Since its founding in 1985, Breast Cancer Awareness Month has been held in October every year. Originally an American enterprise, the event has become global, with its recognizable pink ribbon theme transformed into pink branding for items as varied as food packaging to make-up and toiletries to professional athletic gear. The purpose was originally to raise awareness of this type of cancer at a time when it was inadequately addressed and poorly understood and to increase screening efforts to allow for early and potentially life-saving interventions. While these campaigns have been critiqued for their corporate nature and emphasis on awareness over action, rates for breast cancer screenings have increased significantly over time, reflecting the tireless efforts of activists and donors as well as cancer survivors and their loved ones.
These efforts have taken hold in the Arab region as well. In the United Arab Emirates (UAE), pharmaceutical giant Pfizer launched the second phase of a campaign specific to the region, “Take Action,” to promote awareness and self-screening, including a roundtable with a breast cancer survivor. Meanwhile, as part of the “There’s no shame in it” campaign in the Gaza Strip, health authorities, charities, religious leaders, and even bakers came together to encourage early detection and screening. These efforts are particularly important in Gaza: treatments are not available for advanced cancer because of the siege on the strip. Despite greatly different economic and political conditions, breast cancer is the most common type of cancer in women in both Gaza and the UAE; however, diagnosis is late, which reduces treatment options and survivability.
Public health infrastructure in the Middle East and North Africa (MENA) is poor; this is no surprise to the region’s residents. Long-standing structural weaknesses and the overall inequalities between states became even more clear during the COVID-19 pandemic. Yet as the pandemic shows some signs of waning, an entirely different health crisis, with unique challenges and trajectories, has been quietly emerging for years. Cancer rates are increasing in the Arab states, and these nations, regardless of income level, are not prepared as they face unprecedented population growth and varying degrees of political instability.
Cancer as a Threat to Health
Cancer is a disease that can present when a group of cells begins growing out of control in tissue, eventually invading other parts of the body. It is a leading cause of death in almost every country in the world, and it affects people across demographics and geographies. As life expectancies around the world rise and exposure to cancer risk factors (like highly processed diets and pollution) reach more people, both diagnosis and mortality increase. In 2020, there were approximately 19 million new cases diagnosed globally, most of which were breast, lung, or colorectal cancer, and 10 million deaths. Men are more likely to die from cancer than women due to the distribution of cancer types, and diagnosis and treatment vary depending on environmental and socioeconomic characteristics of countries and communities.
Long-term planning is essential. Yet many regions in the world, including the MENA, are thus far either incapable or uninterested in pursuing policies that would improve public health, including reducing cancer rates.
The World Health Organization (WHO) estimates that 30–50 percent of cancers are preventable with lifestyle choices; many others are highly treatable when detected early. Due to poor access to healthy foods and opportunities for physical activity, greater exposure to pollutants, higher levels of smoking, and poor access to diagnostic and treatment options, about 70 percent of cancer deaths occur in low- and middle-income countries (LMIC). The WHO predicts that on current trajectories, cancer rates will increase by 60 percent over just the next 20 years; 81 percent of that increase will be in LMIC. The impending impacts of climate change will increase exposure to carcinogens and disruption in access to care, contributing to cancer growth in ways that are unpredictable. Cancer not only increases population mortality and disability but poses significant strain to health systems and health financing. Many cancers develop over the long term, and there is no way to reverse population affliction rates overnight. Thus, long-term planning is essential. Yet many regions in the world, including the MENA, are thus far either incapable or uninterested in pursuing policies that would improve public health, including reducing cancer rates.
The Status and Trajectory of Cancer in the Arab Region
Debate continues about the degree to which cancer is caused by random mutations in dividing cells as opposed to personal and environmental factors. Yet there is almost no debate that many incidences of cancer could be prevented with changes in individual and societal practices. WHO has identified six areas for cancer prevention:
- tobacco (80 percent of the world’s smokers live in LMIC),
- physical inactivity and dietary factors (including alcohol use),
- infections (cancers from preventable infections like hepatitis and HPV make up 25 percent of cancer cases in LMIC),
- environmental pollution (including household air pollution from cooking with fuel indoors),
- occupational carcinogens (such as exposure to asbestos),
- radiation (including ultraviolet radiation from the sun).
