|Al-Ahram Weekly Online
1 - 7 November 2001
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A Diwan of contemporary life (414)
A royal decree establishing a health ministry was issued in 1936 but Mohamed Shahin, the ministry's appointed chief, was already several steps ahead. In a series of articles published in Al-Ahram in 1927 Shahin, King Fouad's personal physician, presented an ambitious 16-point health reform programme defining Egypt's health needs. The plan began with rural health since the majority of Egyptians at the time lived in the countryside. Maternity care was high on the list because of high infant mortality rates. The plan also included the fight against endemic diseases like bilharzia, public awareness campaigns and the transport of doctors to the site of infectious disease outbreaks. Professor Yunan Labib Rizk* goes through the plan which aimed at the well-being of all Egyptians
Health care visionary
On 7 April 1936, three weeks before his death, King Fouad I issued a royal decree establishing the Ministry of Health. The ministry would embrace the Health Authority, then under the Ministry of Interior, and the various health and hygiene-related departments that were under the Ministry of Public Works. Three days later, another royal decree appointed Mohamed Shahin, King Fouad's personal physician, to head the new ministry.
From the top: Khedive Tawfiq; Mohamed Shahin; King Fouad and Ali Maher
Hassan Pasha Youssef, who had served as deputy chief of the Royal Cabinet for 10 years, tells an interesting story behind this development. During the last weeks of his life King Fouad went into frequent diabetic comas. Following one of these attacks, he awoke to find Shahin tending to him. Moved by his physician's vigilance, he said, "I am deeply grateful to you, your excellency the minister." Youssef said this "royal pronouncement" put Prime Minister Ali Maher Pasha in a quandary, for now he would have to put a ministerial portfolio under the care of the royal physician. His solution was to stitch together various government departments concerned with health and create the Ministry of Public Health.
As incredible as this story may sound there are reasons to believe it. The morale of the king at this phase in his life was such that he needed to make a generous gesture towards his physician. Such was the attachment of Maher to the palace that he would do his utmost to ensure that Fouad's "royal pronouncement" was met, and Shahin was the natural choice to head a ministry of health. Thus, some chapters in Egyptian history can only be explained in terms of the personal whims and motives of the individuals involved.
Whether or not the story is true, if royal will alone led to the creation of the ministry, the new institution probably would have been short-lived. That the Ministry of Public Health is still alive today suggests there were some concrete reasons for its inception, beyond the wishes of a man approaching his final hours.
Indeed, as early as 1927, Al-Ahram cited many of these reasons in a series of articles published in July that year under the headline, "The health reform programme." Coincidentally, the author of these articles was none other than Shahin Pasha, then deputy minister in the Health Authority.
The man who was later to become Egypt's first minister of public health opened with what he described as "a brief summary of the history of the development of the Public Health Authority." The agency had its origins in the Military Health Department founded by "the father of the noble royal family, Mohamed Ali Pasha" in 1820, and in the Health Commission established five years later. Then, in 1827, Antoine Clot Bey, one of the many European experts Mohamed Ali sent for to help with his modernisation programme, founded the medical school in Abu Zaabal. Ten years later, the school moved to its new headquarters in Qasr Al- Aini, where it remains today, 160 years later. The hospital he founded there became the core of the Egyptian health service.
The establishment in 1850 of the Personnel Bureau of the Quarantine Authority under Khedive Abbas I was followed by a series of decrees issued by Khedive Said Pasha six years later which "created the core of the modern health and pharmaceutical systems and delineated the powers of the national Medical Board." The board essentially laid the foundation stone of the Public Health Authority. According to Shahin, it was responsible for "the administration and supervision of all branches of civilian and military medical services with regard to the art of medical treatment." Its functions also included "advising health officers in hospitals, army divisions and the provinces on everything pertaining to the practice of medicine and pharmacology, recommending the means necessary to improve the health services, publicising the latest advances in modern medicine and new methods of treatment and recommending necessary public health measures and the necessary precautions to prevent the spread of epidemic diseases and minimise the toll of such diseases."
Two years later, Said Pasha merged the Quarantine Authority, which had been based in Alexandria, with the Medical Board in Cairo to create the Public Health Board, responsible for "all quarantines on the coasts and ports; all domestic health and medical services, hospitals and pharmacies; and the medical school and chemical laboratory."
That such important landmarks in the development of the national health services took place under Said suggests that history has not been kind to him. Said has generally been viewed as the ruler who opened the door to European intervention in Egypt by granting Ferdinand de Lesseps permission to build the Suez Canal. However, there is much to indicate that he was not the greedy dupe as portrayed in modern dramas of his era. Indeed, Said Pasha rekindled the spirit of the Egyptian army, which had been broken as it became little more than a weak and ineffective security force under his predecessor Abbas I. And he sought to rebuild the Egyptian navy that had collapsed at the end of the reign of Mohamed Ali. Said pasha was also responsible for the agrarian land ownership legislation that led many historians to dub his rule "the golden era of the Egyptian peasant." In light of the reforms he introduced to the health services, we should add that his rule was also a golden era for public health.
