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Developing Countries: Egypt, China, India, and South Africa
ones & Bartlett Learning, CarolLLC Holtz T FOR SALE OR DISTRIBUTION Ibrahim Elsawy
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“It’s immoral that people in Africa die like ἀies of diseases
that&noBartlett one dies ofLearning, in the United LLC States. And the more disease © Jones & Bartlett Learnin © Jones there is, the more political unrest there will be, leading to NOT FOR SALE OR DISTRI NOT FOR SALE OR DISTRIBUTION more Darfurs.”
Former President Bill Clinton
© Jones &Objectives Bartlett Learning, LLC NOT FOR OR AἀerSALE completing thisDISTRIBUTION chapter, the reader will be able to:
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1. Discuss family planning, infertility, abortion, and sterilization practices in Egypt, China, India, and South Africa. 2. Explain how communism affects health and health care in China. 3. Discuss women’s rights issues in South Africa. Learning, LLC & Bartlett Learning, 4. Compare the health and healthcare systems© of Jones Egypt, China, India, and South Africa. LLC
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Introduction This chapter addresses the health conditions of four developing countries: Egypt, China, India, and South Africa. These countries were selected for examination because they differ in culture, economics, politics, ©regions, Jones Bartlett © Jones & Bartlett geographic and&types of healthLearning, care and healthLLC issues.
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Egypt
Background Egypt (the Arab Republic of Egypt) is located in the far northeastern part of the African continent, bor© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC dered on the north by the Mediterranean Sea, on the east by the Red Sea, on the west by Libya, on the NOT FOR SALE OR DISTRIBUTION SALE DISTRIBUTION south by Sudan, and on the northeast by the Gaza Strip and Israel. NOT Egypt isFOR traversed by the OR Suez Canal,
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54 Chapter 3: Developing Countries: Egypt, China, India, and South Africa
which is located between Asian and Learning, African territories. The country’s total land area is© 1,002,450 square © Jones &itsBartlett LLC Jones & Bartlett Learnin kilometers. Most of Egypt is located in Africa, but part of its land, the Sinai Peninsula, is located in Asia. SALE OR DISTRI NOT FOR SALE OR DISTRIBUTION The majority of its population of approximately 83 million people lives on the banks of NOT the NileFOR River or on the coasts of the Mediterranean Sea, the Red Sea, and the Suez Canal. The largest defined landmass within Egypt is the Sahara Desert, which is very sparsely populated. The largest cities include Cairo (the capital), Alexandria, and other cities in the Nile Delta. Ninety-eight percent of the Egyptian population lives on just 4% of the country’s land (Arab Republic of Egypt, Ministry of Foreign Affairs, 2010). © Jones &Most Bartlett Learning, Jones Bartlett Learning, LLC of Egypt’s rainfall occursLLC during the winter months, with © only 0.1 to 0.2& inches of precipitation NOT FOR SALE OR DISTRIBUTION NOT DISTRIBUTION falling each year. Before the construction of the Aswan Dam, the Nile RiverFOR floodedSALE annually,OR producing good soils and good harvests in its floodplains. Arabic is the official language; English and French are the most commonly used foreign languages. The majority ethnic groups are Egyptian, Bedouin Arab, and Nubian. Education is compulsory for children aged 6–15 years, and the literacy rate is 58% (“About Egypt,” 2010). ones & Bartlett Learning, Jones &over Bartlett Learning, Egypt hasLLC a distinguished cultural heritage,©accumulated the thousands of years ofLLC its history. of the Egyptian successive civilizations (Pharaonic, Greco-Roman, Coptic, and Islamic) contribT FOR SALE OREach DISTRIBUTION NOT FOR SALE OR DISTRIBUTION uted to the areas of philosophy, literature, and the arts. Because of its long-held ties with Europe, Egypt has been a cultural pioneer in the modern Arab world. In 2002, with the support of the United Nations Educational, Scientific and Cultural Organization (UNESCO), the new Bibliotheca Alexandrina was inaugurated. This world-recognized special historical site is located in Alexandria. The goal of the reconstruction© of the ancient&Library of Alexandria was to revive for science Jones Bartlett Learning, LLCthe legacy of this universal center © Jones & Bartlett Learnin and knowledge (“About Egypt,” 2010). NOT FOR SALE OR DISTRI NOT FOR SALE OR DISTRIBUTION In terms of religion, the Egyptian population consists of 94% Muslims and 6% Christians. The two main Islamic institutions in Egypt are the oldest and the most important Islamic institutions in the country: ■■
Al-Azhar, which was built by the Fatimids to spread the Shiite sect in North Africa. Later Salah El-Din converted it to Sunni University, which became one of the main pillars of Sunni Islam in the world. el Eἀaa, founded in 1895 LLC and headed by the Grand Muἀi of© Egypt. &Dar Bartlett Learning, Jones & Bartlett Learning,
■■ © Jones NOT FOR SALEOrthodox OR DISTRIBUTION The Coptic Church, one of the
LLC NOTin FOR SALE DISTRIBUTION churches the world, and OR the Roman
oldest Christian Orthodox Church of the Arab Republic of Egypt are located in Alexandria (Arab Republic of Egypt, Ministry of Foreign Affairs, 2010).
