Making Things Complicated

In August 2012, Hisham Salah was in his own neighborhood of Al-Manial when he was shot during clashes between pro- and anti-Muslim Brotherhood groups. His friends immediately took him to the nearest hospital — Qasr El-Aini in Garden City. They now say it was the worst decision they ever made.

Salah’s family claim that he was kept in the emergency room three days before doctors operated on him, but they could not remove the bullet. Four days after the operation, his temperature spiked dangerously. His family knew that there was something wrong, but they allege none of the hospital’s doctors knew why Salah’s temperature was rising. It was only after the family transferred him to a private hospital in Mohandiseen that the doctors diagnosed Salah with a salmonella infection, caused by bacteria found in feces. The family members claim Salah contracted the infection during his operation in Qasr El-Aini.

On its website, the 12-story, 1,200-bed Qasr El-Aini hospital proclaims itself an icon and a milestone in the world of medicine. It is certainly one of the best known of the nation’s public hospitals, attracting poor and middle-class Egyptians who cannot afford care in private hospitals, where the simplest operation can cost up to LE 30,000. It may be an icon, but it is also a symbol of the decaying national health care system.

Salah is a victim of what is known in the medical community as a healthcare associated infection (HAI), contracted during a hospitalization and often resulting in an additional week or more of medical treatment. It’s a global problem, but in developing countries like Egypt, the rate of infection is higher than the global average, occurring in 15 percent of Egyptian surgical and intensive care patients compared to 13 percent of hospital patients globally, according to the World Health Organization (WHO). Many cases of HAI can be prevented with basic hygiene procedures.

“It is very obvious that there is negligence inside  Qasr El-Aini,” asserts Ahmed Salah, Hisham’s brother. “Everything was dirty: cats all over the hospital, insects [everywhere] and bloodstains on the floor. When my brother Hisham was inside the emergency room we all could go in and out unsupervised, because the man who was guarding the door was too busy smoking a cigarette 20 feet away from my brother and the [fourteen other] patients in the ER.”

In March 2013 Salah transferred to a hospital in Germany, where he is still receiving treatment for the infection, the bullet and the spinal cord injury it caused.

“I received the worst medical care ever at Qasr El-Aini,” Salah told Egypt Today over the phone. He also claims that doctors there failed to diagnose a spinal cord injury even though he constantly complained of back pain.

“Aside from the fact that they barely had medications,” recounts Salah, “when I was told I needed a blood transfusion, my family had to buy it from the blood bank because the hospital didn’t have any. The nurses were extremely unprofessional and unhygienic and all I was thinking of at the time was that I couldn’t bear the smell of cigarette smoke that filled the ER from the security man’s cigarette.”

Qasr El-Aini Hospital has no visiting hours, and many people who get in end up camping inside the hospital to be with their sick relatives or friends. It’s not uncommon to see people with blankets sleeping in the hallways, smoking and eating.

On a recent visit to investigate the allegations, this reporter was met with a trail of bloodstains on the floor leading all the way inside the emergency room. When asked to call someone to clean up the blood as it was unhygienic and probably infectious, the security guard at the main gate glibly replied, “Don’t worry about it, it will soon dry up.”

Inside the ER, the ceiling was leaking above the patients, trashcans were overflowing, and syringes were thrown on the floor. Insects buzzed and crawled around — there was even a rat. The bathrooms were filthy, and people were smoking anywhere they pleased.

“Cases like Hisham’s are very common in the hospital,” says Dr. Khalid Mohamed Mansour, who works in Qasr El-Aini. “It’s not the doctor’s job to sanitize his equipment. It’s the nurse’s job, and because of their ignorance they do not believe that they have to [do this] after every operation. […] We filed hundreds of complaints but what do you expect when the [former] Health Minister herself, Dr. Maha Al-Rabbat, says on television whenever you see a cat just shoo it instead of taking a picture of it?”, referring to an incident in February 2014, when TV show host Wael Al-Ebrashi confronted Al-Rabbat with a picture of a cat curled up on a hospital bed at a government-run hospital.

“It’s impossible for us doctors to work in such an environment and give 100 percent,” Mansour continues. “The hospital administration are never available, and we, as Egyptians, we do not give 100 percent unless the management is there to observe and punish those who are not doing their jobs. I blame the janitors and the nurses, and of course I blame the hospital’s management.”

Naglaa Mohsen, a nurse who used to work at Qasr El-Aini, agrees with Mansour. “No one can deny that there is of course negligence inside the hospital, from the nurses, the janitors and the doctors; but above all the administration is most negligent. Whenever we ran out of alcohol, which we used to sterilize the equipment, the administration always told us to use hot water instead because they were reducing costs by not buying the alcohol. We used to bring our own water boilers to sterilize the equipment before the doctors used them to operate. This unprofessional atmosphere is what led me to quit the hospital and join a private facility.”

