'Entitled to a decent life'

By Gihan Shahine

Answering the wake-up call: the changes to the five hospitals transferred to the jurisdiction of the Ministry of Health are greater than a coat of paint and a volley-ball court; but a shortage of financial resources and qualified, empathetic staff may impede real, long-term change for the better photo:Antoune Albert

As a cool summer breeze blows gently, the sun drifts slowly down toward the horizon. Music is playing, and the patients, lined up in two groups, men in one and women in the other, prepare for the party. Some clap, others take a few tentative steps in time to the music. Many, however, are immobile and inexpressive. The hospital's medical and nursing staff watch from a distance, satisfied smiles playing across their lips.

"Thank you very much for the changes," says one patient, delivering a speech specially prepared for the party. "The development of the hospital means that mental patients are accounted for. It is also a sign of a general consensus that mental patients are entitled to a decent life."

Another patient adds: "The recent changes are perfect," and gives the doctors a thumbs-up sign.

Not long ago, the very idea of a "decent life" was a contradiction in terms for many mental patients. Dr Hamdi El-Sayed, the chairman of the Doctors' Syndicate, speaking at a Peoples' Assembly Health Committee meeting, maintained that "mental health care is largely neglected in Egypt; patients in state-run mental hospitals are treated like animals."

High mortality rates and brutal treatment, especially by the nursing staff, form the backbone of the horror stories. Malnutrition, insufficient medical care, lack of space, and poor equipment and utilities have all made life difficult, to say the least, inside public mental hospitals.

Today, the picture is not as dim. Mental health came into public and official focus last September when two brothers fire-bombed a tourist bus as it was parked in front of Cairo's Egyptian Museum, killing nine German tourists and their Egyptian driver. One of the brothers, Saber Farahat, had been responsible for a 1993 terrorist attack in Cairo's Semiramis Hotel. Farahat was never put on trial at the time because an examination by psychiatrists at the government Abbasiya Mental Hospital confirmed that he was schizophrenic. Consequently, he was confined to the Al-Khanka Mental Hospital as of 27 January 1994.

The investigation into the bus attack revealed that Farahat used to bribe doctors and nurses at the Al-Khanka Hospital to allow him to leave and return at his own free will. It was on one of these hospital leaves that he and his brother conducted their attack on the tourist bus. Farahat, who has since been condemned to death, had also told interrogation authorities that he had bought the certificate confirming his disturbed mental state for LE50,000.

In reaction, a presidential decree was immediately issued, removing five public mental hospitals -- those of Al-Abbasiya, Al-Khanka, Heliopolis, Helwan and Al-Ma'moura -- from the jurisdiction of local councils and placing them under the jurisdiction of the Ministry of Health instead.

Since then, the ministry has launched a LE40 million plan to upgrade services in these five hospitals, which currently house some 8,500 patients, and to tighten regulations pertaining to admittance and home leaves.

The first move was implemented at Abbasiya. Prime Minister Kamal El-Ganzouri and Minister of Health and Population Dr Ismail Sallam recently inaugurated the portion -- around 40 per cent -- of the hospital infrastructure that has been upgraded. The project, worth LE5 million, is the first part of a two-phase plan to upgrade the infrastructure and services of Abbasiya, and a small part of a long-term plan to improve care in the five Ministry of Health-affiliated hospitals.

To visitors who knew the old hospital, the newly refurbished men's section of Abbasiya is breathtaking. To an outside observer, the tiled entrance of the new section looks like part of a five-star hotel. The 15,000 square metres of greenery are well laid out; tree-lined promenades are well paved, lined with lamp-posts and dotted with seats for a brief rest.

Today, patients can enjoy football and basketball games in four new playing fields, or indulge in some table tennis in a special hall. Less active patients may also watch TV or doze on a bench in the garden. Those who are confined to their beds can still gaze at the gardens from the windows of the new navy-blue wards.

Patients, furthermore, will no longer have to fight over beds or bathrooms. The new wards are furnished with 200 additional beds and sewage networks have been upgraded. A new health care centre with X-ray facilities has also been built and the establishment of a medical centre and a sleep lab are well underway, officials say. Upgrading the women's wards, as well as some of the remaining men's wards, is the next stage of the project, which should add another 800 beds to the hospital's capacity, says Mustafa Fahmi, the new director. "The changes made at Abbasiya mean a new beginning in the lives of mental patients," Fahmi asserts. The Abbasiya Mental Hospital was built in 1850, and almost no restoration work has been carried out since then. "When the project is complete, it will be one of the world's most up-to-date mental health care establishments. The upgraded sections of the hospital are a far cry from their original state," he notes.

Fahmi explains that in the old wards, around 30 patients had to share two bathrooms, and patients sometimes slept two to a bed. Fresh food as well as medical supplies and services were lacking. Entertainment, a necessary part of therapy, was completely overlooked.

Fahmi's words are amply illustrated by the section of the hospital that has not benefited from the upgrade. The yellow wards are shabby and windowless. The buildings are floundering under the dual onslaught of over-taxed, outdated sewage networks and dirt.

