Hepatitis C, COVID-19 and the Egyptian Regime’s Approach to Health Care

In Egypt, the spring of 2020 was rich in contrasts in the field of health. In late March, The New England Journal of Medicine published an article penned by some of Egypt’s most prominent physicians.

The piece described the success of the country’s nationwide testing and treatment campaign for the hepatitis C virus, which began in 2014.[1] Before its start, Egypt had the highest burden of infections with the virus of any country in the world. It is now on track to eliminate hepatitis C, according to the terms outlined by the World Health Organization, by 2030.

With the end of one epidemic in sight, however, another threatened to overtake the country. As the SARS-CoV-2 virus (also known simply as the coronavirus) spread across the globe, some commentators forecast that it would overwhelm Egypt.[2] After tourists who had visited the town of Luxor were infected, the country braced itself for what might come, grounding international flights, closing schools, mosques and churches as well as constructing quarantine facilities. While Egypt has yet to be crushed by COVID-19, the arrival of the virus shook its health care system. As of December 10, 2020, approximately 120,000 infections had been officially recorded, a number that is certainly much lower than the real case count. Thousands have died, including more than 200 health care professionals working on the frontlines. Evidence indicates that another wave is building as recent cases and deaths are on the rise.

As social phenomena, epidemics and the responses they generate reveal much about a country’s political economy and a state’s relationship with its citizens. In Egypt, the manner in which President Abd al-Fattah al-Sisi’s regime has approached an epidemic of hepatitis C on the one hand and the arrival of the coronavirus on the other illustrate that the politics of healthcare in Egypt are evolving.

The regime has shown interest in addressing the major challenges that plague the healthcare system and with respect to hepatitis C, it invested significant capital and energy in advocating for the health of its citizens. But the fight against COVID-19 has exposed how its wide-ranging endeavor to quash dissent threatens the project of health care reform by alienating physicians and medical staff, some of the primary stakeholders in this system. Moreover, Egypt’s pharmaceutical industry stands to profit from the current pandemic through the manufacture of new vaccines and therapeutics, an area of the economy in which Egypt’s military is likely to carve a larger role for itself. It remains to be seen whether recent policy announcements will result in real investment and reform or whether these efforts will be hamstrung by the military regime’s authoritarianism and its efforts to deploy its power to confer economic advantage upon itself.

The Colonial Roots of an Epidemic

 

The roots of Egypt’s epidemic of hepatitis C can be traced to the environmental transformations of the late nineteenth century under British colonial rule. It was during this period that the country developed an agricultural economy rooted in the production of cotton for export, much of it shipped to textile mills in the north of England. Cotton was thirstiest when the Nile River was low. To provide it with water, irrigation canals and drains were dug throughout the Nile Delta and deep into central Egypt. To help fill these canals, the British directed the construction of the first modern dam, Khazan Aswan or the Aswan Low Dam, on the river.

The canals and drains that made cotton cultivation possible also sickened the farmers who relied on them for irrigation. Many were infected with the parasitic disease schistosomiasis—also known as bilharzia—which in Egypt is caused by the parasites of the Schistosoma haematobium and Schistosoma mansoni species. Schistosoma parasites and the tiny freshwater snails that are their intermediate hosts existed in abundance in the canals and drains that watered cotton. In rural communities, male farmers developed schistosomiasis in large numbers, as did women and children who relied on canals for their water needs. The symptoms of infection include fatigue, fever, aching, cough, diarrhea and blood in the urine. Chronic infections, which became increasingly common, can contribute to cancer of the bladder and cause high blood pressure through the liver, an enlarged spleen, the build-up of fluid in the abdomen and swollen areas in the esophagus and digestive tract that rupture and bleed. By the middle of the 1930s, approximately 60 percent of Egypt’s population was infected with Schistosoma haematobium, Schistosoma mansoni or both species of the parasite. In the heartland of cotton cultivation, sometimes as much as 90 percent of the population suffered from schistosomiasis.[3]