Egypt Today’s attempt to speak with administrators for a response to the complaints of negligence ended with our reporter being escorted off the premises by security guards.

Dr. Mohamed Sayed Hassanein, official spokesman at the Ministry of Health, says, “The government is well aware of the transgressions in the hospital and we are doing our best to turn Qasr El-Aini Hospital into the best place for treatment in all of Egypt.” When asked how and when the ministry planned to do this, Hassanein declined to answer.

In the area of HAI, at least, Qasr El-Aini has made some small progress over the years. In the article “Nosocomial Infections: A Study Among Surgical Patients in Kasr El Aini Hospital,” published in the July 1998 issue of The Egyptian Journal of Medical Microbiology, a group of Egyptian physicians reviewed cases in 10 of the hospital’s surgical units for HAI cases and found an infection rate of 12.1 percent. The researchers called for stricter surgical and antibiotic protocols, concluding, “An improvement in this situation will only be achieved by a greater commitment from health authorities and hospital administrators to solve the problem. More investment in targeted research and in establishment of effective infection surveillance and control programs will inevitably result in better healthcare and a consequent improvement of hospital costs.”

In 2009, a similar study reviewed two of Qasr El-Aini’s surgical units. The paper “Incidence and Predictors of surgical site infections at Cairo University Hospitals,” published in the January 2012 issue of The Egyptian Journal of Community Medicine, found an HAI rate of 9 percent. While it was lower than the 1998 study, researchers concluded, “[Surgical Site Infection] rate was found to be quite high in comparison to developed countries,” and recommended the “establishment of an organized SSI surveillance programs in Qasr El-Aini Hospital.”

Amr Imam, a lawyer specializing in human rights, says that since 1998, 49 lawsuits by different lawyers have been filed against Qasr El-Aini Hospital; seven of which were related to “lack of hygiene,” 28 lawsuits were against doctors working in the hospital, three were against the hospital’s security personnel, another three alleged “black marketing of blood and organ donations” at the hospital as well as eight others. No verdicts have been issued in any of the cases.

“In any advanced country, and in some third-world countries, if a patient or any visitor came across negligence in a hospital and went to the authorities, this hospital would be immediately subjected to a fine — and sometimes it goes as far as imprisonment of the ones responsible,” Imam says. “But here in Egypt matters go differently. Since negligence in hospitals goes beyond Qasr El-Aini, here the minister himself should be subjected to trial, and whether he wins or loses the case, he should submit his resignation. This goes beyond the administration of Qasr El-Aini; this hospital is the government’s responsibility and they should start acting responsibly toward it.”

“The main reason that Qasr El-Aini is a free hospital is because the students of Cairo University’s faculty of medicine get to be trained at the hospital, so the probability of operational errors is very high,” says Dr. Samar Hanafi, a senior advisor with the Egyptian Doctors Syndicate. “We all agree that the hospital is among the worst in the world; so try to imagine the standards that we are setting for our future doctors,” says Hanafi, who argues, “It’s not the doctor’s responsibility to make sure that the hospital is clean, they have a lot on their plates to begin with, but we all take matters into our own hands since that we already know that no one else will. But it’s very tough to try and coordinate our time to see patients, operate and assign janitors to clean the hospital bathrooms, hallways and stairs.

The conditions are so dire, Hanafi claims, “No one wants to work because they do not get properly paid,” Hanafi continues. “The janitor shows his face in the morning because that is the only way he will get paid 500 pounds at the end of the month. The government needs to work on generous salaries for the doctors, nurses, janitors and security of the hospital so that they realize the importance of the positions they are holding. We have contacted the minister of health, the governor, the prime minister and even the president hundreds of times, but all we get are false promises.”

Part of the problem is that there is no independent body to monitor healthcare facilities. In the United States, for example, the Joint Commission is a non-profit organization that audits and certifies healthcare facilities that meet a set of standards.

“There should be a group of doctors, preferably from the Egyptian Doctors Syndicate, to serve as a watchdog over Qasr El-Aini and all public and private hospitals, to ensure that they are performing the way they should be,” says Imam. “Those doctors should be appointed by the Ministry of Health to provide detailed analysis of the performance of the hospitals in Egypt, and give suggestions on how to improve the quality of the medical care provided.”

Salah isn’t the only one leaving the country in search of decent healthcare. In an informal poll, Egypt Today asked people in Egypt and abroad to list reasons why Egyptians would immigrate to another country. Healthcare was a common response, given as much weight as decent jobs, education and security.

Hassan Hassan, an Egyptian engineer who moved to the UAE, sums it up: “Egyptians immigrate to other countries because the life of an Egyptian citizen in Egypt has no value. People prefer going to countries where they treat humans humanely, and they fear for the person’s welfare. I decided to live abroad when I realized that I cannot trust the Egyptian hospitals in case I, or any member of my family, got sick. And at some point everyone needs to visit a hospital.”