CAIRO — As the pandemic swept up the Nile this spring, one idealistic young doctor at a bustling Cairo public hospital at first grew anxious.
Then he became angry.
Patients were flooding through the hospital doors but resources were alarmingly scarce. Doctors lacked protective equipment, often making do with a single mask for a 24-hour shift. Testing kits were in short supply. Colleagues and friends caught the virus. Several died.
Six years earlier, President Abdel Fattah el-Sisi of Egypt had vowed to put health care reform “at the heart” of his agenda.
It didn’t work out like that.
Egypt’s public health system was straining badly, the doctor, Ibrahim Bediwy, 27, warned in a message posted online in May. “Any doctor in the current situation is not safe,” he said. “And neither is his family.”
Days after Dr. Bediwy’s post, Mr. el-Sisi’s security officials burst into his parents’ home and whisked him away. He now faces a raft of terrorism-related charges.
For almost every nation on earth, — including the richest —not only has the coronavirus proved an extraordinary, often humbling challenge, it has brought a political reckoning for their leaders. It lifted the fortunes of some, while endangering the futures of others.
In Egypt, the pandemic offered Mr. el-Sisi a chance to showcase the sweeping health care reforms he promised in 2014, at the start of his presidency. Instead, it exposed chronic weaknesses.
In the early months of the crisis, overstretched hospitals struggled badly. Angry doctors went on strike, and those who dared criticize the government’s efforts were thrown in jail. Egypt soon had one of the highest fatality rates in the Arab world.
At the same time, Mr. el-Sisi continued to cut subsidies to the poor while splurging on arms deals for warships and fighter jets totaling at least $12 billion.
Mr. el-Sisi can claim some credit for his pandemic response. With more than 109,000 declared cases and 6,380 deaths, Egypt has been nowhere as badly hit as Europe or the United States.
Yet testing levels remain strikingly low, at 953 tests per 100,000 people, according to data Egypt reports to the World Health Organization, which means that large numbers of cases are likely going undetected. Concerned health experts say this approach is giving the public a false sense of security.
“People tend to believe the pandemic is over,” Dr. Pierre Nabeth of the World Health Organization told a news conference in Cairo last month. “This is an alarming situation because in fact the winter season is starting.”
In the region, Egypt’s testing rate exceeds only the figures of countries in crisis like Yemen (33) and Syria (199), and is far behind Iraq (7,554), Jordan (20,540) and even war-torn Libya (5,421).
And the fragility of Egypt’s underfunded public health system, exposed in the early days of the pandemic, highlights a core element of Mr. el-Sisi’s harsh rule, where a tiered system of privilege perpetuates inequality and rewards a powerful military — often at the expense of an increasingly poor citizenry.
“Weapons purchases and vanity megaprojects have been his priorities, even during the pandemic,” said Michele Dunne, an Egypt scholar at the Carnegie Endowment for International Peace. Egypt’s military has become “increasingly rapacious” under Mr. el-Sisi, she added. “And that has diverted scarce government resources from the critical needs of the Egyptian people.”
WHAT WE FOUND
An Autocratic Compact, Not Kept
Mr. el-Sisi broke his first promise to Egyptians almost as soon as he made it.
Hours after he swept to power in July 2013, backed by troops and tanks, Mr. el-Sisi, then a general, declared that Egypt’s armed forces had no desire to rule.
“They are out of politics,” he said.
It soon became clear, however, that Mr. el-Sisi had no intention of relinquishing power. In June 2014, he won a pro forma presidential election with 95 percent of the vote.
The night he was inaugurated, he delivered a speech that amounted to an authoritarian compact with Egyptians.
In return for limiting political freedoms, Mr. el-Sisi pledged security, prosperity and vastly improved public services. Reforming the health care system was “at the heart” of his plans.
Budgets would soar and new hospitals would be built. Underpaid Egyptian doctors, who had been emigrating to oil-rich Persian Gulf countries in droves, would get a pay rise.
Underpinning those promises was a new Constitution that committed the government to spending 3 percent of Egypt’s gross domestic product on health care every year, effectively doubling the former amount.
But Mr. el-Sisi’s ambitious agenda quickly ran into stiff headwinds. An exploding Islamist insurgency in Sinai blunted his promise of security. A currency crash in 2016 led to painful economic reforms that hit Egypt’s poor the hardest. By last year, the government’s own figures showed that one-third of Egyptians lived in poverty, up from 28 percent in 2015.
Then the pandemic hit.
WHAT WE FOUND
Military comes first. And second. And third.
In the early stages of the virus, it appeared Mr. el-Sisi’s reputation might be burnished by Egypt’s response.
He turned to the military to project an image of swagger and competence. Slick government videos showed soldiers in chemical warfare suits striding through empty streets, spraying disinfectant. Serried rows of military ambulances lined up in the desert, awaiting patients.
Mr. el-Sisi even turned the crisis into a public relations opportunity, dispatching planeloads of medical supplies to other countries in a pointed display of strongman largess.