Another landmark in the development of the Public Health Authority occurred on the basis of a recommendation submitted in 1880 by two of Egypt's top physicians to divide the national health service into two departments, one remaining in Cairo as the Public Health Administration and the other, concerned solely with quarantine administration, to be relocated to Alexandria. Khedive Tawfiq approved the recommendation and the following year issued a royal decree forming the Public Health Board. Based in Cairo and under the authority of the Ministry of Interior, the board was responsible for "monitoring all health services in Egypt and administrating all royal and military hospitals, as well as the public medical supplies stores." The decree further put the medical authorities in all governorates and directorates, the health inspectors and veterinary authorities and the chief surgeons of government hospitals in Cairo and Alexandria directly under the control of the Public Health Board.
If Fouad's royal pronouncement of 1936 marked the official birth of the Ministry of Public Health, it was Tawfiq's royal decree on 8 February 1886 that issued the official birth certificate of the Public Health Authority and delineated the structure of that institution that would remain intact for the next 50 years. The director of the authority, who was appointed by royal decree, was first in rank, followed by the inspector of public health, who would take over during the director's absence. The powers of the authority were much broader than its predecessor. It was to monitor all concerns pertaining to public health so as to eliminate and prevent disease and epidemics, including animal diseases; issue practitioner licenses in all fields of medicine, chemistry, pharmacology and veterinary care; and ensure that no one practised midwifery or surgery without authorisation based on the results of an examination.
The first to head the new authority was a British expatriate physician by the name of Green. The trend would last for the next three decades, for all of Green's successors were also British. Perhaps the British monopoly on this post explains why the Public Health Authority remained for so long under the Ministry of Interior, a British preserve since the occupation in 1882. It may also explain why it took so long to create an independent Ministry of Health, since that would have required the appointment of an Egyptian minister to head it, something the British were not about to agree to.
Shahin explains the decision to create the Public Health Authority. "The scope of activities of the public health services had broadened considerably and had become of increasingly crucial importance due to the general progress of the country and the great increase in population. As it was hoped that all possible means and methods should be exploited to improve the conditions of health and hygiene in the country it was felt that these goals would be achieved through the creation of a higher authority, commensurate with the importance of these goals." One imagines that this is precisely the reasoning that led to the creation of the Ministry of Health almost a decade after Shahin wrote these words. Shahin also took the opportunity to remind readers that he had served as deputy minister of interior for public health since 1923. This, in addition to his proposed programme for health reform, seems to suggest that he already had a dream of a separate ministry which he would be in charge of.
Qasr Al-Aini Hospital
Al-Ahram readers must have been overawed by the health reform programme -- it was a 16-point plan -- which Shahin outlined in July 1927. It was ambitious, comprehensive and practical, clearly reflecting a systematic mind acutely aware of the diverse health and hygiene needs of his country.
Naturally, his starting point was rural health, as the bulk of the Egyptian population at the time lived in the countryside and sanitary conditions were still rudimentary at best. Of first order was the need to supply purified water for consumption and domestic use. "The best means to do this," he writes, "is to divide the country into reasonably sized zones into which can be routed public water resources. In the more remote villages, water should be pumped from artesian wells into a cistern from which water would be distributed to the village inhabitants." He also urged the promulgation of legislation to ensure that proper sanitation and hygiene codes are observed in the construction of new villages. In existing villages, new roads should be constructed in order to reduce overcrowding and informal housing schemes. Of prime importance, too, was the need to devise the most efficient means for street cleaning and refuse disposal. The author went on to spell out the necessary means to realise his goals, especially with regard to possible sources of funding.
In view of the high infant mortality rates at the time, it is not surprising that his next topic of concern is maternity and child care. Although the Child Care Society had existed in Egypt since 1908, that, according to Shahin, did not absolve the government of its responsibilities. His recommendations for reforming this sector of health care included the creation of children's clinics that could provide initial first-aid and, if necessary, transfer patients to hospital. Child care centres would monitor mothers beginning from their fourth month of pregnancy and advise them on the appropriate hygiene precautions to observe during pregnancy and shortly after the birth of their children. He also suggested the creation of a school for midwives to ensure that proper midwifery services would be available to the poor. In this regard, Shahin informs his readers that a midwifery school had actually existed as one of the first departments in the Qasr Al-Aini medical school founded by Mohamed Ali and that it continued to operate until World War I began in 1914. Now was the time to revive it, he wrote.