Dr Kamal El-Fawwal, the head of Al-Ma'moura Mental Hospital, and Dr Bahaa Osman, the head of Al-Khanka, also pride themselves on recent changes. The ministry has allocated LE20 million a year to upgrading the infrastructure of the mental hospitals affiliated to it, El-Fawwal notes.

At Al-Ma'moura Hospital, the construction of new wards for female patients, estimated at LE1.5 million, is underway. "The hospital has changed radically, in terms of buildings and services," says El-Fawwal. "It is becoming one of the most modern hospitals in Egypt."

Osman is equally enthusiastic about the changes currently taking place at Al-Khanka. Following the Tahrir bombing, security measures at Al-Khanka came into the limelight. Now the hospital is subject to tighter security control, and a fence encircles the hospital where none stood before. Home leaves for convicts receiving psychiatric treatment are now prohibited, and the development of infrastructure and buildings is ongoing.

"At least now our patients have new, clean clothes, are provided with plenty of healthy food, have cold and hot water any time, and can play sports and enjoy all sorts of entertainment," Osman notes.

Many psychiatrists are thrilled at the development. "The government's strategy is in keeping with the global trend to integrate patients into society by establishing well-equipped psychiatric hospitals inside the urban centres," says Gamal Madi Abul-Azayem, a psychiatrist who headed Al-Abbasiya for ten years. "Entertainment and greenery are major parts of therapy. This way, government-run hospitals will soon catch up with the latest progress in psychiatric care."

But for the ministry's strategy to attain the desired goals, many believe other elements should be taken into account. "The recent focus on psychiatric hospitals is positive, no doubt. Yet financial resources are short," says head of the Doctors' Syndicate Hamdi El-Sayed. The People's Assembly health committee has demanded that LE45 million be put aside to meet mental patients' daily needs. "But the government has allocated only LE6 million a year instead, which hardly covers very basic food, medicine and clothes," El-Sayed complains.

Both psychiatrist Dr Yehia El-Rakhawi and El-Sayed also agree that human resources can make or break reforms.

"It is common knowledge that mental patients are ill-treated by the nurses, and sometimes by doctors as well. The majority of staff are not qualified to deal with mental patients," El-Sayed explains.

El-Rakhawi agrees: "The reform of Al-Abbasiya is far more than we expected, but less than we could hope for. The real problem, which cannot be remedied with more money or cleaner buildings, is the efficiency and training of the physicians and the nursing staff. A real effort is being made in this domain, but I think more is needed for the staff to become qualified."

According to Dr Ahmed Okasha, professor of psychiatry at Ain Shams University and president of the Egyptian Psychiatric Association, there are only about 500 to 600 psychiatrists in Egypt. About 300 of them are still interns. The World Health Organisation recommends a ratio of one psychiatrist to every 10,000 people. In Egypt, however, there is only one psychiatrist per 200,000.

At Al-Abbasiya, which houses 2,000 patients, there are only seven psychiatrists, 13 assistants, and 22 interns. At Al-Khanka, 12 doctors care for 1,300 to 1,400 patients.

Osman attributes the shortage in the number of psychiatrists to the fact that "psychiatry is overlooked in the university curriculum, and is not even included in the post-graduate training year."

A lack of financial incentives has also driven many of Egypt's qualified psychiatrists to accept contracts in Gulf countries, and many nursing students to avoid working in the field.

To solve the problem, the ministry has made salary adjustments and offers incentives to the staff of public psychiatric hospitals. Every hospital now has its affiliated nursing school, providing specialised training for nurses.

"I think that in the very near future, many doctors and nurses will start to specialise in the field," says Fahmi. Osman quickly adds that incentives have raised the morale of the staff, especially the nurses, who are traditionally underpaid. This improvement, in turn, has reflected on the way they treat patients.

"We also have a complaint box in every ward for the patients and their relatives. I collect all the complaints myself, study them, and start investigating and questioning staff. The strategy has proved successful and now I feel that patients are better treated than before," Osman says.

Problems, however, remain. The lax conditions prevailing in some hospitals until recently mean that several patients may have simply walked out and are now roaming the streets, disoriented and deprived of medication. In 1992, many hospitals released large numbers of patients, having declared them cured, because there were not enough beds available. According to press reports, more than 800 patients were released at the time. Now, these patients can only be taken in if they are picked up by the police. "We have no legal authority to admit potential patients to hospitals, even if we are sure they need medical care," says Osman. Only the police can refer individuals to a hospital for evaluation and observation. If the evaluation reveals a psychiatric problem, admittance follows. But Osman believes the problem will only be solved if "psychiatrists are given some authority in admitting patients".

According to the most recent statistics, there are only 14 psychiatric hospital beds per 100,000 people in Egypt. This is one of the lowest rates world-wide.

The government's new strategy aims at making more beds available, and numbers have, indeed, begun to increase. But this has not solved the problem. "We don't have enough beds because mental patients spend long years, if not their whole lives, in hospitals, leaving almost no room for newcomers. Relatives usually abandon patients, for mental illness is seen as a stigma. But for the government's strategy to succeed, the media, NGOs, private clinics, schools and universities should join forces to change public attitudes towards mental patients. Only then can we speak of a new beginning for them," concludes Abul-Azayem.