Editorial Br J Ophthalmol: first published as 10.1136/bjophthalmol-2014-306527 on 26 March 2015. Downloaded from

admitted that ‘the work is now very Arthur Ferguson MacCallan: trachoma onerous’ and ‘I don’t know how long – I shall be able to stand this sort of life’. pioneer in 1903 1923 Nevertheless, he persevered, recognising the overwhelming need by the population Michael MacCallan for professional treatment. Indeed, so suc- cessful were the results from the first TOH that, in 1904, Cassel provided the Arthur Ferguson MacCallan CBE, MD, Sir Ernest Cassel became so shocked at funds for a second one, initially estab- FRCS (1872–1955) was an ophthalmic the extent of ophthalmia among the vast iii lished at Fayoum. surgeon who undertook his pioneering workforce that, in 1902, he established a The high incidence of ophthalmia led work in Egypt between 1903 and 1923 trust fund of £E40 000 (equivalent to £4 Arthur to conclude that the availability of fi i ( gure 1). He became a world authority million today) with the objective of teach- treatment at that time was just ‘adropin fi ‘ on trachoma; the MacCallan Classi cation ing the principles of ophthalmic surgery the ocean’ even with the second TOH. ’ of Trachoma, initially published in 1908, to Egyptian surgeons . The trustees Thus, a bolder, long-term plan was fi fi was the rst grading system used to stand- decided to establish a rst, experimental, needed. To address this, Arthur planned ardise the diagnosis of trachoma and was travelling ophthalmic hospital (TOH) as to ‘create a stable central ophthalmic later adopted by the WHO. He also estab- had been used successfully in Russia. In administration with the best possible clin- lished the ophthalmic hospital infrastructure 1903, Arthur, aged 31 years, was working ical and scientific teaching adjuncts’, along consisting of travelling and permanent hos- as an unpaid ophthalmic surgeon at with establishing a permanent ophthalmic fi pitals, along with the training of surgeons. Moor elds. By a stroke of good fortune, hospital in each of Egypt’s 14 provinces. fi ‘ ’ This ght to eliminate trachoma continues, which transcended even my dreams ,he Over the next 20 years, Arthur worked with the WHO setting a target date for the was offered the position in Egypt to tirelessly to achieve his self-imposed goals. Global Elimination of Blinding Trachoma operate that TOH and teach the Egyptian Arthur is probably best known among ‘ ’ by 2020 ( GET 2020 ). As a contribution to doctors the appropriate surgical skills. the international ophthalmic profession achieving this goal, the International Arthur arrived in Cairo in July 1903. for his research into and ‘classification of Coalition for Trachoma Control (ICTC) He rapidly concluded that hospital the stages of trachoma’. His initial find- ‘ ’ii inaugurated the ICTC MacCallan Medal doctors had little knowledge of eye treat- ings were published in 1908 and then in 2014. By naming this award after Arthur, ment but that success of the TOH scheme further developed in his books Trachoma it recognises his pioneering spirit and would be assured, given the potential and its Complications in Egypt (1913) accomplishments which continue to reson- overwhelming demand for treatment. The and Trachoma (1936). In 1952, the WHO fi ate with the profession today. rst TOH, at Menouf, was opened to adopted MacCallan’s Classification as the ’ fi The seeds of Arthur s work were sown patients in January 1904 ( gure 2). standard. He was also instrumental in when the highly contagious eye-disease Initially, some of the fellaheen were suspi- founding the major ophthalmic research ’ trachoma, which had existed in Egypt for cious of Arthur s motives. However, these establishment at , then known as the centuries, was imposed on the Europeans prejudices were soon overcome by the Memorial Ophthalmic Laboratory,iv due to the return of the British and other empathy, skill and professionalism, by which was formally opened in 1926 ’ combatants troops to their respective which Arthur organised and treated his (figure 3) and which is still operational countries after Napoleon’s invasion and patients; they could literally ‘see’ the ben- today. Arthur stated that ‘this laboratory http://bjo.bmj.com/ – fi subsequent defeat in Egypt (1798 1801). e ts of his operations. Demand for treat- was envisaged by me many years before- In Britain, this led to the opening, in ment grew rapidly thereafter. hand. I got the site, the money for the ’ 1805, of the dispensary for Curing Arthur s volume of work was enor- building, arranged the endowment, and ‘ fi ’ fi Diseases of the Eye and Ear ( Moor elds ) mous. During the rst 3 months of 1904, designed the interior, with all detail’.He ’ to treat the disease. Britain s further at Menouf, he treated 6157 patients and believed that this Laboratory was ‘the involvement in Egypt increased from performed 615 operations. Where anaes- coping stone of my work’. 1882, to protect its interest in the Suez thetics were required, opium, cocaine or However, in order to treat the numer- on October 1, 2021 by guest. Protected copyright. Canal, but it was not until the late 1890s, chloroform were used; in some cases, ous patients with trachoma and other eye fi during the construction of the rst Aswan where no anaesthetics were available, diseases, funding was required. To under- fi Dam, that the nancier and philanthropist patients might still insist on treatment so take this successfully, Arthur recognised great was their desire for sight. This was that it was essential to involve the govern- also the era before antibiotics. Working ment in plans to create and develop an conditions were harsh with the heat, sand, ophthalmic hospital infrastructure. This iSource: Light out of Deep Darkness: A fl ‘ ies, lice and mosquitoes as big as spar- was achieved when, in 1905, the Egyptian biography of Arthur Ferguson MacCallan by rows, very bony and strong’. This combin- Michael MacCallan, privately published in Government took over the administration ation of work and the environment put 2013. of the Cassel Fund and started providing iiThis award recognises a current practitioner’s great strain on Arthur personally and he funding. Arthur was delighted and noted outstanding contribution in eliminating that ‘the national importance of the trachoma.

