| Community Mental Health Delegation to Egypt
Heidi Herinckx, delegation leader
October 8 – 17, 2000
October 10, 2000
Cairo, Egypt
Behman Hospital
Behman Hospital is located in Helwan, a suburb of Cairo. We were greeted by Dr. Sheirf and then met the hospital medical director Dr. Nasser Loza. Dr. Loza gave us a historical overview of the hospital and current treatment provided. Behman Hospital started as a small private nursing home in the 1940s, and today there are 200 patient beds.
The hospital is well staffed with six psychiatrists, six psychiatrists in training, six social workers, 16 nurses, and a number of nurses’ aides. The nurses’ aides are local residence of the community served and have worked at the hospital for a number of years. Average cost per month is 6000 – 7000 pounds or 2000 – 2500 dollars US per month.
The population served is acute and chronic patients of all psychiatric disorders, neurological disorders, addictions, and geriatric patients. The hospital has an advanced Alzheimer’s inpatient unit. Heroin is the major drug of choice among drug addicts. Almost all drug addiction patients are male. The hospital has inpatient, outpatient units as well as a halfway house, and assessment center.
Most people served at Behman have private insurance funded by employers or insurance companies. The hospital serves patients from Egypt; however, patients come from all over the Middle Eastern to be treated at Behman Hospital. Usual hospital admissions are 5 – 6 weeks. Outpatient clients with psychotic disorders are seen once a month.
Dr. Loza discussed the active role that Arab families play in treatment. Because of the interdependent nature of Arab families, the patient is supported by and relies heavily on the family for support. The patient will be discharged into the community to live in a family unit, either with the parents or with a spouse. This is in sharp contrast to the U.S., where adults with serious and persistent mental illnesses are often alone, and a large portion of the support services offered upon discharge are to support the individual to achieve independent living. Community based support services are limited in Egypt.
We attended a clinical staff meeting, where Dr. Loza shared some of his research on Pharonic psychiatry and gave us a copy of his article, “Insanity on the Nile.” Dr. Loza has studied Pharonic medicine by reading hieroglyphic material on medicine, medical teachings for students, marriage laws and medical papyrus. Dr. Loza stated that in these medical historical documents, not much is written about psychiatry because these conditions did not fall into the domain of medicine but into the spiritual domain. The act of writing during Pharonic times was very symbolic. It was thought that the act of writing or documenting things was the act of keeping them to be carried on into the next world. So, another reason for the lack of documentation of psychiatric problems may have been an active attempt to rid people of their existence. References to “disabilities of the heart” read in context seem to indicate depression and “kneeling of the mind” to dementia or psychosis. There is evidence that Pharonic society felt that those with disabilities were to be protected as was written, “You will not poke fun of the man who is between the hands of Gods.”
The delegation and staff of Behman Hospital held an informal discussion and reception in the courtyard of the Hospital followed by a tour of the facilities. Behman Hospital offers a therapeutic environment, well-maintained gardens, and recreational areas. The delegation was impressed by the warmth and beauty of Behman.
Egyptian Association for Psychological Studies, Ain Shams University
We met with the Director of the Psychiatric Institute, Dr. Abel Sadek, and Dr. Abdel Nasser, Assistant Professor, two psychiatric nurses and other staff members. Ain Shams University houses a government hospital, providing both inpatient and outpatient services. The inpatient unit has 80 beds, of which 55 are public beds or “free” beds, and 25 of which are private or “paid” beds. This public mental hospital serves a catchment area of 4 – 6 million, in Heliopolis, Cairo and Giza. A broad base of patients is served including addictions, psychiatric and neurological diagnoses, geriatric patients and children. The university provides an extensive range of services including brain imaging, counseling, group psychotherapy, rehabilitative services, substance abuse detoxification and rehabilitation. The children’s services provided are also extensive. Medications as well as all services are provided for free. The government covers a portion of the costs, but the other portion is covered by philanthropic donations. Medications provided include the most state-of-the-art medications, atypical anti-psychotics and others. Because drugs are provided for free, and are so costly, the university is not able to keep up with demand and there is often a shortage of needed drugs.
The psychiatric unit at Ain Shams University conducts research in geriatric psychiatry, psychophysiology, neurological and sleep disorders. The institute has a biological focus with many research projects undertaken by junior faculty. There is a new geriatric psychiatry unit with a dementia and memory clinic.
