At the time of the creation of the World Health Organization, in 1948, health was defined as ‘a state of complete physical, mental, and social well being and not merely the absence of disease or infirmity ’. Moreover, mental health is also more than the absence of mental disorders. The World Health Organization defines mental health as ‘a state of well being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community .’ Is there a relationship between mental health and the political system that governs the country? To what extent is this relationship a strong one? Is it important for a psychiatrist to be aware by the political system of the country? These questions are difficult and studies discussing these issues are scarce.
Mental health is determined by multiple and overlapping cultural, social, psychological, and biological factors. Definitely, the political system of the country is one of these multiple factors . A psychiatrist is not a politician; however, he/she should be aware by the political system of the country. This political system can change many issues in the norms of the people and in the healthcare system used by them .
The aim of this review was to highlight these issues, mainly in Egypt. The review is a trial to discuss the different psychological and psychopathological aspects of dictatorship and their impact on mental health of people and on mental health services.
The investigator sought the Internet to review the literature discussing the issue of dictatorship and its relation to mental health and tried to sum up and conclude under the following headings: (i) introduction about Egypt; (ii) definition of dictatorship; (iii) impact of dictatorship on mental health of people; (iv) psychology and psychopathology of dictators; (v) impact of dictators on healthcare system; and lastly (vi) prepresidency psychological assessment.
Egypt, officially known as the Arab Republic of Egypt, is a country situated mainly in North Africa. Egypt is a major power in the Middle East and in the Muslim world. Covering an area of approximately 1 million square kilometers, Egypt is bordered by the Mediterranean Sea to the north, by Palestine to the northeast, by the Red Sea to the east, by Sudan to the south, and by Libya to the west. Egypt is one of the most populous countries in Africa and the Middle East. The great majority of its estimated 85 million people live near the banks of the Nile River, in an area of approximately 40 000 square kilometer .
The economy of Egypt is one of the most developed and diversified in the Middle East, with sectors such as tourism, agriculture, industry, and service at almost equal production levels . In early 2011, Egypt underwent a revolution, which resulted in the removal of the dictator of 30 years, Mohamed Hosni Mubarak. The revolution of Egypt was a peaceful clean and white one. It was a novel revolution in which the youth used Facebook and other international websites to gather each other and to unify their goals and requests. Millions of people stayed in major squares in many large cities of Egypt for 18 days until victory was achieved and Mubarak was dislodged. The revolution was described positively by many leaders from all over the world [7–9].
Dictatorship is considered a description of certain types of governments or leaders who are characterized by having absolute sole power over their people, and usually this power is used in a cruel way . Dictatorships may consist of a single individual, a royal family, an army, a political party, or a religious organization . Moreover, the will of any dictatorship is regarded as above the will of the individuals it governs . The relationship of the dictatorial state to its citizens and to other states is one of force.
Impact of dictatorship on people's mental health
To what extent people under dictatorship governments can achieve the different domains of the concept of mental health. Usually these people fail to achieve the concept and loss all domains. An environment that protects and respects basic human, political, socioeconomic, and cultural rights is also fundamental to mental health promotion. Without the security and freedom provided by these rights, it is very difficult to maintain a high level of mental health .
Increasing and persisting socioeconomic problems that are usually associated with dictatorship are recognized risks to mental health. In addition, the greater vulnerability of disadvantaged people in a dictatorship community to mental health disorders may be explained by factors such as the experience of insecurity and hopelessness and the risks of torture and violence against them.
People under dictatorship control are frustrated to the degree that they believe that their leaders can do everything, everywhere, and at anytime the same as Gods. People usually hope to get rid of their dictator leaders but these dictators remain for many years and people lose their hope even for natural death of these dictators as Gods never fall sick or die.
Just two or three decades ago, the personality of most of Egyptians was unique and well known all over the world. Anyone who visited Egypt observed this. Their simplicity, warm heartedness, honesty, desire to help, and bravery were characteristic features .
