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.

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A Third More Hospitals in Two Years
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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.

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Vaccinations a Public Health Success, but Lifestyle
Diseases Rising
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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.

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Need to Focus More on Prevention
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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.

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HIV/AIDS System - Counseling, Surveillance, Treatment
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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.

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Lack of Transparency Seen at All Levels
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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.

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Why is Egypt Polio-Free, but not Saudi Arabia?
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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.)

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Comment
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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