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PUBLIC HEALTH IN EGYPT.
715 In disarticulation at the shock. PUBLIC HEALTH IN EGYPT. there is much less shock, but the bony surfaces left, notably the prominences of the Appointment of Commission. acromion and the coracoid process, present a very IN June, 1917, Sir Reginald Wingate, the Egyptian High awkward shape. Excision of the scapula is of the greatest value only in cases where the growth is Commissioner, took the prescient step of appointing a Comto inquire into the Public Health Department of strictly confined to that bone, but in the case mission for the present condition of this Department was, in Egypt, the of the axilla Mr. Grant were recorded by glands his opinion, capable of improvement, while its future affected, so that not only at the primary operation organisation offered problems of a difficult administrative but also at two subsequent operations glands were and scientific character. removed from the axilla and from the posterior It was not, however, until June of this year that the triangle of the neck. The choice between these preliminary arrangements were completed and the terms of various operations is generally dictated by the extent reference settled, when the Commission was duly appointed, and the limitations of the disease, which clearly show as was announced in THE LANCET, with the toll owing how much must be removed. Though the shock is composition : President, Lieutenant-Colonel Andrew B4.1four, great with Berger’s operation, yet the clean sweep R.A.M.C., Director-in-Chief, Well come Bureau of Scientific made of the contents of the axilla is in marked Research ; members, Lieutenant-Colonel G. E. F. Stammers. Director of the Medical DepartR.A.M.C.; Mr. E. S. contrast to the slow dissection necessary when the ment of the Sudan Crispin, Government ; and Dr. Charles Todd, have to be removed without axillary glands injury Director of Laboratories in the Egyptian Public Health to the vessels and nerves. There is a further Department. The terms of reference of the Commission were : (1) To point in Mr. Grant’s cases worthy of note, and this is that in each case a number of exposures to consider the organisation and duties of the Public Health X rays were given to the affected part, either for Department and its relations with other departments conthe removal of recurrent nodules or for a pro- cerned in public health; (2) to make in general terms for increasing the efficiency of the Department; phylactic purpose. The benefit of the use of X rays suggestions to indicate the nature and number of the official appointin the prophylaxis of recurrence of malignant (3) ments to the Department which seem to be required, without disease cannot be considered to be proved, but the nominating persons to fill them. To these ends the Commethod has logical reasoning behind it, and time mission was empowered to call the necessary evidence will show its real value. Mr. Grant is to be con- and have access to documents in framing a report to be sent gratulated on the results obtained in all of his cases. to the Prime Minister or President of the Sultan’s Council.
the amount of
shoulder-joint
GLANDULAR TUBERCULOSIS IN RELATION TO PHTHISIS. Wallgren has made an inquiry as to the fate of over 500 patients at the surgical clinic of Upsala, Sweden, operated on in the period 1885-1905 for tuberculosis of the lymphatic glands ; the inquiry bore special reference to the subsequent occurrence He was successful in of pulmonary tubercle. getting particulars of 224 out of the 500. The number becoming tuberculous was found to be 6246 from pulmonary phthisis, 9 from miliary tuber-
culosis, and 7 from tuberculous meningitis. This a quarter-is obviously greater than the incidence of pulmonary tubercle in the general population. The disproportion must be
proportion-over
The Commission got to work in a practical manner, determining to make themselves personally intimate with all the existing details and conditions. They instituted a series of inspections in Cairo, Alexandria, and the provinces, thus familiarising themselves with the varying aspects of the work discharged by the Public Health Department. They met on 76 occasions, and the result is the return to the Prime Minister of a very outspoken series of findings.
