[Neither the Arab world nor Africa have figured prominently in reporting about the COVID-19 pandemic. Despite serious challenges and what are in many cases under-funded and poorly staffed health systems, these regions have—despite suggestions of incomplete reporting—generally avoided the horrific death rates experienced in Europe and the Americas. At the same time, they have, like all societies, experienced the public health, social, and economic impacts of the pandemic. Mouin Rabbani, editor of Quick Thoughts and Jadaliyya Co-Editor, interviewed Khaled Fahmy, Professor of Modern Arabic Studies at the University of Cambridge, Fellow of the British Academy, and a leading historian of modern Egypt, to get a better understanding of the pandemic’s impact upon one the Arab world and Africa’s central states. This interview was conducted in late September 2020 and includes data valid at that time.]
Mouin Rabbani (MR): Egypt's population exceeds that of most of the rest of the Arab world combined. It is the third most populous country in Africa, and its capital Cairo is one of the world's largest and most congested cities. Yet there has been very little coverage of how the COVID-19 pandemic has affected Egypt. Are things going that well in terms of infection rates, fatalities, and the like, or is this a case of media attention being primarily focussed elsewhere?
Khaled Fahmy (KF): Given the size of Egypt’s population, which is nearly 101 million, the overall infection rate in the country is relatively low. According to the Johns Hopkins University COVID-19 dashboard, Egypt as of mid-September 2020 had 102,000 recorded cases, with an incidence rate of ninety-nine per 100,000 (compared to 2,328 in Kuwait, 2,180 in Israel; 1,114 in South Africa; 847 in KSA; 429 in Lebanon; and 275 in Morocco). Since the outbreak of the pandemic and through mid-September, Egypt experienced 5,787 fatalities due to COVID-19. These figures put Egypt in the thirty-first place globally.
The first case was officially recorded on 14 February, and the daily number of confirmed cases reached a peak on 18 June; since then, the curve has been declining. However, on 16 September, the minister of health, Hala Zayed, said that the country is bracing itself for another wave.
In preparation for a possible second wave, the minister of health announced plans to increase the country’s reserves of medical supplies, increase PCR testing, tighten testing at airports, and plan for the production and distribution of a vaccine. Most significantly, on 18 July, the minister of health said Egypt had signed a deal with the British-Swedish pharmaceutical company AstraZeneca in collaboration with the University of Oxford to reserve thirty million doses of their vaccine.
MR: To what extent did the government prepare for the pandemic, and how has it responded since the virus arrived in Egypt?
KF: The health care system in Egypt is an old and robust one, with its origins dating back to the beginning of the nineteenth century. Suffice it to say that Egypt was one of the first countries in the world to have a nation-wide smallpox vaccination program, and it was also a pioneer in having put in place a sophisticated system of collecting vital statistics which enabled it to conduct the first census in the region in 1848.
Despite its long history, the health system has serious fault lines, which became more apparent in the wake of the COVID-19 pandemic. For one thing, the health care system is inequitable, with rural areas, especially in Upper Egypt, suffering disproportionally.
The system also has serious gaps and shortcomings. For example, despite Egypt having the oldest medical school in the region (Qaṣr al-‘Aini Hospital, which is Cairo University’s School of Medicine), the country has a physician density rate of 0.8 physicians per one thousand of the population, at a time when the World Health Organization (WHO) estimates that at least 2.3 health workers per one thousand would be required to achieve coverage of primary healthcare needs. The country also has a low hospital bed density of 1.43 per one thousand according to the WHO, and 1.35 according to the official Central Agency for Public Mobilization and Statistics (CAPMAS), which puts Egypt in 119th place globally. More seriously, this figure has been deteriorating steadily over the past two decades: in 2002 the figure was 2.1 per one thousand. Furthermore, despite the government having taken the first steps towards providing comprehensive national health insurance coverage, seventy-two percent of healthcare costs are still covered out of pocket.
MR: How has the health care system in Egypt responded to the crisis, and have health care workers, media, and others been able to provide the public with relevant information, and openly discuss government policy?
KF: While the government response to the crisis was competent in the beginning, over time it became clear that it was incapable or unwilling to tackle both the structural and contingent problems of the health system, with the result that both health workers and the public at large felt betrayed by a government that was supposed to protect them during this crisis.
A stimulus package worth some 6.13 billion US dollars (1.8 percent of GDP) was announced to mitigate the economic impact of COVID-19. Interest rates were reduced on loans to the tourism, industry, agriculture, and construction sectors.
In April, Minister of Finance Mohamed Maait stated that the planned budget would see a forty-six percent increase in government spending on health in fiscal year 2020-21. This would translate into an increase in the percentage of government spending on health care from 1.19 percent to 1.37 percent of GDP. Contrary to the minister’s claims, this falls far short of the three percent constitutionally stipulated percentage, and constitutes the third lowest annual expenditure on health during the past seven years.
By June, the government announced that 376 hospitals had been earmarked for treating COVID-19 patients. Despite this, there was widespread reporting that hospitals were overwhelmed. Nevertheless, at the same time, i.e., mid-June, which saw the first peak of the pandemic, the government insisted that state hospitals had only reached eighty-four percent of their maximum capacity. This was despite widespread complaints from the public that people were having difficulties being admitted to hospital and were being turned away from them.
In addition to the problem of hospital beds, there have been consistent complaints of insufficient and faulty testing. According to the Committee for the Right to Health, an independent NGO, only 0.13 percent of the population has been tested for COVID-19, which is a very low percentage globally and which may explain the relatively low incidence rate mentioned above. Moreover, Egypt primarily relied on antibody rather than PCR tests, and according to the WHO the former are not as reliable as the latter. Egypt used this test in airports to check arriving passengers, as well as in hospitals for health workers. BBC reported in August that this had adverse consequences and may have inadvertently spread the virus given the incidence of false negative results.
