The blockade’s effect on public health in Qatar

Background

Qatar is a small sub-peninsula on the North coast of the Arab peninsula, having one land border, with Saudi Arabia. It is home to approximately 2.7 million people with a GDP PPP of $131,000 per capita, the highest in the world. Most of this wealth is generated by crude oil and petrochemical exports and its greatest expenditures are on imports of luxury goods, machinery used in oil extraction, large tourism-based events and its news agency, Al Jazeera.

On June 5th 2017, 4 Arab nations (Egypt, Bahrain, United Arab Emirates, and Saudi Arabia) abruptly cut diplomatic and economic ties with Qatar, citing the Qatari government’s association with, and funding of, terrorist groups as the reason for the abrupt isolation of Qatar. The Saudi-Qatari border was immediately closed and all air-traffic to and from the two groups was ceased, as well as coalition’s airspace closing to air-traffic bound for Qatar. These, coupled with the cessation of shipments to Qatar by these close trading partners, created a potentially crippling blockade around Qatar, who would be forced to rely on new partners to feed and medicate its citizens.

The blockade was designed to hold Qatar to ransom, as the coalition sent Qatar’s government a list of 13 demands to be met within 10 days. This deadline was ignored and the demands leaked by Qatar. The most highly publicised of these was the demand to close Al Jazeera and its subsidiaries. This demand was the cause of Israel’s government taking the side of the coalition in the dispute, which put Israel’s allies the United States of America at odds with itself, both needing to support Israel (as the President did) and needing to defend Qatar (which is home to 11,000 US military personnel in their region’s largest Airbase, Al Udeid). This left the US Secretary of State conducting ‘shuttle diplomacy’ between Qatar and its coalition neighbours in order to ease tensions. The principal intermediary role between the two sides was mainly conducted by Kuwait, one of the two gulf states that has remained neutral in the dispute, the other being Oman.

The coalition’s main grievance is Qatar’s relationship with Iran. This is due to Qatar previously acting as an intermediary between the Gulf Cooperation Council (Bahrain, Kuwait, Oman, Qatar, Saudi Arabia and the United Arab Emirates formed the GCC as an economic, political and military bloc) and Iran. The map below shows the alarming proximity of these power brokers in the Arabian Peninsula.

Screen Shot 2017-12-18 at 00.33.01.pngBBC News. Countries that cut ties with Qatar [Internet]. 2017 [cited 9th December 2017). Available from: http://www.bbc.co.uk/news/world-middle-east-40173757

As of today, the 9th December, the blockade has been in place for over 6 months and there is no end in sight.

Qatari Public Health

Healthcare in Qatar is currently nationwide (achieved universal health coverage) and the state is investing heavily in its healthcare structures. However, its work is marred by a high prevalence of diabetes, obesity, heart disease and hypertension. The latest publicly available health report from the Qatari government is for 2012 but contains information on the structure of the Qatari medical services. The report, finalised in early 2014, highlights the emphasis on hospital care and neglect of primary care, with 40% of the country’s healthcare budget being spent in hospital care, a further 26.3% being spent on ambulatory care providers as opposed to only 0.4% being spent on preventive care and 2.3% being spent on long term, day curative, or rehabilitative care. Qatar also spends 4.3% of this national health budget on ‘medical goods’, a figure which includes medicines.

The national healthcare expenditure in Qatar is almost 80% funded by the government, with the remaining 20% split evenly between household out of pocket payments and voluntary contributions from individuals and organisations. This is likely to have changed as the 2012 report signalled a 25% increase in government funding between 2011 and 2012. Being a rapidly developing country (in terms of infrastructure and population size and wealth, rather than in terms of development index) there is a large burden on Qatar’s already limited water supply, which raises questions about the sustainability of population growth on food production and subsequently nutritional security.

