Egypt has long suffered from a wide variety of diseases and major public health problems. The socio-demographic composition of its population, plus the deleterious effects of the Nile River, sub-standard insect control programs, economic underdevelopment, agricultural insufficiencies, and perennially poor leadership have combined to create massive suffering and death throughout the centuries in this most prominent of North African nations (Baker, 1978, passim). Further compounding these problems have been illiteracy, ignorance and poor hygiene among broad swaths of the population. These trends have persisted even in contemporary times in spite of denial by Egyptian Health Ministry officials and governmentally sponsored public awareness campaigns that claim significant progress in nationwide health care has been made (Shalnab, 1999).

This special health profile of the Arab Republic of Egypt will review the history of disease in this nation. It will mention, as well, the evolving patterns of health care over the centuries, and intends to outline, both graphically and descriptively, the primary ailments afflicting the people of both the Upper and Lower Nile as well as the urban populations of Egypt's major cities (CIA, 1999). As the discussion progresses chronologically, attention will be focused on contemporary governments' efforts to alleviate the effects of disease and destitution of the masses. Emphasis will, of course, be placed on modern health care policies, facilities and trends.

More than four thousand years ago, in the period known as the Old Kingdom (2750 B.C.), throughout the Second Intermediate Period which ended in 1539 B.C., and well on into the Roman Period of Egyptian Civilization (30 B.C. to 400 A.D.), health care was predicated on religiously-based superstition. Sometimes, too, it was founded on traditional practices and even on occasional common sense (Carnegie, 1999). Records demonstrate that formal medical care was reserved for the wealthy. Due to rudimentary health care methods, however, many high ranking priests, functionaries and even Pharaonic family members succumbed not to disease but to treatment. Health care amounted to lavish pampering and little more. Among the enslaved peasants and workers, of course, diseases simply ran their course, culminating in premature death or prolonged debilitation.

Informed speculation among Egyptologists as to the nature of the leading causes of death in Ancient Egypt revolves around the fairly well documented Plagues of Egypt, bubonic, encephalic and enteric, such as those that decimated Europe in the 11th and 12 centuries. Causes of these Egyptian plagues, killing tens of millions, are traceable to foul water supplies, mammalian and insect vectors, as well as to failure to understand the sources of contagion. It is fair to state that ten of millions of people, of all ages, died of communicable diseases in Pharaonic Egypt, as annual floodwaters rose (Sullivan, 1995, 141). They died for many centuries, before construction of the Aswan Dam. The Nile’s floodwaters invariably brought infectious contamination in the form of diseased fish, decaying vegetable matter and insect larvae. Sources of information are unreliable, of course, and only scattered accounts of the precise symptoms and nature of the diseases of Ancient Egypt have been passed on to us by hieroglyphic tablets (Carnegie, 1999)

With the coastal invasion of the Romans and, later, in the early centuries of the Christian Era, not to mention ever-shifting educational influences from Asia Minor, health care and the overall medical status of the Egyptian people changed substantially for the better. Dietary improvements and new knowledge in the field of agriculture and social organization led to a decrease in the frequency and prevalence of epidemics and new circumstances emerged, favoring the development of rudimentary hospices and hostels where disease-stricken or moribund patients could at least receive terminal care. Unfortunately, not all regions of Egypt in the 400 to 1500 A.D. timeframe were graced with knowledge from the Mediterranean Basin; indeed, the populations of Upper Egypt still suffered abysmally from the same types of epidemics and perennial patterns of disease which had afflicted their ancestors millennia earlier. While people were perishing of enteric fevers and dysentery in the Upper Nile zones, in Cairo and Alexandria there were reports of tuberculosis on a prominent scale in the teaming ghettoes of the working class district. Officially speaking, the first truly identifiable health care facility in Egypt was established in 1798, to help cope with these alarming conditions (Omran, 1959, 26).

