Chris Sandal-Wilson, University of East Anglia
Joelle M. Abi-Rached, ʿAṣfūriyyeh: A History of Madness, Modernity, and War in the Middle East (Cambridge, MA: The MIT Press, 2020)
In 1982, after more than eight decades of operation, the Lebanon Hospital for Mental and Nervous Disorders officially closed its doors. Seven years into the Lebanese civil war, as hospital employees – who had braved bullets and shells to continue providing counselling to the increasingly anxious population outside the hospital’s walls during the war – desperately sought to overturn the decision to close and to secure the salaries they were owed, the archives of the hospital were abandoned. It was through the initiative of Hilda Nassar, director (until 2013) of the Saab Medical Library at the American University of Beirut, and the work of the archivist Linda Sadaka that the archive of this remarkable institution was saved, as Joelle Abi-Rached tells us at the start of the equally remarkable history that she has woven out of both this and an impressive number of other archives.
ʿAsfuriyyeh: A History of Madness, Modernity, and War in the Middle East traces the rise and fall of an institution which started out life as the Lebanon Hospital for the Insane in the twilight years of the nineteenth century, became the Lebanon Hospital for Mental Diseases in 1915, the Lebanon Hospital for Mental and Nervous Disorders in 1950, and was in throes of a further transformation, this time into the Lebanon Psychiatric Institute in 1976, when war intervened. The hospital’s many names might be taken as indexing how the history of psychiatry unfolded in Lebanon across these decades, as the institution developed from a home for forsaken, impoverished, often chronic cases into the central node in a network of outpatient clinics which aimed to bring mental hygiene to the masses.
But the hospital could never shake off another name, derived from its original location to the east of Beirut on the foothills of Mount Lebanon: ʿAsfuriyyeh, the place of the birds. The name came – like Bedlam in the British context – to serve as a pejorative stand-in for asylums and madness in general, cropping up in novels, plays, and love songs, in spite of the institution’s relentless efforts to stress its scientific credentials and its relocation to a new site in the 1970s. It is a term which has regional currency, too, in a testimony to the hospital’s long history of treating patients and training medical students and psychiatric nurses from Syria, Palestine, Jordan, and beyond. Abi-Rached’s sympathy for this misremembered institution is clear. As well as rescuing ʿAsfuriyyeh from the myths and rumours which have grown to surround it, her concern is to remember the hospital at a time when its original site is at risk of being ‘developed’, like so much of historic Beirut, into amnesiac high-rises.
Weaving together a prodigious range of sources, including Arabic-language scientific and medical journals, missionary accounts, diplomatic correspondence, and hospital reports, Abi-Rached’s aim goes beyond simply narrating an institutional history. Instead, she treats the history of ʿAsfuriyyeh as a ‘sampling device’, or as ‘metonymy and metaphor’,[1] to reveal broader themes. Some of these will be of particular interest to historians of Lebanon and the wider region, but many of them have global resonances. In Abi-Rached’s capable hands, the story of ‘Asfurriyeh helps us think through the often complex relationships between the mind sciences and modernity; medicine, missionaries, and empires; war, conflict, and mental disorder; as well as a host of other crucial themes, including sectarianism, gentrification, memory, and ruination. ʿAsfuriyyeh’s six chapters proceed largely chronologically, with a pause near the middle of the book for a more synoptic exploration of the diagnosis and treatment of patients.
The opening chapter, ‘Oriental Madness and Civilization’, explores understandings of madness in the decades before ʿAsfuriyyeh was established, mobilising two distinct literatures to do so. The first half of the chapter draws on the writings of European and American travellers, missionaries, and medical doctors, who were concerned above all with the abusive treatment of ‘lunatics’ in the region, and the pathological nature of even the ‘normal’ local mind. The second half traces how the sciences of the mind were introduced and elaborated in the pages of Arabic-language scientific and medical periodicals like al-Muqtataf (‘The Digest’), which emphasised a naturalistic account of mental illness. Abi-Rached underlines the strikingly dissonant interests of these literatures and their authors: rather than accepting European accounts of the inherently pathological nature of the so-called ‘Oriental mind’, local intellectuals tied the question of insanity and the deterioration of care for the mentally ill to their wider programme for reforming the late Ottoman state and its people.
