9—
The Continuing Evolution of Concepts of Disease and Medicine

We return to the question, were the medical institutions and technologies introduced by Muhammad Ali adaptable to local circumstances or did their Western origins make them inappropriate for Egypt? We have seen that a public health service was created in Egypt gradually and piecemeal, by Muhammad Ali's responses to specific problems. The viceroy first became alarmed about the number of military draftees who were unfit for service or who perished in the training camps, and he charged Dr. Clot to organize a military medical corps. In 1827, Clot, reasoning that European contractees would always be inadequate for the huge army Muhammad Ali had in mind, founded a medical school to train Egyptian physicians. Devastating cholera and plague epidemics in 1831 and 1835 further alarmed the viceroy, and he commissioned the European consuls to organize a quarantine service in Alexandria. Around 1836, Clot initiated a vaccination service by assigning Egyptian medical officers to the districts where government schools were located. In 1841, an outbreak of plague aroused Muhammad Ali's concern for ensuring the marketability of Egyptian commodities abroad, and he issued a comprehensive sanitary code for Alexandria. The year following, he united the agencies of the military Medical Council in Cairo and the Quarantine Board in Alexandria in a general urban and provincial

health service. In 1846, the viceroy ordered civil hospitals established in all districts where government factories existed. A final decree in 1846 confirmed the provincial health service's functions and extended Alexandria's comprehensive sanitary code to cities, towns, and villages. Appendix 1 charts the ramification of these agencies from the original establishments of the School of Medicine and the Quarantine Board.

Although the Egyptian Gazette consistently reported these initiatives as evidence of Muhammad Ali's solicitude for the people, it is clear that he was motivated by reasons of state: concern to ensure the battle readiness of the armed forces and the free movement of Egyptian products in the world market, the two major instruments of his drive for power and wealth. Like the liberation of the serfs and the zemstvo medical system in Tsarist Russia, Egypt's small network of urban and rural health centers was a ruler's rational response to the demands of growing industrialization in the world and the expansion of international trade. Thus fortuitously created, did Egypt's public health establishment serve to protect and promote the health of the people?

Quarantine

Since maritime quarantines were strongly contested as efforts to contain communicable disease, it is appropriate to look again at claims for quarantine's efficacy in preventing plague epidemics. The great historian of plague, Jean-Noel Biraben, has proposed that the Ottoman Empire's adoption of the European maritime quarantine system in 1841 was the single most important factor in the elimination of plague from the entire Mediterranean basin. It is difficult to support unequivocal claims for the elimination of plague by maritime quarantines alone, for they were never observed universally. Yet plague mysteriously receded from Egypt for 55 years after a series of epidemics between 1834 and 1844.

To clarify the disappearance of plague from Egypt after 1844, we can draw comparisons from the voluminous literature on plague in Western Europe. In addition to allegedly more efficient quarantine procedures, epidemiologists and historians have suggested four possible explanations for plague's withdrawal from Western Europe after the seventeenth century: a gradual development of immunity to

the bacillus among people subject to contact with plague-bearing rats and fleas; a gradual development of general resistance to disease gained from improved nutrition; improvements in housing, which separated flea-bearing animals from human habitation; and changes in the dominant rat and flea species.^[1]

In the case of Egypt, the fourth factor may explain the establishment of a locus for plague in Upper Egypt in the twentieth century.^[2] None of the other factors satisfactorily explains the disappearance of plague in Egypt after mid-century, however. A gradual development and, conversely, gradual decline of immunity may explain periodic fluctuations in epidemic outbreaks, but, as Pollitzer pointed out, immunity has been only relative and temporary. As for improved nutrition, housing, and general living standards, it is not clear that the masses of poor Egyptians enjoyed a higher level of living after 1844 than they had at the outset of the century. Egypt's population increased markedly during the second half of the century primarily because of the imposition of order in the country and the elimination of compulsory military service. Contemporary accounts indicate that because of growing population pressure in urban and seaboard communities, poorer Egyptians' living conditions probably deteriorated. Reports on housing in port cities at the time of the cholera epidemic in 1883 describe conditions that were as bad as, if not worse than, those of a half-century earlier.^[3]

Quarantine procedures thus remain the most likely explanation for the disappearance of plague from Egypt. As we have seen, stringent isolation measures in schools, hospitals, army barracks, and other government installations during the plague epidemic of 1834–1836 did protect those groups that otherwise might have suffered mass mortality. In the stone way, the combination of detention and isolation procedures at the Ottoman ports of debarkation as well as at ports of entry in Egypt—defied, evaded, and imperfectly applied as they were—must have intercepted rats and fleas and prevented the entry of infection.

