SPECIAL ARTICLE Vincent (C˙ ensu) Tabone, an Ophthalmologist and a President of the of

Robert M. Feibel, MD

incent Tabone may be unique in the of ophthalmology. He practiced ophthal- mology for 40 years in his homeland, the Republic of Malta. During that time, he be- came well known as a pioneer in the international effort to eradicate trachoma world- wide. At age 53, he began a long and successful political career as a member of parliament, Vthen as a cabinet minister, and, finally, as the democratically elected president of the Republic. He was active in European diplomacy and made important contributions at the . He may be the only ophthalmologist who has made great contributions in the field of medicine and in the democratic development of his country. Arch Ophthalmol. 2012;130(3):373-377

The Republic of Malta is an archipelago of Tabone received his medical degree and small islands in the center of the Mediter- a degree in pharmacy in 1937; he then be- ranean Sea, between and Tunisia. Vin- gan his practice as a general physician. As cent (C˙ ensu) Tabone was born on March was the custom at the time, he worked at a 30, 1913, on , the second largest of the pharmacy, where patients came to con- 3 islands of Malta.1 He was the youngest of sult with him. He remembers that his first 10 children. His father, a physician and sur- patient had conjunctivitis. Life as a gen- geon working as a governmental medical eral physician was demanding, and the pay officer, died when Tabone was only 9 years was low. He wished to specialize in oph- old. As a result, he was brought up in mod- thalmology because of the high incidence est circumstances. of trachoma in Gozo, but there were no All Gozitan natives who wanted to ad- ophthalmologic training opportunities in vance in the world had to leave the island Malta (Paul Cauchi, FRCOphth, consul- for further education, so at age 11, Tabone tant ophthalmologist and grandson of Ta- was sent to a Jesuit boarding school on the bone; oral communication; May 10, 2010). main island of Malta.1 Despite being un- When World War II broke out in Sep- happy away from his family, he spent 6 years tember 1939, Tabone immediately volun- in school there and was an excellent stu- teered for the Royal Malta Artillery regi- dent; and history were his favorite sub- ment and was commissioned as a lieutenant jects. At school, he learned English and Ital- in the medical service. He served as a regi- ian, which were in common use in Malta mental medical officer at various at the time. hospitals on the island for the duration of In 1930, when he was 17, he enrolled the war; after a year of service, he was pro- in the University of Malta to become a phy- moted to the rank of captain. As the war sician like his father and his 2 older broth- moved away from Malta in 1944, his army ers. The 7-year term of study consisted of duties were less onerous and his final hos- 3 years to complete the Bachelor of Sci- pital posting gave him the chance to be- ence degree, followed by 4 years of medi- come an ophthalmic trainee with a British cal school. Tabone took an early interest ophthalmologist, an opportunity that might in politics; while at the university, he ran not have been possible if not for the war.1 unsuccessfully (losing by 1 vote) to be- Tabone was demobilized from the come president of the Student Represen- armed forces in 1946 and was awarded a tative Council. scholarship that allowed him to travel to England for postgraduate training. Ini- Author Affiliation: Department of Ophthalmology and Visual Sciences, tially, he was a house officer at the Washington University School of Medicine, St Louis, Missouri. Moorfields Eye Hospital in London and ob-