The second chapter, ‘The Struggle for Influence and the Birth of Psychiatry’, draws on diplomatic archives as well as the records of ʿAsfuriyyeh itself to reconstruct the history of the founding and early development of the hospital. Although founded by a Swiss Quaker missionary, Theophilus Waldmeier, Abi-Rached argues that the hospital needs to be understood not as a unilateral attempt at proselytization, but rather within the context of a complex struggle for power and influence in the region which involved local as much as international actors. Good relations with the Ottomans were key to the survival of the hospital, with its British medical director and matron permitted to remain on site during the First World War, when they were technically enemy subjects. Although avowedly non-sectarian and cosmopolitan in outlook, the hospital was perceived as ‘Protestant’ and ‘Anglo-Saxon’, both of which fuelled French suspicion of the institution once they replaced the Ottomans after the war, though their policies – covering hospital fees through the introduction of the assistance publique, for instance– indirectly benefited ‘Asfurriyeh.
The third chapter, ‘The Rise of ʿAsfuriyyeh and the Decline of Missions’, charts the transformation of the institution across the middle decades of the twentieth century, as the missionary zeal which had played a role in its foundation withered away and – contrapuntally – psychiatry’s domain was extended to encompass not just the obvious ‘lunatic’ but the everyday strains of industrial modernity. After the Second World War, a series of neuropsychiatric clinics were founded, as well as a forensic unit for prisoners, to bring mental hygiene to the home, school, factory, and military. If the impressive uptake at these outpatient clinics is any indicator, the wider population welcomed psychiatry’s expansionist ambitions. While in part encouraged by demand, these innovations were driven too by competition with a rival institution, Dayr al-Salib, a convent to the north of Beirut which had been converted in the 1920s by a Lebanese Capuchin priest into an asylum for elderly priests, and subsequently transformed into a psychiatric institution in the 1950s. Abi-Rached also stresses the role played by successive leaders in this period, above all Dr Antranig Manugian, medical director from 1962, whose transformational vision of ʿAsfuriyyeh as a modern psychiatric institute would be torpedoed by the outbreak of the Lebanese civil war.
The fourth chapter, ‘Patriarchal Power and the Gospel of the Modern Care of Insanity’, grapples with the backgrounds, diagnosis, and treatment of patients at ʿAsfuriyyeh right across its lifespan, notably through quantitative analysis of annual reports. This throws up interesting trends: peaks in admissions, for instance, to the hospital during the First and Second World Wars, as well as in the 1950s and 1960s at a time of growing economic prosperity, inequality, and substance use. While Abi-Rached makes some use here of patient case files – mostly from the hospital’s early years – she is reluctant to immerse herself in this archive, on the grounds that ‘the patients’ voices, personal narratives, and singular stories are buried in medical dossiers under the “tyranny” of their diagnosis’.[2] Instead, Abi-Rached largely limits herself to deploying these files to puncture myths surrounding the (in)famous case of Mayy Ziyadah, the influential feminist and poet admitted to the hospital in 1936. No one would deny that medical case files are tricky to work with, methodologically as well as ethically, and it may well be the case that these are amongst the files still in the process of being organised by archivists and so perhaps inaccessible. But they do seem to represent a rich, and here largely untapped, vein for researchers to explore further in future.
