Samia’s face appears weary as she explains that her husband, Magdy, is fighting an acute infection after undergoing an operation to amputate his leg.
This is Magdy’s third amputation in the last three years. Diagnosed 18 years ago with diabetes type 2, Madgy’s health began to seriously deteriorate in 2014, when one of his toes became infected.
Along with complications including blindness, kidney disease and increased risk of infections, coronary heart disease and stroke, diabetics are prone to have issues with blood circulation and nerve damage. This can cause numbness in extremities such as the feet, increasing the likelihood of ulcers and foot sores that can go unnoticed, are often difficult to treat, and can become life threatening.
Seeing that one of Magdy’s toes had gone black, Samia went with him to the Qasr al-Aini Cairo branch of the Diabetes Institute. She describes the center as having the feeling of an asylum or prison with 10 or more patients crammed into each room. The doctor there told them it was nothing to worry about so they went home but the infection then spread to another toe.
Subsequently they went to a doctor elsewhere who told them to recite Quran and use honey to heal the affected limb. But with Magdy’s condition deteriorating they went back to the institute and confronted the first doctor they had seen, accusing him of incompetence. Hearing the family’s distress, and seeing the limb was dead, and fast becoming a source of gangrene, a consultant physician stepped in. He told them they needed to operate to remove all five toes on his right foot immediately. Later, he would also have another operation to remove infected flesh from the same foot.
Problems arose again just before Ramadan this year when an infection appeared on Magdy’s left foot and he had to have his leg amputated up to the knee.
In hospital for weeks with a fever that left him unable to eat, doctors struggled to contain the latest infection to his leg. During his lengthy hospital stay, there was no one to spend the night with him because his son works at night, while as a young unmarried woman, his daughter was not allowed to spend the night in the men’s ward.
Magdy’s psychological state has rapidly deteriorated over the past three years since the amputations began. Now losing his sight, he lives in almost constant pain because his body has built up a tolerance to painkillers. He was fired from his job when his health troubles began, and has largely been unable to leave the house since, as the family lives in a fourth floor apartment with no elevator.
For Samia, Magdy’s illness has been an unrelenting battle. She had already been working cleaning homes for many years to be able to afford the children’s education. Of their three children, one has Down syndrome and has also been diagnosed with diabetes type 2, while Samia herself suffers from heart disease.
Doctors recently told her she must have a life-saving operation on her heart. The surgery will cost LE20,000. She was granted state support that she applied for due to her low-income status, and LE12,000 will be paid for by the state and hospital. Struggling to make up the LE8,000 difference, one of her employers came to her aid.
Magdy’s illness has put strain on an already difficult marriage, and at one point Samia left the family home, no longer able tolerate her husband’s angry and sometimes volatile moods following his health troubles and inability to work.
Despite his situation, Magdy is better off than many in similarly dire health, because he has health insurance, having acquired it following a stint working at a garment factory. Before his insurance card was finalized, however, the treatment that he received at the Diabetes Institute had to be paid for by the family, amounting to thousands of pounds.
A public health calamity?
In the western world, diabetes type 2 is one of several illnesses termed “preventable lifestyle diseases” and government-funded public health campaigns on how to make better food and lifestyle choices are common.
Having worked for decades from 9am often until 2am in jobs that largely involved standing all day, in areas where only a toxic combination of street food or packaged refined snacks were available — and in a country where there is little public space to exercise — it would be unreasonable to deem Magdy’s health issues as indicative of a personal lifestyle failure. Rather, his health issues and those of his wife and son, are an inevitable consequence of a food and health system that is broken.
Magdy’s predicament is a case study in what happens when lack of access to good food, long working hours and lack of physical movement collide.
Increasing rates of diabetes are an inevitable consequence of a food and health system that is broken
His diabetes could have been prevented, or at least managed, when he was first diagnosed and in relatively good health. With access to healthy food and competent medical attention, Magdy would likely have remained in good health, continuing to work and living to old age without issues related to his diabetes.
Cardiovascular diseases remains the leading cause of premature death in Egypt, accounting for over 40 percent of all deaths in 2013 up from a third in 1990. The rates of diabetes, which itself can lead to heart disease, are also rising. In 2015 alone there were over 7.8 million documented new cases of diabetes according to the International Diabetes Federation. The number of adult deaths due to diabetes was officially recorded as 78,184 but is likely to be much higher. There are also no statistics available on how many people, like Magdy, were left incapacitated or unable to work as a result of complications from heart disease and diabetes.
Eating habits and the question of access
Samia describes what the family eats on an average day: meals typically include bread, cheese, foul and falafel from the street. For lunch, it’s usually chicken, rice, macaroni, various dishes with béchamel sauce and more bread. Fruit is off the menu, while frequent cups of tea with sugar and soda are staples.
She has a government ration card to buy bread, sugar, oil and rice, but despite several attempts to renew it, it hasn’t worked for the past six months. She complains that the cost of food is spiraling out of her reach.
“Just yesterday I bought just a few small things for the house and it was LE150,” she says. “It’s too much for us.”
