NEWS
Arab health professionals hold key to future
No region has changed as radically as the Arab world in the past 12 months, and the changes are not over. Fiona Fleck talks to Samer Jabbour.
Q: How is the 'Arab spring' changing the public health landscape?
A: The 'Arab spring' is a term used by the mainstream international media. Very few people living in the region refer to what is happening as a 'spring'. Instead they say 'revolutions', 'revolts' or 'uprisings' depending on the situation. Yes, the current developments are changing the public health landscape, but the full impact will take years to unfold. These popular uprisings have exposed important social issues, such as unemployment, exclusion and poor social services, including poor health services as we saw in signs raised in Tahrir square [in Cairo, Egypt]. These are key social determinants of health with which public health needs to engage. There is the monumental task of rebuilding health system institutions, for example, in Libya. For the first time in decades, new democratically elected governments will have to live up to electoral expectations in all sectors; public health is no exception.
Q: How decisive is the rise of civil society for improvements in public health?
A: The rise of civil society is important for public health, but the changes we are witnessing now may not translate automatically into public health benefits. Change in public health and social policy may lag behind and fail to catch up with popular sentiments and political change, especially where conservatism and narrow interests dominate the medical and public health establishment. Change will depend on whether the newly-emboldened masses will push - directly or through their new representatives - for new policies and practices that are good for public health. This is where organized civil society groups and health professionals can be decisive as, together, they can lead or guide this process.
Q: In 2006, you and your colleagues argued (in a BMJ article) that health professionals could contribute to political and social reform and democracy building. Can you elaborate on their roles in light of the current events?
A: This time of change is an historic opportunity for health professionals to make an impact that we could not have imagined a few years ago. This is already happening. Health professionals have been part of the social mobilization in every country where political change has taken place, leveraging their social status and respect among the public in support of the democracy movement. In Bahrain and the Syrian Arab Republic, for example, we have seen heroic efforts by health professionals who have responded to the call of duty to treat victims of state brutality despite threats and even imprisonment. Once the acute situation settles and re-building efforts start, health professionals can indeed play a decisive role in ensuring that people's demands for dignity, participation, democracy and accountability are respected within health system institutions as fully as they are by their new governments.
Q: Could you give an example of how health professionals are taking a more decisive role now?
A: In Egypt, health professionals are at the forefront of large-scale civil society mobilization, for example, the Committee for the Defence of People's Right to Health, to oppose liberalization of health services and to advocate health sector reforms that address the right to health. Workers at al Mansoura hospital [in Daqahliyah 150 km north of Cairo] for the first time pushed to elect a director rather than have a director appointed by the central authorities. Health professionals can also play an important role in expanding the discussions on health in the region from the traditional narrow focus on services to the broader scope of social, economic and political determinants of health.
Q: You are the lead editor of a new book due out this year entitled Public Health in the Arab World. What is the idea behind it?
A: This book attempts to bring a regional voice to international attention. We felt that the public health library needed a book that treats the Arab world as a unit of analysis. In the literature, the region is usually treated as part of the Middle East and northern Africa, which doesn't include some of the southern and poorest countries, or as part of the Eastern Mediterranean region, which doesn't include countries such as Algeria and Mauritania. The book is based on critical scholarship and multidisciplinary collaboration and is meant to be comprehensive but it is also innovative. It takes a social-determinants-of-health approach and covers new topics in public health, such as community resilience and human security. The effort drew together 80 authors from multiple continents and backgrounds to write 38 chapters.
Q: How similar are the Arab countries in their approach to public health?
A: The book discusses how investments in public health and health system development in countries after independence were made in the context of building welfare states. Remarkably, this was the case in both republics and monarchies. This contributed to tremendous improvements in health and education. But with the introduction of neoliberal reforms starting in the 1980s, these investments were scaled back in many countries. Today, the region is characterized by diversity in public health approaches and health systems reflecting differences in the availability of resources as well as historical and political factors. Public health remains heavily influenced by the biomedical model and dominated by doctors. Its strength varies between countries but is generally poor. All countries have mixed health systems oriented towards services rather than a comprehensive population health approach.
Q: For example?
A: Some countries such as Lebanon have a predominantly privatized health system and a weak state role in health, while others such as the Syrian Arab Republic maintain a strong presence for state structures even as they attempt to liberalize health services. In others, such as some in the Gulf Cooperation Council, there is almost universal coverage of health services for nationals but limited coverage for expatriate workers. The book attempts to expose both similarities and differences.
Q: Is there a need for more scientific and health journals in the Arabic language?
A: Theoretically, journals in local languages can devote more attention to local issues, while international journals may be better positioned to bring together the community of researchers and practitioners to address a broader audience. However, some colleagues have raised caution about the phenomenon of "publish globally and perish locally", which applies when local research is not shared locally and, as a result, does not have the necessary impact. Obviously, there is a need for a healthy mix of publishing in local, regional and international journals. The region still needs a strong and dedicated regional public health journal to help raise the quality of its public health scholarship.
Q: Do you see any improvement in the health and welfare of people in the Arab world since the Arab Human Development Report 2002 was published?
A: Since 2002, the sheer number of deaths and casualties, and the degree of suffering associated with oppression, insecurities and large scale displacement in conflict areas such as Iraq, Libya, the occupied Palestinian territory and Somalia dwarf any overall improvements in health and welfare indicators. But even in non-conflict areas, improvements in health and development indicators must be evaluated critically. In the UNDP's Human Development Report 2010, five Arab countries, including Tunisia, were among the 'top 10 movers' of the Human Development Index in the past 40 years. This is due mainly to major improvements in health and education. The report says that life expectancy rose from 51 years in 1970 to almost 70 with marked variability. But the Arab uprisings still started in Tunisia, which international agencies considered a 'success story'. Obviously, the people there felt otherwise. Public health as a field of study and practice is always keen to see improvements in health indicators. But, as the case of Tunisia shows, numbers alone are not enough and there is a need for a broader conceptualization of health. This brings us back to the WHO definition of health that recognizes the central place of equity and social justice for well-being.
Q: How do you see the role of international organizations in efforts to improve health and wellbeing in the Arab world?
A: Health professionals recognize that international organizations such as WHO have already played an important role in developing public health in the region and in supporting its pillars of education, research and practice. These organizations can build on this goodwill towards pushing for more change. First and foremost, international organizations should show solidarity with the people and a commitment to addressing their real and expressed needs. Doing so requires working with many partners within countries, including civil society and, when needed, being willing to offer and accept constructive criticism. The old paradigm that "our only counterpart is the government" and "we can only do what governments allow us to do" must change.
Q: How lasting do you think the changes of the last year will be?
A: It is safe to say that the region has already changed in many ways and there is no turning back the clock. A change that carries the potential for the most lasting impact is that people are ready to fight for their rights and willing to make the needed sacrifices. What we have seen in this regard has humbled us all. 
Samer Jabbour is a senior lecturer at the Faculty of Health Sciences at the American University of Beirut and lead editor of Public Health in the Arab World, due to be published by Cambridge University Press soon. He earned his medical degree from Aleppo University Faculty of Medicine in the Syrian Arab Republic in 1989 and a master of public health degree from Harvard School of Public Health in 1998.