Malnutrition is a complex challenge for the Eastern Mediterranean Region, with many countries having multiple forms of malnutrition among their populations at the same time. Populations are mainly affected by undernutrition (wasting, stunting, underweight).17 The overall estimates for stunting, wasting and underweight are 28%, 8.7% and 18% respectively (Fig 2).17 The prevalence of anaemia (haemoglobin <11 g/dl) that is the result of iron deficiency ranges from 7.4% to 88% in children aged < 5 years and from 16 to 81% in pregnant women.17
Decreased water availability and extensive population movements across and within the countries, especially in areas with porous borders like the Horn of Africa and from the Sahel to the Northern African countries, make difficult the identification of trajectories of transmission of water-borne diseases like cholera which have affected several EMR countries over the last years. The cumulative number of suspected cholera cases reported in Yemen since 2017 until the end of 2019 was 2,188,503 3,750 associated deaths, resulting in a 0.17% case fatality rate.18 Acute Watery Diarrhea (AWD) had affected Sudan since 2016 infecting over 36,000 people and killing over 800.19 Somalia is highly endemic for cholera and regular large outbreaks both after flooding and during droughts are observed.20 Cholera outbreaks also occur in Iraq every 3 to 5 years, with last considerable outbreak occurring in 2015, and have a distinct seasonality that typically start in September and continue through December.21
Up to 60% of the worldwide burden of cutaneous leishmaniasis is in the EMR.22 Massive destruction of urban settlements during the crises, poor waste management, limited access to safe and clean water, presence of domestic animal that act as the reservoir for the sandflies and lack of effective vector control program put large number of people at risk of Leishmaniasis in the region.22
The geographic diversity in the EMR determines malaria variability in terms of endemicity, intensity of transmission and type of malaria. Malaria-endemic countries of the region are situated in the three eco-epidemiological zones of malaria: Afrotropical, Oriental and Palearctic.23,24
In Saudi Arabia, Yemen and the sub-Saharan countries of the region (Djibouti, Somalia, Sudan), P. falciparum is predominant. In the other endemic countries, mainly Afghanistan, Islamic Republic of Iran and Pakistan, both P. falciparum and P. vivax are transmitted.23 More than 20,000 have been recently reported in Djibouti with the introduction of a new vector.
The under-five mortality ranges from less than 10 deaths per 1 000 live births in in the Gulf countries and Lebanon, up to more than 50 deaths per 1 000 live births in Afghanistan, Djibouti, Pakistan, Somalia, Sudan and Yemen. The same pattern is present for the neonatal mortality, with Afghanistan, Pakistan and Somalia reaching highest incidence (>35 deaths per 1 000 live births).13
Eighty seven percent (564.08 million) of the Region’s total population has access to at least basic drinking-water services. Thirteen percent (84.4 million people) remain without even basic water services, of which 64.6 million live in Afghanistan, Pakistan, Sudan, Somalia and Yemen and 15 million live in Iraq, Islamic Republic of Iran and Morocco (Fig 3).25
Estimates for safely managed drinking-water are available for only 9 out of 22 countries of the EMR (Bahrain, the Islamic Republic of Iran, Jordan, Kuwait, Lebanon, Morocco, Oman, Pakistan and Tunisia). Bahrain, Islamic Republic of Iran, Kuwait, Jordan and Tunisia have the highest percentage of the population (over 89%) with access to safely managed water services.25
Twenty seven percent (175 million people) remain without basic sanitation services, of which 154 million live in Afghanistan, Islamic Republic of Iran, Pakistan, Somalia, Sudan and Yemen and 17 million live in Egypt, Iraq and Morocco (Fig 4).25 Around 51.7 million people in the region still defecate in the open, mainly in rural areas, of whom 46.5 million live in Afghanistan, Pakistan, Somalia, Sudan and Yemen. Access to water and soap for handwashing varies greatly, ranging from 10% in Somalia to around 90% in Tunisia, Egypt and Iraq.24
The humanitarian food assistance continues in Yemen through early 2019, especially for the significant declines in commercial imports and conflict that cuts populations off from trade and humanitarian food assistance for an extended period, potentially leading to Famine.26
For Afghanistan, the Famine Early Warning Systems Network (FEWS NET) estimates that the overall population in need of emergency food assistance in 2019 is between 5 and 10 million.15
Pakistan has made gains becoming a food surplus country, and a major producer of wheat. However, around 2 million persons are estimated to be in need of emergency food assistance,15 primarily due to limited economic access by the poorest and the most vulnerable.
The collapse of the economy, soaring food prices, loss and disruption of livelihoods as well as the decline in food production have contributed to widespread food insecurity across Syria. More than 5 million Syrians are now estimated to be in need of emergency food assistance.13 Similar dynamics in the neighboring Iraq have led to around 2 million people in need for the year 2019.15
Well above average staple food prices are expected to drive high 2019 assistance needs in Sudan, and more than 5 million population is now estimated to be in need of emergency food assistance.15
Countries in the EMR are at different stages as to the presence of functioning drought early warning systems. While a dedicated regional network is well set-up for most of the Arabian Peninsula countries and for northern African countries like Morocco and Tunisia,27 other countries like Iran rely on government centers. Afghanistan and Somalia rely on specific donors funded projects28 while all the other countries do not have specific monitoring initiatives.
As host to some of the world’s biggest emergencies and protracted crises, the EMR carries the largest burden of displaced population globally.29 Out of 58 million displace persons worldwide, almost 30 million (52%) come from the Region. As far as internally displaced persons (IDPs) are concerned, Syria reaches the peak of around 6 million IDPs, followed by Afghanistan (around 2 million), Iraq, Somalia, Sudan and Yemen; Libya and Pakistan feature (around 200,000 IDPs each).16
The conflict in Yemen is marked by severe blockades to humanitarian access including aerial and naval blockade of humanitarian goods. Import blockage to food, fuel and medicine have directly impacted on nutritional status, water, sanitation and hygiene (WASH), and health care of the population.30
Several decades of conflict and insecurity have led to extensive degradation of infrastructure and public services across all sectors in Somalia.31
The new ongoing conflict in Libya has caused several casualties including health care workers.32 Similarly, occupied Palestinian territory (oPt), Syria and Afghanistan struggle to provide health care services in insecure and under-resourced settings.33
The health consequences vulnerability index score yielded well defined-areas at risk for drought. The below map indicates how Afghanistan, Yemen and Somalia are “hotspots” due to poor population health status and access to basic sanitation; other elements like high food insecurity, displacement and the conflicts/political instability render these contexts further vulnerable.