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©2012 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 tained his Diploma in Ophthalmic norance of the causes and treat- pioneering expert in this field. The Medicine and Surgery in 1947 from ment of the disease by physicians and main conclusions that he learned and the Royal College of Physicians of the lay population. For example, in subsequently taught worldwide were London and the Royal College of Sur- 1901, 72% of all patients treated at as follows: eradication of trachoma in geons of England. He then attended the Ophthalmic Institute of Malta countries where it is endemic re- the University of Oxford, taking a had conjunctival afflictions, of which quires a detailed, nationwide cam- 2-month course with Professor Ida most were trachoma. Trachoma was paign underwritten and supported by Mann; there, Tabone earned his Di- the leading cause of ocular disease the government, and simply treat- ploma in Ophthalmology. He stud- in the islands, even more than cata- ing individuals on a case-by-case ied ophthalmic surgery at Adden- ract. On Gozo, 30% of all families had basis will not work. Prospective and brooke’s Hospital in Cambridge. at least 1 member affected.3,4 universal screening, compulsory Overall, he spent a year in England. In 1948, the notification of the presence of tra- After returning to Malta, he still felt established a program to send an oph- choma, and compulsory treatment the need to obtain a fellowship in ad- thalmologist to Gozo to develop a free of charge for all infected per- dition to his 2 diplomas; he took a program to evaluate and treat tra- sons must be provided. Careful epi- correspondence course from Edin- choma with the use of sulfon- demiological findings must be re- burgh University in Scotland for the amides, which had been introduced corded to document the extent of the specialized degree in ophthalmol- into the treatment of trachoma a de- incidence of trachoma and to show ogy that was not available from the cade earlier. Tabone was appointed the progress of the eradication cam- Royal College of Surgeons of En- to this position and became a con- paigns. Extensive public education gland. In 1949, he worked at the sultant at the Gozo Hospital. He ex- must be used to inform the popula- Royal Infirmary in Edinburgh for 2 amined 4058 schoolchildren and tion of the necessity for this cam- months and took the written exami- found 721 cases of trachoma, an in- paign; the importance of personal and nations to obtain the Fellowship of cidence of 17.8%. Oral sulfon- communal hygiene and sanitation the Royal College of Surgeons of Ed- amides, sulfa drops, and sulfa oint- must be stressed. The incidence of tra- inburgh, specializing in ophthalmol- ment were used as treatment. The choma in school-aged children was ogy (Vincent Tabone, MD; written results of this campaign were excel- found to be 4-fold that of adults; be- communication; September 5, lent: after 2 years of treatment, the in- cause children serve as the reservoir 1949). Tabone was the first Mal- cidence was reduced to 6 cases for recurrent infections, children and tese national to obtain this fellow- (0.15%). However, when Tabone pre- infants should be treated preferen- ship (Records of the Royal College sented his data at the XVI Interna- tially. His treatment of choice was sul- of Surgeons, Edinburgh, Scotland; tional Congress of Ophthalmology in fonamides taken orally, which he written communication; Novem- London in 1950, his findings were re- found more effective than when used ber 16, 2010). ceived with doubt. Some of the older topically. He also used aureomycin With these impressive creden- ophthalmologists were skeptical of his (chlortetracycline hydrochloride) or tials, Tabone became one of Malta’s results, still convinced that no cure terramycin (oxytetracycline) topi- leading ophthalmologists for the next for trachoma existed; they argued that cally. The most serious problem he 40 years. He performed all types of Tabone was curing only the second- encountered in implementing his ophthalmic surgeries, including cata- ary infections.5 Tabone published his campaign was adherence to the treat- ract surgery using Graefe sections results in the British Medical Journal ment program; hence, Tabone al- and the cryophake, retinal detach- in 1951.6 This article gained atten- ways emphasized that teachers or ment surgery using diathermy and tion in the field of trachoma re- school physicians should adminis- scleral buckle, strabismus surgery, search and was subsequently re- ter the drugs on a regular basis. He and a wide range of oculoplastic sur- printed in 2 other journals dedicated was concerned about reinfection rates gery. He was a strong proponent of to trachoma (one in French and the and advocated that the length of an using local anesthesia in surgery other in Italian) and thus gained bet- antitrachoma campaign should be no rather than the more commonly used ter credence and publicity for his con- less than 3 years. He noted that the general anesthesia and was one of the clusions. Tabone continued to work use of mechanical and surgical meth- first ophthalmologists to introduce on this project in Gozo for more than ods of treatment of trachoma would contact lenses into the country (Paul 10 years; in his last report, in 1960, become unnecessary in the vast ma- Cauchi, FRCOphth; written com- he found the incidence of trachoma jority of patients and predicted that, munication; September 24, 2010). in the school population to be 0.3% eventually, the disease could be abol- Trachoma was a huge problem in (Vincent Tabone, MD; written com- ished,7 a goal that is nearing fruition Malta. It became endemic when the munication; December 31, 1960). today.8 Egyptian ophthalmia spread from The fact that trachoma was mark- In 1948, the newly established British troops who were garrisoned edly reduced but still present after 10 World Health Organization (WHO) in Malta after having been evacu- years of work shows how persistent joined with other organizations that ated from the Egyptian campaign of such a campaign must be for com- had previously worked for interna- 1802.2 The disease spread through plete eradication of this disease. tional trachoma control prior to the population due to the usual This small-scale pilot program World War II and organized the causes: poverty, poor personal and gave Tabone many insights into how Study Group on Trachoma. In alli- communal health, and general ig- to eradicate trachoma; he became a ance with the United Nations (UN)

