Ghinwa El Hayek, Tahrir Institute of Middle East Policy
The COVID-19 response has been different among the 22 countries that make up the Arab region, due to their different political, social and economic landscapes. The response lacked a regional approach,[1],[2] which could have helped in handling the pandemic and softening its health and economic impacts. While the Gulf Cooperation Council (GCC) countries had a national rapid response and an economic recovery plan in place, middle and low-income countries as well as countries with conflicts lagged behind.[3],[4] Multiple countries in the region are affected by conflicts, displacement, political unrest and economic crises, fostering additional vulnerabilities to the pandemic. The early warning surveillance systems established in countries experiencing such complex emergencies were not sensitive enough to detect emerging infectious diseases. In fact, Yemen was the last in the region to report a COVID-19 case.[5]
Health surveillance systems
The pandemic revealed gaps in health surveillance systems and response to health security threats, even though some countries did have pandemic preparedness plans in place. Many countries in the region had to counteract previous outbreaks, such as the two other novel coronaviruses, SARS-CoV and MERS-CoV, as well as the 2009 H1N1 pandemic.[6] Effective preparedness plans require a strong and timely surveillance system for emerging diseases, and specific action plans (including logistics and supply management, risk communication, etc.) detailing what to do when a novel pathogen case is spotted. Surveillance systems are expected to produce routine real time information on a set list of diseases and symptoms, collected at the local level of the population to identify any unexpected symptoms or significant increase in certain cases of a potentially novel virus. Ideally, designated healthcare institutions or focal points in specific areas would be responsible for collecting such data, and sharing it on either a daily or weekly basis with relevant public health authorities.[7] The latter should be monitoring and analyzing the input to notify of any changes on local, national, and international levels.[8] In addition to the detection, and diagnostic capabilities, genomic surveillance is important as it leads to the recognition of the novel virus or other organism that is infecting humans.[9]
National or local health surveillance systems, including genomic surveillance, have been established in the majority of the Arab countries, yet they need maintenance, funding, up to date technology and a dedicated workforce, conditions that are not available in all countries of the region. Indeed, most Arab countries do not publicly report comprehensive and disaggregated epidemiological data on COVID-19[10] on levels such as sex, age groups, displacement status, nationalities, etc., let alone share open data on the matter.[11],[12] Only Iraq stood out, as it had data desegregated by sex, age groups, refugee status, regions, comorbid conditions, and hospital admissions.[13] During the first year of the pandemic, whole-genome sequences of SARS-CoV-2 were lacking from seven out of the twenty-two Eastern Mediterranean countries,[14] particularly those in conflict such as Syria, Libya and Yemen.[15],[16] Comprehensive and reliable data are essential for understanding the implications of the health crises to develop prompt and contextualized responses. Many countries in the region have probably under-reported COVID-19 cases and mortality rates,[17] due to their limited capacities in health surveillance, namely testing, contact tracing, and vital statistics registration. The underinvestment and undervaluation of routine sources of data and challenges to data sharing across several countries of the region can be addressed through prioritized governmental expenditure, creation of data protection policies, and use of available digital technologies.
A rigorous health surveillance system is on its own insufficient to respond to an outbreak. It is the strategy plan detailing the different measures and actions to take that is crucial. The implementation of different public health measures is key, but this is inconsistent across the different Arab countries.[18] Effective responses include a rapid response, an evidence-based approach that is well communicated, good coordination, transparency, leadership, and partnership spirit.[19] Then monitoring, evaluation and accountability of the enacted public health policies and measures should follow.
How Arab States Responded
The World Health Organization-Regional Office for the Eastern Mediterranean developed a regional strategic preparedness and response plan to aid Middle Eastern countries to counteract the COVID-19 pandemic in an attempt to build a coordinated reaction. Nevertheless, countries acted on an individual basis. An effective response requires a whole government and whole society approach, with collaboration between state and non-state actors (private healthcare sector, non-governmental organization, academic institutions).[20] For most countries, the response has been characterized by non-pharmaceutical interventions (NPIs) that were rarely instigated and monitored in many contexts, especially those with limited state capacity and conflict.
