Efficiency, market concentration and bank performance during the COVID-19 outbreak: Evidence from the MENA region.

This study aims to contribute to the existing literature that explores the impact of market concentration on bank efficiency in emerging economies. Using a sample of 225 banks in 18 countries in the Middle East and North Africa (MENA) region over the period 2006-2020, we empirically investigate the significance of this relationship. Since the evidence of concentration effect on efficiency during the COVID-19 outbreak is ambiguous, we test the hypothesis that the efficiency is positively affected by the level of banking market concentration in the MENA region. We adopt fixed effect model specifications and test the robustness of our results with the two-step Generalized Method of Moments (GMM) estimation technique. Our analysis finds a strong positive association between market concentration and bank efficiency. The analysis of different types of banking systems that co-existing in the MENA region (Islamic and conventional) indicates the market concentration effect is more pronounced when the banking institution is Islamic and during the COVID-19 outbreak. Moreover, the better economic performance of Islamic banks during the initial stage of pandemic further increases their efficiency. Our analysis indicated that the impact of market competitive conditions on bank efficiency varies significantly across banks with different ownership structures and is more pronounced for government-owned banks. The results are robust using different model specifications and alternative estimation techniques.

Economic growth, social, and welfare development during COVID-19 pandemic: do country-specific characters matter in the MENA region?

The coronavirus disease 2019 (COVID-19) pandemic has generated major shocks that have crippled the economic development of many countries and regions. The COVID-19 pandemic has hampered not only economic development but also global countries from achieving their sustainable development goals through various channels. Given their first experience, many countries have no guidelines for measuring the true impact of the pandemic on their economic and social development, either at the global, regional, or country level. Amid the current slow research development in this area, this study investigates the medium- and long-run impact of the COVID-19 pandemic on the United Nation's achievement of sustainable development goals. The sample in the study comprises the Middle East and North African countries, including Algeria, Bahrain, Egypt, Iran, Iraq, Israel, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Qatar, Saudi Arabia, Syria, Tunisia, United Arab Emirates, and Yemen. The social development goals are approximated by economic growth and human development index, which play as the dependent variables representing two models, respectively. From another aspect, independent variables are derived from three primary sectors: government, households, and healthcare providers. In estimating the model, the study implements the panel regression estimation method using multiple variance estimators. The study findings will help policymakers formulate deliberate policy plans to stabilize economic and social fluctuations in the region and to improve the performance of basic macroeconomic parameters.

Digital health in fragile states in the Middle East and North Africa (MENA) region: A scoping review of the literature.

INTRODUCTION: Conflict, fragility and political violence, that are taking place in many countries in the Middle East and North Africa (MENA) region have devastating effects on health. Digital health technologies can contribute to enhancing the quality, accessibility and availability of health care services in fragile and conflict-affected states of the MENA region. To inform future research, investments and policy processes, this scoping review aims to map out the evidence on digital health in fragile states in the MENA region. METHOD: We conducted a scoping review following the Joanna Briggs Institute (JBI) guidelines. We conducted descriptive analysis of the general characteristics of the included papers and thematic analysis of the key findings of included studies categorized by targeted primary users of different digital health intervention. RESULTS: Out of the 10,724 articles identified, we included 93 studies. The included studies mainly focused on digital health interventions targeting healthcare providers, clients and data services, while few studies focused on health systems or organizations managers. Most of the included studies were observational studies (49%). We identified no systematic reviews. Most of the studies were conducted in Lebanon (32%) followed by Afghanistan (13%) and Palestine (12%). The first authors were mainly affiliated with institutions from countries outside the MENA region (57%), mainly United Kingdom and United States. Digital health interventions provided a platform for training, supervision, and consultation for health care providers, continuing education for medical students, and disease self-management. The review also highlighted some implementation considerations for the adoption of digital health such as computer literacy, weak technological infrastructure, and privacy concerns. CONCLUSION: This review showed that digital health technologies can provide promising solutions in addressing health needs in fragile and conflict-affected states. However, rigorous evaluation of digital technologies in fragile settings and humanitarian crises are needed to inform their design and deployment.

