Joelle Abi-Rached's monograph ʿAṣfūriyyeh: A History of Madness, Modernity, and War in the Middle East is a long-awaited work that thoroughly examines the institutional history of Asfuriyyeh, Lebanon's first psychiatric institution founded in 1896. What is instantly impressive about the book is Abi-Rached's extensive archival research from various sites in Lebanon, UK, and France; her analysis of diverse primary sources in medical and travel literature; and her use of aggregate and empirical data to build a topography of mental disorders in Lebanon from the 1900s to the 1970s. These rich data allow her to adopt a “long durée” lens, recounting an intricate and manifold biography of Asfuriyyeh and of its various visionaries, managers, and experts.
Abi-Rached insists that the story of Asfuriyyeh is not only a national one but also a telling of the circulating and connected knowledge on health, expertise and therapeutics, and of the global history of psychiatry and madness. Viewed as “a cosmopolitan institution” at the turn of the century, described as “the Lebanese bimaristan” (48) by Nahda intellectuals, and considered a model institution to many British psychiatric hospitals at the beginnings of the 1960s, Asfuriyyeh represents a “sampling device” (2) and “a window” (3) through which questions of modernity, war, migration, sectarianism, and health policy can be addressed, as well as the evolution of mental illness and its ethics and practices of care.
The text presents a comprehensive look at the various frictions, contestations, and interests accumulating around Asfuriyyeh as a site of therapeutic practice where sectarian relations, competing projects of modernity, health policies, and political violence were enacted amidst transformations in sociopolitical and economic contexts. A variety of actors emerge as part of the story of Asfuriyyeh, such as medical elites, missionaries, the institution's executive committees, armed militants, superintendents and directors, psychiatrists, Ottoman, French and British forces, and the Lebanese state. A comparative approach is adopted where Asfuriyyeh is read in relation to other forms of psychiatric institutions in the region such as the preexisting bimaristan and the lunatic asylums in Constantinople and Cairo and, later, with regard to more contemporary institutions like Dayr al-Salib and Dar al-ʿAjaza al-Islamiyya in Lebanon. This contextualized and relational reading provides a rich and meticulous account of this institution's distinctive role in the region, its nonsectarian health care policy, its patient population and the geopolitical, moral, and health economies that shaped its development, international influence, and eventually its downfall in 1982. It also traces the expansion of psychiatry in Lebanon, as a form of expertise, education (i.e., university curriculums) and practice (i.e., the development of psychiatric nursing and neuropsychiatric clinics).
Throughout the book, Abi-Rached makes dispersed contributions to several debates relevant to Middle East history and politics and to the history of psychiatry, such as the relation between psychiatry and power, theories of sectarianism, modernity and Protestant missionaries at the Fin du siècle Levant, and health and war. She chooses to depart from what she calls a Foucauldian and postcolonial framing of psychiatry in colonial sites and frames the birth of psychiatry in Lebanon as a part of a universal and humanitarian concern with mental illness in the nineteenth century that drew on competing interests and investments in institutional and knowledge building.
The concept of “competing interests” enables Abi-Rached to draw more on the dynamics and connections between the local and global forces involved in the institutionalization of psychiatry in Lebanon, and to show how generative, international, progressive, and therapeutic it was, in comparison with other forms of colonial psychiatry. In this case, Asfuriyyeh's psychiatry emerges almost as democratic rather than oppressive (100), as it has equally treated and attended to patients from various ethnic and religious backgrounds. While I agree with the author that more nuance and context are needed when addressing the relation between psychiatry and power, the text often creates binaries about psychiatry in terms of oppression/democratization and power/progress that are not necessarily in opposition to another but instead complement each other. It is precisely here that the text remains stuck in a Foucauldian framework that privileges the generative, formative, and progressive nature of knowledge-power and the kinds of subjects that it produces.
The case of Asfuriyyeh generates provocative debates and discussions along the line of several topics, yet I choose to focus my review here, as a medical anthropologist, on the relation between psychiatry illness and culture. What seems to be missing from the text is an overall attention to the social lives of the psychiatric disorders and their historical contingencies in Lebanese society and in relation to concepts such as “stigma,” “superstition,” “culture,” and “tradition” that themselves need situating and unpacking within the overall medical and social discourses. Second, the text's linear history of Asfuriyyeh has demarcated progressive and stage-like levels of psychiatry, ending with the institution's demise and the rise of sectarian health policies in Lebanon. This form of historicization overlooks the ways in which various forms of health and healing systems can coexist and have remained porous, dynamic, and interactive with modern psychiatry.
Therefore, rather than taking for granted and departing from the notion that mental illness is both real and constructed (xxii), there is also important work to be done in situating it materially and historically within a conglomerate of discourses on health, affliction, and society. Tracing the ways in which psychiatric disorders are made, both biologically and socially, is also a significant part of the history and science-making of psychiatry and of its cultural authority in translocal sites.
By following a more classical and linear reading of Asfuriyyeh, the text also privileges the accounts of the medical elite and experts and abides by the official historical narrative of the institution. This reading fails to include and take seriously the more marginal narratives and stories found in the archives and to construct a more interactive and wholesome picture of Asfuriyyeh. Chaghig Arzoumanian's book, Asfuriyeh: On Fools and Lands (2017), is a poignant example of such an alternative reading of the hospital's archives that brings to life the trees and the gardens, the patients, the name of the hospital, the charts, and Arzoumanian's own personal involvement with the institution. It is precisely these kinds of readings of history that create new sites of memoro-politics on violence, illness, and suffering in Lebanon, something Abi-Rached's monograph seeks to contribute to.
Overall, the book is a foundational and rigorous contribution to the growing field of medical humanities in Lebanon. It is highly recommended to a wide variety of disciplines in Middle East studies, history of psychiatry, political science, and health sciences, as well as both students and scholars alike. It is also a highly enjoyable read for the general audience interested in knowing more about the history of this institution.
