Health consequences of Drought in the WHO Eastern Mediterranean Region: hotspot areas and needed actions.

doi:10.21203/rs.3.rs-48466/v2

Background: Over the past four decades, drought episodes in the Eastern Mediterranean Region (EMR) of the of the World Health Organization (WHO) have gradually become more widespread, prolonged and frequent. We aimed to map hotspot countries and identified key strategic actions for health consequences.

Methods: We reviewed scientific literature and WHO EMR documentation on trends and patterns of the drought health consequences from 1990 through 2019. Extensive communication was also carried out with EMR WHO country offices to retrieve information on ongoing initiatives to face health consequences due to drought. An index score was developed to categorize countries according vulnerability factors towards drought.

Results: A series of complex health consequences are due to drought in EMR, including malnutrition, vector-borne diseases, and water-borne diseases. The index score indicated how Afghanistan, Yemen and Somalia are “hotspots” due to poor population health status and access to basic sanitation as well as other elements such as food insecurity, displacement and conflicts/political instability. WHO country offices effort is towards enhancing access to water and sanitation and essential healthcare services including immunization and psychological support, strengthening disease surveillance and response, and risk communication.

Conclusions: Drought-related health effects in the WHO EMR represent a public health emergency. Strengthening mitigation activities and additional tailored efforts are urgently needed to overcome context-specific gaps and weaknesses, with specific focus on financing, accountability and enhanced data availability.

Epidemiology

Toxicology

Drought

Eastern Mediterranean Region

Preparedness

World Health Organization.

In the World Health Organization (WHO) Eastern Mediterranean Region (EMR), with around three quarters of its surface consisting of desert, drought, defined as a prolonged dry period in natural climate cycle, is a common phenomenon.¹

Over the past four decades, drought episodes in the EMR have gradually become more widespread, prolonged and frequent.² The drought that lingered between 1998 and 2012 was likely the worst of the past nine centuries for countries like Jordan, Lebanon, Palestine and Syria.² In particular, the 4-year drought that started in 2006 in Syria has had major consequences with mass migration from the countryside to the cities.²

The Horn of Africa has been affected by prolonged drought in 2016 and 2017 and has been identified as an important vulnerability area along with the south-western Arabian Peninsula (Yemen).³Similarly, large scale drought conditions erupted in selected and contiguous provinces of Afghanistan and Pakistan during the last trimester of 2018.³

Being a slow-onset, long duration, spatially diffuse emergency, rather than a sudden, high-impact event (such as flash flood), drought differs from other natural hazards and has many multiple “downstream” effects that might result in increased morbidity and mortality (Fig. 1).⁴

The nutrition-related morbidity and mortality are the best recognized health impact of drought.⁵ Drought affects ecosystem, thereby reducing food supplies like crops and livestock, and its related food shortage is only one aspect of the much more important concept of food security (defined as “... physical and economic access to sufficient, safe and nutritious food to meet dietary needs.).⁶

Decreased water availability is a defining feature of most drought. As water levels are typically low, this may lead to both reduced dilution capacity and to contamination of the few remaining sources. The likelihood for an outbreak of infectious disease (e.g. Cholera) to occur increases when more users are there for a water source.⁴Similarly, skin infections are common because of lack of water for washing and include scabies and leishmaniasis.

On the other hand, as soils become increasingly dry during a drought, dust circulated in the air is more likely. Dust, in its turn, can be harmful via two mechanisms: pathogen carriage and direct trauma from inhaled particulates.⁵

It is also important to note that density of mosquitos, among the most important arthropod vectors involved in the transmission of various vector-borne pathogens, has been found to dramatically increase following natural drought events due to the loss of competitors and predators.⁷

Also, the proliferation of water storage tanks as an adaptation strategy during drought conditions, may create a potential for transmission of diseases like dengue,⁸ chikungunya⁹ and Rift Valley fever.¹⁰

Research suggests that drought contributes to the business-related pressures that farmers must face, with severe drought resulting in financial impacts and consequent emotional stress.⁴

Finally, effects of flooding in the area subjected to drought are particularly devastating because of rainfall not being absorbed into the soil to nurture crops.⁴

The factors linking drought with effects on health occur within the context of existing infrastructure (i.e., health, sanitation and other resources) and baseline public health (i.e., the capacity of populations to be resilient in the face of adverse conditions).⁴

In consideration of all the ongoing as well as future potential adverse health outcomes of drought, a public health situational analysis was conducted with the overall objective of guiding the World Health Organization towards preparedness actions in the Eastern Mediterranean Region. More specifically, this analysis was guided by the need of: I) Assessing the health consequences of drought and their vulnerability characteristics (i.e. food security, water, sanitation and hygiene) at EMR level; II) Mapping hotspot countries for health consequences according to these vulnerability characteristics; and III) Identifying the key strategic actions for WHO actions against health consequences of drought.

Health consequences of drought and vulnerabilities in WHO EMR

A review of scientific literature and WHO EMR documentation indicating updated trends and patterns of the drought health consequences from 1990 through 2019 was carried out. To do so, we relied on publically available articles in PubMed, on data displayed on the WHO Regional Health Observatory, on EMR specific programmes documents, and on WHO Country Office reports.

