Psychiatric services in Egypt - an update.

For over a thousand years, the Hippocratic system of medicine prevailed in Europe. It went into oblivion during the Dark Ages, when there was a reversion to the demoniacal theories of mental illness. Hippocrates' works survived, however, in the library at Alexandria, where they were translated into Arabic. These and other classical works were retranslated into Latin and Greek from the 12th century on, ushering in the Renaissance.

Around 1284 CE, the Sultan of Egypt, Al Mansour Kalawoon, bequeathed one of his palaces in Cairo for the construction of a general hospital with a department of psychiatry. It soon became one of the most famous hospitals throughout the Islamic world. It was, and still is, known as Dar Al Shefa, literally the House of Healing (Okasha et al, 1993). Two features were remarkable for that era: the care of mental patients in a general hospital, and the involvement of the community in the welfare of the patients, which foreshadowed modern trends by six centuries (Baasher, 1975).

The mentally disturbed usually received baths, fomentation, compresses, bandaging and massage with various oils. Blood-letting, cupping and cautery were also widely used. A familiar term for an antidepressant in the medieval period was mufarrih an-nafs, ‘gladdening of the spirit’. Those suffering from insomnia would be placed in a separate hall to listen to harmonious music and to hear skilled story-tellers recite their tales (Buergel, 1975; Dols, 1992).

Mental health resources

Today, the population of Egypt is around 61 000 000 (National Information Centre, 1997). There is one psychiatric bed for every 6000 citizens; psychiatric hospital beds represent less than 10% of the total. These are largely concentrated in Cairo, bringing the ratio there to 1 bed per 2200 – the four public psychiatric hospitals in Cairo provide 5800 beds, and the remaining 1200 beds are distributed over the rest of Egypt (Ministry of Health, 1998). Psychiatric hospitals are currently experiencing difficulties in the provision of care, treatment and rehabilitation, as they have limited resources.

Egypt has one psychiatrist for every 130 000 citizens, compared with one physician for every 500. Clinical psychologists total around 250 in the whole country, most of them also concentrated in the capital. The nurses working in the mental health field are general nurses – most have little or no training in psychiatric care. The more highly qualified nurses graduating in Egypt generally prefer to work abroad, often in the Gulf, where remuneration is much higher. There are many social workers practising in all psychiatric facilities, but they are mostly generic social workers, who have minimal graduate training in psychiatric social work. There is no training for occupational therapy in Egypt (Okasha & Karam, 1998).

Training

There are 13 medical schools in Egypt, each with a department of psychiatry (mainly providing out-patient services). Undergraduate training in psychiatry is often limited to a few days in the curriculum. There is a 4-year postgraduate psychiatric training programme in several of these schools. In 1948, Cairo University started a diploma in psychological medicine and neurology.

Health expenditure

According to United Nations Development Programme (UNDP), health expenditure, estimated as a percentage of gross domestic product (GDP), is 1% in Egypt. This is far below the minimum expenditure of 5% of GDP recommended by the World Health Organization, and may be compared with 13.7% in the USA (World Health Organization, 1996). The Ministry of Health budget constitutes 1.9% of the national budget (Ministry of Health, 1998). The allocation of resources is directed towards endemic problems such as malnutrition, parasitic infestations (e.g. bilharzia), tuberculosis and maternal and child morbidity.

Around 1284 CE, the Sultan of Egypt, Al Mansour Kalawoon, bequeathed one of his palaces in Cairo for the construction of a general hospital with a department of psychiatry.

In a postal survey conducted by Okasha & Karam (1998) looking at psychiatric services in several Arab countries, there was a consensus among Arab psychiatrists about the need for:

public mental health education

an increase in the number of psychiatrists

upgrading of the training and education of mental health professionals

the development of preventive and community mental health care services.

Research in Egypt

Egypt is the most productive country in the Middle East in terms of the number of articles published per year over the past 30 years (176 articles). However, using another method of measuring research productivity – the number of articles per million of the population – Egypt would rank average to low (1.5 articles per million).

The region seems to lack a strategic, policy-oriented position on the research agenda. Furthermore, funding for academic research is limited and depends on the interests of the different financing organisations. On the other hand, collaboration between different centres at the Arab, regional or international level will doubtless contribute to the development of research in the Arab world (Okasha & Karam, 1998).

Collaboration between different centres at the Arab, regional or international level will doubtless contribute to the development of research in the Arab world.

Policies and future directions

Egypt has a Mental Health Act dating back to 1944 and a documented health policy. Four years ago, the Ministry of Health adopted a new strategy, of centralisation of mental health services. In collaboration with several international agencies, this has facilitated the implementation of several projects to upgrade mental health services:

a Finnish project on human resource development and the introduction of community-based services

a UNDP project that concentrates on improving treatment services and rehabilitation for addiction

a World Health Organization project on the inclusion of psychiatry in primary care services, as well as support for community-based services.

Mental health and culture

As in the majority of developing countries, patients tend to present with somatic psychological symptoms. This presentation of mental ill health is reflected in the pattern of consultation. Patients tend to pass through different health care ‘filters’ before they reach psychiatric clinics and hospitals. According to Goldberg & Huxley (1992), almost two-thirds of patients with psychiatric symptoms attend only their general practitioner, and only 50% of those would be recognised as having a psychiatric disorder.

In this context, traditional and religious healers play a major role in primary psychiatric care in Egypt. They deal with minor neurotic, psychosomatic and transitory psychotic states using religious and group psychotherapies, suggestion and devices such as amulets and incantations (Okasha, 1966). It was estimated that 60% of out-patients at the university clinic in Cairo, which generally serves people from low socio-economic classes, have been to traditional healers before attending a psychiatrist (Okasha & Hassan, 1968). In rural areas, community care is implemented without the need for health care workers. Egyptians, especially those living in the countryside, have a special tolerance of mental disorders and an ability to assimilate those with a chronic mental illness. For example, these patients, and those with mild or moderate learning disabilities, may cultivate crops along with, and under the supervision of, family members.

Traditional and religious healers play a major role in primary psychiatric care in Egypt. They deal with minor neurotic, psychosomatic and transitory psychotic states using religious and group psychotherapies, suggestion and devices such as amulets and incantations.

Thus, the real challenge for mental health professionals is the first filter, that is, patients acknowledging their mental health problems. However, this challenge cannot be met without a reorganisation of both the health-providing structures and the approach to medical education and training. The latter cannot be systemically tackled without the guidance of action-oriented and policy-oriented research.