Americans with roots in the Middle Eastern and North Africa region (MENA) are classified as “white” according to census data, but this diverse population has enough genetic attributes in common to warrant its own grouping for the purposes of medical research. This is becoming a particularly pressing issue with the ongoing health pandemic and the resurgence of the COVID-19 delta variant. And while the states of Michigan and, more recently, Illinois have taken the lead on collecting COVID-related data on Americans with genetic roots in MENA, these efforts offer too little too late and may instead cause harm. In the meantime, the lack of medical understanding of the MENA population continues to hinder the ability of medical providers like me to ensure a high standard of care for members of these communities.
MENA populations, as well as those indigenous to the Mediterranean Basin, have in common a myriad of genetic disorders and dispositions, diet and lifestyle habits, in addition to some overriding psychological and cultural issues that remain overlooked and understudied, putting them at greater risk of COVID-19 infections and complications.
Indeed, according to 2020 statistics, some of the main COVID-19 hotspots across the United States overlapped with the largest hubs of MENA populations, including in New York, New Jersey, Michigan, California and Illinois.
But since federal funding for research is awarded based on population data, MENAs do not qualify for any substantial amount of money. They are simply, and erroneously, considered part of the general “white” population. This has caused a detrimental downstream effect: Less funding for research leads to less availability for targeted interventions, which leads to a limited understanding of the health issues this population faces.
The recent move by the state of Illinois to add the demographic identifier of “Middle Eastern or North African” on its vaccine portal allows for the collection of some data, but it will be incomplete and inaccurate. The vaccine has been available in Illinois for over nine months, and many of the MENA populations received it before this demographic identifier was introduced. This poses the potential problem that Illinois will use the incomplete and inaccurate data it has just started to collect as a benchmark for research funding, and that would shortchange the MENA population.
Additionally, many of the adverse health outcomes related to COVID-19 in our community have already happened, resulting in too many untimely deaths within the first two surges. We will not be able to retrospectively study this population and learn best practices to apply in the future.
For other populations, specifically Hispanics and African Americans, having federally funded research allows physicians and healthcare workers to better understand these patients’ unique health needs. There are some diseases that are more prevalent in these populations, like diabetes, hypertension, heart disease and high cholesterol, which could substantially affect outcomes for patients infected with COVID-19.
African Americans, for example, are known to have greater rates of asthma, sarcoidosis, lung cancer, sickle cell anemia and stroke when compared with their white counterparts, making African Americans especially susceptible to COVID-19 symptoms and risk to life. Understanding this has allowed physicians and the greater healthcare team to tailor medical care to better manage patients with asthma and superimposed COVID-19 infections.
Similarly, there has been federally funded research to show that Hispanics have greater rates of liver disease, diabetes, hypertension and obesity when compared with their white counterparts. The preliminary research that was published at the start of the pandemic indicated that patients with coexisting health issues, such as diabetes, hypertension, obesity or any underlying lung condition like lung cancer or asthma, had worse outcomes with COVID-19 infections, tended to have more severe infections, and required intubation and greater level of critical and intensive care than their counterparts.
If there was research available for other populations, specifically for MENA populations, then there would be guided interventions, a process to address preexisting diseases and superimposed infections, and an opportunity for patient-centered care.
We have understood from small population studies — and from observing public health issues in MENA countries — that MENA Americans face a greater rate of obesity, diabetes, coronary artery disease, lung cancer, asthma and high blood pressure than the U.S. average. Some of these diseases are what we colloquially term “the silent killers”; they don’t have sudden or physically tangible symptoms even when they progress to the more harmful stages of the disease and cause sudden fatalities or permanent health impairments. These diseases make any population that much more vulnerable to infections and pandemics.
We can also extrapolate further information about the MENA population from the general immigrant health research that is available, which has consistently shown that immigrants have less access to health resources and, when they do, are less inclined to take advantage of it, thus leading to health disparities. Some of the most commonly witnessed issues in immigrant health include food insecurity, limited health literacy, medication compliance, medical misinformation and, particularly relevant in times of a pandemic, low confidence in vaccines.
One of the saving graces of the MENA population is the overall Mediterranean diet, which consists of plenty of vegetables and healthy fats like olive oil, lean proteins like fish, legumes like lentils and chickpeas as well as whole grains, herbs and spices. But despite these “good habits,” MENA populations generally suffer from a variety of nutritional deficiencies, including iron, folic acid, vitamins B12, C and D — the latter deficiency in MENA countries being the highest in the world due to a multitude of factors, including limited exposure to the sun because of the heat, skin pigmentation and the religious observation of wearing the hijab, which reduces the amount of exposed skin to sunlight. These nutritional deficiencies do not necessarily disappear when MENA populations immigrate to the U.S.
