TUBERCULOSIS IN GREECE An Experiment in the Relief and Rehabilitation of a Country By J. B. McDOUGALL, C.B.E., M.D., F.R.C.P. (Ed.), F.R.S.E.; Late Consultant in Tuberculosis, Greece, UNRRA INTRODUCTION In Greece, we follow the traditions of truly great men in all branches of science, and in none more than in the science of medicine. Charles Singer has rightly said - "Without Herophilus, we should have had no Harvey, and the rise of physiology might have been delayed for centuries. Had Galen's works not survived, Vesalius would have never reconstructed anatomy, and surgery too might have stayed behind with her laggard sister, Medicine. The Hippo- cratic collection was the necessary and acknowledged basis for the work of the greatest of modern clinical observers, Sydenham, and the teaching of Hippocrates and his school is still the substantial basis of instruction in the wards of a modern hospital." When we consider the paucity of the raw material with which the Father of Medicine had to work-the absence of the precise scientific method, a population no larger than that of a small town in England, the opposition of religious doctrines and dogma which concerned themselves largely with the healing art, and a natural tendency to speculate on theory rather than to face the practical problems involved-it is indeed remarkable that we have been left a heritage in clinical medicine which has never been excelled. Nearly 2,000 years elapsed before any really vital advances were made on the fundamentals as laid down by the Hippocratic School. The world had to wait on the results of physical and mechanical research before it was in a position to add to what it had inherited from the Greek medical school of thought. 104 TUBERCULOSIS IN GREECE In the spring of 1945, when UNRRA was invited to make a survey of the tuberculosis requirements of Greece, after four years of German, Italian and Bulgarian occupation, and a month or more of civil war, it was clear that public-health organization was completely out of hand. It must be left to others to describe the difficulties in sanitation, in malaria control, in maternity and in child-welfare schemes, and even in general hospital administration; here I concern myself only with the tuberculosis scheme as I encountered it in the early months of 1945. Improvements in any direction for the amelioration of the soeial and medical conditions had become impossible from the moment when, on 28 October 1940, the Italians advanced to the attack on the Albanian frontier. A country normally dependent upon the importation of much of its food was now rationed beyond the wildest dreams. Even pre-war there was chronic under-nutrition in many areas in Greece; it has been reliably estimated that 30 per cent of the population was undernourished. During the famine years (1940-1942) the intake was reduced to 750-900 calories per day, and the increase in the general death-rate was fivefold. 1 CHORTIS 2 found in a series of 108 patients who had tuberculosis and hunger cedema during the famine period, that the common histologic changes were a cloudy swelling of the parenchyma cells in all the organs, serous impregnation of the interstitial cells, and complete disappearance of fat vesicles. Tuberculous localization in the viscera was common, due to frequent bacillaemia and decrease of local resistance. He noted that there was reversal to an acute exudative form of the disease, with rapid and fatal progression. This he attributed to the various biological factors producing a great decrease in the general immunity against tuberculosis and to mecha- nical factors producing great increase in the respiratory function of the lung, with extension of the disease. The Greek Army, with the pay of the private soldier at less than a penny per day, lived and fought throughout the Albanian campaign on a diet of bread, raisins, tea and cognac: many lived for days on nothing but bread. The civil population fared even worse, for, with the Germans and Bulgarians on the north, and the Italians on the 1 Preiminary Report on the Un&rnuri8hment of Greee during the Period of Occupation. Greek Government Sub-Committee on Undernourishment, August 1945. Unpublished. 2 " Tuberculosis and Hunger (Edema. " Amer. Rev. Tuber. 