Reforming Greek Public Health
Athens City Hall Statue - Credit Scott Kinney
27 MAR 2017 by JEFFREY LEVETT
‘Man can do a great deal more than he imagines’ says Gide; ‘Man is in a mess!’ said he; God said ‘Let him get out of it’ adding, ‘I must say that mankind has disappointed me greatly’.
In 2016, the Association of Schools of Public Health in the European Region (ASPHER) held its General Assembly in Athens. Representatives from more than 100 member institutions from 43 countries met in the National School of Public Health (Hellenic School) to highlight a landmark event and sign the Athens ASPHER Accord. It was due recognition of the contribution of the Hellenic School to the Association and to the development of a scientific culture in Greece.
In celebrating one half century on the European stage, ASPHER in Athens reminded the world that the Hellenic School emerged from a short-lived revolution in public health in response to the deplorable state of health of the Greek people. It was a state that had persisted unchanged in the 100 years following on from the Greek War of Independence (1821-1930). It prompted Daniel Webster to request Congressional aid having in mind a modern Greece fighting against unprecedented odds for the common experience of human existence.
During and after devastating wars (Napoleonic, WWI, WWII) Europe witnessed famine and disease, unemployed veterans unable to feed their families, generations of women without men and genocide. Horrendous environmental disasters have on occasion knocked the world out of kilter. One in 1815, had long term global affects and provoked a dark summer when the sun did not shine (1816). It was larger by far, than the earthquake that jolted the earth’s axis to set up a tsunami that precipitated a nuclear accident (Fukushima, 2011).
In Ireland, the light failed as a result of typhus, creating a massive need for humanitarian relief. Disaster struck twenty five years ahead of the potato famine, which caused mass migration to the USA. From the health turmoil, came an English fever committee that evolved into a Board of Health for the English colonies. One important result was the contemplation of a preventive system for public health management.
Public health developed as a product of disasters, filth diseases, the industrial revolution and urbanization. It emerged to a background of environmental miasma and the sanitary revolution. Political will and charismatic individuals played key roles (Edwin Chadwick, John Simon). Its English narrative has good and romantic people blowing up sewers in slums to stop disease spread. In the German narrative 1817 is the year of the beggar and lead up to social medicine evolving with Rudolf Virchow. When Chancellor Otto von Bismarck challenged him to a dual for his criticism of excessive military spending, Virchow chose two pork sausages as his duelling weapons. Legend alleges that one was filled with a deadly biological parasite that was killing many.
In good times, public health is almost invisible. In times of authoritarian government its autonomy is questioned and some of its institutions destroyed. Dictatorships have misused it and tortured its practitioners. Institutes and Schools of public health have slipped or been pushed off the map during authoritarian rule [Nazi Germany, Pinochet Chile] and even under democratic governance (Canada, Scandinavia). Schools in Ankara, Athens, Sophia, and Zagreb came unstuck to varying degrees as a result of coups. In the Eastern Bloc, Institutes were lumbered with the non-productive trappings of a centralized bureaucracy.
Today in Syria, public health a weapon of war, withheld from those who need it and the international community can do little about it. One School in Tbilisi, Georgia was destroyed when its director and staff were executed by Beria. Not even an appeal by the President of France to Stalin could stay their execution. Felix d’Herelle a nominee for the Nobel Prize fled Georgia to alert France; Andrija Stampar dismissed for incompetence in Yugoslavia went into exile in China. Felix died in obscurity but has a Parisian street named after him and his cottage in Tbilisi was made use of by the KGB; Andrija became the first President of the World Health Organisation [WHO, 1948] and recognised as a universal role model in public health.
Other role models include UNESCO’s Jim Grant, who was a long standing officer in the Rockefeller Foundation, Joe Asval of the World Health Organization (WHO), Europe with its HFA strategy and its 38 operational targets and David Byrne a lawyer in the image of Chadwick who was responsible for England’s public health laws of 1848. Byrne was awarded the coveted Stampar award from the Association of Schools of Public Health in the European Region (ASPHER) for his work on the scourge of tobacco and its control; so was Peter Piot for his Ebola work and Halfdan Mahler, an expert on tuberculosis and the 3rd Director General, WHO for his promotion of primary health care. Mahler succeeded for a short while to give more political dimension to the WHO. In 1969, he and I were locked into systems analysis and its use in health management. His still current work on essential pharmaceuticals was opposed by America which in 1982 threatened to withhold contributions to WHO. Today, a similar situation is unfolding.
Notwithstanding its important contributions to society, Public Health receives reluctant recognition and limited support from the state. Political interests, bureaucratic constraints and medical dominance have all curbed its full-flowering. When society is threatened however, it calls upon its services but do not always work effectively, as in America’s recent Ebola health scare. Politics must reject society’s “ugly duckling” role of public health by moving it up the European agenda to a position more beneficial to population health and peoples’ wellbeing and by reinforcing human rights and reducing inequality.
Speaking before the National Convention of the Medical Committee for Human Rights (1966), Martin Luther King Jr. proclaimed in Chicago that of all the forms of inequality, injustice in health is the most shocking and the most inhumane. Johnson had just declared war on poverty and got Medicaid and Medicare off the ground. Jonathan Mann who was tragically killed in an air disaster would later term the juxtaposition of health and human rights as mankind’s new ethical space. Today, it is being dismantled by greed, globalisation and politics. Today, Obamacare is under threat. Today highly developed public health is more than ever needed to help stem population vulnerability but still reluctantly supported.
