The Painful History of Epidemics in Saudi Arabia

For Saudi Arabia, the Covid-19 crisis is just another episode in a long series of viruses which have struck the Kingdom since the Spanish flu of 1919.

On 27 April 2020, a few worshippers were allowed to perform the Isha prayer while keeping a distance from each other next to the Kaaba, in a context of an unprecedented ban on mass gatherings and prayers.

When Saudi Arabia announced its first Covid-19 case on 2 March 2020, it seemed to many Saudis that history was repeating itself. While neighbouring Yemen has since 2016 been the victim of endemic cholera which thrives amidst the ruins of the civil war and Saudi-led coalition bombardments, the Kingdom is constantly on the lookout for cases of Ebola carried by pilgrims from West Africa. It has barely emerged from the crisis caused by the previous coronavirus (MERS-CoV), of which the first case in the world was detected in a Saudi patient hospitalised in Jedda in 2012. Three years before that, the H1N1 virus had arrived, with a Philippina nurse officially identified as the first case.

In the 18th and 19th century Arabic chronicles from the peninsula, epidemics appear as frequently as locust attacks on crops. Plague, especially smallpox and cholera and all coming under the generic appellation of ta’un or waba’, penetrated the peninsula via the ports of the Gulf and the Hejaz. The diseases spread through the movement of pilgrims towards Medina and Mecca, of merchant caravans, or through the migration of Bedouin tribes. They are sometimes described as a divine punishment, but more often seen as a recurrent inevitability of nature and of the numerous contacts linking the societies and economies of the Peninsula to the rest of the world.

Memories of Spanish flu

As the number of recorded Covid-19 cases rose during March 2020, the Saudi press produced a number of articles on the 20th century’s first pandemic, the so-called Spanish flu of 1918–1919. The Kingdom’s editorialists drew many more or less scientific comparisons between the two public health crises. The earlier episode had not been forgotten, as it was a formative moment in the emergence of Saudi Arabia. Spanish flu struck the central Najd region and the neighbouring emirates for three months in 1919. It was so virulent that Saudi historians of the period, and surviving folk memories, describe that time as “the year of compassion” (sanat al-rahma) or of “fever” (al-sakhna). In the towns, the daily death toll ran into dozens - in Riyadh, 100 a day at the height of the pandemic, and around 25,000 altogether in the towns of central Arabia, according to the British explorer and Saudi adviser H. St John Philby. The flu decimated nomadic groups already hard hit by a harsh drought and the paralysis of trade during the First World War. It aggravated their distress and stirred the first revolts of the famous Ikhwan [note] against the Emir Abdulaziz Ibn Saud at a time when he was setting about some difficult conquests in northern Najd (an emirate of the Āl Rashid of Ha’il) and in the Hejaz (the Hashemite Kingdom of Mecca).

Rather than reaping the usual victims of an epidemic, the old and the frail, this time the memory was of a virus which attacked active young men with startling virulence - merchants, ulema, farmers, soldiers; the vital elements of the emirate. Abdulaziz Ibn Saud himself lost his son and heir apparent, Turki, as well as Jawhara, one of his wives. Among more or less effective traditional preventive measures, Arabia revived the practice of isolating the sick or suspected cases. Ibn Saud was obliged to call in the chief medical officer of the American Protestant mission in Bahrain, Paul Harrison, whose arrival added somewhat to the discontent of the Ikhwan and further weakened their support.

Resort to Syrian, Lebanese and Egyptian medics

Five years later, when the two holy cities, Mecca and Medina, and the port of Jedda had just been conquered, the emir ordered the creation of a first public health agency at Mecca, with branches in the rest of the future Kingdom. The emirate took in hand its subjects’ health care and made it known, but as with the other new institutions of the nascent state, Ibn Saud initially surrounded himself with Syrian, Lebanese and Egyptian doctors and administrators, there not being their equivalents among the Saudi population, and it is they who take charge, not without some real successes.

The memory of the 1919 flu epidemic remained stronger in Arabia than in other Middle Eastern countries which had also been hard hit. It was not just because the Saudi emirate and its Gulf neighbours were relatively spared by the world war. Those three months of epidemic confronted the Saudi state in the throes of its establishment under the constraints of globalisation, the fragility of its own ecosystem, and the risks inherent in resorting to foreign expertise at a critical moment in its territorial expansion and institutional formation.

The nascent state made health care, the legacy of the flu epidemic and the conquest of the holy places, part and parcel of its strategy for control of both territory and people. This royal monopoly, jealously guarded, was also a way of curbing the international interference which epidemic crises tend to favour. In the 19th century, cholera carried by pilgrims at Mecca spawned the development of an international system which put the holy city under the supervision of the great powers. Immediately after the Second World War, it was Aramco (the American company exploiting Saudi oil resources) that carried out a series of campaigns to eradicate malaria which was endemic in the kingdom’s eastern province, Ahsa. Here the state’s new health remit was to become a mechanism for controlling the majority-Shiia population, often caught up in rival Arab nationalism.

