Health in Saudi Arabia Volume Two: Second Edition

By Zohair A. Sebai

Health in Saudi Arabia Vol. One, published in 1985, presented and introduction to health problems, health manpower and medical education in Saudi Arabia.

This book Vol. two discusses the epidemiology of certain health problems and the development of health services and health manpower. The material is based upon a two year project supported by King Abdul Aziz City for Science and Technology under Grant No. At-5-26. The book has been published in the year 2008. Still it would be of interest for those who would like to study health and health services development in the country.

• Language: English
• Publisher: Partridge Publishing Singapore
• Release date: Dec 3, 2014
• ISBN: 9781482829037

Zohair A. Sebai

Zohair Sebai, MBBCh, DTM, MPH, DrPH, MRCPG, is a professor of Family and Community Medicine. Since the time he graduated from Bernard-Nocht Institute in Germany with a postgraduate Diploma in Tropical Medicine and from Johns Hopkins School of Public Health in USA with a Master and Dr. in Public Health, Dr. Sebai was occupied by Health Promotion in the Arab World. He was the founder of two medical Schools in Saudi Arabia, the president of the Arab Board for Family and Community Medicine and the president of the Arab Society of School Health and Environment. Dr. Sebai is nationally known as a leader in the field of health education. For 15 years he presented a weekly program on health education in the Saudi Television titled “Medicine and Life”. In the year 2000 he was selected as a Member at Johns Hopkins University Society of Scholars, MJHUSS. Dr. Sebai has served as member in Shoura Council (consultant council to the King) for 12 years and a member of the Board of Trustees of the Arab Gulf University and WHO & UNICEF Short Term Consultant

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Copyright © 2014 by Zohair A. Sebai.

Library of Congress Control Number:          2014958203

ISBN:          Softcover          978-1-4828-2902-0

                    eBook              978-1-4828-2903-7

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CONTENTS

PREFACE

ACKNOWLEDGEMENT

INTRODUCTION

CHAPTER I

HEALTH PROBLEMS

MALARIA

SCHISTOSOMIASIS

TUBERCULOSIS

VIRAL HEPATITIS (TYPE B)

TRACHOMA

NUTRITIONAL DISORDERS

DIABETES MELLITUS

DISORDERS OF HEMOGLOBIN SYNTHESIS

CANCERS

ROAD TRAFFIC INJURIES

CHAPTER II

HEALTH SERVICES

AN OVERVIEW

PRIMARY HEALTH CARE

HEALTH MANPOWER

PROBLEM SOLVING EXERCISES

LIST OF TABLES

LIST OF FIGURES

REFERENCES

REFERENCES

PREFACE

H ealth in Saudi Arabia, Volume I, published in 1985, presented an introduction to health problems, health manpower and medical education in Saudi Arabia.

Volume II now discusses the epidemiology of certain health problems and the development of health services and health manpower. The material in Volume II is based upon a two-year project supported by King Abdul Aziz City for Science and Technology under Grant No. AT-5-26.

The two volumes cannot be comprehensive, but strive to give baseline information on health in a country which is developing very fast but still is relatively inexperienced in medical research.

The first edition of the book has been published in the year 1987. Still it would be of interest for those who would like to study health and health services development in the country.

ACKNOWLEDGEMENT

I wish to thank the members of the editorial committee, Professors David A. Price Evans, Sheikh Mahjoob, Hassan Abu Aisha and Hassan Bahakim, and Dr Monir Madkour for their critical reviews and constructive ideas.

I am also grateful to Dr Othman Rabia and Mr. Adnan Al-Beshr for supervising the fieldwork, Dr Adnan Barri for the data analysis and Dr Hassan Bella for preparing the educational material. The great assistance given by Mr. Abdul Rashid Bhatti in typing the manuscript on the word processor, Mr. Eddie Musngi in typesetting and composing, Mrs. Hoda Sharabash and Mrs. Jane Duncan in reviewing and editing, made the writing a pleasant task.