Report of Commission:Scheme of Central Health Organisation. The Report begins by recording the impression that the general plan devised by the Public Health Department for dealing with the many and difficult health problems of Egypt was a sound one. It had been valuable in checking the spread of cholera, plague, typhus, and relapsing fever ;= it had none of the haphazard character with which it is generally credited ; and for future needs its scheme is well fitted both for adaptation and development. The Com.
discounted a tittle because 29 of the 224 had mission finds, in fact, that the future needs of the country from signs of tubercle in their lungs while in the the health point of view have also received great attention, This group showed very heavy after- while they single out for special and favourable mention the clinic. mortality. But of another group in which the case- last Assistant-Director of the Department, Dr. Cyril Goodman. notes contained express mention of the lungs being But the Report states that the Department suffers from having no proper official status; being not an entity but a healthy, 11 per cent. became consumptive. The branch of the Ministry of the Interior, it has no direct writer concludes that, on the whole, individuals who official access to the High Commissioner, while the channels have had adenitis are more likely than indifferent -namely, the Adviser or the Under-Secretary of State for persons to get consumption, although he does not the Interior-are without the necessary technical training to deny that occasionally, in particular cases, an attack understand the needs of the Public Health Department. of adenitis may even confer a certain amount of Upon the outbreak of war the efficiency of the Public Health already hampered by the multifarious nature protection against the more serious disease, a of its duties, was gravely affected, says the Report, by the species of immunity which has been invoked by fact that its officials were allowed to be seconded for duty Marfan and others. Lastly, those individuals whose with the troops at the very moment when the personnel of adenitis recurred after treatment became consumpthe Department should have been strengthened instead of tive oftener than did the rest. It is a pity that weakened, although effective organisation managed to avert enquetes such as the above are not made oftener, any disaster. With general reference to the present-day consince they have an actuality, an a posteriori quality, ditions in Egypt so far as they have a bearing on public health, which is denied to laboratory experiment. So far the report is sanguine. Developments in roads, railways, and as the above investigation goes, it confirms the canals will occur, having regard to the successful issue of praiseworthy caution of the attitude which refuses the war, while education in modifying the outlook of the to act on the assumption that tuberculosis in early Egyptian peasant and rendering the future of sanitation life confers later protection, and builds rather on more hopeful is expected to have a powerful effect. "It is the obvious facts that infection with tuberculosis obvious," says the Report, "that the signs are propitious, and owing to the war, the time may not yet be actually having once taken place is extremely likely to though, for extensive modifications in health organisation, yet recrudesce even after long periods of apparent cure. ripe it is clear that the of and advance
Department,
present period
1 Wallgren:
July 3 1st, 1918.
Centralblatt für die gesamte
Tuberkulose-Forschung,
change
offers special facilities for the consideration of a scheme of reform." But immediately afterwards the Report speaks in
716
they should be better paid and that there should be chance for Health Inspectors in the Mudiria (who are Egyptian doctors and next in rank to Divisional Inspectors) being raised to the position. Below the Madiria Health Inspectors comes the Markaz doctor, on whom at the present moment, and for very low pay, there fall the private practices in the Markaz as well as much public health work, care of schools and prisons, registration duties, and medico legal work. A Markaz, it may be said, is a district of a province, and may contain many large villages. Some of the Markazes have, we understand, as many as 80,000 inhabitants. The Commission responsible for the Report have perhaps devoted more time and thought to the remedy of the Markaz conditions than to any other part of their work. They obtained valuable evidence and arrived at the conclusion that the best course to pursue eventually would be to divide the Markaz doctors into two categories according to their work, (a) Sanitary and (b) Medical. The (a) Markaz doctor would under the scheme be in sanitary charge of public works, excluded from private practice, and be responsible for general sanitation, notification and public treatment of communicable disease, vaccination, quarantine, and care of pilgrims. The (b) Markaz doctor would be in charge of the medical side of some of this work-namely, the treatment of communicable disease, the medical work done in prisons and schools, the examination of prostitutes, and all medicolegal work. He would be, of course, allowed private practice, which would, as stated, be denied to the (a) Markaz doctor, to whom, however, promotion to the Mudiria Health Inspectorships would be open. The Commissioners recognise that at the present time this scheme is not feasible, but suggest that it be given a trial in certain suitable areas. To meet immediate needs they propose a large increase in the number of Markaz doctors, whose duties would thus be lightened in A notable recommendation in the Report is some measure. the introduction of qualified British sanitary inspectors-i.e., men of the N.C.O. class-both in the case of the provinces and the large towns. In the former they would be