Unfortunately, all these factors are present in the MENA and are exacerbated by many fragile governments and countries in conflict that are unable to meet even the most basic health needs of their populations.
Smoking is among the most pervasive behaviors that contribute to cancer in MENA, especially lung cancer. Although smoking rates are decreasing around the world, up to 50 percent of the population of MENA uses tobacco, and rates are expected to increase to 62 percent by 2025. There remains high variation between nations, with Oman reporting the lowest rates. Jordan reports the highest smoking rates in the world, with more than 80 percent of Jordanian men say they have smoked or used nicotine products. The small nation also ranks second in the world for tobacco company interference, with significant lobbying efforts by the industry and overt involvement in crafting permissive regulation. This has contributed to “alarmingly high” cancer rates in Jordan, many diagnosed in patients younger than age 50. In Lebanon, where cancer rates are among the highest in the MENA, smoking (cigarette and water pipe) led to most cancer diagnoses. About a third of the residents in Beirut report smoking, including 30 percent of doctors and 20 percent of pregnant women. The country, deep into a financial and political crisis, faces smoking-related health costs close to $150 million. Smoking remains prevalent among university students across the MENA, establishing life-long behaviors that bode poorly for cancer prognosis across the life course. Aside from the health risks, the economic effects are undeniable; in 2015 alone, it was estimated that the region lost $30 billion due to smoking-related deaths.
While lung cancer is among the most common cancers in males in the MENA, women are less likely to smoke. In women from the region, as is the case worldwide, breast cancer is the most prevalent type of cancer and accounts for the majority of cases throughout the region. In 2016, 11 women per 100,000 died due to breast cancer in the Arab region. Clinical outcomes of breast cancer are determined by when the cancer is detected; when detected early before the cancer spreads, survival rates are approximately 99 percent. Reviews of the trajectory of breast cancer in recent decades show an increasing trend in MENA, yet part of that may be attributed to more widespread screening efforts. Unfortunately, few countries collect high-quality data consistently; only Kuwait, Oman, Jordan, and Tunisia had breast cancer registries before 1998. Arab women seem to report lower rates of breast cancer than women in most other regions, perhaps because of higher fertility and breastfeeding rates, and unlike some other types, breast cancer incidence seems to be higher in wealthier states. It may be that lifestyle changes occurring throughout the Arab world, such as delayed marriage and childbirth, use of oral contraceptives, and increases in obesity and smoking, are contributing to the gradual rise in breast cancer cases.
Aside from smoking, the highest risk factors for many forms of cancer include a poor diet, low physical activity, and greater rates of obesity, and the MENA region is transitioning to greater rates of all these factors.
Aside from smoking, the highest risk factors for many forms of cancer include a poor diet, low physical activity, and greater rates of obesity, and the MENA region is transitioning to greater rates of all these factors. Egypt, Bahrain, Jordan, Kuwait, Saudi Arabia, and the UAE report the highest rates of overweight and obesity, ranging from 74 to 86 percent of women and 69 to 77 percent of men. This is significantly higher than the global averages for overweight (39 percent) and obesity (13 percent).
The traditional Mediterranean diet, long considered one of the healthiest in the world, is being increasingly replaced by a more traditionally western diet that includes processed foods, less fruits and vegetables, more red meat and dairy, and less fiber and healthy fats. Across the region, physical inactivity is increasing in adults (especially women) and children, in part due to high temperatures; lack of support for physical activity from parents, peers, and teachers; and gender norms that discourage physical activity among women. These factors are hypothesized to lead to higher cancer rates; for example, up to 30 percent of breast cancer cases are thought to be brought on by lifestyle factors such as obesity and poor diet.