The effect of COVID-19 infection on the menstrual cycle: a cross-sectional investigation in the MENA region.

Due to the paucity of literature on COVID-19 and menstrual irregularities, this study aims to investigate the effect of COVID-19 infection on menstrual changes in premenopausal women within the Middle East and North Africa (MENA) region. A cross-sectional investigation utilizing a self-administered online questionnaire was conducted between July and August of 2021. A total of 499 females participated in our survey with a mean age of 35.2 ± 8.4 years. The majority of participants had regular periods (74.1%) and were disease free (81.6%). Mild, moderate, and severe symptoms were documented in 58.9%, 26.7%, and 3.0% of the studied cohort, respectively. Females experienced significantly more menstrual abnormalities after COVID-19 infection than during the pandemic prior to infection (p < 0.001). Those females were significantly older (p = 0.031), had more severe symptoms (p = 0.029), and were more likely to have experienced irregularities during the epidemic (p < 0.001). COVID-19 infection seems to induce menstrual abnormalities in premenopausal females. These abnormalities could manifest as increased frequency or severity and are associated with older women.

Patient-centered care in the Middle East and North African region: a systematic literature review.

BACKGROUND: The need for patient centered care (PCC) and its subsequent implementation has gained policy maker attention worldwide. Despite the evidence showing the benefits and the challenges associated with practicing PCC in western countries there has been no comprehensive review of the literature on PCC practice in the Middle East and North African (MENA) region, yet there is good reason to think that the practices of PCC in these regions would be different. OBJECTIVES: This paper summarizes the existing research on the practice of PCC in the MENA region and uses this analysis to consider the key elements of a PCC definition based on MENA cultural contexts. METHODS: Five electronic databases were searched (EMBASE, Cochrane, Medline, CINAHL and Scopus) using the search terms: patient OR person OR client OR consumer AND centered OR centred AND care. The MENA countries included were Bahrain, Iran, Iraq, Jordan, Kuwait, Lebanon, Oman, Palestine, Israel, Qatar, Saudi Arabia, Syria, United Arab Emirates, Yemen, Algeria, Egypt, Libya, Morocco, Tunisia, Djibouti, Pakistan, Sudan, and Turkey. Identified papers were imported to Covidence where they were independently reviewed against the inclusion criteria by two authors. The following data were extracted for each paper: author, year, location (i.e., country), objectives, methodology, study population, and results as they related to patient centred care. RESULT: The electronic search identified 3582 potentially relevant studies. Fifty articles met the inclusion criteria. Across all papers five themes were identified: 1) patient centered care principles; 2) patient and physician perceptions of PCC; 3) facilitators of PCC; 4) implementation and impact of PCC; and 5) barriers to PCC. CONCLUSION: The preliminary findings suggest that the concept of PCC is practiced and supported to a limited extent in the MENA region, and that the implementation of PCC might be impacted by the cultural contexts of the region. Our review therefore highlights the importance of establishing patient-centered care definitions that clearly incorporate cultural practices in the MENA region. The elements and impact of culture in the MENA region should be investigated in future research.

SARS-CoV-2 chronological genomic evolution and epidemiology in the Middle East and North Africa (MENA) region as affected by vaccination, conflict and socioeconomical disparities: a population-based cohort study.

