Doctors and Brothers

by Steven Brooke
published in MER269

There are few obvious reasons to visit Basatin, a poor district off the Ring Road at the southern edge of Cairo. Getting there requires a driver willing to bob and weave through a succession of potholed lanes barely wide enough to accommodate pedestrians and the tiny shops that spill into the street. The problems of Basatin are the problems of Egypt: grinding poverty, overcrowding and the slow deterioration of state services. The neighborhood has learned to fend for itself, and non-residents are regarded with suspicion. I stick out more than most. One man watches me curiously for a while, and wanders over to ask if I am Syrian.

“Welcome to Mubarak’s Egypt,” Galal Ibrahim says drily as we survey the scene in front of the Tan‘im Hospital, where he is director and a doctor. Indeed, the contrast between run-down Basatin and upscale Maadi a short distance away mirrors the yawning inequalities that deepened during Husni Mubarak’s 30-year turn as Egyptian ruler. The Tan‘im Hospital is one of some 30 sites managed by the Islamic Medical Association (IMA), an organization established by and affiliated with the Society of Muslim Brothers. Most IMA facilities are in Cairo and Giza, but there is also a center in Asyout in Upper Egypt and one in Ismailiyya on the Suez Canal, as well as a few scattered in the Delta. In addition to regular hospitals, there are dedicated centers for eye care, fertility, dialysis and people with special needs. According to IMA officials, as of the spring of 2013 the organization employed around 10,000 Egyptians, nearly half of them doctors, most of whom have “day jobs” in government or university hospitals. In the 2010-2011 fiscal year, IMA personnel treated around 1.5 million people. The busiest IMA hospital, in Helwan south of Cairo, handled over a quarter of a million cases during that time. This workload is what a Muslim Brother spokesman meant when he described the group’s activities as a “scaffold” holding up Egypt’s crumbling state institutions.

Technically, the Islamic Medical Association functions as a type of hospital management corporation. It staffs the clinics, minds the legal requirements and keeps the books. But the IMA has also built some facilities from the ground up. Its flagship Central Charity Hospital in Nasr City, an eastern Cairo suburb, was erected with funds partly raised in a professional campaign featuring soccer stars Muhammad Abu Turayka and Nadir Sa‘id. But most of the centers are acquired piecemeal, with the profits (if any) fueling expansion -- new equipment, new hires and renovations. In the case of Tan‘im, says Ibrahim, a local religious figure donated the land, including a small structure, in 2009, and the IMA converted it into a hospital step by step. Opened in early 2012, the facility now holds some three dozen beds. In Maadi, the group has steadily transformed an apartment building into the large al-Farouq Hospital complex.

Even in ramshackle Basatin, the quality of IMA infirmaries is several steps above what is on offer at nearby government hospitals. In our tour, Ibrahim points out a laboratory, a pharmacy, and optical and dental examination rooms, as well as facilities for ear, nose and throat, pediatrics, dermatology, urology, anesthesiology and minor surgery, radiology, and obstetrics and gynecology. One of the three obstetricians is a woman, and although the hospital is searching for another, the unreliable public transportation makes it difficult to recruit and retain doctors. The hospital is clean and orderly. When an attendant tries surreptitiously to close the door to a bathroom/janitor’s closet, Ibrahim pushes it back open. “He’s here to see the hospital,” he admonishes her, “and that means everything.”

Nearly all IMA facilities offer a similar array of basic services, and standards at the higher end of the spectrum rival those in the United States and Europe. The Central Charity Hospital, for instance, has top-of-the-line “open MRI” machines, nationally and internationally recognized specialists, and incubators for premature infants. It offers “hotel-level services” to attract rich patients who will, essentially, subsidize the care of poor ones. Two hospitals in the IMA network are piloting a fully digitized system for tracking patient records, almost completely unheard of in Egypt (at one public hospital I visited, the “patient records office” looked as if someone had dropped 40 years’ worth of paper on the floor and then used a leaf blower to sort out the mess). In addition to the equipment, doctors and staff tout “the Islamic atmosphere” of compassion for patients, something they claim is lacking at government hospitals.

