On May 18th 2018, Mohamed Awad, a doctor in Sahel Teaching Hospital got beaten by one of the patient’s family members; it was claimed that the patient’s family could not find a place in the emergency room. The incident left Awad with a fractured nose. On January 28th 2016, two doctors got assaulted by police officers after one of the doctors, Moamen Abdel-Azzem, refused to fabricate a medical report for one of the officers in Matariya Hospital.
According to many doctors, beatings by angry patients constitute the daily reality of any doctor working in any public hospital in Egypt, from Cairo to Alexandria to Sharqia and other governorates. However, these incidents rarely get any coverage, and there hasn’t been concrete steps to solve the root of the issue, simply because it hasn’t been identified yet.
In an email interview with Egyptian Streets, Soha Bayoumi, a lecturer in the Department of the History of Science at Harvard University, whose research addresses the question of social justice with a focus on health in the Middle East, said that the official media discourse has been blaming doctors for the deteriorating state of healthcare in public hospitals, while completely ignoring the objective circumstances under which those physicians are operating.
In other occasions, the blame is mainly put on the patients whose behaviour should be changed; “they should be less violent and learn how to manage their anger” some citizens comment.“It’s just the natural behaviour of the Egyptian patients” social media users remark, “patients in any civilized country would not go about attacking doctors” they say.
However, the important questions remain unasked: why are these patients angry in the first place? Are there concrete steps to be taken by the authorities to avoid the escalation of violence? Are the hospital services in Egypt comparable with those of the other supposedly ‘civilized’ countries to draw broad conclusions about the ‘nature’ of Egyptian patients?
Over the ages, and across many cultures, being a doctor has been one of the most venerated jobs. In Egypt, the faculty of medicine is the most difficult to get into, with millions of students across the country dedicating a huge portion of their time and efforts to get the almost perfect score in their secondary education.
In accordance to society’s good image of the profession, they are enticed by the promises of prestige, ability to help others, save lives and potential good monetary reward that would be accessed throughout their long and tortuous careers as doctors.
But little do most realize about the actual conditions of doctors who work in the public sector.
Egyptian Streets spoke with a couple of doctors who engage and/or witness these daily brawls with angry patients to let them talk about their first hand experience, and get to know the possible reasons behind the recurrent violent incidents. This was done in the hopes of pinpointing the core reason behind violence against doctors in Egyptian public hospitals through speaking with those who experience the daily routine of public hospital life and are in direct contact with the available resources in the pertinent medical facilities.
“There are punches every single day. You have to be aggressive to go through your shift”, says Walid Attiah to Egyptian Streets. Attiah is a senior resident Internist in Zagazig University Hospital, he was of the top 100 students of his cohort, and was thus chosen to be part of the academic staff of Zagazig University.
According to Attiah, Zagazig University Hospital, which is of reasonable quality compared to neighbouring governorates’ public health facilities, is supposed to serve a total population of 25 million people from Egypt’s eastern border to Sharqia governorate. Despite the huge number of people it is given the task of tending to, it only has 59 beds in the intensive care with nine of them being accessible only after paying around 1000LE (almost 56$).
According to Attiah, the reasons as to why patients and their families become angry and violent can be attributed to several reasons: they could be diagnosed as psychotic, and this increases their tendency to violence. Or, more realistically, they find no places in the hospital, nor the necessary basic resources to get treated, so they become desperate.
In 2016, the Zagazig University Hospital had shortage of glucose solutions and Insulin, both of which are considered two core substances in any medical facility.
“Patients sometimes had to buy saline solutions at their own personal expenses for 15 LE(0.84$), instead of the regular price of 3 LE(0.17$)” explained Attiah before adding that the University Hospital is supposed to deliver treatment free of charge.
In the same governorate, Roaa Youssry, who works as a sub-senior resident dermatologist in Zagazig General Hospital, corroborated Attiah’s account.
“Violence against doctors does not differentiate between males and females; a newly appointed female doctor was followed in the on-call room, where she was supposed to rest, and was physically attacked,” she tells Egyptian Streets.
Roaa also recounts the story of a personal friend of hers who works in Kafr El Sheikh General Hospital; the friend was left with a broken jaw broke after she was punched by an angry patient.
The root cause?
In a Facebook post in July, Doctor Mona Mina, the former deputy head of the Doctor’s Syndicate addressed a common view held by the patients, delineating the common excuses made by the doctors which usually result in the patient’s outrage, such as: “bring the plaster and cotton from outside [the hospital]”, “the operation has been postponed due to the lack of utilities”, “buy the syringes from outside [the hospital]”.
Dr. Mina has contributed in leading the 2016 doctors’ strike which had been sparked following the brutal attack of a police officer on a doctor in Matariya hospital after the doctor refused fabricating a medical report for the officer.
