The mental health system is under stress and seems frozen in the past, lacking the impetus needed to respond to the requirements of a society in transformation.
For Algerians having to care for sick relatives, the search for professional treatment is no picnic. Finding psychiatric care is even harder. Take this woman with features drawn by sleepless nights seated in the waiting room of an Algiers hospital that dates from the turn of the 20th century and who never takes her eyes off the man sitting next to her. It was a real achievement bringing him here all by herself to consult a psychiatrist.
Quizzically she surveys the crowded room where the psychiatrist on duty is doing his best to oversee the arrival of emergency cases, often with the clamours of agitated patients, at the same time as the regular appointments. The woman hopes for an admission which would relieve her of the extenuating surveillance of a bipolar male in crisis, but she has no guarantee. This typical scene is a good illustration of the situation of mental health care in Algeria: an increasing need for treatments and a system which is unable to cope.
Massive departure of specialists
In a country which ‘has trouble with statistics’ it is hard to get a precise idea of the mental health situation. But various projections attest to the existence of a worrisome situation. In 2007, a Swiss study on mental health around the world revealed that at least two million Algerians (out of 33 million) needed psychiatric care. The estimations made public at an International psychiatric conference in Algiers were relatively modest by comparison with a US study which estimated that between 10 and 12% of Algerians suffered from mental diseases.
In 2012, Farid Chaoui, a gastroenterologist at Kouba Hospital in Algiers gave an interview to The Nation in which he drew an alarming picture of the state of mental health in his country, aggravated by the massive exodus of specialists during the dark decade.
Ten years later, practitioners observe some improvement, while underscoring the need for a real ‘metal health policy’. A few official figures give us an inkling of the dimension of the problems. In 2017, mental diseases, at 5.44%, were ranked as the sixth most frequent pathology. In 2020, according to the National Institute of Public Health (INSP), nearly half a million Algerians suffered from schizophrenia and there were just as many cases of bipolarity.
In this complex and piecemeal tableau, a human raster emerges composed of individual challenges and systemic failings. And it is obvious that the country is facing a proliferation of mental disorders requiring an adaptation of care in terms of prevention, treatment and rights.
Algeria is affected by five of the century’s most prevalent pathologies: schizophrenia, bipolar disorder, addictions, depression and obsessional-compulsive disorders. Aside from these ills identified in the WHO’s classification, Algerians have known periods of mass violence which gave rise to disorders of post-traumatic stress which remained untreated.
Farid Chaoui insisted on one rather unique characteristic:
Ours is a population caught between two major traumatic events, the war of liberation, on the one hand, and a civil war on the other. And between the two, the generations overlapped. The one that lived through the war of liberation and was subjected to its traumatisms was never treated psychologically (…) Moreover, that generation underwent, along with others, the civil war, also very stressful or even more so than the war of liberation in terms of psychological shock.
A society collectively impacted by a traumatism that was never recognised and never treated? The question is a subject of debate even if some do see it as an explanation for the latent violence and the deviant behaviours to be observed today. Besides which, the country has experienced major natural catastrophes and mutations in the family structure linked to a runaway demography which have affected the mental health of Algerians, as was emphasised in the National Plan for Mental Health for 2017–2020.
Measures have been implemented to improve health services, but the multiplication of mental disorders is a challenge for all those involved in health care, social well-being and politics. Psychiatric consultations represent approximately 1.5% of all medical consultations, while 7% of all chronic affections are mental diseases. All the data available, though quite disparate, speak of a significant decline in the mental health of the nation.
Significant regional disparities
Algeria has 19 specialised psychiatric hospitals, 27 psychiatric services in public hospitals and six services in university hospital centres.
These structures total 5,299 beds with a ratio of 131 beds for 10,000 inhabitants. As for the local facilities, there exist 161 intermediate mental health centres out of the 188 planned in the National Mental Health Program. As for the structures aimed at preventing and combatting addiction, 42 intermediate addictology centres are in activity out of 53 provided for in the program. Very few psychiatric hospitals have been built since independence which conveys a notion of the very relative importance attached to mental health. In point of fact, the health system does not respond to an increasingly urgent demand, exacerbated by huge regional disparities.