During the initial stages of the British occupation in the 19th Century, health conditions remained essentially horrific for the vast majority of the population. Although medical schools and research institutes were being established, they served the colonial population and the hierarchical members of the Monarchy, supported by the British. Many of these same institutes are being funded by contemporary Egyptian Governments, and still others by foreign sources interested in influencing health and social policy within Egypt today. Conditions, nonetheless, in the Upper Nile Valley and in the major cities, under British occupation until the early 1950s, steadily deteriorated with high incidence of poliomyelitis, tuberculosis, water-borne disease and enteric fevers, all leading to prolonged incapacitation, permanent disability or premature death (Baker, 1978, passim).

Social tensions rose, and for a variety of reasons, the corrupt monarchy of King Farouk, propped up by the British, was overthrown in the 1950s by the Free Officer Movement, a group of forward-thinking, socially enlightened, although ambitious, army officers (Vatikiotis, 1978, passim). One of them, Abdel Gamal Nasser, emerged as leader in a matter of two or three years, and the health care panorama of Egypt changed dramatically for the better.

Nasser, himself a member of the lower middle class, was aware of the needs and priorities of his nation. His government, based initially on Islamic principles of egalitarian distribution of assets, launched a number of National Health Reforms which were, even much later into the 1960s, 70s and 80s, under successive leaders Sadat and Mubarak, further strengthened. They have been considered far from totally effective, however, and major health care problems have still endured in large geographic sections of the nation, notably in rural areas, even within as little as 100 kilometers from the capital. The network of Health Clinics and Social Service Centers that were to have impartially served urban and rural populations has clearly not done so (Baker, 1978, 224).

Prior to analyzing in some depth the types of diseases, their incidence and their prevalence throughout the nation, it is important to provide a concise 'health profile overview' of the Arab Republic of Egypt, a nation struggling under the burden of massive health problems and related socio-economic deficiencies.

On Table I, below, several key socio-demographic and health-related indicators have been tabulated from a variety of authentic and impartial sources. It is important to recall that figures flowing from the Government stand in sharp contrast, in all areas of health care and incidence of disease, to those compiled by independent health care providers or agencies. The following data, therefore, represent an amalgam of sources and, hopefully, reflect some meaningful indications of the health care dilemma faced by the last two Egyptian Governments over a period of three decades. This chart, although quite basic, provides a glimpse of the magnitude of the challenge faced by contemporary Egyptian governments. Such figures as these simply set the stage, however, for a discussion of the major afflictions, health risks and diseases that cause such loss of life and economic productivity throughout the country.

It is important, therefore, to inquire as to the specific types of illnesses, frequently chronic or immediately fatal, affecting all social classes in Egypt, but particularly the poor. Observers generally acknowledge that the below-itemized major health problems, in descending order of prevalence, involve an almost classic range of third world diseases. These endemic, and sometimes epidemic, disorders are: bilharziasis, hookworm, trachoma, dysentery, beriberi and typhus (Kurian, 1992, I, 570). Surely, all of these conditions can lead to premature death among all ages, and others can produce subsidiary symptoms, organic dysfunction, chronic incapacitation and dependency. The secondary effects of beriberi, for example, are stunted growth, quite a widespread phenomenon in Egypt, and mental retardation or insufficiency (The Economist, 1999). By way of contrast, dysentery, an essentially diarrheal condition, leads to immediate dehydration and possible death. Additional damage to health is attributable, in apparent dysentery cases, to tropical diseases, which at various stages of development include diarrhea, such as Schistosoma mansoni among school children and bilharziasis among all layers of the population (Malone, 1997). Some emphasis is being placed on improvement of diagnosis and pharmaceutical intervention, but with mixed results for all of the diseases listed as major causes of mortality or morbidity by Kurian (1992, 570).

Eye diseases are especially prevalent with, it is generally thought, trachoma leading the list of such afflictions (Omran, 1999, 16). Ophthalmic conditions literally deprive the patient of a means to survive, unless family members are willing to provide vocational rehabilitation opportunities or basic subsistence. Trachoma in the Upper Nile Valley, and in most rural areas is a major debilitating force in small villages. The onerous burden of these types of diseases is almost too much for local economies to bear (Baker, 1978, 219). In fact, eye diseases, combined with the other afflictions identified by Kurian (1992, passim), impact village infrastructure so dramatically that 80% of the fellahin (peasants) are judged unfit for normal social activity, including the military (Baker, 1978, 219). It is important to note, in passing, that subsidiary village illness, sometimes only transitory but physiologically weakening, such as hepatitis A, B and C, is quite prevalent, and affects from 14.5% to as much as 70.4% of all fellahin who fall victim to subsequent liver dysfunction (Halim, 1997, El-Gohary, 1995).

