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SAMJ: South African Medical Journal

On-line version ISSN 2078-5135
Print version ISSN 0256-9574

SAMJ, S. Afr. med. j. vol.98 n.7 Pretoria Jul. 2008




A society in transition



Chris Ellis

Chris Ellis is a family physician from KwaZulu-Natal who is currently lecturing in the Middle East




Medical practice in Arabia and here in the United Arab Emirates provides interesting scenarios, and ones that are very different compared with South Africa. Whereas in South Africa HIV/AIDS is considered in most differential diagnoses, here it is diabetes that is the main topic of conversation. This is because there are only about 500 cases of HIV/AIDS in the country, although official figures are hard to come by despite its being a notifiable disease (doctors are reminded of this by posters on the hospital noticeboards).

Before you can work here as an expat and be issued with a resident's permit, you must have an HIV test. This poses what is a major problem in Arabic countries - medical confidentiality. After my blood test I returned to the hospital for the result with a medical school driver. He fetched the paper and came out waving it, saying 'Good news, professor, your HIV test is negative!' So much for confidentiality!

After a consultation, husbands or brothers may enquire what the matter with the patient is and expect to be told. This is part of the collectivist culture of sharing information and making decisions in families, as opposed to the Western individualistic and autonomous culture of the one-on-one consultation. Like anywhere else in the world, a positive HIV result is a life-changing event. But the changes here are drastic. If you are an expat you are admitted to hospital with a police guard until the plane arrives from your country of origin; you are then immediately deported. (This also applies to tuberculosis and hepatitis C.) For the local people the results are no less disastrous, with the patient typically being shunned by the shamed family. Doctors may advise patients who ask for HIV tests to have the test done outside the country and arrange for treatment, if necessary, to be sent to them.

Diabetes has reached epidemic proportions in the region because of the high incomes of the population and the easy availability of fast-food outlets. Shopping malls all have huge 'food courts' with the modern outlets such as McDonalds and KFC, and even our own Nandos and Mugg and Bean. There is food everywhere, and obesity is uncontrolled. People sail around the malls like cement mixers on steroids. Nationals over the age of forty years are approaching a 40% rate of type 2 diabetes. Because of the recent high incomes and a naive population, who think they have landed in Disneyland, eating behaviours are very difficult to manage.



Another medical problem that will need to be addressed is a high level of consanguinity, with over fifty per cent of the population married to cousins. Thirty per cent are married to first cousins and the rest to second cousins, resulting in an increase in autosomal recessive disorders such as thalassaemia and sickle cell disease, as well as other congenital disorders. Occasionally two brothers marry two sisters who are their cousins and then their children marry each other (called double consanguinity), causing further genetic problems. Add to this is a society in transition from a nomadic life to the 21st century, and you have some interesting problems. Transition over the last two generations has been fast and far-reaching. Grandparents of the present generation hardly ever divorced, whereas the divorce rate now is 46%. The traditional Arab family is now highly stressed, with dissonance between grandparents and parents and their children. There is great unhappiness in the land of plenty. Working overseas gives one different perspectives, and many South Africans are looking over the fence for greener pastures. I am sorry to tell you, there ain't none. You are already in the green pasture.



C Ellis

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