Reception Dinner Talk
Tuberculosis and the Athens School of Public Health
I do not wish to detract from your food nor your reflections or reflective moments in this wonderful setting of the Acropolis Museum so I will be brief. Your deliberations on human rights and public health measures in tuberculosis (TB) control are extremely important. Your two days of work in the National School of Public health reminds me that it was this School that 80 years ago made a distinctive mark on TB control, in Greece. TB could have been the reason for its inauguration. It wasn’t. Dengue fever took precedence and there in lies some insight into decision making. The prime minister suffered dengue and was hospitalized in Evangellismos... More later!
Homer recorded the first epidemic (“loimos”) in our general region, which occurred outside the walls of Troy. It has been hypothesized as malarial fever. Another epidemic of the plague of Athens influenced the Athenian – Spartan conflict. Malaria was endemic until recent times and together with the plight of desperate refugees from Asia Minor trying to fit in, they placed a serious brake on socio-economic development.
TB as you know is one of the ancient enemies of man, one of his greatest killers. Hippocrates saw phthisis or consumption as the most widespread of all diseases. It spread with the migrations of milk-drinking Indo-Europeans.
In modern times it became the romantic disease, when consumption was understood as love-sickness and was equated with the beautiful and a better sort of people. Consumption influenced the poetry of John Keats and maybe we have a poetic definition of it as in the Nightingale:
Fade far away, dissolve, and quite forget
What thou among the leaves hast never known,
The weariness, the fever, and the fret
Here, where men sit and hear each other groan;
Where palsy shakes a few, sad, last grey hairs,
Where youth grows pale, and spectre-thin, and dies;
A personal experience comes from my early youth when suddenly I was not permitted to see a young girl of my own age. There was little explanation - then she disappeared. Later I learned that she had gone into a sanatorium for convalescence from TB.
On the European level and with respect to public health, we should be thankful for three things: the German tradition in social medicine which gave inspiration to the development of American Schools of Public Health, the work of the international division of the Rockefeller Foundation, which supported the development of Schools of Public Health all over the world, including the Athens School and the League of Nations which put together international health committees, one of which examined the lack of health in Greece. TB was a very serious problem.
Some European Schools gained international recognition through support of colonialism in the improvement of sanitation and control of disease in hot climates. Their prestige abroad exceeded their cooler acceptance on the home soil. They were repositories of information and knowledge about social conditions and became focal points for change in their opposition to slavery and support for human rights.
The League of Nations, Geneva in 1929 judged Greece to be unsanitary and dangerous, where tubercular sufferers were “abandoned” to their fate. However, the poor houses of England (see Dickens) were no better. In an address to the House of Lords in support of the downtrodden of society in the working class parts of Nottingham, Byron (a friend of Keats) said that “never under the most despotic of infidel governments” had he seen “such squalid wretchedness” as those in “the very heart of a Christian country”. Byron went on to fight for Greece in the War of Independence against the Ottoman Turk.
In Greece, the first attempt to organize public health was in 1828 as a result of an epidemic of cholera and the dreadful condition of the population, following the War of Independence.
The decade 1920-30 was a decade of massive social and economic shocks, sustained bad management with little skill to cope with turbulent change as population vulnerability escalated. The number of people in Athens doubled during the decade, as a result of the influx of refugees who lived in conditions of misery and in need of social rehabilitation. The descriptions of health and social conditions reveal an exceedingly low health status of the population from appalling malnutrition and the relentless battering by infectious diseases. Mortality was 17/1000, infant mortality 93/1000, Tuberculosis accounted for 20% of all deaths, 1/6 of the population was infected with malaria, and venereal disease was rife while 75% of the working population lived in a single room.
Refugees overwhelmed Greece in 1922 and one dedicated doctor wrote that, “the conditions of public health are most pitiful”. Desperately fleeing Asia Minor they met with dysentery, typhus and hunger. Many died on route, aboard ship. Typhus lurked in all Greek ports and in most cities. One “miracle” of the time was that by the spring of 1923, dedicated doctors had inoculated 550,000 refugees.
In 1928 a pandemic of dengue fever struck Greece mainly in urban centers. Dengue is recalled as a painful and debilitating sickness.The name dengue probably derives from “dingo” in Swahili. It was also known by such names as dandy and breakbone fever, because of distressing nocturnal pains that prevent sleep. Benjamin Rush, co-signer of the Declaration of Independence and father of American psychiatry, gave the first description of dengue. Contemporary reporting gives figures of 80-90% morbidity, with a total of 1-1.3million cases (650,000 in Athens and Piraeus) and 1,500-3000 fatalities. One anecdotal story from a friend recalls that his grandfather kept many canaries, all of which died during the dengue pandemic.