A lively discussion focused on the role and function of a clinical social worker on a multidisciplinary treatment team. It seems that the role and function of social workers in Egypt are limited in scope to the equivalent of case managers in the U.S., i.e. individuals who coordinate the social aspects of care. However, not much treatment is delivered in the community. It is rare for the case manager to see patients in the community. When social workers do conduct work in the community it is seen as above the call of duty and they are not necessarily paid for this time. The members of the delegation, who are clinical social workers, explained the role of clinical social work in the U.S. This included the training and certification requirements, the skills and ability to conduct clinical assessments, and the similarities and differences between the role of a psychiatrist and clinical social worker on a treatment team. We learned later at the World Psychiatric Association Mental Health Conference that Egypt does not have clinical social workers. This explained some to the confusion and surprise on the part of our Egyptian colleagues about the role of clinical social workers.
We concluded the visit with a brief tour of the children’s clinic, which primarily works with Autistic children.
World Psychiatric Association Conference, “Mental Health Policy and Economics in Arab Countries & Sub-Saharan Africa,” Plenary Session, Arab League Building
Dr. Ahmed Okasha, President Elect of the World Psychiatric Association (WPA), who is Egyptian, presided over the Plenary Session. He has published over 250 articles on mental health and was editor of the Egyptian Journal of Psychiatry.
Dr. Okasha began the Plenary Session by expressing the mental health needs in the Arab world. He presented data from the World Health Organization and the United Nations. There are 22 countries in the Arab League. The mental health needs of the Arab world are incompatible with existing financial resources. On average Arab countries spend 15% of their GNP on weapons. Arab countries spend much less on health and education; over twice the money is spent on arms than on education and health. Egypt for example spends 1.8% of its GNP on health and 4.8% on education Worldwide, 170 billion dollars is spent on health care each year. Ninety percent (90%) is spent in the industrialized or first world countries, which only represent 20% of the world’s population.
The United Nations has created a Human Development Index from measures including literacy, education, health, and well-being, mortality rates, infant birth weights, etc. (174 countries have been assessed and ranked using this index) The High Development Arab countries include Kuwait, Bahrain, the United Arab Emirates and Saudi Arabia. Egypt ranks in the middle range. Egypt has a 53% literacy rate. There is an inverse relationship between cigarette smoking and ranking on the human development index.
Egypt has four journals of mental health and three mental health associations. Egypt has the most mental health professionals, psychiatrists, psychologists, social workers, and psychiatric nurses of any other Arab country. However, Dr. Okasha emphasized that there are no clinical social workers in Egypt and that there is a great need for them. Traditional and religious healers are not generally considered part of the psychiatric treatment team but are used actively. In 1944, Egypt passed the Mental Health Act. Mental health needs to be met in Egypt are:
· Increased community based mental health services
· Increased public awareness of psychiatric disorders and decreased stigma
· Increased training by General Practitioners
· Increased drug abuse treatment programs
At least in Egypt, Dr. Okasha stated that training of specialized mental health staff is happening and is not a top priority need. Therefore the number one priority for raising the quality of mental health services in Egypt is increasing mental health resources primarily by providing mental health services integrated as part of general health care not through specialized care.
Dr. Satorius next presented on the impact of mental health on society. Dr. Satorius presented a theoretical framework, which discussed a society’s capital in terms of economic capital, human capital and social capital. Social capital is the public good that results from mutual supportive relationships between members of society. No one can possess it, but everyone can contribute to it, and everyone can benefit from it. Social capital contributes to the wealth of a society. Social capital and economic capital do not co-vary. If anything, there appears to be an inverse relationship between the two. It seems that as a society has more economic capital, people believe everything is to be bought and sold and that generosity and goodwill declines. It would be useful to develop a technique for how to measure social capital.
Mental disorders decrease human capital creating losses in economic capital for a society. The needs of the mentally ill that need to be addressed by society include:
· Recognition as human beings, individuals not as a diagnosis
· Access to the mental health services they need
· Acceptance of their unavoidable abnormalities
· Opportunities to use their assets
· To maintain their self-respect
· To learn to live with disease or impairment
Mental health interventions can prevent disability and increase a society’s human and economic capital. However, social stigma is the biggest barrier to meeting the needs of the mentally ill and to investing more in mental health services.
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