The difference from public hospitals can indeed be stark. A November 2012 dispatch in al-Ahram described a dialysis center at a government-run hospital in Helwan as “an island in a huge pile of rubbish. Gray paint was peeling off its walls and a sewage drain had erupted near the entrance filling the air with an abominable stench…. The stone stairs are broken, dirt blackens green walls, the bathroom is filled with broken chairs and more rubbish, and puddles fill the corridors leading to the wards.” Horror stories abound throughout Egypt of bribery, corruption, overworked doctors, neglectful nurses and unsanitary equipment. One acquaintance told me of how hemodialysis failed to arrest a relative’s kidney disease; after her death the family discovered that the hospital staff had not bothered to change or sterilize the machine’s filters between patients.

The decrepitude is partly due to the toxic mix of 50 years of population growth, urban sprawl and shrinking state budgets. Measured as a percentage of GDP, according to the World Bank, Egypt’s spending on public health has hovered below 2.5 percent for years. In fact, says ‘Amr Shoura, a leader of doctors’ strikes in 2011, the physicians demanded a dramatic increase in public health spending to 15 percent of GDP and better security for workers at hospitals, frequent targets of thieves after Mubarak’s fall. Alongside the budgetary austerity, there has been a wave of privatization. The new for-profit hospitals in the market are far superior to their public counterparts but so expensive that only the wealthy can afford a stay there. The result is that most Egyptians are forced to choose between the impossible and the intolerable.

It was precisely the dearth of affordable health care options for the growing middle classes that spurred the establishment of the IMA in the late 1970s. As a largely middle-class organization, composed of university graduates and professionals, the Brothers were not only acutely aware of these problems, but well positioned to address them. According to ‘Abd al-Mun‘im Abu al-Futouh, an early IMA doctor and later member of the board of directors (he has since left the organization, as well as the Brothers), the association was founded “because at that time we saw two systems for medical care in Egypt: the governmental, weak, fraying system, and the investment [private] system, which was for the rich. So the people had a problem.... Most people, not just the poor, had to go to the free medical service, the governmental one. It was humiliating. But it was not just the poor. If it’s a judge who is sick, who can consider him a poor person? Or even a new doctor like me at that time? If someone like this has to go to the free service, he’ll be humiliated. He can’t go to private hospitals because he doesn’t have money. So the reason behind establishing [the IMA] was offering this medical service, providing decent care for an appropriate cost.” The statistics bear this point out: Although IMA hospitals do offer discounted and free care to the poor, these patients account for a minority of those treated. In the fiscal year 2010-2011, for instance, “poor patients” were only about 4 percent of the total number seen at IMA facilities across Egypt.  

The scale of initiatives like the IMA brings accusations that the Brothers are engaged in something more than charity. When it comes to health care, for instance, the Brothers’ Freedom and Justice Party runs highly publicized “medical caravans” featuring volunteers decked out in shirts and hats with party logos. Although the FJP is certainly not the only party to mount such efforts, they are the most successful. According to statistics from the Brothers, during their “Together We Build Egypt” campaign (which ran from January 21, 2013 until petering out in the early summer), they deployed 3,908 of these caravans and provided care to 1.75 million citizens.

For their part, IMA officials flatly reject the suggestion of an ulterior motive. The association’s mission statement, prominently displayed at every hospital and specialized center I have visited, promises top-notch care to everyone “regardless of gender, nationality, color or creed.” The IMA is a registered, legally independent entity and the officials claim they perform their duties without any direction from the Brothers. As Muhi al-Zayt, general manager of the Central Charity Hospital, told me: “Yes, we are Muslim Brothers, but here I am a physician. I remove any political affiliation…. The patient here is a human being, and I am a physician. There is no political orientation or social class.” (Al-Zayt left Egypt following the coup.) To emphasize the point, ‘Ali Abu Sayf, the manager of all the IMA’s medical centers, dug out an official reprimand sent to the director of an IMA hospital in the Delta for campaigning on the job. “We do not provide any support to any party or trend or person, and we deal respectfully with all of them,” it reads. “Please fully comply with everything we have mentioned….” The ellipsis ends the letter.