1946, 54, 219. TUBERCULOSIS IN GREECE 105 west, and with the Mediterranean sea-routes virtually closed to shipping, many Greeks in selected districts were cut down to a dietary valued at no more than 400 to 600 calories a day, during the winter of 1940-41. At this time malnutrition assumed epidemic proportions; anemia and emaciation were the common lot of the majority of the population. Environmental conditions reached a deplorable level. (See Figures I-IV.) 1 And in 1945, the aftermath. The enemy had gone, except for the trapped 20,000 Germans in the west corner of Crete, but in their exit from the country they had left a trail of disorder in roads, railways, bridges, hospitals, homes and fields-a confusion which had been added to by the unfortunate civil war of December 1944. Hospitals all over the country, especially sanatoria on the fringes of Athens, became strong-points of military vantage; equipment still left by the Germans was further mutilated and pillaged in the civil strife. Hospital wards became barracks, and even patients joined in the fray. The sick people of Greece were deprived of thousands of beds which they fondly hoped would be available after the withdrawal of the enemy. Further, with so much work to be done in reconstruction, the Government of the country was quite unable to set the wheels of industry in motion. Unemployment became rife in the chief centres of population, though in the rural districts agricultural pursuits went on in the hope that, when the harvest was due, there would be transport facilities to carry the sheaves to the granaries of Greece. THE PROBLEM In general topography and in the distribution of the population, Greece bears a strong resemblance to Scotland. The Grampians are reflected in the Pindus Range: the Forth and Clyde might have their prototypes in the Gulf of Corinth and the Saronic Gulf, almost, but not quite, dividing the country into two, and in this area the popu- lation is most dense. All round the coast of Greece the sea prods its way into the mainland, reminiscent of the western shores of Argyllshire, and the Islands are, as in Scotland, one of the chief features of the country. Rural life is, however, more intense in Greece since communications 1 Note by the Editor. - The photograpths reproduced in this article were supplied by UNRRA, except where otherwise indicated. Figure I to IV, representing some of the environmental conditions under which Greek peasants live. I m--.Yw&x1\ 1\ .+,^ E1:\, \\_ \ \ : s~~~~~ Fiqure 1. Figure II. 7-1 Figure III. F U Figure IV. lp8 1P8 ~~TUBERCULOSIS IN GREECE with large centres of population are more difficult, and self-sufficiency is for many Greek peasants synonymous with life itself. It would not be strictly accurate to say that the Greeks had neglected the large rural population in pre-war days, but the tend- ency to concentrate effort in Athens and the Piraus, and in the Salonica regions was even then too apparent. Since 1940, however, there has been little choice; even the large centres have, from force of circumstances, been neglected in the public-health design. All this must be borne in mind when the picture which I am about to draw of the tuberculosis scheme in Greece in early 1945 is being interpreted. As one would expect, a preliminary survey of the tuberculosis position in Greece, with socio-economic conditions in such a chaotic state, led to some appalling discoveries. Reference to the map of Greece (Figure V) shows that the majority of institutions for the treatment of tuberculosis were centred round Athens and are mostly on the north side of the city. Pre-war, there were some 3,500 beds for tuberculous patients in this area alone. Their proximity to the capital, their picturesque setting in the rising ground with Hymettus, Pentelikon and Parnes adding their illustrious splendour in the background, and the blue Attic sky as an almost perpetual canopy, made this area an easy, if not altogether wise, choice for such an accumulation of tuberculous patients. Of the Attic sanatoria, no fewer than five were "private "- that is, they admitted patients prepared to pay the necessary fees. A few of these " private " sanatoria admitted patients for whom the State accepted financial responsibility. Of the institutions owned by the State, by far the most ambitious is the Sotiria Sana- torium, surely one of the largest institutions for the treatment of tuberculosis in any country in the world, with 2,000 beds potentially available. Of the other tuberculosis institutions in Greece, that at Asvestochorion, near Salonica, is worthy of special mention for reasons which I shall state presently. The sanatoria in the Pelopon- nesus are important too, because they were completely unoccupied in April 1945, as were also the institutions at Petra near Mount Olympus, Parnithos on Mount Parnes and others. Although Voula Sanatorium, also near Athens, is the recognized centre for the treatment of non-pulmonary tuberculosis, there are a number of beds reserved for such cases in the Sotiria Sanatorium, and in some of the general hospitals throughout the country. TUBERCULOSIS IN GREECE 109 Figure V. - Anti-tuberculosis institutions at the commencement of 1945. The dispensary service in Greece had likewise been centred round Athens with twenty-three out of the total of twenty-six for the country as a whole.