by Dr Iain Murray-Lyon MD FRCP FRCP (ED)

The available statistics give a vivid picture of the current healthcare problems in the country and the future challenges. The total fertility rate at 8.8 is one of the highest in the world and although there is a high infant mortality rate of 109 per 1,000 live births (compared with 6.5 in the UK) the population is growing fast at 3.7% per annum. The population can be expected to double in 18 years. The most cursory observation shows a high proportion of children and young people, and 52% of the population are under the age of 15 (compared with 19% in the UK). Life expectancy is currently 52 years for males and 53 for females.

The high infant and maternal mortality rates (maternal mortality 330 per 100,000 live births compared with 7 in the UK) give great cause for concern. Malnutrition and poor infant vaccination coverage are areas for priority attention, particularly given the uncertainty of future growth of food and water supplies. Fortunately population control is now being discussed in government circles. Contraception is practised by only a minority of couples (17%), but a range of programmes integrated with healthcare of mothers and children is planned to extend contraceptive usage.

A visit to the hospitals in Sana’a reveals a very different pattern of adult medical disease to that now seen in the UK. The wards are full of cases of rheumatic fever and rheumatic heart disease as well as chronic liver disease due largely to viral hepatitis, and chronic renal failure. Tuberculosis (often resistant to standard drug treatment) is a major problem throughout the country. Tropical diseases such as malaria, amoebiasis, schistosomiasis and onchocerciasis are common.

Yemen is short of doctors and nurses. There are about 20 doctors per 100,000 population (compared with 92 in the UK and 242 in Germany per 100,000 population). The majority are in the towns. Until recently many medical students were educated abroad (especially in Russia and Romania) with a few (like Professor Abdulla Abdulwali Nasher, Minister of Health and President of the Yemen British Friendship Society) graduating from a British university. Clearly the longterm solution must be local education. The Medical School in Aden started in 1975 and in Sana’a in 1983. Both now graduate over 100 students per annum. Links with overseas schools in the UK, Egypt and Sudan are supporting postgraduate studies and the university has to be congratulated on starting a Yemen Medical Journal, which will help with the important task of keeping graduate doctors up-to-date in a fast moving world.

I have been privileged over the last 10 years to collaborate in a range of projects with my Yemeni colleagues, particularly Professor Abdulla Gunaid, Professor Abdulla Abdulwali Nasher and Dr Abdulkader el-Guneid. The areas covered reflect my personal training and interest. New fields are opening up with the help of other specialists.

Qat

The leaves of this plant (Catha edulis Forsk.) contain a range of chemicals but it is Cathinone which is chemically related to amphetamine which is probably responsible for the pleasurable stimulant effect on the brain. Unwanted side effects may include constipation, lack of appetite, sexual disfunction and difficulty with micturition in the male. We have shown that Cathinone acts on smooth muscle to produce these effects and have demonstrated delay in stomach emptying after a meal as well as an effect on the bladder neck which is completely reversed by alpha 1 blocking drugs (widely used by British men with mild prostatic problems).

Cancer

Cancer of the oesophagus and stomach are far more common in Yemen than in western Europe. Factors responsible include dietary deficiencies of antioxidant vitamins, smoking and qat chewing. The role of pesticides and carcinogens in food is being researched.

An important cause of cancer in the stomach is chronic infection with the bacteria Helicobacter pylori. It is probably spread by contaminated food and water and is thought usually to be acquired in childhood. This organism is also well known to cause stomach and duodenal ulcers. We found the bug present in the majority of Yemenis tested. We are trying to work out an effective and cheap drug regime to eliminate the infection. The re-infection rate in a developing country such as Yemen is unknown and this too is under study.

Hepatitis

There are at least 5 different viruses which cause acute hepatitis (types A, B, C, D and E). In a recent study of 78 adult acute cases with jaundice from Ta’iz and Sana’a, we found types B and E accounted for 41%. To our great surprise in 51% of cases we could not find a viral cause despite using the most sophisticated laboratory methods. There must either be an unknown virus responsible or some environmental toxin. Clearly further work is needed.

Certain types of viral hepatitis (particularly types B and C) have the propensity to become chronic and may cause cirrhosis. Chronic hepatitis B is very prevalent in Yemen. We found about 20% of apparently healthy people were carrying the virus (compared with 1 per 1000 in UK). It may be transmitted from mother to child or by scratches, needles and transfusions. It is entirely preventable by vaccination, but this is not generally available in Yemen due to its cost.

Chronic hepatitis C is also prevalent in Yemen and an important cause of cirrhosis and liver cancer. It is transmitted by similar routes to hepatitis B. We found about 2% of apparently healthy individuals are infected. There is presently no vaccine. The strain of virus found in Yemen (Type 4) is particularly resistant to currently available treatment.

Yemen has made great strides forward in the past 10 years or so in tackling its health problems, and I have every confidence - given the excellence of the senior medical leaders in the country - that the pace of improvement will quicken. It is lack of resources rather than skill and commitment which is holding back the pace of progress.

(Dr Ian Murray-Lyon has paid ten annual visits to the University of Sana’a Medical College, principally to help with final MB exams.)

December 1997