Cholera in Egypt and Cholera in Egypt and the Origins of WHO, the Origins of WHO,

1947 1947

Marcos Marcos CuetoCuetoProfessor Professor

Universidad Universidad PeruanaPeruanaCayetanoCayetano HerediaHeredia

PartPart ofof a a largerlarger studystudy onon thethe historyhistory ofof WHO, Global Health Histories WHO, Global Health Histories initiativeinitiative, E. , E. FeeFee, T. , T. BrownBrown et al.et al.

General theme and questions:General theme and questions:In 1947 the organizers of WHO planned to hold the 1st World HealIn 1947 the organizers of WHO planned to hold the 1st World Health th

Assembly within a few months but the process took longer and facAssembly within a few months but the process took longer and faced urgent ed urgent problems such as a cholera outbreakproblems such as a cholera outbreak

Tension between the need to respond to emergencies and institutiTension between the need to respond to emergencies and institution on building processes building processes

How to combine relief with prevention?How to combine relief with prevention?How to modernize quarantine regulations? How to modernize quarantine regulations?

How to work in a conflictive region and period? How to work in a conflictive region and period? (Palestine refugees, the creation of Israel, (Palestine refugees, the creation of Israel,

the beginning of the Cold War)the beginning of the Cold War)

John Lennon John Lennon ““Life is what happens to you while you are busy making Life is what happens to you while you are busy making other plansother plans””

BackgroundBackgroundBetween 1882Between 1882--1920s part of the British Empire 1920s part of the British Empire

but never officially a colony but never officially a colony

In 1922 the UK unilaterally declared In 1922 the UK unilaterally declared independenceindependence

However, British influence continued However, British influence continued (maintaining its control over the (maintaining its control over the

Suez canal) Suez canal) Occupied by the Germans during most Occupied by the Germans during most

of the WWIIof the WWII

In the early 20In the early 20thth century an export century an export economy: cotton economy: cotton

In 1947 the total population of the In 1947 the total population of the country over 19 millioncountry over 19 million

British soldiers at the piramid of Giza, c. 1899

www.artehistoria.com

H.MH.M. Farouk I, King of Egypt and of Sudan. . Farouk I, King of Egypt and of Sudan. ruled Egypt between 1936 and 1952.ruled Egypt between 1936 and 1952.

Undermined by accusations of a lavish royal lifestyle Undermined by accusations of a lavish royal lifestyle in a poor country, corruption and pickin a poor country, corruption and pick--pocketing pocketing

A country on the threshold of a revolutionA country on the threshold of a revolutionA military coup in 1952, directed by A military coup in 1952, directed by GamalGamal A. Nasser, forced Farouk to abdicate A. Nasser, forced Farouk to abdicate

A year later a republic emergedA year later a republic emerged

In 1945 Egypt became a member of the Arab League with In 1945 Egypt became a member of the Arab League with headquarters in Cairo; against UN plan for partition of Palestinheadquarters in Cairo; against UN plan for partition of Palestine e

into an Arab and a Jewish state into an Arab and a Jewish state Egypt was defeated during the 1948 ArabEgypt was defeated during the 1948 Arab--Israeli War Israeli War

but maintained control of a strip of territory around Gazabut maintained control of a strip of territory around Gaza

Shortly after WWII: about 1000 Arab refugees homeless in LebanoShortly after WWII: about 1000 Arab refugees homeless in Lebanon, Syrian, Jordan and Gazan, Syrian, Jordan and GazaMedical and relief programs under WHO`s Medical and relief programs under WHO`s The Lamp is Light, the Story of WHOThe Lamp is Light, the Story of WHO, 1951, 1951

Medical Medical ModernizationModernizationin in EgyptEgypt duringduring thethe 20th 20th centurycentury

Rene Francis, Public Health in Egypt, Cairo 1951, NLM

Medical Medical ModernizationModernization in in EgyptEgypt

A medical tradition of 5,000 years. A medical tradition of 5,000 years. NaguibNaguib Pasha Pasha MahfouzMahfouz, , leading gynaecologist leading gynaecologist and and

international lecturer international lecturer A Serum and Vaccine Institute A Serum and Vaccine Institute

at Cairo at Cairo IIn 1936 a Ministry of Health definitely established n 1936 a Ministry of Health definitely established