Economy
ones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Table 3-1 presents statistics on Egypt’s current economy. T FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION TABLE 3-1
Egypt’s Economy GDP GDP growth © Jones & Bartlett Learning, LLC Inflation,NOT GDP deflator FOR SALE OR DISTRIBUTION Agriculture, value added Industry, value added Services and other revenue sources, value added Exports of goods and services Imports of goods and services Jones & Bartlett Learning, LLC Gross capital formation
© NOT FOR SALE OR DISTRIBUTION Source: World Bank, 2010.
$218.91 billion 5.2%/year © Jones & Bartlett Learnin 10.1%/year NOT FOR SALE OR DISTR 10% of GDP 29% of GDP 61% of GDP 21% of GDP 28% of GDP Jones & Bartlett Learning, LLC 19% of GDP
© NOT FOR SALE OR DISTRIBUTION
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Health © Jones & Bartlett Learning, LLC
Table 3-2NOT presents population health statistics for Egypt. FOR SALE OR DISTRIBUTION
55
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Healthcare Systems The majority of Egyptians have access to health care for basic health services, managed by the Ministry of Health and Population (MOHP), the Health Insurance Organization (HIO), private health practitioners, © Jones Bartlett Learning, LLC & Bartlett LLC and& nongovernmental organizations (NGOs). The HIO covers 45% of©theJones population, and there is aLearning, growing and unregulated private healthcare sector. Pharmaceuticals account for nearly all healthNOT FOR SALE OR DISTRIBUTION NOT FORone-third SALEofOR DISTRIBUTION care costs (World Health Organization [WHO], 2011).
TABLE 3-2
ones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Egypt’s Population Health Statistics, 2011 T FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Birth rate Underweight children Population younger than age 15 years Population 65 years or older Total births per woman © Jones & Bartlett Learning, LLC Adult literacy rate (among persons 15 years or older) NOT FOR SALE DISTRIBUTION Population with sustainable accessOR to improved water sources Population with sustainable access to improved sanitation Smoking rate of adults Total government expenditure per capita on health Total government expenditure on health as a percentage of GDP Jones & Bartlett Learning, LLC Out-of-pocket expenditure on health per capita
© NOT FOR SALE OR(per DISTRIBUTION Human Resources 10,000) Physicians Dentists Pharmacists Nurses and midwives Hospital beds LLC Learning, Primary healthcare units and centers
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Primary Health Care (per 100) Population with access to healthcare services Contraception prevalence Prenatal care Births attended by skilled personnel
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© Jones & Bartlett Learning, LLC
Source: WHO, 2011.