Dictators usually give priority to their safety and security and allot a great budget for this issue. President Mubarak retained his power by suppressing freedom of opposition. He created his own guards. Thousands of people worked to protect him. His secret police inspired fear and silence in those who might protest. In Egypt, these issues were a leading cause to deteriorated safety and security services for people. Police was not concerned with crime rates, traffic control, corruption, and other important issues. As a result of corruption all over the country, a gradual decline in standards of all professional ethics has occurred. There has been an increased rate of unemployment, delayed age of marriage, and increased poverty. Many Egyptians deteriorated below the poverty line and the Middle social class dissolved and was abolished. Many people tried legal and illegal immigration to other countries for work and many of them died by drowning in the Red sea and in the Mediterranean Sea. People became frustrated due to lack of any achievement in their life. This is why Egyptians started to bypass the red sign in streets, tried to get their rights by physical fights, and through hiring thugs. Moreover, thugs were hired by the police and government to control students in universities, to attack protesters, and to prevent people from going to vote in the election of parliament. Military courts replaced regular courts in any opposition. Regular courts were not supported, which is why in many cases the court took many years to reach a final decision in different crimes. The rate of achieving final court decisions had been reduced to frightening rates. Corruption became widely prevalent as many people said ‘why me? Why not use some of my rights?’ Many of the Egyptians became irresponsible, aggressive, manipulative, and opportunistic. Bribery and embezzlement became widely spread in Egyptian governmental companies. Moreover, Egyptians were scared to talk, hesitant to speak up, and to stand up for themselves, were desperate and exhibited traits such as pessimism and lack of initiation, of self-confidence, and of self-management. President Mubarak's dictatorial system made Egyptians always busy and dizzy, wandering for their basic physiological needs and preoccupied by subsidiary conflicts. Simply, during the dictatorship of President Mubarak, many Egyptians forgot how good a people they were.
President Mubarak as a dictator succeeded through a lot of opportunistic helpers in different associations to change the attitudes of Egyptians. They played with the Egyptian's emotions, thoughts, and behaviors in different issues during the 30 years under his dictatorship control. At many times, Egyptians were forcibly convinced that Islamic groups are more dangerous than outside enemies. They tried to change the attitude of people toward Palestinian's crisis, Iran, and corruptors from ministers and business owners. Thieves were considered as national heroes, failed people were considered achievers, production rates and growth of economy were exaggerated and inflated. Basically, the minds of Egyptians were the ground of a big stadium for many virtual games.
Egyptians lost all dimensions of the definition of mental health as they were not in a state of well being, lost their abilities to cope with stresses of life, some of them were unproductive, and others were unemployed, unable to make any contribution to the community. Egyptians not only lost the definition of mental health but also their physical health, which deteriorated as the rate of cancers increased to a great extent due to environmental pollution. The rate of hepatitis C virus infection is higher than in other countries due to negligence and corruption, whereas the rate of anemia and malnutrition increased due to poverty and the rate of death and head injuries increased considerably due to road accidents .
It is also worthy to say that the dictatorship of Mubarak was not the only reason of deteriorated mental health in Egypt. There are many other reasons that played an important role in the same direction, for example globalization forces, world economic crisis, increasing world competition, international food crisis, etc.
After dislodgment of the dictator and destruction of the fear's borders, and due to many negative traits that had developed, objections and oppositions all over the country are expected to occur and this is happening in Egypt currently. These oppositions if continued will impair the production in Egypt and will endanger economic growth, which is why current oppositions should be considered a top priority for the new government.