Qatar’s incredible wealth and expenditure on health care has allowed it to eliminate many infectious diseases but it is still affected by Middle-East Respiratory Syndrome (MERS-CoV), a zoonotic infectious disease that can be transmitted to humans from camels, of which there are many in Qatar. The country is predominantly marred by non-communicable diseases, which increases its reliance on medicines, all of which it imports. Here, these medicines are split into “packaged” and “unpackaged medications”, packaged indicating they are more likely to be destined straight to the consumer or as over the counter pharmaceuticals, as opposed to unpackaged which are more commonly used in hospital and (the limited) primary care settings.

Screen Shot 2017-12-18 at 00.33.25.pngOEC – Countries’ percentage share of packaged medication exports. Available from: https://atlas.media.mit.edu/en/profile/hs92/3004/

Screen Shot 2017-12-18 at 00.33.50.pngOEC – Countries’ percentage share of unpackaged medication exports. Available from: https://atlas.media.mit.edu/en/profile/hs92/3003/

The figures above show the countries with the largest global share of the respective $10.6 billion and $306 billion unpackaged and packaged medicines industries. However, this is not a symptomatic of Qatar’s imports. In 2016, Qatar imported half of its unpackaged medicines from Saudi Arabia and most of the remaining 50% from the United Kingdom, United States of America and Kuwait. For packaged medicines, the field is much more varied but Saudi Arabia and fellow Arab nation, Jordan, both feature in the top suppliers to Qatar.

Screen Shot 2017-12-18 at 00.34.12.pngOEC. Countries’ percentage share of packaged medication exports 2017 Available from: https://atlas.media.mit.edu/en/visualize/tree_map/hs92/import/qat/show/3004/2016/

The blockade’s effect on access to medicines and chronic diseases

Although Qatar has a lower dependence on its Saudi neighbours for packaged medicines (which is a significantly greater proportion of Qatari medicines imports than unpackaged), the impact of the blockade on access to medicines is logically going to be significant for Qatar’s supply of medicines. However the issue has been absent from the news and therer has not been enough time between the beginning of the conflict and now for data on the effect to be gathered, verified and published. Beyond speculation that the shortfall in medicines will have been made up for by an increase in imports from the USA, Germany and the UK who have all (officially) sided with Qatar in the dispute, it is difficult to say, with any certainty or evidence, what the current situation in this area is. The lack of availability of medicines is likely to have effected Qatari citizens with chronic and non-communicable disease, such as heart disease and diabetes. Reducing their access to medicines is likely to put these already high-risk groups under even greater risk, but this is just speculative due to no data being published on this topic.

The blockade’s effect on food availability

Qatar is mostly desert and so doesn’t produce very much food (only 1% of Qatari land is used to farm crops making it especially vulnerable to food insecurity, with cultural practices and little knowledge of, or investment in, food security being cited as causes of this weakness. It is said that as much as 90-99% of food in Qatar is imported and that if (hypothetically) all supplies were cut off, there would only be three days’ worth of food in the country. In 2015, Qatar imported over 15% of its food from the United Arab Emirates, over 14% from Saudi Arabia and a smaller 3% from Bahrain. In total, almost 35% of Qatar’s food imports came from countries that were members of the coalition blockading Qatar (this figure is disputed as some organisations suggest that 40% of Qatar’s food is imported from Saudi Arabia and up to 80% from ‘other gulf neighbours’). This created an acute lack in food availability in Qatar, both in city supermarkets and in poorer areas along the Saudi border where many Qatari citizens (used to) cross the border to buy cheaper food.

The immediate food scare’s effects were mitigated by the importing of food from Iran and Turkey by plane and by ship (the costs of which have increased tenfold). This immediately changed the nature of the diets of Qatari citizens, causing an increase in food prices due to individual’s food stockpiling but also decreased the availability of milk, dairy products and meat. Although this caused an initial scare and platform for taunting by Saudi journalists, the potential damage from acute lack of food has, so far, been minimal thanks to food imports by plane from Iran, promising vast sums of fruit, vegetables and meat to be transported to Qatar.

The blockade has sparked an increase in investment in food security measures including diversifying suppliers to include suppliers such as Oman, Pakistan, Australia, the European Union and India, and increasing its food production at home including expanding meat production and importing cows (and expert herdsmen) from Europe to be housed in state-of-the-art facilities to produce fresh milk and dairy products.

