The pattern of increased threats to health security has been increasing in the Middle East, especially in centers of internal armed conflict. Diseases such as cholera, tuberculosis, typhoid, leishmaniasis and hepatitis have started to appear and spread. Due to a number of reasons, these diseases have taken on a politicized nature. These reasons include the collapse of public healthcare systems, the targeting of medical and treatment centers, the absence of medical personnel, hindering the activities of international aid organizations, medical supplies not reaching the sick regularly, the targeting of water transport systems, ineffective sanitation networks, increased cuts to healthcare funds, decreasing financial resources, living in regions under terrorist control, the flow of foreign fighters to conflict zones and governments failing in their traditional roles.

Conflict Diseases:

The experiences of the last few decades show that disease and epidemics are serious threats to the security, economy, and immunity of nations, especially given that some appear suddenly, without allowing for early warning signs or preparations to control their effects. According to American President Barack Obama, prime examples of diseases that became international threats are HIV AIDS, SARS (Severe Acute Respiratory Syndrome), Coronavirus (Middle East respiratory syndrome coronavirus) and Ebola...

Another main factor that shapes how diseases in the Middle East are faced is politicization, making this wave of infectious diseases different from past occurrences due to the Hajj season, the flow of foreign workers or internal migration. Factors affecting and causing disease and their spread and subsequent control in the region are now connected to political circumstances, including a number of internal and external elements that have led to the politicization of healthcare in the region, as shown below:

1. The collapse of healthcare systems: Diseases have spread in the region, especially diabetes, high blood pressure, heart diseases, dyspnea, hepatitis, as well as nervous breakdowns, which have reached the third-highest emergency level as categorized by the United Nations. The main reason for this is the collapse of healthcare systems, especially in Arab conflict zones which have witnessed cracks in their infrastructure. This was confirmed by the 63rd session of the World Health Organization’s (WHO) Regional Office for the Eastern Mediterranean (EMRO) in October 2016.

The Director-General of the WHO, Dr. Margaret Chan, indicated that the region’s health and social crises stemmed from its political situation, especially in Syria, Iraq and Yemen, adding, “The war in Syria has entered its sixth year. This means that, every month, at least 15,000 people suffer conflict-related injuries, which has created a vast need for mental and physical healthcare. In Iraq, there are millions of refugees with no safe haven, and the healthcare system has collapsed in Yemen.”

Destroyed Infrastructure:

2. The destruction of medical facilities: The Assad regime and its supporting international powers (Russia) have targeted medical facilities in opposition-controlled regions, as well as schools, universities and markets, to force large swaths of the population to migrate,escape, or accept compromises in what is known as local reconciliation sessions. In that context, the Russian Human Rights network exposed in an October 31, 2016, report that Russia had targeted the Idlib School of Medicine on October 23rd.

Leonard S. Rubenstein, Senior Scholar at the Center for Human Rights and Public Health at the Johns Hopkins Bloomberg School of Public Health, indicated a similar sentiment in various statements, “This is the worst concerted attack on healthcare in living memory… In the decades I’ve been studying this issue in places like Bosnia, Chechnya, Afghanistan and the Gaza Strip, there has been nothing like what has happened in Syria.”

The attack on medical and “field” facilities also occurs in Libya, especially between the agents of the two warring governments in Tripoli and Tubruk. Open hospitals there are only partially operational. As for Yemeni hospitals, they suffer from constant power outages, as is the case in Hadida, affecting the operation of kidney dialysis machines and other equipment.

Targeted Attack:

3. An absence of specialized talent: People who can handle serious injuries are in short supply, whether due to being pursued by security forces or escaping the hell of daily armed conflict, as is the case in Syria. This has forced the medical associations in the twin towns of Madaya and Bakin, both under opposition control in the Western rural areas of Damascus, to suspend their medical work on October 27th. These suspensions were a result of the challenges faced by the two towns, especially in the absence of people who would be able to consistently and urgently treat the injured. In addition to the lack of medical staff, the facilities were are running out of analgesics, medicine, and antibiotics.

A similar situation occurred in Libya after targeted attacks on patients, their families, or and medical personnel, leading to large increase in fatalities caused by treatable diseases and injuries. The situation was exacerbated by the absence of nursing staff after the Philippines announced in August its intention to recall 13,000 citizens from Libya, including about 3,000 medical employees, although there are no clear indications of when that will actually occur.

Specialized doctors are also in short supply, including psychologists, which is a particular challenge for aid organizations in Arab conflict zones. This is true among both citizens and refugees with the spread of autism, suicidal tendencies, night terrors,the rise of child murder, attacks on women and the genocide of minorities.

4. Hindering the work of aid organizations: Emergency aid organizations face a number of challenges in carrying out their humanitarian work, especially in the delivery of medical and food supplies to conflict zones. These challenges include those deliberately placed by the Assad Regime against Doctors Without Borders, as well as Houthi obstacles against medical convoys organized by non-governmental organizations, whether by confiscating their supplies or not allowing them acess. This was recently indicated by the WHO representative in Yemen Dr. Ahmed Shadoul, who stated, “Cholera is a dangerous indicator of the dire humanitarian crisis caused by the conflict in Yemen,” and encouraged the international community to support healthcare and provide the materials necessary for medical partners to overcome this disease and prevent any other future outbreaks.