The Northern regions of the country are much better endowed, with 83% of high-level care facilities concentrated in that privileged zone, especially thanks to five out of the country’s six university hospitals. A concentration, however, which goes hand in hand with a distressing reality: 77% of the wilayas1 cannot provide the most basic treatments, which seriously diminishes the overall availability of medical care.
According to hospital practitioners, the country has improved the quality of psychiatric treatment, especially in structural terms. According to Othman Telba, head of the psychiatric service at the Biskra Hospital,
There are new specialised structures, and many psychiatrists have been trained in recent years. However there remains a lot to be done, in terms of personnel or equipment or accompanying social support.
We hear the same story from Mohamed El Amine Bencharif, head of the legal psychiatry service at Frantz Fanon Hospital in Blida, who feels that the number of hospitals and psychiatrists is globally appreciable but that there are still many shortcomings to be addressed:
It is undeniable that the mental health system in Algeria is faced with structural problems. Care is centred around hospitalisation. This “hospitalo-centrism” is expensive, inefficient and hinders the development of alternative treatments.
As for the development of drug therapy, both physicians agree that efforts have been made, but that ‘the availability of medicaments remains a problem, aggravated by repeated stock shortages,’ says Dr. Bencharif. In his view, it is imperative to make treatments more easily accessible, to promote recourse to psychotherapy and to create structures facilitating the post-cure transition for patients, as close as possible to their usual environment. Such an integrated approach would help to develop a more holistic treatment of mental illness.
Doctor Telba is of the same opinion, and he points out that patients are often
victims of social rejection or homelessness, whom we manage to stabilise and treat but who, on leaving the hospital, interrupt their treatments and have a relapse – which is almost normal for patients left to themselves. These same patients will show up again in the psychiatric emergency ward a few weeks or months later, having been involved in problems of disturbance of the peace, for example. It’s a great shame! These patients aren’t taken in hand by the other public institutions that are supposed to ensure a follow-up after their release from hospital.
Fragmentation of care services
The hopes for a satisfactory treatment of mental health come up against the limitations of a compartmentalised medical system. In Doctor Bencharif’s opinion:
The lack of a comprehensive mental health policy produces a fragmentation of treatments. It is imperative to re-evaluate the coordination between the public and private sectors and between ambulatory care and in-hospital care. Multidisciplinary collaboration is indispensable. Which implies the inclusion of social workers, specialised educators, psychiatric nurses, psychologists, occupational therapists, etc.
To a certain extent, the Algerian mental health system appears frozen in the past, lacking the resilience necessary to meet the needs of a society in transformation. Efforts to improve post-cure support, accessibility to treatments and the integration of families remain inadequate.
Nonetheless, Doctor Telba points out that hospitalisation is becoming less frequent:
Hospitals and polyclinics are resorting much more often to out-patient procedures than to internment. The hospitalisation should be reserved exclusively for a certain category of patients. What used to be the norm has ceased to be now and our patients are far better off.
As for Doctor Bencharif, he speaks of the hospitalisation conditions of psychiatric patients which
are becoming more complicated because of a serious overcrowding problem. Psychiatric hospitals, though the number of available beds has increased, are faced with overcrowded wards causing a decline in the quality of treatments. We must rethink the distribution of medical resources and explore innovative solutions to improve people’s accessibility to care, especially in the remote regions where medical structures are inadequate or even non-existent.