The incident garnered both national and international criticism.
In her Facebook post, she relates the inability of the doctors to provide the basic services to the low governmental budget dedicated for the health sector. She adds that “both the doctors and the patients are victims” of the unconstitutionally low health budget, thus the anger should be directed at the system which harms both.
According to Article 18 of the Egyptian constitution, “the [Egyptian] nation is committed to to public spending on healthcare with a minimum of 3% of the Gross National Product (GNP)”. However, a report by the Egyptian Initiative for Personal Rights shows that in the year 2017-2018, the actual money spent on health ranges around 1.3% of the GNP, which is also lower than the amount spent in 2016-2017 (both being unconstitutional), needing a total additional spending of 68 billion LE to meet the minimum constitutional requirements.
The numbers obtained through the Egyptian Initiative of Personal Rights (EIPR) are usually contested by critics of the report. They claim that the alleged 1.3% of the GNP do not include the spending on providing drinking water and drainage to the public hospitals, thus the unconstitutionality of the public spending is false. However, Dr. Mina points out that the money spent on providing drinking water and drainage should be part of the state’s general spending on public facilities, not part of the state spending on the health sector.
Even if the constitutional levels of spending are to be met, Prof. Bayoumi tells Egyptians streets that the country would “need to double that [spending] percentage in order to have a functioning healthcare system that provides universal healthcare coverage”.
Other health professionals have a different take on the issue. Dr. Mohamed Nasr, the head of Doctors’ Syndicate of Gizeh told Egyptian Streets that there are other factors that contribute to the violence against doctors. Dr. Nasr claims that the “lack of general awareness about the likelihood of complications during or post operations” results in the patients’ family members directing all their anger at the doctor who performed the operation in case the patient did not improve.
In other cases, Dr. Nasr believes that doctors sometimes “don’t take an emotionally intelligent approach to contain the anger of the patient”. This is why he suggested that that doctors should take special trainings on dealing with the patient’s families in an emotionally intelligent way.
In all cases, Dr. Nasr reiterated the importance of protecting the doctor by all means necessary. “When a altercation happens between a doctor and a family member, it has to be legally dealt with as an assault on an institution, not as a personal conflict between the doctor and the aggressor”, he stressed.
In an interview on the Egyptian Channel 2, Dr. Nasr succinctly asked: “Can anyone touch a prosecutor or a police officer [like they do to doctors]?”
Doctors question their role
When asked about the role of those in higher positions to alleviate the problems doctors face, Attiah tells Egyptian Streets that they do very little to solve the recurrent problems.
He claims that they are a big part of the problem itself. “The director of Zagazig University Hospital dismisses all the violence we go through as just a reality that all past doctors have been through. It’s been normalized.”
“We cannot object. We are unable to express our grievances,” Attiah says; however, according to Egyptian labour law, workers have the right to take the necessary procedure to ask for better working conditions and payment. These procedures usually take the form of collective bargaining, and/or striking, which are both protected by the labour law and the Egyptian constitution.
However, when the option of collective action was suggested, Attiah smiled and said: “We would be simply fired”.
Roaa also abruptly dismisses the idea of a strike or any form of collective action, referring to the 2017 Nurses strike in Zagazig University Hospital.
The latter had for aim to demand higher pay and better equipment to properly tend to the patients and avoid constant humiliation from the patients and their families in case nurses are unable to serve them.
The hospital administration did not respond to the demands of the nurses, and brought in nursing students and interns (who are not legally allowed to work as nurses) to fill in their jobs. The administration also forced doctors to do nursing jobs and privately paid external nurses to substitute the striking nurses while the hospital nurses were on strike.
“Nurses relatively have the power to collectively shake things up due to their indispensability, but doctors don’t,” says Roaa to Egyptian Streets.
Not only are doctors suffering from or dealing with violence in their workplace everyday and are unable to speak up about it, their poor working conditions strongly affect their ability to perform.
Attiah earns a total of 3000 LE per month, while Roaa earns 2400 LE (including overtime). Their salaries did not change even after the pound devaluation, which resulted in an inflation that reached a staggering 35% in July 2017 according to the Egyptian Central Bank.
Next to meeting the regular job schedule, Attiah is doing his masters degree (a mandatory requirement as a potential university staff), which sets him back around 7000 LE, which he paid from his personal budget.
According to the latest figures presented by Prof. Bayoumi, around 80% of doctors work in the private sector in addition to their additional work in public hospitals due to the low salaries provided in governmental facilities. Estimates suggest that around 50-60% of Egyptian physicians work abroad, resulting in a severe brain drain in the Egyptian healthcare.
Furthermore, in an early August interview on MBC Masr, Khaled Amin, a doctor in Boulak El-Dakrour Hospital outlined how doctors are at a constant risk of infection by other patients.
