| ABSTRACT
The Eastern Mediterranean
Region comprises 22 countries and is less researched,
especially on health and demography. This region
can be demarcated into three different sectors
viz., South East Asia, Middle East Asia and
Africa. On the basis of land area both South
Asia and Middle East Asia sectors together have
a share almost equal to that of the Africa sector,
but on the basis of population, all these three
sectors have equal share, with density varying
widely across countries. Demographically, this
region has a sex ratio favoring males, age structure
showing early stage of demographic transition,
having a higher proportion of children and adults
and an initial phase of ageing. Health characteristics
seem to be well developed except in the case
of fertility rate (pronatalistic approach),
almost universal immunization, with good standards
in health provision and utilization. There are
certain communicable diseases that are specific
in this region. Even though, the developmental
indicators appear to be appreciating, a few
nations namely Somalia, Sudan, Afghanistan and
Pakistan deserve attention and support.
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1.
Introduction
Countries on the east and
south east of the Mediterranean Sea are often termed
as Eastern Mediterranean countries. There are 22 countries
in this region that spread across Asian and African
continents. Pakistan and Afghanistan from South Asia,
Iran and countries in the Gulf region from Middle
East Asia, Somalia, Djibouti and Sudan from East Africa,
Egypt, Libya and Tunisia from North Africa and Morocco
from West Africa together forms the Eastern Mediterranean
Region.
This region has many common
features relating to ethnic origin, language, religion,
values and customs. But there are differences across
countries in terms of politics and socio-economic
development. There are very stable and rich countries
but there are less rich countries and also there are
poorly endowed and less stable countries.
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Fig.1
Map showing countries in the Eastern Mediterranean
Region
Source: WHO EMRO, Cairo
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There are three different
segmentations in Eastern Mediterranean viz., South
Asia comprising of Afghanistan and Pakistan; Middle
East Asia consisting of Bahrain, Iran, Iraq, Jordan,
Kuwait, Lebanon, Oman, Palestine, Qatar, Saudi Arabia,
Syria and Yemen; and African countries consisting
of Egypt, Libya, Morocco, Somalia, Sudan and Tunisia.
These three geographical clusters represent three
different stages of demographic development and health
characteristics.
2 Land Area of Eastern Mediterranean
The region comprising 22 countries
spread across two continents has a total land area
of 13, 177,918 square kilometers (Palestine is excluded
from this analysis due to shortcomings in data). Of
the countries in the region, Sudan, Saudi Arabia,
Libyan Arab Jamahariya and Islamic Republic of Iran
are the largest in area in that order. A total of
62 percent of land area has been occupied by these
four countries. Countries viz., Bahrain, Lebanon,
Qatar and Kuwait are small in area in the region.
Given in Fig. 2 is the proportional distribution of
countries by geographic area.
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Fig.2 Land
Are by Nations in EMRO
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Of the land area 6.5 percent
falls in South Asia; 41.8 percent in Middle East Asia
and 51.7 percent in Africa, thus, indicating that
this region has almost an equal share of land area
in Asian and African continents.
3. Population
Population in this region
has increased from a mere 194 million in 1970 to 298
million in 1984-85 with an annual growth rate of 3
percent (EMRO, 1987)1. At present this region has
nearly half a billion population of which a major
share live in Pakistan (30%) and which is followed
by Egypt (14%) and Iran (13%) in that order. The lowest
share of population in this region is in Qatar, Bahrain,
Kuwait, Djibouti, UAE and Lebanon. Fig. 3 gives a
diagrammatic representation of Eastern Mediterranean
region in terms of its population share across various
countries.
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Fig.3
Population by Nations in EMRO
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Of the population, a large
share lives in South Asia as Pakistan is the highly
populous country in the region, otherwise, the total
population has been divided almost equally among the
three geographic segments. It can also be seen that
South Asia is the most densely populated region as
compared to their Middle East Asia or Africa counterparts.
It can be seen from Table 1 that this region is very
sparsely populated as its density is noticeably low.
The region has a density of 37 persons per square
kilometer, which means that there are 37 persons living
in one square kilometer area, on average. This low
density situation could have resulted because of the
vast deserts and hills which are unsuitable for habitation.
