Profile Middle East
Kanisha Dezarn
Despite the rising risk factor exposure and non-communicable disease (NCD) mortality across the Middle East and the North African (MENA) region, public health policy responses have been slow and appear discordant with the social, economic and political circumstances in each country. Good health policy and outcomes are intimately linked to a research-active culture, particularly in NCD. In this study we present the results of a comprehensive analysis of NCD research with particular a focus on cancer, diabetes and cardiovascular disease in 10 key countries that represent a spectrum across MENA between 1991 and 2018.
The study uses a well validated bibliometric approach to undertake a quantitative analysis of research output in the ten leading countries in biomedical research in the MENA region on the basis of articles and reviews in the Web of Science database. We used filters for each of the three NCDs and biomedical research to identify relevant papers in the WoS. The countries selected for the analyses were based on the volume of research outputs during the period of analysis and stability, included Egypt, Iran, Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia, Turkey and the United Arab Emirates.
A total of 495,108 biomedical papers were found in 12,341 journals for the ten MENA countries (here we consider Turkey in the context of MENA). For all three NCDs, Turkey's output is consistently the highest. Iran has had considerable growth in research output to occupy second place across all three NCDs. It appears that, relative to their wealth (measured by GDP), some MENA countries, particularly Oman, Qatar, Kuwait and the United Arab Emirates, are substantially under-investing in biomedical research. In terms of investment on particular NCDs, we note the relatively greater commitment on cancer research compared with diabetes or cardiovascular disease in most MENA countries, despite cardiovascular disease causing the greatest health-related burden. When considering the citation impact of research outputs, there have been marked rises in citation scores in Qatar, Lebanon, United Arab Emirates and Oman. However, Turkey, which has the largest biomedical research output in the Middle East has the lowest citation scores overall. The level of intra-regional collaboration in NCD research is highly variable. Saudi Arabia and Egypt are the dominant research collaborators across the MENA region. However, Turkey and Iran, which are amongst the leading research-active countries in the area, show little evidence of collaboration. With respect to international collaboration, the United States and United Kingdom are the dominant research partners across the region followed by Germany and France.
The increase in research activity in NCDs across the MENA region countries during the time period of analysis may signal both an increasing focus on NCDs which reflects general global trends, and greater investment in research in some countries. However, there are several risks to the sustainability of these improvements that have been identified in particular countries within the region. For example, a lack of suitably trained researchers, low political commitment and poor financial support, and minimal international collaboration which is essential for wider global impact.
Copyright: 2020 Aggarwal et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
The social, economic and political impacts of non-communicable diseases (NCDs) are now recognized to be some of the greatest challenges facing countries in their efforts to deliver on Sustainable Development Goals (SDGs) and Universal Health Coverage (UHC) [1]. Whilst the public policy dialogue has focused on communicable diseases, research into NCDs has received little attention [2] [3].
Relative to their available economic resources, many of the Middle East and North African (MENA) countries have not, historically, achieved good health outcomes [4]. The recent Health Systems Reform series on health in the MENA region provided evidence of the heterogeneous patterns of health outcomes across this region [5]. Despite poor outcomes in conflict-impacted countries such as Syria, Iraq, Libya, Yemen and Afghanistan over the last two decades, child and adult mortality rates have declined across the MENA region as a whole, particularly in Saudi Arabia, Iran, Qatar, the United Arab Emirates, Oman, and Turkey [6, 7]. [8].
The MENA population most at risk of NCDs, i.e. those aged over 60, currently ranges from 0.8% in the UAE to 10.6% in Turkey [9]. These percentages are expected to increase significantly by 2030 as a result of the demographic transition due to continuing improvements in life expectancy. Compounding this demographic effect, is exposure to NCDs risk factors such as tobacco, obesity and hypertension, which is highly prevalent across the MENA region.
Cardiovascular disease, cancer and diabetes represent up to one third of the current disease burden in the MENA region. The cardiovascular disease burden has remained relatively stable between 2000 and 2015 rising from 17.5% of all DALYS to 18.9%. The burden is twice that of Cancer, the burden of which has increased from 8.6% to 10.2% of all DALYs in the same time period. Diabetes represented 4.3% of all DALYs in 2015, up from 2.5% in 2000.
Despite the rising risk factor exposure and NCD mortality, regional public health policy responses have been slow. Historical and future R&D activity in NCD is foundationally dependent on the knowledge economy of these countries, however, in many places this is still lagging behind ( -middle-easts-state-of-knowledge/). In the face of the significant public health threat from NCDs and the drive to improve health systems research and address the knowledge gap in the MENA region, there is a need for evidence-based inter-sectoral measures for NCD prevention and care in the MENA region and for an understanding of how to improve the NCD research capacity and capability across the region.
To achieve this, it is important to understand from a public policy perspective how, why, and which particular NCD research domains have evolved. For example, how do different countries influence the NCD research agenda, either through the volume of research they publish, the citation impact of their articles, or their commitment to particular research domains (eg, basic science)? An empirical analysis of research outputs would also highlight gaps and provide direction as to which research areas should be prioritized to meet current and future challenges.
A number of different definitions for country composition of the MENA region currently exist [18] with some including Turkey. Our analysis of NCD research activity covers the 10 major research-active countries in this region (defined according to the volume of research outputs) for the 28-year period between 1991 and 2018. The selected countries are: Egypt, Iran, Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia, Turkey, and the United Arab Emirates. International Standards Organization (ISO) digraph codes for each country are listed in Table 1. We excluded countries that are considered politically unstable e.g. Iraq, Yemen and Syria and did not include smaller research producing countries such as Bahrain, Libya, Palestine, as they would not be informative for understanding overall NCD and workforce policy in the region. We also wished to look at broad trends of countries within a specific research-political nexus, hence exclusion of both low output countries and specific countries in North Africa that are not part of the intra-regional research nexus.
Research papers (articles and reviews) from the 10 selected countries were identified from the Web of Science (WoS) in the selected NCDs by means of three separate algorithms (filters), developed by GL in collaboration with experts in these NCD fields (See Appendix 1). Each of these three filters consisted of two parts: a list of specialist journals for each NCD and a list of specific title words. There were 185 specialist journals listed for cancer, 115 for cardiovascular disease and 36 for diabetes, and there were 323 title words or phrases used for cancer, 125 for cardiovascular disease and 35 for diabetes. Of note the cardiovascular filter includes cerebrovascular accident (CVA). Each filter was independently applied to all papers identified from each of the 10 countries within the WoS. Papers satisfying either criterion (i.e. containing a specific NCD title word or published in an NCD specialist journal), or both, were selected for analysis.
Each of the filters has undergone a process of calibration during the development phase to assess their precision (specificity) and recall (sensitivity)[19]. The filters have been used previously in other analyses[14, 20, 21] and the process of development of the cancer filter for example is listed [22]. For the three NCD domains sensitivity and specificity rates were calculated as follow, with sensitivities and specificities above 90% considered high:
A separate filter for biomedical research was developed and also applied to the WoS [19]. The rationale for this was to provide a baseline from which the relative increases in volume of research outputs in the three NCD domains can be considered. It also provides the relevant context for understanding the commitment of each country across all biomedical research domains.
This was based, not on title words, but on words in the addresses of the papers that indicated the name of the department, e.g. Department of Cardiology, or the institution, such as NIH (US National Institutes of Health). There were a total of 172 terms in this filter, and it has been found to distinguish well between biomedical and non-biomedical papers in multi-disciplinary journals such as Nature and Science.
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