attached Egypt. Provincial Administration. directly to the British Divisional Inspectors and would The Report becomes very detailed in character when supervise the work of the Egyptian inspectors of nuisances, at present do not exist in the provinces, and whose dealing with provincial organisation for the public health of who is strongly urged. creation I in for than central are the rather administration, here, Egypt, Provision is made in the Report for the institution of chief defaults to be found, and here reform will get its quickest returns. The first weakness noted in provincial training centres in the large towns, where the methods and administration is the paucity of British Provincial Inspectors. appliances of sanitation can be taught to these inspectors of These officers are few in number, do not live permanently in nuisances. An eloquent plea is here founded on Lord their districts, and are kept so constantly moving about by Kitchener’s latest work for village sanitation service. The the multifarious nature of their duties that they rarely get authors of the Report protest against allowing the fellaheen into close touch with any section of the population. "A to live under existing sanitary conditions. Proper village good type of man," says the Report, " has undoubtedly been water-supplies, incinerators, latrines, and conservancya an officer of the Royal Army Medical Corps, possibly in part systems. are required to make Egyptian village life less of because he has received a special training in hygiene and sanitary scandal. understands discipline. This source of supply should be Concluding Remctrks. The various departments of medical service receive detailed readily available in the future." Reference here must clearly be made to medical men who have received notice-the department of epidemic service, of hospital temporary commissions in the Royal Army Medical Corps management and inspection, of police, prison, and railway during the past four years, because there could not possibly medical service, of school inspection and other subdivisions have been any successful demand made previous to the of medical work are all carefully noticed in the Report, as war upon the Hoyal Army Medical Corps, whose cadre was well as such subjects as medical schools and research then lamentably short. The Report continues: "The posts laboratories, public health laboratories, and vaccination should be filled by men of about 25 years of age, and they institutions. A special section of the Report is devoted to should preferably have held some hospital appointment the public health of Alexandria, Cairo, and other large towns. before joining the service of the Ministry. It would be a We hope that the Report will soon be printed and available for distinct advantage if they possessed diplomas in public the study of the profession. It is an outspoken document, health or in tropical medicine and hygiene." Such men covering a large amount of ground and giving information will not be found in any quantity relinquishing at the age in a readable and intelligible form, which is valuable to all of 25 the Royal Army Medical Corps, but it seems possible, sanitarians as well as to those whose interests lie specially in if the Egyptian bureau of health comes into rapid being, Egypt. We trust, therefore, that the Report will not share that British Provincial Inspectors might be obtained from the ill-fortune of many of its similars and remain the mere among those who have held temporary commissions. The literary record of an ideal. It can easily be understood that sort of work indicated should be quite attractive to many the unification of health activities in such a country as after their military experiences, but if Egypt is to get any Egypt constitutes a grave problem, but it is exactly the sort of problem which the British mind is best fitted to tackle. large supply the conditions of service must be inviting. The Report indicates that these Divisional Inspectors, If those in authority are prompt in translating the recomas they are officially called, should be first placed under mendations of this Report into the legislation of the Proa senior officer so as to become familiar with Egyptian tectorate their reward, in the future saving of trouble, will manners and to acquire Arabic, while arrangements, it be very great. is proposed, should be made whereby they can visit Cairo in rota and get an insight into the higher machinery Miss Gladys K. M. Simmons, who died of pulof the service. The general duties of a Divisional Inspector tuberculosis at Bournemouth on Nov. 15th on the monary may be described as those of a medical officer of health of the eve of her 27th birthday, had for the last two years been a Mudiria (province or county). The Report recommends not valued helper in the editorial work of THE LANCET, although only that there should be many more Divisional Inspectors, to her bed. almost unmeasured language of the plague of filth in Egypt, and the first section concludes by unanimous agreement that a Ministry of Health is essential for securing proper sanitary reform in the Protectorate. A scheme for a central health organisation is then outlined. It commences with the statement that the Ministry of Health must be a separate bureau with an Under-Secretary of State at its head as President. Immediately below him it is suggested there should be a Director-General of Health, who is intended to be the main driving force in the Ministry, as his duties will require him to coordinate the work of important subordinates as well as to prepare the annual Budget. The President will also have the advantages of a Technical Adviser, who, under the alternative title of Director of Medical Intelligence, will conduct a bureau of information, control the laboratories and research work, keep in touch with scientific developments in other countries, and be resp