OBJECTIVE: To describe the chronological genomic evolution of SARS-CoV-2 and its impact on public health in the Middle East and North Africa (MENA) region. METHODS: This study analysed all available SARS-CoV-2 genomic sequences, metadata and rates of COVID-19 infection from the MENA region retrieved from the Global Initiative on Sharing All Influenza Data database from January 2020 to August 2021. Inferential and descriptive statistics were conducted to describe the epidemiology of SARS-CoV-2. RESULTS: Genomic surveillance of SARS-CoV-2 in the MENA region indicated that the variants in January 2020 predominately belonged to the G, GR, GH or O clades and that the most common variant of concern was Alpha. By August 2021, however, the GK clade dominated (57.4% of all sequenced genomes), followed by the G clade (18.7%) and the GR clade (11.6%). In August, the most commonly sequenced variants of concern were Delta in the Middle East region (91%); Alpha (44.3%) followed by Delta (29.7%) and Beta (25.3%) in the North Africa region; and Alpha (88.9%), followed by Delta (10%) in the fragile and conflict-affected regions of MENA. The mean proportion of the variants of concern among the total sequenced samples differed significantly by country (F=1.93, P=0.0112) but not by major MENA region (F=0.14, P=0.27) or by vaccination coverage (F=1.84, P=0.176). CONCLUSION: This analysis of the genomic surveillance of SARS-CoV-2 provides an essential description the virus evolution and its impact on public health safety in the MENA region. As of August 2021, the Delta variant showed a genomic advantage in the MENA region. The MENA region includes several fragile and conflict-affected countries with extremely low levels of vaccination coverage and little genomic surveillance, which may soon exacerbate the existing health crisis within those countries and globally.

A review about COVID-19 in the MENA region: environmental concerns and machine learning applications.

Coronavirus disease 2019 (COVID-19) has delayed global economic growth, which has affected the economic life globally. On the one hand, numerous elements in the environment impact the transmission of this new coronavirus. Every country in the Middle East and North Africa (MENA) area has a different population density, air quality and contaminants, and water- and land-related conditions, all of which influence coronavirus transmission. The World Health Organization (WHO) has advocated fast evaluations to guide policymakers with timely evidence to respond to the situation. This review makes four unique contributions. One, many data about the transmission of the new coronavirus in various sorts of settings to provide clear answers to the current dispute over the virus's transmission were reviewed. Two, highlight the most significant application of machine learning to forecast and diagnose severe acute respiratory syndrome coronavirus (SARS-CoV-2). Three, our insights provide timely and accurate information along with compelling suggestions and methodical directions for investigators. Four, the present study provides decision-makers and community leaders with information on the effectiveness of environmental controls for COVID-19 dissemination.

Nutrition and Food Literacy in the MENA Region: A Review to Inform Nutrition Research and Policy Makers.

BACKGROUND: Improving food and nutrition literacy is fundamental to tackling the Middle East and North Africa (MENA) region's enormous challenges, including malnutrition and food insecurity. To direct initiatives, it is crucial to assess the region's food and nutrition literacy. Thus, we aimed to review studies on food/nutrition literacy status in the MENA countries and illuminate the region's research gaps in these areas, in terms of assessment, policy, and program implementation. METHODS: PubMed and Google Scholar databases were searched between 18 December and 8 May 2022, to identify relevant articles published up to 2022 in the MENA region. RESULTS: Twelve studies were included in this review. Lebanon, Palestine, and Iran are the only three MENA countries where nutrition and/or food literacy were assessed. People in these countries mostly had inadequate food and/or nutrition literacy levels, especially in the skills rather than the cognitive domain. Food and/or nutrition literacy showed associations with food habits, food-label use, food-consumption patterns, school performance, food security, dietary diversity, and nutrient adequacy. The MENA countries developed no policies or programs to address food and nutrition literacy. CONCLUSION: This review is a wake-up call for researchers and policymakers to develop a robust approach to combat food and nutrition literacy concerns in the MENA region.

Status of the HIV epidemic in key populations in the Middle East and north Africa: knowns and unknowns.