Although their criteria for susceptible merchandise were arbitrary and illogically applied, Mediterranean quarantine authorities were justified in suspecting that cargo could be a source of infection. The chief threat came from commodities harboring plague fleas acquired in rat-infested warehouses or transport vessels. Trade in grain and cotton has historically been the most important vehicle for propagating plague.^[4] And since recognizing the mode of transmission

is more useful for disease control than identifying the causative agent—witness Snow's demonstration that cholera is primarily a waterborne disease almost thirty years before the discovery of the cholera vibrio—some procedures followed by quarantine administrators were sound practice, even if based on faulty theory.^[5] Exposing suspected goods to strong sunlight in the Mediterranean lazarettos was reasonable. And although the methods were rule of thumb, the use of sulfur fumes for fumigation also was rational, as was the later use of chlorine gas and heat for disinfection, especially in Russia, where plague continued to break out periodically.^[6]

As for cholera, the much-disputed maritime quarantine system was relatively effective in protecting the country from disease invasions if rigorously enforced. As we observed in the accounts of cholera epidemics in 1831, 1849, 1865, and 1881, in every case, it was the failure to require detention and isolation of suspected carriers at the outset which permitted the disease to spread throughout the country.

At the time Muhammad Ali sought expertise from European states to combat the diseases that threatened Egypt's manpower, Western medicine and public health were in a state of transition. Far from enjoying superiority in theory or practice for dealing with infectious disease, the Western world wrestled with mounting community health problems arising from runaway urbanization, accelerated transport, and expanded international trade. Everyone is familiar with the appalling health conditions in overcrowded port cities and factory towns, which remained neglected for a quarter of a century until Victorian reformers found a solution in the technology of sanitary engineering.

The importation of alien infectious diseases was more aggravating in its complexity. In the Americas, efforts to contain cholera were complicated by recurring yellow fever outbreaks, while Europe and Mediterranean Asia and North Africa were frustrated by the seemingly futile quarantine practices inherited from the fourteenth-century Black Death. In this prebacteriological era, the medical profession was baffled in attempting to identify common causes in epidemics carried by vastly different, and still unsuspected, agents: human beings, polluted water, mosquitoes, rats, and fleas.

Since physicians were powerless to cure or prevent outbreaks of the killer diseases, state authorities attempted to reduce panic, maintain order, and contain the epidemics by any action possible. Local

governments revived old municipal boards of health or created new ones ad hoc; in some cases, the central government created a national agency to advise and coordinate actionú Historians attribute Western nations' first faltering efforts to establish public health agencies to their traumatic experience with cholera epidemics.^[7] As each crisis passed, the institutions languished and sometimes disappeared, until another epidemic aroused renewed official action. The pattern of alternating initiatives and neglect, with frequently appalling losses of life, demonstrated that crisis-generated action was insufficient; effective health protection required consistent effort with at least minimal government funding and administrative support.

But a wave of political liberalism following the repudiation of monarchical rule in France, reinforced by the success of economic liberalism in England's industrial transformation, rejected government intervention in society's affairs. The British government anxiously sought defense measures against cholera which would not require any increase in local taxes, while economic unrest added fear of possible uprisings to their planning for epidemic control. In 1832, France had just undergone a revolution; a cholera epidemic was rumored to be a royalist poison plot to undermine republicanism, and physicians calling on patients wore workers' clothing to avoid being mobbed as suspected poisoners. Popular violence flared quickly, and the Paris municipal council was helpless to prevent city scavengers from upsetting and destroying new covered night soil wagons introduced as a sanitary measure but seen as an intrusion into familiar working habits. In both countries, the lower orders fought hand-to-hand battles with police who tried to transport cholera victims to emergency hospitals set up during the epidemic. Regulations introduced by the British Board of Health provoked so much opposition that the board was allowed to expire, and the Times celebrated its demise by observing, "The British nation abhors absolute power. . . . We prefer to take our chance of cholera and the rest than be bullied into health."^[8]