onsible for an educational museum. The Central B ard of Health, it is suggested, will be completed by seven officers appointed as directors respectively of Sanitary, Epidemic, and Medical Services, of Lunacy, Medical E ducation, Public Health Laboratories, and Sanitary Engineering. The first three of these Directors being designated as ex-officio members of the Board, it would seem that it is intended to co-opt the others as occasion requires. A Secretary-General is added not only to manage the records and deal with all questions relating to subordinate personnel but also to sift the work of the Director-General, who might otherwise become overburdened with detail. The Report goes very carefully into the separate and combined duties of these various important central officials, indicating that technical inspection will undoubtedly be needed in many directions, as for provincial and ophthalmic hospitals and pharmacies, schools, and food and water control. The establishment of a chair of Hygiene in the Kasr-el-Aini School of Medicine and of a Diploma in Public Health is strongly advocated. The Report then passes to the consideration of the provincial organisation of public health in
but that
a
confined
the amount of
shoulder-joint
GLANDULAR TUBERCULOSIS IN RELATION TO PHTHISIS. Wallgren has made an inquiry as to the fate of over 500 patients at the surgical clinic of Upsala, Sweden, operated on in the period 1885-1905 for tuberculosis of the lymphatic glands ; the inquiry bore special reference to the subsequent occurrence He was successful in of pulmonary tubercle. getting particulars of 224 out of the 500. The number becoming tuberculous was found to be 6246 from pulmonary phthisis, 9 from miliary tuber-
culosis, and 7 from tuberculous meningitis. This a quarter-is obviously greater than the incidence of pulmonary tubercle in the general population. The disproportion must be
proportion-over
The Commission got to work in a practical manner, determining to make themselves personally intimate with all the existing details and conditions. They instituted a series of inspections in Cairo, Alexandria, and the provinces, thus familiarising themselves with the varying aspects of the work discharged by the Public Health Department. They met on 76 occasions, and the result is the return to the Prime Minister of a very outspoken series of findings.
Report of Commission:Scheme of Central Health Organisation. The Report begins by recording the impression that the general plan devised by the Public Health Department for dealing with the many and difficult health problems of Egypt was a sound one. It had been valuable in checking the spread of cholera, plague, typhus, and relapsing fever ;= it had none of the haphazard character with which it is generally credited ; and for future needs its scheme is well fitted both for adaptation and development. The Com.
discounted a tittle because 29 of the 224 had mission finds, in fact, that the future needs of the country from signs of tubercle in their lungs while in the the health point of view have also received great attention, This group showed very heavy after- while they single out for special and favourable mention the clinic. mortality. But of another group in which the case- last Assistant-Director of the Department, Dr. Cyril Goodman. notes contained express mention of the lungs being But the Report states that the Department suffers from having no proper official status; being not an entity but a healthy, 11 per cent. became consumptive. The branch of the Ministry of the Interior, it has no direct writer concludes that, on the whole, individuals who official access to the High Commissioner, while the channels have had adenitis are more likely than indifferent -namely, the Adviser or the Under-Secretary of State for persons to get consumption, although he does not the Interior-are without the necessary technical training to deny that occasionally, in particular cases, an attack understand the needs of the Public Health Department. of adenitis may even confer a certain amount of Upon the outbreak of war the efficiency of the Public Health already hampered by the multifarious nature protection against the more serious disease, a of its duties, was gravely affected, says the Report, by the species of immunity which has been invoked by fact that its officials were allowed to be seconded for duty Marfan and others. Lastly, those individuals whose with the troops at the very moment when the personnel of adenitis recurred after treatment became consumpthe Department should have been strengthened instead of tive oftener than did the rest. It is a pity that weakened, although effective organisation managed to avert enquetes such as the above are not made oftener, any disaster. With general reference to the present-day consince they have an actuality, an a posteriori quality, ditions in Egypt so far as they have a bearing on public health, which is denied to laboratory experiment. So far the report is sanguine. Developments in roads, railways, and as the above investigation goes, it confirms the canals will occur, having regard to the successful issue of praiseworthy caution of the attitude which refuses the war, while education in modifying the outlook of the to act on the assumption that tuberculosis in early Egyptian peasant and rendering the future of sanitation life confers later protection, and builds rather on more hopeful is expected to have a powerful effect. "It is the obvious facts that infection with tuberculosis obvious," says the Report, "that the signs are propitious, and owing to the war, the time may not yet be actually having once taken place is extremely likely to though, for extensive modifications in health organisation, yet recrudesce even after long periods of apparent cure. ripe it is clear that the of and advance
Department,
present period
1 Wallgren:
July 3 1st, 1918.