Cultural habits of MENA populations also come as a double-edged sword and need to be studied. Observant Muslims, for example, may not drink alcohol, and non-Muslim or nonobservant households may drink only in moderation because excessive drunkenness is frowned upon. However, this taboo may inhibit alcoholics and other addicts within the community from seeking the help they need.
And people from MENA also espouse a few cultural “bad habits.” They are more likely to smoke tobacco, including use of the culturally ubiquitous hookah. They also consume excessive sugar in their tea and coffee and eat dessert in excess during long and sedentary social sittings, which are also a cultural habit. These are issues that medical care providers could address if we had good studies as a reference.
We can identify from medical research and observation in various MENA countries a slew of disorders that, based on anecdotal evidence, also appear in the MENA population in the U.S. Sickle cell anemia, for example, is widely prevalent around the Mediterranean Basin. It occurs when the red blood cells are not properly shaped and therefore are unable to adequately carry oxygen throughout the body. It causes severe pain and fatigue and can increase the chance of infection. The misshapen red blood cells also often die early and lead to anemia.
Another common blood disease in populations indigenous to the Mediterranean Basin is thalassemia, in which the body makes too little hemoglobin or not the right type. Hemoglobin, a protein found in red blood cells, carries oxygen throughout the body.
Then there is what is known as benign ethnic neutropenia, a chronic, lifelong condition seen in MENA populations at a greater rate than in others. It is a disease wherein the body does not have enough white blood cells to fight off infections.
Familial Mediterranean fever, a rare, genetically inherited autoimmune inflammatory disease with characteristic recurrent fevers, rashes of the ankles, swollen painful joints, and inflammation of the lung and abdomen, is also endemic in MENAs, as is G6PD deficiency, which any emergency room in the MENA region could easily diagnose but can be fatally overlooked in the U.S. G6PD deficiency is an inherited blood disorder in which red and white blood cells separate from each other like oil and water as a bad reaction to certain dietary triggers like fava beans, a staple food in MENA.
Making matters worse for genetic disorders in MENA populations is consanguinity — marrying relatives — which is known to contribute to higher rates of diabetes, high blood pressure, hearing loss, heart disease, asthma, mental illness, epilepsy and blood disorders. The closer the relation, the greater the probability for a genetically related disease or disorder to manifest in the next generation.
Last but not least, populations from the MENA region suffer what I call a “common psyche,” borne from living a common experience in post-9/11 America. Many hail from politically unstable countries and, in recent years, many have endured some level of war trauma from events “back home.” This, combined with a rise in Islamophobia and targeted hate crimes, may have physical and mental health ramifications on the community that remain unstudied. General studies have shown that populations that endure constant racism and discrimination in society will suffer greater rates of depression, coronary artery disease, hypertension and obesity, as well as other stress-related disorders like maternal morbidity and mortality, which was observed in MENA populations in the U.S. after 9/11.
Indeed, when COVID-19 began to affect MENA communities in the U.S., many clinicians noticed how poorly these patients were doing. Infections were also rampant within the community because of multigenerational households, another cultural signature.
In Chicago, all three generations of a particular family were infected with COVID-19 within days of one of the family members testing positive in April 2020, right at the start of the pandemic. By the end of the week, their family, neighbors and other relatives who lived nearby all became infected.
There have been similar stories across MENA communities in Paterson, New Jersey; Detroit, Michigan; and Houston, Texas. One must wonder if these infections could have been prevented had healthcare providers been better informed about their patients in the MENA community.
Ideally, the goal would be to have a demographic identifier that places MENA as a separate category in the census, therefore allowing more medical and health-related research to occur in these populations and adequate funding for targeted interventions. Having cultural competency about how we can target health related interventions in these populations would help improve health outcomes. One recent and good example of how this worked unfolded during Ramadan in Michigan, where vaccine clinics remained open from 8 p.m. to 1 a.m to allow Muslims who were observing the fast to receive their COVID-19 vaccines during their nonfasting hours.
But as things stand, social media and communication apps like WhatsApp have become the preferred and trusted platforms for COVID-19 news by many within the MENA communities across the U.S., thus facilitating the spread of misinformation within the community. Much to my dismay, I have seen too many forwarded messages of homemade remedies or folk science to “fight off corona” from community members and friends who live all over the U.S. I forwarded one of these misleading messages to a group of ambitious medical students who took it upon themselves to translate the official guidelines of the Centers for Disease Control and Prevention into Arabic and Farsi, hoping to counteract the damage of false messaging. But in the absence of federal funding for population-specific research, such individual efforts amount to a mere drop in the ocean.