While many countries took early actions, others delayed for many reasons.[21] Countries such as Lebanon,[22]Jordan[23] and the UAE[24] acted quickly to contain the outbreak, enforcing school closures, and other forms of physical distancing. Saudi Arabia canceled Umrah pilgrimage and access to Mecca to non-residents in an effort to contain the rapidly spreading virus.[25] In Qatar, thermal cameras were set up in the airport, and education campaigns for healthcare professionals began as soon as the outbreak started in Wuhan.[26] Other countries invested in information technology to share epidemiological information[27],[28] to predict COVID-19 among women with underlying conditions,[29] or for invasive contact tracing.[30] Many governments relied on scientists and academicians for advice during the pandemic, promoting knowledge exchange, scientific diplomacy, and an evidence based approach.[31],[32] On the other hand, some governments lacked transparency in enacting pandemic related policies without solid scientific evidence, and some downplayed its severity.[33] For countries in conflict or socio-economic crises, the non-governmental sector was an indispensable part of the response, and a much-needed financial, logistic and educational support to governments.[34],[35] For the first year of the pandemic (i.e 2020), most countries had strict policies on masks, quarantine, school and business closure and airport monitoring, on top of digital contact tracing.[36] The measures relaxed by spring 2021, whereby many countries notably GCC had vaccinated the majority of their population. In countries stricken with conflicts, where only 50% of hospitals are fully functional, non-pharmaceutical public health measures were scarce and seldom applied.[37],[38] There is growing evidence that the implementation and the adherence to public health measures during the pandemic is related to trust in the government and the governance of the healthcare sector; more research is needed on this topic.[39]
Even with these early measures, the adherence to health policies and mandates, and with some countries still having lockdown and emergency states until February 2022, such as Morocco[40], 7 out of 22[41] countries reported higher cumulative confirmed COVID-19 deaths per million people than the world average.[42] Considering that many countries having limited capacity to detect and report the death cases due to COVID-19, the number of might be under-reported. Additionally, the concentration of healthcare services on the pandemic response should not disrupt the delivery of other routine healthcare matters such as medical check-ups and immunization among other services. Yet this was not the case in some countries such as Iraq, Djibouti and Tunisia, where 40% of the population did not receive timely medical care.[43]This would have repercussion on the quality of life, morbidity and then mortality in those countries. It shows that the health systems, notably in low and middle-income Arab countries are fragile and not ready for the future health threats. Investment in the healthcare infrastructure, governance and personnel is warranted.
Vaccines
As vaccines were rolled out, many Arab countries participated in the clinical trials.[44] The GCC were the first to start their vaccination campaigns, in addition to supporting COVAX.[45] Other countries followed rapidly, notably Lebanon, Jordan, Tunisia and Morocco; with the latter two being some of the most vaccinated against COVID-19 countries in Africa.[46] [47] Jordan and Lebanon’s case is unique as a big proportion of their population are refugees; as such, their vaccination campaigns had to be inclusive. Jordan’s vaccination plan was acclaimed for including refugees. Currently the majority of Syrian refugees are vaccinated with support from UNHCR.[48] Lebanon’s campaign was the first to be financed by the World Bank,[49] yet it was criticized for not including refugees and migrant workers explicitly in its plan.[50] However, this was contradicted as everyone was invited to be vaccinated, with weekly campaigns in collaboration with UN agencies and humanitarian organization targeting refugees and vulnerable populations.[51],[52]
When it comes to vaccine and treatment creation, only Egypt has been working on fabricating two COVID-19 vaccines that are currently in trials.[53] Nonetheless, many countries are currently manufacturing already approved COVID-19 vaccines; UAE[54] and Morocco,[55] and Egypt[56] are producing Sinopharm and Sinovac respectively. Other nations are planning to manufacture other vaccines, such as Lebanon signing an agreement to produce Sputnik,[57] and Egypt and Tunisia participating in the knowledge transfer hub for m-RNA vaccines established in Africa.[58] All of these actions and deals are motivated by political and business circumstances, as countries want to be regional hubs for COVID-19 vaccines in either Africa or Asia, in addition to ramp up uptake of vaccines in their own countries, to reach the needed immunity to be able to remove non pharmaceutical public health measures.
With all these efforts in the region, only eight out of the 22 Arab[59] countries vaccinated at least 60% of their population.[60] This exposes caveats in the vaccination strategy of the countries not vaccinating the majority of their populations; and in vaccine accessibility and equity in the region, especially in conflict affected or politically unstable nations. Indeed, Yemen, Sudan, Somalia and Syria have less than 15% of their populations vaccinated with at least two doses of COVID-19 vaccines.[61] Although these countries benefit from COVAX, high-income nations in the region should support the vaccination efforts of low-income countries in the region, by either directly providing them with extra doses of vaccines or financing the vaccination campaign through UN agencies or their own aid agencies.
Misinformation
Countries with enough doses of vaccines and low vaccination rates should put risk and health communication at the forefront of their strategy, to counter misinformation and address the different challenges preventing people from getting vaccinated. Mainstream and social media would come in handy for the rapid dissemination of health messages that should be contextualized to the country and even the targeted community. Investment in communication and social marketing during pandemics is imperative.