Regardless of the motivations, it seems undeniable that the IMA’s 30-plus years of providing low-cost, high-quality care earned it -- and the Brothers -- considerable good will among many Egyptians. The Mubarak government was not pleased. The IMA has since its inception been a fully registered charity, providing intrusive bureaucrats with several means of meddling and disruption. In a number of cases reported to me by IMA administrators, inspectors seized on small violations -- a uniform left on the floor, a leaking or missing faucet -- to close hospitals for extended periods. At other times, they dispensed with legal niceties in order to send a stronger message. In 2005 Fathi Surour, the powerful speaker of Parliament, seized control of the IMA’s oldest hospital, adjacent to the Sayyida Zaynab mosque in his home district. In 2010, workers from the Cairo governorate descended on the Central Charity Hospital with picks and sledgehammers and began a round-the-clock effort to destroy the facility from the inside out, ostensibly due to building code violations. When the building’s structure proved resistant, they brought in heavy equipment. By the time the IMA’s lawyers were able to stop the destruction, two floors had been wrecked and a number of sensitive machines had been rendered unusable. According to al-Zayt, “Mubarak’s final crime” cost the hospital approximately 5 million Egyptian pounds (around a quarter of a million dollars) in repairs and delayed its completion by three and a half years. Today, the top floors of the facility remain closed, still bearing the scars from the attempted demolition.

Like Mubarak before them, Egypt’s new rulers are struggling to balance their enmity for the Islamists with a desire for stability. Months after the military’s removal of President Muhammad Mursi, in September 2013, a Cairo court banned the Brothers’ activities and froze their assets. In early December the government confiscated around 150 Brother schoolhouses, and later that month it froze the bank accounts of a number of charities, including the IMA.

According to Abu Sayf, the asset freeze denies the IMA access to around 4 million pounds stored in 11 accounts. This amount is a fraction of the organization’s roughly 100 million-pound annual budget, but the freeze has nonetheless been disruptive. For dialysis treatments, for example, the IMA must outlay around 80 pounds per patient to make up the shortfall between the treatment’s cost and what the government reimburses. General numbers of patients are down, and one hospital in northern Cairo reportedly has shut down neonatal incubators to save on energy bills.

The IMA expressed surprise at the court order and launched a campaign for judicial review. In addition to organizing a demonstration of aggrieved dialysis patients outside the Ministry of Social Solidarity, the IMA published a letter on the front page of the national daily al-Ahram. The letter petitioned the prime minister, as well as the ministers of social solidarity, justice and health, to release the funds “in the name of 2 million sick people and tens of thousands who receive kidney dialysis on a continuing basis, and premature infants, and those unable to pay for their treatment.” According to Abu Sayf, negotiations to return the IMA to full operation are proceeding smoothly, although one condition is that the Association remove board members who also sit on the Brothers’ Guidance Council, such as Mahmoud ‘Izzat, deputy chairman of the IMA and (reportedly) acting general guide of the Brothers.

The talks illustrate a dilemma for the regime: Much as the regime may want it to, the IMA is too big to fail. “When I meet with the Ministry of Health,” says Abu Sayf, “they know we are taking their load.” Three decades of privatization and liberalization, paralleled by Islamist expansion, has entwined the Brothers more and more snugly within the fibers of Egypt’s social service net. It is hard to imagine that the regime’s strategy of demonizing those groups upon whom many Egyptians privately rely will end up as anything other than a failed attempt to establish stability atop citizens’ suffering.

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