The fifth chapter, ‘The Downfall of ʿAsfuriyyeh and the Breakdown of the State’, was to my mind the most compelling and haunting of the book. Zooming in on ʿAsfuriyyeh between the start of the Lebanese civil war in 1975 and the hospital’s closure in 1982, Abi-Rached draws on the correspondence of the hospital’s medical director, Dr Manugian, to paint a deeply felt picture of a hospital which not only found itself in the midst of war, but a target within that war. Staff, students, and patients were kidnapped, injured, sexually assaulted, and killed, and every building hit at least once by shells. It is a harrowing story which Abi-Rached locates within a broader shift in the nature of political violence over the century towards targeting hospitals as a strategy of war – a strategy tragically familiar to us today, whether in Syria, Yemen, Gaza, Afghanistan, or elsewhere.
The final chapter of the book, ‘The Politics of Health, Charity, and Sectarianism’, takes us past the official closure of ʿAsfuriyyeh in 1982 to develop some of the previous chapter’s reflections on non-sectarianism as the hospital’s deeply held – and ultimately, at a time of sectarian conflict, costly – ideology. Not only is it the case that health services, including mental health services, have been ‘sectarianised’ in Lebanon since 1982, but the very memory of ʿAsfuriyyeh itself is under threat of being sectarianised, with legal consequences: the Supreme Council of the Protestant Community in Syria and Lebanon is seeking to assert its control over this ‘Protestant’ institution in the courts. Abi-Rached vigorously contests this strategic misremembering of an institution whose executive committees, staff, and patients were always drawn from a range of backgrounds.
There is much here to digest for anyone interested in the histories of psychiatry, Lebanon, or the modern Middle East; certainly more than enough to guarantee the book a well-deserved place on undergraduate as well as postgraduate course syllabi, where some of its larger claims are sure to provoke reflection and discussion. At a time when re-institutionalisation is increasingly mooted in the West, Abi-Rached is at pains to emphasise that the closure of ʿAsfuriyyeh cannot be seen as part of any broader movement towards de-institutionalisation, as in Europe and North America. Instead, vast psychiatric hospitals continue to accommodate thousands of patients in Lebanon and the wider region: Dayr al-Salib, which historically rivalled and ultimately outlived ʿAsfuriyyeh, has a bedstrength of 1,100 today, a staggering figure which is nonetheless surpassed by at least two mental hospitals in Egypt and a further institution in Iraq.
Abi-Rached also takes issue with two components of Foucault’s account of the asylum: rather than replacing the leprosarium, Abi-Rached argues the asylum should be seen as emerging in the Middle East as a result of the decline of the bimaristan, charitable healing institutions with their own long history of managing the mentally ill; and rather than any ‘great confinement’, Abi-Rached argues that neither numbers, nor the routes by which patients arrived at ʿAsfuriyyeh, support this picture of the mass incarceration of the insane in Lebanon. While both these narratives have been roundly critiqued on empirical grounds not only in histories of psychiatry beyond Europe, but within it too,[3] one gets the sense that ʿAsfuriyyeh feels obliged to return to them, as the first English-language monograph on the history of psychiatry in the region, for its historiographical moorings.[4]
ʿAsfuriyyeh is a rich, original, deeply researched, and often moving work. Given its many strengths, I wondered whether it needed to be quite so pugnacious in its engagement with the few existing works on ʿAsfuriyyeh, which are criticised for being ‘still stuck in the Foucauldian and postcolonial frameworks’.[5] To give an example, in the otherwise excellent fifth chapter, Abi-Rached takes a tilt at Eugene Rogan for dismissing the hospital’s non-sectarianism as a mere public relations ploy. But Rogan doesn’t quite, at least in my reading, argue this.[6] At other points, a focus on rebutting these interpretations leaves some bigger, and more interesting, questions undisturbed. Responding in the fourth chapter to the claim that the Ottoman authorities embraced ʿAsfuriyyeh because it offered a means to cleanse the streets of lunatics, Abi-Rached marshals statistics to show that a majority of patients at the hospital were almost always private. But the more difficult question this leaves – as Abi-Rached recognises – is the degree to which coercion and dubious motives on the part of families, if not the state, may still have played a role in these admissions. Patient case records might have offered the beginnings of an answer.