iiiAt that time, it was estimated that some 90% Correspondence to Michael MacCallan, 15 Queen’s of the population suffered from ophthalmia, Gate Gardens, London SW7 5LY, UK; with many operations being performed by ivNow known as ‘The Giza Memorial Institute [email protected] ‘quacks’. for Ophthalmic Research’.

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Figure 1 Arthur, the Pioneer, Menouf Camp, 1904, with Saladin. struggle against ophthalmia has thus been donations of land and money from advertisement’ for the essential work being recognised and must henceforth take its wealthy individuals. done, resulting in significant donations place amongst the measures essential to The TOHs continued to play a vital role from the public. Given the flexibility of the the prosperity of the country’. The first in treating patients around the country. In TOHs, these ‘hospitals under canvas’ were permanent ophthalmic hospital was 1904, for example, the two TOHs treated used to great effect in 1915, during World opened at (1908); further hospitals patients at Menouf, Fayoum, and War I, when they were commissioned by were constructed over the years funded by Calioub. Their mobility, and the effective the military to treat the sick and wounded a combination of local and government treatment received by patients, led to the from the campaigns at the Suez Canal, finance and, in many cases, generous TOHs being a powerful ‘roving Gallipoli and Salonica. The largest tent http://bjo.bmj.com/ on October 1, 2021 by guest. Protected copyright.

Figure 2 Mat huts at Menouf. These replaced canvas tents in summer.

578 MacCallan M. Br J Ophthalmol May 2015 Vol 99 No 5 Editorial Br J Ophthalmol: first published as 10.1136/bjophthalmol-2014-306527 on 26 March 2015. Downloaded from