In Spain, 1966 a B-52 bomber crashed carrying four unarmed hydrogen bombs. 50 years later, the threat of nuclear winter grows even worse. It is a result of accumulated nuclear materials including 50 stolen warheads now in the hands of illegal groups, the existence of a North Korean nuclear threat and the enormous stockpile of nuclear war heads distributed among the nuclear powers. Most of them are in the arsenals of the USA and Russia. man’s living space is threatened by radioactive pollution while in and around Chernobyl, poverty is by far the greater threat. Of note is that nuclear science in medicine, nuclear research and radioprotection were strong agenda items in the early days of WHO and the European Community.
In the Balkans (1966-1968), the statutes of an Association better known as ASPHER were adopted and the inaugural General Assembly conducted to give birth to the Association of Schools of Public Health in the European Region. It was strongly supported by the WHO but with a distinctive French flavor. It produced a strengthening of European public health.
The first General Asembly was organized by Brancho Kesic and Fedor Valic of the Stampar School of Public Health, Zagreb and precipitated a discussion that touched upon public health’s future. It is said that the first meaningful utterance came out of an inebriating mist of alcoholic fumes in a mountain side wine cellar but different to the miasma of industrial revolution England. Stampar would have been shocked by the drinking of Slivovic for one of his many battles was with alcoholism in rural Croatia.
Throughout 2016, ASPHER celebrated its many achievements in inter-disciplinary post-graduate education and training for population based health on the European stage. Athens was the chosen platform from which deep concern would be expressed over rising population vulnerability from austerity, large refuge trails and from terrorism. the Athens ASPHER Accord petitions politics, the European Parliament and the administrations of individual countries to help fashion a more equal, stable and democratic world by reinforcing public health and its related Schools.
Notice of the Accord even by its parents has not been taken seriously and the international community should do more for public health. Public Health needs a re-conceptualized socially and politically as one of the crucial avenues to promote rational socioeconomic development. Several centuries ago, Sir William Petty clearly demonstrated a strong link between productivity of a community and the health of its working population. King echoes this in his Where Do We Go from Here: Chaos or Community? Implicitly, similar thinking comes through in health in all other policies in the Maastricht Treaty  to which ASPHER responded with the Athens Memorandum.
A School of Public Health for Greece was first conceptualized in 1905 and became a reality in 1929 (Eleftherios Venizelos) with help coming finally from the League of Nations with support from the Rockefeller Foundation. It precipitated a little known revolution in public health that over the next 40 years ensured major contributions to the well being of Greeks.
Notwithstanding such contributions; eradication of malaria and control of tuberculosis throughout its life span it has run run a rough passage. The Hellenic School was constrained by dictatorship, buffeted by the medical establishment and dominated by an obsolete bureaucracy and legalism. A spiking of malaria saved it in the 1950’s, it survived in 1969 as a result of an intervention by prestigious scientists who went on record that no state with a school had ever abolished it. On his return from exile (1974), Constantine Karamanlis made its rejuvenation a priority.
It is worth noting that in a pending and planned dialogue for public health reform (2017) and to celebrate 100 years of the Ministry of Health, its foster child, and School of Public Health not even in the guise of education, does it figure on the agenda, except in the affiliation given for several participants. a similar high level consultation four years ago, between the Hellenic Ministry and the WHO also in Athens provides a sense of déjà vu. Days are long gone since Eleftherios Venizelos started a revolution in public health, Constantine Karamanlis prioritized the rejuvenation of the School after the dark days of the dictatorship and since Spiros Doxiadis enabled its development?
In 1984 the School took a significant step forward by introducing new directions (health systems management, systems theory, biomedical technology, economics, health politics and sociology). by 1990, it was clear that the health condition in the Balkan region would need to be monitored during transition, that the Hellenic School needed a reconnect to the international communty. During ASPHER’S 14TH General Assembly (1992) the School conducted a unique Balkan Public Health Forum in the dynamic presence of representatives of WHO, EHMA, WFPHA wih upport from DGV and the Hellenic Ministries of Health, Home Affairs, Public Order, Civil Protection, and Foreign Affairs. Ten years later it conducted a similar event in Belgrade through the European Center for Peace and Development with the participation of Council of Europe.
In 2016, Athens became ASPHER’s platform to reach out to the European leadership demanding greater support of public health as a scientific, social and moral obligation. Athens recalled the horrendous population displacements resulting from WWII and the holocaust as well as earlier displacements concomitant with the collapse of the Ottoman Empire and with the most recent ones in the Balkans. It underscored that protection and promotion of minority and migrant health are of fundamental importance to public health and its practitioners.
Half a century on from the inebriating vapors of a Zagreb wine cellar and 90 year since the inauguration of one of the first Schools of public health in Europe, interdisciplinary public health still does not command either the ear of the international community or of the Greek authorities. The still unused unread Athens ASPHER Accord urges the Greek authorities to remove all impediments to the function of the socially beneficial and historic Hellenic School (1929) and demands a level of European support for public health commensurate with the size and complexity of the problem space it now faces.
A positive response to these demands is for the common good of all Europeans. Not to respond, will result in a still poorer Europe.
Levett Jeffrey, Public health in Greece
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Jeffrey Levett is Director Emeritus, Department of Public Health Management and founding Dean of the National School of Public Health, Athens Greece. He is currently, Professor, International Health and a member of the Executive Board, European Center for Peace and Development, United Nations University for Peace, Belgrade, Serbia. Full profile