Cultural Norms and Non-Transparency Hamstring

UNCLAS SECTION 01 OF 03 RIYADH 002544 SIPDIS SIPDIS SENSITIVE HHS for Office of Global Health GENEVA FOR WHO REPRESENTATIVE E.O. 12958: N/A TAGS: TBIO KHIV SA SUBJECT: Cultural Norms and Non-Transparency Hamstring a Saudi Medical System Focused on Treatment, not Prevention REFTEL: A) 2004 Riyadh 01862, B) 2005 Riyadh 05571 ¶1. (SBU) Summary: Meetings with public health officials during the visit of regional ESTH officer to Saudi Arabia provided a snapshot of Saudi health issues: a population increasingly afflicted with costly illnesses of the wealthy - obesity, diabetes, and heart disease - and a health system that, for cultural and bureaucratic reasons, is focused on extensive treatment rather than prevention. Amman- based Regional ESTH officer and Riyadh Econoff discussed health issues on March 21 with the World Health Organization (WHO) Representative in Saudi Arabia, Dr. Awad Mukhtar, and with the brand-new Ministry of Health Deputy Minister for Preventive Medicine, Dr. Khalid Zaharani, as well as his MOH colleague, Dr. Nasser Al-Hozaim, Director General of Parasitic and Infectious Diseases. All agreed Saudi Arabia has a good health care system, but cultural biases that prevent frank exchanges between doctors and patients make the system less effective and prevention- oriented as it could be. While government vaccination programs were successful in eliminating many communicable diseases that once were major public health threats, complications from increasing cases of diabetes and cardiovascular disease are severely taxing the health care network. Social stigma and the strong Saudi sense of privacy still cause many Saudis to delay necessary treatment to their detriment, or to deny they have a disease, especially in the case of HIV/AIDs. Avian flu issues reported septel. End summary. -------------- A Third More Hospitals in Two Years -------------- ¶2. (SBU) MOH Assistant Deputy Minister Dr. Zaharani, who had been unexpectedly named to his new position only the day before, discussed a range of health issues with visiting ESTH officer and emboff. (Embassy Note: Dr. Zaharani's quick rise to the Deputy Minister position was reportedly the result of King Abdullah's removal of the previous Deputy Minister when the King learned of a recent outbreak of dengue fever in Jeddah through the media, rather than via reports from the Ministry of Health itself. End Note.) Dr. Zaharani said that the health system in Saudi Arabia will expand from 
the current 220 hospitals to 300 hospitals within 2 years, with hospitals ranging in size from 50 to 1000 beds. He stated that the Gulf Cooperation Council has an active and strong Ministry of Health Council, which coordinates programs on communicable and non- communicable diseases, as well as coordinates the purchase and stockpiling of medicines by GCC member governments, ensuring a lower price due to bulk volume purchases. -------------- -------------- Vaccinations a Public Health Success, but Lifestyle Diseases Rising -------------- -------------- ¶3. (U) Dr. Zaharani said that non-communicable diseases such as hypertension, diabetes, and cardiopulmonary diseases are on the rise in Saudi Arabia, while many communicable diseases have been effectively eradicated. He noted that vaccination campaigns against polio and measles had been very successful, with roughly 95% of children vaccinated. He expressed concern about a global shift to injectable polio vaccine. The SAG prefers oral polio vaccine. He added that, despite these successes, the MOH needed a larger budget to better manage other communicable diseases. -------------- Need to Focus More on Prevention -------------- RIYADH 00002544 002 OF 003 ¶4. (U) Dr. Zaharani said that 20-30% of Saudis are affected by diabetes, with the percentage growing each year due to a diet high in fats and sugar and a sedentary lifestyle. (See ref A for an extensive look at the implications of the rising rate of diabetes on the Saudi health system.) He said that communicable diseases such as avian flu are "noisy," attracting public and media attention, but the MOH needs to focus its resources on public health education, because it is highly cost effective. The SAG does have a public awareness campaign to promote breast cancer detection, he noted, which has had some success. He commented that the percentage of Saudis who smoke is dropping, although he did not quote any figures. He attributed this in part to an anti-smoking education campaign and to smoking cessation clinics. -------------- -------------- HIV/AIDS System - Counseling, Surveillance, Treatment -------------- -------------- ¶5. (U) Dr. Zaharani at the MOH described the Ministry's national plan for HIV/AIDS control. There were a cumulative total of 2,316 cases of Saudi citizens with HIV/AIDS between 1984 and 2005, he said, and 7,804 cases of non-Saudi nationals reported. There is