Centralblatt für die gesamte
Tuberkulose-Forschung,
change
offers special facilities for the consideration of a scheme of reform." But immediately afterwards the Report speaks in
716
they should be better paid and that there should be chance for Health Inspectors in the Mudiria (who are Egyptian doctors and next in rank to Divisional Inspectors) being raised to the position. Below the Madiria Health Inspectors comes the Markaz doctor, on whom at the present moment, and for very low pay, there fall the private practices in the Markaz as well as much public health work, care of schools and prisons, registration duties, and medico legal work. A Markaz, it may be said, is a district of a province, and may contain many large villages. Some of the Markazes have, we understand, as many as 80,000 inhabitants. The Commission responsible for the Report have perhaps devoted more time and thought to the remedy of the Markaz conditions than to any other part of their work. They obtained valuable evidence and arrived at the conclusion that the best course to pursue eventually would be to divide the Markaz doctors into two categories according to their work, (a) Sanitary and (b) Medical. The (a) Markaz doctor would under the scheme be in sanitary charge of public works, excluded from private practice, and be responsible for general sanitation, notification and public treatment of communicable disease, vaccination, quarantine, and care of pilgrims. The (b) Markaz doctor would be in charge of the medical side of some of this work-namely, the treatment of communicable disease, the medical work done in prisons and schools, the examination of prostitutes, and all medicolegal work. He would be, of course, allowed private practice, which would, as stated, be denied to the (a) Markaz doctor, to whom, however, promotion to the Mudiria Health Inspectorships would be open. The Commissioners recognise that at the present time this scheme is not feasible, but suggest that it be given a trial in certain suitable areas. To meet immediate needs they propose a large increase in the number of Markaz doctors, whose duties would thus be lightened in A notable recommendation in the Report is some measure. the introduction of qualified British sanitary inspectors-i.e., men of the N.C.O. class-both in the case of the provinces and the large towns. In the former they would be attached Egypt. Provincial Administration. directly to the British Divisional Inspectors and would The Report becomes very detailed in character when supervise the work of the Egyptian inspectors of nuisances, at present do not exist in the provinces, and whose dealing with provincial organisation for the public health of who is strongly urged. creation I in for than central are the rather administration, here, Egypt, Provision is made in the Report for the institution of chief defaults to be found, and here reform will get its quickest returns. The first weakness noted in provincial training centres in the large towns, where the methods and administration is the paucity of British Provincial Inspectors. appliances of sanitation can be taught to these inspectors of These officers are few in number, do not live permanently in nuisances. An eloquent plea is here founded on Lord their districts, and are kept so constantly moving about by Kitchener’s latest work for village sanitation service. The the multifarious nature of their duties that they rarely get authors of the Report protest against allowing the fellaheen into close touch with any section of the population. "A to live under existing sanitary conditions. Proper village good type of man," says the Report, " has undoubtedly been water-supplies, incinerators, latrines, and conservancya an officer of the Royal Army Medical Corps, possibly in part systems. are required to make Egyptian village life less of because he has received a special training in hygiene and sanitary scandal. understands discipline. This source of supply should be Concluding Remctrks. The various departments of medical service receive detailed readily available in the future." Reference here must clearly be made to medical men who have received notice-the department of epidemic service, of hospital temporary commissions in the Royal Army Medical Corps management and inspection, of police, prison, and railway during the past four years, because there could not possibly medical service, of school inspection and other subdivisions have been any successful demand made previous to the of medical work are all carefully noticed in the Report, as war upon the Hoyal Army Medical Corps, whose cadre was well as such subjects as medical schools and research then lamentably short. The Report continues: "The posts laboratories, public