Samia goes on to describe what Magdy used to eat daily from the streets surrounding his work. Koshari, sandwiches, hawawshi (minced meat sandwiches), basbousa and sugary tea are the most common fixtures. It is a diet comprised primarily of what Habiba Hassan Wassef, a nutritionist and health policy analyst who has been studying the eating habits of the country for five decades, calls the three poisons of modern food: salt, sugar and fat.
“The poorer you are, the more you are at the mercy of what is available in your immediate surroundings and what’s subsidized,” Hassan Wassef explains. “Thus the high carbohydrate content, from cheap sources such as rice and pasta. You eat empty calories — calories with very low nutrient value.”
“The poorer you are, the more you are at the mercy of what is available in your immediate surroundings and what’s subsidized”
Hassan Wassef says the high consumption of black tea is particularly damaging and is linked to kidney disease and diabetes. She explains that this is because the tannins it contains inhibit the body’s absorption of iron and other minerals.
Historically, Egyptians ate a Mediterranean-style diet, a combination of fresh vegetables, fruit and some protein, which correlates to low levels of heart disease and diabetes. However there have been fundamental shifts in the country’s eating habits, associated with changes in working patterns and the high cost of food, especially fruit, compounded by a subsidy program that only subsidizes carbohydrate-heavy food — with the working poor being the least able to cope.
Hassan Wassef describes the country’s population as “poor, undernourished and simultaneously obese.”
“It’s education and money,” she says. “Poverty removes access to expensive and relatively better food, especially essential green vegetables and herbs. And health literacy, the essential knowledge people need to be able to make good food choices, is integral to the health of the nation and we don’t have any.”
As awareness about food quality and the importance of nutrition has grown in the upper classes, initiatives that provide fresh, local, and organic food have been embraced. So too have gyms and private clubs, that provide ample space for the well off to exercise without the annoyances of traffic, noise pollution and harassment.
But with the obesity rate hovering close to 70 percent, the majority of Egyptians are without the same information or resources. For them, good quality food remains out of reach, and so lacking money for prevention, treatment and management, a cluster of diseases related to poor eating habits — including diabetes, heart disease, high blood pressure, and stroke — present the country with an imminent public health crisis.
Beyond feeding and toward nourishment
Poor diets constitute a greater public health risk internationally than unsafe sex, and alcohol, drug and tobacco use combined, the Global Panel on Agriculture and Food Systems for Nutrition concluded in a 2016 report. Examining a number of low-middle income countries, the panel found that current food systems are failing citizens because of an emphasis on feeding people, rather than nourishing them.
While famine may have decreased, the report noted, the production of foods that undermine nutrition is growing exponentially, such as the increasing use of agricultural produce as ingredients for processed foods. It calls for repositioning food systems from merely feeding people to nourishing them well.
For Egypt, addressing the problem of equal access to a consistent supply of affordable, clean fruit, vegetables and pulses is at the heart of the country’s food problems.
What is needed is a multifaceted approach, says former food researcher Hala Barakat, who questions the logic of exporting large amounts of fresh produce abroad before the local population have been sufficiently provided for. Addressing this is policy is one key element in addressing supply issues, she says.
Crucial too is the question of subsidies. Barakat suggests that price controls and subsidies on fresh produce would encourage consumption of these foods. Hassan Wassef notes that beans have recently been added to the list of items subsidized by the state, but bemoans the absence of a scientific approach on the part of the relevant ministries to evaluate the health value of the foods that are subsidized.
Barakat shares this assessment, and advocates for doctors and nutritionists being placed in charge of reevaluating all items currently on the subsidy list. These same experts could also begin devising a strategy for how to provide alternatives to the nutritionally empty street food that millions currently consume while at work or commuting.
Moving the public away from a diet heavy on subsided wheat and sugar would help to combat disease, Barakat emphasizes, and would also see the state make significant financial savings. She proposes state assistance to farmers to grow enough wheat for domestic supply to reduce costly dependence on foreign imports.
This year, the Food and Agriculture Organization of the United Nations set up a pilot program of 15 agricultural field schools in partnership with Egypt’s Agriculture Ministry. Aiming to support farmers in increasing yields of nutritionally rich produce, farmers are taught how to grow their own vegetables, instead of wheat and corn, using practices that minimize the environmental impact. The program also encompasses Nutrition Kitchen Schools where family members, usually women, are shown how to use the produce to best optimize the nutritional content of the food they prepare.
“We’re aiming to improve nutrition on a household level in the five poorest governorates in the country,” explains Zahra Ahmed from the FAO team undertaking the project. “And we’re finding people are interested and ready to accept new ideas on how they can tweak nutrition, what to grow and when.”
Implementing this program or any other changes on a wider scale would necessitate a breakdown of traditional bureaucratic barriers between the ministries of agriculture, supply, and health. Cooperation between the relevant ministries, should, Hassan Wassef says, also involve a joint commitment to facilitate a sustained nation wide public awareness campaign on how to make good food choices for their health, which could be facilitated through social media, television and state-owned media.
Doing so would require a seismic shift in the mindset of the powers at be that food systems are not merely production systems, but rather a key node of health systems that determine the well-being of society as a whole. Hassan Wassef remains skeptical that real action will occur citing ignorance and a lack of political will.
“The people who understand why this is important are not in a position to act,” she laments. “Those that are in such a position are not aware or don’t recognize the consequences of inaction.”