(a) Sickle cell disease and sickle celI trait with or without associated Thalassaemia is very common in Arab population. Since this has been adequately discussed in the standard text books of medicine, I do not wish to go into the details of these except the following remarks:—

Most of the "sicklers" have already been diagnosed in their countries. It will be very unlikely that a patient having severe abdominal pain due to sickling crisis will be misdiagnosed by a specialist here, because nearly always the information has been given to him by his doctors back at home. Although once in a while I have seen florid bone manifestations of sickle cell disease, it is otherwise very unlikely for a patient of joint pain or joint disease to have undiagnosed sickle cell disease as a cause. Since most of the patients do not come along with their families (which are always large), detailed work up of this disease cannot be carried out.

As mentioned elsewhere, Arabs dislike 'long-term' therapy. Off and on, I see an Arab with sickle cell disease or Thalassaemia, who has discontinued folic acid tablets or sodabicarb. I have to coax him to start this treatment again.

(b) Iron deficiency anaemia—it is surprising that while underweight, wasted, Yemenis men and women have near normal blood counts, off and on, iron deficiency anaemia is seen in obese Bahraini women. Interestingly these women apply such a face make-up and look so pink that they could misguide any layman. Also their nails are polished and in some Arabs the palms are coloured with "Mehendi" (applied for cooling effects) (see fig. alongside). So anaemia has to be picked up only by examination of tongue, palate and palpebral coniunctiva. Some of these women do lose more blood during menstrual periods, but others do not. Dietetic cause of this anaemia is unlikely because the diet is not very different elsewhere in the Arab countries

Leucopenia

A lower total white cell count is seen in many Arab patients In nearly 10% patients, the total W.B.C. count is below five thousand, and off and on even less than 4000/cmm. These findings are observed in absolutely normal Arab population

Lymphocytosis

This condition is seen in as many as 20% of normal Arab patients with normal total white cell count. Off and on I have seen a physician's report, where even the bone marrow examination was asked for because of a severe Iymphocvtosis!

G6PD deficiency

So common is this condition in Arab population that in some of the areas in Saudi Arabia and U.A.E., more than 30% of the patients will show evidence of this deficiency (in the text books, for some areas of Saudi, the figures are as high as 60 percent). in general, in Arabs, the incidence is about 10 to 20 percent. In patients having sickle cell trait, G6PD deficiency is more commonly seen.

It is worthwhile asking for this test in the following type of Arab patients:

1. Having anaemia.
2. Having raised reticulocyte count on a routine blood examination.
3. Having slightly increased indirect reacting bilirubin seen on S.M.A. 12/60 examination
4. Who would be undergoing any surgical procedure (where he would certainly need plenty of pre and post-operative drugs).
5. Showing elevated L.D.H. levels on a routine S.M.A. 12/60 examination.
6. In whom malaria is suspected (e.g. in patients developing pyrexia after a blood transfusion) or malarial parasites are seen and who, therefore, are likely to be administered antimalarial therapy.

I observed that many of these patients land up with general practitioners in Bombay, who have administered to them a lot of drugs and injections (incidentally many Arabs specially from Yemen, Oman and Saudi, are fond of "injection therapy"). Also a number of these patients of G6PD deficiency get operated upon in private nursing homes and hospitals and are administered multiple drug therapy during their hospitalization. And yet I did not see a single case of "frank" haemolysis with clinical manifestation of haemoglobinuria and jaundice, which I see in Indian subcornmunities, having G6PD deficiency.

During a recent study on the pattern of distribution of glutathione transferase enzyme in the red blood cells, in our laboratory at Jaslok Hospital, it was noticed that this enzyme is in much higher concentration in the red blood cells of Arabs.

Thus, it is possible that this enzyme protects the red blood cells against massive haemolysis. which does not take place in this population.

In conclusion, G6PD deficiency though very common in Arab community, is of the "benign" type.