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INTRODUCTION

D uring the last decade Saudi Arabia has experienced a rapid development which is probably unsurpassed by any other nation. It has been a historical phenomenon. The government revenues from oil and other sources recorded an almost 40-fold increase, rising from SR5.7 billion in 1970 to SR211 billion in 1980 (US$ 1 equals SR 3.75). In the same period of time the total number of schools increased from 3,100 to more than 11,000, representing an average growth of 14.5%. From 1970 to 1985, the number of hospital beds increased from 9,039 to 30,707 and the number of physicians increased from 1,172 to 14,335. The natural population growth is estimated at 2.8% per year.

The expansion of health services has brought medical care to almost every village in the country. The rapid growth in economy, health care facilities, urbanization and mass media have changed, in one way or another, health knowledge and the attitudes and practices of the people.

In spite of the dramatic development in the health sector, some problems remain. The physical development has not been complemented in this short period of time by a parallel development in national human resources. The expatriate health personnel face cultural and language barriers, especially in rural areas. Information on the magnitude and distribution of health problems and resources is sporadic and incomplete.

Health services remain predominantly curative. Most of the health personnel are products of patient-oriented, hospital-based medical institutes, and the people’s demand, as expected, is for curative care.

This volume discusses certain health problems, mostly from an epidemiological perspective, and presents the main features of the health services and health manpower in Saudi Arabia.

The problems of malaria, schistosomiasis, tuberculosis, viral hepatitis, trachoma, nutritional disorders, diabetes, disorders of hemoglobin synthesis, cancer and road traffic injuries are discussed. The selection of these problems was made partly because of their importance and partly because they are within my field of interest. Other problems such as cardiovascular diseases, leishmaniasis and health during pilgrimage would also have been discussed if time had permitted.

The chapter on health services and health manpower is based on a field survey carried out under the auspices of the Department of Medical Planning and Research, Ministry of Health, with a contribution from the Department of Statistics, College of Sciences, King Saud University. The voluminous data which came out of the survey are under analysis by the Ministry of Health and College of Sciences. I used just some of the data, relevant to the purpose, in the book.

Volumes I and II of Health in Saudi Arabia have been written for physician medical students and health personnel in general. I hope that they will provide the reader with basic knowledge of health in Saudi Arabia and will stimulate discussion and bring new ideas.

ZOHAIR SEBAI

CHAPTER I

HEALTH PROBLEMS

Health problems in Saudi Arabia vary from communicable diseases such as hepatitis and schistosomiasis, to those of a modern society with stress related diseases, pollution and traffic injuries. In this chapter ten selected health problems will be discussed.

• Malaria

• Schistosomiasis

• Tuberculosis

• Viral Hepatitis

• Trachoma

• Nutritional Disorders

• Diabetes

• Hemoglobin Synthesis Disorders

• Cancer

• Road Traffic Injuries

MALARIA

Introduction

O f all the infectious diseases, malaria has caused the greatest harm to the greatest number of people. Approximately 1.6 billion people live in malarious areas in the tropics and subtropics, and at least 150 million people are infected. One million deaths occur annually in Africa alone.

Man is the only important reservoir of malaria, and the female Anopheles mosquito is the intermediate host. Four Plasmodium species cause malaria in man, P. falciparum (the malignant form), P. vivax, P. malariae and P. ovale. The clinical picture includes fever, chills, sweating, anaemia and splenic enlargement. Complications, mainly due to the malignant form, can lead to shock, renal failure, jaundice, severe anaemia and coma.

Malaria is a classic example of a disease which must be prevented and not merely treated.

History

Malaria or Humma al thuluth (the fever which attacks man every third day) has been mentioned in Arabic writings since the pre-Islamic era. In recent times many travellers in the Arabian peninsula including Doughty,¹ Philby  ² and Scott  ³ have mentioned malaria as a prevailing disease in Arabia. In the 1948 Marett  ⁴ reported that Anopheles mosquitoes were abundant about the wells and marshy areas in Al-Hasa and Qatif oases and nearly 100% of the population had suffered from malaria at one time or another.