The cultivable and inhabitable land constitutes only
a fraction of the total surface area in this region.
There is a low pressure on the land in terms of population.
Among the nations, Bahrain appears to be the most
densely populated country and is followed by Afghanistan,
Lebanon and Pakistan in that order.
Click
here to view table 1
It can be noted that the region
has leaned against females. The region as a whole
has a sex ratio (number of males per 100 females)
of 105 meaning that there are 105 males per 100 females.
The situation varies from a pro-woman centred to an
anti-woman centred population. It is in Lebanon where
a pro woman sex ratio (94) has been noted. There are
only 94 males per 100 females. Qatar on the other
hand has a sex ratio of 189, which is unbalanced.
It shows that there is a low balance on the number
of males and females. This is followed by Kuwait,
UAE and Bahrain in that order. This biased sex ratio
might have resulted from the expatriate male workforce
in these Gulf countries. Qatar, as an example has
a population of 7,44,483, has 71 percent of population
in 15-64 years (as per the data supplied by CIA, Washington3).
This high proportion of persons in the working age
reflects immigration of labor force. Sex ratio is
as high as 248 among this age group. On the contrary,
sex ratio of the child population is 104. Kuwait has
a population of 1,973,572 of which 68 percent are
aged 15-64 years. Sex ratio among them remains at
176. Sex ratio of UAE's population aged 15-59 years
(68 percent) remains at 176. KSA, another country
having a significant share (5%) in the region has
a sex ratio highly favorable to males (125). Sex ratio
of native Saudi's is found to be 101 whereas that
of non-Saudi population is 200. The above statistics
shows that there is a balance in the native population
but not in the expatriate population who are employed
in these countries.
The high sex ratio of Middle
East Asia could have resulted from in-migration. But
in comparison, South Asia and Africa are also found
to have a sex ratio in favor of males. Sex ratio in
these two subcontinents might have been different
when the out-migrant male population has been taken
into account. Research shows that a majority of expatriate
males in the Middle East Asian countries are from
South Asia (including India and Philippines) and Africa
(Rajan 20044).
4. Age Structure
The region has a very young
population, which is seen in the age pyramid (Fig.
3). The region has a very expansive pyramid referring
to a high proportion of children and a low proportion
of higher aged population (See Devi et al., 2002 for
details regarding age pyramid). This age structure
characterizes an underdeveloped demographic situation.
Even though the region experiences higher birth rates,
the death rates are extremely low which is comparable
to developed countries. But the overall effects of
low mortality are not reflected in the age pyramid,
which might be because of the high fertility situation
that prevails in this region.
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Fig.4
Age Distribution of Eastern Mediterranian Region
in 2000
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Since this region forms nations
of varying socio-economic and development levels,
a blanket statement might be misleading, which makes
it empirical to examine age structure of each segment
of this region separately.
For example, the age structure
of the South Asia region appears to be slightly different
from that of the region as a whole. The South Asian
countries viz., Afghanistan and Pakistan seems to
be in a less advanced stage as far as demographic
transition is concerned. The region as a whole has
almost entered into the transition phase; while the
South Asian countries are slightly behind in the process.
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Fig.5
Age Distribution
of South Asian Countries in The Eastern Mediterranian
Region in 2000
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Middle East Asia, in comparison,
has an age structure which started showing constriction
especially at the bottom of the pyramid. This is a
population group that is characterized by a higher
number of in-migrants of working age group.
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Fig.6
Age Distribution
of Middle East Countries in The Eastern Mediterranian
Region in 2000
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The age pyramid of African
Eastern Mediterranean Countries started showing constriction
more than their counterparts in South Asia, even though
at a lower pace than the countries in the Middle East.
It shows the onset of demographic transition in these
countries.
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Fig.7
Age Distribution
of African Countries in The Eastern Mediterranian
Region in 2000
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5.
Population by Broad Age Groups
The region as a whole has
a high proportion of children, adolescents and women
in reproductive ages. The proportion of older persons
remains low.