It was emblematic of the way Mr. el-Sisi has run Egypt, where army generals and security officials dictate who sits in Parliament and even censor soap operas.
Egypt was the world’s third-largest importer of weapons between 2015 and 2019, according to the Stockholm International Peace Research Institute. Mr. el-Sisi has also committed $58 billion to a sprawling new capital under construction in the desert outside Cairo.
Health budgets rose, too, thanks in part to offshore gas discoveries. But Mr. el-Sisi remains far from his targeted spending of 3 percent of gross domestic product — last year, the figure was between 1.3 percent and 1.8 percent, by different estimates.
Egypt is hardly at the bottom of the list. Indonesia, an economic peer, spends 1.4 percent of its gross domestic product on health. Pakistan clocks in at 0.8 percent.
But in Egypt, where the health care system is fragmented along class lines, the standard of care received by a patient may depend on their status or job.
Of the country’s 740 public hospitals, about 25 cater to the military and another 110 are run by universities or treat police officials and some civil servants.
At the bottom of the ladder are about 600 public hospitals, many in poor condition, where the pandemic hit hardest.
In its fight against the coronavirus, Egypt has sought to balance public health with protecting its economy, World Health Organization officials said. The government eschewed widespread testing, which would be expensive in a country of 100 million people, in favor of allocating resources to hospital care and public awareness campaigns.
Even so, when the first peak hit around April, many patients in Cairo struggled to get treated, doctors went on strike, and the medical doctors’ union warned that the health system was under great strain and headed for “catastrophe.”
The coronavirus response was “typical of Egypt under Sisi,” said Nadim Houry, executive director of the Arab Reform Initiative. “On the surface, things seem to be under control. But underneath, the story is not so good.”
Egypt’s health ministry and the State Information Service did not respond to questions.
What We Found
Failure to Halt an Exodus
Even before the pandemic, the doctors who were key to fulfilling Mr. el-Sisi’s health care promise had continued to flee Egypt, seeking higher wages and better working conditions.
The number of doctors at government hospitals declined from 113,100 in 2014 to 75,700 in 2018, according to government statistics. Just over half the country’s 220,000 registered doctors work abroad, according to the main doctor’s union.
The virus further thinned their ranks.
At least 203 doctors have died, according to Egypt’s main doctors union. Indonesia, which has recorded almost four times the cases of Egypt, has lost 130 doctors.
Upon graduation, doctors earn no more than $190 a month — barely enough to get by. And they and other health professionals continue to head for the airport.
Islam el-Sayes, a pharmacist, earned $300 a month and traveled in cramped buses when he lived in Alexandria. Now working in Saudi Arabia, he has his own car.
“Our leaders spend money on the military, judges and Rafales,” Mr. el-Sayes said, referring to a kind of French warplane. “But not on doctors, hospitals or people.”
What We Found
Some Victories, and Ambitious Plans
Mr. el-Sisi can claim some victories. Life expectancy continues to rise, reaching 72 in 2018. A campaign to eliminate hepatitis C has achieved remarkable progress.
An ambitious new health insurance system promises to revolutionize public health care by regulating quality and ensuring even the poorest Egyptians have access to good treatment. But the new system will take up to 15 years to roll out.
“The early indications are that it’s working,” said Amr el-Shalakani, a senior health specialist at the World Bank, which has contributed $400 million to the first phase.
To fight the pandemic, Mr. el-Sisi allocated $6 billion for an emergency plan that included monthly payments to 1.5 million jobless laborers. And his decision to avoid a hard lockdown may be paying economic dividends.
This coming fiscal year Egypt’s G.D.P. will grow by 2.3 percent, according to the World Bank — far less than is needed to sustain the country’s soaring population, but more than nearly every country in the region.
WHAT WE FOUND
‘A Tragic State’
One promise made by Mr. el-Sisi in June 2014, which he has kept, was to show “no leniency or reconciliation” to his perceived enemies — a category that widened during the pandemic to include dissenting doctors.
Dr. Bediwy remains in detention, one of at least nine medical workersimprisoned for criticizing the government’s handling of the pandemic, according to Amnesty International. His wife gave birth to a daughter, Maria, last month.
The arrests are a test for the World Bank, which in March announced it would not tolerate “reprisals and retaliation against those who share their views about Bank-financed projects.” The Bank has pledged Egypt $58 million in Covid relief.
A spokesman for the World Bank declined to comment on whether the arrests of doctors would affect aid to Egypt, while noting the anti-reprisal policy “applies to all projects approved in support of Egypt.”
Now, as fears of a second wave loom large, disillusioned young doctors continue to emigrate.
Nermene, 27, recently moved to the United States, where her sister, a dentist, already lives.
“It’s not a nice feeling to have to leave home for work,” she said, requesting partial anonymity to avoid reprisals against her family. “But Egyptian hospitals are in a tragic state.”
The Takeaway: Political freedom or better social services? Egyptians got neither under a president who prioritizes the military.
Sheri Fink and Nada Rashwan contributed reporting.