Monday, 26 October 2020

Andrija Štampar Croatia's Genius Of Public Health And His Gift To The World

March 5, 2021 – An appreciation of Croatia's most influential doctor, Andrija Štampar, pioneer of public health and the man we have to thank for the World Health Organisation

A pandemic is an infectious disease that spreads over a wide area. It does not respect natural boundaries nor national borders. Indeed, to such a disease, the flags that mark your territory are irrelevant.

Nobody was more aware of this than Croatian doctor, Andrija Štampar, who helped found the World Health Organisation. His work still informs how the global response to such health crises are managed. And in the era of Coronavirus, we never needed more to thank him.

As COVID-19 flew around the globe in 2020, facilitated by a speed of travel Andrija Štampar could only have guessed of, never had the world required such a joined-up, international response. It was the World Health Organisation who were largely responsible for coordinating the response. Its work, and the health of millions prioritised over appeasing individual nations, their leaders, their laws and their petty, fleeting politics.

In doing so, the World Health Organisation drew the ire of American president Donald Trump. His decision to stop American contributions to WHO funding at the height of a global pandemic beggared belief, even judged against the rest of his monstrous stupidity.

But, this was nothing new. Andrija Štampar himself was removed from office by authorities in Belgrade loyal to the Serbian monarchy. And, later, he was even imprisoned by the Ustaša in Croatia for prioritising public health over towing the political line. In doing so, he set the laudable precedent which the WHO still follows. Subsequently, millions of people (rather than the minuscule number of power holders) reap the benefit.

Andrija Štampar, a genius of public health, born in Croatia

Andrija Štampar was born in Brodski Drenovac, halfway between Nova Gradiška and Slavonski Brod, in 1888. Even while attending high school in Vinkovci he was noted for his dedication and intellect. After completing his studies there, he was accepted at the prestigious University of Vienna Medical School and graduated in 1911. His first appointment was at Karlovac city hospital, but within the year he returned to Slavonia to take up the position of district health officer for Nova Gradiška.

That year was 1913 and in this small Slavonian town, Andrija Štampar would start a revolution in medicine that would travel around the world. Prior to this time, medical knowledge was a precious and, admittedly hard-earned commodity. Doctors were the gatekeepers of this knowledge and for their services, they insisted on payment. At this time, the Hippocratic Oath was a seemingly optional code, open to personal interpretation. It would take until 1948 for the World Medical Association (WMA) to modify this code and set it, within the Declaration of Geneva, as a standard of ethics to be observed worldwide. But, in Štampar's view, the public health of those under his jurisdiction could not wait that long, and people's ability to pay was an irrelevance to him in comparison to the wider good.

Alongside the documents for peers he published at the time in the Croatian Medical Association, Štampar presented his knowledge and research directly to the people. He made pamphlets guiding the local population on best practices for maintaining health and avoiding disease. These were posted in public places and distributed to whoever could read them. These series of leaflets he titled 'Public Health Library' and they passed on, free of charge, the latest discoveries in hygiene, health awareness, and illness prevention.

Andrija Stampar © Croatian State Archives

Andrija Štampar, Belgrade, Zagreb, Yugoslavia

This remarkable and effective work was not embraced positively by all within the medical profession, but it certainly got him noticed, thankfully by the many more-enlightened sections of the industry. In 1918, Štampar was made health adviser to the Croatian Commission for Social Welfare. In 1919 he became the head of the Department of Public Health in Belgrade. There, he began constructing Yugoslavia's first network of more than 250 hygienic institutions. Prior to these efforts, such a health system had never been envisaged. Previously, each of the institutions acted completely independently. By affiliating them, he sought to standardise healthcare. And, in particular, he wanted to change the role of the physicians who worked within them.

Štampar's work had convinced him that the best way doctors could address public health issues was to make them assume extra responsibilities. Such responsibilities were more akin to those in the role of a social worker or public educator. And these interventions were to be undertaken completely independent of a patient's ability to pay. Štampar's view was that, ultimately, the health of the entire population would benefit as a result. Such an outlook prioritised preventive medicine rather than curative medicine. This then-revolutionary thinking has today been proved as the cost-effective method of battling illness. So much so, that in the modern era we view it as simple common sense. It is observed and employed by medical practitioners and governments across the globe.