Next followed a scheme for "fighting hookworm and bilharzia, the two endemic diseases that had become increasingly widespread. Shahin noticed a connection between the expansion of irrigation projects and the stagnant waters in which the disease bearing organisms breed. Shahin urged a two- pronged approach to combating the diseases. Firstly, the government should establish both permanent and mobile hospitals specialising in their treatment, as well as clinics to be set up in rural schools for that purpose. Secondly, teams of Egyptian and foreign experts were needed "to determine how to prevent infection and eliminate the cause of the diseases." He continues, "The Public Health Authority has already moved to create a special laboratory for this purpose, choosing the land on which it is to be built and inviting the famous specialist in bilharzia research, Lepier, to come to Egypt in order to conduct further research here. It is our hope that these measures will result in the total elimination of these diseases in Egypt."
Public awareness campaigns were and continue to be a vital component of health care, and today's readers may be surprised to learn that the Ministry of Health's department of information dates back to the 1920s. Shahin writes that in 1924, the Public Health Authority founded "a special department for disseminating health information," the primary function of which was "to place notices in the daily press on how to avoid infection and other advice, all written simply so that it can be easily understood by ordinary people." Much of this advice found its way into students' schoolbooks, perhaps the most important being, "Wash your hands before and after you eat."
The campaign also included educational films that were screened in public assemblies in the provinces. As for the more remote villages "whose inhabitants do not have the opportunity to view the films screened in the larger towns and cities," physicians of the Health Authority "travel to these villages by car in order to screen and explain their contents."
Another landmark in the heath awareness campaign, of which Shahin seemed particularly proud of, was the Fouad Museum of Health, which was nearing completion and which would explain various illnesses and diseases, along with the means to prevent infection.
Shahin next addressed the need to develop the means to detect communicable diseases and prevent their spread as much as possible. The measures he proposed to this end included closer monitoring of fatalities that occur throughout the country in order to ensure that precautions can be taken speedily should a death turn out to have been caused by an infectious disease. The government, he added, should be particularly alert to a sudden increase in mortality rates in any one area. In this regard, he expressed his regret over what he perceived to be a growing tendency by villagers to proceed with the burial of their loved ones without notifying the public authorities. For this reason, he added, his authority had allocated funds from which rewards would be paid to those who inform officials on "secret burials."
Another point in Shahin's health reform programme concerned infectious diseases brought into the country from abroad. Of particular concern was cholera, the plague and yellow fever that could spread particularly rapaciously during the pilgrimage season. Shahin was a proponent of an "ounce of prevention" and recommended immunising pilgrims against these diseases before they left the country. He also recommended setting up clinics to monitor the health of pilgrims in the Hijaz. Indeed, Shahin tells us, the Health Authority had already established two small clinics to treat pilgrims who became suddenly ill and to serve as early warning centres for health authorities in Cairo.
In addition, as air transport between Egypt and other countries had become increasingly commonplace in the 1920s, quarantine precautions were being extended to airports "so as to avoid the dangers of infectious diseases imported from abroad." Measures included the presentation of a medical certificate that had to be signed by airport officials before "anyone arriving in Egypt by plane is allowed to enter the country." Visitors would also have their health monitored "during their stay in the country." It would be impossible to implement this plan in Shahin's programme today, given the immense volume of international air traffic.
The 1920s were still early days for smallpox vaccinations and Shahin urged routine inoculation against this disease every seven years, "in view of the poor efficacy of the vaccine beyond this period." He called for more isolation wards to be established in areas in which specialised hospitals for tropical diseases did not exist. Some 20 such wards had been built, but in his view, they were insufficient.
Among the practical issues that concerned the author were the transport of physicians and their equipment to the sites of infectious diseases. The Ministry of Public Health had a number of automobiles and motorcycles with sidecars "for health inspectors and physicians to use following the outbreak of epidemics." However, he complained that government cutbacks included a halt to expenditures on these modes of transport, as a result of which the authority had no more than 17 motorcycles available to a handful of physicians in the country for the purpose of inoculation.
The final phase of Shahin's programme was concerned with ways to combat insects which spread disease. Flies and mosquitoes, naturally, were of top priority. Flies are notorious transmitters of conjunctivitis, typhoid and other diseases. Refuse dumps within the city were breeding grounds for these pests and Shahin urged the Ministry of Public Works to introduce furnaces to burn refuse as well as to institute arrangements whereby animal pens and stables, where flies also multiply, could be relocated away from heavily populated residential quarters.
In order to combat malaria-transmitting mosquitoes, Shahin called upon the government to fill in the stagnant ponds and swamps where the insects breed and relocate whatever fish exist in them into freshwater lakes. The Ministry of Public Health, he said, was currently exerting strenuous efforts towards meeting this objective.
If this Public Health Authority official, who later became King Fouad's personal physician, hoped this report would encourage officials to create a separate Ministry of Health, he would have to wait another nine years, until the prime minister announced the royal decree that fulfilled his dream. Then, only six days after becoming Egypt's first minister of health, fate ruled that severe illness force him to leave the post he had sought for so long. Moreover, the government of Maher Pasha, which assumed Shahin's responsibilities, fell less than a month later.
* The author is a professor of history and head of Al-Ahram History Studies Centre.
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