Smallpox Vaccination

In this connection, it is instructive to compare Egypt's relatively successful efforts to control smallpox with those of her two mentor states, England and France. In both countries, the govern-

ment's immunization programs proceeded by fits and starts. Although Jenner's own nation made a promising beginning early in the century, specialists with a vested interest in inoculation soon led a broad front of antivaccination resistance. Libertarian sentiments reinforced the opposition to the mandatory Vaccination Act passed in 1853, and it was not enforced until a serious smallpox epidemic moved Parliament to approve funds for its implementation in 1871. France was even more laggard. Napoleon had attempted to reach the entire population when he introduced Jennerian vaccination in 1801; local government agencies trained health officers and midwives in the approved vaccinating technique, supplied rural practitioners with vaccine gratis, and manned free vaccination centers in municipalities. After 1815, however, frequent changes in administration combined with professional and popular hostility to defeat immunization programs, and the French government did not pass a compulsory vaccination act until 1902. In the meantime, the results of abandoning the Napoleonic model of military efficiency became evident in the Franco-Prussian War of 1870–71, when smallpox removed about 20,000 French troops from action while Prussian forces remained immune through vaccination.^[9]

Comparison of the experience with smallpox vaccination in England, France, and Egypt suggests that in all three countries demonstrable good results did not automatically carry conviction. Facts do not necessarily speak for themselves; they are examined and interpreted to conform with the assumptions and concerns of the examiner.^[10] For different reasons, during the nineteenth century, a large proportion of the population in all three countries resented or were mistrustful of government officials. All were suspicious of functionaries who most often represented either the detested tax collecting or police operations of government. But ideology—nineteenth-century individualism and libertarianism—played a stronger role in opposition to vaccination in France and England than alleged Muslim fatalism did in Egypt. Once the threat of military conscription had passed, Egyptian resistance to vaccination gradually disappeared.

Two positive factors facilitated the success of Egypt's immunization program. First, the use of local barbers as paramedics allowed the village people a certain degree of control and participation in the effort. But most important was government support of the program, of the health officers' "outreach" campaign, their monitoring of the results and enforcing accountability at the community level. As was

noted earlier, when local functionaries no longer feared retribution from above, when they subverted funds and failed to make incentive payments to vaccinators, or neglected record-keeping, the program ground to a halt. These observations were confirmed by the WHO-sponsored program to eliminate smallpox in the 1970s when medical teams offered monetary incentives for immunization monitoring as they tracked the disease to its final hiding places in the villages of India and the tribal camps in Somalia. What has been overlooked in hailing the program's success as a Third World triumph is the half-century preceding, during which the Western world became resigned to public health administration: decades of compulsory vaccination of schoolchildren, public health bureaucrats distributing vaccine, and border functionaries all over the world examining yellow vaccination cards carded by obedient travelers.

Western-trained Professional Physicians

A third innovation imported from Europe was hospital-based clinical training for the aspiring professional physicians at Egypt's School of Medicine. Acquiring a European-style medical school at exactly the time when Western nations were transforming the character of medical practice from an aristocratic and scholarly calling to an autonomous profession should have been serendipitous for Egyptian physicians. But few among future generations of Egyptian medical practitioners would enjoy the European professional prerogatives because they evolved in the process of socioeconomic change accompanying industrialization, a process in which Egypt did not participate.^[11]

European powers' intervention to remove Muhammad Ali from Syria in 1841 and ensure his capitulation to the Ottoman sultan had two important results: reduction of the Egyptian armed forces to 18,000 men and compliance with the Anglo-Ottoman trade conventions of 1838 which granted British merchants the right to engage in free trade throughout the Ottoman Empire. The trade agreement meant the end of Egyptian government export monopolies and the removal of any protection for native industries. To escape the consequences of his loss of monopoly control over the land, the viceroy granted large areas to family members and court favorites, creating a semifeudal system in private landownership. The modernization of

agriculture for export brought about expansion of irrigation, development of transportation and communications, and establishment of financial links with the international community, which eventually led to the accumulation of a public debt. All of the service sectors of the economy—commerce, transport, and finance—were geared primarily to moving the cotton crop, with no spillover of investment into other sectors and little stimulus on social development.

