Sunday, 20 November 2011

Public Health Enlightenment, Greece: From the Athens to the Hellenic National School of Public Health

Jeffrey Levett
At the time of the Greek Revolutionary war (1820-30) the human condition was tragic as plague and many other infectious diseases killed far more people than those who fell in battle . It was rendered more so by a lack of doctors and medicines. The first governmental steps with regard to public health occurred between the years 1828 through 1866. The first regulation and provision for public health came with the watershed order of John Capodistrias for strict application, 1828. In 1833 and through 1866 the operation of hospitals, the fight against endemic illnesses and the practice of medicine were all regulated. In 1852, qualifications and positions were designated for doctors in the provinces. In 1910, they were abolished for economic reasons with serious consequence to services and the operation of existing institutions for hygiene and sanitation. The last quarter of the 19th century and the first decade of the 21st were witness to great indifference in the progress of public health and to the sanitary organisation of the country. In the 19th and 20th century malaria was the biggest contributor to stunted economic development. Two notable landmarks were the establishment in 1905 of an important pioneering institution for public health, namely, the Antimalarial Association and the passage of the quinine law in 1908. To respond to epidemics, specialised hygienists were engaged in 1911 while three years later the positions of public health doctors in the prefectures were reintroduced, together with a number of “emvoliaston” or inoculators.

In 1920, the average Greek was no better off than he had been a century before. Several short and sequential descriptions of health related conditions in Greece between 1918 -1930 are both informative and worth noting:

First curious, then fearful, then came indescribable sadness […] Death came by boat, late 1918 (Spanish Influenza). Weeping and wailing gave way to mutterings and murmurings coming from homes full of sickness and death as well as from a few old women, out of their minds, stumbling about seeking help to bury their children and grandchildren, while the crows waited expectantly […] On doors, ladders and on donkeys the bodies of mothers and children were taken silently to the cemetery, where untold dead were strewn about awaiting burial […] Frightened doctors remained behind closed doors and the islanders were left to the mercy of god […] In 20 days Charon took 600 souls (15% of inhabitants), mainly the young […] On the 17th day the grim reaper grew tired, death receded, the crows went silent and the sun again appeared .
An angry curse grips the nation (kakomoiria) and a vicious thirst thrashes almost all the cities of Greece […] health, see for yourself the big god of happiness of the population […] no one can claim that the problems of population health have been resolved, nor can the state certify to us, its people, that its health policy is triumphant (1925) .
In 1928, dengue fever  is referred to as the frightful pandemic of unknown cause (some thought it was related to syphilis) and with no known therapy that brings sudden death to exhausted people with chronic disease. It is dubbed break bone fever because of its racking pain and is mainly attributed to by the large increase in breeding habitats for the mosquito Aedes aegypti as a result of the erection of a large number of temporary shelters to house many of the 1,5 million refugees repatriated from Turkey . With respect to Prime Minister Eleftherios Venizelos on his 11th day of hospitalisation - illness unfolds normally – general condition good – Temperature 38 degrees – Pulse rate 60 and normal. Trade in dengue cures developed quickly and various products were sold such as "Black Flag".
In 1928, on behalf of the League of Nations the health of the Greek population was described as being worse than that existing in Brazil , while at the height of the pandemic of dengue it was seen as a great threat to the external world and European capitals called for stronger measures of protection.
In 1930 a student of the Athens School described conditions in Northern Greece an exceedingly low level of health and a largely and systematically undernourished population, uninterruptedly ravaged by the pestilence of contagious disease.

Following on from the Balkan wars (1912-22), First World War (1914-18), the global influenza pandemic (1918) and the Asia Minor military campaign (1920-1922) and with cumulative progression, millions of people in the Balkans were left homeless, undernourished, diseased, wounded, and cold. Human refugee trails were long and suffering was incredible. There were no public health doctors, little interest in sanitation, hospitals were abysmal places and the high rates of maternal and infant mortality were even more abysmal . In parallel, the world was witness to developments in international health and new concepts of public health as well as the socio-economic factors of disease. In Germany social medicine was well established while in England public health gained ground, Schools of Public Health were inaugurated (London, Liverpool) and the Welfare State began to emerge (school meals, mother and child care). Greece had to wait for such amenities.