Figure 3 Memorial Ophthalmic Laboratory, Giza, 1925. camp contained 650 beds; this was initially 133 750: 40×), and operations per- this day, as witnessed by the ‘ICTC established in and then moved formed, (1268 to 76 035: 60×). On MacCallan Medal’. Arthur’s pioneering to Giza for the winter of 1915. Arthur was Arthur’s departure in 1923, there were 23 spirit continues to inspire, and resonate commended by Surgeon-General Ford that operational ophthalmic hospital units, with, today’s profession as they continue his hospital was ‘a model of what a war including five TOHs and two planned the fight to eliminate blinding trachoma. hospital under canvas should be’. hospitals. As important, however, was the Two other areas addressed by Arthur were fact that Arthur established robust founda- Competing interests None. also essential to the successful achievement tions for the ophthalmic hospital infra- Provenance and peer review Commissioned; of his goals. First, he organised the training structure to develop after his departure. internally peer reviewed. of ophthalmic surgeons to staff the hospi- By 1937, there were 63 permanent oph- tals; by 1923, the members of the Egyptian thalmic hospitals, 15 travelling hospitals http://bjo.bmj.com/ Ophthalmological Society had increased and treatment centres in 38 government from 17 to 96. Second, Arthur believed that schools. Many of these hospitals are oper- ‘the most important work carried out was ational today with the Fayoum ophthalmic the institution of ophthalmic treatment in all hospital celebrating its centenary in 2015. Open Access Government Primary Schools throughout Arthur bore the mantle of ambassador in Scan to access more Egypt’. Given that trachoma was highly con- promoting and ensuring the implementa- free content tagious, particularly in the close environ- tion of his self-imposed goals. Over the on October 1, 2021 by guest. Protected copyright. ment of the family unit or schools, Arthur years, he persuaded both the government Open Access This is an Open Access article fi distributed in accordance with the Creative Commons dedicated much effort in educating people and local notables to provide signi cant Attribution Non Commercial (CC BY-NC 4.0) license, on the benefits of personal ophthalmic funding and other support for the develop- which permits others to distribute, remix, adapt, build hygienev and so prevent the spread of the ment of the ophthalmic hospital infrastruc- upon this work non-commercially, and license their disease. Indeed, one of his first professional ture. Arthur successfully achieved his goals derivative works on different terms, provided the original work is properly cited and the use is non- calls in 1903 was to the headmaster of while recognising that much still remained commercial. See: http://creativecommons.org/licenses/ Menouf School with the offer of inspecting to be done. In 1931, Arthur’s colleagues by-nc/4.0/ the pupils for ophthalmia and offering from the Egyptian ophthalmic service dedi- appropriate treatment. cated a commemorative bust to honour his The tangible results of Arthur’s efforts illustrious career and accomplishments; over 20 years led to a significant growth this may still be seen today at the Giza in the number of patients treated (3397 to Memorial Institute for Ophthalmic Research. It is touching to note that, when To cite MacCallan M. Br J Ophthalmol 2015;99:577– the bronze bust was imported into Egypt in 579. 1930, the Ministry of Finance agreed to vThis emphasis on hygiene (clean hands, faces Published Online First 26 March 2015 and towels) continues today as part of the waive the customs duty in recognition of WHO—endorsed SAFE strategy (‘F’—facial the ‘moral significance’ of Arthur’swork Br J Ophthalmol 2015;99:577–579. cleanliness). over 20 years. This sentiment remains to doi:10.1136/bjophthalmol-2014-306527

MacCallan M. Br J Ophthalmol May 2015 Vol 99 No 5 579 Laboratory science

Project (31370893), Research Fund for the Doctoral Program of Higher Education 15 Franke A, McGovern DP, Barrett JC, et al. Genome-wide meta-analysis increases to of China (20115503110002), Basic Research Program of Chongqing 71 the number of confirmed Crohn’s disease susceptibility loci. Nat Genet (cstc2013jcyjC10001), Chongqing Key Laboratory of Ophthalmology (CSTC, 2010;42:1118–25. 2008CA5003), National Key Clinical Specialties Construction Program of China, 16 Dubois PC, Trynka G, Franke L, et al. Multiple common variants for celiac disease Key Project of Health Bureau of Chongqing (2012-1-003), Chongqing Science & influencing immune gene expression. Nat Genet 2010;42:295–302. Technology Platform and Base Construction Program (cstc2014pt-sy10002) and 17 Sawcer S, Hellenthal G, Pirinen M, et al, International Multiple Sclerosis Genetics C, Fund for PAR-EU Scholars Program. Wellcome Trust Case Control C. Genetic risk and a primary role for cell-mediated immune mechanisms in multiple sclerosis. Nature 2011;476:214–19. Competing interests None. 18 Jin Y, Birlea SA, Fain PR, et al. Genome-wide association analyses identify 13 new Patient consent Obtained. susceptibility loci for generalized vitiligo. Nat Genet 2012;44:676–80. et al Ethics approval The Ethics Committee of the First Affiliated Hospital of Chongqing 19 Cooper JD, Smyth DJ, Smiles AM, . Meta-analysis of genome-wide association fi Nat Genet Medical University (permit number: 2009-201008). This project was registered in study data identi es additional type 1 diabetes risk loci. 2008;40: – the Chinese Clinical Trial Registry (registration number: ChiCTR-CCC-12002184). All 1399 401. fi et al experimental steps obeyed the principles of the declaration of Helsinki. This research 20 Grant SF, Qu HQ, Brad eld JP, . 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Correction

MacCallan M. Arthur Ferguson MacCallan: trachoma pioneer in Egypt 1903–1923. Br J Ophthalmol 2015;99:577–9. The Provenance and peer review statement should read: Commissioned; externally peer reviewed.

Br J Ophthalmol 2015;99:1154. doi:10.1136/bjophthalmol-2014-306527corr1

1154 Gao X, et al. Br J Ophthalmol 2015;99:1150–1154. doi:10.1136/bjophthalmol-2014-306163