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©2012 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 Children’s Fund, the WHO set up programs for worldwide trachoma control, and the first Expert Com- mittee on Trachoma met in 1952.8 On the basis of his experience and published results from his program on Gozo, Tabone was the first oph- thalmologist hired by the WHO as a consultant. He immediately em- barked on extensive travel to other countries to replicate his antitra- choma campaign. He worked ini- tially in Asia, spending 6 months visiting many countries, including Taiwan, Indonesia, Borneo, Ma- laya, Hong Kong, the , Singapore, Vietnam, Cambodia, and Sarawak (Figure 1). He met with the local ophthalmic practitioners and guided them in setting up trachoma control programs. He also per- Figure 1. Vincent Tabone screening a child for trachoma. Reproduced with permission from Henry formed surgical procedures and docu- Frendo, DPhil. mented the high incidence of vita- min deficiency with keratomalacia as on Trachoma for a 5-year term.9 As bers and classes of society and was another cause of blindness (Vincent his reputation spread, he was re- embraced as a “people’s politician.” Tabone, MD; written communica- quested to consult and advise on tra- Although Tabone held no gov- tion; date uncertain). Reading the 68 choma eradication in other coun- ernmental office after his first failed typewritten pages of his reports from tries such as Iraq, , Tunisia, and bid for parliament, he cultivated his these missions reveals the intensity Sudan. political skills as the secretary gen- and enthusiasm of his work. While still practicing ophthal- eral of the Nationalist Party and Taiwan was his greatest chal- mology and working with the WHO, served in this post for the next de- lenge because trachoma was wide- he became a founder and the first cade.1 His job was to reorganize the spread there. When he first arrived president of the Medical Officers structure of the party. He increased in 1952, he estimated the incidence Union of Malta, protesting against and regularized party membership, of the disease to vary between 44% low pay for and political control of developed an outreach program with and 90% of the population and found physicians employed by the Labour- the formation of a women’s sec- that 18% of all patients with tra- controlled government.1 For 10 years tion, and kept careful minutes of the choma were blind (Vincent Tabone, he served as president of the physi- executive meetings. MD; written communication; Octo- cians’ union, now known as the In the election of 1966, at age 53, ber 16, 1952). The main focus was Medical Association of Malta. This Tabone was elected handily to par- treatment of schoolchildren with oral event marked his transition from liament and was returned to that of- sulfa drugs followed by topical chlor- ophthalmology to national politics. fice in the next 4 elections through tetracycline hydrochloride. A year Tabone first ran for a seat in par- 1987. His party had become the rul- later, when he returned to Taiwan, liament in 1962 but failed to win the ing party, and he was invited imme- he documented that 86% of tra- election. He was a strong adherent diately to become a cabinet minis- choma cases had been cured (Vin- to the beliefs of the Nationalist Party, ter. He was not asked to be the cent Tabone, MD; written commu- which favored Maltese indepen- Minister of Health but the Minister nication; July 25, 1953). These dence from the but of Labour and Social Welfare.1 Be- campaigns were so successful that with continuing ties to Western cause his governmental position was when Tabone returned to visit Tai- democratic nations and member- considered a full-time job, he had to wan 20 years later, a former ophthal- ship in the British Commonwealth. suspend his ophthalmic practice and, mologic colleague with whom he had Tabone was affiliated closely with thus, he suffered financially. As a worked told Tabone that he could no his local parish church and with the physician, Tabone used his formal longer find active cases of trachoma Sliema Philharmonic Society, of first name, Vincent. But as an indi- to demonstrate to his students. Ta- which he was president for 29 years.1 cation of his devotion to the na- bone said this was one of the proud- The organization was an example of tional service he was undertaking, est moments of his life. a band club, a type of local group when he was first appointed to the From 1952 to 1960, these inter- found throughout Malta that pro- Cabinet, he took the oath of office national travels and consultations vides musical, social, and cultural ac- using his childhood nickname, were a large part of his professional tivities in its neighborhood and also C˙ ensu, an abbreviation of Vinc˙ensu, life. He was appointed a member has great political influence. Ta- the Maltese version of Vincent. Dur- of the WHO Expert Committee bone was approachable to all mem- ing his political and governmental