The collapse of Muhammad Ali's ambitions for political and economic autonomy and the reduction of the armed forces removed the driving force in development, and it was taken up later by foreign capital and foreign enterprise. European development of Egypt's resources had two major flaws. First, development followed the path of least resistance—extension of irrigation and expansion of cotton exports. No attempt was made to diversify the economy by creating new forces of production in other fields. Second, the influx of foreign entrepreneurs, technicians, and professional people inhibited the development of native entrepreneurs and technicians and the incentive for education at all levels—mass, technical, and professional. Except for the Schools of Engineering and Medicine, the schools founded under Muhammad Ali were allowed to decline. The Khedive Ismail attempted to revive education by encouraging community support of primary schooling, by patronizing professional training, especially at the medical school, and by promoting secondary schools, the essential preparation for any higher education. But funds for education were among the first to be cut when Egypt's national budget came under Dual Control in 1876.

Neglect of education did not slow down economic growth, however, because imported personnel as well as imported capital built up and ran the economy, developing Egypt's natural resources with no corresponding development of human resources. The benefits of economic growth accrued mainly to foreigners or stimulated higher consumption by rich Egyptian landowners. Wealthy Egyptians bought more land; the educated entered the civil service; and the rail-road and irrigation absorbed those few who were technically trained. The untrained majority could not compete for job opportunities with the growing number of Europeans resident in Egypt; only 5,000 in 1840, they had increased to 68,000 by 1878.

A flood of foreign goods followed imported personnel and capital into the country. European products abounded not only in Alexandria and Cairo but even in the more distant towns of Upper Egypt. In

addition to the bazaar with local wares, every town had its smart Greek store where "Bass's ale, claret, curaçao, Cyprus, vermouth, cheese, pickles, sardines, worcester sauce, blacking, biscuits, preserved meats, candles, cigars, matches, sugar, salt, stationery, fireworks, jams, and patent medicines can all be bought at one fell swoop."^[12] Trivial as the list of merchandise in a grocer's shop may seem, each item had symbolic significance, serving as a reminder that European products were desirable and superior; everything indigenous was rustic, "baladi, " not up to cosmopolitan standards.

This was the attitude the Egyptian physician had to overcome during the century-long apprenticeship he served under European domination. Many accounts in nineteenth-century literature referred to the gullibility of well-to-do patients who were swindled by charlatans, some native, but more often itinerant Europeans who exploited the popular notion that all European practitioners represented a superior level of the art. The mystique of European training influenced a greater number of Egyptians as the European presence became increasingly noticeable during the century. "These people will no longer consult an Arab hakim if they can get a European to treat them," Lady Duff-Gordon wrote during the reign of Ismail; "they ask if the Government Doctors have been to Europe to learn Hikmah ; if not, they don't trust them."^[13]

By any standard, the Egyptian medical graduates who entered government service had to perform under multiple disadvantages. As men of inferior rank in the military establishment, they were bullied by upper-echelon officers; channeled later into serving the civilian population, they were scorned by European practitioners and mistrusted or ignored by the Egyptian people. Yet they became the backbone of a rudimentary public health service for Egypt at a time when endemic and imported health hazards were about to multiply.

Muhammad Ali had sponsored the creation of a Western-style school of medicine with hospital-based clinical training in order to command a corps of trained physicians who could safeguard the health of target groups in the population drafted into government service. He later deployed those Egyptian physicians in the countryside to disarm European trading partners' mistrust of the country's state of sanitation and health. To repeat what we noted about the vaccination campaign, two features of the budding public health service that resulted promised potential positive development to address the changing needs of the people: the utilization of local personnel in

administering the system and emphasis on sanitation and prevention of disease outbreaks.

We have already noted how the village barber became the chief agent in a national vaccination program. Sanitary regulations also were to be carried out by familiar minor officials or service personnel at community level: gendarmerie or military forces in local garrisons were charged with sanitary policing; the scavenger and water carrier corporations' street-cleaning duties were regularized under the supervision of the local shaykh; and the muhtasib, or market supervisor, was directed to broaden his surveillance to assist the district medical officer in pure food inspection. Thanks to the insistence of two rival groups of European physicians, the provincial health service specifically provided for two prophylactic measures, smallpox immunization and quarantine for infectious diseases. The local medical officers' duties also included sanitary regulation or "sanitary works"—street cleaning, refuse removal and disposal, filling in ponds, and relocating cemeteries. These would soon prove inadequate as the population grew, but the fact that they were statutorily specified as the local medical officer's responsibility established a healthy precedent for evolution in the future, when microbiology would provide a scientific rationale for sanitary procedures. The public health surveillance duties required of local functionaries also might have evolved later into new health care roles when guided by advances in the biomedical sciences.