With such a clear mission and passion, the charismatic Štampar was a difficult man to dissuade. And, it wasn't long before his high ideals for public health lead him into conflict. The regime of the Serbian royalty were the first to make life difficult for him. They asked him to join their government. He responded by demanding free elections. That didn't go down well at all and in 1930 he was forced to leave the Yugoslavian Ministry of Public Health. But, by that time, his revolutionary work in public health had been noted internationally. He was almost immediately taken on by the Health Organization of the League of Nations, the precursor to the WHO.

Andrija Stampar in China © Croatian State Archives

Croatia's Dr. Andrija Štampar helps form the World Health Organisation

His work at this League Of Nations body entailed writing a constitution for global public health guidelines and parameters. These would eventually be adopted by the World Health Organisation. It is the basis for the way the WHO operates to this day. He also began educating and lecturing on public health internationally.

He lived in China for a time, where he introduced public health as a matter of urgency. Specifically, he did so in response to the mass of infectious diseases which occurred there following devastating floods in 1931. At first, his radical proposals were too revolutionary for Chinese rulers. But, by the time he left, he was championed as a hero. Subsequently, he educated and gave his lectures across Europe, Africa, the Middle East and at American Ivy League universities like Yale, Cornell, Johns Hopkins, Cincinnati, Vanderbilt, McHarry, Tulane, Texas, Los Angeles, Berkley, Portland, Minnesota, Toronto, McGill, Columbia, Galvestone and Harvard. Indeed, at the latter, he became a professor. So influential was his altruistic and selfless distribution of public health information to the international community that he is still commemorated around the world. Statues dedicated to Štampar exist in China and Morocco, the latter is attributable to his assistance in fighting malaria in the country.

Andrija Štampar's return to Zagreb, the university, the Ustaša and the Second World War

Although his attentions and ambitions had taken on a global view, Štampar never forgot his home. He had already founded the School of Public Health in Zagreb in 1927 and in 1940 he was elected as the Dean of the Medical School in Zagreb. Indeed, there he introduced the directives he'd started in Belgrade and in doing so reformed the training of physicians.

His efforts were halted suddenly by the mindless actions of the fascist Ustaša regime. The public health of Croatians was of no concern to them. The Ustaša shut down all of his innovative schemes and arrested Štampar. Subsequently, he was imprisoned right until the end of the Second World War. He was rescued and freed by Communists and was begged to return to his work in Zagreb. He reattained his position as a professor at Zagreb's Medical School and became head of the city's School of Public Health.

Andrija Stampar in Russia © Croatian State Archives

At the International Health Conference in New York in 1946, Štampar's proposals for the formation and constitution of the WHO were finally accepted. Thereafter, Andrija Stampar was unanimously elected as the first President of the Assembly. In 1955 he was awarded the Leon Bernard medal, the most prestigious international acknowledgment within the field of social medicine. He died on 26 June 1958 aged 69. But, not before he played a part in setting up the now prestigious Medical Faculty of the University of Rijeka.

Croatia has a lot to thank Andrija Štampar for. But, the world owes him even more. More so than ever before, in today's global response to Coronavirus, epidemics, pandemics and disease, we can clearly see this. So many street names and squares in Croatia are named after those with blinkered perspectives, who rarely looked beyond the country's borders. Meanwhile, it is left for the international community to appropriately celebrate Andrija Štampar. While this must be the cause of bewilderment to anyone who rightly values his considerable worth, perhaps one day things will change? If a Croatian child ever asks their parents who was the man that Andrija Štampar street or Andrija Štampar square was named after, they will be embarking on the tale of arguably the greatest Croat to have ever lived.

Dr. Andrija Štampar’s principles for public health and social medicine:

1. It is more important to inform the people than to follow the law of the land.

2. It is most important to prepare the ground in a certain sphere and to develop the right understanding for hygiene issues.

3. Public health and its improvement must not be monopolized by medical authorities. It has to be cared for by everybody, for only by working together can progress in health be obtained.

4. The physician must primarily be a social worker; using treatment alone, they cannot attain much. Social therapy is the means of success.

5. A physician must not be financially dependent on his patient; this hinders them in the accomplishment of their principal tasks.