To explore the regional vulnerability factors affecting the health impact of drought, we searched for all updated specific documentation in line with the WHO criteria.¹The criteria were: health status of the population before the disaster; infrastructure like water supply and sanitation systems; food insecurity; absence of warning systems; population displacement; and other concurrent situations like economic crisis, political instability and armed conflict.

The specialized WHO Centre for Environmental Health Action (CEHA) was contacted to provide relevant documentation on access to water and sanitation in the EMR countries.

Drought health consequences hotspot map

In order to map the burden of health consequences due to drought in the EMR, an index score, which that takes into account all the above-mentioned vulnerability factors, was developed, and all EMR countries were assessed against them after categorization as follows:

Under-5 mortality¹¹ (U5M) was used as proxy for the health status of the population and dichotomized, in line with the Sustainable Development Goal (SDG) 3.2, in “0” if U5M rate was less than 25 deaths per 1,000 livebirths and “1” if otherwise.

Even if SDG 6.2 target is 100% of people have access to adequate and equitable sanitation and hygiene, we have considered 3 levels of access: countries were coded as “0” if more than 90% of the population had access to basic sanitation, “1” if this proportion was between 50 and 90%, and “2” if otherwise.¹²

To estimate the food insecurity¹³ status, we used the estimated population in need of emergency food assistance in 2019, and considered the four categories proposed by the Famine Early Warning System (FEWS) maps.¹³ Countries with population in need accounting for less than 1 million, between 1 million and 5 million, between 5 million and 15 million, and for more than 15 million, were coded as 1, 2, 3, and 4 respectively.

Countries were assigned a code equal to “0” if no Early Warning System for drought was in place and “1” if otherwise.

Last vulnerability factor considered was the internal displacements, using UNHCR figures on Internally Displaced Persons (IDPs).¹⁴ Countries were coded as “1” if they had less than 1 million IDPs, “2” if IDPs were between 1 and 5 million, and “3” if they were more than 5 million IDPs)

For each country, an index score (from “2” up to “11”) was calculated after summing all the vulnerability factors’ scores. Hotspots were identified as countries with the highest scores for health consequences due to drought.

In line with the described index score, an EMR map was produced with colours reflecting the status of health consequences vulnerability due to drought.

Malnutrition is a complex challenge for the Eastern Mediterranean Region, with many countries having multiple forms of malnutrition among their populations at the same time. Populations are mainly affected by undernutrition (wasting, stunting, underweight).¹⁵ The overall estimates for stunting, wasting and underweight are 28%, 8.7% and 18% respectively (Fig 2).¹⁵ The prevalence of anaemia (haemoglobin <11 g/dl) that is the result of iron deficiency ranges from 7.4% to 88% in children aged < 5 years and from 16 to 81% in pregnant women.¹⁵

Decreased water availability and extensive population movements across and within the countries, especially in areas with porous borders like the Horn of Africa and from the Sahel to the Northern African countries, make difficult the identification of trajectories of transmission of water-borne diseases like cholera which have affected several EMR countries over the last years. The cumulative number of suspected cholera cases reported in Yemen since 2017 until the end of 2019 was 2,188,503 3,750 associated deaths, resulting in a 0.17% case fatality rate.¹⁶ Acute Watery Diarrhea (AWD) had affected Sudan since 2016 infecting over 36,000 people and killing over 800.¹⁷ Somalia is highly endemic for cholera and regular large outbreaks both after flooding and during droughts are observed.¹⁸ Cholera outbreaks also occur in Iraq every 3 to 5 years, with last considerable outbreak occurring in 2015, and have a distinct seasonality that typically start in September and continue through December.¹⁹

Up to 60% of the worldwide burden of cutaneous leishmaniasis is in the EMR.²⁰ Massive destruction of urban settlements during the crises, poor waste management, limited access to safe and clean water, presence of domestic animal that act as the reservoir for the sandflies and lack of effective vector control program put large number of people at risk of Leishmaniasis in the region.²⁰

The geographic diversity in the EMR determines malaria variability in terms of endemicity, intensity of transmission and type of malaria. Malaria-endemic countries of the region are situated in the three eco-epidemiological zones of malaria: Afrotropical, Oriental and Palearctic.^21,22

In Saudi Arabia, Yemen and the sub-Saharan countries of the region (Djibouti, Somalia, Sudan), P. falciparum is predominant. In the other endemic countries, mainly Afghanistan, Islamic Republic of Iran and Pakistan, both P. falciparum and P. vivax are transmitted.²¹More than 20,000 have been recently reported in Djibouti with the introduction of a new vector.