But the evidence indicates that this promising beginning later was neglected in favor of the urban-based, curative medicine-oriented Western model that carried the prestige of the successful and prosperous leading nations of the world. Government policies assigned a low priority to rural health and welfare, and the provinces' health centers never received adequate support to realize their potential as channels for scientifically based preventive and curative medicine to the village population.^[14] In neither England nor France was there official recognition of the health and sanitation needs of the rural population which might have served as a model for Egypt. The industrializing world in the nineteenth century opted for high-quality medical care for a few, rather than minimal health care for the many, and the twentieth century has been slow to reject that model.

Since the mid-nineteenth century, Western systems of medical care delivery have been hospital oriented, providing personal care for individual patients by private physicians. Today, the standard

indicators used worldwide to assess health care resources are the number of physicians and hospital beds per capita. A popular reference work summarizing data on nations of the Third World offers an example in the chapter on Egypt, under the heading of "Health." "In 1975 there were 1,444 hospitals in the country with 77,611 beds or one bed per 464 inhabitants. In 1974 there were 7,495 physicians, or one physician per 5,000 inhabitants."

Without any attempt to link the two sets of data, the work goes on to state that in Egypt, "major health problems are bilharziasis, hookworm, trachoma, tuberculosis, dysentery, beriberi, and typhus."^[15] Urban-based hospitals and physicians are ill-equipped to deal with this spectrum of environmental and deficiency diseases requiring preventive medicine or social welfare measures: improved nutrition, housing, sanitation, parasite control, or education in hygiene. But these measures have not been considered part of the practice of medicine in the Western world since nineteenth-century society separated medicine from public health and defined the roles of hospital and physician exclusively in terms of curing disease.

For some idea of what Egypt's provincial public health service might have become, we can look at the fate of zemstvo medicine in Russia. The Bolshevik Revolution's leveling of society inevitably eliminated the zemstvo physicians, members of the aristocratic intelligentsia who joined the "Narodniki," or populist movement, to bring the people the benefits of education and science; only 15 percent of the total medical profession at the turn of the century, they nevertheless had played a vital role as exemplars of the socially conscious physician devoted to the welfare of others without regard for his own compensation. To uphold the revolution's egalitarian principles, the Bolsheviks also attempted to dissolve the feldshers because they were considered second-class practitioners. But, like the Jacobins who had sought to abolish hospitals as symbols of the ancien régime's stultifying charity, they had to reverse their plans because of overwhelming need. By the 1920s, the government had to establish new schools to train feldshers, and, again like the Jacobins, Soviet officials tried to make them more useful socially by gradually upgrading their training.

Today more than 400,000 feldshers, many of whom are women, work in various physician-substitute or "physician-extender" roles in the Soviet health system. Some feldshers in Soviet cities have specialized roles as industrial hygienists or midwives, but more com-

monly they act as the primary screening health worker in polyclinics or hospital outpatient departments. In rural areas, primary care is provided by feldsher-midwife stations with a wide range of responsibilities including epidemic control measures, reduction of childhood morbidity and mortality, "predoctor" medical aid to adults and children, sanitary and hygienic measures to improve the living and working conditions of people engaged in farming, and health education.^[16]

With the Russian system for comparison, it seems reasonable to conclude that the Western system imported to Egypt has proved inappropriate for the country's needs. The biomedical technology that developed within the matrix of a single patient-doctor transaction emphasized curative procedures required for individual ailments rather than preventive medicine measures for social and environmental health hazards threatening the majority in society.

Evolving Concepts of Health and Sickness

To return to the nineteenth-century squabble over disease causation, in view of the ineffectiveness of physicians' efforts to control epidemics, their self-confidence appears paradoxical. Considering the provisional, incomplete nature of their etiological knowledge at the time, how do we account for the dogmatism of champions of the two opposing theories, particularly the supporters of the miasmatic hypothesis, which we now recognize as dangerously inadequate in explaining the transmission of plague and cholera?