Newspaper articles called attention to the pre-epidemic absence of even basic health services and the failure of the state to secure safe drinking water and sanitary conditions of life. Public health was considered non-existent. Given the rising levels of incidence, morbidity and mortality, it is surprising that related reportage was usually tucked away in back pages. Perusing the inside pages one is struck by a sense of pushing aside the pitiful situation in hygiene and third world conditions as well as the appearance of some form of censorship to avoid political accountability.
In 1929, the British Ambassador concluded that Greece was a dangerous country from a point of view of hygiene. His informant was Dr. L. Rajchman medical director of the international team of experts visiting Greece who described the conditions as being worse than in Brazil. Representatives of many countries sent related “sickness of the nation” reports by diplomatic sack to their respective governments. To reduce danger to Europe it underscored the need for effective health service organization and responsible local government, in a fashion reflecting the Austrians in Bosnia 75 years earlier.
Until 1930 there was no systematic, organized effort against the control of malaria or other diseases and only in 1937 the government began to provide adequate funding for the ongoing anti-malarial campaign. However, support was intermittent and the limited medication fell mainly into black-market hands.
Although the Athens School perpetuated the enlightened social policy commitment of Eleftherios Venizelos, for “political reasons” the overall advice of the League of Nations was never completely applied. One contributing element is the absence of a more positive influence of the medical establishment, which in spite of its considerable prestige and persistent presence of a significant number of its members in parliament, it has never facilitated a vertical policy for clinical medicine nor has it permitted the emergence of a horizontal policy for public health. It is also worth noting that detailed record keeping during the pandemic of dengue in 1928 was perhaps too much to expect, even though the General Statistical Service was established in 1921. Nonetheless, Greece still lacks a comprehensive health information system and vital statistics are still approximate.
The Athens School was created during what is referred to as the “four golden years” (1928-32) to a background of malaria and 5000 deaths per year. Its establishment in 1929 was a landmark in the history of sanitation and public health in Greece and a corner stone of Greek social policy development. Chronologically, it was amongst the first Schools of Public Health founded in Europe. It distinguished itself as the pivot of the country’s sanitary reorganization programme, and its main purpose was the step-by-step organization of modern health services along with the provision of post-graduate scientists, capable of dealing with the serious public health problems of the day. The words “Without health, Life suffers” is inscribed on the parchment of the original degree.
The small School in Athens, has made a major contribution to the health status of the people of Greece and much credit should be given to those few pioneering doctors and health inspectors who with little means at their disposal and big hearts struggled against the scourge of many diseases to make their world a better place. The days of dengue with their nights of pain and sorrow facilitated the creation of one of the oldest Schools of Public Health in Europe. It went on to eradicate malaria and bring tuberculosis under control.
Although the School vigorously promoted the social policy commitment of the Prime Minister Eleftherios Venizelos, the overall advice of the League of Nations and its international committees was for “political reasons” never completely applied. One major contributing element was the absence of a more positive influence of the medical establishment, which in spite of its considerable prestige and persistent presence in parliament, never facilitated a vertical policy for clinical medicine nor permitted the emergence of a horizontal policy for public health.
Sir Macfarlane Burnet, the Australian Nobel Laureate stated: One can think of the middle of the 20th century as the end of one of the most important social revolutions in history, the virtual elimination of the infectious diseases as a significant factor in social life.”. This sense of optimism is still necessary but we must be realistic and you are realistic.
Today, we are faced with emerging threats, the failure to rollback malaria, the continuing spread of AIDS and the global crisis in tuberculosis. We should not forget that dengue is now widespread in the Americas and is a potential future global threat. We are and always will be vulnerable to hostile agents (pathogens, microbes, viruses, unhealthy behavior). When we are “attacked” considerable resources are needed to deal with the fallout. Public health is revealed anthropology. In the Plague, the primary health care doctor is asked his secret of great learning. Camus has him reply, “suffering”, which is the indicator of tears and of refugee mothers within a context of social exclusion. Given the large influx of immigrants and refugees coming into Europe from regions where TB incidence is high, and together with additional complications of an increasing number of drug-resistant cases monitoring systems for TB are today insufficient. There is probably a substantial underestimation of TB burden, especially in Greece.
Today, global health is one of the areas where there is a most urgent need for strengthened public health as well as a need for the deployment of widespread health diplomacy as the 21st century undergoes profound changes. Health transcends national boundaries. It is more than a cluster of technical matters, it is now an element in foreign policy, security policy and trade agreements. Consequently, new skills and capacities are needed to negotiate international agreements. We do not know where the next catastrophic event will strike.
Let me end with Things Ended a poem of Cavafy:
Engulfed by fear and suspicion, mind agitated, eyes alarmed, we try desperately to invent ways out, plan how to avoid the obvious danger that threatens us so terribly. Yet we are mistaken, that’s not the danger ahead: the news was wrong (or we didn’t hear it, or we didn’t get it right). Another disaster, one we never imagined, suddenly, violently, descends upon us, and finding us unprepared – there’s no time now – sweeps us away.