However, However, still a country with still a country with bilharziabilharzia, hookworm, malaria, hookworm, malaria

““Egyptian doctors have an eye for disorder that even a Dutch housEgyptian doctors have an eye for disorder that even a Dutch housewife ewife cannot equalcannot equal““

FrancisFrancis, Public Health in Egypt, Public Health in Egypt

11945. 945. United Nations ConferenceUnited Nations Conference, San Francisco. Souza (Brazil) and , San Francisco. Souza (Brazil) and SzeSze (China) (China) propose to create an international health organization. Both mempropose to create an international health organization. Both members of the Health bers of the Health

Division of United Nations Relief and Rehabilitation AdministratDivision of United Nations Relief and Rehabilitation Administration,ion, UNRRA.UNRRA.

1946 1946 April: Technical Preparatory Committee prepares a Constitution April: Technical Preparatory Committee prepares a Constitution

1946 1946 July: International Health Conference in NY creates an Interim July: International Health Conference in NY creates an Interim

Commission, IC Commission, IC 1946 1946

IC absorbs OIHP (Paris) IC absorbs OIHP (Paris) Offices in Geneva and NYC Offices in Geneva and NYC Between April 1947 and January 1948 IC meets at four months inteBetween April 1947 and January 1948 IC meets at four months intervalsrvalsAlsoAlso absorbsabsorbs ffunctionsunctions of the League of Nations Health Organization and of the League of Nations Health Organization and

UNRRA UNRRA 1947 September & October: Cholera epidemic in Egypt 1947 September & October: Cholera epidemic in Egypt

1948194824 June24 June--24 July: 1st World Health Assembly, Geneva (65 nations)24 July: 1st World Health Assembly, Geneva (65 nations)

A A BriefBrief ChronologyChronology ofof WHO, 1946WHO, 1946--19481948

Paradox: For its organizers the definitive establishment of WHOParadox: For its organizers the definitive establishment of WHO was slow because was slow because ratifications took longer than expected; seen from the present iratifications took longer than expected; seen from the present it appears as a short t appears as a short period. Itperiod. It questions the common perception that progress in international questions the common perception that progress in international health health

usually proceeds slowlyusually proceeds slowly

Organizing principlesOrganizing principles

A A singlesingle specialized agency with a high degreespecialized agency with a high degree of of independenceindependence

Link new medical developments and public healthLink new medical developments and public health needsneeds

Anticipate the major needs on world health. A selection of Anticipate the major needs on world health. A selection of prioritiespriorities

IncludeInclude as manyas many member States as possible member States as possible

PublicationsPublications: : Bulletin of WHO, Chronicle of WHO; Weekly Bulletin of WHO, Chronicle of WHO; Weekly

Epidemiological Record, Epidemiological and vital statistics repEpidemiological Record, Epidemiological and vital statistics report, Official ort, Official

Records of the World Health Organization, International Digest oRecords of the World Health Organization, International Digest of Health f Health

LegislationLegislation

Work through Work through InternalInternal and and ExternalExternal CommitteesCommittees: : Internal; Internal; Administration and Finance, Epidemiology and Quarantine,Administration and Finance, Epidemiology and Quarantine,

Headquarters, Priorities, RelationsHeadquarters, Priorities, Relations

ExternalExternal: Bacteriological Standardization, : Bacteriological Standardization, QuarantineQuarantine, Drugs,, Drugs,MalariaMalaria, Pilgrimage & Sanitary Conventions, , Pilgrimage & Sanitary Conventions, TuberculosisTuberculosis,,VenerealVenereal DiseasesDiseases, Pharmacopoeias, Revision of, Pharmacopoeias, Revision of thetheInternational Lists of Diseases and Causes of DeathInternational Lists of Diseases and Causes of Death

NetworkNetwork ofof WHO WHO epidemiologicalepidemiological radioradio--broadcastsbroadcasts in late 1940sin late 1940s

AndrijaAndrija StamparStampar, from Yugoslavia, , from Yugoslavia, Chairman WHOChairman WHO--IC; President of IC; President of

11stst World Health AssemblyWorld Health Assembly.