Enteric fevers decimate large numbers of people, particularly among the working classes, even in urban areas, since insect control measures in Egypt are seldom effective. Health measures, begun under Nasser in 1955 (Baker, 1978, 221), have not proven to be comprehensive enough to stem the increase – in sub-tropical and tropical zones – of malaria which is now (in the case of several strains) becoming resistant to quinine prophylaxis. As a case in point, Plasmodium falciparum is increasingly resistant to standard treatment with Chloroquin and Camoquin (Davis, 1999).

Table II itemizes several of the leading causes of death among the general population of Egypt for the year1992. These figures are reliable since they emanate from the World Health Organization, an impartial body devoted to the dissemination of accurate information. Some data appearing elsewhere in this report originate from Egyptian Government sources, are usually less reliable, and are sometimes even intentionally distorted.

The foregoing Table indicates the relative severity in modern times of the primary causes of death, medically identified, within the context of the on-going health crisis throughout Egypt. However, there are several socio-geographic distinctions that constitute contributory elements of this problematic public health equation.

The rural areas of the nation have long been neglected. Under the British, hospitals and clinics were clustered in urban centers (Baker, 1978, passim). But the revolutionary fervor of the Free Officer Movement, under the inspired leadership of Nasser, following a short period of transition, pledged to reform inadequate rural health care systems and to distribute care, idealistically, to all of the country’s citizens. In 1962, a National Health Charter was proclaimed encompassing an amazing "unconditional guarantee" of health care to everyone as a "first right." (Baker, 1978, 218) Some early progress under this doctrine was documented, but much still needs to be accomplished forty years later, especially in outlying areas. The diseases of the rural poor are so well entrenched, and distances from urban centers are so great that most of the ‘non-urban’ nation, in spite of decades of altruistic intentions, is still woefully under-equipped to deal with the soaring numbers of patients. Many of these new patients are afflicted with dangerously escalating diseases in categories heretofore unnoticed, such as STDs and newly evolving viral infections. Beyond these new phenomena, of course, the old ones continue to rank high: anemia, blindness and bilharziasis, among those many other endemic diseases and causes of death cited earlier.

What new policies are being enacted under the present Mubarak government to cope with the now recognized non-performance of the earlier Nasser and Sadat health care models?

Following the assassination of Anwar Sadat who had attempted to improve the Health Care System originally planned and financed by the Nasser Government, but which had been considered a massive failure by leading sociologists, the press, and the public, the Mubarak government reviewed options available.

The existing government-sponsored health care network, a combination of urban hospitals, rural clinics and social service centers, was an abysmal failure because it was not able to address the growing health risks in rural areas, and ran into serious problems with financing and competent staffing even in urban areas. Egypt produces more physicians than she requires, many of whom are only marginally qualified by Western standards (Baker, 1978, 219). In rural areas, such doctors seldom stay more than a few weeks, disenchanted with working conditions and facilities. In urban areas, the competition is so stiff among doctors, that quality care is not possible due to rate-undercutting, sub-standard facilities, marginal academic preparation and other factors that combine to form a bleak picture in the government sector (Kandela, 1998). Sources more recent than Baker (1978) and Kandela (1998) confirm that this scenario has remained the same in spite of reinforced efforts on the part of President Mubarak (Le Monde, 2000).

In Cairo and Alexandria the presence of the media has spurred new interest in the internal dynamics of the malfunctioning government health care system. Because 83% of the hospitals are government affiliated and financed, and most of these serve the capital and the Mediterranean coastal sectors, there is tremendous pressure placed by such noteworthy newspapers as El-Ahram on the Health Ministry to revitalize public health services available to the general population. While there may well be some phases of the Ministry’ s program which are commendable, such as family planning and reproductive care, other categories of public sector medical services are lamentable.