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Fig.8
Proportional Distribution in Eastern Mediterranean
Region by Broad Age Groups
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Since this region comprised
nations of varying developmental stages, national
disparities are very clearly visible. In the Gulf
region, Yemen has a higher percentage of children
(47.5%) which is followed by Sudan, Somalia and Afghanistan
in that order. Qatar, Lebanon, Kuwait and Tunisia
have low proportions of children. Of these four countries
Qatar and Kuwait are in-migrant countries whereas
Lebanon and Tunisia shows demographic change as the
reason for low proportions of children.
As far as proportions of adolescents
are concerned, Iran (24.2%), Libya (22.6%), Lebanon
(22.2%) and Syria (22.2%) have high proportions. Countries
viz., Bahrain (15.3%), Qatar (15.5%) and UAE (17.2%)
have low proportions of adolescents. As far as the
working age (25-59 years) population is concerned
Qatar (53.7%), Bahrain (50.1%), Kuwait (47.9%) and
UAE (45.9%) have high proportions; their proportions
are low in Afghanistan (31.4%), Iraq (31.5%), Sudan
(31.5%) and Yemen (26.7%).
Click
here to view table 2
As far as the old age population
is concerned, Lebanon (9.5%), Tunisia (8.7%) and UAE
(8.3%) have higher proportions. Countries viz., Oman
(3.8%), Saudi Arabia (3.5 %) and Sudan (3.7%) have
very low proportions of old aged population.
6. Indices of Ageing
The structural composition
of EMRO population has been further analyzed to understand
the pace of change towards demographic prosperity.
The results confirm that the population as a whole
remains young with a comparable proportion of children
but a low proportion of elderly (see Devi et al.,
2002 for a detailed interpretation of ageing indices5).
The indices calculated from
the age structure of this population include:
a.
Child Woman Ratio - the ratio of children (aged
less than 5 years) to 1000 woman in the age group
of 15-49 years. It has been observed that the overall
ratio is 577 indicating that there are 577 children
per 1000 women of reproductive age. The ratio appears
to be higher in South Asia and which is followed by
Africa and Middle East Asia in that order. The child
woman ratio of Pakistan has found to be higher than
that of Afghanistan but Oman, Yemen, Djibouti and
Somalia registered a ratio higher than that of Pakistan.
Countries viz., Iran, Lebanon and Tunisia have registered
a low ratio in the region.
Click
here to view table 3
b.
Aged-Child Ratio - the ratio of elderly persons
(60 years and above) to 100 children (aged below 10
years) has been found to be low in the region especially
in South Asia. Afghanistan registered a ratio lower
than that of Pakistan. Oman from Middle East and Sudan
from Africa have registered a still lower aged-child
ratio. This ratio indicates a high economic burden.
c.
Median Age - The average age of a population
- the central value after ordering individual ages,
is a measure of central tendency. This shows the point
to which age of a maximum number of persons fall.
It has been found that the median age remains low
especially in South Asian countries. Both Middle East
Asian and African countries in the region have a higher
median age. It is in Yemen and in Sudan and in Somalia
the median ages are found to be low.
d.
Dependency Ratio - the ratio of children (less
than 15 years) and old aged (60 years and above) to
100 persons in working age indicates the dependency
burden in a given population. This results from the
structural composition. This indicator also remains
at a higher end in case of South Asia as compared
to Middle East and also Africa. It has been understood
that this region has a very high dependency burden.
Such a high dependency burden might have resulted
from the existing high birth rates and low death rates.
7. Public Health Scene
Public health in this region
has become a firm political orientation and commitment.
Positive trends namely improvement in distribution,
quality and type of health services and broadening
of services are visibly noted in the region. But the
services are provided for specific population groups
viz., mothers and children with quality of care differing
from nation to nation. Maternal and Child Health (MCH)
programs including family planning are oriented to
disease prevention and health promotion through home
visits and healthy family practices. This high importance
attached to health care delivery in the region has
been an important contributing factor in creating
a better public health scenario as observable from
key indicators.
The key indicators considered
to explain the public health scene in this section
refer to births and deaths and the resultant life
expectancy. These indicators show the national prospects
in social, demographic and health sectors.
a.
Crude Birth Rate remains high in South Asia
especially in Afghanistan. As far as birth rates in
the Middle East Asia are concerned, high rates prevail
in Yemen, Saudi Arabia and Iraq whereas lower rates
are observed in UAE, Lebanon, Iran and Kuwait. Djibouti,
Somalia and Sudan are found to have high birth rates
in Africa.
b.