The Middle East and north Africa is one of only two world regions where HIV incidence is on the rise, with most infections occurring among key populations: people who inject drugs, men who have sex with men, and female sex workers. In this Review, we show a trend of increasing HIV prevalence among the three key populations in the Middle East and north Africa. Although the epidemic continues at a low level in some countries or localities within a country, there is evidence for concentrated epidemics, with sustained transmission at considerable HIV prevalence among people who inject drugs and men who have sex with men in over half of countries in the region with data, and among female sex workers in several countries. Most epidemics emerged around 2003 or thereafter. The status of the epidemic among key populations remains unknown in several countries due to persistent data gaps. The HIV response in Middle East and north Africa remains far below global targets for prevention, testing, and treatment. It is hindered by underfunding, poor surveillance, and stigma, all of which are compounded by widespread conflict and humanitarian crises, and most recently, the advent of COVID-19. Investment is needed to put the region on track towards the target of eliminating HIV/AIDS as a global health threat by 2030. Reaching this target will not be possible without tailoring the response to the needs of key populations, while addressing, to the extent possible, the complex structural and operational barriers to success.

Effects of temperature and relative humidity on the COVID-19 pandemic in different climates: a study across some regions in Algeria (North Africa).

After more than a year from the first confirmed cases of coronavirus (COVID-19) disease, the role of meteorological factors in the transmission of the virus still needs to be correctly determined. In this scenario of deep uncertainty, the present study aims to investigate the effects of temperature and relative humidity on daily new cases of COVID-19. For this purpose, the COVID-19's development of infection in fourteen Algerian cities characterized by different climatic conditions, during the period from April 1, 2020, to August 31, 2020, has been investigated. A detailed time series analysis along with linear regression was used to state a possible correlation among some climate's factor variability (temperature and relative humidity) and daily new confirmed cases of COVID-19. The results showed a weak correlation between daily new cases of COVID-19 and meteorological factors throughout the selected regions. In addition, we concluded that the COVID-19 could fit to high or low values of temperature and relative humidity, and other factors not climates could affect the spreading of the virus like demography and human contact. So, after the discovery of the vaccine and before vaccination of 70% of the world's population, living with the virus has become an inevitable reality, and it is mandatory to apply the sanitary procedures to slow down the COVID-19 transmission.

Public acceptability of COVID-19 vaccines and its predictors in Middle Eastern/North African (MENA) countries: a systematic review .

INTRODUCTION: COVID-19 vaccines emerged as a worldwide hope to contain the pandemic. However, many people are still hesitant to receive these vaccines. We aimed to systematically review the public knowledge, perception, and acceptability of COVID-19 vaccines in the Middle East and North Africa (MENA) countries and the predictors of vaccine acceptability in this region. METHODS: We systematically searched databases of PubMed, Scopus, Web of Science, and Cochrane and retrieved all relevant studies by 5 August 2021. RESULTS: There was a considerable variation in the COVID-19 vaccine acceptance rates, from 12% in a study from Israel to 83.3% in Kuwait, although two other studies from Israel mentioned 75% and 82.2% acceptability rates. Concerns about the side effects and safety of the vaccine were the main reasons for the lack of acceptability of taking the vaccine, which was reported in 19 studies. . CONCLUSION: Several factors, such as age, gender, education level, and comorbidities, are worthy of attention as they could expand vaccine coverage in the target population. .

Impact of COVID-19 pandemic on psychological wellbeing of Oncology clinicians in the Middle East and North Africa (MENA) region.

OBJECTIVE: The reorganization of cancer services and the increased work burden on health care providers during the COVID-19 pandemic are likely to be associated with significant negative psychological impact. The aim of this study is to evaluate the impact of COVID-19 pandemic on the psychological well-being of oncology clinicians in the Middle East and North Africa (MENA) region. MATERIALS AND METHODS: We randomly invited 1500 oncology clinicians including medical oncologists, clinical oncologists, radiation oncologists and surgical oncologists from 17 countries in the MENA region to complete a web-based survey to determine the level of psychological stress during the COVID-19 pandemic from October 2020 to January 2021. The questionnaire was based on the Perceived Stress Scale (PSS), Generalized Anxiety Disorders Scale (GAD-7) and WHO Well-being Index (WHO-5). The data was analyzed using SPSS version 21 and the difference between groups was measured by t-test and ANOVA. RESULTS: Overall, 520 (35%) clinicians including 368 (71%) males and 152 (29%) females participated in the survey with 247 (47%) participants between the ages of 36 to 45 years. Average score of 29.6 for males and 30.2 on PSS-10, indicative of high-perceived stress in both the genders. Compared to males, females had significantly higher anxiety levels on GAD-7 scale (p=.04), but this difference in stress level and well-being was not observed on PSS-10 (p=.134) and WHO -5 well-being index (p=.709). Clinicians of age 25-35 years had significantly higher anxiety levels on GAD-7 scale (p=.004) and higher stress on PSS (p=.000) as compared to other age groups. Age over 55 years was associated with lower levels of anxiety and stress on GAD-7 and PSS. Oncology clinicians working in public sector experienced significantly lower stress as compared to private sector on PSS scale (p=.041). CONCLUSIONS: Anxiety and stress levels among oncology clinicians have significantly increased in COVID-19 pandemic in the MENA region. Females and young clinicians had higher anxiety and stress, while oncology clinicians over the age of 55 years and working in the public sector reported less stress and anxiety. The general wellbeing of clinicians was well preserved even in a highly stressful and anxious situation.

