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Researchers Confront Puzzles About Risk and Disease in the Arab World

ABU DHABI—Researchers already know that different social groups in the Arab region face unequal risks when it comes non-contagious diseases, like cancer. But their understanding of exactly why is less clear.

That was the message delivered by statistician Hoda Rashad at recent conference organized by New York University–Abu Dhabi.

Rashad, director of the Social Research Center at the American University in Cairo, warned that this knowledge gap is a significant obstacle for anyone who wants to help solve the problem of disease inequality.

“It’s not a clear picture and that’s a problem if you want to make policies with an impact,” she says.

Data from the World Health Organization estimates that at least 2.2 million people are killed every year by non-infectious diseases in the Eastern Mediterranean region, which encompasses Northern Africa, the Middle East, Cyprus, Afghanistan and Pakistan. Just four conditions—diabetes, chronic respiratory disease, heart disease and cancer—are responsible for 77 percent of those deaths. (See a related article, “Patterns of Disease Are Changing in the Arab World.”)

More than half of the people who die from a non-infectious disease in the Eastern Mediterranean are under the age of 70, which means they’re also classed as premature deaths.

Inconsistent Data on Risk

In general, it’s usually the more disadvantaged groups in society that are most at risk, but the causes don’t hold true within the region—and that muddies the water.

“For example, in Country A it might be demonstrated using the available data that the social group with lower levels of education suffers from higher levels of cancer,” says Rashad. “While for another country, those with higher education might suffer more.”

Education level is just one means of gauging a population’s social status, but the same thing can happen when measuring income, self-declared social status or the size of a person’s house.

In a systematic review published in 2012, scientists collated the results of 72 individual research papers that sought to measure the links between socioeconomic status and obesity in the developing world.

The results were inconsistent.

In low-income countries, such as Yemen, the association between the two is positive for both men and women—that’s to say, the richer or more educated people are, the more likely they are to be obese. But in middle-income countries, like Jordan, the association is mixed for men and mostly negative for women.

The question, says Rashad, then becomes: Why do we get dissimilar results?

Measurement Issues

Marco Bardus, an assistant professor of health promotion and community health at the American University of Beirut, points to one potential explanation: the difficulty of finding reliable “proxy” measures of factors like social class.

“In these studies, you aren’t actually measuring social class,” says Bardus. “Instead, you’re measuring a proxy of social class, and the way you measure that proxy has an impact on the outcome.”

For example, if a researcher uses self-reported income as a means to measure a survey participant’s socioeconomic class, that metric has its issues. “Many people either under or over-report their salaries because it’s a sensitive question,” he says.

Alternatively, researchers can use the number of people per bedroom as a way to measure a household’s wealth, which is easier to verify than salary. Sociologists can even combine these metrics together and add in education level to create a triangulated way of measuring socioeconomic status.

Arab-Specific Challenges

But even after all that number crunching, there’s still an additional hurdle for researchers in the region to overcome—a lack of baseline data to understand social and economic norms.

“There’s a lack of primary source data,” says Bardus. “There are almost no national representative surveys from which to build on.”

In other words, even if a sociologist has the perfect means of measuring socioeconomic status, how do they know how many of each social group to include in their study to make sure their sample matches the wider population of a country?

In most Western countries, there are regular and reliable census reports for researchers to use as a yardstick for their own study samples. In Lebanon, however, the last official census was produced in 1932 when the country was under French control.

Elsewhere in the Arab world, some countries have a better situation. Egypt, for example, does have a regular census, but many of Cairo’s citizens live “off grid” in unofficial housing, which makes it harder to keep track of the true population. This problem is shared by other countries in the region, including Iraq, where old refugee camps become permanent suburbs. (See a related article, “Iraqi City Displays Grassroots Urban Planning.”)

Rashad also says researchers need to build up region-specific data. “It allows us to understand the pathways of influence and hence to recommend the policies and actions to deal with them,” she says. “The Arab region is faced with the measurement trap, where a lack of data and the lack of interest are self-reinforcing.”

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