© Jones & NOT FOR SALE OR DISTRIBUTION 28.3 4.2 16.7 35.2 17.3 LLC Learning, 0.7
Health Status NOT FOR SALE OR DISTRIBUTION Life expectancy Infant mortality rate (per 1000 live births) Under-five mortality rate Maternal mortality rate Probability of not reaching 40 years of age Jones & Bartlett Learning, Smoking prevalence (among malesLLC 15 years or older)
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28.9 per 1000 7.5% 31.7% 3.7% © 3Jones & Bartlett Learnin 71% NOT 94% FOR SALE OR DISTRI 94% 19% $124 6.4% Bartlett 58.7% Learning, LLC
88 57.6 52 84
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72.3 years 17 21.8 per 1000 55 per 100,000 10.3% & Bartlett 40% Learning,
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56 Chapter 3: Developing Countries: Egypt, China, India, and South Africa Communicable Diseases © Jones & Bartlett Learning, LLC
© Jones & Bartlett Learnin
Within the last decade there has been a huge decline in deaths from communicable diseases in Egypt, NOT FOR SALE OR DISTRI NOT FOR SALE OR DISTRIBUTION largely due to the high rate of vaccinations for preventable diseases. Hepatitis B and C continue to be problems, however. Schistosomiasis (a parasitic disease caused by flatworms), hepatitis C (affecting 9.8% of the general population), and tuberculosis are the top three infectious diseases found in Egypt today (WHO, 2011). study conducted in Egypt and supported by USAID to prevent typhoid fever in rural communities © Jones &ABartlett Learning, LLC © Jones & Bartlett Learning, LLC used the intervention of hand washing with soap. Studies indicate that 9000 to 42,000 cases of typhoid NOT FOR SALEinOR DISTRIBUTION NOT FOR SALE DISTRIBUTION are reported this country each year. Typhoid fever is transmitted by the fecal–oral route, soOR it is appropriate to build prevention strategies against this infection—yet only 40% of all households in Egypt had soap and water available for hand washing at the time the intervention was undertaken. The scarcity of water and problems with waste disposal are related issues for hand washing. As part of the intervention, proper hand washing techniques were taught and general education of disease transmission was ones & Bartlett Learning, LLCindicated improvement in hand © Jones Bartlett Learning, LLC performed. Results washing & rates in the rural Fayoum region of Egypt T FOR SALE OR(Lohinivak, DISTRIBUTION NOT FOR SALE OR DISTRIBUTION El-Sayeed, & Talaat, 2008).
Maternal and Infant Health
Despite health clinics that are accessible to the general public, maternal and infant mortality rates in Egypt are high, with an infant mortality rate of 17 deaths per 1000 live births and a maternal mortality © Jones & Bartlett Learning, LLC © Jones & Bartlett Learnin rate of 55 deaths per 1000 live births. In addition, the 21.8 per 1000 death rate for children younger than SALE OR DISTRI FOR SALE ORreflect DISTRIBUTION age five isNOT considered high. These rates exceptionally high mortality rates among NOT women FOR and children in rural Upper Egypt. Child survival initiatives, such as cord care, delivery instrument antisepsis, and infant warming have reduced the rate of mortality of children younger than five years. As is true in most developing countries, most births in Egypt take place in the home. A major contributing factor to maternal and infant morbidity and mortality is unhygienic conditions, which increase © Jones Bartlett Learning, © Tetanus Jonestyphoid & Bartlett Learning, LLC the& likelihood of infections withinLLC both the mother and the newborn. immunization is NOT FOR SALEofOR DISTRIBUTION NOTcan FOR ORof DISTRIBUTION one method reducing deaths due to tetanus, but many other infections occurSALE at the time birth. Infection ranks third among the causes of maternal mortalities in Egypt. A cohort study explored the use of a clean delivery kit as a means of reducing infant and maternal infections. Kits were distributed from primary health facilities, and birth attendants received training on how to use the kits. Results from the study of 334 women indicated that neonates of mothers who had the use of the kits were less likely to develop sepsis from fewer postpartum infections (Darmstadt et al., 2009). ones & Bartlett Learning, LLCcord infection and mothers had © Jones & Bartlett Learning, LLC Pregnancy outcomes in Egypt are poorer as compared to those in other developing nations with simiT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION lar per capita gross national products (GDPs). The national rate of low birth weight in Egypt is 12% of all live births, but for 30% of low-birth-weight infants in Egypt, the mortality rate is 2.5 times that of full-term infants. These increased risks of mortality for low-birth-weight children persist throughout the first year of life and beyond, with this risk factor also being associated with increased cognitive disabilities. A special antenatal © nutrition project in Al-Minia,Learning, in Upper Egypt, demonstrated an ability to improve birth weight Jones & Bartlett LLC © Jones & Bartlett Learnin in newborns. Women in this project received food supplements and nutrition education as well as prenatal NOT FOR SALE OR DISTR NOT FOR SALE OR DISTRIBUTION care and home visits. Results indicated that infant birth weights increased, which ultimately resulted in healthier babies who were less likely to contribute to the infant mortality rate (Ahrani et al., 2006).