Fake news and misinformation were detected on social media[62] and even on messaging apps such as WhatsApp.[63]However, it was not until some countries imposed vaccine mandates that protests erupted, refusing these measures, with anti-vax messages at the core, such as in Lebanon[64] and Morocco.[65] Social media channels failed to some extent to regulate and filter online misinformation in Arabic versus the ones in English.[66] To counter the infodemic, some governments collaborated with UN agencies to counter the spread of misinformation;[67],[68] there were also community led initiatives, such as journalists in Libya developing a Facebook Page where they write articles refuting COVID-19 misinformation.[69] Another example is SMEX, an organization working on advancing digital rights in the Arab region, launching the #VaxFacts campaign to verify online information about the COVID-19 vaccine by inviting its community to report any suspicious content.[70]
The Next Pandemic
This pandemic taught the region many lessons to prepare for the next one, which might occur in the near future, in fact as this article is being published a Monkeypox outbreak is spreading in non-endemic countries, including Arab countries since end of May.[71] It should be an opportunity for structural change in the health systems towards universal healthcare coverage with equity and social justice at the core. Gulf countries already took a step forward by creating the Gulf Center for Disease Control.[72] Nevertheless, if there are no drastic changes in the health systems specifically, many countries in the region risk not surviving the next pandemic. Only two countries, Oman and UAE are well prepared when looking at their scores on seven indicators to fight future health threats. Other countries have some work to do on either their laboratory systems, surveillance systems, preparedness plans, risk communication, emergency response operation strategy, workforce development, and national legislation.[73]
Though each of these points needs to be examined at a national level and addressed in a contextualized manner, the main lesson remains cooperation and coordination in the response, as well as investment in public health infrastructure, pandemic preparedness, and global biosecurity on a regional level. The cross-country collaboration, which is both political and scientific, is expected to encourage the exchange of expertise and resources among countries in the region, developing scientific and clinical ventures. It is fundamental to have investments in medical research and pharmaceutical industry to pioneer the next medicine or vaccine preventing or curing the next threat. The pandemic reminded us that health is a basic human right and not a commodity. Governments should assume their responsibilities to protect this right for all by drawing on the different capacities in their societies.
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[3] Alden, Chris, and Charles Dunst. “Covid-19: Gulf States and the Gulf Cooperation Council (GCC).” London School of Economics and Political Science. Accessed March 30, 2022. https://www.lse.ac.uk/international-relations/centres-and-units/global-south-unit/COVID-19-regional-responses/Gulf-States-and-COVID-19.
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[7] Davenhall, Bill. “Building a Community Health Surveillance System.” ESRI News. ESRI. Accessed March 22, 2022. https://www.esri.com/news/arcuser/0102/comhealth1of2.html.
[8] Center for Disease Control and Prevention. “Public Health Surveillance at CDC.” Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, August 24, 2018. https://www.cdc.gov/surveillance/improving-surveillance/Public-health-surveillance.html.
[9] Center for Disease Control and Prevention. “What Is Genomic Surveillance?” Centers for Disease Control and Prevention. Centers for Disease Control and Prevention. Accessed March 21, 2022. https://www.cdc.gov/coronavirus/2019-ncov/variants/genomic-surveillance.html#:~:text=Genomic%20sequencing%20goes%20beyond%20testing,throughout%20the%20COVID%2D19%20pandemic.
[10] Wehbe, Sarah, Sasha A. Fahme, Anthony Rizk, Ghina R. Mumtaz, Jocelyn DeJong, and Abla M. Sibai. “COVID-19 in the Middle East and North Africa region: an urgent call for reliable, disaggregated and openly shared data.” BMJ global health 6, no. 2 (2021): e005175.
[11] AlSawahli, Heba. “Reliable Health Data in the MENA Region: The Hard Pill to Swallow.” Tahrir Institute for Middle East Policy, December 2, 2021. https://timep.org/commentary/analysis/reliable-health-data-in-the-mena-region-the-hard-pill-to-swallow/.
[12] Wehbe, Sarah, Sasha A. Fahme, Anthony Rizk, Ghina R. Mumtaz, Jocelyn DeJong, and Abla M. Sibai. “COVID-19 in the Middle East and North Africa region: an urgent call for reliable, disaggregated and openly shared data.” BMJ global health 6, no. 2 (2021): e005175.
[13] El Hayek, Ghinwa, Sirine Anouti, Ghina R. Mumtaz, and Lilian A. Ghandour. “Data with Borders for a Borderless Virus: Insights and Recommendations from the Case of Lebanon.” Arab Reform Initiative. Arab Reform Initiative, October 19, 2021. https://www.arab-reform.net/publication/data-with-borders-for-a-borderless-virus-insights-and-recommendations-from-the-case-of-lebanon/.