In 1920, the treatment of individuals infected with the widespread parasite began at Qasr al-`Ayni, Cairo’s main hospital. In the years that followed, the Public Health Department established parasitic disease clinics in large towns and at sites throughout the countryside. By the 1940s, nearly a half a million Egyptians passed through these facilities annually. Even as access to treatment spread, rates of infection remained stubbornly high. Most of those who were cured of the parasites that cause schistosomiasis were infected again after returning to the patterns of behavior that marked rural life. During the 1950s and 1960s, under the populist authoritarian regime of President Gamal Abdul Nasser, the state redoubled efforts to treat the disease by expanding public health outreach, establishing rural clinics and partnering with international health organizations. Despite these developments, schistosomiasis continued to impact a large portion of the population, especially those who lived in the countryside.

 

The Campaign to Eliminate a Lurking Virus

 

Inadvertently, the project to treat schistosomiasis infected many Egyptians with the hepatitis C virus. Until the 1980s, treatment for the parasite was administered by injection. When glass syringes were used, they were sterilized through boiling, which does not reliably eliminate viral contamination. In addition, in the midst of mass treatment campaigns, syringes were not always sterilized and on occasion the same syringe was used to inject multiple patients. Undetected, the hepatitis C virus began to spread exponentially in Egypt in the 1930s.[4] As treatment programs for schistosomiasis multiplied, the number of Egyptians who received injections, and thus the proportion of the population exposed to hepatitis C, increased.

During the 1950s and 1960s, it became evident that liver problems were widespread in Egypt. Infection with the hepatitis C virus causes damage to the organ as do severe cases of Schistosoma mansoni infection. Moreover, there was a strong overlap between patients infected with the parasite and those infected with the virus since those who received treatment for schistosomiasis were at the greatest risk of being infected with hepatitis C. While physicians often attributed the liver damage that they observed to Schistosoma mansoni, not all patients who presented with damage to the organ had been treated for schistosomiasis. Scientists first isolated the hepatitis C virus in 1989, and in the 1990s it became clear that hepatitis C infection was responsible for most of the liver damage that was observed in Egyptian patients.[5] The prevalence of the virus meant that it was also passed through blood transfusions, routine medical and dental procedures and contact among members of the same household.

State-supported treatment of hepatitis C began in 2007. One year before, the Egyptian government had formed the National Committee for the Control of Viral Hepatitis, whose members included a set of prominent physicians who had long lobbied the government to take action. Under the committee’s direction, a tiny subset of those infected were treated with the therapeutics available at the time. Seven years after the state’s treatment program began, the development of a new therapeutic by US-based Gilead Sciences made it possible to cure most patients infected with the virus, even those with more advanced cases of disease. The primary obstacle to obtaining such a cure was its high cost, which the government overcame by negotiating a reduced price with Gilead and funding treatment for most patients. While the cost of one month of treatment in the United States was $30,000, in Egypt, the cost of a complete course of treatment was reduced to just $1,650.[6]

The Egyptian government’s aggressive approach to negotiations with Gilead had roots in the early 2000s. It was then that the South African government allowed manufacturers of generic drugs to copy expensive HIV treatments in contravention of international patent law, changing how governments in the Global South perceived the possibilities structuring their relationships with large pharmaceuticals. When Egypt’s patent office rejected Gilead’s application and local pharmaceutical companies began to manufacture generic versions of the drug, the cost of hepatitis C treatment dropped even lower, to just $85. By 2018, more than 2 million Egyptians had been treated, or roughly 40 percent of infected individuals. To reach the remaining 60 percent, the government launched the 100 Million Healthy Lives campaign, which sought to identify all of those infected through nationwide testing and to treat those whose results returned positive. Between October 2018 and April 2019, approximately 80 percent of those targeted for screening were tested.[7]

 

Health Care Reforms Undermined by Authoritarian Impulses

 

In the past two years, the government’s efforts to address the prevalence of hepatitis C have been part of a broader endeavor to improve the quality of all medical care. In 2018, the World Bank funded the Transforming Egypt’s Healthcare System project, one plank of which is the control of hepatitis C. The state announced its support for universal health insurance and has begun to invest in improvements to the country’s network of public hospitals. Spending on health care also increased in the second half of 2019, which is notable because the state consistently underfunded this sector in the past.