From seasonal flu, to more serious diseases, such as Hepatitis B and C, doctors are at regular exposure to a variety of viruses, to which they are compensated a meagre 19 to 36 LE in the form of ‘infection allowance’.
“I have personally done four heart surgeries to patients with HIV/AIDS in 2018,” says Dr. Nasr to Egyptian Streets before adding that he was following up on another patient who has Hepatitis C. This patient had an open heart surgery by Dr. Nasr.
After a collective plight by the Doctor’s Syndicate to increase the infection allowance to 1000 LE, the High Administrative Court overturned the decision to increase the compensation, sparking outrage amongst the medical community when the doctor’s infection allowance is compared to that of the Egyptian judges’ which amounts to 3000 LE.
Doctors claim they are more likely to get infected, and potentially lose their lives; this was exemplified through the four Egyptian doctors who died due to a “mysterious virus” during work.
Therefore 19-36 LE is far from sufficient to account for the risks they are exposed to.
A game of blame
It’s not uncommon to hear about an acquaintance or a loved one having an accident. Due to their unplanned nature, patients are transmitted to the closest possible hospital to the accident site. In case there is no place in the intensive care, in case there is no blood for transfusion, or in case there is no basic consumables, such as plaster or syringes, to help the patient in a timely manner, who is to blame for the doctor’s inability to save the patient?
Dr. Nasr tells Egyptian Streets that “as long as the hospitals are technologically qualified, and the doctors have the necessary knowledge and experience to deal with the patients and their families, the doctors are not to blame”.
But the experiences of the doctors and other professionals reflect a reality that is not discussed by many. According to Prof. Bayoumy, sometimes “hospitals would either be understaffed, which would increase wait times for patients, or would not have the necessary supplies and medications”. Doctors have constantly talked about how they have to send patients outside the hospital to purchase supplies or medications, due to their unavailability at the hospital.
“This would leave many patients and/or their families understandably indignant”, adds Prof. Bayoumi, corroborating Dr. Mina’s account who emphasized that both doctors and patients are victims of the underfunded health sector.
Prof. Bayoumi asserted that “Violence cannot be reduced without improving the conditions under which healthcare is delivered in Egyptian public hospitals”. Naturally, such improvements necessitate revamping the healthcare sector.
Talks about healthcare reform have been ongoing starting 1995, but throughout these decades, material progress has not yet been felt by the average Egyptian citizen. For the past years, these talks of reform have been renewed, which ended in passing the Universal Healthcare Act in the Egyptian parliament in late 2017.
When asked about universal healthcare in Egypt, Prof. Bayoumi highlighted that it is “the only viable option that makes both economic and moral sense”. Such a system, if applied as envisioned, would potentially ensure access to healthcare for all Egyptians regardless of income, employment or social background.
Dr. Nasr is one of the biggest proponents of the new universal healthcare system, as he was on the parliamentary committee drafting the law. He extensively talked about how important it is to have a system where all citizens contribute a certain percentage according to their total income. “This would consequently lead to the rich contributing more to health funds than the poor”, which is an important step in achieving social justice.
Some health professionals, such as Dr. Mona Mina, have some reservations about the new universal healthcare law. She argues that it opens the door for the privatization of public hospitals to meet the required standards, instead of increasing public spending to improve the current derelict public facilities.
According to Prof. Bayoumi, Egypt is faring worse than most MENA countries in terms of life expectancy and has one of the highest infant and child mortality rates.
If the brain drain keeps happening at the current rate, Egypt would lose its advantageous ratio of doctors and nurses to population, which is better than most MENA countries. “Health and education need to be a priority for Egypt, but that’s certainly not been reflected in the public spending priorities of any of the past or current regimes.” she told Egyptian Streets.
Healthcare is a fundamental pillar of any nation who aspires to provide a dignified life for its citizens. This is reflected in the intense national debates surrounding health, such as in the healthcare reform in the USA and the funding of the National Health Service in Britain.
Healthcare in Egypt is a multifaceted, yet critical, issue that has never dominated public consciousness for long. But so long as the healthcare sector is underfunded, the doctors are underpaid, overworked and legally unprotected, and the patients (and their loved ones) are desperate in seeking the right of receiving affordable and high-quality treatment, it’s imperative to position health issues at the forefront of the political discourse in Egypt.
It is in the material interest of every single Egyptian citizen to care about healthcare reform and the rights of doctors, especially in a time marked by, as Prof Bayoumi characterized it, “the foreclosure of the public sphere and the crackdown on civil society [leaving] very little room for meaningful mobilization”.
This could preclude doctors and other workers in the medical field from collectively demanding better working conditions and hence the inability to assuage the patients’ (and their families) anger and desperation, resuming a vicious cycle of violence and frustration.