[14] Eastern Mediterranean region is defined as per the World Health Organization division, it comprises 21 Member States and the occupied Palestinian territory (including East Jerusalem): http://www.emro.who.int/countries.html
[15] Omais, Saad, Samer Kharroubi, and Hassan Zaraket. “No association between the SARS-CoV-2 variants and mortality rates in the Eastern.” Eur J Clin Invest(2020): e13423.
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[17] Cousins, S. “Arab countries brace against COVID-19.” Nature Middle East (2020).
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[19] Al Saidi, Ahmed Mohammed Obaid, Fowsiya Abikar Nur, Ahmed Salim Al-Mandhari, Maha El Rabbat, Assad Hafeez, and Abdinasir Abubakar. “Decisive leadership is a necessity in the COVID-19 response.” The Lancet 396, no. 10247 (2020): 295-298.
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[21] Cousins, S. “Arab countries brace against COVID-19.” Nature Middle East (2020).
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[32]Plackett, B. (2020. “Public Health Experts Are Often Missing From Arab World’s Coronavirus Battle”. Al Fanar Media, April 3, 2020. https://www.al-fanarmedia.org/2020/04/public-health-experts-are-often-missing-from-arab-worlds-coronavirus-battle/.
[33] Yasmina Abouzzohour,”The Amplification of Authoritarianism in the Middle East and North Africa in the Age of Covid-19”
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[39] Robert Kubinec, “COVID-19 Responses in the Middle East and North Africa in Global Perspective”
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[41] Date of data extraction: 26-April-2022
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[47] Date of data extraction: 26-April-2022
[48] “Refugee vaccinations against COVID-19 increase in Jordan.” UNHCR Jordan, February 7, 2022 https://www.unhcr.org/jo/17339-refugee-vaccinations-against-covid-19-increase-in-jordan.html
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[57]Lewis, Emily. “A Local Drug Company Is Set to Make the Sputnik Vaccine, but Its Price and Financing Mechanisms Remain Unclear.” L’Orient Today. L’Orient Today, June 3, 2021. https://today.lorientlejour.com/article/1263925/a-lebanese-drug-company-is-set-to-make-the-russian-covid-19-vaccine-but-its-price-and-financing-mechanisms-remain-unclear.html.
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[59] Date of data extraction: 26-April-2022
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[61] Ditto
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[63] Khalifa, Hussein, Mujeeb Saif Mohsen Al-Absy, Sherif A. Badran, Tamer M. Alkadash, Qais Ahmed Almaamari, and Muskan Nagi. “COVID-19 pandemic and diffusion of fake news through social media in the Arab world.” Arab Media & Society 30 (2020).
[64] Chehayeb, Kareem. “’Vaccine Dictatorship’: Many Lebanese Refuse the Covid Jab.” News | Al Jazeera. Al Jazeera, January 14, 2022. https://www.aljazeera.com/news/2022/1/14/lebanon-vaccine-hesitancy.
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[66] O’Connor, Ciarán, and Moustafa Ayad. “Mena Monitor: Arabic Covid-19 Vaccine Misinformation Online.” Institute for Strategic Dialogue, 2021. https://www.isdglobal.org/wp-content/uploads/2021/04/MENA-Covid-Vaccine-Misinformation-Monitor-1.pdf.
[67] “UNICEF Reaches Nearly 150 Million People with Information on Covid-19 across the Middle East and North Africa.” UNICEF. Accessed March 21, 2022. https://www.unicef.org/mena/press-releases/unicef-reaches-150-million-people-information-covid-19-middle-east-north-africa.
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[69] Ali, Moutaz. “A Group of Libyan Journalists Is Battling Covid-19 Fake News in Social Media.” D+C, July 6, 2021. https://www.dandc.eu/en/article/group-libyan-journalists-battling-covid-19-fake-news-social-media.
[70] Beydoun, Maha. “Vaccine Misinformation: Is Doubt Key to Certainty?” SMEX, March 9, 2022. https://smex.org/vaccine-misinformation-is-doubt-key-to-certainty%EF%BF%BC/.
[71] World Health Organization. “First case of monkeypox reported in WHO’s Eastern Mediterranean Region.” WHO-EMRO., May 24, 2022. http://www.emro.who.int/media/news/first-case-of-monkeypox-reported-in-whos-eastern-mediterranean-region.html#:~:text=24%20May%202022%2C%20Cairo%2C%20Egypt,capacities%20for%20this%20viral%20disease.
[72] “Gulf CDC.” Gulf Health Council. Accessed April 27, 2022. https://ghc.sa/en/studies-resources/.
[73] “Our Interactive Map: See Your Country & Neighbor’s Preparedness Score.” Prevent Epidemics, January 10, 2020. https://preventepidemics.org/map/?lat=30.3&lng=19.89&zoom=2.5.