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©2012 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 mittee of Ministers. He advocated for Malta. He continued his hobby, re- human rights for political dissi- pairing old clocks, particularly grand- dents in the Soviet Union, helped father clocks. According to an anec- develop organizations to foster dote, when he became president, he democratic institutions through- personally mended some of the old out , and spoke out strongly clocks in the presidential and against totalitarian governments.1 office that had not worked in years. In 1987, as a result of his party’s Tabone served as a dedicated oph- electoral victory, Tabone became the thalmologist for 40 years and as a suc- Minister of Foreign Affairs. Tabone cessful public official for 30 years. was instrumental in calling for the Either of those jobs would have suf- European nations to defend the ficed for most people. Which was world’s climate against man-made more satisfying to him? Obviously, he threats and was one of the first world was inspired to improve the gover- statesmen to propose climate con- nance of his country and so assumed trol and environmental protection of a major role in politics and govern- the seas. In 1988, he addressed the ment, always advocating strong General Assembly of the UN and democratic and humanitarian poli- proposed a resolution, “Conserva- cies. From his appointment as sec- Figure 2. Official photograph of Vincent Tabone tion of Climate as Part of the Com- retary general of the Nationalist Party when he was . Reproduced mon Heritage of Mankind.” This led with permission from Paul Cauchi, FRCOphth. in 1962 to his retirement in 1994, he to the unanimous adoption of a UN served 5 terms as a member of par- resolution on climate protection to liament and held 2 positions as a cabi- career and to this day, he continues reduce man-made environmental net minister, with his career culmi- ˙ 1 to be known as Censu. impact. nating in a successful and historic Tabone’s main ministerial con- In 1989, Tabone was active and term as president of Malta.1 cerns were unemployment and job vigorous at age 76. At that time, his Tabone was widely recognized as creation, labor-industrial relations, party selected him to serve in the an outstanding statesman and dip- and measures to alleviate economic largely ceremonial office of presi- lomat in Europe and was decorated and medical problems for elderly, dent of the Republic for a 5-year term by 9 European countries. The Coun- widowed, orphaned, and handi- (Figure 2). According to the Mal- cil of Europe honored him by issu- capped individuals. In 1968, as a re- tese constitution, this position is sult of his cabinet experience, he sub- given not as the result of an elec- ing a postal stamp with his portrait mitted a proposal to the General tion by popular vote but by a vote on it. Malta awarded him its highest Assembly of the UN calling atten- of the members of parliament. Ta- civil honor, the Companion of Honor tion to the needs of the world’s grow- bone was the first president elected of the Order of Merit. He received ing number of elderly individuals. from the Nationalist Party. On the honorary degrees from the Univer- Tabone clearly foresaw increasing international scene, the first major sity of Malta and from the Beijing human longevity and the conse- event of his presidency was hosting Medical College in China. Perhaps his quently increasing burden on gov- the summit meeting in Malta in 1989 most singular honor was the award ernments to support elderly indi- between Presidents George H. W. of the Presidential Gold Medal from viduals. His proposal led to the Bush and that the Royal College of Surgeons of Ed- establishment, in 1988, of the UN In- ended the . Other impor- inburgh. This medal was given for his ternational Institute on Ageing, an tant events included the visit of contributions to ophthalmology and organization that continues to func- John Paul II (the first pope ever to his election as president of Malta. This tion from its headquarters in Malta.10 visit Malta) and the visit by Presi- award is not given on a regular basis In the general elections of 1971, dent Richard von Weizsa¨cker of the but serves to acknowledge great con- Tabone’s Nationalist Party was voted newly reunified country of Ger- tributions by a fellow of the college out of office and was replaced for the many that served as a healing act to (Records of the Royal College of next 16 years by the . end bitterness left over from the Ger- Surgeons; written communication; Tabone continued to serve in par- man attacks during World War II. November 17, 2010). liament in the opposition party as Tabone was so well regarded at the Tabone openly said that he shadow Minister of Foreign Affairs end of his term that the opposition missed ophthalmology when he had and the spokesman for his party for Labour Party asked him to con- given it up. He maintained that his international relations. Since being tinue as president for a second term, proudest achievements were in oph- a member of parliament was con- an unprecedented offer. However, thalmology, not politics (Paul sidered a part-time job, he was able Tabone declined; in 1994, he re- Cauchi, FRCOphth; written com- to resume his ophthalmic practice. tired from public service and the munication; May 10, 2010). His role Tabone served as a member of the medical profession at the age of 81.1 in eradicating trachoma, first in Maltese delegation to the Council of In retirement, he continued to Malta and then as a WHO consul- Europe in Strasbourg, France, and keep up with current events and tant in many foreign countries, was served as the chairman of its Com- taught a course at the University of his greatest satisfaction.