Noncommunicable Diseases Neuropsychiatric digestive diseases (11.5%), chronic respiratory diseases&(6.9%), cardiovascular © Jones & Bartlett (19.8%), Learning, LLC © Jones Bartlett Learning, LLC diseases (6.7%), and diabetes are major noncommunicable diseases whose incidence continues to increase NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION in Egypt. Smoking, substance abuse, failure to use car seats and seat belts, lack of exercise, and consumption of fatty and salty foods are major contributors to the disease burden. Diabetes mellitus affects © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. 0085
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Egypt TABLE 3-3 © Jones
& Bartlett Learning, LLC FOR SALE OR DISTRIBUTION Top FiveNOT Cancers in Egypt Males
Females
57
© Jones & Bartlett Learnin NOT FOR SALE OR DISTRI Both Sexes
1. Bladder 1. Breast 2. Liver 2. Non-Hodgkins lymphoma © Jones & Bartlett lymphoma Learning, LLC 3. Non-Hodgkins 3. Ovary 4. Lung 4. Colorectal NOT FOR SALE OR DISTRIBUTION 5. Leukemia 5. Leukemia
1. Breast 2. Bladder ©3. Jones & Bartlett Learning, LLC Non-Hodgkins lymphoma 4. Liver NOT FOR SALE OR DISTRIBUTION 5. Leukemia
Source: WHO, 2011.
ones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC nearly 3.9 million people in Egypt, and its prevalence is expected to increase to 9 million by 2025. A study T FOR SALE ORconducted DISTRIBUTION FOR SALE ORtoDISTRIBUTION in 2011 in Cairo indicated that type 1NOT diabetes mellitus care needs be carefully monitored,
as complication rates were nearly 50% among patients in the study. Regular exercise for patients in this study demonstrated a significant positive effect for children and adolescents (Ismail, 2011). Table 3-3 lists the top five most frequently occurring cancers in Egypt. Breast cancer accounts for 38% of all new cancer cases among women living in this country. The age-standardized rate (ASR) for © Jones LLC © Jones & Bartlett Learnin breast cancer incidence&inBartlett Egypt is 37.3Learning, per 100,000, and the mortality rate is 20.1 per 100,000. Incidence NOT SALE OR DISTRI FOR ORwomen DISTRIBUTION of breast NOT cancer is lower SALE in Egyptian than in U.S. women, possibly due to a lower rate FOR of cancer screening, and mortality rates for Egyptian women are higher than those for U.S. women (International Agency for Research on Cancer, 2010).
Mortality and Burden of Disease
© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Table 3-4 provides child mortality data for Egypt in 2009 and 2010. Table 3-5 lists adult mortality rates, NOT FOR SALE DISTRIBUTION FOR SALEa OR DISTRIBUTION defined as the OR probability of dying between 15 and 60 years of ageNOT per 1000 population; breakout is provided for the maternal mortality rate. Table 3-6 identifies age-standardized mortality rates by cause. Table 3-7 gives causes of death for Egyptian children younger than age five. Table 3-8 provides mortality data related to HIV/AIDS, tuberculosis, and malaria.
ones & Bartlett Learning, LLC TABLE 3-4 T FOR SALE OR DISTRIBUTION
Child Mortality in Egypt, 2009 and 2010
© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION Year
Under-five mortality rate (probability of dying by age 5 per 1000 live births) © Jones & Bartlett Learning, LLC Number of under-five (thousands) NOT FORdeaths SALE OR DISTRIBUTION Infant mortality rate (probability of dying between birth and age 1 per 1000 live births) Number of infant deaths (thousands) Neonatal mortality rate (per 1000 live births) Number of neonatal deaths (thousands) Jones & Bartlett Learning, LLC Stillbirth rate (per 1000 total births)
© NOT FOR SALE OR DISTRIBUTION Source: WHO, 2011.
2010 2010 2010 2010 2010 2010 Jones & 2009
Rates 22
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35 9 18 Bartlett13Learning,
© LLC NOT FOR SALE OR DISTRIBUTION
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58 Chapter 3: Developing Countries: Egypt, China, India, and South Africa TABLE 3-5 © Jones
& Bartlett Learning, LLC Adult Mortality in Egypt, 2008 andDISTRIBUTION 2009 NOT FOR SALE OR Year Male
© Jones & Bartlett Learning, LLC Female Both sexes NOT FOR SALE OR DISTRIBUTION Maternal mortality ratio (per 100,000 live births; interagency estimates)
2009 2009 2009 2008
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Number of Deaths Among Persons Aged 15–60 Years per 1000 Population 215
© Jones130 & Bartlett Learning, LLC 174 NOT FOR SALE OR DISTRIBUTION 82 (range: 51–130)
Source: WHO, 2011.