still denial among many afflicted with HIV because of the social stigma. Zaharani believes that sexual contact is the main vector for HIV/AIDS in Saudi Arabia. The MOH has established three specialized HIV/AIDS centers that offer medical and counseling services. The Ministry has a good surveillance and monitoring system, especially of high-risk groups such as drug addicts. Surveillance is conducted throughout the country based on a list of notifiable diseases, and information is reported on a daily or weekly basis, as indicated, to a central data collection office. Medications, including antivirals, are available free to any HIV-positive Saudi. (Embassy note: While free treatment is provided to Saudis, third party nationals diagnosed with HIV or AIDS are given only minimal treatment and returned home, see ref B. End note.) There is an active outreach and education campaign that distributes literature to the public and to the health community. The Ministry actively cooperates with the WHO on HIV, TB and malaria prevention, Dr. Zaharani said, noting that the SAG contributes $10 million to the UN Global Fund on HIV, TB and Malaria. -------------- Lack of Transparency Seen at All Levels -------------- ¶6. (SBU) In a separate meeting, WHO Representative Dr. Awad Mukhtar offered his opinion that the medical system in Saudi Arabia is hindered by a lack of candor and transparency at all levels: personal, professional, institutional and governmental. Patients hide diseases out of shyness or embarrassment in a conservative society that stresses maintaining privacy, as well as delay consultations with doctors until their illnesses can no longer be ignored. By then, treatment is more difficult, more expensive, and less effective. As a case in point, he noted the high number of kidney transplants for renal failure in Saudi patients (700- 800 per year, he said),a preventable complication from diabetes caused by the patients' failure to seek timely treatment. ¶7. (SBU) Dr. Mukhtar said that he did not feel the reported numbers on HIV/AIDS cases in Saudi Arabia were accurate, due to underreporting because of the stigma of the disease, and because of a lack of transparency by doctors and the government. In support of his assessment of underreporting, Dr. Mukhtar cited the static number of cases reported by the SAG over the last few years, a period during which all other countries have noted an increase in the number of HIV/AIDS victims. Further, the majority of the Saudi RIYADH 00002544 003 OF 003 Government's reported cases are third party nationals, with many fewer reported cases of Saudi nationals. This breakdown of cases was unrealistic, Dr Mukhtar indicated. ¶8. (SBU) Zaharani noted that a lack of public candor about public health issues is not uncommon in the MOH, commenting that the MOH had attempted to play down previous outbreaks of dengue fever in Jeddah and surrounding areas, like that which resulted in the reassignment of Dr. Zaharani's predecessor as MOH Deputy Minister. Technocrats in the Saudi government are highly risk averse, he said, compounding the problem. Zaharani added, however, that he believes the current Minister of Health is more committed to openness. -------------- --- Why is Egypt Polio-Free, but not Saudi Arabia? -------------- --- ¶9. (SBU) Dr. Mukhtar said Saudi Arabia has a good primary healthcare system but that there is "poor" government and public awareness of how to use the public health system to prevent disease, rather than treat illnesses after they strike. The U.S. Government and Americans pay much more attention to public preventive health than does the Saudi Government. The result is that Saudis are more focused on treating illnesses than on prevention, at greater cost to society. He asked, "Why is Egypt, which is a poor country with a large population, certified as polio- free, while Saudi Arabia, with a smaller population and much better financial resources, is not?" (Embassy Note: Mukhtar's point is valid, though his example to illustrate it may not be the best proof: The Saudi MOH reports that its only cases of polio in the last decade were imported cases of infected immigrants and Haj pilgrims. End Note.) -------------- Comment -------------- ¶10. (SBU) During the 1990's, the Saudi public health system was pinched for funds as oil revenues fell, but has been a focus of increased spending in recent annual budgets, no doubt fueling the increase in hospitals and medical facilities. Saudi doctors also suffered from lack of training opportunities during the financially lean years. Public health campaigns - from vehicle safety to nutrition - that focus on lifestyle changes are still not fully incorporated into public health policy, but as Saudis are increasingly afflicted with "rich man" diseases like diabetes and obesity, the Saudi government will need to direct resources towards both prevention and treatment. OBERWETTER