Richard Smith: Research and the Arab Spring

Richard SmithThe Arab world, despite its proud intellectual history and some of its countries being among the richest in the world, produces little research. Now the Arab Spring has shaken the whole region, and researchers in the Arab world think that the time has come to relate to the social earthquake and to promote research for health. To that end a collection of Arab researchers, supplemented by a few outsiders like me, met last week at Bellagio, the exquisite villa and estate owned by the Rockefeller Foundation that lies high on a hill at the bifurcation of Lake Como in Italy.

Low inputs to research
Most Arab countries invest little in research. The UK, for example, spent 1.82% of its GDP on research in 2007 compared with 0.05% in Saudi Arabia, 0.23% in Egypt, and 0.17% in Oman. The only Arab country at that time to invest more than 1% of its GDP in research was Tunisia at 1.02%, and Tunisia’s investment has fallen since the Arab Spring. Qatar does now invest 2.8% of its considerable GDP in research. In contrast to the low investment in research in most countries, Oman spent 10.4% of its GDP, and Saudi Arabia 8.2%, on the military.

In 2008 there were 398 universities in Arab countries, which was twice as many as a decade earlier. But many of the new universities are private and of low quality. Some of the older universities have suffered terribly from the wars in the region. In 2006-7 there were 19 000 academics in Iraq. Since then 3000 have been expelled, 5000 have migrated, 400 have been killed, and 74 kidnapped. Some 118 professors from the University of Baghdad have been assassinated. Two thirds of academics in Iraq fear being killed at any time. Syria—a “jewel that is being destroyed,” as one Syrian academic described it—is the current centre of war in the Arab World, but “war and conflict are our daily lives,” said a professor from Beirut.

Unfortunately some of the most prestigious universities in the region are very outdated. For example, the University of Cairo, which admits 1600 medical students per year, allows only medically qualified students onto its masters course in public health, and the teachers must be graduates of Cairo University.  The dean of one medical school in the region was sure that his school taught public health, but he had to ask for help to identify the person who taught it.

The numbers of researchers in the Arab world is low. While Finland in 2007 had over 7000 researchers per million, Saudi Arabia had 42, and Egypt 617. Tunisia again did better with 1588, and Jordan had the most with 1952. Unsurprisingly with such low inputs the outputs are low. Arab countries  published just over 13 000 scientific articles in 2008, which is 41 per million population compared with a global average of 147. Again there is big variation within the Arab world with Kuwait managing 225 publications per million population and Tunisia 196, whereas it was 70 for Saudi Arabia, 40 for Egypt, and 2 for Yemen.

It would be wrong to think that everything is bleak in the Arab world. There are examples of centres in Cairo, Beirut, and Sousse of researchers doing important research on health equity, climate change, and non-communicable disease, and the Lancet will be running a theme issue on Arab health in December. Plus a book, Public Health in the Arab World, published by Cambridge University Press, has served as a focus for building a network of 400 people interested in public health in the Arab world.

Riding the wave of the Arab Spring
But the meeting was energised by the Arab Spring. The whole region is going through transformational change, and research for health should “ride the wave.”  The crowds who have gathered in the squares and streets of the Arab World have been demanding dignity, freedom, and justice. They have not been demanding health and certainly not research for health, but health is a great marker for social justice (and injustice), and research is essential for improving health and for development. And when asked Arabs have many complaints about their healthcare—listing inequitable access, inadequate quality, top down decision making, corruption, low accountability, lack of transparency, the dishonesty of practitioners, their attitude to patients,  limited time, administrative procedures, corruption, and having to pay everybody for everything even within the public system. And when asked where they would like to see increased expenditure they answer education and health.

But the transformational change extends beyond the Arab Spring. Egypt has had three revolutions in the past century, and countries like those in the Gulf have been through the most dramatic change in the past 40 years with cities filled with skyscrapers—like Dubai and Abu Dhabi—appearing almost magically out of empty desert. Then there is the slow transformational change of population growth, the changing position of women, and of climate change. The Arab world is the most environmentally unsustainable region in the world.

So there is huge change underway and great need for research, but how best to respond? Three days of energetic and loving debate were needed to find a way forward.

What is the Arab World?
One debating point was whether the Arab world really means anything. This world includes some 22 countries with 400 million people, half of them under 25, and huge heterogeneity—for example, Qatar with a per capita income of $57 000, is one of the richest countries in the world, whereas Mauritania with a per capita income of $1400 is one of the poorest. There are at least four broad divisions in the Arab world—the Maghreb of North Africa, the Mashriq of the Middle East, the Gulf states, and the very poor countries like Somalia.

There seems to be little regional solidarity between the rich and the poor with the poor receiving much more aid from outside the region than from within it.

Then there are some five million Arabs in North America, and there are more Lebanese, Palestinians, and Syrians outside their countries than inside them.

Those at the meeting were very clear, however, that they wanted to concentrate on the Arab world, including all the Arab countries, Arabs living outside the region, and even “outsiders” like me who have links with and a love for the Arab world. When we talked about what bound the world together people described the magnificent pre-colonial times when Arabs kept learning alive in Europe’s dark ages, the colonial times of the Ottoman Empire followed by Europeans creating havoc, and the “gross inequities” of today. People didn’t mention language and culture, but perhaps these went without saying.

Concentrate on research alone?
The great debate of the meeting was whether to concentrate on improving research for health or whether to adopt a broader agenda. Those who favoured a broader agenda, who eventually carried the meeting, thought that a concentration on research would be too narrow in times of such momentous change.  Researchers needed to connect with those in the streets, and so two “pillars” were added to the agenda—promoting health equity and reforming public health, particularly public health education. Those at the meeting all understood and agreed that the three pillars are all interconnected and that one can’t be achieved without the other. But the challenge is to convince policymakers, the public, funders, and the “old guard.”

The way forward
The most difficult part of these meetings is always to find ways forward and make them happen. Some worried that broadening the agenda might impede progress, but eventually all agreed that it was important to work on all three pillars. The next step will be to prepare position papers to show clearly how advancing research for health, promoting health equity, and reforming public health and public health education are intimately connected. The papers will be brought together at a meeting in June and then shared with a broader group towards the end of the year. In parallel the group will hope to expand the network of those interested, put together a theme issue of a journal on the subjects, prepare a proposal for funders, and plan a larger meeting for next year bringing together policymakers, funders, NGOs, and researchers. After that meeting the hope is that all the countries in the Arab world will prepare a national plan for health research; at the moment very few countries have such a plan.

All of this will interweave with the World Bank’s strategy for improving health in the region, EMRO’s plans for promoting health and health research, and other activities. Partnership is essential.
Surrounded by the great physical beauty of the mountains, the three arms of Lake Como, and the ancient villas of the Bellagio Centre, we worked hard to find a way to bring together the need for improved research, increased health equity, and modernised public health. Let’s not just hope that these things are achieved but make sure that they are. We learnt about the five ingredients that are needed to make change happen: vision, creativity, perseverance, passion, and courage. My judgement is that those at the meeting have all five in abundance.

You can learn more about the meeting through a website, reading blogs at SciDev, and reading a series of Tweets under the hashtag #R4HArabWorld

Competing interest: RS’s employer paid his travel expenses to attend the meeting and, as is the usual case, the Rockefeller Foundation supplied accommodation, excellent, healthy food, wine with lunch and dinner, and some excellent grappa one evening.

Richard Smith was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.