The Middle East is an area undergoing great transition. Behind the political conflicts that dominate the international headlines is a region whose demographics are changing dramatically. Some Middle Eastern countries, such as Yemen and Sudan, are predominantly rural, with relatively low educational levels, and high mortality due to infectious diseases. By contrast, countries such as Egypt, Jordan and Lebanon are experiencing increasing urbanisation, raised educational levels, an increase in chronic diseases, and population shifts, with great numbers of adolescents and elderly people.

Such changes have profound consequences for health policy and practice. To gain greater insight into these transitions, the Wellcome Trust is funding Huda Zurayk and her team at the Faculty of Health Sciences at the American University of Beirut (AUB) in a wide-ranging study of the health consequences of population change across the Middle East.

A key aim of the award to Dr Zurayk and the AUB is to make a significant contribution to the regeneration of the academic science base in Lebanon. "Beirut is coming out of more than a decade of civil war," says Wendy Ewart, a Scientific Programme Manager at the Wellcome Trust, "during which the previously thriving academic life of the city was seriously damaged. Now the war is over, institutions like the AUB are trying to rebuild, and we hope our funding will contribute to that by enabling high-quality, locally based, multidisciplinary research to be undertaken."

The AUB has a long history. Founded in 1866, it is one of the oldest centres of learning in the Middle East, and has particular strengths in the humanities and social sciences. A major aim of the Wellcome Trust award is to help strengthen research capacity in those areas of AUB's work most relevant to the health consequences of population change. A programme of work in women’s reproductive health has been funded, and several 'development awards' will enable AUB researchers to carry out preliminary studies in various areas, as well as providing an opportunity for them to develop more ambitious proposals for consideration by the Trust.

Equally importantly, the award will also enable Dr Zurayk and her colleagues to develop links with other colleagues in the region. Young researchers at the AUB will be funded for travel to other regional centres, and collaborative projects will be initiated with groups elsewhere in the Middle East. Of particular importance will be links to the American University of Cairo, in Egypt, which has been funded by the Wellcome Trust to run a three-month research training scheme in research methods and policy analysis for promising young scientists in the Arab world.

"It's a way of maximising benefits," explains Dr Ewart. "We hope to create a 'critical mass' of researchers interested in the health consequences of population change in the Middle East, so they can all share experiences and learn from one another. That way the whole research infrastructure should prosper."

Reproductive health

The issue of women's reproductive health in the Middle East is an important aspect of the new programme's research. "There is a huge disparity between the good care given to some women in the region, and the quite poor care experienced by many others," Dr Ewart points out.

Dr Zurayk is well aware of the issues involved: "Before coming to AUB, I spent ten years in Cairo with the Populatic Council, coordinating the regional Reproductive Health Working Group. The RHWG adopted an explicitly multidisciplinary perspective, aiming to improve reproductive health by taking into account both the cultural context of the Middle East, and women’s social situation."

Maternal health problems are the largest cause of ill-health for women in developing countries. Research has focused on maternal mortality – as most deaths can be prevented with adequate emergency obstetric care. However, attention has begun to shift towards the needs of all pregnant women, not just those with complications. "Childbearing in many countries in the Middle East is moving towards hospital deliveries," says Dr Zurayk, "and new research must take account of this. We want to understand how maternity care can be made safer for women and their children."

Research by members of Dr Zurayk's team and others has already shown that although many women in the Middle East give birth under professional care, the care is not standardised, and many women's experiences are not positive. In Lebanon, for example, 88 per cent of all deliveries take place in hospital. But procedures shown to be ineffective – such as denial of water, perineal shaving and routine enema – are still followed, and nearly a third of Lebanese hospitals require women to lie down during labour, a practice now considered harmful.

Tamar Kabakian-Kasholian, a research associate with Dr Zurayk at the AUB, together with Dr Oona Campbell at the London School of Hygiene and Tropical Medicine, will coordinate research into current delivery care and women's preferences in Lebanon, Egypt, Jordan, Syria and Palestine. The three-year programme will investigate national policies and professional standards and practice in all aspects of maternity care, as well as women's own experiences of childbirth. "We will be working collaboratively," says Dr Zurayk, "with policy makers, professional associations, healthcare providers and women themselves."

Development projects

The new award will also enable Dr Zurayk and her colleagues to begin developing other strands of research, which could lead to more extensive projects in the future. These projects touch upon some of the most important health issues in the region.

One area of interest, which will involve collaboration with Dr Salah Mawajdeh at the Jordan University of Science and Technology, is that of health sector reform, particularly in relation to women's health. Reforms aimed at improving healthcare in developing countries share many of the characteristics of health sector reforms in the UK and elsewhere – decentralisation of budgets, more local management, greater private involvement, new financing schemes and staff restructuring. How reproductive healthcare in developing countries will fare in these reforms is not clear.

The Beirut researchers will also be focusing on women's work-related health problems. Traditional definitions of work are based on 'participation in the labour force', a definition that renders much of women’s work – for example domestic work, unpaid subsistence work, selling of family products, work in the informal sector – invisible. Key issues, such as work-related injuries and physical assault and the stress of combining work and family responsibilities, are also overlooked.

Lebanon provides ideal ground for exploring work-related problems among women. In the last 30 years in Lebanon, women have moved into the workforce in a significant way. Lebanon is now a predominantly urban society, where women are literate and well-educated, marry later than women in other Middle Eastern countries, and have comparatively low fertility.

Another area of interest relates to prioritisation and attempts to assess the impact of disease. In short, if you are trying to improve the health of a country or region, how do you decide which problems to tackle first? Current approaches use the 'global burden of disease' measure – a summary measure of the most prevalent problems and how disabling they are. The World Health Organization is sponsoring Dr Zurayk's co-investigators at the Faculty of Health Sciences to review epidemiological data on 40 diseases in Lebanon as part of its national burden of disease study.

Across the world, infectious diseases are decreasing, therapeutic advances continue, and access to healthcare is increasing. But the speed of these 'health transitions' varies between different countries, and also within them. Lebanon is a case in point, says Dr Zurayk. "It is a country with two disease profiles, one 'pre-transition' – dominated by infectious diseases – and one ‘post-transition’ – dominated by chronic diseases." The global burden of disease measure will not reflect these variations. How, therefore, should health priorities be decided?

To complement the WHO study, Dr Zurayk and her team are also researching the essentially sociological factors that determine health in two groups in Lebanon: adolescents and older people. Previous research has thrown up some interesting aspects to Lebanese life. For example, intentional and unintentional injuries among young people are a particular problem: 6 per cent of first-year university students have attempted suicide, and 30 per cent have been involved in a physical fight within the last 12 months.

The work will have important implications for research and healthcare delivery throughout the Middle East. "The whole programme of work being undertaken by Dr Zurayk will build local capacity for sustainable future research on health and population change across the Middle East," points out Dr Ewart. "It not only positions the American University of Beirut as a centre of excellence, but greatly enhances collaboration between different centres of expertise right across the region."

External links

• American University of Beirut Lebanon
• American University in Cairo Egypt
• LSHTM: London School of Hygiene and Tropical Medicine
• Jordan University of Science and Technology
• World Health Organization