While these programs have the potential to improve the quality of care for a large portion of Egypt’s population, how they will unfold and whether they will bear fruit remains to be seen. The health care expenditures outlined in the 2020–2021 budget do not suggest the type of significant investment that is necessary to produce real reform. The arrival of COVID-19 has illustrated—once again—that considerable changes will be required to improve medical care.

Egypt’s public hospitals are underfunded, overcrowded and poorly maintained. The fact that 68 percent of Egyptians opt to pay out of pocket for private medical care while 33 percent of the population lives below the poverty line is testament to this fact. As the coronavirus spread during the spring, doctors and patients both fell victim to these conditions. Physicians and nurses reported inadequate supplies of personal protective equipment and several hospitals closed after staff members were infected with the virus. Controversy emerged when it came to light that antibody tests were being used rather than tests for active infections. In May, a protest campaign began on social media that declared support for Egypt’s doctors. While health care deficiencies are not unique to Egypt, the arrival of a new virus is straining a system with few resources at its disposal and making victims of its physicians and medical staff.

For Egypt’s doctors, the regime has added the threat of its muscle to that of the virus. In the early days of the pandemic, the military regime celebrated physicians as warriors engaged in battle. But when these same warriors criticized conditions on the ground or took action to protect their own lives, sanctions were swift. On April 10, ophthalmologist Hany Bakr was arrested for a Facebook post that criticized the government’s decision to send protective equipment abroad while Egyptians suffered shortages. Bakr was later charged with spreading false news, misusing social media and joining a terrorist organization. In July, the Associated Press reported that at least ten doctors had been arrested since the pandemic began. In a well-known case, Alaa Shaaban Hamida, who was pregnant, was imprisoned after a nurse used her phone to report a case of infection to the Ministry of Health instead of to the hospital’s managers. When some doctors suggested they would stay home over concerns for their own safety, the state responded with condemnation and intimidation. The threats faced by Egyptian physicians highlight the contradictions that mark their professional lives: While they benefit from a certain amount of social prestige and have the potential to earn generous salaries, many doctors—in particular those who staff public hospitals—labor for very little pay and are subjected to violence from agents of the state and sometimes their own patients.[8]

While doctors work under threat, the regime is actively maneuvering to provide Egyptians with access to COVID-19 vaccines. Over the summer, the government announced a set of deals with different global players. In June it publicized an agreement with AstraZeneca, a pharmaceutical company headquartered in Britain, through which Egypt would receive the vaccine that is in development at Oxford University. Next came an announcement that the Chinese government had chosen Egypt to manufacture its vaccine for distribution in Africa. Production has ramped up in preparation for its release. At the end of September, Russia joined the fray: 25 million doses of its vaccine will be distributed in Egypt through the local Pharco Group. While there is still much uncertainty about specifics, the regime seems to have positioned Egypt strategically within global production networks so that it might benefit from the multiple processes of vaccine development underway.

The agreements to provide vaccines also potentially further the military regime’s own economic interests. The Egyptian military has long been engaged in a wide range of sectors beyond that of defense. After assuming power in 2013 it enlarged its role in the economy and in certain sectors maneuvered aggressively to edge out private actors. The military is not only involved in engineering mega projects that include the construction of infrastructure and new cities: It manufactures a wide range of consumer goods including food products, bottled water, household appliances and electronics. In 2016, after the government decided to float the Egyptian pound, the price of raw materials rose, affecting the manufacture of some essential drugs. To mitigate the crisis, the military stepped in and opened its own pharmaceutical company.