In the case of Great Britain, the obvious success of sanitary reform in reducing the incidence of waterborne diseases circumstantially seemed to vindicate the validity of the miasmatic theory. Although policy planners ignored John Snow's evidence incriminating water as the medium for disease transmission, by creating sewage systems to dispose of the human waste they believed the cause, they fortuitously protected the water supply and applied the proper remedy, if for the wrong reason. In addition, Great Britain's preeminent place in world affairs cannot be ignored as an important factor contributing to the medical profession's self-confidence. Physicians from British India especially, unaccustomed to having their opinions challenged, could see in Egypt all the features that guided their policies in South

Asia, and they believed they had the answers to what appeared to be analogous social and medical problems.^[17]

Clot is an interesting example of the continental physicians committed to variations of the miasmatic, anticontagionist hypothesis. To his advocacy of "indigenous" institutions, Egypt owes its School of Medicine, the School of Hakimas, the promotion of universal smallpox immunization by village barbers, and the extension of Egyptian physicians into provincial health centers after demobilization of the military medical corps. The initial institutionalization and nationalization of Western medicine in Egypt is largely due to Clot's drive and organizing genius. But on the subject of disease transmission, he was dogmatic. In rebutting arguments for the contagiousness of plague, he loses sympathy when he asserts that by 1840 all enlightened men, "except Italians and Spaniards," had abandoned the idea of contagion for scrofula, scabies, leprosy, ophthalmia, phthisis, dysentery, typhus, yellow fever, and cholera as well as plague. He shudders at the "ridiculous and barbarous custom" of Romans who segregated pulmonary consumption patients from other patients in their hospitals.^[18]

It was the cogency of the Morgagni paradigm that confirmed Clot's frequent diagnoses of "gastroenteritis" by revealing enteric lesions in corpses and strengthened his conviction, enhanced his self-confidence, and led him to doctrinaire attacks on his opponents. By the end of the century, the Morgagni paradigm had vindicated Clot's Italian and Spanish contagionist adversaries by identifying specific microorganisms as the pathogenic agents for the diseases over which they had quarreled. Although both sides believed they were dealing with definitive scientific truths, both theories were only limited, partial, and approximate descriptions of reality.

Concepts of the diesase process have evolved during the intervening century, and proposals for a new paradigm for medicine have appeared in recent decades.^[19] The pathology- or disease-focused concept of sickness sharpened to the principle of etiological specificity, which was vindicated by the bacteriological discoveries of the late nineteenth and early twentieth centuries, provided the perfect key concept for understanding infectious diseases and opened the way for rational therapeutics. The clinical system worked, and by focusing on pathology as the core discipline in hospital training, it established accuracy in diagnosis as the medical practitioner's major aim

and primary skill. The emergence of bacteriology next became the vehicle that first introduced the ideology of science into medicine, and paradoxically it led physicians away from the bedside to the laboratory.

More important for agrarian societies like Egypt, the ideology of science appears to have reinforced the idea that authentic medicine is curative medicine, a more serious pursuit than preventive or environmental control measures. No doubt Egyptian medical students and practitioners who are reluctant to practice in the countryside are influenced by the lack of social amenities, poor accommodations and facilities, inadequate supplies and assistance, and perhaps daunting social problems. But some of their dissatisfaction with rural practice may be attributed to training that encourages self-definition as scientists in the forefront of the latest discoveries. Confronting infectious diseases, the scientist-physician is concerned about the availability of broad-spectrum antibiotics; mounting a campaign of pest control or a program of hygiene education for villagers would be outside his area of responsibility.

The nineteenth-century divorce of the practice of medicine and community or public health concerns may be the most unfortunate aspect of the Western system transferred to the non-Western world. And Western leaders in medical science continue to insist, as one member of the elite of academic medicine declared, that "when the emphasis is shifted from sick individual human beings to people in the aggregate, clinical medicine becomes esoteric medicine, biochemistry and physiology become irrelevant, and the appropriate disciplines are more in the nature of economics and sociology."^[20] As long as the West upholds urban hospital-based curative medicine for the individual as the ideal for "health care," the lives of rural Egyptians and many others may continue at risk.