Total Fertility Ratio (TFR), an indicator that
shows reproductive behavior of the present cohort
of women under the existing scenario, shows varying
trends. TFR is registered to be high in the South
Asian countries especially in Afghanistan. Even in
the Middle East Asia, TFR is found to be high in Yemen,
Iraq, Syria, Saudi Arabia and UAE. In Africa, the
rates have registered to be high in Somalia, Sudan
and Djibouti.
c.
Crude Death Rate is also found to be high in
Afghanistan as compared to Pakistan. All countries
in the Middle East have low death rates. Among the
African countries, Somalia and Djibouti are found
to have high death rates.
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here to view table 4
d.
Infant Mortality Rate (IMR), another important
indicator of public health shows varying levels of
ill health among children and mothers. Afghanistan
is registered to have the highest IMR in the whole
region and which is followed by Somalia, Iraq and
Djibouti in that order. Oil rich countries in the
Middle East Asia have low levels of IMR indicating
'good maternal and child health' scenarios. Even the
African countries have been able to reduce infant
mortality to a large extent except Somalia and Djibouti.
e.
Expectation of Life at Birth, an important
variable that explains national the demographic situation
is the end result of social, economic, demographic
and health development. Nations all over the world
are in a struggle to increase life expectancy through
various interventions in medicine and technology.
As has been seen earlier, Afghanistan in South Asia
and Djibouti, Somalia and Sudan in Africa are found
to be at a disadvantage on this indicator.
f.
Childhood Immunization is not only a health
indicator but also a development indicator as it determines
health status of future population. In order to build
a healthy population, it is mandatory to immunize
children against all infectious diseases and disabling
diseases.
In the Eastern Mediterranean region, childhood immunization
is found to be common in almost all countries. It
is the South Asian countries especially Afghanistan
that lag behind in this parameter. Childhood Immunization
is universal in the Middle East except in Iraq and
Yemen. Djibouti, Somalia and Sudan have not achieved
a universal childhood immunization as far as the African
sector of this region is concerned.
Click
here to view table 5
g.
Health Services Utilization
Utilization of health facilities, in this region,
are found to be varying from low in South Asian sector
to high in the Middle East Asian Sector. Utilization
in the African sector of this region varies widely.
Afghanistan is found to have a lesser percentage of
population having access to improved water sources,
an important development indicator, as compared to
Pakistan. Yemen in the Middle East Asia has a lower
proportion of population with access to improved water
sources (Iraq has only 61 percent). Except Somalia
all countries in the African sector have a significantly
higher proportion of population with access to improved
water source (Sudan has only 60 percent).
Click
here to view table 6
Percentage of population with
access to improved sanitation is found to be high
in all the countries except Yemen in Middle East Asia
(percentage quoted for Saudi Arabia appears erroneous).
Antenatal care utilization
has been found to be high in this region. Countries
having a lower proportion of women accessing such
services are found to be Afghanistan and Pakistan
from South Asia, Iraq and Yemen from Middle East Asia
and Somalia from Africa.
Births attended by skilled personnel is commonly observed
in the Middle East Asia except Yemen but such practices
are found to be very low in both countries of South
Asia and in Somalia from Africa.
Percentage of pregnant women
who receive all the three doses of immunization is
found to be low in Iran and Yemen in the Middle East
Asia. This indicator shows good utilization in other
sectors.
Underweight children are found
to be common in this region especially in both countries
of South Asia, Yemen in Middle East Asia and Djibouti,
Somali and Sudan in Africa.
Contraceptive practices are rarely noted in this region.
But in Bahrain, Iran, Jordan, Kuwait, Lebanon, Syria,
Egypt, Libya and Morocco have more than 50 percent
of couples protected by contraception.
Maternal Mortality is found
to be very high in this region especially in Afghanistan
and Pakistan in South Asia, Iraq and Yemen in Middle
East Asia and Djibouti, Somalia and Sudan in Africa.
h.