Most seriously, right from the beginning of the pandemic, there were widespread complaints from healthcare workers that they were not being adequately protected and that the government was callous and negligent with respect to the provision of proper testing, sufficient and suitable Personal Protective Equipment (PPE), and the implementation of credible and equitable staffing plans. Seeing many of their colleagues falling prey to the virus, and a large number of doctors dying, doctors at a Cairo government hospital in May submitted a collective resignation.
On 23 June, Prime Minister Mustafa Madbouly put the blame on doctors, asserting that the hike in the number of COVID-19 fatalities was due to doctors not reporting to work. This triggered an angry response from the Doctors’ Syndicate, which said that doctors were neither negligent nor inconsiderate towards their patients. Despite the prime minister’s office issuing a faint clarification about this provocative accusation, it was clear that the government would not tolerate any criticism of the way it was handling the crisis. A doctor who asked Madbouly to provide an unequivocal apology was promptly arrested. Soon thereafter, several other doctors were also arrested for raising questions about the government’s response to the pandemic.
Indeed, from the very beginning of this crisis, the government has clearly indicated that it will not tolerate any criticism. In March, it announced that it would issue a fine of 20,000 Egyptian pounds (approximately 1,300 US dollars) to anyone who spreads “false rumours” about the pandemic. In June, Amnesty International published a report in which it documented the cases of at least six doctors and two pharmacists who were arrested for criticizing the government’s handling of the pandemic. In July, the Associated Press reported that rights groups documented the cases of ten doctors arrested for the same reason.
Like other governments around the world, the Egyptian government has taken advantage of the COVID-19 pandemic to justify and divert attention from crackdowns on press freedom. Accordingly, it was not only doctors who were arrested; any and all dissenting voices are muzzled.
The authorities started with foreign journalists, sending a clear signal about their tolerance for reporting about the government’s handling of the pandemic. In March, the New York Times’ Cairo bureau chief, Declan Walsh, was censured for “showing bad faith to harm Egyptian interests.” That same month Ruth Michaelson, The Guardian’s correspondent, was expelled from the country for questioning the official tally of cases. The government then turned upon Egyptian journalists. In May Lina Attalla, editor-in-chief of Mada Masr, was arrested. The following month it was the turn of Nora Younis, editor-in-chief of al-Manassa. Mohamed Monir, a journalist who had appeared on Al Jazeera, was also arrested, in his case “for spreading false information”. He was released ten days when it was discovered that he had COVID-19. He died shortly thereafter.
MR: Prisons have emerged as an area of particular concern worldwide because they are by nature susceptible to disease transmission. In Egypt, there is the added factor of a large and growing prison population since General Sisi seized power in 2013. What are your main observations in this respect?
KF: In the wake of the pandemic, health conditions in prisons all over the world have become a subject of deep concern. Being enclosed, crowded places, prisons are particularly vulnerable environments, in which the virus can easily spread. However, this concern about the health conditions of prisons is most acute in the case of Egypt, where prisons are notoriously overcrowded and where complaints about unsanitary conditions were common even before this pandemic.
To understand the gravity of the situation regarding hygiene in Egyptian prisons we need to keep two things in mind. The first is the huge increase in the prison population. The second is the very dangerous transformation in penal policy that the regime has implemented during the past five or six years.
The expansion in the Egyptian prison population is due to a surge in the number of political prisoners, and specifically to the increased recourse by the Egyptian authorities to a recent legal amendment that allows for pretrial detention to be used as punishment. The background to this change in the law is the current regime’s determination to prevent the recurrence of mass demonstrations like those during the events of 2011- 2012.
The result has been a huge increase in the prison population, and dangerous over-crowdedness in prisons. While the state has built many new prisons to alleviate the pressure on existing places of incarceration, these are still dangerously overcrowded. A report published by the Egyptian Initiative for Personal rights states:
[M]ost prisons do not have beds… Prisoners sleep on the floor using blankets brought to them from outside. The space of the room or cell is divided between the prisoners, sometimes down to the centimeter. The per-person share might be the span of a hand and two fingers or the span of a hand a fist… [One of the prisons] has very small cells big enough only for one person, but accommodating more than 13. [In another prison] the rooms are no bigger than 3 by 15 meters but hold 33–34 persons.
According to a 2016 Human Rights Watch report, Egyptian prisons were already operating at 150 percent of their capacity. And according to the official Egyptian Council for Human Rights, the overcrowded conditions of prisons in and of itself constitutes a health hazard.
The second reason behind the dangerous increase in the Egyptian prison population is the development of a new penal policy that is informed by neither constitutionalism nor legality, let alone principles of justice or human rights, but rather by a vendetta against activists, against youth, against any form of political mobilization, and a determination to prevent the revolutionary moment of 2011 from being repeated. And the tools that the government is using to achieve this end are the illegal tools of forced disappearance, arbitrary arrests, and pretrial detention whereby people are imprisoned indefinitely.
There is also a return to an older philosophy of punishment in which prisons were seen as places of exile, banishment, and even death. People are now thrown into prisons without being sentenced. They are incarcerated in order to be forgotten, to rot, and to die. Egyptian prisons have therefore once again become sites of imminent danger.
It is true that COVID-19 is a global pandemic threatening the population of the entire planet. However, the vindictive, short-sighted policy of the current Egyptian regime is making the pandemic much more dangerous and lethal. By refusing to heed the call of human rights groups to release political prisoners who are illegally detained, the Egyptian authorities are not only endangering the lives of thousands of innocent detainees; they are also exacerbating the public health crisis that Egypt is facing with COVID-19.