Will Revolutions Extend to Mental Health Care?
Abstract
The first of the demonstrations that toppled autocratic regimes in Tunisia and Egypt earlier this year began with the suicidal despair of a 26-year-old Tunisian fruit and vegetable seller.
The cascade of events across North Africa was set off when Mohammed Bouazizi set himself on fire on December 17, 2010, after officials confiscated his produce because he did not have a permit. He died a month later of his burns. The ensuing demonstrations ultimately led former president Zine al-Abidine Ben Ali to flee the country after 23 years in power.
"I don't know if the system will change with the new government, but I hope that the distress of Mohamed Bouazizi will raise awareness about the need for psychosocial help in the community," said Imen Ben Cheikh, M.D., a graduate of the University of Tunis Faculty of Medicine and now a psychiatry resident at the Université de Sherbrooke in Quebec.
Ben Cheikh said she spoke recently with physicians and a psychologist in Tunisia.
"They all participated in the demonstration on January 14, the last major event before Ben Ali's departure," she told Psychiatric News. "One of the doctors has provided assistance to demonstrators at other events after January 14. He also met with mothers of young people killed by gunfire during protests. He said that the mothers were badly affected and felt the need to talk, to tell their distress, but that there was nobody to listen to them."
Ben Ali's regime violated human rights by restricting freedom of speech and intimidating, harassing, imprisoning, and even torturing those who dared to express their opposition and ask for more freedom, said Ben Cheikh. Regime insiders enriched themselves while most citizens remained poor.
In general, mental health care in Tunisia is provided in hospitals, primarily at one large psychiatric hospital in the capital, Tunis; the hospital is stigmatized by Tunisians as "the madhouse," she said.
"People who can afford it consult private psychiatrists," she noted, "but the poor majority of the population in need of psychological care cannot find any, because there are no accessible, public, community agencies to provide help."
The events in Tunisia inspired demonstrations in Egypt, which had lived for three decades under the autocratic rule of Hosni Mubarak (see Pendulum Shifted Mood From Despair to Hope).
At first, the situation in Egypt was quite stressful when it was unclear what the authorities would do, said Egyptian-born APA member Wagdi Attia, M.D., now in private practice in Silver Spring, Md. He has been in frequent contact with friends and family in his home country since the start of demonstrations there.
An Egyptian protester chants slogans last month during a demonstration at Tahrir Square in Cairo. Psychiatrists were among the crowds there who expressed their opposition to the Mubarak regime.
"There was a mixture of hope and fear for the first two or three days when the protesters had no protection from counterdemonstrators," said Attia, in an interview. Eventually the army stepped in to prevent violence between regime supporters and opponents.
"For 7,000 years we have been ruled by a pharaoh," he said. However, most people were too busy with the daily tasks of living or too intimidated to consider action against the regime.
Over the last three or four decades, corruption and poverty increased, the middle class has all but disappeared, and the currency has weakened dramatically, Attia explained. "All of this has had a great impact on the stress on the Egyptian people and on mental health services in the country."
In Egypt, mental health services account for just 2 percent of the national health budget, according to a 2006 World Health Organization (WHO) report. About 60 percent of that went to mental hospitals, although the government was "encouraging development of community-based psychiatric units and outpatient facilities" around the country, according to the WHO.
"The beauty of the revolution was that it started with younger people who had the brains, the heart, and the vision to see what was going on in the rest of the world," said Attia. "A good infectious virus went through everyone to get what they want."
One American psychiatrist found himself in the midst of the upheaval in Egypt.
David Baron, D.O., a professor and executive vice chair of psychiatry and behavioral sciences at the Keck School of Medicine at the University of Southern California, is a frequent visitor to Egypt where he lectures and helps train local psychiatrists. He arrived the weekend before the demonstrations began expecting to lecture on head trauma in sports.
Baron visited Tahrir Square from time to time during the crisis. The demonstrators were largely peaceful.
"I've seen more unruly crowds when the Phillies won the pennant," he told Psychiatric News.
"One spark overcame years of defeat," said Baron. The predominant emotion was joy, he said. "People said: ‘For the first time, I'm proud to be an Egyptian.’"
Baron observed a group-therapy session in one of the psychiatric hospitals and found the patients caught up in the same euphoria.
"Even the psychotic patients were not fearful," he pointed out. "There was a universal sense of joy and pride. The affective tone of the inpatients was not much different than that in the streets."
With Egyptian colleagues, he is now gathering data on the mental health effects of the revolution and hopes to publish the material in about a year.
Meanwhile, some of the newly emancipated are doing what they can to help those fleeing ongoing battles nearby. For example, "volunteer psychologists recently went to the Libyan border to provide support to refugees arriving in Tunisia," said Ben Cheikh.