Regional Starvation:

Another side to the crisis is the Houthi strategy of starving certain areas. Governor Abdullah Abu-Gheith of Al-Hadida warned of a possible famine in the governorate during his meeting with the King Salman Center for Relief and Humanitarian Aid on October 31st. The meeting was attended by the Minister of Social Affairs and Labor, the Vice President of the High Committee for Relief, Samira Khamis; Cabinet Secretary-General Galaa Fakira; and Public Healthcare and Population Deputy Minister Abdullah Dahhan; all of whom confirmed the importance of urgent relief to save thousands of residents in the governorate after the Houthis surrounded it to prevent the entry of aid from the United Nations, the Red Cross International Committee, and Gulf and Japanese government and non-governmental aid organizations.

5. Pure water shortages: Assad regime forces and their allies have targeted the two main water pumping stations in Aleppo (the Sulayman Al-Halabi and Bab Al-Nayreb stations) repeatedly, taking them out of commission. Meanwhile, the Assad forces siege of Aleppo’s eastern neighborhoods is now in its third month, and has forced residents to depend on wells as their main source of water. The use of wells is not a safe source for water, as it leads to the appearance of digestive and skin diseases including diarrhea, leishmania, typhoid and toxemia due to the inviability of water in most Aleppo wells, thanks to the presence of heavy metals such as arsenic and lead, both considered public health hazards.

The situation is similar in Yemen, with the governorates of Sanaa and Taaz facing a challenge with the spread of cholera due to contaminated food and water. UNICEF representative Julien Harneiss stated on October 7th that, "Children are at a particularly high risk if the current cholera outbreak is not urgently contained, especially since the health system in Yemen is crumbling as the conflict continues.” Meanwhile, the situation in areas under the control of the legitimate government is less dire, thanks to the efforts of the Saudi and Emirati governments.

Financial Austerity:

6. Rising financial crises in some Arab countries: Some countries, such as Iraq, are facing financial crises due to dropping oil prices and the increasing costs of the war against ISIS. Add to that the continued corruption and mismanagement, reflected in worsening health care services in the face of a disease like hepatitis, which is now threatening wide swaths of the Iraqi population.

Hepatitis testing has stopped completely in some Iraqi governorates due to the financial austerity faced by medical organizations, with only a few special cases breaking that rule.

The situation in the Waset governorate is particularly dire, it is now possible to designate it as a carrier governorate for a number of diseases and epidemics. The breakdown starts from health care facilities, a lack of health checks on food at border crossings and polluted water. Even though private clinics discover cases of hepatitis every day, patients are not treated seriously, and do not register as carriers for fear of social isolation, further complicating the responsibility of government healthcare organizations.

ISIS Epidemics:

7. Living in terrorist-controlled areas: Civilians trapped in ISIS-controlled areas such as Mosul —Iraq’s second-largest city with about 2 million residents—face the threat of spreading diseases due to decreasing immunity and worsening hygiene. This was also the case in Fallujah prior to its liberation. Difficulties are faced in providing children with vaccinations, and there is virtually no prenatal care, as confirmed by WHO Regional Director for the Eastern Mediterranean Dr. Ala Alwan.

In some cases, hospitals are turned into military barracks, as was the case with the Canadian hospital in the northern part of Aleppo. Some hospitals are also turned into courthouses, such as the Eye and Children’s hospitals in the Kadi Askar neighborhood after they came under ISIS control in mid-2014. This is also the case with the Houthis in Yemen, who have captured a number of hospitals and turned them into arms storehouses.

Cross-Border Spread:

8. Foreign combatants moving to conflict zones: Regional conflicts promote the spread of cross-border diseases, as seen in the case of Pakistani ISIS fighters, who spread polio into Syria after it had disappeared from the country in 1999. Polio had in fact been eradicated from most of the world except for Pakistan, Nigeria and Afghanistan.

According to Special UN Envoy to Syria Staffan de Mistura, there are 900,000 unvaccinated children in the country in spite of UN efforts to vaccinate children against several infectious diseases such as polio and measles.

9. Government failure to carry out their traditional roles: This is particularly evident in Iraq, where the government feared announcing the actual number of cholera patients in the last third of 2015 after a number of occurrences and deaths were reported. The Iraqi government was also forced to push the start of the school year to October 18th to protect students from contracting cholera, further proof of its failure to provide basic services to its citizens.

Compounding Burdens:

In summary, the decline of public healthcare in countries that are home to or neighboring conflicts in the Middle East continues, especially with the absence of early detection and the gap between the funds needed and the funds available. In addition, there is a dangerous shortage of medical supplies, humanitarian and medical teams are targeted, there is a water shortage, power outages, and nations are being broken up into regions controlled by terrorist groups and armed militias, increasing the complication of facing the reasons for the declining health care in the region.