Screen Shot 2017-12-18 at 01.10.22.pngA herd of imported cows in Qatar. Photograph: AFP/Getty Images https://www.theguardian.com/world/2017/oct/20/land-of-milk-and-money-qatar-looks-to-farms-to-beat-the-gulf-boycott

These measures are in place to protect the food security of richer members of the population, but over half of the 15,000 Qatari camels that were previously grazed over the border in Saudi Arabia, have died due to starvation (despite emergency measures being implemented in some areas), with unknown numbers of farmers’ sheep thought to have perished, causing immediate food insecurity to their owners and the people that rely on these livestock for income, as well as food.

Acute malnutrition has not deemed to have been as prevalent among Qatari citizens as was initially feared. However, the change in dietary sources may have a positive impact on health in Qatar, as more food from Turkey is imported and a more Mediterranean diet is adopted, it can be speculated that the incidence of dietary related, non-communicable diseases, such as diabetes and obesity, may decrease in Qatar (Turkey has a 27.8% risk factor of obesity, compared to Qatar’s 33.2%), with the most prominent difference being in rates of diabetes, where diabetes has been responsible for 1% of deaths in Turkey vs 8% in Qatar. This speculation is made plausible by increased evidence for Mediterranean diets reducing the risk of developing diabetes.

The blockade’s effect on Middle-East Respiratory Syndrome

As previously mentioned and popularly documented, the cessation of people’s ability to cross the Qatar – Saudi border has dramatically increased the population density of camels in Qatar, as farmers were forced to bring all of their animals home with them, as they and their livestock were officially ejected by the Saudi government.

Camels have been shown to be hosts of the viral disease Middle-East Respiratory Syndrome Coronavirus (MERS-CoV) (AKA Camel Flu), which has been responsible for the deaths of hundreds in Saudi Arabia and scores in South Korea (via a traveller who was returning from the gulf). MERS-CoV has a ~40% fatality rate and is mainly spread between humans but, although the exact transmission route is not understood, the index case of each outbreak has been documented as being someone who has come into contact with a camel. Camels in Qatar have previously been confirmed to be seropositive for MERS-CoV.

Screen Shot 2017-12-18 at 00.45.05.png

Camels cross Saudi Arabia’s remote desert border into Qatar https://www.reuters.com/article/us-gulf-qatar-saudi-camels/camels-caught-up-in-qatar-feud-reunited-with-their-owners-idUSKBN19B1ZC

Conclusion

The abrupt discontinuation of trade with Qatar, and imposed blockage and impedance of supplies to Qatar by the coalition of Egypt, Bahrain, United Arab Emirates and Saudi Arabia sent shockwaves both socially, politically and economically, across the gulf region, causing immediate panic in the country and the global community, as concerns that the country with the highest GDP per capita would become unable to feed and medicate its citizens.

The supply of medicines remains an unresolved issue in this article but presumptions that Qatar will be able to afford to import medicines from the United States of America, India or European Union members, hold. As more study of the topic is undertaken and more data are released the picture will become clearer.

The concerns regarding food were quickly quelled by food shipments from ‘new friends’ in the region and has prompted Qatar to diversify its food suppliers, work to increase its own food security and potentially alter its own country’s burden of non-communicable diseases by shifting away from unhealthy diets to those less conducive to conditions such as diabetes.

Only time will tell whether MERS-CoV will cause an outbreak in Qatar but the World Health Organisation recommends that “people with diabetes, renal failure, chronic lung disease, and immunocompromised persons … should avoid contact with camels, drinking raw camel milk or camel urine, or eating meat that has not been properly cooked”. The risk is presumed to be high but the situation is very unclear, and worrying on a global level.

The blockade has had a limited (currently-documentable) effect on public health in Qatar but the long-term sustainability of plugging the food security gaps with Qatar’s vast sovereign wealth remains a concern. The lifting of the blockade does not appear likely in the near future but if Qatar continues increasing investment in food security it will cease to regard it as a public health issue.

 

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