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The impact of COVID-19 and older epidemics on the Arab Gulf States

2020; Medknow; Volume: 21; Issue: 3 Linguagem: Inglês

10.4103/heartviews.heartviews_162_20

0976-5123

Hajar Ahmed Hajar Albinali,

Healthcare Systems and Reforms

Our home, the Arab Gulf, had suffered from recurrent epidemics of the flu, cholera, smallpox, and the dreadful plague. Over many centuries, the trade relations between the Arab Gulf sailors and India were strong. India was the frequent and most favorite destination for the Gulf ships. Besides cloth, rice, spices, and building material imported from India, they also brought communicable Indian endemic diseases to the Gulf. However, all that was in the past. Neither the people of my generation nor I had witnessed an epidemic in the Gulf, until this year with COVID-19. In the Gulf Heart Association (GHA), my colleagues and I decided to collect all our individual state experience in dealing with this COVID-19 epidemic, in this unique historical issue of our official cardiovascular journal, Heart Views. I am supposed to write an editorial for this special edition on the COVID-19 epidemic in the Gulf, but after reading almost all the articles for this issue and spending my evenings in the past 6 months updating my knowledge on this new coronavirus, I frankly got sick of it. The impact of COVID-19 and the individual Gulf state response to it was our main aim for this issue. I am glad that we accomplished that well, as you will see. We have four cardiovascular original articles, three interesting case reports, four reviews, one guideline for safety, of echo procedures and two medical history articles. I may add that a part of my editorial is devoted to the history of epidemics in our region. I will briefly tell you about two other important epidemics (smallpox and plague) in the Arab world history, emphasizing the Gulf. I am sure that not many of my colleagues, the busy physicians and surgeons, had time to read that part of our history. I will come back to end up this “editorial” with a few more words about our current epidemic of COVID-19. As you will see, I do not write a formal, rigid editorial, but my style of writing is informal because I am mainly addressing my friends and colleagues in the GHA. I might have been influenced by the style of my favorite great old Arab prose writer, Al-Jaḥi[Latin Capital Letter z with dot below] (776–868 AD) of Al-Basra, Iraq. He frequently used to get out of the subject to entertain the reader and then goes back to it briefly. Unfortunately, no good records are available on the recurrent epidemics that hit the Gulf in the past centuries. I was able to find some information in the writings of doctors in the Gulf (mainly the American Christian Missionary) and some Western visitors. Smallpox, in brief, is a disease of the past. The World Health Organization said that they have eradicated it from the world in 1980. It is an acute viral disease caused by the variola virus, usually transmitted by airborne droplets and entering the body through the upper respiratory tract like the coronavirus. The mortality rate of smallpox by major variola virus is 25%–30%. Smallpox infection ended up in one of only two ways: death or long-lasting immunity. Blindness, pocked, and scarred faces are common in survivors. I have no memory of the disease itself, but I clearly remember the pocked and scarred faces of those relatives and neighbors who survived the disease. The scarred faces looked fine and not ugly. Because such faces used to be common, they were well accepted by the society. Women in the Gulf traditionally used the face cover (“Burka”), which also hide the scars. I will translate what a famous poet, Ibn al-Rumi of Baghdad, Iraq (Died 896 AD) who nicely described a good-looking girl with smallpox: When the fever, in her body played The pink color on her skin stayed, The pink color on her skin stayed, Smallpox looked like pearls on jade, Artistically over the face was laid. Her cheek looked fine, Like an apple, sprayed with wine. See the original Arabic verses (below) When an epidemic hits one part of the Gulf, it quickly spread to the rest of the Gulf coastal cities through ships. The Oman coast (the present UAE) was frequently hit with waves of smallpox while its population was small. I remembered from our elementary school geography lesson in Ras Al-Khaimah (RAK), in 1954, that the entire population of the Oman coast states then was very much <100,000! In 1897, smallpox killed 6000 people there, and in April 1900, it killed in the small city of Sharjah alone 500 people. In 1935, the Oman coast lost many lives due to smallpox. Shaikh Sultan bin Salim Al Qasimi, the ruler of RAK, requested that the British government helps send vaccines to his state. The British agreed and got by air 1000 doses urgently from Pakistan, but the British quickly changed their mind and sent the shipment to Sharjah instead because they had British nationals in their airbase there. Two months later, they shipped to RAK. On March 1, 1936, RAK complained to the British agent in Bahrain that the British vaccine sent to RAK was ineffective and expired.