In a sense, the book’s pioneering focus on the history of psychiatry in the modern Middle East means that Abi-Rached has to work hard to find bodies of scholarship with which to engage. While the connections she draws are almost always fresh and thought-provoking as a result, the invocation of a spectral figure of ‘Foucauldian and postcolonial frameworks’ at times jars. This does not at all detract from the accomplishment of this book, which not only provides a compelling history in its own right but generously offers future lines of inquiry an essential point of departure. In the opening pages of ʿAsfuriyyeh, Abi-Rached states that her goal is ‘to save this influential institution from oblivion’.[7] This is too modest a description of what she has achieved here, but it does capture a quality which I think characterises this remarkable history: a deep sympathy at its heart for ʿAsfuriyyeh, its reputation, and its people.
[1] Here Abi-Rached is drawing on Charles Rosenberg, ‘What Is An Epidemic? AIDS in Historical Perspective’, Daedalus 118, 2 (1989) and Michel de Certeau, L’écriture de l’histoire (Paris: Gallimard, 1975) respectively.
[2] Abi-Rached, ʿAsfuriyyeh, p.99. Here Abi-Rached is quoting Charles Rosenberg, ‘The Tyranny of Diagnosis: Specific Entities and Individual Experiences’, Milbank Quarterly 80, 2 (2002), pp.237-60.
[3] For example, in this journal, Andrew Scull, ‘Michel Foucault’s history of madness’, History of the Human Sciences 3, 1 (1990), pp.57-67. For colonial psychiatry and the ‘great confinement’, see Megan Vaughan, ‘Idioms of madness: Zomba Lunatic Asylum, Nyasaland, in the colonial period’, Journal of Southern African Studies 9, 2 (1983), pp.218-38.
[4] Happily this situation looks set to change in the near future, with forthcoming monographs by Lamia Moghnieh, Beverly A. Tsacoyianis, and this review’s author. For the history of psychiatry in Israel, see Rakefet Zalashik, Ad Nafesh: Refugees, Immigrants, Newcomers, and the Israeli Psychiatric Establishment (Tel Aviv: Hakibutz Hameukhad, 2008) [Hebrew] and Das Unselige Erbe: Die Geschichte der Psychiatrie in Palästina und Israel (Frankfurt: Campus Verlag, 2012) [German]; for the history of psychiatry in the Ottoman empire, see Fatih Artvinli, Delilik, Siyaset ve Toplum: Toptaşı Bimarhanesi (1873-1927) (Istanbul: Boğaziçi Üniversitesi Yayınevi, 2013) [Turkish]. For earlier histories of madness in the Middle East, see Michael Dols, Majnun: The Madman in Medieval Islamic Society, ed. Diana E. Immisch (Oxford: Oxford University Press,1992), and Sara Scalenghe, Disability in the Ottoman Arab World, 1500-1800 (New York: Cambridge University Press, 2014), esp. ch. 3. Much more attention has been paid to the career of psychoanalysis in the region: see in particular Omnia El Shakry, The Arabic Freud: Psychoanalysis and Islam in Modern Egypt (Princeton and Oxford: Princeton University Press, 2017).
[5] Abi-Rached, ʿAsfuriyyeh, p.18.
[6] The reference given here is to Eugene Rogan, ‘Madness and Marginality: The Advent of the Psychiatric Asylum in Egypt and Lebanon’, in Eugene Rogan, ed. Outside In: On the Margins of the Modern Middle East (London: I.B. Tauris, 2002), p.115. This is what Rogan has to say about ‘public relations’: ‘As a private institution without government support, the Lebanon Hospital dedicated tremendous effort to what would now be termed public relations. On the one hand, the hospital was entirely dependent on networks of private subscribers… On the [other] hand, they sought to preserve good relations with the Ottoman officials of the Mutasarrifiyya (governor general).’
[7] Abi-Rached, ʿAsfuriyyeh, p.xxvii.