BrockBrock Chisholm, from Canada, Chisholm, from Canada, Executive secretary WHO Interim Executive secretary WHO Interim

Commission (1946Commission (1946--1948); 1st Director1948); 1st Director--General WHO (1948General WHO (1948--1953)1953)

AlyAly TewfikTewfik ShoushaShousha PashaPasha““a medical politiciana medical politician”” Henry Van Henry Van ZileZile HydeHyde

----One of three viceOne of three vice--chairmen of WHOchairmen of WHO--IC and later 1st IC and later 1st chairman of WHO Executive Board chairman of WHO Executive Board

----A bacteriologist in the Public Health Laboratories in A bacteriologist in the Public Health Laboratories in Cairo in 1917 and in 1930 director of this institution Cairo in 1917 and in 1930 director of this institution

----UnderUnder--secretary of State for Health in Egypt since 1940 secretary of State for Health in Egypt since 1940 (and during the epidemic) (and during the epidemic)

----Helped to establish the US medical research unit in CairoHelped to establish the US medical research unit in Cairo

----One of the first foreigners to receive the US Freedom MedalOne of the first foreigners to receive the US Freedom Medal

Joined the WHO staff in 1949 as the First director of the RegionJoined the WHO staff in 1949 as the First director of the Regional al Office for the Eastern Mediterranean (held position until 1957)Office for the Eastern Mediterranean (held position until 1957)

CholeraCholera in in EgyptEgypt in 1947. in 1947. Vibrio Vibrio CholeraCholeraAccording to a WHO officer: According to a WHO officer:

the the most dramatic storymost dramatic story of the Interim Commission.of the Interim Commission.

An outbreak on September 22, 1947 in eastern Egypt An outbreak on September 22, 1947 in eastern Egypt

El El KoreinKorein: a village of 15,000 inhabitants : a village of 15,000 inhabitants Most cases in rural areas with no sanitation. Most cases in rural areas with no sanitation.

The epidemic came from outside but found local propitious The epidemic came from outside but found local propitious conditions conditions

The peak of the epidemic came in late October with 500 deaths The peak of the epidemic came in late October with 500 deaths and 900 new cases in one day and 900 new cases in one day

A disease that reA disease that re--emerged in Egypt after an absence of about emerged in Egypt after an absence of about 45 years45 years

Fear of spread to Europe Fear of spread to Europe 18171817--1923 pandemics coming from India spread east and west of India. 1923 pandemics coming from India spread east and west of India.

However, after 1923 no major western spread of cholera beyond AfHowever, after 1923 no major western spread of cholera beyond Afghanistanghanistan

FirstFirst responses responses toto CholeraCholera epidemicepidemicPanic and counterproductive police control Panic and counterproductive police control

According to According to TheThe LancetLancet it was a return to the it was a return to the ““quarantine of the junglequarantine of the jungle””

Land quarantines, isolation of the sick, disinfection of houses,Land quarantines, isolation of the sick, disinfection of houses,prohibition of public markets and iceprohibition of public markets and ice--cream cream

Prohibition Prohibition of washing cloths or bathing in the Nile and of open prayingof washing cloths or bathing in the Nile and of open praying--

places on the banks of the Nile places on the banks of the Nile Suppression Suppression

of outgoing movements of pilgrims from Egypt to India of outgoing movements of pilgrims from Egypt to India (Pilgrim season to Moslem holy places started in early October (Pilgrim season to Moslem holy places started in early October

and 7,000 pilgrims ready to leave Suez)and 7,000 pilgrims ready to leave Suez)

Hysteria: Hysteria: neighboring countries closed their frontiers to passengers, goodneighboring countries closed their frontiers to passengers, goods (including s (including

cotton) and mail from Egypt cotton) and mail from Egypt

In In OctoberOctober, , thethe GreekGreek GovernmentGovernment cancelledcancelled allall flightsflights toto Cairo Cairo becausebecause ofof thethe epidemicepidemicDDT used for an DDT used for an ““antianti--fly campaignfly campaign””