In spite of this bleak assessment there are still several reputable medical associations that attempt to provide care which is impartially viewed as both modern and efficient; however, these facilities are classified as private in nature and most costs associated with their services are prohibitive for the average Egyptian. Only the elite can afford care in them. They represent approximately 17% of health care facilities in all of Egypt; although they serve a much smaller fragment of the population than such a percentage would indicate. Table III, below, provides a cross-sectional overview of many prominent Societies and Associations that serve the elite members of Egyptian society:

Three large medical schools in Cairo and Alexandria provide trained doctors to staff the private and public health centers and hospitals of Egypt. There is a fourth training institute in Upper Egypt, at Asiut, which serves medical needs in that area directly and indirectly since medical students, before graduating, care for the local population as part of their internship programs (Omran, 1959, 26). Some students still complete their medical studies in England as they have done since the end of World War II.

Over the years, the number of hospital beds in Egypt has increased dramatically, although this trend is not necessarily an indication of the quality of care provided.

Source: Omran (1959), Arab Chamber of Commerce

Most of these beds are clustered in urban zones; the rural population even under the Mubarak Government seems quite neglected, according to certain reports (Le Monde, 2000).

The outlook, therefore, due to financial constraints and widespread misappropriation of existing health funds, is fairly bleak for large regions of the country. The Egyptian parliament, prodded by the press, occasionally examines and publicizes glaring inadequacies in the public health care network, inclusive of the social service care organization which is ‘tied into’ the hospital system. These social service centers evaluate, refer and assist patients whenever possible, although they, too, have been identified as less than effective in recent decades (Baker, 1978, passim).

Contributing factors to Egypt’s health status are not all governmental, of course. Basic infrastructure is lacking and impassible roads, unsafe water, unmonitored insect vectors and pollution all play a part in the high mortality rates indicated earlier.

The magnitude of the problem cannot be adequately grasped due to altered statistics, even though W.H.O. data presented above (Table II) seem reliable as far as they go. With a verified six million people afflicted with schistosomiasis, alone, other parasitic diseases, by simple inference, can be placed into perspective (El-Khoby et al., 1998). Appendix A provides merely an approximation of the gravity of the contemporary health care system’s failure to stem all types of disease, and the government’s inability to eliminate sources of contamination and, hence, unnecessary human suffering throughout Egypt.

Viable solutions for Egypt’s health care crisis are certainly not clear-cut, obvious or easy to define. With a burgeoning population, plus ever-present high-risk factors, widespread poverty and illiteracy, standard measures such as those implemented in most Western nations are not a practical option in Egypt. There is a surplus of doctors, but most are poorly trained. Facilities exist, but they are geographically inaccessible to whole segments of the population. Funds are available, but they are misappropriated. Complicating matters further, new diseases are on the rise.

One solution involves population control; another seems to consist of a straightforward nationwide radio and TV campaign. The government of Hosni Mubarak is attempting to implement these measures; but analysts feel he may be encountering mixed results, as did his predecessors, Nasser and Sadat.

The rise in STDs, HIV and new viral sources of infection is worrisome. Yet, on-going battles against bilharzia, schistosomiasis, trachoma and even diabetes must continue. In spite of set-backs, the Public Health Ministry must persist in its efforts.

Slowly, gradually, progress can be made. Priorities of public and private sector care should be centered around both rural health care (parasitic disease) and urban ghetto health care where the prevalence of tuberculosis, pneumonia and other relatively curable diseases appears to be ever-increasing (Appendix A). If efforts are concentrated, on a nationwide scale, to eradicate certain recurring and disturbingly prevalent diseases, then the health of Egypt’s population will be immeasurably improved. Great success has already been achieved in elimination of smallpox and in significantly reducing the incidence of poliomyelitis, not only in Egypt but in neighboring nations. New efforts, aimed perhaps at STDs, bilharzia and schistosomiasis, need to be sustained and encouraged in the best interests of future generations of Egyptians in all social classes.