However, the question of human means is still significant. In Doctor Telba’s view,
a better patient support implies more personnel. Today, according to the Ministry’s figures, we are almost 1,000 psychiatrists. But this is not nearly enough in view of the number of pathologies and the size of the population. If we consider that there are already 500,000 cases of bipolarity and 500,000 schizophrenics, we are already far too few. Many of our friends and colleagues in psychiatry have gone abroad (especially to France) over the past 3 years, not to mention those who have moved into the private sector…
When traditional beliefs provide an alternative
In the land of Mahfoud Boucebci, one of the founding fathers of modern Algerian psychiatry, murdered on 15 June 1993 by Islamists in front of the Algiers psychiatric hospital, and in the adoptive country of Frantz Fanon, mental illness is still being treated with talismans and spells. A poll taken by the National Institute of Public Health in 2007, shows that 78.80% of Algerians believe that the Koran can cure their ills. Mental illness is often experienced as a manifestation of the divine will to punish, to test or to purify the patient’s soul; every Algerian knows the saying ‘God gives sickness and it’s God who cures it’.
Invoking God, the Prophet and sometimes the patron saints is credited with the power to heal. Resorting to the rokia is very frequent to fight the consequences of the evil eye, or a sense of ill-being and in extreme cases to rid oneself of the clutches of a djinn or a demon. The rokia2 is a ritual in which the rakiwho officiates recites verses from the Koran. He may also use holy water (Zenzem water) and burn incense and other substances to bring relief to the patient. Healing by religion has always existed in Algeria but it was practiced only by talebs and imams, figures respected in the community for their theological knowledge.
Today it has become a lucrative business, often exploited by quacks who recruit ‘their customers’ on the social networks and in mosques. Yet Algerians consult them with confidence because
this cultural model of interpretation makes it possible to alleviate anxiety by objectifying persecution, by designating one or more presumed persecutors. Illness is no longer an endogenous process specific to the patient, but an accident from without, the intrusion of a bad object to be expelled as soon as possible.
Such is Maabrouk Laawadj’s explanation in his essay ‘Mutations psychosociales et maladies mentales en Algérie’ published in the journal Dirassat by the University of Oran in 2015.
Since Koranic medication requires no diploma, it has been taken on board by psychiatrists and psychologists who propose no miracles but long-term treatments. To be regarded as mentally ill involves real suffering in itself, stigmatisation and social marginalisation. The madman, and even more the mad woman (‘el mahboula’/‘el majnouna’), are hidden away by their families, socially excluded like shameful blemishes on their loved ones.
Resorting to witchcraft is prohibited by Algerian law, which takes its cue from the Chariaa. On the other hand, pilgrimages to the tombs of saints among many other rituals, though denigrated by the Islamists, enable the patient’s entourage to signify their powerlessness before God’s will. These practices sometimes have dramatic consequences as in the case of a little girl killed during a rokia session at the end of May 2020. Recognized by the Chariaa and not prohibited by Algerian law, the rokia thrives in this juridical no man’s land. On 16 April 2024, the Internet channel TSA broadcast the video of a collective rokia session organised by a TikToker who goes by the name of ‘Sheikh Nacer’. A petition also appeared, signed by several associations demanding sanctions against this man. However, in the absence of any specific legislation, it is unlikely that the Koranic healing business is under threat. And we mustn’t throw out the baby with the bath water. Hamid Salami, a psychologist and orthopsychiatry explains that psychological symptoms and disorders are ‘coded’ by the patient’s cultural origins.
It is important to understand scientifically the signification of, for example, the notions of evil eye, possession, enchantment … without reducing them to structural diagnoses elaborated by classical psychiatry and psychology. We work simultaneously at building bridges between scientific disciplines and maintaining and encouraging complementarities between the different practitioners dealing with our patients. It is both a group therapy and a family therapy.
Modern and multidisciplinary approaches, ongoing training of medical personnel, improvements of infrastructure and creation of synergies between in-house treatment and day-care systems … these appear to be priority areas. And finally, the elaboration and application of a coherent mental health policy making it possible to transcend the old psychiatric model and respond to the challenges of our time.
1EDITOR’S NOTE. Algeria is divided into 58 territorial collectivities called wilayas.
2Editor’s note: roqya char’iya consists mainly of reciting Koranic verses at the patient’s bedside and saying a few prayers. One of its uses is to heal the “possessed” person and expel the “djinn” from their body; this practice may also involve beating, humiliating and cauterising various parts of the body.