Health Provision
Provisions were made in these countries as per the
international standards of health care delivery, with
regard to physicians, dentists, pharmacists and nurses
to serve a particular number of the population. The
physician-population ratio has found to be the highest
in Lebanon but the lowest in Somalia. This ratio has
found to be very low in Afghanistan in South Asia,
Yemen in Middle East Asia and Somalia, Djibouti and
Sudan in Africa.
Dentists to serve the population vary from 2 per 100,000
in Somalia to 110 per 100,000 in Lebanon. Afghanistan
and Pakistan in South Asia has a lower number of dentists
whereas Lebanon, Syria and Jordan have a higher number
of dentists in Middle East Asia. As far as African
countries are concerned, Somalia and Djibouti have
less numbers of dentists per 10,000 population.
Click
here to view table 7
As far as the number of pharmacists
per 10,000 population is considered, the provision
is found to be low except in Egypt, Jordan, Lebanon,
Qatar and Syria. Number of nurses per 10,000 people
is low in Afghanistan and Pakistan in South Asia and
Somalia and Sudan in Africa. Countries in the Middle
East Asia have better standards in this indicator.
Number of hospitals per 10,000 population is found
to be high in the Middle East Asian Countries except
Yemen whereas it is low in South Asian Countries.
African sector of this region has better standards
except Morocco, Somalia and Sudan. Primary Health
Centres (PHCs) are found to be very low in this region
in all countries except Lebanon and UAE, showing that
such a concept has not yet developed in this region.
i.
Morbidity in this region shows high incidences
of water borne diseases and childhood diseases. Incidence
rates of such diseases are very high in South Asia
as compared to that in the other sectors of this region.
Incidences of Measles, Pulmonary
Tuberculosis, Tetanus and Meningitis are found to
be high in the Middle East. All the diseases have
high incidence rates in African countries even though
there are differences across countries.
Conclusions
This extract has been solely
dependent upon the statistics given by the International
Data Base of U.S. Bureau of Census and WHO Regional
Office for Eastern Mediterranean. Even though national
level data varies slightly from this, wide disparities
are not observed. And thus this extract has been prepared
with the assumption that the above data are reliable
for a primary level examination.
The Eastern Mediterranean
Region that consists of South Asia, Middle East Asia,
East Africa and North Africa is diverse in many respects.
Countries in this region are of different size in
terms of both land area and population pressures.
Population is distributed sparsely across countries
in this region. South Asian countries are highly populated
whereas countries in Middle East and Africa are sparsely
populated except where there are a higher proportion
of immigrants. Sex ratio is slightly turned in favor
of males but higher imbalance has been found in countries
having expatriate workers, which might be because
of the gender differentials in labor migrations.
The age structure of the population
in this region shows early stage of demographic transition.
While South Asia passes through the very early stage
of transition, Africa has progressed slightly over
South Asia. Middle East has progressed highly in this
process. Since, a major share of population in the
Middle East is expatriate, the above age structure
requires to be compared with the native and also that
of the expatriate population. Efforts are needed to
bring a harmony in sex ratio especially of the expatriate
population. This has relevance for upholding religious
values and also in ensuring reproductive health, thereby
reducing epidemics viz., HIV/AIDS.
Since, this region passes
through an early stage of demographic transition,
a high proportion of population are in childhood and
teen ages. As per the theoretical contention, this
cohort will move to working age in the coming years.
So, in future there are higher chances of expansion
in the number of people in working ages, provided
birth rates are controlled to the absolute minimum.
Ageing of population has not been a prominent issue
in this region, though their numbers are high and
increasing. Even though, as preparation to meet challenges
of population of ageing, countries need to start planning.
Public health indicators show
that populations in this region are healthy except
in a few countries where vital statistics are registered
to be high and expectation of life at birth is found
to be low. Childhood immunization is found to be appreciable
in a great majority of these countries, yet, there
are a few countries where the proportion of children
immunized against major infectious diseases is low.
A unique morbidity pattern
has been revealed in this region, with common diseases
varying from that of other regions. Careful interventions
are recommended to protect the population from life
threatening and disabling diseases that are spread
in this region.
Overall, this region is heterogeneous
having three sectors. Within the sector, African sector
is again heterogeneous. This resourceful region requires
consideration and solidarity to contribute to the
poor performing nations and uplift needy and suffering
populations, that is part of Islamic culture.
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