A School of Public Health for Greece was first conceived of at the beginning of the 20th century and throughout the 1920’s received encouragement from the League of Nations. Between 1923 and 1930 several muddled entities existed side by side, namely the Central Laboratory of State Hygiene for training of doctors serving in public services and several parallel Schools to train Hygiene Doctors, Malaria Experts, for Hygiene in Hot Climates, for public health nursing and the Athens School of Public Health (1929). The initial proposal for the establishment of a school of public health came from such notables as Constantine Savvas, John Cardamatis, and Phokion Copanaris , whose mission it was, to control malarial disease (1905) . They found it deplorable that the government remained unmoved in the country where the goddess of public health Hygiene once thrived. They pushed insistently for her rebirth, namely, the development of public health and its application as an interdisciplinary science to improve the most precious of all human goods, health. They were well acquainted with European developments in public health and in close contact with international health organisations. It took about 25 years for their dream to come true. When it did, the Athens School emerged, public health evolved, health status improved with dramatic health gains expressed in terms of falling infant mortality and increased longevity. Between 1930 and 1970 and in spite of famine in Athens  and the dictatorship’s heavy hand on public health, life expectancy increased by 20 years.

Following the Asia Minor Disaster, external economic help was necessary in order to accommodate, feed and clothe 1,3 million incoming refugees which added a sudden 33-percent increase in the population. Sanitary conditions were abysmal and the risk of infection lurked everywhere. Thanks to a donation by Fridtjof Nansen the High Commissioner for Refugees of the League of Nations a vaccination for cholera, malaria, and typhus coined a "miracle" of salvation was administered to half a million refugees by dedicated doctors between 1921-1923. In 1923, the Greek government unsuccessfully requested the Rockefeller Foundation’s technical and scientific assistance. When the Ambassador of Greece  asked the League of Nations for a loan (1923), the German ambassador and other representatives rebuffed and humiliated him saying “address yourself to bankers, we are not financiers”, whereas the American population responded positively with considerable help.

In 1928, the Greek government again appealed for support in order to effectively deal with the problems of social turmoil especially relating to the disastrous health conditions of the population from the scourges of infectious disease. Support from the League of Nations and the Rockefeller Foundation finally came, as a significant but short lived response . Their presence in Greece provided access to an international network of actors, financial resources, educational and research opportunities and exchanges of experience while they introduced Greece to public health values, scientific arguments and advocacy know-how for social hygiene and social medicine oriented to public health systems in Europe. It provided expertise and funding to conduct field studies, organise services and health programmes. However, suggestions by foreign health experts as to the necessity of staffing health services with experts on the basis of skills and avoid political appointments were dismissed.  One point of contention was that of the prevailing perception that local scientists were incapable of developing a complete public health program, which contributed to the government’s decision to utilise foreign scientists by asking for the official participation of the League of Nations (April 1929). Coexistence of Greek officials at the Ministry of Hygiene and foreign experts proved difficult. The latter accused local officials of being incompetent and  professionally inefficient. Alexander Pappas, tried to reconcile the two opposing parties with one disparaging the other. The most important contributions by the Rockefeller Foundation were for the anti-malaria campaign and support for the Athens School of Hygiene . Its first director was Dr Norman White, an eminent expert in public health who left Greece in 1934 disappointed with continuous political interventions and bureaucratic inertia. Numerous scholarships for the training of Greek doctors and engineers in the USA were provided by Rockefeller Foundation while the Athens School provided free tuition for post university study in Greece, which was a global first in post graduate education. The last effort in Greece of the Rockefeller Foundation was the establishment of the Ambelokipi Health Organization with an aim to organise a model health service that could serve as training ground for students of the Athens School of Public Health and other health workers . The anti-malaria service of the Ministry was abolished as a consequence of this bitter rivalry and the “quinine scandal” when government provided medicine for malaria was sold privately. With the country close to bankruptcy and the change from liberal to conservative government promising prospects for development were squandered . In 1934, cutbacks in expenditures for public health were an indication of the intentions of the incoming government. By 1935 sanitary reform in Greece was dead. In 1944 there were only six doctors and fifty sanitary workers engaged in malarial control and the Greek government offered as many workers as was necessary if DDT was made available.