6. In matters of national health, no difference is to be made between the rich and the poor.

7. It is necessary to form organized public health in which the physician seeks out the patient, not the patient the physician; this is the only way to gather an ever-increasing number of those whose health we have to care for.

8. The physician must be a teacher to the people.

9. The issue of national health is of greater economic than humanitarian importance.

10. The principal places of action for a physician are communities, not laboratories or consulting rooms.

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Friday, 15 May 2020

Zadar's Bacteriological Institute: Croatian Public Health As It Once Was

May 15, 2020 — Croatia has grown well-acquainted with its medical professionals and public health institutes. But what about their ancestors?

The National Archives in Zadar created a virtual exhibit of the town’s former Bacteriological Institute, a predecessor to the modern epidemiologists and public health apparatus. The slideshow and text is part of the joins the seventh festival of history - Kliofest.

Taken together, it chronicles the institute's creation then nearly instant battles with a cholera outbreak. Many of its practices — of informing the public, communicating strategies — exist today.

Archivist Edi Modrinić organized the exhibition, bringing photographs and newspaper articles from the institute’s founding in the late 19th century to the end of World War II. 

The photos show sparse labs and researchers working in a sterile white environment.

The Bacteriological Institute was located within a military hospital, in the former monastery St. Nikola. It’s now the International Center for Underwater Archeology in Zadar.

The 19th century bred many scientific discoveries, especially in the fields of physiology, pathology, and microbiology. The changes eventually bred a sea change in health care. A chemical-bacteriological laboratory was founded in Zadar at the end of the 19th century to exploit these advances. It was led by a young doctor, Alfons Boara. It dissolved quickly, but local medical professionals saw a need for such a facility.

Dr. Božo Peričić in 1905, encouraged by a local cholera outbreak, publish a translation of a scholarly article about the need for public medical facilities and institutes in local paper Narodni List. Peričić — well known in local circles — "considered it worthwhile to translate it, because even in our circumstances, reading will be useful to everyone, and it may encourage our leaders to think and act more vividly in regard to some of the issues raised here.”

Looking out for the public good (and perhaps some more stable employment), Peričić asked the institute be revived to protect against typhus, diphtheria, tuberculosis, and cholera. The diseases hit Zadar in waves throughout the 18th and 19th centuries, along with the plague, making the Adriatic hub one of the world’s foremost authorities on mass quarantine.

“About ten years ago, such a laboratory was established on the Dalmatian governorate,” Peričić wrote. “Sure it was a start but definitely a good start. Envy and negligence quickly found themselves at work to destroy everything. The view of epidemics (dangers to which Dalmatia as a country by the sea is more exposed than others) and the view of the antimalarial struggle, the lack of a well-organized laboratory is a shame and damage from which other provinces do not suffer.”

The Bacteriological Institute’s second iteration opened in 1912, the first institution of its kind in Dalmatia.

They aimed to improve scientific efforts and control in the fight against epidemics and infections, and at the same time to educate future doctors. 

The institute was equipped with modern devices, materials, and resources, which can be seen in the photos. Among other things, it had ten study rooms that housed a hygiene department, a bacteriology department, an animal research room. In it, various diseases could be diagnosed by biochemical and microbiological methods, such as malaria. 

The institute turned into a hub of medical and serological innovation, including the first case of brucellosis or undulant fever.

The Dalmatian Governorate invested substantial sums of Vienna’s money into the institute to fund its research. 

After the First World War, the Institute continued to operate as the Laboratory of Hygiene and Bacteriology (Laboratorio di vigilanza igienica e batteriologica). About 600 bacteriological, chemical and bromatological tests were performed that year. 

The laboratory was led by bacteriologist Dr. Giovanni Venturelli, who led a lavish and well-equipped institute — in danger of closing due to lack of work. In 1923, the Ministry decided to close the laboratory only to be reopened again in 1934.

During the Allied bombing in World War II, the laboratory building was severely damaged, yet some laboratory equipment was preserved. A new chemical-bacteriological laboratory was opened on October 6, 1944 — the fourth version — in a small villa housing the naval command ambulance was located at the time. It remained underutilized until Zadar’s hospital opened. This final iteration of the laboratory is considered a parent to the Croatian Institute of Public Health — currently leading the charge against the coronavirus by Krunoslav Capak.