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©2012 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 Submitted for Publication: January major political figure in Malta, in- (1798-1979). San Gwann, Malta: Publishers Enter- prises Group; 2005:487-494. 19, 2011; final revision received June cluding a full-scale biography by Dr 5. Tabone V. Aureomycin in Trachoma: Acta XVI Con- 16, 2011; accepted July 7, 2011. Frendo concentrating on his politi- cilium Ophthalmologicum (Britannia) 1950. Lon- Correspondence: Robert M. Feibel, cal career, but much of this article don, England: British Medical Association; 1950: is based on Tabone’s unpublished 1423-1426. MD, Department of Ophthalmol- 6. Tabone V. Anti-trachoma campaign in Gozo [re- ogy and Visual Sciences, Washing- medical papers, which were gener- printed in Rivista Italiana del Tracoma and Revue ton University School of Medicine, ously made available to me by his Internationale du Tracome]. Br Med J. 1951;1 family, and on conversations with Dr (4709):738-740. 660 S Euclid Ave, St Louis, MO 7. Tabone V. Trachoma Control. Paper presented at: 63110 ([email protected]). and Mrs Tabone and their family. Annual Joint Meeting of the International Orga- Financial Disclosure: None re- nization Against Trachoma and the Ligue contre REFERENCES le trachome; June 1952; , France. ported. 8. Taylor HR. Trachoma: A Blinding Scourge From Previous Presentation: Presented the to the Twenty-first Century. Mel- at the Cogan Ophthalmic History 1. Frendo H. C˙ ensu Tabone, The Man and His Country. bourne, Australia: Haddington Press; 2008:20. , Malta: Maltese Studios; 2001. 9. World Health Organization. Expert Committee on Society Meeting; April 16, 2011; 2. Feibel RM. John Vetch and the Egyptian ophthalmia. Trachoma, Second Report. Geneva, Switzerland: Philadelphia, Pennsylvania. Surv Ophthalmol. 1983;28(2):128-134. World Health Organization; 1956. Technical Re- Additional Information: The sources 3. Cassar P. Medical . London, En- port Series; No. 106. gland: Wellcome Historical Medical Library; 1964: 10. History of the International Institute on Ageing. In- for this article include extensive lit- 235-239. ternational Institute on Ageing Web site. http://www erature regarding Tabone’s role as a 4. Savona-Ventura C. Contemporary Medicine in Malta .inia.org.mt/aboutus.html. Accessed August 1, 2011.

Archives Web Quiz Winner

ongratulations to the winner of our October quiz, Juan D. C Arias, MD, Oncology Service, Wills Eye Institute, Philadel- phia, Pennsylvania. The correct answer to our October challenge was acute retinal necrosis following herpes zoster vaccination. For a complete discussion of this case, see the Small Case Series section in the November Archives (Charkoudian LD, Kaiser GM, Steinmetz RL, Srivastava SK. Acute retinal necrosis after herpes zoster vaccination. Arch Ophthalmol. 2011;129[11]:1495-1497).

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