Failure’s reasons were multiple, including a non-professional public sector bureaucracy, political favouritism, and corruption. One small School, the Athens School of Public Health survived by tooth and by nail and lived on as “the lighthouse of public health”, to participate in all future and fundamental changes in the health sector including the establishment of the NHS. Though not well received, it survived because it filled a vacuum in training of public health officers. The growth and momentum imparted by a scientifically trained faculty and a significant body of expertise, which consisted of those trained abroad and those trained in the Athens School was catalytic . In 1931, the newspaper Ethnos referred to the establishment of the Athens School as a post war imposed necessity based on the conviction that first among all things the Greek population must live and develop under healthy conditions. This concept was strongly reinforced by the Venizelos Government (1928-1932), which allocated a significant funding to improve health.

The Athens School got off the ground as a result of a bizarre pandemic of dengue fever (1928), which brought Greece and the organs of government to a standstill. Scenes of suffering on the streets and in overcrowded homes were traumatic. Theaters closed, commerce stopped and basic supplies to Athens trickled through. To avoid panic, information was censured. Newspapers placed their reports on the back pages. After hospitalization with dengue and following a visit to Italy, Eleftherios Venizelos re-examined a proposal earlier introduced by Apostolos Doxiadis (1873-1942) to establish a school of public health. Doxiadis had Austrian experience where he became knowledgeable in social medicine and was the first doctor to diagnose the Spanish influenza in Greece.

Venizelos entrusted the Schools implementation to Alexander Pappas who had practiced medicine in Constantinople and was one of his personal physicians. The establishment of the Athens School of Public Health (1929) was a corner stone in social policy reform. The Athens School went on to eradicate endemic malarial disease, which held the Greek state in a grip of underdevelopment, to bring tuberculosis under control and to make a significant contribution to the emergence of a Modern Greek State . Malaria control quickly increased crop production in certain areas of Greece . The socioeconomic development owes much to the Athens School.

The medical community was quick to criticise the establishment of the Athens School of Public Health considering it unnecessary, costly, inapplicable and even detrimental. The thought of forming an elite of public health professionals aroused controversy with politicians and with doctors. The doctors in parliament had little concept of prevention and wanted health reform to emphasis therapy, not preventive medicine. They argued that health issues should not be placed in the hands of the Athens School while its natural protectors, the doctors are debarred.

At the Schools official inauguration by Eleftherios Venizelos, a journalist asked “Well why do we need the Athens school of Public health when we have the Medical Faculty of the University of Athens? They are not the same! Alexander Pappas went on to say that the principles and practices of Medical Schools are different from Schools of Public Health, all over the world. A doctor is one thing a public health doctor is another. Explicit definitions of medicine and public health were given and he described how they differ in practical significance. He was echoing the earlier thoughts of Greek experts that medical study is insufficient to provide the relevant knowledge, that will render the doctor a specialist in hygiene, capable of undertaking service in population health. Busts of Venizelos and Pappas stand at the entrance to the Athens School .

Following World War II, the Athens School suffered severe losses of prestige, staff and parts of the its physical facilities were taken over by the military services for veterans and the police . In 1949, another international committee recalled the earlier efforts to create a network of health services, coincident with the establishment of the Athens School, saying that had Greece followed through on the earlier advice of the League of Nations it would have had a national health system equal to its needs. In 1994, yet another international committee dubbed the “wise ones” reviewed the workings of the Greek health sector, found it largely curative and identified points of resistance that stymied development. It noted the weakness of information systems, the absence of hospital medical records, the lack of primary health care as well as unethical practices relating to under the table payments to doctors. They considered training in public health inadequate; poor at the undergraduate level; good in part at the graduate level.

In 1950, in agreement with the Ministry of Social Welfare, a project was proposed for the reorganization and improvement of the Athens school by a former dean of the London School of Hygiene and Tropical Medicine. In 1953, a compromise draft proposal for the reorganization of the Athens School acceptable to the Ministry of Social Welfare, was started through legislative channels. It retained recommendations from the 1929 study by the Rockefeller Foundation .

Daniel E. Wright was an important actor in the evolution of the Athens School. He visited Greece with the Marshall C. Balfour in 1930, to help the Greek State on issues of health policies after the positive support of the Rockefeller Foundation. Together, they conducted spot checks in the countryside, to detect the morbidity of malaria and to propose measures to combat it. After the liberation of Greece, Wright returned as an army colonel of the US Department of Health and Director of UNRRA to re-stimulate cooperation between the Greek State and the Rockefeller Foundation which had been interrupted by war. At the tail end of 1944 he was collaborating with Gregory Livadas of the Athens School in the implementation of DDT spraying across the country, as a new method then of combating malaria.