[1] My mother told me that they had smallpox endemic at the time of my birth in RAK 1943. She never heard about any vaccine then. Many people died. They used to isolate the sick in tents made of palm-tree sticks in places out of the towns. Those who had smallpox before, like her mother, attended the sick relatives and cared for them. After my birth, the old ladies in the neighborhood advised my mother to expose me to an ill patient to catch smallpox, claiming that a baby sick with smallpox does not suffer as much as adults with the disease. The purpose of such a risk on my life was to save me from getting smallpox as an adult. My mother took their advice to heart and took me with her mother to a relative patient sick with smallpox. They placed me in his lap for a few minutes. The sick patient was happy to have a child in his lap while in isolation from society. One week later, my mother was disappointed that I did not catch the disease. She retook me to the patient for another exposure. Her second attempt was not successful either; therefore, she, sadly, gave up on me. If she did not, I might not be participating with you in this issue. I wonder, if a newborn has some immunity from his mother if she had smallpox before. Smallpox was known from ancient times in Asia. The Moslem Physician Al-Razi (854–932) was the first to describe the difference between smallpox and measles. Smallpox was India's disaster. It was endemic, becoming active every 4–8 years to kill a lot of children born after the previous endemic. A statement was made in India: “A child should never be counted as permanent members of the family until infected with smallpox and survived.” It was more stubborn and malicious in nature than cholera and plague. It causes death in one-third of cases. It was responsible for three-quarters of blindness in India. It has a presence in the religious beliefs and rituals. Indians had a smallpox goddess, who was worshipped in all parts of India (Shitala or Sheetala or Sitala). Sitala is a Hindu goddess widely worshipped in North India, West Bengal, and Nepal, as the pox-goddess. Indians do not burn the dead smallpox patient for fear of hurting the goddess.[2] The plague was known from ancient times. Galen said that the cause of the plague is bad air. Many old Arab physicians followed Galen's opinion. Ibn-Sina did not know the cause but gave observational signs that predict the coming of plagues time: “Insects breeds a lot in dirty, smelly places and animals that dwell underground, like rats, runs up to the surface.” There is no record showing that the ancient pre-Islamic Arabs in the desert knew the plague in their isolated arid desert environment. When they migrated in the early Islamic era and settled in the fertile lands in Iraq, Syria, and Egypt, they came in contact with the pandemics. The Prophet Mohammed (570–632 AD) told his followers: “If you hear about the Plague in the land you are in, do not run away from it, and if it is in another land, do not enter it.” The Arab Umayyad Caliphate (661–750 AD), during its 91 years, was hit by twenty waves of the plague, killing thousands in Syria, Egypt, and Iraq. The Roman army used the time of the plague on the Arab side to attack. In 689 AD, the Caliph Abdul Malik ibn Marwan agreed to pay the Roman 1000 Dinar weekly to halt the attacks. The worst wave of plague was in 706 AD when it wiped out many of the population in Syria. It was reported that it was difficult to find grave diggers; people ended up digging their own graves and waiting to die in them. Some historians believed that the plague contributed to the fall of the Umayyad Caliphate.[3] During 1347 and 1352 AD, the plague hit the Middle East and North Africa and reached Europe and killed two-third of its population. An Arab poet Abu Dhowaib (644 AD), when he lost his five sons to the plague while in Egypt, said: If death inserted its nail, All amulets will fail. See the original verses (below) The best account of the plague in the Gulf that I could find was a description of an American Missionary doctor S. J. Thoms, M. D., in Bahrain. He wrote: In April 1903, bubonic Plague appeared, in a virulent form, and people were dying everywhere like flies. Many were taken with fever, and within twenty-four hours, would be carried to their hastily dug graves in the cemetery just back of the hospital. The people were panic-stricken. Each night was a long death wail, and each day a long funeral procession. Whole families were exterminated, and the people turned to their religious leaders, or mullahs, to explain this scourge.