44 Middle East & Africa The EconomistNovember 21st 2020
2 who admitted (under interrogation) to
working forthe QudsForce’s Unit 400,
whichspecialisesincovertoperations.The
suspectsaidhewasrecruitedwhileona
pilgrimagetoIranandthathehadtravelled
tothecountryseveraltimesforweapons
training.Hesaidhehelpedbuildnetworks,
gatherintelligenceorbribepoliticiansin
thecar, Chad,Eritrea,Gambia,Sudanand
SouthSudan.Iranalsotoldhimtoseek
mininglicencesinthecarandNigerto
helpoffsettheimpactofAmericansanc-
tionsonIranandtofundcovertoperations.
Othercurrentandformercounter-ter-
rorismofficialsfromtheWestconfirmthis
generalpatternofactivity.“Iranisclearly
tryingtospreaditswingsasfaraspossi-
ble,”saysone.“Itmakessenseforthemto
uselocalswhocanworkundertheradar.”
Arethoselocalsworkingona plottoretali-
ate for Suleimani?“They are looking to
generateheadlines,”saysanotherintelli-
gencesource.“TheyhavechosenAfricabe-
causeit’seasytooperatethere.” 7F
or those with money, Lebanon’s
health-care system was once the envy of
the Middle East. Private clinics and hospi-
tals were staffed by doctors trained at top
places in the West. Wealthy patients from
across the Arab world jetted in for treat-
ment. Today, though, it is the doctors get-
ting on planes. One surgeon says his salary,
paid in local currency, is worth about $200
a month—less than a dollar an hour. An-
other says his hospital was wrecked in the
explosion on August 4th at Beirut’s port.
Both are applying for jobs abroad, joining a
long exodus of Arab doctors.
The Middle East, like much of the north-
ern hemisphere, is hunkering down as co-
vid-19 cases climb. In Lebanon, where more
than 80% of intensive-care beds are occu-
pied, the government ordered most busi-
nesses to shut on November 14th. Tunisia
has imposed a curfew and halted travel be-
tween regions. Other countries are consid-
ering similar measures. But the closures
offer scant relief for doctors forced to fight
the virus short-handed.
Though there is no universal standard
for a well-staffed health-care system, the
World Health Organisation suggests a
minimum threshold of 45 skilled person-
nel—doctors, nurses and midwives—per
10,000 people. At least nine Arab states fall
below that benchmark. In some the short-fall is particularly stark (see chart). Egypt
had fewer than five doctors per 10,000 peo-
ple in 2018, down from more than 11 in 2014.
The number of doctors in government hos-
pitals, which serve the bulk of the popula-
tion, fell by one-third during that period.
This is not for lack of talent. Arab uni-
versities produce plenty of doctors. In
Egypt about 7,000 of them graduate each
year—15% more than in America, adjusted
for population. Careers in medicine offer
prestige and stability. Competition for uni-
versity places is fierce. (Nursing is a less de-
sirable career, and many Arab states rely on
nurses hired from abroad, a problem that is
not unique to the Middle East.)
Once they graduate, though, many doc-
tors are eager to leave. Money is the most
obvious reason. A newly minted doctor in
Egypt can expect to earn just 2,000-2,500
pounds ($128-160) a month. For a typical
family, that is not even a subsistence wage:
the average Egyptian household spends
more than 4,000 pounds a month on living
expenses, a figure that has soared since the
pound was devalued in 2016. In Tunisia a
specialist with decades of experience,working in a public hospital, may take
home the equivalent of $15,000 a year. She
could earn the same sum each month prac-
tising in a rich Gulf country.
Working conditions are better abroad,
too. State hospitals in many Arab countries
are notoriously crowded and short of
equipment. Iraq has just 13 hospital beds
per 10,000 people, compared with 22 in
Saudi Arabia and 28 in Turkey, its neigh-
bours to the south and north. The Iraqi
health-care system was shattered by de-
cades of war and sanctions, and successive
governments have invested little in re-
building it. In 2017 Iraq spent just $210 per
person on health care, estimates the World
Bank (the regional average was $459).
Egypt’s constitution, approved in 2014
after a coup, committed the state to spend-
ing 3% of annual gdpon health care. That
provision has gone ignored: spending in
2018 was just 1.4% of gdp. The constitution
also promises free speech, which has not
stopped police from arresting doctors who
complain about the government’s poor
handling of covid-19; the disease has killed
an estimated 200 medical staff. Under-
funded hospitals cannot keep pace with a
fast-growing population. In the three years
after the constitution was approved, the
number of hospital beds per 10,000 people
fell by 8%, from 15.6 to 14.3.
In Lebanon an worsening economic cri-
sis means even basic medical supplies are
scarce. Chemists are running out of every-
thing from blood-pressure pills to para-
cetamol. An estimated 400 Lebanese doc-
tors, almost 3% of the total workforce, have
left in the past year. The National Council
of the Order of Physicians of Tunisia says
40% of its members practise outside their
home country. In Egypt the figure is closer
to 50%. The exodus has given rich coun-
tries a glut of doctors to hire. But it has left
much of the Arab world short of them—just
when they are needed most. 7BEIRUT
The Arab world trains a lot of doctors,
but not enough of them want to stayDoctors in the Middle EastOut of practice
Aching to leave?Not what the doctor ordered
Medical staff per 10,000 people
2018 orlatestavailableSource:WHOMoroccoEgyptIraqAlgeriaBahrainLebanonTunisiaUAEKuwait100806040200Doctors Nurses/midwivesMinimum WHO
recommendation