In 1949 the transmission of malaria was stopped in most of the country and the newly established WHO in “Ten steps forward” referred to the accomplishments of Greece and Italy and the pioneering position of Greece while in 1957 the eradication of malaria was an international global innovation .

During the dictatorship (1967-1974) the Athens School was manacled and just managed to keep its doors open. In 1975, Constantine Karamanlis placed the School of Public Health again on the political agenda and the institution was saved after being tripped up by bureaucratic obstacles and the submersion of public health in the dark of dictatorship (Presidential Edict 332/1975). In 1990 an attempt was made by the Minister of Health (George Merikas, Academician) to transform the Athens school into a national faculty of public health. The proposed law was drawn by a distinguished member of the Athens law faculty. It never materialised because of unsubstantial objections by both Senate and Medical Faculty of the University of Athens . Four years later it was granted national status and renamed the National School of Public Health (NSPH). Legislation was proposed and passed after a stormy parliamentary debate but was never fully implemented. Paradoxically, and to the best of my knowledge it was the first time anywhere that socialist politicians deliberately attempted to impede the progress of public health. Ties to the medical establishment were just one reason for this.

The Athens School played an important role in the evolution of the National Health System (1983) and for almost 20 years it has been promoting a policy for public health development in the Balkan region supported by the Greek authorities. Curricula renewal took place in 1984 with the introduction of new subjects , management of health services and systems, health economics and the sociology of health, which enabled the introduction of a program in management of health services, stimulated the traditional program in public health and introduced additional subjects (biomedical technology) and new modes of teaching (problem oriented learning, case studies). It also brought about a re-connect of the School to the world at large through interactions with the WHO, ASPHER, EHMA, FICOSSER and AUPHA. Through its academic program the School provides quality educational opportunities that relate to both the academic and personal development of its students. Its educational programs aim to combine the principles of public health learning and include theory and practice as well as practical service in the health sector community. Of particular importance are the acquisition of skills to improve the capacity of the health sector and the School’s recent commitment to the principle of lifelong learning.

The Athens School is considered a sister School to those in London, Zagreb and Ankara . The London School of Hygiene and Tropical Medicine had more prestige in British colonies than at home. Today is the first School in Europe. In Soviet times the second became bureaucratic while today it is in the process of renewal and the focal point of the PH Network, SEE. The third was disbanded by the Turkish dictatorship and its faculty dispersed thus setting up foci for public health throughout the country. The Athens School recently celebrated eight decades of vital contributions to Greek society and two decades of activities in the Balkan region. It is a founding associate of the PH Network, SEE. Noteworthy was the hope of G. S. Parkinson, nicknamed "Parky ", a popular figure at the London School of Hygiene and Tropical Medicine before World War II that success attend the efforts being made to re-equip and re-establish the Athens School on an even higher standard than that which it previously attained. He had no doubt that all schools throughout Europe eagerly awaited the speedy return of the Athens School to its rightful place among them. In 1966 the Athens School became a founding member of the Association of Schools of Public Health in the European Region (ASPHER) and was represented in Ankara (1966) and Zagreb (1967) by Professors George Belios and Christos Floras.  European promotion was considerably strengthened by the Marrieta Giannakou, Minister of Health (1990) by her promotion of new relations to ASPHER and to the Network of European Universities (ESST-Europe Society Science and Technology) and as a founding member.

Regional interconnectivity was facilitated by such EU programmes as PHARE (Albania), INTERREG (Albania, Bulgaria), DAC-OECD (Balkan and Black Sea Regions) and Greek Technical Aid (Albania, Palestine, Eastern Mediterranean). Engagement with ministries, institutions, NGO’s and individuals in Albania, Armenia, Bosnia and Herzegovina, Bulgaria, Croatia, Egypt, FYROM, FRY, Georgia, Montenegro, Moldova, Rumania, Slovenia and Turkey occurred with varying degrees of linkage at different points in time. Good relationships with the Association of Schools of Public Health in the European Region (ASPHER) and the Federation of International Cooperation of Health Services and Systems Research Centers (FICOSSER) as well as WHO and the Council of Europe were facilitating factors. Of particular note was help provided through the Hellenic Ministry of Foreign Affairs. In 1992 the first Balkan Forum on Public Health was conducted in Athens in collaboration with the WHO and the EU. 14th General Assembly in Athens. The workshop (1992) was the forum, bringing together specialists from Eastern and Central Europe so as to interact with specialists from Western Europe and America. This meeting was made possible by funding from PHARE and the introduction of joint research and international action programs,  contributed to cooperation in the broader sense, to understanding and to friendship.