Psychology and psychopathology of dictators
Egypt has known dictators since thousands of years. During the era of prophet Moses, Egypt had been governed by a king from Pharaohs, most commonly known as King Ramesses II . King Ramesses II claimed that he was the God and was dealt with Egyptians as if this is the truth. He governed Egypt for 66 years . He killed a lot of people and he took their money and lands; he wanted them to see through his vision and to obey his holy orders. His power and authority were created by his people and his helpers such as Haman and Magicians. In the end, he refused Prophet Moses's message from God and died by drowning in the sea behind Moses and his people . In contrast, the last dictator of Egypt was President Mubarak. He did not claim that he was a god, but he dealt with people in the same way. Thousands of people were protecting his routes daily. Millions of people were delayed daily due to obstructed ways for his safety and security measures. He governed Egypt for 30 years. He killed thousands of people due to his negligence and lack of concern and due to corrupted people surrounding him and his family. The country lost billions of dollars and resources under his presidency . Again, he wanted people to see through his vision and to obey his holy orders. His power and authority were created by his people and his helpers mainly from security forces, tailors of law, corrupted business owners, and some corrupted media professionals .
President Mubarak refused to hear anything about his reduced general health due to aging, up to the extent that a new crime was invented in the Egyptian law for rumors about the president . He refused to be a human being liable to sickness and death, again similar to King Ramesses II thousands of years ago.
Different dictators through the years have taken different routes to get to the top. Some were elected like President Mubarak. Some inherited the job like Kim Jong-un in North Korea. Some took over in military coups like Muammar Gaddafi. The reality is that the personality of a dictator is the same whether he or she is running a company or running a country. The dictator personality has three core priorities: ‘me, me, and me’. Moreover, if he/she has added anyone else to these priorities, they usually added wife/husband, sons, and daughters. Egyptians have tried to deal with this situation as a joke, which said that ‘can you imagine Egypt as a Limousine and the driver is 80 years old. He puts his son on his legs and allows him to play all the time with the driving wheel. Will you accept going anywhere with this limousine?’ Not only the driver and his son as mentioned in the joke but also in most cases some of the surrounding people succeeded in attaining the chance and tried to obtain benefits from the situation. In case of King Ramsses II, Haman was the assistant of the King and succeeded in obtaining many benefits. However, in the case of President Mubarak, a lot of people played this role and corruption became increasingly prevalent. The world watched these scenarios many times.
This narcissistic personality shows itself with two abusive behaviors of every dictator. First, the dictator will do anything, anywhere, at anytime, and at any cost to retain power. Second, he /she will take advantage of people and his or her position to take whatever he/she can.
As a result of this focus on the ‘me and my family’ in the administration of a country, it has been observed that the outcomes of a dictator in politics are the same. For example as a result, the country's political system has descended to frightening levels of coercion, oppression, and cruelty, and eventually a revolt ensued.
Are people dictators because they are mad? Or does being a dictator make a person mad? Dictators are not born as dictators, but they are made by the surrounding persons and get powerful and stronger by the feared people. Most dictators are evils, but some are mentally ill. However, one like Muammar Gaddafi is both. It is very obvious that Gaddafi is in an unstable frame of mind and his perception of reality is distorted . Having watched some of his speeches on television, his comments and speech seem very erratic. What he was saying did not make any sense and it was very incoherent. Muammar Gaddafi had lost touch with reality. When we read or listen to what he has been saying, it is not really possible to follow his meaning, because none of it has any coherent message. From his speech and behavior, Gaddafi would be diagnosed as suffering from some kind of psychosis.
Dictators have antisocial personality traits as they lie, steal from their people, manipulate, use force against their people, and have callous emotions. Moreover, most of them have narcissistic personality traits as they believe that the world is revolving around their heads. They believe their orders are laws and their desires are orders. Some of them have borderline personality traits as they are impulsive in their decisions. Many of them have paranoid personality traits and so hire thousands of people to protect them. They give green light to security forces to arrest thousands of their imaginary enemies. Dictators usually use defensive mechanisms excessively, especially denial, rationalization, and projection.
It is usually easier to say that dictators are crazy but it is more difficult to obtain the truth about their mental health. Some dictators are abused during their childhood; for example, Hitler, who was basically living in streets after his mother died, was a loner and was subjected to abuse . Saying that a dictator is mentally ill is not only insulting to people with legitimate mental illness but is an insult to every single person who was tortured or who died during the era of this dictator. The rule here is ‘Dictators are usually sane enough to rally thousands and may be millions of people behind them’.