health laboratories, and vaccination should be filled by men of about 25 years of age, and they institutions. A special section of the Report is devoted to should preferably have held some hospital appointment the public health of Alexandria, Cairo, and other large towns. before joining the service of the Ministry. It would be a We hope that the Report will soon be printed and available for distinct advantage if they possessed diplomas in public the study of the profession. It is an outspoken document, health or in tropical medicine and hygiene." Such men covering a large amount of ground and giving information will not be found in any quantity relinquishing at the age in a readable and intelligible form, which is valuable to all of 25 the Royal Army Medical Corps, but it seems possible, sanitarians as well as to those whose interests lie specially in if the Egyptian bureau of health comes into rapid being, Egypt. We trust, therefore, that the Report will not share that British Provincial Inspectors might be obtained from the ill-fortune of many of its similars and remain the mere among those who have held temporary commissions. The literary record of an ideal. It can easily be understood that sort of work indicated should be quite attractive to many the unification of health activities in such a country as after their military experiences, but if Egypt is to get any Egypt constitutes a grave problem, but it is exactly the sort of problem which the British mind is best fitted to tackle. large supply the conditions of service must be inviting. The Report indicates that these Divisional Inspectors, If those in authority are prompt in translating the recomas they are officially called, should be first placed under mendations of this Report into the legislation of the Proa senior officer so as to become familiar with Egyptian tectorate their reward, in the future saving of trouble, will manners and to acquire Arabic, while arrangements, it be very great. is proposed, should be made whereby they can visit Cairo in rota and get an insight into the higher machinery Miss Gladys K. M. Simmons, who died of pulof the service. The general duties of a Divisional Inspector tuberculosis at Bournemouth on Nov. 15th on the monary may be described as those of a medical officer of health of the eve of her 27th birthday, had for the last two years been a Mudiria (province or county). The Report recommends not valued helper in the editorial work of THE LANCET, although only that there should be many more Divisional Inspectors, to her bed. almost unmeasured language of the plague of filth in Egypt, and the first section concludes by unanimous agreement that a Ministry of Health is essential for securing proper sanitary reform in the Protectorate. A scheme for a central health organisation is then outlined. It commences with the statement that the Ministry of Health must be a separate bureau with an Under-Secretary of State at its head as President. Immediately below him it is suggested there should be a Director-General of Health, who is intended to be the main driving force in the Ministry, as his duties will require him to coordinate the work of important subordinates as well as to prepare the annual Budget. The President will also have the advantages of a Technical Adviser, who, under the alternative title of Director of Medical Intelligence, will conduct a bureau of information, control the laboratories and research work, keep in touch with scientific developments in other countries, and be resp onsible for an educational museum. The Central B ard of Health, it is suggested, will be completed by seven officers appointed as directors respectively of Sanitary, Epidemic, and Medical Services, of Lunacy, Medical E ducation, Public Health Laboratories, and Sanitary Engineering. The first three of these Directors being designated as ex-officio members of the Board, it would seem that it is intended to co-opt the others as occasion requires. A Secretary-General is added not only to manage the records and deal with all questions relating to subordinate personnel but also to sift the work of the Director-General, who might otherwise become overburdened with detail. The Report goes very carefully into the separate and combined duties of these various important central officials, indicating that technical inspection will undoubtedly be needed in many directions, as for provincial and ophthalmic hospitals and pharmacies, schools, and food and water control. The establishment of a chair of Hygiene in the Kasr-el-Aini School of Medicine and of a Diploma in Public Health is strongly advocated. The Report then passes to the consideration of the provincial organisation of public health in
but that
a
confined