The Impact of Sociodemographic, Nutritional, and Health Factors on the Incidence and Complications of COVID-19 in Egypt: A Cross-Sectional Study.

This study was intended to explore sociodemographic, nutritional, and health-related factors on the incidence of COVID-19 infection within the Egyptian population by assessing the frequency and determinants of post-COVID-19 symptoms and complications. A cross-sectional study using a structured survey on 15,166 participants was adopted. The results revealed common symptoms including fever (79.1%), cough (74.5%), anosmia& ageusia (68.4%), and dyspnea (66.9%). The patients were nonsmokers (83.9%), while 9.7% were mild smokers. The percentage of infected patients with comorbidities versus those without comorbidities were 29%, 71%, respectively. The highest incidence of infection was in those patients with hypertension (14.8%) and diabetes (10.9%), especially females with age >50 years and obesity (BMI; 30-39.9). The highest risks were observed for anticoagulants in the age above 50 years, morbid obesity, presence of comorbidities, and being a healthcare worker. The predictors of clot risk were in the age above 50 years, non-educated, and eating meat and eggs. Nonetheless, the highest risk of using antidepressants was in patients >50 years and those who traveled abroad. These findings and similarities within the surrounding region, the Middle East, North Africa, and South Europe, indicate the possibility of sharing the same viral strain and characteristics that may predict a similar vaccine efficacy and response.

The burden of stroke and its attributable risk factors in the Middle East and North Africa region, 1990-2019.

Stroke is one of the leading causes of mortality and morbidity across the globe. Providing comprehensive data on the burden of stroke in the Middle East and North Africa (MENA) could be useful for health policy makers in the region. Therefore, this article reported the burden of stroke and its attributable risk factors between 1990 and 2019 by age, sex, type of stroke, and socio-demographic index. Data on the point prevalence, death, and disability-adjusted life-years (DALYs), due to stroke, were retrieved from the Global Burden of Disease study 2019 for the 21 countries located in the MENA region from 1990 to 2019. The counts and age-standardised rates (per 100,000) were presented, along with their corresponding 95% uncertainty intervals (UIs). In 2019, the regional age-standardised point prevalence and death rates of stroke were 1537.5 (95% UI: 1421.9-1659.9) and 87.7 (78.2-97.6) per 100,000, which represent a 0.5% (- 2.3 to 1.1) and 27.8% (- 35.4 to - 16) decrease since 1990, respectively. Moreover, the regional age-standardised DALY rate in 2019 was 1826.2 (1635.3-2026.2) per 100,000, a 32.0% (- 39.1 to - 23.3) decrease since 1990. In 2019, Afghanistan [3498.2 (2508.8-4500.4)] and Lebanon [752.9 (593.3-935.9)] had the highest and lowest age-standardised DALY rates, respectively. Regionally, the total number of stroke cases were highest in the 60-64 age group and was more prevalent in women in all age groups. In addition, there was a general negative association between SDI and the burden of stoke from 1990 to 2019. Also, in 2019, high systolic blood pressure [53.5%], high body mass index [39.4%] and ambient particulate air pollution [27.1%] made the three largest contributions to the burden of stroke in the MENA region. The stroke burden has decreased in the MENA region over the last three decades, although there are large inter-country differences. Preventive programs should be implemented which focus on metabolic risk factors, especially among older females in low SDI countries.