[4] From the beginning of July to the end of June of 1903, the plague spread again in Bahrain. In 1911, Dr. Stanley Miller wrote in the American Mission Journal[5] about the spread of the plague in Bahrain, where the plague was not absent from the Gulf region, except for a few years distant from the beginning of the 20th century, and each time it reaped thousands of deaths with it. He wrote: “Plague is with us. All-day long funerals have been taking place, and as the number of deaths increased, the funeral's usual rites and ceremonies were cut short. Bodies were no longer washed before burial and Instead of being carried to the grave a bier, were bundled along to their last resting-place with scant respect, by the daylight and the moonlight and by the light of the lantern dimly burning, the sad business of interring the dead goes on. They do not dig their graves deep enough. Already some five hundred people have died, not a very large number when considered in the aggregate, but large in a proportion of the population of the district– about twelve thousand. A patient of mine said: “I, myself, have lost mother, wife, brother, and uncle, and hardly a house but lost someone.” Our hearts go out with them. I personally saw the death of about seventy cases, among them Arab sheiks, Indian merchants, Persian merchants, Indian pearl merchants, in addition to craftsmen and porters. The Plague did not separate people at all.” Let me move out of that sad history and go back to the present COVID-19 again. As you know, the widespread and very transmissible coronavirus (SARS-CoV-2) that caused COVID-19 started at the end of 2019 in the Chinese city of Wuhan. It had spread worldwide including our Arab Gulf region, the Gulf Cooperation Council (GCC). In Qatar, the first case was discovered on February 28, 2020. Major commercial centers, mosques, and schools were closed initially, but no lockdown was imposed. Citizens were free to go out but advised to wear masks and keep away 2 m form other people. I composed and published in a local Qatari newspaper, a very long Arabic poem about COVID-19, and its ill impact on our society.[6] In March, while I was walking for exercise in the neighborhood fresh air, a young Qatari policeman drove slowly near me and said: “It is better if you wear a mask.” I acted as a layman and requested him to stop his car and teach me about the corona. He stopped his car in the middle of the empty road and explained to me about the virus and why I should follow his advice. I admired the young man's attitude and care for advising the people. I had the desire to know him, but I did not ask him about his name, because I did not want to tell him mine. He may get embarrassed if he found out that I was not a layman but a former minister of health. I did say to him in the end that I heard that the mask is not needed outside in an open space. COVID-19 was fading and resurging again in many countries. I read today (August 20, 2020) that the number of cases worldwide has passed 22 million, and more than 780,000 people have died. Arab Gulf citizens, who were in Europe and the USA in March and April for business, tourism, or treatment, ran out of those countries quickly and rushed back home when they realized that the medical facilities in those counties are suffering from a lack of intensive care beds, adequate staff, and equipment to deal with COVI-19 disaster. The GCC countries were well equipped with state-of-the-art medical technologies, adequate staff, supplies of protective equipment, lifesaving medicines, and detailed plans to deal with the pandemic. Fortunately, in the Gulf, unlike many countries in the world, the politicians did not interfere with the medical care of patients but wisely left the in-charge physicians to deal with the epidemic. I am sure that all the GCC figures and health statistics, you will see in this issue, are true and accurate. After over 8 months of global experience in dealing with this virus, we still do not know the secrets of this, fearful infective, very tiny parasitic-like, noncreature invader. However, we are learning and will master it soon. The experience we gain today will be the future history for the coming generations of physicians after us. We are now impatiently waiting for the anticipated vaccine to suppress it so that we could gain some of our lost freedom. The hope for its complete eradication may not be possible very soon. It does not seem that it will ever leave us and go away.