PossiblePossible originorigin ofof thethe epidemicepidemicAccordingAccording toto TheThe LancetLancet, , 8 8 SeptemberSeptember 1947,1947,

notnot relatedrelated toto pilgrimagepilgrimage

««...many think that they have traced the origin of the infection ...many think that they have traced the origin of the infection to to Egyptian labourersEgyptian labourers……coming from India to British Army coming from India to British Army aerodromes, where the labourers work...There is also a aerodromes, where the labourers work...There is also a

coincidence between the Egyptian epidemic and that which coincidence between the Egyptian epidemic and that which started on August 15, 1947, in the Punjab after its partition started on August 15, 1947, in the Punjab after its partition

between Pakistan and Hindustan and the migration of about 5 between Pakistan and Hindustan and the migration of about 5 million persons that followed itmillion persons that followed it»»

WHO (IC) WHO (IC) InterventionIntervention

DirectorDirector--General and Expert Committee on Quarantine helped to coordinate General and Expert Committee on Quarantine helped to coordinate the sending of tons of vaccine and supplies the sending of tons of vaccine and supplies

Supplies sent from the US reached Egypt in less than 3 days Supplies sent from the US reached Egypt in less than 3 days Medical supplies such as: Medical supplies such as:

syringes, hypodermic needles, blood plasma and sodium chloride syringes, hypodermic needles, blood plasma and sodium chloride and glucose, and glucose, for rehydration, and sulfonamides for rehydration, and sulfonamides

& & WHO warned about WHO warned about ““exaggeratedexaggerated”” measures taken by bordering countriesmeasures taken by bordering countries

Epidemic brought under control within six weeksEpidemic brought under control within six weeks

In 1902 the cholera epidemic had a death rate of 85 % or 35,595 In 1902 the cholera epidemic had a death rate of 85 % or 35,595 people. people.

In 1947 the total of cases was 20,804 with 10,277 deaths (death In 1947 the total of cases was 20,804 with 10,277 deaths (death rate: 50 %)rate: 50 %)

In 1947 population of Egypt over 19 millionIn 1947 population of Egypt over 19 million

Health Health campaigncampaign linkedlinked toto health health improvementsimprovementsHealth workers before the epidemic were about 1,700. During the Health workers before the epidemic were about 1,700. During the epidemic the epidemic the

figure increased to 3,400 figure increased to 3,400 An opportunity for improving water systems. Chlorination. New saAn opportunity for improving water systems. Chlorination. New sanitary pumpsnitary pumps

Vaccination perceived as a Vaccination perceived as a ““magic bulletmagic bullet””and applied on a large scale. and applied on a large scale.

A second vaccination in February 1948 A second vaccination in February 1948 Over 13 000 swabs taken from deceased persons between Dec. 1947 Over 13 000 swabs taken from deceased persons between Dec. 1947 –– Jan. 1948 Jan. 1948

According to experts, autumn and vaccination ended the epidemic According to experts, autumn and vaccination ended the epidemic Only 10 cases in 1948. Only 10 cases in 1948. None in the next year None in the next year

According to a study in hospitals, the fatality rate among the iAccording to a study in hospitals, the fatality rate among the inoculated was lower noculated was lower than among the nonthan among the non--inoculatedinoculated

In 1973 WHO abolished cholera vaccination for international travIn 1973 WHO abolished cholera vaccination for international travel el requirements in the International Health Regulationsrequirements in the International Health Regulations

TheThe antianti--choleracholeracampaigncampaign in full in full

swing swing Francis, Francis, PublicPublic Health in Health in

EgyptEgypt

««Thanks to the colossal efforts of the Egyptian public health Thanks to the colossal efforts of the Egyptian public health

authorities, it had been possibleauthorities, it had been possible……to circumscribe the to circumscribe the

epidemic to Egyptepidemic to Egypt»»

BrokBrok Chisholm, cited in Francis Chisholm, cited in Francis

««People discouraged by reports of dissension among different People discouraged by reports of dissension among different States may thus become more aware of the tremendous States may thus become more aware of the tremendous

potentiality of WHO and of the great opportunities of progress potentiality of WHO and of the great opportunities of progress through international cooperationthrough international cooperation»»