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Female circumcision has been a tradition in Egypt since the Pharaonic period. The prevalence of female circumcision is widespread in Egypt; 91% of all women age 15–49 have been circumcised. The female circumcision rate among women younger than age 25 is lower than the corresponding rate in the 25–49 age group, in which 94% to 96% of women have been circumcised. The rate also is lower among never-married © Jones & Bartlett Learning, LLC & Bartlett Learnin than ever-married women (81% and 95%, respectively). Urban women are less likely to©beJones circumcised than ruralNOT women (85% and 96%, respectively). The likelihood that a woman is circumcised alsoFOR declines NOT SALE OR DISTRI FOR SALE OR DISTRIBUTION with the woman’s education level and is markedly lower among women in the highest wealth quintile than in other quintiles (78% versus 92% or higher). The majority of circumcised women (63%) report that (midwives) were responsible for performing the procedure. Trained medical personnel (primarily doctors) performed most of the remaining circumcisions (Egypt Demographic and Health Survey, 2008).
© Jones & Bartlett Learning, LLC Spousal Violence in Egypt NOT FOR SALE OR DISTRIBUTION
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Nearly three-fourths of women visiting family health centers in Alexandria, Egypt, have experienced spousal violence in their lifetimes. Approximately half of the women experienced physical violence (“Spousal Violence in Egypt,” 2010).
ones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Mental Health T FOR SALE ORADISTRIBUTION NOT inFOR SALE OR DISTRIBUTION national household survey of prevalence of disorders five governorates, using the Mini International Neuropsychiatric Interview–Plus (MINI-Plus) instrument, indicated that almost 17% (range: 11% to 25.4%
TABLE 3-6 © Jones
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Age-Standardized Mortality Cause, 2008 (per 100,000 population) NOT FOR SALERates OR by DISTRIBUTION Mortality rate from communicable disease Mortality rate from noncommunicable disease Mortality rate from injuries Source: WHO, 2011. Learning, LLC © Jones & Bartlett NOT FOR SALE OR DISTRIBUTION
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76 749 34
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59
TABLE 3-7 © Jones
& Bartlett Learning, LLC © Jones & Bartlett Learnin Causes of DeathFOR Among Children Than Age Five Years, 2008 (percentage of allFOR deaths)SALE OR DISTRI NOT NOT SALE ORYounger DISTRIBUTION Prematurity Pneumonia Diarrhea Birth asphyxia © Jones & Bartlett Learning, LLC Injuries Neonatal sepsisOR DISTRIBUTION NOT FOR SALE HIV/AIDS Measles Malaria Other
ones & Bartlett Learning, LLC Source: WHO, 2011. T FOR SALE OR DISTRIBUTION
30 11 6 5 5 © Jones & Bartlett Learning, LLC 1 NOT FOR SALE OR DISTRIBUTION 0 0 0 23
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in different governorates) of adults in Egypt had mental disorders, with the common being mood disorders (6.4%), anxiety disorders (4.9%), and somatoform disorders (0.6%). Psychoses were seen in 0.3% of © Jones Bartlett Learning, LLC © Jones & Bartlett the population (WHO,& 2005).
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Environmental Problems Air pollution, especially in Cairo and Alexandria, is a major source of chronic respiratory diseases (WHO, 2006). According to the Country Cooperation Study, Egypt receives 98% of its fresh water from the Nile River; unfortunately, there is excessive water pollution in the Nile due to large discharges of pes© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ticides, nutrients, and heavy metals from industry in Cairo, making obtaining clean water a major health NOT FOR SALE OR DISTRIBUTION NOT SALE DISTRIBUTION challenge for the country’s population. Tap water assessments indicate thatFOR lead levels are atOR a high risk level as well. A recommendation by the WHO suggested that lead and other heavy metal residuals should be lowered for health safety of the population (Lasheen, El-Kholy, Sharaby, Elsherif, & El-Wakeel, 2008).
ones & Bartlett Learning, LLC TABLE 3-8 T FOR SALE OR DISTRIBUTION
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HIV/AIDS, Malaria, and Tuberculosis in Egypt, 2008 and 2009
Deaths due to HIV/AIDS (per 100,000 population per year) Deaths due malaria (per 100,000 population per year) ©toJones & Bartlett Learning, LLC Deaths due to tuberculosis among HIV-negative people NOT FOR SALE OR DISTRIBUTION (per 100,000 population per year) Prevalence of HIV among adults aged 15 to 49 (%) Incidence of tuberculosis (per 100,000 population per year) Prevalence of tuberculosis (per 100,000 population) Source: WHO, 2011. Learning, LLC © Jones & Bartlett NOT FOR SALE OR DISTRIBUTION
Year
Data (Range)
2009 2008 2009
0.6 (0.5–0.9) (0.1–0.2)& © 0.2 Jones 1.10 (0.74–1.50)
2009 2009 2009
