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85 7 Saudi Arabia and Neighboring Conflict Zones of the Middle East and North African Region Until relatively recently, the region known as MENA—Middle East and North Africa—was not considered a major “hot zone” for NTDs. However , emerging information indicates that MENA is an important area for the world’s neglected diseases, especially NTDs that are now arising in ISIS-­ occupied conflict areas in Syria, Iraq, and Libya, as well as in Yemen. Kingdom of Saudi Arabia Despite the fact that it is a wealthy G20 nation, Saudi Arabia has an extreme vulnerability to the NTDs. These diseases threaten the health and economy of the country for multiple reasons. First, even though the kingdom has vast oil wealth and GDP that will soon reach $1 trillion, a segment of Saudi Arabian society lives in poverty. Much of the nation’s poverty and its impoverished population is hidden and not easily viewed. According to a 2013 article in the Guardian, of Saudi Arabia’s population of almost 30 million, approximately 2–4 million of the native Saudis live below the nation’s poverty line (estimated then at $530 per month), despite government efforts to aggressively invest internally as a means to address this problem [1]. Indeed, during drives with the American Embassy staff in my role as US science envoy, it was possible to see firsthand evidence of acute poverty in the kingdom , but it was seldom obvious and required traveling away from major thoroughfares to find it. Hotez.indb 85 6/22/16 11:02 AM 86 Blue Marble Health NTDs are strongly associated with Saudi Arabia’s poverty, along with factors related to climate. As of 2013, schistosomiasis was still endemic in Al-­ Bahah Province in the southwestern part of the country [2]. Cutaneous leishmaniasis is also widespread and was epidemic in the Al-­ Hassa oasis during the 1980s; both Leishmania tropica and L. major are present, although a national control program focused on case detection, vector control, and other measures is reducing the total number of cases [3]. Whether recent drops in oil prices will expand poverty and poverty-­related diseases in Saudi Arabia remains to be seen. A second driving force for NTDs in Saudi Arabia is its geographic location , sandwiched between two major conflict zones: ISIS-­ held Syria and Iraq to the north and Yemen to the south. The risk of NTDs from ISIS areas is discussed below, but even in the years prior to the Syrian conflict, Yemen was also “ground zero” for NTDs in the MENA region, with some of the highest prevalence rates of schistosomiasis, fascioliasis, intestinal helminth infections, and trachoma, among others [4]. Superimposed on these two socioeconomic forces— poverty and conflict—is the Hajj, the annual Muslim pilgrimage to Mecca, which brings 2–3 million visitors to Saudi Arabia during the last month of the Islamic calendar. The majority of the pilgrims arrive from Muslim countries belongingtotheOrganisationofIslamicCooperation(OIC), which includes MENA countries, many sub-­ Saharan African nations, and large Islamic Asian countries such as Bangladesh and Indonesia. Previously, I found that OIC countries (fig. 7.1) are also disproportionately affected by poverty and NTDs, especially intestinal helminth infections, schistosomiasis , trachoma, and leprosy [5]. From an epidemiological framework, the Hajj is a vast mixing bowl that has the potential to spread NTDs and other emerging infections across the Muslim world. There are particular concerns about respiratory viruses such as avian influenza and MERS coronavirus, but it is also believed that during the 1990s the Hajj may have introduced dengue fever into Jeddah, the location of the major international airport closest to Mecca. Nucleic acid sequencing of Saudi Arabian dengue virus strains suggests that it could have been first introduced by African pilgrims infected with an Asian genotype [6]. The number of dengue cases has been reported on the rise in the years between 2006 and 2013, and some investiThe major driving forces that promote NTDs in the Kingdom of Saudi Arabia include hidden poverty, geographic proximity to conflict zones, and the annual pilgrimage. Hotez.indb 86 6/22/16 11:02 AM Saudi Arabia and Neighboring Conflict Zones 87 gators have called for stepped-­ up control measures to combat dengue and related vector-­ borne virus infections [7]. Still another major issue related to NTDs in Saudi Arabia is their possible links with noncommunicable diseases. NCDs are on a steep rise throughout the Arab world [8]. During my time in Saudi Arabia, I was impressed by high NCD rates among its...


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