A. ShousaShousa

««A new and important element entered into the A new and important element entered into the bilateral health story in 1947bilateral health story in 1947…… [[thatthat]] communism communism

breeds on filth, disease, and human misery. breeds on filth, disease, and human misery. Immediately after the enunciation of the Truman Immediately after the enunciation of the Truman

Doctrine of containment of communism, a Doctrine of containment of communism, a Mission was sent to Greece. It contained an Mission was sent to Greece. It contained an

important health component composed of U.S. important health component composed of U.S. Public Health Service officers Public Health Service officers »»

Henry Van Henry Van ZileZile Hyde, Hyde, ““International Health: bilateral International Health: bilateral international health programs of the United States,international health programs of the United States,”” 41 41 American American

Journal of Public HealthJournal of Public Health (1951) p. 1475(1951) p. 1475

«Historians may remember 1948 as the Historians may remember 1948 as the year in which the peoples of the world lived year in which the peoples of the world lived alternately between fear and hope: fear of alternately between fear and hope: fear of atomic war, total destruction; hope that the atomic war, total destruction; hope that the UN would eliminate this threat. And they UN would eliminate this threat. And they may well conclude that the coming into may well conclude that the coming into force of the UN WHO gave the people force of the UN WHO gave the people

additional reason for hope, when hope was additional reason for hope, when hope was most neededmost needed»»

BrockBrock ChisholmChisholm, , ““NationsNations UniteUnite forfor World Health,World Health,””UnitedUnited NationsNations BulletinBulletin 5, 15, 1

((JulyJuly 1, 1948) p. 5291, 1948) p. 529

ConclusionsConclusionsControl of epidemic a form of validation, WHO not only a Control of epidemic a form of validation, WHO not only a ““debating societydebating society””

A learning experience on how to combine longA learning experience on how to combine long--term planning and rapid responses term planning and rapid responses to emergencies to emergencies

The notion that The notion that ““disease has no bordersdisease has no borders”” acquired a real meaning acquired a real meaning

Encouraged the work for improving quarantine systems, internatioEncouraged the work for improving quarantine systems, international health and nal health and rural health systems rural health systems

Mixed results in terms of cholera control. Cholera appeared contMixed results in terms of cholera control. Cholera appeared controllable and role of rollable and role of carriers were established carriers were established

but traditional methods and discrimination continued but traditional methods and discrimination continued

WHO could not avoid being involved in the Cold War WHO could not avoid being involved in the Cold War

Major challenge for developing countries was to maintain gains aMajor challenge for developing countries was to maintain gains and overcome a nd overcome a

history of discontinuityhistory of discontinuity

CholeraCholera in in EgyptEgypt andand thethe OriginsOrigins ofof WHO, WHO, 1947 1947

Marcos Cueto, Marcos Cueto, ProfessorProfessor, ,

Universidad Peruana Cayetano Heredia Universidad Peruana Cayetano Heredia Mcueto@upch.edu.peMcueto@upch.edu.pe

RegionRegion Date Date ofof CreationCreation FirstFirst DirectorDirector FirstFirst HeadquartersHeadquarters

SouthSouth EastEast--AsiaAsia 1 1 JanuaryJanuary 19491949 ChandraChandra ManiMani NewNew DelhiDelhi

AmericasAmericas 1 July 1949 1 July 1949 (Agreement)(Agreement)

FredFred. L. . L. SoperSoper Washington, D.C.Washington, D.C.

EasternEasternMediterraneanMediterranean

1 1 JulyJuly 19491949 AlyAly ShoushaShousha AlexandriaAlexandria

EuropeEurope SeptemberSeptember 19511951 Norman D. Norman D. BergBerg GenevaGeneva

WesternWestern PacificPacific 1 1 JulyJuly 19511951 I.C. I.C. FangFang ManilaManila

AfricaAfrica SeptemberSeptember 19511951 FranFranççoisoisDaubentonDaubenton

BrazzavilleBrazzaville