The first reliable data on malaria in Saudi Arabia came from Aramco (Arabian American Oil Company) in the Eastern Province in 1941.⁵ Malaria was persistently the most significant health hazard and the leading cause of morbidity and mortality among the Aramco Saudi population. Annual morbidity rates during the period 1941-1947 varied between 1000 and 2700 cases per 10,000. Most of the cases came from the two major oases, Al-Hasa and Qatif and were typical oasis malaria described by, Daggy ⁶ as follows:

"Oasis malaria is characterized by its sharp delimitation to the island-like cultivated areas in a sea of sand. The population is chiefly concentrated in one or two main centers, and the remainder is in scattered small villages surrounded by irrigated date-palm groves. Within this area are also concentrated the breeding places of the anopheline vectors, primarily Anopheles stephena. Hence man, mosquito, and parasite are all closely confined to the cultivated areas, and here malaria is hyperendemic. Only a few miles from the well-defined borders of these oases, Bedouins or other travelers are perfectly safe from the disease."

The survey conducted in Qatif in 1947 showed an infant parasite rate of 100%; among other age groups the parasite rate was 85% and the spleen rate in the 2-14 year age group was 93%. Although P. falciparum, P. vivax, and P. malariae were present, P. falciparum was the most important in terms in prevalence, morbidity and mortality.⁷

In 1948 Aramco, with the cooperation of the Ministry of Health, launched the first campaign against malaria and a dramatic reduction in malaria incidence was accomplished by the early 1950s. Cases of anopheline resistance anti-larval measures and the spraying of houses with DDT were recorded.⁸ During the 1960s malaria continued to occur in Al-Hasa and Qatif at a lesser rate. In the mid-1970s malaria transmission was completely interrupted and the improvement was well maintained in the Eastern Province ¹⁰ (Table 1???

Haemoglobin S, an important gene marker for Al-Hasa and Qatif population gave some protection against P. falciparum by reducing the parasite burden affected children.¹¹

Preliminary surveys conducted by the Ministry of Health in the early 1950s revealed the endemicity of the disease in many parts of the Kingdom ranging from mesoendemic levels in the Northern and Western Provinces hyperendemic levels in the South Western Provinces. A malariometric survey carried out among children from 2 to 9 years old in Wadi Fatima, near Makkah showed a spleen rate of 32% and a parasite rate of 9%. Plasmodium falciparum was the predominent species, and Anopheles sergenti and arabiensis (A. gambiae) were the main vectors.

The success attained in the Eastern Province encouraged the Ministry of Health in 1952 to initiate a malaria control program assisted by the World Health Organization (WHO) along the route of pilgrims in the Western Province. In 1956, the National Malaria Control Service was created. In 1966, the Ministry of Health signed an agreement with WHO to launch a malaria pre-eradication program. The program paid off. By early 1970 malaria transmission was completely interrupted in the Northern and Western Provinces with the exception of some endemic foci, particularly in Khayber (near Madinah) and the surrounding villages. The South Province was still hyperendemic. In 1970 the pre-eradication program was promoted to control program and action became more progressive.¹²

In the late 1970s, a survey of malaria  ¹³ reported the highest incidence in the Southern region and the lowest from the Northern and Eastern regions. The Western region showed a regular and uniform occurrence of infection throughout the year. Five anopheline vectors were identified; A. stephemi, A. sergenti, A. gambiae, A. superpictus and A. fluriatitis.

From Ref. 10.

By 1980 malaria was almost under control. Transmission had been interrupted in Qatif, Al Hasa and Sikaka areas, and in the Jeddah, Makkah and Madinah areas malaria had been reduced to a low incidence. In other areas where control measures have not yet, or only partially, been established incidence was rather high. The Tihama area along the Red Sea was left uncovered by the program due to communication difficulties and a shortage of manpower.¹²

In 1981 a malaria training center was established in Jizan and by 1983 eight malaria stations and 15 substations were already established in the Kingdom with the headquarters in Riyadh. By that time malaria control activities had successfully reached all endemic areas in the Kingdom with the exception of Tihama and some residual foci in the Western and South Western provinces.