From H1N1 to MERS-CoV

If, a century later, the Spanish flu of 1919 was rapidly resurrected in the Saudi press alongside Health Ministry bulletins, it was because this epidemic saga always remained part of contemporary history. The memory of old epidemics is sustained by later ones. The most recent, MERS-CoV—camels were identified among its vectors—continues to claim victims in the Kingdom, killing more than 850 people between 2012 and 2020 according to the WHO. From one epidemic to the next, the crisis symptoms displayed by the Saudi state recur with astonishing regularity: the broadening scope of state intervention, medical and security control of the holy places, and a nervous relationship with the outside world.

In 2012, the spread of MERS-CoV in the Mecca area stirred all the more anxiety as the authorities were criticised (including by the WHO) for the slowness of their preventive measures and their reluctance to share information on the new virus with international health agencies and laboratories. In the view of its own citizens as well as foreign observers, the state had failed to learn lessons from the wave of H1N1 flu three years earlier.

The political crisis was eased for the time being by the replacement of the minister of health in 2014, by the creation of a centre and national laboratory for the control and prevention of epidemics in the country, and by a major reorganisation of preventive measures in hospitals and the holy places. Saudi medical publications which appeared in early April 2020 even concluded that “MERS-CoV was a blessing for the improvement of disease prevention and control in Saudi hospitals”.

King Salman’s address

Since March 2020 the Ministry of Health has brought to the fore the experience drawn from these successive crises. Systems for monitoring the public, and information exchange, have been improved. The minister of health’s background, with a PhD in IT, has made itself felt. A regime of tests and isolation was rapidly put in place after a heavily watched TV address on 19 March by King Salman, son of Abdulaziz Ibn Saud. The paternalistic tone of the speech, and the mass of measures taken to stem the epidemic and support the economy, the state and its institutions back at the centre of Saudi life. In a country always anxious about the security of its food supply, the minister of agriculture even announced a boost to stocks of grain and livestock. Such measures ran counter to several years of the neoliberal model pursued by Crown Prince Muhammad bin Salman with his “Vision 2030.” He has been unusually quiet since the crisis began.

As with the previous public health crises, Saudi leaders and their foreign interlocutors were particularly concerned by the situation at Mecca and Medina. While the curfew was gradually lifted in the Kingdom’s main cities, it remained in place at Mecca even at the height of Ramadhan. After the suspension of the minor pilgrimage, the ‘umrah, an extraordinary cancellation of the hajj seems to be next on the agenda. Given the economic crisis brought about by the collapse of oil prices, the decision to sacrifice the Kingdom’s second most important source of foreign currency after oil was particularly tough to take, further undermining the plans for economic diversification in which the pilgrimage revenues had an ambitious part to play.

Campaign to expel immigrants

While it was a Saudi recently returned from Iran who was officially diagnosed as the Kingdom’s first Covid-19 case, the epidemic revived the distrust felt by the majority Sunni population towards the Shia of the eastern province, and towards foreigners near (the almost 10 million expatriates) and far (the Iranian neighbours), accused of being the main sources of infection. The mainly Shia Ahsa region and the town of Qatif were the first to be quarantined, and the inhabitants particularly checked. The campaigns to expel immigrants which regularly follow epidemic crises, as in 2013–2014, took off again in April 2020. But the King’s inclusive speech of 19 March, addressed to the Kingdom’s “citizens and residents,” raised hopes of a degree of flexibility in a country where, according to 2018 figures, the majority of medical personnel are still foreigners.

The King announced that, whatever the nationality of coronavirus patients, the cost of their treatment would be borne by the state. As in other Gulf countries, the epidemic triggered articles and online debates criticising unscrupulous employers for their treatment of migrant workers and demanding greater state control in this field as well. When the first expulsions of Ethiopian workers in April provoked a storm of protest, the authorities stepped up their explanations, defending their exemplary handling of the epidemic by underlining the Kingdom’s financial and diplomatic contribution to the efforts of international institutions such as the WHO and G20, the contribution of its medical students to the battle against the virus in Europe, and the humanitarian aid provided to affected countries such as China.

As Saudi Arabia prepares for what King Salman in his address called “an even more difficult phase ahead on the global level,” questions about the future of the fantastically ambitious Vision 2030 may well already be outdated. The epidemic appears even to have provided an opportunity to settle, at least diplomatically, the continuing crisis in Yemen, with the successive announcements of a unilateral ceasefire and massive financial and humanitarian aid.

The epidemic of 2020, like that of a century ago, comes at a particularly uncomfortable economic and political time. As on the previous occasions, it brings the Saudi kingdom up against some old demons of which the people have never lost sight from one generation to the next: the extension of the state’s economic and social role, the interests guiding it in managing the sanctuaries at Mecca and Medina, the status it confers on non-Sunni Saudis and foreigners on Saudi soil, and more generally, the shape of its participation in globalisation. The Kingdom’s epidemic history suggests that once again, the public health crisis will for the Saudi state be a moment both of accelerated change and of expansion in its own role.