An important issue is that not all dictators are evil. Some of them try to do the right thing for the people they are making choices for and the famous example here is Francisco de Franco of Spain.
Dictatorship and healthcare system
Apart from torture, in Egypt, more sophisticated ways of abusing human rights was prevalent, especially in the way healthcare was delivered during the last three decades. The falsification of morbidity and mortality figures; not paying attention to diseases such as cancers; not talking about the hazards of environmental pollution; and the deteriorated quality of generic drugs are all products of the dictatorial system that governed the country.
As a result of corruption, a lot of business owners succeeded in registering generic antipsychotic and antidepressant drugs with limited quality of their products. These drugs replaced the original expensive drugs because of their cheaper price but at the cost of their efficacy and safety.
Under the dictatorship control and due to deteriorated professionalism of the police, policemen would abuse rights of mentally ill people as they used to arrest the mentally ill people and accused them of many crimes.
Under dictatorship in Egypt, due to the inflated budget of the safety and security of the president and due to corruption, the government had dedicated a small percentage of the budget to healthcare and a smaller percentage for mental health. This is why the Ministry of Health had failed to establish community mental health centers, was unable to secure essential pharmaceuticals, and did not develop a viable mental healthcare monitoring system . Egypt serves as an example of how political culture shaped mental health programing.
Can a prejob psychiatric interview or psychological assessment predict a future dictator attaining the presidency seat?
A preemployment psychological evaluation is a specialized examination of an applicant's psychological suitability for a public position. Psychological suitability includes, at a minimum, the absence of relevant mental conditions that would reasonably be expected to interfere with safe and effective performance. A preemployment psychological evaluation should be a part of the medical examination before taking the presidency seat. Presence of physical or mental problems in the president may lead to disturbance for many others inside and outside the country. Reassuring people that their future president is physically and psychologically healthy is one of their rights. However, a simple prejob psychological interview conducted by one expert cannot exclude a future dictator to the presidency seat. Many dictators are charismatic and are geniuses and they may not be discovered through an ordinary interview. Hence, here we are talking about a complicated interview with an expert team and with objective measures. Preemployment psychological evaluation may include tests that are designed and used to measure personality traits, behaviors, or characteristics such as judgment, stress resilience, anger management, integrity, conscientiousness, teamwork, negotiation skills, and social competence. Surely if we look longitudinally to the attitudes of the presidents before the presidency job, we may find some roots for dictatorship or suspicious personality traits. To what extent can this occur in countries of the Middle East and who has the authority and the ability to tell the people that this person is suitable or not for presidency seat? Moreover, who will protect the team if the person who is not suitable takes the presidency seat? All are difficult questions and need further discussion and agreement, especially as decisions such as these are based on probability rather than on certainty.
Countries torn by dictatorship face higher levels of distress, and yet they are most in need of productive, healthy citizens. Treating or reducing the psychological impacts of dictatorship and promoting resilience in otherwise physically healthy individuals are critical to help to rebuild these countries. This is why new leaders and governments in Egypt should pay attention to this issue in the new era. A team of professionals should be sought to put together a plan to revert the effects of dictatorship. Negligence of this issue could repeat the same scenario observed in other countries such as Iraq.
Owing to the political changes currently occurring, we now have the means and the willingness to explore the extent of the abuse of human rights in our healthcare system and to find those who assisted the dictatorship in the performance of its antihuman activities.
Lastly, I wish to thank all those who have helped to make our revolution a key contribution to the future of mental health in the region: the martyrdoms whose death has opened new important horizons; the military forces whose hard work and helpful insight have further sharpened and protected the message of the revolution; the media professionals who uncovered the last dictatorship of Egypt; and all professionals in Egypt whose effort will bring mental health back to Egypt.
The author has no conflict of interest to disclose.