Gendered Impacts of the COVID-19 Pandemic on Food Behaviors in North Africa: Cases of Egypt, Morocco, and Tunisia.

The COVID-19 pandemic-related measures in the Near East and North Africa (NENA) region have resulted in many lifestyle modifications, including changes in diet and food buying patterns among adults. However, the pandemic has impacted women and men differently and exacerbated existing socio-economic and gender inequalities. Indeed, numerous studies conducted worldwide have shown that the COVID-19 pandemic had a disproportionately negative impact on women compared to males. Therefore, this paper aims to analyze the effects of COVID-19 on women's food behaviors in three countries of the North Africa sub-region, namely, Egypt, Morocco, and Tunisia. The study was based on an online poll conducted by SurveyMonkey from 15 September to 5 November 2020, with 995 participants. The outcomes of the research found that when compared to men, (1) women tend to consume more food out of fear, anxiety, or boredom; (2) women prefer to eat more unhealthy food; (3) women tend to stockpile a greater amount of food; and (4) women tend to modify their shopping habits more often. The findings should inform gender-sensitive strategies and policies to address the negative impacts of the pandemic and foster transition towards healthier diets and resilient food systems during the recovery period.

Assessing vaccine hesitancy in Arab countries in the Middle East and North Africa (MENA) region: a scoping review protocol.

INTRODUCTION: Vaccine-preventable disease outbreaks have increased in past years, and there is great public health interest in monitoring attitudes towards vaccination as well as identifying factors contributing to vaccine hesitancy and refusal. Although the WHO declared vaccine hesitancy as one of the top threats to global health in 2019, studies focused on the determinants and extent of vaccine hesitancy in Arab countries in the Middle East and North Africa (MENA) region are lacking. This scoping review explores the various factors surrounding vaccine hesitancy, including but not limited to geographic, cultural and religious factors, and examines the extent and nature of the existing evidence on this topic. In light of current development of various COVID-19 vaccines, our work seeks to elucidate the barriers to vaccine uptake in specific populations. METHODS AND ANALYSIS: This review will be conducted using the Joanna Briggs Institute Manual for Scoping Reviews. It will comply with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines. Studies published in English, Arabic and French between January 1998 and December 2020 will be drawn from PubMed, Embase, Cochrane and Scopus. The search strategy will include terms related to vaccination and vaccine hesitancy in Arab countries in the MENA region. We will also include grey literature on the topic by searching Google and Google Scholar. Studies will be selected according to the Participants-Intervention-Comparators-Outcome model, and all study titles and abstracts will be screened by two reviewers. Disagreements will be resolved with a third reviewer's input. ETHICS AND DISSEMINATION: This review is exempted from ethical approval and will be published in a peer-reviewed open-access journal to ensure wide dissemination.

T cell counts and IL-6 concentration in blood of North African COVID-19 patients are two independent prognostic factors for severe disease and death.