Modest landmarks relating to Europe, the Eastern Mediterranean and Balkan region include the Athens and Acropolis Memoranda; ASPHER’s response to Article 129 of the Treaty of Maastricht and public health development in a turbulent Palestine, respectively. The Athens School aided the inauguration of a School of Public Health in the Gaza Strip, the writing of the Barsentum Statement on Mediterranean collaboration and an important collaboration with the University of Bielefeld, Germany. Noteworthy are: “Neighbours in the Balkans: Initiating a dialogue for health” , which became a prompt for the Council of Europe when it examined population vulnerability in SEE, the Skopje Declaration on Public Health, Peace and Human Rights and the Barsentum Memoranda. The Dubrovnik Pledge by regional ministers addressed population vulnerability reduction; The Skopje Declaration written by the writor on Public Health, Peace and Human Rights is an expression of the social conscious of public health and was adopted by the World Federation of Public Health Associations.

Several interesting titbits: Gerasimos Alivisatos an early professor of the Athens School served as Director of the Institute of Hygiene of Niš, Serbia (1918-1926) providing expertise on restructuring and in the organization of public health education;… It is not by accident that a fish pond existed in the garden of the Athens School. During an official dinner in Rome (1928) an Italian doctor informed Venizelos that dengue can be fought with a microscopic fish. The doctor promised that he would send a quantity of these useful fish to Greece. They should be thrown into stagnant waters to eat the eggs of mosquitoes and clean up the marshes. When they duly arrived some were placed in the School’s pond. Others were put into motionless waters where it is said that they can still be found there to this day ; …Both the Asia Minor disaster and the dengue fever pandemic live on in the Greek psyche and have given rise to songs, one example being the following ditty: sometimes with dengue, sometimes with the flu, not for a moment is a doctor far away, while all along the road noses are kept covered and mouths tightly closed;…  During the Civil War the basement of the Athens School was used as a police holding centre (“boudrumi”);… Anecdotally, a Colonel Minister of Health entered a classroom of the Athens School, dismissed the professor and proceeded to lecture the students on public health;… On the 60th anniversary of the Athens School, Melina Mercouri congratulated the Athens School for its large contribution in the sector of health and to culture. With emotion she noted that her grandfather as the Mayor of Athens was present at the School’s official inauguration.

Eighty years ago the abysmal health situation brought about the presence of the League of Nations in Greece, the deployment of the Health Section of the League of Nations and the support of the Rockefeller Foundation, which resulted in the laboured birth of Athens School of Public Health ably assisted by two doctors Doxiadis and Pappas. Adding to the considerable efforts of Savvas, Cardamatis, and Copanaris and the work of the antimalarial campaign the Athens School went on to eradicate malaria. Today the health status of the Greek nation is roughly equivalent to that of Western Europe with life expectancy among the highest in the world, but the cracks appearing should not be pushed under the carpet. The route to the maintenance of health status and the improvement of the health sector must surely follow the one carved out by Eleftherios Venizelos when he founded the Athens School of Public Health. Inscribed on the parchment of the first diploma presented to Constantine Vlachopoulos are the words he proclaimed “Χωρίς Υγείας Άβιος Βίος” (Without Health, Lifeless Life). Its symbolism and significance for health is obvious. Without population health, community life is unbearable. The actual origin of this statement on the parchment is unclear. It may reflect the words of Disraeli “The health of the people is really the foundation upon which all their happiness and all their powers as a state depend.” I would argue that its origins may lie with the division of good and bad of Epicurus and Empedocles, in Galatians 2:20 I am crucified with Christ, nevertheless I live and in Buddhism without health life is not life; it is just a state of languor and suffering and an image of death.

In eight decades the Athens School has come a long way but it still has promises to keep and a distance to go before it takes its just and rightful position in Greek higher education. It mirrors or presents an alternative history of political struggle and historical corners of Greece. As in the days of dengue, so might it be in any coming “plague” in any form, if and when it knocks on the door. In the current case of austerity’s affects on health which has already pushed open the door to health damage there is an imperative need to strengthen the Athens School.

The Athens School of Public health has an interesting and intriguing history and an impressive track record of achievements. There is still much to be teased out from its difficult historical steps.

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