While there is uncertainty about the extent of the military’s presence in the pharmaceutical sector—recently it denied that it owned a chain of local pharmacies—developments in other areas of the economy suggest that it might seek to play a larger role in the future.[9] In addition to vaccine manufacture, there are opportunities to produce and distribute therapeutics. In June, Eva Pharma, an Egyptian generics manufacturer, began to produce the drug Remdesivir, which has been used to treat COVID-19 patients, after obtaining a license from Gilead to distribute it locally and to 127 other countries.

 

Authoritarian Medicine

 

In 2013, just a year before the hepatitis C treatment campaign began, the Egyptian military announced that it had developed a device that could detect and eliminate the HIV and hepatitis C viruses in the blood, transforming them in the process into nutrients like those present in kofta (a kabab of spiced meat). For many, the scandal that unfolded—known as “Kofta Gate” in some circles—was easier to swallow than the success of a treatment program sponsored by an increasingly repressive and violent regime. The government’s hepatitis C treatment program has enabled the authoritarian regime to curry favor with its citizens and lay claim to a public relations triumph. It has also cured millions of Egyptians of a disease that, for some, would have proved fatal. The pairing of effective public healthcare with aggressive authoritarianism is not a unique attribute of Sisi’s regime.

Nasser did much the same. Sisi, in his love of grand projects from the widening of the Suez Canal to the construction of a new capital city, seems to have deliberately chosen a strategy with resonance in Egyptian history. Egypt’s current president, however, does not have Nasser’s charisma nor is his regime associated with the type of popular ideology that helped fuel support for Nasser’s authoritarian state.

The current regime’s approach to the health care system also threatens to undermine its own objectives. Its attacks on doctors have alienated some of the primary players in Egyptian medicine just as the regime has made moves to reform the system. It also remains to be seen whether the military’s aggressive approach to cultivating its own economic interests will extend to pharmaceuticals and thus diminish opportunities for local actors. While the organization of the state’s hepatitis C program has demonstrated the power of partnering with caregivers and negotiating with global pharmaceutical companies, the treatment of a single disease is not the same as the provision of adequate health care. The repression and intimidation that have been on display during the COVID-19 pandemic do not bode well for the project of systemic reform, or for the health of Egypt.

 

[Jennifer L. Derr is an associate professor of history and the founding director of the Center for the Middle East and North Africa at UC Santa Cruz.]

 

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Endnotes

 

[1] Imam Waked, et al, “Screening and Treatment Program to Eliminate Hepatitis C in Egypt,” The New England Journal of Medicine 382/12 (March 19, 2020).

[2] “Coronavirus: Cairo May Become the Next Wuhan, Opposition Group Warns,” Middle East Eye, May 26, 2020.

[3] Jennifer L. Derr, The Lived Nile: Environment, Disease, and Material Colonial Economy in Egypt (Stanford, CA: Stanford University Press, 2019), pp. 103–108.

[4] O. G. Pybus, “The Epidemiology and Iatrogenic Transmission of Hepatitis C Virus in Egypt: A Bayesian Coalescent Approach,” Molecular Biology and Evolution 20/3 (March 1, 2003).

[5] G. T. Strickland, “Liver Disease in Egypt: Hepatitis C Superseded Schistosomiasis as a Result of Iatrogenic and Biological Factors,” Hepatology 43 (2006).

[6] Waked, et al, p. 1166.

[7] Ibid, pp. 1166, 1168.

[8] “Coronavirus: Egypt’s Doctors Outraged as Prime Minister Blames them for Deaths,” Middle East Eye, June 24, 2020. Marwan Shalaby, “Doctors in Egypt’s Hospitals Get Beaten Everyday. Who Is to Blame?” Egyptian Streets, September 11, 2018. 

[9] Taarek Refaat, “Military Denies Possession of Pharmacy Chains,” Sada Elbalad English, August 28, 2019.