The immune system plays a crucial role in the response against severe acute respiratory syndrome coronavirus 2 with significant differences among patients. The study investigated the relationships between lymphocyte subsets, cytokines, and disease outcomes in patients with coronavirus disease 2019 (COVID-19). The measurements of peripheral blood lymphocytes subsets and cytokine levels were performed by flow cytometry for 57 COVID-19 patients. Patients were categorized into two groups according to the severity of the disease (nonsevere vs. severe). Total lymphocytes, T cells, CD4+ T cells, CD8+ T cells, B cells, and natural killer cells were decreased in COVID-19 patients and statistical differences were found among different severity of illness and survival states (P ˂ 0.01). The levels of IL-6 and IL-10 were significantly higher in severe and death groups and negatively correlated with lymphocyte subsets counts. The percentages of Th17 in the peripheral blood of patients were higher than those of healthy controls whereas the percentages of Th2 were lower. For the severe cases, the area under receiver operating characteristic (ROC) curve of IL-6 was the largest among all the immune parameters (0.964; 95% confidence interval: 0.927-1.000, P < 0.0001). In addition, the preoperative IL-6 concentration of 77.38 pg/ml was the optimal cutoff value (sensitivity: 84.6%, specificity: 100%). Using multivariate logistic regression analysis and ROC curves, IL-6 > 106.44 pg/ml and CD8+ T cell counts <150 cells/µl were found to be associated with mortality. Measuring the immune parameters and defining a risk threshold can segregate patients who develop a severe disease from those with a mild pathology. The identification of these parameters may help clinicians to predict the outcome of the patients with high risk of unfavorable progress of the disease.

Lessons learned in stroke care during COVID-19 pandemic and preparing for future pandemics in the MENA+ region: A consensus statement from the MENA+-SINO.

BACKGROUND: COVID-19 pandemic has negatively impacted stroke care services at multiple levels. There was a decline in acute stroke admissions. Fewer interventions have been performed. Increased "door-to-needle times and "door-to-groin puncture" during this pandemic. These factors combined have led to declining in the favoured outcomes of stroke patients' globally. Yet this pandemic permits an opportunity for higher preparedness for future pandemics. OBJECTIVES AND METHODS: This paper aims to shed light on the main lessons learned in the field of stroke care during the first wave of COVID-19 pandemic. Here we are presenting proposals and initiatives for better preparedness in future similar emergencies. These proposals are based primarily on literature review of COVID-19 publications, as well as the first-hand experience gained during the first wave at the regional level. In addition to the consensus and collective ride of stroke experts in the Middle East North Africa Stroke and Interventional Neurotherapies Organization (MENA+-SINO) and interaction and collaboration with international stroke specialists from the Stroke World Organization (WSO), European Stroke Organization (ESO) and stroke and COVID-19 papers authors. CONCLUSION: Stroke care is very complex, particularly in the initial hours after onset of symptoms. A successful outcome requires very close collaboration between clinical personnel from multiple specialties. Preparedness for future pandemics requires the improvement of care plans that allow for rapid assessment of stroke patients and ensuring that regular 'mock exercises' familiarize quintessential services that care for the stroke patients.

The Middle East and COVID-19: time for collective action.

Revised: Nov 6 2021The shortfalls of multilateral and regional organizations in respect of handling the COVID-19 pandemic have been well rehearsed by scholars and policy makers in multiple publications and statements. While the World Health Organization (WHO) and its regional offices have coordinated global responses, regional organizations, like the European Union, Association of Southeast Asian Nations, or African Union, have played complementary roles. However, the response of different regions has varied, revealing multiple deficits in the structures of regional governance. The Middle East and North Africa (MENA) is a region affected by chronic ongoing conflicts and serious inequalities in health and welfare provision, reflected in the absence of concerted responses to the pandemic. Its young population has meant lower comparative mortality rates, but the socio-economic spill-over effects are grave in terms of interrupted education, high unemployment, particularly in respect to vulnerable communities like refugees and migrant workers. With the current situation remaining critical, this paper reviews the impact of COVID-19 on MENA and considers the variable performance of states and institutions to the pandemic, highlighting the shortfalls, but also opportunities for collective action. Drawing on data from the WHO, United Nations (UN), regional organizations, media and secondary sources, it first discusses the wider global-regional context; second, reviews the actions of regional bodies, like the League of Arab States, Gulf Cooperation Council and the cross-regional Organization of Islamic Cooperation; and third, looks at some country-specific situations where both evidence of good practice and the absence of appropriate regional level provision have exposed deep regional divides. It concludes with a call for more collaboration between states and international organizations: better regional coordination is urgently needed to supplement existing multilateral efforts. A collective local response to the COVID-19 pandemic could help transcend regional divides and spur much-needed security cooperation in other areas.