There are many other factors contributing to increasing cancer rates and mortality in the MENA region, some in situations that are difficult to quantify. For example, it is known that poor public health infrastructure makes health promotion and outreach efforts more difficult, which is the case in MENA. However, on many other health indicators, like life expectancy, MENA has been improving, suggesting some public health success. That said, longer life spans mean increased risk of cancer. MENA also features high rates of armed conflict, and although much more research is needed, links between armed conflict and cancer have emerged from recent literature. While most studies on the links between cancer and war are conducted on veterans, evidence from Iraq post–US invasion showed a dramatic jump in forms of cancer not previously seen in the country, especially in areas where heavy military action occurred. Further, the resources devoted to conflicts, and the societal breakdown inherent in them, takes energy and resources away from battling threats to health and well-being.
Can MENA Chart a Different Course?
With all the instability and destruction in the region, few analysts would consider cancer one of the top priorities in the MENA at the moment. That said, separating rising cancer rates, or really any health concern, from the other factors negatively impacting the region is representative of a nonintersectional and depoliticized approach to health that, especially in light of the pandemic, is outdated and does not adhere to increasing evidence about social and political determinants of health. Thus, identifying steps that could improve population health, including reducing the cancer burden, goes hand in hand with mechanisms that can rebuild broken societies and realign public priorities.
The first priority for the MENA must be in prevention. This is difficult because it necessitates changes at the state level, in corporate practices, and in the individual behaviors of tens of millions of people at a time when misinformation about health has never been higher. Further, health is often demoted as a priority in MENA. The reality is that a country cannot thrive politically, economically, or socially without a healthy populace. Well-intentioned leaders in MENA should prioritize public health promotion and outreach about topics like diet, physical activity, stress, and exposure to toxins and pollutants. Less well-intentioned leaders should be pushed by donors and international organizations to take meaningful actions to improve long-term population health. Even in topics as well understood as the health effects of smoking, many in MENA still do not appreciate the consequences, or have misconceptions about water pipes or e-cigarettes being “healthier” than cigarettes. In some countries, it is still acceptable to smoke anywhere, including indoors or when around children and vulnerable adults. With a mix of health-forward regulations and public education, populations could be both incentivized to take certain cancer-preventing actions while dissuaded from engaging in actions that increase cancer risks.
Aside from populations not being informed about the importance or availability of screening, many MENA countries lack the equipment or trained personnel to conduct screenings.
For all forms of cancer, across demographics, early screening and treatment is key in preventing it from advancing and in increasing survivability. Yet despite some improvement in accessibility in recent decades, cancer screening is still largely underdeveloped across the region, including in the most prevalent and lethal cancers like colorectal cancer, cervical cancer, and lung cancer. Aside from populations not being informed about the importance or availability of screening, many MENA countries lack the equipment or trained personnel to conduct screenings. In some environments, like the occupied Palestinian territories, cancer diagnosis and treatment equipment are unavailable not for lack of capacity or funding, but because they are blocked by an antagonist, Israel. This prevents populations from being diagnosed at an early stage and then often requires them to travel abroad (for Palestinians, this often includes to Israel) to receive needed care. Countries across MENA must have the internal capacity to manage cancer diagnosis and treatment within their borders, preventing ill and vulnerable patients from needing to navigate complex bureaucratic processes, travel long distances, or be denied permission to travel altogether.
Neither of these initiatives—preventing cancer and ensuring sufficient capacity to treat it—is possible from a perspective that devalues human life at the expense of political and economic power. While we have yet to develop a cure for cancer, there are tangible and meaningful interventions that can prevent some of its incidence and improve the quality of life for those diagnosed with it. For many Arab states, it is not only financial resources that prevent these efforts, but lack of prioritization from the top–down. The cancer trajectory of the region in the coming decades is unlikely to show a reversal of the increase in recent years without making necessary changes today. While some countries are taking some steps, most measures are superficial or not at the necessary scale. Like many of the other challenges facing the region in the 21st century, a long-term approach (still not the norm in many Arab states) is needed.