Management and Organization

The Malaria Control Program is a division of the Department of Preventive Medicine in the Ministry of Health. The headquarters in Riyadh plans and supervises the implementation of the program through eight malaria station and 23 substations distributed all over the country.

The malaria manpower in the headquarters and the peripheral stations is a follows:

public health officers (3), medical officers (18), engineers (12), parasitological technicians (56), entomological technicians (17), field inspectors an supervisors (152), squad leaders (110), and administrators (65).

They face the general problem of health manpower in Saudi Arabia; in that the personnel are mostly non-Saudi, unevenly distributed and require continual training.

The malaria program in the Kingdom is coordinated with the adjacent Arabian countries through committees representing the Ministers of Health of Arabian States of the Gulf Area and North Yemen.¹⁴

Malaria in the 1980s

Epidemiologically, the country could be divided into three malarious areas (Fig. 1).

1. Areas where malaria transmission has been completely interrupted and the situation is maintained through parasitological and entomological vigilance (Eastern and Northern Provinces).

Figure 1. Malarious areas & main vectors in Saudi Arabia - 1983.

Figure%201a.tif

From: Ref. 16.

2. Areas where malaria transmission has been interrupted but residual foci remain (Western Province).

3. Areas where control has been recently initiated (Southern Province).

Tihama presents a special case, being the most endemic area in the country. It is an agricultural area inhabited by approximately half a million people, mostly villagers and some nomads. Geographically it is a long narrow lowland which extends for about 600 km along the coastal line of the Red Sea down to the borders of North Yemen. Its width ranges from 70 to 100 km from the seashore up to the foothills of the Sarawat Mountains. The area has the highest amount of rainfall in the Kingdom, ranging from 300 to 400 mm annually.

Until recently Tihama, and in particular its central part known as Tihamat Kahtan, has been out of the reach of the national malaria control program. Malaria endemicity is hyperendemic along the foothills of Sarawat Mountains and meso –– to hypoendemic on the coastal plain. The predominant strain is P. falciparum and the main vectors are A. arabiensis and A. serganti. From the Ministry of Health records, ¹⁵ the number of clinical malaria cases reported from Gizan (in the southern half of Tihama) were 142,283 in 1977 and 92,847 in 1978 and 67,277 in 1979 (rates were not given).

In 1983, eight malaria substations were established in various parts of Tihama. A geographical reconnaissance of premises and water sources was initiated. This, in addition to the training center established in Gizan in 1981 has accelerated action in Tihama.

Methods of Evaluation

Various methods are being used to evaluate the malaria control program in Saudi Arabia in order to assess the magnitude of the problem.¹⁶ These include the following.

Passive Case Detection (PCD)

This is the principal parasitological assessment method under current use. All hospitals, health centers and dispensaries are required by law to report every suspected malaria case and send with the report a blood film to the Ministry of Health. Tables 2 and 3 show the results of passive case detection of malaria from all over the Kingdom. Recently there has been an increase in the rate probably due to improved diagnostic methods.

From Ref. 16.

Modified from Ref. 16.

Malariometric Survey

School children 6-9 years old are examined for an enlarged spleen, and a sample of blood is taken from the finger. These examinations are usually carried out in highly endemic areas in order to measure the prevalence.

Infant Parasite Survey

In certain villages all babies in the age group of 0-12 months old are examined monthly for blood parasites. This survey measures the incidence and defines the malaria transmission season.

Epidemiological Contact Survey (ECS)

This survey is carried out in hypoendemic or malaria-free areas to detect the source of infection for any positive case found. In the Eastern and Northern Provinces, in 1983, the 16 malaria cases found by ECS were imported. In the Western and Southern provinces the ECS was rather difficult to conduct because of constant movements of the inhabitants.

Mass Blood Survey (MBS)

Finger blood specimens are taken from inhabitants of new settlement areas (Hejrat) for baseline data.

Compulsory Blood Examination of Arriving Foreign Laborers

All laborers coming from malarious countries are tested for blood parasites before