Abstract
In 2009, Egypt adopted the “Law for the Care of Mental Patients,” a rights-based legislation intended to bring the country’s mental health system—otherwise defined by resource gaps and chronic underfunding—closer to global standards of care. Yet, the new act stirred dissension among Egyptian psychiatrists. And, in the immediate aftermath of the 2011 uprising, debates about the 2009 law became intertwined with debates about the present and future of the ‘new Egypt.’ Based on field research in Cairo, this article provides an ethnographic analysis of the making of this mental health act and of the ensuing debates as they unfolded in 2011–2012. Showing the diverging perspectives at the core of these debates on psychiatric power, patient rights, and the law’s fit in society, the article highlights the challenges of psychiatric reform in a country of the Global South. It also argues that in a context of revolutionary upheaval, debates about psychiatric reform become a site for political reflection and provide a language for imagining the future of the nation. The article also highlights the centrality of temporality in debating psychiatric reform in times of political transformation.
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Notes
For more on the events that followed the first 18 days of the Egyptian uprising, see Armbrust (2019, pp. xix–xxii).
The data at the basis of this article were collected as part of a broader research project that examined therapeutic debates at the intersection of Islamic revivalist exorcism and psychiatry. For that project, I conducted qualitative interviews with over 30 mental health professionals from both the public and the private sector and carried out observations in the outpatient clinic and female wards of ‘Abbasiyya, Egypt’s oldest mental health hospital. All these interviews touched upon the 2009 mental health act, which I also discussed in detail over several interviews with 5 close interlocutors among psychiatrists. In addition to the above-mentioned psychiatric conference, I also attended several meetings of the group “Psychiatrists of the Revolution,” briefly discussed later in the article.
Official Gazette, May 14, 2009, no. 20.
See https://www.eipr.org/en Egyptian Initiative for Personal Rights (eipr.org). Last accessed November 10, 2022.
The history of private psychiatric practice in Egypt began in the 1930s when foreign nationals opened hospitals in Cairo and Alexandria. Of those, the only one still standing is currently directed by Dr. Nasser Loza, the initiator of the 2009 mental health act (Mayers, 1984, pp. 209–210 and our history—The Behman hospital Last Accessed August 18, 2021). The 2006 WHO report mentions seven private psychiatric hospitals in Cairo with approximately 760 beds (WHO, 2006b, p. 111).
An effect of this marginalization has been the reduction of clinical psychology in public hospital settings to testing (Mayers, 1984, p. 223). It has also meant that Egyptian psychiatry has not undergone the same turn from psychoanalysis to neurobiological psychiatry that has shaped US and European psychiatry since the 1980s.
These have led to dilapidated public hospitals, inadequate health coverage, increasing out-of-pocket expenditures, corruption and negligence, as well as a widening gap between public and private services.
For example, between 1974 and 1981, Egypt was one of the centers of a WHO project to integrate mental health into primary care (WHO, 2006b, p. 109). In 2002, a bilateral development program between Egypt and Finland had the goal of improving mental health delivery and mental welfare (Jenkins et al., 2010; WHO, 2006b, p. 114).
While the UN’s CRPD was mentioned in reports around the draft legislation, such as EIPR’s (EIPR, 2009a), my interlocutors did not make any reference to it during our conversations. An exception was Dr. Ragia Elgerzawy, who considered that seeing mental disorder through a disability lens was still incipient in Egypt at the time.
A few also mentioned that the law would put Egypt at the forefront of other countries in the Middle East, which either lack any kind of legal framework, have fragmented rules, or have not updated their legislations in decades (e.g., Kerbage et al., 2016; Okasha et al., 2012; Sarhan & Alqam, 2018). Yet, most of my interlocutors barely made any references to neighboring countries, a reflection of the Euro-American orientation of Egyptian psychiatry.
Other important provisions are the obligation to notify the Council of Mental Health of involuntary admissions, as well as the Public Prosecutor’s office within 24 h of an involuntary admission made by a nonspecialized physician or in a non-emergency case. Compulsory admissions must be independently reviewed within 7 days of admission and such decisions can be appealed by patients and other parties in local courts. For an overview of the law’s regulations concerning compulsory admission and treatment, see Zaky (2009).
They criticized the lack of time limits for supervisory councils’ assessment of involuntary admissions, the absence of oversight during patients’ forced transfer, and unclear parameters for treatment in emergency cases (EIPR and El Nadeem Center, 2009, pp. 2–4).
The most criticized aspects were the subordination of psychotherapy under psychiatric authority and the allowance of two compulsory ECT treatments without independent assessment (Loza, 2021).
They were released after international outcry https://www.reuters.com/article/us-egypt-rights/egypt-to-free-members-of-leading-rights-group-sources-state-media-idUSKBN28D2JO (see Egypt frees members of leading rights group | Reuters Last Accessed June 2, 2021).
The criteria for compulsory admission and treatment were also debated before the law’s passing, in the drafting period and during parliamentary discussions (Zaky, 2009, p. 58).
The names of my interlocutors that include only the first name are pseudonyms.
A similar framing of opposition to the law as a form of patriarchal power is found in one of the few articles that mention the debates around the 2009 law prior to the uprising, co-authored by Dr. Nasser Loza—the law’s initiator himself (Loza & El Nawawi, 2012, p. 65).
For similar positions within US community psychiatry, see Brodwin (2013).
While the private and public psychiatric spheres are stratified by resources and capacities, medical professionals are not bound to one domain; they frequently move between them or work simultaneously in both.
See, for example https://maganin.com/content.asp?ContentID=18983بيان ائتلاف نفسانيون من أجل الثورة (maganin.com) Last Accessed November 9, 2022.
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Acknowledgements
Most of all, I am grateful to all the Egyptians who shared their thoughts and opinions about the 2009 Mental Health Act with me. Many people have contributed to this article with comments and suggestions, or by just lending an ear. My thanks go especially to Soraya Altorki, Ali Atef, Christopher Dole, Zhiying Ma, Lamia Moghnieh, Daniel Moseley, Ellen Rubinstein, Christine Sargent, and Kym Weed. I am also grateful for the thoughtful engagement of two anonymous reviewers and the journal’s editor.
Funding
The research on which this paper is based was funded by the National Science Foundation (# 1022063) and the Wenner Gren Foundation for Anthropological Research (# 8228).
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The research on which this paper is based was approved by the IRB office at the Graduate Center, City University of New York (# 10-06-152-0135). Verbal informed consent was obtained from all individual participants included in the study.
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Vinea, A. Psychiatry, Law, and Revolution: A View from Egypt. Cult Med Psychiatry (2023). https://doi.org/10.1007/s11013-023-09837-1
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DOI: https://doi.org/10.1007/s11013-023-09837-1