University Press, 1990.

Gallagher, Nancy. Medicine and Power in Tunisia. New York: Cambridge University Press, 2002.

El Katsha, Samiha, and Watts, Susan. Gender, Behavior, and Health: Schistosomiasis Transmission and Control in Rural Egypt. New York and Cairo: American University in Cairo Press, 2002.

Kuhnke, Laverne. Lives at Risk: Public Health in Nineteenth-Century Egypt. Berkeley and Los Angeles: University of California Press, 1990.

Rahman, Fazlur. Health and Medicine in the Islamic Tradition: Change and Identity. Chicago and Lahore: Kazi Publications, 1998.

nancy gallagher