The under-five mortality ranges from less than 10 deaths per 1 000 live births in in the Gulf countries and Lebanon, up to more than 50 deaths per 1 000 live births in Afghanistan, Djibouti, Pakistan, Somalia, Sudan and Yemen. The same pattern is present for the neonatal mortality, with Afghanistan, Pakistan and Somalia reaching highest incidence (>35 deaths per 1 000 live births).¹¹

Eighty seven percent (564.08 million) of the Region’s total population has access to at least basic drinking-water services. Thirteen percent (84.4 million people) remain without even basic water services, of which 64.6 million live in Afghanistan, Pakistan, Sudan, Somalia and Yemen and 15 million live in Iraq, Islamic Republic of Iran and Morocco (Fig 3).²³

Estimates for safely managed drinking-water are available for only 9 out of 22 countries of the EMR (Bahrain, the Islamic Republic of Iran, Jordan, Kuwait, Lebanon, Morocco, Oman, Pakistan and Tunisia). Bahrain, Islamic Republic of Iran, Kuwait, Jordan and Tunisia have the highest percentage of the population (over 89%) with access to safely managed water services.²³

Twenty seven percent (175 million people) remain without basic sanitation services, of which 154 million live in Afghanistan, Islamic Republic of Iran, Pakistan, Somalia, Sudan and Yemen and 17 million live in Egypt, Iraq and Morocco (Fig 4).²³ Around 51.7 million people in the region still defecate in the open, mainly in rural areas, of whom 46.5 million live in Afghanistan, Pakistan, Somalia, Sudan and Yemen. Access to water and soap for handwashing varies greatly, ranging from 10% in Somalia to around 90% in Tunisia, Egypt and Iraq.²²

The humanitarian food assistance continues in Yemen through early 2019, especially for the significant declines in commercial imports and conflict that cuts populations off from trade and humanitarian food assistance for an extended period, potentially leading to Famine.²⁴

For Afghanistan, the Famine Early Warning Systems Network (FEWS NET) estimates that the overall population in need of emergency food assistance in 2019 is between 5 and 10 million.¹³

Pakistan has made gains becoming a food surplus country, and a major producer of wheat. However, around 2 million persons are estimated to be in need of emergency food assistance,¹³ primarily due to limited economic access by the poorest and the most vulnerable.

The collapse of the economy, soaring food prices, loss and disruption of livelihoods as well as the decline in food production have contributed to widespread food insecurity across Syria. More than 5 million Syrians are now estimated to be in need of emergency food assistance.¹³ Similar dynamics in the neighboring Iraq have led to around 2 million people in need for the year 2019.¹³

Well above average staple food prices are expected to drive high 2019 assistance needs in Sudan, and more than 5 million population is now estimated to be in need of emergency food assistance.¹³

Countries in the EMR are at different stages as to the presence of functioning drought early warning systems. While a dedicated regional network is well set-up for most of the Arabian Peninsula countries and for northern African countries like Morocco and Tunisia,²⁵ other countries like Iran rely on government centers. Afghanistan and Somalia rely on specific donors funded projects²⁶ while all the other countries do not have specific monitoring initiatives.

As host to some of the world’s biggest emergencies and protracted crises, the EMR carries the largest burden of displaced population globally.²⁷ Out of 58 million displace persons worldwide, almost 30 million (52%) come from the Region. As far as internally displaced persons (IDPs) are concerned, Syria reaches the peak of around 6 million IDPs, followed by Afghanistan (around 2 million), Iraq, Somalia, Sudan and Yemen; Libya and Pakistan feature (around 200,000 IDPs each).¹⁴

The conflict in Yemen is marked by severe blockades to humanitarian access including aerial and naval blockade of humanitarian goods. Import blockage to food, fuel and medicine have directly impacted on nutritional status, water, sanitation and hygiene (WASH), and health care of the population.²⁸

Several decades of conflict and insecurity have led to extensive degradation of infrastructure and public services across all sectors in Somalia.²⁹

The new ongoing conflict in Libya has caused several casualties including health care workers.³⁰Similarly, occupied Palestinian territory (oPt), Syria and Afghanistan struggle to provide health care services in insecure and under-resourced settings.³¹

The health consequences vulnerability index score yielded well defined-areas at risk for drought. The below map indicates how Afghanistan, Yemen and Somalia are “hotspots” due to poor population health status and access to basic sanitation; other elements like high food insecurity, displacement and the conflicts/political instability render these contexts further vulnerable.

The World Health Organization is currently supporting several countries by strengthening the coordination of humanitarian response at central and provincial level. Humanitarian response involves also coordination with partners focusing on the provision of adequate quantities of clean water and improvements in sanitation.

WHO direct support is also towards to: 1) Access of the population to essential healthcare services through provision of mobile health clinics as well as strengthening static health centers; 2) Rapid assessment of the routine Expanded Programme on Immunization (EPI), considering the lower EPI coverage and the tendency for the measles outbreaks in drought affected areas; 3) Procurement and distribution of essential medical equipment, medicines and laboratory supplies and reagents; 4) Nutrition surveillance and monitoring; 5) Community-based psychosocial support; 6) Strengthening disease surveillance and response through provision of protocol, guidelines, surveillance tools, and capacity building of healthcare staff for implementation; 7) WASH support; and 8) Risk communication.